Every finding on record at Stonehaven Health and Rehabilitation Center

Based on interviews, review of the Director of Nursing's (DON's) job description, and review of a facility policy titled, Competency Evaluation, Employee Identifier (EI) #2, the DON, failed to have a system in place to ensure nursing services personnel were competent and able to demonstrate timely and appropriate response, in accordance with facility policy, for Cardiopulmonary Resuscitation (CPR) in the event of residents becoming unresponsive and requiring CPR. On [DATE] at approximately 9:59 PM, EI #4, a Certified Nursing Assistant (CNA), found Resident Identifier (RI) #58 unresponsive and alerted the Licensed Practical Nurse (LPN), EI #3. Without knowing RI #58's code status, EI #3 said he began chest compressions and continued, without providing rescue breaths, until about 10:14 PM, when he stopped to go find out RI #58's code status and to make phone calls to the resident's representative and the DON. EI #3 failed to call out for assistance from other staff who were in the building, including EI #5, Registered Nurse (RN)/House Supervisor, who was on duty at the time of the occurrence. EI #3 further failed to call EMS until 10:44 PM, approximately 45 minutes after RI #58 was found unresponsive. No code was ever announced and the facility crash cart was not utilized. EMS arrived at the facility at 10:52 PM. RI #58 was pronounced deceased on [DATE] at 11:12 PM after EMS interventions. This deficient practice placed RI #58, one of three sampled residents reviewed for the provision of CPR, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. This deficient practice also had the potential to affect any other resident in the facility who may be found unresponsive. The facility's Form CMS-672 Resident Census and Conditions of Residents reflected a census at the time of the survey of 52. On [DATE] at 3:59 PM, EI #1, the facility Administrator; EI #2, the DON; EI #14, the [NAME] President of Clinical Operations; and EI #15, the Director of Operations were given a copy of the immediate jeopardy (IJ) template and notified of the IJ findings in the area of Nursing Services, at F726-Competent Nursing Staff. Findings include: During the survey concerns were identified regarding staff response after finding RI #58 unresponsive on [DATE] at approximately 9:59 PM. EI #3, the Licensed Practical Nurse (LPN) who responded, gave chest compressions only, with no rescue breaths. Further, EI #3 did not call for assistance or initiate a code. The facility crash cart was not utilized, and Emergency Medical Services (EMS) was not contacted until 10:44 PM. Cross Reference F678. A review of the Director of Nursing's Job Description (EI #2) that was signed on [DATE] revealed, . Job Description Director of Nursing Qualifications . Basic Job Responsibilities 1. To adhere to American Health Corporation's Philosophy, objective, policies, and procedures with direct responsibility to the Administrator. 2. To ensure that the Nursing Service Department is in compliance with rules and regulations of Federal, state and local authorities. 3. The primary purpose of the position is to plan, organize, develop, and direct the overall operation of the Nursing Service Department to ensure the highest degree of quality care is maintained at all times. 5. You are responsible for carrying out the resident care policies established by the Corporation. Responsibilities . 2. Plan, develop, organize, implement, evaluate, and direct nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long term care facility. 4. Implements policies and procedures with follow-up and supervision of staff to ensure compliance. 18. Monitors the nursing service department to ensure nursing service personnel are performing their work assignments in accordance with acceptable nursing standards and Corporate policies and procedures. Ensures positive outcomes are accomplished for residents; . 21. Ensures medical record documentation and that the care planning process is interdisciplinary, consistent, timely, and reflective of resident needs and in compliance with regulations at all times. Marginal Responsibilities 1. Participates in the identification of staff educational needs. Policies . 2. Procedures are completed according to methods outlined in procedure manuals and/or standards of practice. A review of a facility policy titled, Competency Evaluation, with a revision dated of [DATE], revealed: . Policy: It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. 5. A variety of methods may be used to evaluate learning and/or skills competency. e. Review of the employee's documentation. g. Review of adverse events or other data. An interview was conducted on [DATE] at 10:56 AM with EI #2, the DON. EI #2 was asked what process was followed the night RI #58 coded. She said she was not there, so she did not know what steps were taken. EI #2 further stated EI #3 was the only staff involved in efforts to revive RI #58. EI #2 admitted all nurses and CNAs should have been involved. EI #2 said no one else was involved in the resuscitation efforts because EI #3 and EI #4 did not notify anyone. EI #2 said the nurse could have hollered out, paged on the intercom or instructed someone to get additional assistance. EI #2 said EI #3 told her he performed CPR, so she was under the assumption he had called the code. EI #2 was unaware EI #3 had not called for assistance. EI #2 admitted she should have known the steps taken during the code. On [DATE] at 2:11 PM, EI #2 denied gathering any information after RI #58, a full code resident, expired in the facility. When EI #2 was asked what oversight she gave to ensure the protocol was followed for the full code resident that expired, she said she asked the nurse if he performed CPR and notified the Physician and family. EI #2 was asked if she did not interview, review the process that occurred and determine what failures might have occurred, how she could prevent these errors from happening in the future. EI #2 said she could not. A follow-up interview was conducted on [DATE] at 10:38 AM with EI #2, the DON. EI #2 acknowledged she had no knowledge of any conflicting information in RI #58's record, including time of death, until [DATE]. EI #2 was asked why someone had not reviewed RI #58's record for accuracy to identify these discrepancies. EI #2 said she went by what EI #3 told her on the phone. EI #2 acknowledged EMS was called at approximately 10:45 PM and arrived to the facility at 10:52 PM. EI #2 further stated EI #3 told her RI #58 was deceased when he called her at approximately 10:15 PM. On [DATE] at 4:10 PM, another follow-up interview was conducted with EI #2. EI #2 stated when a resident expires, she reviews the documentation in the chart. EI #2 further stated she would want to know the details of the event when a full code resident expired. EI #2 said she did not ask details about RI #58's code to discover the concerns related to the events of [DATE]. She further stated she did not ask the Supervisor on duty [DATE] on the 3 PM to 11 PM shift about the events. EI #2 said the usual process when there was an unusual occurrence in the facility was that they find out what happened or caused the unusual occurrence. EI #2 acknowledged she should have been aware of the concerns regarding RI #58's code. EI #2 said if she had been aware of the discrepancies, she would have followed up, interviewed staff and tried to establish a root cause. EI #2 was asked what she did to provide oversight of Nursing Services to ensure CPR guidelines and the facility policy were followed. EI #2 answered she did none. EI #2 said she does not monitor staff to ensure they are aware of the policies. EI #2 was asked what system was in place to ensure that staff knew what to do in the event of a nonresponsive resident who was a full code. EI #2 said, nothing. EI #2 said the facility would need to educate, in-service and practice mock codes or drills to ensure staff respond in accordance with CPR guidelines and facility policy. On [DATE] at 10:54 AM a follow-up interview was conducted with EI #2. EI #2 said a mock code was when you go through all the steps of how staff should respond in the event of a code. EI #2 was asked who does the mock codes. EI #2 answered there were no designated mock codes performed and she did not know when the last mock code was performed. EI #2 was asked when they were done, and she answered they have not been done. EI #2 said the mock code entailed an unresponsive resident found (pretend), check for pulses and respirations, call for help, verify the code status, begin CPR, have someone call the code, direct staff to get the crash cart if they have not already done so, have someone to call 911, tell someone to document the times and steps. When asked how she expected staff to know what to do in the event of a code if she was not doing all these things, she answered she could not expect them to. EI #2 was asked why there was not a system in place to ensure that staff knew what to do in the event of a non-responsive resident who is a full code. She answered that she thought it was just an oversight. This deficient practice was cited as a result of the investigation of complaint/report number AL00043033. ***************************************************************************** On [DATE] at 4:52 PM, the facility submitted the following acceptable Removal Plan addressing F726: Removal Plan for 726 On [DATE], education was provided to the Administrator, Director of Nursing, by the Corporate Consultant, Regional Director of Operations, regarding emergency procedures, code blue drill, crash cart locations and cardio-pulmonary resuscitation. Education provided: How to do a code blue drill - simulation of a resident in need of cardiopulmonary resuscitation Where the crash carts are located and what belongs on the crash carts Who needs to be part of the code blue drills - all team members Drills will be completed on a Quarterly basis - this is a plan, not policy The Director of Nursing did a return demonstration of cardiopulmonary resuscitation. Cardiopulmonary Resuscitation policy was reviewed. Where the code status is found in PCC on the resident dashboard and on the resident face sheet This information will be disseminated through the mock codes to all team members On [DATE] the Director of Nursing, corporate nurse, and Director of Operations performed a mock code at 7:17 pm to assess the staff response. Team members 17 (LPN- 3, RN- 2, CNA- 3, Other- 9)-responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy, and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the Director of Nursing performed a mock code drill at 6:00 am to assess the staff response. Team members 7 (LPN- 0, RN-1, CNA- 4, Other-2) responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard: Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the Director of Nursing performed a mock code drill at 9:31 am to assess the staff response. Team members 20 (LPN- 0, RN-2, CNA- 6, Other-12) responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the center had an independent contractor for the American Heart Association trainer on site that is training all nursing staff on American Heart Association Cardiopulmonary Resuscitation. On that date 12 nurses, 8 CNAs and 13 non-licensed staff members were either certified or re-certified in accordance with American Heart Association guidelines and requirements, to include a skills check-off and return demonstration. On [DATE] the administrator, Director of Nursing, corporate nurse, and the regional director of operations developed the Communication of Code Status policy and reviewed and adopted it and reviewed the Cardiopulmonary Resuscitation policy. On [DATE], the DON utilized the Communication of Code Status policy and provided education to 7 nurses, 11 CNA, and 30 non licensed. There are 28 total staff members, 7 - nurses, 10- CNAs and 11- non licensed that still need to be trained on the Communication of Code Status policy. [DATE] - 7 CNAs, 8 LPNs, 1 RN and 7 non-licensed staff were educated, On [DATE] - 2 CNAs, 5 LPNs, and 18 non-licensed. The intention is that this policy be in-serviced to all licensed and non-licensed staff. No staff will be allowed to work [DATE] in the facility until they have received the training on the new policy. An employee list is being used to ensure all staff are participating in mock code blue drills. To ensure all team members are trained, the schedule is being used to make sure anyone that is coming into work gets training prior to starting their shift. We are utilizing the employee list of all staff to confirm who has been trained and who not been trained. The Administrator, Director of Nursing and the staff development coordinator will be available at the start of each shift ensure this education is completed prior to staff starting their shift. No nurses will work in the center without current Americana Heart Association Cardiopulmonary Resuscitation card. and will have been trained on the facility Cardiopulmonary Resuscitation policy by the Director of Nursing. All licensed nurses have current cardiopulmonary resuscitation cards with hands on training verified by the administrator on [DATE]. Copies supplied. The DON identified the LPN had not followed facility policy and terminated this nurse on [DATE]. On [DATE] the [NAME] President of Clinical Operations, educated the Director of Nursing on ensuring all nursing staff are competent and able to demonstrate timely and appropriate response to a resident in need of cardiopulmonary resuscitation. The in-service also included the importance of investigating fully, perform necessary staff interviews, and pursue any unusual occurrences as suspicious, any resident that is a full code or who either experiences a code blue situation, or expires and is a full code, to ensure all incidents and accidents have the correct documentation and have a legible timeline to ensure accuracy of the chain of events and documentation. This education was completed in a written document. On [DATE] the system was implemented that all new hire licensed nursing staff will meet for a one-on-one session with the Director of Nursing before working on the unit, this session will include: Review the cardiopulmonary resuscitation policy and get a return demonstration. The new hire will be shown where to find the code status in PCC on the resident dashboard and the face sheet. The new hire knows to yell for help if she finds a resident unresponsive. Ensure nurse knows that incidents must be documented completely and accurately. The Director of Nursing will perform mock code blue drill on each shift every week for 4 weeks to ensure staff are following the facility policy on cardiopulmonary resuscitation. An employee list is being used to ensure all staff are participating in mock code blue drill. The Administrator will review all occurrences/incidents investigated by the Director of Nursing to ensure it is complete and through. An ad hoc quality assurance performance improvement meeting was held on [DATE], that included Dr., Administrator, Director of Nursing, corporate nurse, and regional director of operations. The root cause of the incident was Director of Nursing is new to her role at the center. Contents will be completed and the immediacy will be removed on [DATE]. **************************************************************** After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F726 was lowered to a F level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on record review, interviews, and review of a facility policy titled Cardiopulmonary Resuscitation (CPR), the Emergency Medical Services (EMS) run report, and the American Heart Association (AHA) Adult Basic Life Support (ABLS) Algorithm for Health Care Providers, the facility failed to ensure CPR response was provided in accordance with facility policy and in accordance with the AHA ABLS Algorithm for Health Care Providers for Resident Identifier (RI) #58 on [DATE], when Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA), found RI #58 unresponsive and alerted the Licensed Practical Nurse (LPN), EI #3, around 9:59 PM. EI #3, the LPN, without knowing RI #58's code status, said he began chest compressions and continued, without providing rescue breaths, until about 10:14 PM, when he stopped to go find out RI #58's code status and to make phone calls to the resident's representative and the Director of Nursing (DON). EI #3 failed to call out for assistance from other staff who were in the building, including EI #5, Registered Nurse (RN)/House Supervisor, who was on duty at the time of the occurrence. EI #3 further failed to call EMS until 10:44 PM, approximately 45 minutes after RI #58 was found unresponsive. No code was ever announced and the facility crash cart was not utilized. EMS arrived at the facility at 10:52 PM. RI #58 was pronounced deceased on [DATE] at 11:12 PM after EMS interventions. This deficient practice placed RI #58, one of three sampled residents reviewed for the provision of CPR, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On [DATE] at 6:49 PM, EI #1, the facility Administrator; EI #2, the DON; EI #14, the [NAME] President of Clinical Operations; and EI #15, the Director of Operations were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of substandard quality of care at the IJ level in the area of Quality of Life, at F678-Cardio-Pulmonary Resuscitation (CPR). Findings include: On [DATE] the State Survey Agency received a third-party complaint involving concerns with inconsistencies in the timeline of events related to RI #58's death. Per the complainant, there was a delay in contacting EMS after RI #58 was found unresponsive on [DATE]. A facility policy titled, Cardiopulmonary Resuscitation (CPR), last revised [DATE], documented: Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Compliance Guidelines: 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR a. Verify scene safety b. Check for responsiveness c. Call out for staff assistance d. Call [DATE] 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order . The American Heart Association (AHA) Adult Basic Life Support (ABLS) Algorithm for Health Care Providers, dated 2020, documents the following sequence of response should be initiated in the event Health Care Providers respond to a person in need of CPR and EMS: . Verify scene safety. Check for responsiveness. Shout for nearby help. Activate emergency response system via mobile device (if appropriate). Get . emergency equipment (or send someone to do so). Look for no breathing or only gasping and check pulse (simultaneously). No breathing or only gasping, pulse not felt . By this time in all scenarios, emergency response system or backup is activated . and emergency equipment are retrieved or someone is retrieving them. Start CPR Perform cycles of 30 compressions and 2 breaths . Check . (for a pulse if no AED). Resume CPR immediately . Continue until ALS (advanced life support) providers take over or victim starts to move. RI #58 was admitted to the facility on [DATE] and had diagnoses to include: Congestive Heart Failure, Dementia, Stage 3 Chronic Kidney Disease, Peripheral Vascular Disease, Coronary Artery Disease, and Physical Debility. RI #58's ADMISSION RECORD documented the following: . ADVANCE DIRECTIVE Code Status: Full Code . RI #58's undated OAK TRACE RESIDENT CARE GUIDE and December Medication Administration Record (MAR) also documented RI #58's code status was Full Code. RI #58's Progress Notes contained the following entries: -On [DATE] at 10:38 PM EI #3, the LPN, documented that RI #58 expired around 10:15 PM, and the facility physician, DON, resident representative, and 911 were called. - A Late Entry note dated [DATE] at 3:51 AM was made by EI #2, the DON. This note documented that the nurse was called to RI #58's room by a CNA who stated RI #58 did not look good. Further, the note indicated the nurse (EI #3) entered RI #58's room at approximately 9:50 PM and found RI #58 unresponsive with no pulse, so CPR was started, 911 was called, and EMS arrived and pronounced RI #58 deceased around 10:15 PM. - Another Late Entry note dated [DATE] at 1:28 PM was made by EI #3, LPN. This note indicated RI #58 was found unresponsive on [DATE], CPR was performed with no positive response, 911 was called and the local EMS team responded and performed CPR until around 11:00 PM, when they gave the official call for expiration (time of death). RI #58's Patient Care Record (run report) from the Local EMS response team documented the following: . Chief Complaint: cardiac arrest Duration: 50 minutes . Narrative Pt. (patient) lying supine (lying on back) in bed on arrival Pt was last known alive at 2130 (9:30 PM) according to nursing home staff . NH (nursing home) staff states patient is a full code . Cardiac Arrest: Yes, Prior to EMS Arrival Estimated time of Arrest: (greater than) 20 Minutes Est (estimated) Time Collapse to 911 (the approximate time from nursing staff finding resident unresponsive until the time 911 was called) : 35 Minutes . Est Time Collapse to CPR (the approximate time from nursing staff finding the resident unresponsive until the time CPR was initiated): 50 Minutes . CPR Initiated by: EMS Time 1st CPR: 22:54 (10:54 PM) [DATE] Incident Times . Call Received 22:44:44 (10:44 PM) At Patient 22:54:00 (10:54 PM) . This run report did not indicate facility staff were performing CPR upon EMS arrival. Further, the report documented an in-field pronouncement of time of death as [DATE] at 11:12 PM. On [DATE] at 5:54 PM an interview was conducted with EI #3, the LPN/Charge Nurse, assigned to RI #58 on [DATE] on the 3 PM-11 PM shift. EI #3 was asked about the incident on [DATE] when RI #58 was found unresponsive. EI #3 said, RI #58's vital signs were taken by EI #4, the CNA, prior to medication pass and they were within normal limits. EI #3 said, when he initially tried to administer RI #58's medications, RI #58 refused. EI #3 went back within approximately 30 minutes and RI #58 accepted them just before 9:29 PM. EI #3 said EI #4, the CNA, came to him about twenty to thirty minutes later (9:49 PM to 9:59 PM) when he was at the nurse's station charting vital signs to tell him RI #58 did not look good. EI #3 said he got up, and they went down to the resident's room. EI #3 said RI #58's head of the bed was elevated about ,d+[DATE] degrees and RI #58 was sitting face-forward, eyes closed, with a small drop of foam at the right corner of his/her mouth. EI #3 said he immediately checked for respirations, then a carotid, apical and wrist pulse and there was nothing on all four. EI #3 claimed at that point, he told the CNA, EI #4, to go call 911 as he started CPR. EI #3 said EI #4 then left the room while he did chest compressions. He indicated he did sets of 30 chest compressions, with no rescue breaths. EI #3 further stated he did not call a code. EI #3 said while doing the compressions, he could not remember if RI #58 was a full code or DNR, so he stopped CPR to go to the nurse's desk to check. EI #3 said RI #58 was listed as a full code. EI #3 indicated while he was at the desk he made calls to 911, RI #58's family, and the DON. When asked why no other nursing staff were involved in the resuscitation efforts for RI #58, EI #3 said he just went with what he needed to do, rather than for him to go look for people that he may or may not have found. When asked what he meant by people he may or may not have found, EI #3 said they could have been on lunch, outside, or the intercom may not have worked. EI #3 was asked when the crash cart was brought to the room. EI #3 answered, it was not taken to the room. EI #3 was asked where the backboard was. EI #3 answered, it was on the crash cart. EI #3 was asked why it was not utilized. EI #3 said, because he was by himself. When asked what other nurses and CNAs were on duty at the time of the incident, EI #3 said he did not know. EI #3 was asked why he did not use the call light to get assistance. EI #3 said, he did not think of it. EI #3 alleged he returned to RI #58's room after making his phone calls and continued CPR until EMS arrived and took over. On [DATE] at 10:09 AM a follow-up interview was conducted with EI #3. EI #3 was asked what the CPR guidelines were from the American Heart Association. EI #3 said check to see if they are breathing, check for a pulse, check for any obstruction (in the airway), call their names, shake them or rub their chest, if no response, start CPR, call for assistance, and call 911. EI #3 was asked when no one else came, why he did not yell out for help. EI #3 said he thought the CNA was getting help. EI #3 was asked why he did not redirect the CNA to call for help. EI #3 said it did not occur to him, because he was continuing CPR. EI #3 said after everything was over, EI #4, the CNA, told him she never heard him tell her to get help or call 911. On [DATE] at 9:39 AM another follow-up interview was conducted with EI #3 regarding discrepancies on the timeline of events on [DATE]. EI #3 was asked what was done between approximately 9:50 PM and 10:50 PM (during this event on [DATE]). EI #3 said he did not just stand around, that he did CPR and called 911, the resident's family and the DON. When asked about the call placed to 911, EI #3 said he told them they had an unresponsive resident, gave them the room number and the facility's address. EI #3 further claimed he was unable to contact 911 from his personal cell phone he had with him because he did not have 911 capabilities on it, so he called from the facility's phone at the desk. EI #3 was asked if he followed the proper protocol for CPR for an unresponsive resident. EI #3 admitted he did not call for additional help. When asked at what point he contacted 911, EI #3 said around 10:15 PM. EI #3 was asked why he did not give other CPR certified nurses in the building the opportunity to assist him with efforts to revive RI #58. EI #3 answered, he was nervous and he was working with what he had on his own. EI #3 was asked why he did not instruct EI #4 to call a code, and he said he guessed it slipped his mind. EI #3 was asked what training he had received that indicated he should pause CPR for a nonresponsive resident to call the DON, EMS and the family. EI #3 said, there was not any that dictated that. EI #3 was asked how could that affect the outcome for the resident. EI #3 said, it could result in being unable to revive the person. EI #3 was asked if calling 911, getting the crash cart and assisting with the CPR would be some things another staff member could have done, if he had called for help. EI #3 acknowledged the AHA guidelines instructed to call for assistance, but said everything was happening so fast it slipped his mind. EI #3 was again asked what he did between 10:14 PM when he made his phone calls and when EMS arrived, and he stated he was in the room with RI #58 providing CPR. EI #3 was then asked how he could have documented a nurses note at 10:38 PM if he was performing chest compressions. EI #3 said, he just did not know. EI #3 was asked if other people were in the facility, why he would not have called for assistance. EI #3 again said he was very nervous. EI #3 was asked, when he found RI #58 without respirations or a pulse at 9:59 PM, why the EMS run report documented they were not called until 10:44 PM. EI #3 said he did not recall; it was all from memory. On [DATE] at 3:41 PM, during a phone interview with the Captain of the local EMS response team, the Captain confirmed the call to 911 was received from EI #3 at Oak Trace Care and Rehabilitation Center on [DATE] at 10:44 PM, as listed on the run report (referenced above). He also confirmed no other calls came in from the facility on this date. An interview was conducted on [DATE] at 3:36 PM with EI #4, the CNA assigned to care for RI #58 on [DATE] on the 3PM-11PM shift. EI #4 was asked what she could tell the surveyor about the night RI #58 was found unresponsive. EI #4 said after finishing rounds, she went to check in on RI #58 around 10:00 PM and found that he/she did not look to be breathing, so she notified EI #3, her Charge Nurse. EI #4 said she then went back down to RI #58's room with EI #3, who shook RI #58's arm and called the resident's name a couple of times. EI #4 also reported that EI #3 checked for a pulse and did not find one. EI #4 said at that point, she left the room because she smelled feces. When asked what EI #3 did for RI #58, EI #3 said she did not know because she left the room to get supplies to clean up the bowel movement. EI #4 was asked if she ever witnessed EI #3 performing CPR. EI #4 said, she did not witness him performing CPR. EI #4 said the next time she saw EI #3, he was standing behind EMS while they performed CPR for RI #58. On [DATE] at 8:14 PM EI #5, the Registered Nurse (RN)/House Supervisor on [DATE] on the 3P-11P evening shift, was asked about RI #58 being found unresponsive on [DATE]. EI #5 said RI #58 expired that night. EI #5 said she never heard a code called, and when she found out about it, EMS was already there and RI #58 was expired. When asked how she would ordinarily hear a code called, EI #5 said over the intercom or someone hollers out for help. When asked who assisted with the resuscitation efforts for RI #58, EI #5 stated nobody but EI #3. EI #5 said, the House Supervisor's responsibility when a full code resident becomes unresponsive is to assist with the code, get the crash cart, start chest compressions, get the ambu-bag, call 911, and assist in the efforts to revive the resident. EI #5 said, that was why they needed to announce the code because they need all the help they can get. EI #5 said, EI #3 should have hollered and someone would have heard him. EI #5 further stated no one can perform a code by themselves. An interview was conducted on [DATE] at 10:56 AM with EI #2, the DON. EI #2 was asked what process was followed the night RI #58 coded. EI #2 answered, she did not know what steps were taken, she just asked if they did CPR. EI #2 then showed the surveyor EI #3's name and phone number on caller ID of a voicemail he left her on [DATE] at 10:14 PM. EI #2 was asked the purpose of the AHA guidelines referenced in the facility's CPR policy. EI #2 said these were guidelines on how to respond in situations in which CPR is necessary or a resident is unresponsive. EI #2 was asked which of those steps were followed for RI #58. She said EI #3 told her he called 911 and that was all that she was aware of. EI #2 reported EI #3 was involved in the resuscitation efforts on [DATE] for RI #58. EI #2 said all the nurses and CNA should have been involved as support. EI #2 said EI #3 and EI #4 did not notify anyone. EI #2 was asked who called for help, and she said no one. EI #2 was asked who should have called for help, and she said the nurse. EI #2 was asked how should the nurse have called a code. She said he could have hollered out, paged over the intercom or sent someone to do it. EI #2 was unsure why EI #3 never called a code to alert the other staff in the building. On [DATE] at 10:38 AM a follow-up interview was conducted with EI #2, the DON. EI #2 reported EI #3 called 911 around 10:45 PM and they arrived at 10:52 PM. When EI #2 was asked what time EI #3 started CPR, she responded he did not give her a time that he started CPR, but he told her that RI #58 was dead at approximately 10:15 PM when he called her. This deficient practice was cited as a result of the investigation of complaint/report number AL00043033. ***************************************************************************** On [DATE] at 4:52 PM, the facility submitted the following acceptable Removal Plan addressing F678: Removal Plan 678 On [DATE], an audit was performed by the Director of Nursing on 2 crash carts to ensure and are complete with an Ambu bag. Crash carts are fully stocked, and accessible to all staff. On [DATE], education was provided to the Administrator, Director of Nursing, by the Corporate Consultant, Regional Director of Operations, regarding emergency procedures, code blue drill, crash cart locations and cardio-pulmonary resuscitation. Education provided: How to do a code blue drill - simulation of a resident in need of cardiopulmonary resuscitation Where the crash carts are located and what belongs on the crash carts Who needs to be part of the code blue drills - all team members Drills will be completed on a Quarterly basis - this is a plan, not policy The Director of Nursing did a return demonstration of cardiopulmonary resuscitation. Cardiopulmonary Resuscitation policy was reviewed. Where the code status is found in PCC on the resident dashboard and on the resident face sheet This information will be disseminated through the mock codes to all team members On [DATE] the Director of Nursing, corporate nurse, and Director of Operations performed a mock code at 7:17pm to assess the staff response. Team members 17 (LPN- 3, RN- 2, CNA- 3, Other- 9)-responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy, and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the Director of Nursing performed a mock code drill at 6:00 am to assess the staff response. Team members 7 (LPN- 0, RN-1, CNA- 4, Other-2) responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the Director of Nursing performed a mock code drill at 9:31 am to assess the staff response. Team members 20 (LPN- 0, RN-2, CNA- 6, Other-12) responded to the code blue drill and received a copy of the Cardiopulmonary Resuscitation policy and were trained on the Cardiopulmonary Resuscitation policy and crash cart location by the Director of Nursing. Education Provided: How to do compressions How to use Ambu bag Where to find crash carts Where to find code status in PCC on the resident dashboard Where on the face sheet the code status is found How to call for help - yell for help When to call 911 - call nurse if nurse not available call 911 yourself On [DATE] the center had an independent contractor for the American Heart Association trainer on site that is training all nursing staff on American Heart Association Cardiopulmonary Resuscitation. On that date 12 nurses, 8 CNAs and 13 non-licensed staff members were either certified or re-certified in accordance with American Heart Association guidelines and requirements, to include a skills check-off and return demonstration. On [DATE] the administrator, Director of Nursing, corporate nurse, and the regional director of operations developed the Communication of Code Status policy and reviewed and adopted it and reviewed the Cardiopulmonary Resuscitation policy. On [DATE], the DON utilized the Communication of Code Status policy and provided education to 7 nurses, 11 CNA, and 30 non licensed. There are 28 total staff members, 7 - nurses, 10- CNAs and 11- non licensed that still need to be trained on the Communication of Code Status policy. [DATE] - 7 CNAs, 8 LPNs, 1 RN and 7 non-licensed staff were educated, On [DATE] - 2 CNAs, 5 LPNs, and 18 non-licensed. The intention is that this policy be in-serviced to all licensed and non-licensed staff. No staff will be allowed to work [DATE] in the facility until they have received the training on the new policy. An employee list is being used to ensure all staff are participating in mock code blue drills. To ensure all team members are trained, the schedule is being used to make sure anyone that is coming into work gets training prior to starting their shift. We are utilizing the employee list of all staff to confirm who has been trained and who not been trained. The Administrator, Director of Nursing and the staff development coordinator will be available at the start of each shift ensure this education is completed prior to staff starting their shift. No nurses will work in the center without current Americana Heart Association Cardiopulmonary Resuscitation card. and will have been trained on the facility Cardiopulmonary Resuscitation policy by the Director of Nursing. All licensed nurses have current cardiopulmonary resuscitation cards with hands on training verified by the administrator on [DATE]. Copies supplied. On [DATE] The DON identified the LPN had not followed facility policy and terminated this nurse. The Director of Nursing will perform mock code blue drill on each shift every week for 4 weeks to ensure staff are following the facility policy on cardiopulmonary resuscitation. An employee list is being used to ensure all staff are participating in mock code blue drill. To ensure all team members are trained, the schedule is being used to make sure anyone that is coming into work gets training prior to starting their shift. We are utilizing the employee list of all staff to confirm who has been trained and who not been trained. The Administrator, Director of Nursing and the staff development coordinator will be available at the start of each shift ensure this education is completed prior to staff starting their shift. An ad hoc quality assurance performance improvement meeting was held on [DATE], that included Dr., Administrator, Director of Nursing, corporate nurse, and regional director of operations. The root cause of the incident was noncompliance of one licensed practical nurse. Contents will be completed and the immediacy will be removed on [DATE]. **************************************************************** After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F678 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, interviews and review of the 2017 Food Code, the facility failed to ensure: 1. two ovens were not found with a heavy build-up of what appeared to be food crumbs in the bottoms and in the crevice between the oven floor and the oven door; 2. a heavy amount of a grease-like build-up was not observed on eight of ten stove top grates; and 3. pots were not stacked on a shelf with crumbs and dust. This had the potential to affect all 52 residents who received meals from the kitchen. Findings Include: The 2017 Food Code of the U.S. (United States) Public Health Service and the FDA (Food and Drug Administration) included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. . (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4-903.11 Equipment, Utensils, Linens, . and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS, . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . An observation was made during the initial tour of the kitchen on 02/06/2023 at 6:26 PM of the following: 1. the left and right ovens had a heavy build-up of what appeared to be food crumbs in the bottom and at the door, 2. a heavy build-up of what appeared to be grease and food cooked onto eight of ten stove top grates, and 3. the shelf that pots were stored on was found with crumbs and dust. An interview was conducted on 02/06/2023 at 6:56 PM with EI #16, the Dietary Manager. She was asked to describe what she saw on the cloth after one wipe across the shelf that pots were stored on. EI #16 described it as crumbs and dust. When asked how she could ensure that the dust and crumbs would not blow up onto the pots, EI #16 said she could not. EI #16 said the build-up on the stove top grates was related to them being due to be cleaned the next day. EI #16 was asked if a heavy build-up that appeared to be greasy with food particles had to wait until a designated day to be cleaned and she said no. EI #16 admitted they needed to be cleaned. EI #16 reported the bottom of the ovens and doors was from spillage/use that had not yet been cleaned. An interview was conducted on 02/11/2023 at 12:12 PM with EI #17, the Registered Dietitian. EI #17 said the concern of pots being found on a shelf with crumbs and dust was the potential for physical contamination. EI #17 said the concern of both ovens being found with a heavy buildup of what appeared to be food crumbs and particles in the bottom of the oven and at the bottom of the inside of the door was that they were supposed to be clean. EI #17 was asked what was the concern of a heavy build-up of what appeared to be grease and food cooked onto eight of ten stove top grates. She said everything is supposed to be maintained and cleaned.

Based on observations, interview, and review of a document provided by the facility titled NURSING HOME RESIDENTS' RIGHTS, the facility failed to ensure mini blinds in Room Locators (RLs) #3, RL #4, RL #5 and RL #6 were not torn during observations made on 02/07/2023, 02/08/2023, and 02/09/2023. This affected four of four RLs observed with torn blinds. Findings Include: A review of a facility document titled NURSING HOME RESIDENTS' RIGHTS, revealed: . Right to a Dignified Existence . A home-like environment . On 02/07/2023 at 6:15 PM the surveyor observed torn blinds in RL #3, RL #4,RL #5, and RL #6. On 02/08/2023 at 7:00 PM the surveyor observed torn mini blinds, with multiple broken slats, in RL #3, RL #4, RL #5, and RL #6. On 02/09/2023 at 8:15 AM an observation was made with Employee Identifier (EI) #10, the Maintenance Assistant. EI #10 was asked to observe RL #3 and was asked what concern he saw with the mini blinds. EI #10 said they were torn and needed to be replaced. An observation was made of RL #4 with EI #10 and he was asked what concern he saw with the mini blinds. EI #10 said they were torn. EI #10 also observed and confirmed the mini blinds in RL #5 and RL #6 were also torn. EI #10 said the blinds should not be torn. EI #10 was asked what the concern was in the mini blinds being torn. EI #10 said, they would not look good or may not be considered homelike.

Based on interview, record reviews, review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument and review of a facility policy titled ICD-10 Coding Integrity, the facility failed to ensure Resident Identifier (RI) #2's Quarterly Minimum Data Set (MDS) dated [DATE], RI #3's Quarterly MDS dated [DATE] and RI #8's Quarterly MDS dated [DATE] were accurately coded to reflect RI #2's, RI #3's and RI #8's active diagnoses. This affected three of twenty-two sampled residents. Findings include: Review of a facility policy titled, ICD-10 (International Classification of Diseases, 10th Revision) Coding Integrity, with an implementation date of 01/01/2023, revealed: .Policy: It is the policy of this facility to report accurate diagnosis codes using ICD-10. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, revealed: . SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status . RI #2 was admitted to the facility 02/22/2018 and readmitted [DATE]. A review of RI #2's Diagnosis Information listed on RI #2's ADMISSION RECORD revealed a diagnosis of Pneumonia as an inactive diagnosis, with an onset date of 04/11/2022. RI #2's quarterly MDS with an Assessment Reference Date (ARD) of 11/18/2022 documented an active diagnoses of Pneumonia. In an interview on 02/09/2023 at 2:17 PM, Employee Identifier (EI) #11, Registered Nurse (RN)/MDS Coordinator, reported pneumonia was not a current diagnosis for RI #2. EI #11 stated RI #2's current MDS, dated [DATE], was coded that the resident had an active diagnosis of Pneumonia. EI #11 stated it was coded in error. EI #11 stated it should not have been coded if the resident did not have pneumonia. EI #11 stated the concern with the resident's MDS being coded inaccurately for active diagnoses was the provider would not get a complete picture of what was going on with the resident at that time. RI #3 was admitted to the facility 02/15/2007. A review of RI #3's Diagnosis Information listed on RI #3's ADMISSION RECORD revealed diagnoses of Pneumonia and Sepsis as inactive diagnoses, with onset dates of 09/22/2021. RI #3's quarterly MDS with an ARD of 01/13/2023 documented active diagnoses of Pneumonia and Septicemia. In an interview on 02/09/2023 at 2:17 PM, EI #11, RN/MDS Coordinator, reported Pneumonia and Sepsis were not current diagnoses for RI #3. EI #11 stated RI #3's current MDS, dated [DATE], was coded that the resident had active diagnoses of Pneumonia and Sepsis. EI #11 stated Pneumonia and Sepsis should not have been coded if the resident did not have Pneumonia or Sepsis. EI #11 stated the concern with the resident's MDS being coded inaccurately for active diagnoses was the provider would not get a complete picture of what was going on with the resident at that time. RI #8 was admitted to the facility 02/18/2022. A review of RI #8's Diagnosis Information listed on RI #8's ADMISSION RECORD revealed diagnoses of Pneumonia and Sepsis as inactive diagnoses, with onset dates of 02/18/2022. RI #8's quarterly MDS with an ARD of 11/21/2022 documented active diagnoses of Pneumonia and Septicemia. In an interview on 02/09/2023 at 2:17 PM, EI #11, RN/MDS Coordinator, reported Pneumonia and Sepsis were not current diagnoses for RI #8. EI #11 stated RI #8's current MDS, dated [DATE], was coded that the resident had active diagnoses of Pneumonia and Sepsis. EI #11 stated Pneumonia and Sepsis should not have been coded if the resident did not have Pneumonia or Sepsis. EI #11 stated the concern with the resident's MDS being coded inaccurately for active diagnoses was the provider would not get a complete picture of what was going on with the resident at that time.

Based on observation, interviews and review of a facility policy titled Handling Clean Linen, the facility failed to ensure laundry staff transported, distributed, handled, and carried clean resident clothing in a manner to prevent the spread of infection. On 02/07/2023 Employee Identifier (EI) #8, Laundry staff, was observed transporting uncovered clean clothing items and delivering them to residents. EI #8 carried items into five resident rooms, and was observed placing clean clothing under his arm while placing another resident's clothing in their closet. This had the potential to affect five of five residents whose clothing was delivered. Findings include: A review of a facility policy titled Handling Clean Linen with a date of 1/1/23 revealed, Policy: It is the policy of this facility to handle, store, process and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Policy Explanation and Compliance Guidelines: . 2. can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminates or contaminated hands. 5. a. Clean linen shall be delivered to resident care units on covered carts. 6. Carry clean linen with clean hands away from your body. On 02/07/2023 at 1:31 PM EI #8, a laundry staff member, was observed delivering resident clothing to the halls, pushing the clean clothing cart with resident clothing uncovered. On the cart was shirts, pants, and socks. EI #8 was observed delivering clothing to five different residents. EI #8 placed clothing from one hand under his left arm, then placed the clothing from the other hand in a resident closet. EI #8 was also noted carrying clothing into rooms that the clothing items did not belong in, then delivering them to other rooms. On 02/07/2023 at 4:12 PM, EI #8 was asked when should clean resident clothing touch his clothing. EI #8 said never. EI #8 was asked when should more than one resident's clothing be taken into another resident's room. EI #8 said, it should not. When EI #8 was asked why he took multiple residents' clothing in multiple rooms, he answered, to save time. EI #8 was asked what would the harm be in taking several residents' clothing into multiple rooms and letting clean residents' clothes touch against his clothes. EI #8 said, it would spread bacteria and be cross contamination. On 02/09/2023 at 10:50 AM EI #9, Housekeeping and Laundry Supervisor, was asked what the policy was for handling and delivering residents' clean clothing to the unit and rooms. EI #9 said, it should be transported on a clean covered cart. EI #9 was asked how should laundry staff transport clean resident clothing to the unit and room. EI #9 said, in or on a covered cart. EI #9 was asked when should the laundry staff take several residents' clothing into other residents' rooms. EI #9 answered, they should not. EI #9 was asked when should laundry staff place and carry resident clothing under their arm, take it into another resident's room, then deliver the clothes to the resident. EI #9 said, they should only take one resident's clothing at a time, unless they have two residents in that same room. EI #9 was asked what would the harm be in transporting residents' clean clothing uncovered. EI #9 said, the risk was contamination. EI #9 was asked what would be the harm in the laundry staff taking several residents' clothes in multiple rooms. EI #9 replied, cross contamination. EI #9 was asked what would the harm be in the laundry staff placing the clean clothing under his arm. EI #9 said, cross contamination because clean clothes or linens should never touch a staff clothing.

Based on interviews, resident record review to include an Activity of Daily Living (ADL) care plan, review of a facility policy titled Care Plans - Comprehensive Person Centered Care Plans and a facility document titled CARE CARD INSTRUCTIONS, the facility failed to ensure Resident Identifier (RI) #8's ADL plan of care intervention for RI #8 to have assistance of two persons with Hoyer lift for all transfers, was implemented on 4/23/21 when RI #8 was transferred without the use of a Hoyer lift by Employee Identifier (EI) #4, Certified Nursing Assistant (CNA), EI #5 CNA, and EI #6 CNA. After transfer to the bed from the chair without the use of a Hoyer lift, RI #8's left ankle was swollen, warm to touch, and RI #8 complained of pain when touched. An order was obtained for x-rays, RI #8's left ankle was found to be fractured and RI #8 had to be transferred to the hospital for evaluation of the left ankle fracture. This affected RI #8 one of three sampled residents who were care planned for the use of a mechanical lift during transfers. Findings Include: Review of a policy titled Care Plans - Comprehensive Person Centered Care Plans with an effective date of 11/28/2016 revealed the following: . 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, .develops and maintains a comprehensive person centered care plan for each resident that requires services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being AND any services that would otherwise be required . 3. Each resident's comprehensive care plan is designed to: . g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; . 14. The facility staff members are to follow the care plan to assure directed care is rendered, as appropriate . Review of an undated facility document titled CARE CARD INSTRUCTIONS revealed the following: 1. READ EACH RESIDENTS' CARE CARD AT THE BEGINNING OF EACH SHIFT. 2. FOLLOW THE INSTRUCTIONS ON THE RESIDENTS' CARE CARD. 5. THE CARE CARD IS THE GATEWAY TO RESIDENT CARE BASED ON THE CARE PLAN. 6. THE CARE CARD IS A VERY USEFUL TOOL IN DELIVERING RESIDENT CARE. RI #8 was readmitted to the facility on [DATE]. A review of RI #8's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/21 documented RI # 8 required total dependence on staff for transfers. Review of RI #8's ADL (Activity of Daily Living) care plan with a start date of 2/17/2020, revealed the following intervention: . Assistance x2 (of two) persons with Hoyer lift for all transfers. 2/17/2020 . Review of RI #8's Care Card on 7/7/21 revealed the following: .TRANSFERS: .Hoyer .place lift pad under (resident) . A review of RI #8's Resident Incident Report revealed: .4/23/21 04:50 PM . cna . told this writer that resident left ankle was swollen and that (RI #8) could not bear weight on (RI #8's) left ankle . left ankle was assessed and area is warm to touch and swollen . Physician notified: . 4/23/21 05:11 PM . Review of RI #8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .X RAy Left Ankle, Left foot, . Review of RI #8's nursing note dated 4/23/21 at 5:50 PM, revealed .left ankle is noted to be swollen and warm to touch. resident complain of pain when touched. md (medical doctor) is notified and order received to xray residents left ankle . left foot . Review of RI #8's diagnostic radiology interpretation with an exam date of 4/23/21 revealed findings that included: . AP (anterior posterior) and lateral views of the left ankle demonstrate acute fractures of the distal tibia and fibula . The soft tissue planes are markedly swollen. Review of RI #8's hospital record titled Patient Visit Information dated 4/23/21 revealed RI #8 was seen for . Bimalleolar fracture of left ankle . Activity Restrictions or Additional Instructions Watch for any severe swelling of the distal extremity or worsening pain. If happens, loosen the splint and if pain is not any better . return for further evaluation. Review of a facility document titled Investigative Summary dated 4/28/21 revealed: . Follow up Summary of Events/ . It was identified via statements of the CNA staff they failed to use the care card, transfer instructions on (RI #8) resulting in this injury. On 7/7/21 at 12:48 PM an interview was conducted with Employee Identifier (EI) #5, Certified Nursing Assistant (CNA). EI #5 was asked about the incident on 4/23/21 involving RI # 8. EI #5 stated she was walking down the hall and was asked to assist EI # 4 and EI #6 with transferring RI #8 from the chair to the bed. EI #5 was asked how RI #8 was transferred. EI #5 explained that she was on RI #8's right side, EI #4 was on her left side and EI #6 lifted RI #8's legs. EI #5 was asked if RI #8 complained of pain while being moved from the chair to the bed. EI #5 stated no, but RI #8 complained after being placed in the bed. EI #5 was asked if RI #8 was supposed to be transferred the way it was done. EI #5 stated she thought RI #8 was supposed to be transferred with a Hoyer Lift. EI #5 was asked if RI #8's care plan indicated a Hoyer lift should be used during transfers. EI #5 responded yes. EI #5 was asked what should have been done to complete the transfer. EI #5 stated they should have tried to get a lift for the transfer. When asked how she would know if a resident used a lift for transfer, EI #5 stated it would be on the care card which is located by the resident's bed. On 7/7/21 at 3:25 PM an interview was conducted with EI #6, CNA . EI #6 was asked what happened with RI #8 on 4/23/21. EI #6 explained that she along with EI #4 and EI #5 transferred RI #8 from the chair to the bed. RI #8 complained of pain and wanted to get back in the bed. EI #6 was asked how RI #8 was moved from the chair to the bed. EI #6 stated she was standing behind RI #8 and EI #4 and EI #5 lifted RI #8. EI #6 stated RI #8 complained of leg pain and RI #8's leg was swollen. EI #6 was asked if RI #8 used a Hoyer lift for transfers. EI #6 stated yes, and RI #8 was supposed to use a lift on 4/23/21. EI #6 was asked how she determined that RI #8 was a Hoyer lift with transfers. EI #6 stated after RI #8 was transferred they looked at the care card and it showed the use of a Hoyer lift with transfers. EI #6 was asked when should she look at the care card. EI #6 stated as soon as they entered the room. EI #6 was asked if a Hoyer lift should have been used when transferring RI #8 on 4/23/21. EI #6 stated yes, because that was the safest way to transfer RI #8 according to the care card and the accident could have been avoided. On 7/7/21 at 4:47 PM an interview was conducted with EI #7, Licensed Practical Nurse (LPN). EI #7 was asked about the incident involving RI #8 on 4/23/21. EI #7 stated it was around 4:15 PM and EI #5 asked if she had seen RI #8's ankle, it was swollen. EI #7 stated she went in the room, saw the ankle and told the Director of Nursing and the Administrator. EI #7 stated RI #8 told her the CNA put RI #8 in the bed and RI #8 heard his/her foot pop. EI #7 was asked if the CNA's followed the care plan for using the lift when transferring RI #8. EI #7 stated no, they did not use the lift. EI #7 was asked, why the CNAs would need to look at the care plan when transferring a resident. EI #7 stated, to know how to care for the resident. EI #7 was asked if she felt this accident would have happened if they had used the lift when transferring RI #8. EI #7 stated no, because the lift would keep RI #8 from being hurt during the transfer. When asked what the negative outcome would be of not following the care plan, EI #8 stated, accident or injury. On 7/7/21 at 5:30 PM an interview was conducted EI #2, Registered Nurse (RN), Director of Nursing. EI #2 was asked if the care plan was followed on 4/23/21 concerning RI #8. EI #2 stated, no they did not use the lift to transfer RI #8. EI #2 was asked how RI #8 was transferred on 4/23/21. EI #2 stated, it was determined in their findings, they had lifted RI #8 into the bed without the lift. EI #2 was asked if that was the proper way to transfer RI #8. EI #2 stated, no they should have used the lift. EI #2 was asked how staff would know to use the lift. EI #2 stated, by looking at the care card that was always in the room. EI #2 was asked where the information on the care card came from. EI #2 stated, the care plan. ************************* Once the facility became aware of the incident on 4/23/21, the following corrective actions were taken: On 4/23/21 after the incident RI #8 was assessed by Licensed staff, an x-ray was obtained and RI #8 was transferred to the hospital. On 4/23/21 EI #4, #5 and #6 were retrained on care cards. On 5/4/21 EI #4, #5 and #6 were counseled concerning the incident. Counseling Form was placed in the employee files. Beginning on 4/24/21 until 4/27/21 all Certified Nursing Assistants were retrained on care cards. Beginning on 4/30/21 the facility monitored 5 residents per week for 4 weeks to assure care card was followed and proper transfer technique was used. Based on result of monitoring additional monitoring will be continued if needed ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 4/23/21- 5/21/21; thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 437.

Based on interviews, review of Resident Identifier (RI) #8's medical record, review of a facility policy titled Accidents and Incidents - Investigating and Reporting, and review of the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #4, EI #5, and EI #6, Certified Nursing Assistants (CNAs), used a Hoyer lift to transfer RI #8 from chair to bed, as instructed by RI #8's plan of care, on 4/23/21 at 4:50 PM. EI #4, EI #5, and EI #6. After transfer to the bed from the chair without the use of a Hoyer lift, RI #8's left ankle was swollen, warm to touch, and RI #8 complained of pain when touched. RI #8's physician was notified, an order was obtained for x-rays, RI #8's left ankle was found to be fractured and RI #8 had to be transferred to the hospital for evaluation of the left ankle fracture. The facility concluded in their investigation, RI #8's injuries were caused by the transfer that occurred on 4/23/21 when the CNAs failed to follow RI #8's care card instructions and transfer RI #8 using a Hoyer lift. This affected RI #8 one of three sampled residents who used a Hoyer lift for transfers. Findings Include: A review of a policy titled Accidents and Incidents - Investigating and Reporting with an effective date of 10/11/17 revealed: . All accidents or incidents involving residents . occurring on our premises shall be investigated . A review of a policy titled Care Plans - Comprehensive Person Centered Care Plans with an effective date of 11/28/16 revealed: . 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, . develops and maintains a comprehensive person centered care plan for each resident that requires services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being AND any services that would otherwise be required . 3. Each resident's comprehensive care plan is designed to: . g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels . 14. The facility staff members are to follow the care plan to assure directed care is rendered, as appropriate . A review of an undated facility document titled CARE CARD INSTRUCTIONS revealed: .1. READ EACH RESIDENTS' CARE CARD AT THE BEGINNING OF EACH SHIFT. 2. FOLLOW THE INSTRUCTIONS ON THE RESIDENTS' CARE CARD. 5. THE CARE CARD IS THE GATEWAY TO RESIDENT CARE BASED ON THE CARE PLAN. 6. THE CARE CARD IS A VERY USEFUL TOOL IN DELIVERING RESIDENT CARE. RI #8 was readmitted to the facility on [DATE]. RI #8's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/21 documented RI #8 was totally dependent on staff for transfers and had bilateral lower extremity impairments. RI #8's Activity of Daily Living (ADL) care plan with a start date of 2/17/20 documented the following intervention: . Assistance x2 (of two) persons with Hoyer lift for all transfers . 2/17/20 . RI #8's Care Card documented the following: . TRANSFERS: . Hoyer . place lift pad under (resident) . Review of RI #8's Resident Incident Report dated 4/23/21 at 4:50 PM documented: . cna .told writer that resident left ankle was swollen and that (RI #8) could not bear weight on (his/her) left ankle . left ankle was assessed and area was warm to touch and swollen . Physician notified: . 4/23/21 05:11 PM . Review of RI #8's Physician's orders dated 4/23/21 revealed .X RAy Left Ankle, Left foot, . Review of RI #8's diagnostic radiology interpretation with an exam date of 4/23/21 revealed findings that included: . AP (anterior posterior) and lateral views of the left ankle demonstrate acute fractures of the distal tibia and fibula . The soft tissue planes are markedly swollen. Review of RI #8's hospital record titled Patient Visit Information dated 4/23/21 revealed RI #8 was seen for . Bimalleolar fracture of left ankle . Activity Restrictions or Additional Instructions Watch for any severe swelling of the distal extremity or worsening pain. If happens, loosen the splint and if pain is not any better . return for further evaluation. RI #8's physician progress note dated 4/25/21 documented: . (RI #8) told me he/she was being put back to bed and somehow the ankle got twisted. (RI #8) has not had any falls. Review of a facility document titled Investigative Summary dated 4/28/21 revealed: Upon Investigation of this event and injury to (RI #8) . care givers reported swelling in left foot and pain to the Charge Nurse on 04.23.2021 . This investigation is initiated immediately to determine the root cause of this injury. Interviewed the care givers involved in the care of (RI #8) when this incident took place on 04.23.2021 at approx. (approximately) 4:40PM, they were attempting to return (RI #8) to bed when (RI #8) stated to them, the girl who got me up broke my ankle. Follow up Summary of Events/ . It was identified via statements of the CNA staff they failed to use the care card, transfer instructions on (RI #8) resulting in this injury . On 7/7/21 at 12:48 PM an interview was conducted with Employee Identifier (EI) #5, Certified Nursing Assistant (CNA). EI #5 was asked about the incident on 4/23/21 involving RI #8. EI # 5 stated she was walking down the hall and was asked to assist EI #4 and EI #6 with transferring RI #8 from the chair to the bed. EI #5 was asked how RI #8 was transferred. EI #5 explained that she was on RI #8's right side, EI #4 was on RI #8's left side and EI #6 lifted RI #8's legs. EI #5 was asked if RI #8 complained of pain while moving from the chair to the bed. EI #5 stated no, but RI #8 complained after being placed in the bed. EI #5 was asked if RI #8 was supposed to be transferred that way. EI #5 stated RI #8 was supposed to be transferred with a Hoyer Lift. EI #5 was asked if RI #8's care plan indicated to use Hoyer lift during transfers. EI #5 replied, yes. EI #5 was asked what she should have done when completing the transfer. EI #5 stated they should have tried to get a lift for the transfer. When asked how would she know if a resident used a lift for transfer. EI #5 stated it would be on the care card which is located by the resident's bed On 7/7/21 at 3:25 PM an interview was conducted with EI #6, CNA. EI #6 was asked what happened with RI #8 on 4/23/21. EI #6 explained that she and EI #4 and EI #5 transferred EI #8 from the chair to the bed. RI #8 complained of pain and wanted to get back in the bed. EI #6 was asked how RI #8 was moved from the chair to the bed. EI #6 stated she was standing behind RI #8 and EI #4 and EI #5 lifted RI #8. EI #6 stated when RI #8 was placed in bed he/she was complaining of leg pain and his/her leg was swollen. EI #6 stated RI #8 told the Licensed Practical Nurse (LPN) EI #7 he/she heard a pop in his/her leg during a transfer. EI #6 was asked if RI #8 required a Hoyer lift for transfers. EI #6 stated yes. EI #6 was asked how she determined that RI #8 required a Hoyer lift with transfers. EI #6 stated after RI #8 was transferred they looked at the care card and it indicated the use of a Hoyer lift with transfers. EI #6 was asked when she should look at the care card. EI #6 stated, as soon as you enter the room. EI #6 was asked if a Hoyer lift should have been used when transferring RI #8 on 4/23/21. EI #6 stated yes, because that was the safest way to transfer RI #8 according to the care card and the accident could have been avoided. On 7/7/21 at 4:47 PM an interview was conducted with EI #7, Licensed Practical Nurse (LPN). EI #7 was asked about the incident involving RI #8 on 4/23/21. EI #7 stated it was around 4:15 PM and EI #5 asked if she had seen RI #8's ankle, it was swollen. EI #7 stated she went in the room, saw the ankle and told the Director of Nursing and the Administrator. EI #7 stated RI #8 told her the CNA put RI #8 in the bed and RI #8 heard his/her foot pop. EI #7 was asked if the CNA's followed the care plan for using the lift when transferring RI #8. EI #7 stated no, they did not use the lift. EI #7 was asked, why the CNAs would need to look at the care plan when transferring a resident. EI #7 stated, to know how to care for the resident. EI #7 was asked if she felt this accident would have happened if they had used the lift when transferring RI #8. EI #7 stated no, because the lift would keep RI #8 from being hurt during the transfer. When asked what the negative outcome would be of not following the care plan, EI #8 stated, accident or injury. On 7/7/21 at 5:30 PM an interview was conducted EI #2, Registered Nurse (RN), Director of Nursing. EI #2 was asked to explain what happened concerning RI #8 on 4/23/21. EI #2 stated she became aware when she received a call around 4:50 PM on 4/23/21. EI #2 directed EI #7 to call the medical director and obtain an order for an x-ray. When the results came back they were positive for a fracture and RI #8 was sent to the hospital for evaluation. EI #2 explained she directed staff to be in-serviced immediately. EI #2 stated EI #4, #5 and #6 were immediately in-serviced on care cards and using lifts. The next day they started investigating and interviewing and did more education. EI #2 was asked if she was able to determine when RI #8's broken ankle occurred. EI #2 stated she was not sure if it happened in the morning when RI #8 was moved to the chair or in the afternoon when RI #8 was moved to the bed. EI #2 stated they were able to determine the lift was not used and care plan not followed. EI #2 was asked if the care plan was followed on 4/23/21 concerning RI #8. EI #2 sated, no they did not use the lift to transfer RI #. EI #2 was asked how RI #8 was transferred on 4/23/21. EI #2 stated it was determined they had transferred and lifted RI #8 into bed without the lift. EI #2 was asked if that was the proper way to transfer RI #8. EI #2 stated no they should have used the lift. EI #2 was asked how staff would know to use the lift. EI #2 stated by looking at the care card that is always in the room. EI #2 was asked where the information on the care card came from. EI #2 stated the care plan. ************************* Once the facility became aware of the incident on 4/23/21, the following corrective actions were taken: On 4/23/21 after the incident RI # 8 was assessed by Licensed staff, an x-ray was obtained and RI # 8 was transferred to the hospital. On 4/23/21 EI #4, #5 and #6 were retrained on care cards, transfer training ( bed to chair, chair to bed) and lift training (Maxy lift, Hoyer lift and stand lift). On 5/4/21 EI #4, #5 and #6 were counseled concerning the incident. Counseling Form was placed in employee files. Beginning on 4/24/21 until 4/27/21 all Certified Nursing Assistants were retrained on care cards, transfer training (bed to chair, chair to bed) and lift training (Maxy lift, Hoyer lift and stand lift). Beginning on 4/30/21 the facility monitored five residents per week for four weeks to assure care card was followed and proper transfer technique was used. Based on result of monitoring additional monitoring will be continued if needed ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 4/23/21- 5/21/21; thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 437.

Based on interviews, review of facility policy titled, Reporting Abuse to Facility Management, resident record review to include Resident Identifier (RI) #4's departmental notes and a review of the Alabama Department of Public Health Complaint Tracking System, the facility failed to report a resident to resident altercation between RI #4 and RI #11 to the State Agency when the allegation was reported to the facility on [DATE]. The facility did not report to the State Agency until 7/9/21. This affected RI #4 and RI #11, two of five residents sampled for abuse. Findings include: Review of a facility policy titled, Reporting Abuse to Facility Management with an effective date of 11/28/16 revealed: . Policy Interpretation and Implementation . 16. ALL ALLEGED VIOLATIONS INVOLVING ABUSE, NEGLECT, EXPLOITATION OR MISTREATMENT, . ARE REQUIRED TO BE REPORTED IMMEDIATELY, BUT NO LATER THAN 2 HOURS AFTER ALLEGATION IS MADE, IF THE EVENTS THAT CAUSE THE ALLEGATION INVOLVE ABUSE . TO THE ADMINISTRATOR OF THE FACILITY AND TO OTHER OFFICIALS INCLUDING THE STATE SURVEY AGENCY AND OTHER REQUIRED AGENCIES, AS REQUIRED PER STATE AND FEDERAL LAW. RI #4 was admitted to the facility on [DATE] and readmitted [DATE]. RI #11 was admitted to the facility on [DATE] and readmitted [DATE]. A review of RI #4's departmental notes dated 6/17/21 at 11:17 PM, signed by Employee Identifier (EI) #3, revealed: . Writer came up to the nurses station and noted resident yelling at another resident. That resident had the foot rest on [his/her] wheelchair in (his/her) hand. This resident said, go ahead and swing at me and I'm going to beat you down. Writer intervened and took the footrest from the hand of the other resident. The other resident stated, (he/she) hit me in the head with (his/her) telephone. Writer asked this resident did (he/she) hit (him/her) and resident stated, I tried to knock (his/her) head off. That's me, I don't care for (him/her). Administrator was called and no answer with voice mail full. DON (Director of Nursing) notified and called MD (Medical Director). During an interview on 7/8/21 at 10:28 AM, EI #3, Licensed Practical Nurse (LPN), stated she heard yelling and observed RI #11 with the foot rest from the wheelchair in his/her hand. EI #3 asked RI #11 what was going on and RI #11 said RI #4 hit him/her. EI #3 took the footrest away and instructed RI #11 to go to his/her room. EI #3 called EI #1, Administrator and Abuse Coordinator, but was unable to reach him. EI #3 called EI #2, DON and informed her of the incident. During an interview on 7/8/21 at 11:41 AM, EI #2, DON, stated she was informed by EI #3 about a resident to resident altercation. EI #2 texted EI #1, Administrator, on 6/17/21 at 7:56 PM asking him to call her because they had a reportable. EI #2 stated she received a call from EI #1 at 8:46 PM. During an interview on 7/8/21 at 6:11 PM, EI #1, Administrator, stated a physical abuse allegation should be reported to the State Agency immediately or within two hours. When asked if the Departmental Notes for RI #4 dated 6/17/21 where it was documented that a resident reported another resident . hit me in the head . was an allegation of abuse, EI #1 declined to comment. A review of the Alabama Department of Public Health Complaint Tracking System for Oak Trace Care and Rehabilitation revealed the abuse allegation received by the facility on 6/17/21 was not reported to the State Agency until 7/9/21 at 12:17 PM. This deficiency was cited as a result of the investigation of complaint/report number AL 437.

Based on record review and interview, the facility failed to ensure the nurse transcribed Resident Identifier (RI) #71's treatment change order onto the physician's orders [REDACTED]. This affected RI #71, one of four residents sampled for pressure ulcers. Findings include: RI #71 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had a [DIAGNOSES REDACTED]. RI #71's WOUND EVALUATION & MANAGEMENT SUMMARY, dated 9/17/2019, documented the following: . DRESSING TREATMENT P LAN Primary Dressing(s) Alginate calcium w/ (with) silver apply three times per week for 30 days . On 9/18/19, Employee Identifier (EI) #2, Licensed Practical Nurse/Wound Care Nurse, documented the following in RI #71's Departmental Notes: . Treatment changed back to [MEDICATION NAME] (Alginate calcium w/ (with) silver) . 3 x (times) weekly . According to RI #71's Treatment Administration Records (TARs), RI #71's wound treatment was changed from [MEDICATION NAME] to collagen on 9/13/19, and then changed back to [MEDICATION NAME] on 9/18/19. However, review of RI #71's printed (MONTH) 2019 Physician Orders, revealed the treatment order had not been updated to reflect the change back to [MEDICATION NAME]. The orders still reflected a daily treatment of [REDACTED]. On 10/16/19 at 1:39 PM, an interview was conducted with EI #2, Wound Care Nurse. EI #2 explained RI #71 should be receiving the calcium alginate with silver treatment three times a week, but said the orders in the medical record still reflected an order for [REDACTED].#2 replied, it was a mistake; they were given a verbal order by the doctor, wrote it on the TAR, but then forgot to transfer/transcribe it to RI #71's orders.

Based on observations, interviews and review of facility policies titled, Personal Protective Equipment - Gloves, Handwashing/Hand Hygiene, and Oral Inhalation, the facility failed to ensure: 1. the licensed nurse did not retrieve medications spilled on top of the medication cart and place them back in the medication cup for ingestion by Resident Identifier (RI) #34. Further, the nurse failed to wash her hands when changing gloves while administering medications to RI #34; and 2. the licensed nurse washed her hands when removing gloves during medication administration for RI #10. Further, the nurse failed to clean RI #10's inhaler mouthpiece before storing the inhaler back in the medication cart. These deficient practices affected RI #34 and RI #10, two of four residents observed during medication pass observations, and two of four nurses observed performing medication administration. Findings Include: A review of a facility policy titled, Personal Protective Equipment - Gloves, with an Effective Date of (MONTH) 1, (YEAR), documented: .8. Wash your hands after removing gloves. A review of a facility policy titled, Handwashing/Hand Hygiene, Revised 04/01/2016, revealed: .7. Hand hygiene is the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. .Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. .3. When removing gloves . 5. Perform hand hygiene. 1.) RI #34 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 10/31/18 at 7:39 a.m., during medication administration, Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was observed retrieving two pills from the top of the medication cart and placing them back into a medication cup. EI #2 entered RI #34's room with the medication cup and handed the medication to RI #34 for ingestion. The surveyor then observed EI #2 apply gloves and administer RI #34's nasal spray, remove those gloves, and then, without washing hands or using hand sanitizer, put on clean gloves and applied RI #34's [MEDICATION NAME]. On 10/31/18 at 8:02 a.m., an interview was conducted with EI #2, LPN. EI #2 was asked what she did with the two pills that were spilled on top of the medication cart. EI #2 said she put them back in the medication cup. EI #2 was asked what was the concern with placing the medications back in the cup for consumption after them being spilled on top of the cart. EI #2 replied, contamination. EI #2 was asked when should she wash her hands when wearing gloves. EI #2 said, before and after. EI #2 was asked did she wash or sanitize her hands after she administered RI #34's nasal spray before she applied clean gloves to administer RI #34's [MEDICATION NAME]. EI #2 replied, no. EI #2 was asked what was the concern with placing potentially contaminated medication back in the medication cup and not washing her hands appropriately when using gloves. EI #2 answered contamination and infection control. 2.) A review of a facility policy titled, Oral Inhalation, dated 05/16, documented: .Procedures .17.wash and thoroughly dry mouthpiece. RI #10 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 10/31/18 at 8:14 a.m., during medication administration, Employee Identifier (EI) #3, LPN, was observed administering RI #10's nasal spray, removing her gloves and applying clean gloves without washing her hands or using hand sanitizer prior to administering RI #10's insulin injection. EI #3 then removed her gloves and applied clean gloves to administer RI #10's inhaler without washing her hands or using hand sanitizer. Upon completion of medication administration for RI #10, EI #3 was observed storing RI #10's inhaler in the medication cart without cleaning the inhaler. On 10/31/18 at 8:35 a.m., an interview was conducted with EI #3, LPN. EI #3 was asked when she should wash her hands when using gloves. EI #3 said, before and after. EI #3 was asked did she wash her hands or use hand sanitizer before and after applying gloves to administer RI #10's nasal spray, insulin injection and his/her inhaler. EI #3 replied, no. EI #3 was asked did she clean the inhaler before storing it back in the medication cart. EI #3 stated she did not clean it. EI #3 was asked what was the concern with not washing her hands appropriately during medication administration, especially during multiple routes. EI #3 answered, infection control and cross contamination. On 10/31/18 at 4:45 p.m., an interview was conducted with EI #1, Registered Nurse (RN)/Assistant Director of Nursing (ADON)/ Infection Control Coordinator (ICC). EI #1 was asked should a nurse pick up medications that were spilled on top of the medication cart and put them back in the medication cup for a resident to ingest. EI #1 said, no. EI #1 was asked when should a nurse wash her hands when using gloves. EI #1 replied, before donning and after removing them. EI #1 was asked should a nurse wash or sanitize her hands after removing her gloves and applying clean gloves with multiple medication routes such as an inhaler, injection, nasal spray, and pain patch. EI #1 said yes. EI #1 was asked what was the concern with those issues. EI #1 answered, infection control.

Based on staff interview, a review of personnel files and a review of the facility's policy titled, Abuse Prevention Program, the facility failed to ensure the abuse registry check was completed prior to hire for Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), and EI #2, a Dietary Aide. This affected two of the five personnel files reviewed for pre-employment screening. Findings Include: A review of the facility's policy titled, Abuse Prevention Program with an effective date of November 28, 2016 revealed the following: . Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion . 2. Our facility conducts employee background checks and will not knowingly employ any individual who . have a finding entered into the state nurse aid registry concerning abuse . Review of personnel files on 10/12/17 at 9:30 a.m. revealed the following: 1. EI #1's file, a LPN was hired on 07/13/17, and the abuse registry check was not done until 07/18/17. 2. EI #2's file, a Dietary Aide was hired on 08/29/17 and the abuse registry check was not done until 10/12/17. On 10/12/17 at 10:15 a.m., an interview with EI #3, Registered Nurse/Clinical Educator was asked who was responsible for ensuring the abuse registry checks were completed on new employees. EI #3 said she was responsible. EI #3 was asked were EI #1's and EI #2's abuse registry checks completed prior to hire. EI #3 replied, No they were not. EI #3 was asked when should the abuse registry checks be done. EI #3 said prior to hire. EI #3 was asked why should the abuse registry checks be done. EI #3 said to make sure no employees are on the abuse registry.

Based on observations, interviews, medical record review, and a review of the facility's policy titled, Medication Administration Nebulizers (Updraft), the facility failed to ensure Resident Identifier (RI) #3's nebulizer mouth piece was place in a plastic bag with the date and his/her name on it. This affected one of two residents sampled receiving respiratory treatments. Findings Include: A review of the facility's policy titled, Medication Administration Nebulizer (Updraft), with no effective date, revealed the following: . PR(NAME)EDURES . 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. RI #3 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 10/11/17 at 10:10 a.m., RI #3's nebulizer mouth piece was observed to be lying on the bedside table and had not been placed in a dated plastic bag. On 10/12/17 at 7:59 a.m., RI #3's nebulizer mouth piece was again observed lying on the bedside table and had not been placed in a dated plastic bag. An interview was conducted on 10/12/17 at 8:25 a.m. with Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), the Charge Nurse. EI #4 was asked how should a resident's nebulizer mouth piece be stored when not in use. EI #4 replied, Normally, usually goes in a zip lock bag. EI #4 was asked if RI #3's nebulizer mouth piece was stored in a bag and dated correctly. EI #4 replied, No. An interview was conducted on 10/12/17 at 12:50 p.m. with EI #5, a Registered Nurse (RN), Infection Control Nurse. EI #5 was asked how should a nebulizer mouth piece be stored when not in use. EI #5 replied, Ziploc bag, labeled with date initiated or put out. EI #5 was asked what was the potential harm if the procedures were not followed. EI #5 replied, Always a chance of infection.

Based on observations, record reviews, interviews, review of a facility's policy titled, Resident Assessment Instrument, and a review of the facilities' Monthly Summary reports, the facility failed to ensure Resident Identifier (RI) #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] accurately assessed RI #4's use of oxygen. This affected RI #4, one of 13 residents whose MDS assessments were reviewed. Findings Include: A facility policy titled Resident Assessment Instrument with an effective date of January 1, 2016, documented: .Policy Interpretation and Implementation . 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity . RI #4 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. RI #4's February and January 2017 physician's orders [REDACTED]. RI #4's Monthly Summary document completed by nursing staff, dated 01/17/2017, indicated in the section labeled Special/Skilled Services resident is receiving, that RI #4 was receiving oxygen therapy during the month of 12/17/2016 through 1/17/2017. A Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 1/9/17, assessed RI #4 as having a Brief Interview for Mental Status (BIMS) score of 7, indicating RI #4 was severely cognitively impaired. Under Section O 0100: Special Treatments, Procedures, and Programs, RI #4 was not assessed as having received oxygen therapy. On 2/15/17 at 3:53 p.m. RI #4 was observed sitting in a chair in his/her room. RI #4 had oxygen infusing by nasal cannula at 4 liters per minute. At this time, RI #4 said he/she always wears oxygen .and has since he/she came back from the hospital (9/12/16). RI #4 was observed having oxygen infusing by nasal cannula at 4 liters per minute on all three days of the survey (2/14/17 at 10:36 a.m., 2/15/17 at 9:30 a.m., and 2/16/17 at 8:08 a.m.). On 2/16/17 at 9:50 a.m. an interview was conducted with Employee Identifier #2, the MDS Coordinator. The surveyor shared with EI #2 that after reviewing RI #4's Quarterly MDS dated [DATE], it revealed RI #4 was not assessed as having received oxygen therapy. However, RI #4's Monthly Summary dated 1/17/2017 revealed RI #4 was receiving oxygen therapy during that time. EI #2 was asked who was responsible for completing Section O 0100 on the MDS, EI #2 replied the MDS Coordinator. EI #2 explained that according to RI #4's Monthly Summary, dated 1/17/2017, which reflects the resident's health status from 12/17/2016 through 1/17/2017, showed RI #4 was receiving oxygen therapy during that time and the Quarterly MDS dated [DATE] should have been checked for oxygen therapy, but it was not. EI #2 was asked if RI #4's MDS was coded incorrectly for oxygen therapy. EI #2 responded yes, it was just an error. EI #2 further explained it is important to correctly code the resident's MDS because everything comes from the MDS. The MDS is the overall picture of the resident.

Based on interviews, record reviews, a review of Potter and Perry's Fundamentals of Nursing, and a facility policy title, Medication and Treatment orders, the facility failed to ensure Resident Identifier (RI) #11 and RI #12 had current orders for [MEDICAL TREATMENT]; and further failed to ensure RI #11's order to assess for thrill and bruit every shift was followed. This affected two of 13 sampled residents whose physician orders [REDACTED]. Findings Include: A review of Potter and Perry's,FUNDAMENTALS OF NURSING ninth edition, copyright 2017, Chapter 23, Legal Implications in Nursing Practice, Page 311 revealed: Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health providers' orders unless they believe the orders are in error, violate agency policy, or are harmful to the patient . 1. RI #11 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. RI #11's physician orders [REDACTED]. RI #11's most current Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2017 revealed RI #11 was receiving [MEDICAL TREATMENT] while a resident in the facility. On 2/16/2017 at 11:30 a.m. a review of RI #11's medical record, including paper and computer chart, was conducted searching for a physician's orders [REDACTED].#11's [MEDICAL TREATMENT] shunt had been checked for thrill and bruit every shift as ordered; no order for [MEDICAL TREATMENT] or documentation could be found. The surveyor asked Employee Identifier (EI) #1, the Director of Nursing (DON) to locate a physician's [MEDICAL TREATMENT] order for RI #11 and documentation showing RI #11's [MEDICAL TREATMENT] shunt had been checked for thrill and bruit every shift as ordered. EI #1 could not provide a physician's orders [REDACTED].#1 provide evidence that RI #11's [MEDICAL TREATMENT] shunt had been checked for thrill and bruit every shift as ordered. On 2/16/17 at 2:30 p.m. an interview was conducted with EI #4, the Licensed Practical Nurse (LPN) that provided care for RI #11. EI #4 explained there was an order to check for thrill and bruit every shift in RI #11's chart, but it was not on the Medication Administration Record [REDACTED]. EI #4 further explained she only assessed RI #11's shunt for thrill and bruit on the days RI #11 went out to [MEDICAL TREATMENT], which is Tuesday, Thursday, and Saturday. When asked why it is important to assess RI #11's [MEDICAL TREATMENT] shunt for thrill and bruit every shift; EI #4 replied, to make sure it is patent because that's how RI #11 receives [MEDICAL TREATMENT], and it could be life saving. On 2/16/2017 at 2:47 p.m. an interview was conducted with EI #1, the DON. EI #1 was asked if RI #11 had a current order for [MEDICAL TREATMENT] in his/her chart. EI #1 replied no, not a [MEDICAL TREATMENT] order. When asked if RI #11 should have an order for [REDACTED]. 2. The facility policy entitled Medication and Treatment Orders, with an effective date of January 1, 2016 revealed, . 1. Medications/treatments shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state . RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the yearly Minimum Data Set (MDS) with an assessment reference date of 11/03/16 revealed a Brief Interview for Mental Status score of 15 of a possible 15, indicated resident was cognitively intact. The MDS also revealed that [MEDICAL TREATMENT] treatment was checked. A review of RI #12's Care Plan revealed a Problem/Need of Requires [MEDICAL TREATMENT] r/t (related to) [MEDICAL CONDITION], with an onset date of 11/09/15. The approached included, .[MEDICAL TREATMENT] schedule of M-W-F (Monday, Wednesday, Friday) Location of [MEDICAL TREATMENT] Center (address) . During the review of the medical record the Physician order [REDACTED]. On 2/16/17 at 11:25 A M, Employee Identifier #3, Licensed Practical Nurse, was asked if there was an order for [REDACTED].#3 was asked how the nursing staff would know to allow RI #12 to leave the facility for treatments outside the facility, EI#3 said RI #12 had always gone to [MEDICAL TREATMENT]. EI #3 stated an order for [REDACTED].>EI #1, the Director of Nursing, was interviewed on 2/16/17 at 2:00 P M. EI #1 stated Orders were checked by the Nurse Managers and then given to the LPN Charge Nurses to double check. When asked if there was a current order for [MEDICAL TREATMENT] for RI #12, EI #1 stated there was none when it was checked but there should have been. When asked what harm could occur if there were no current orders in the medical record, EI #1 replied, The potential is they won't receive the service.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #9 had a care plan to address the care of an indwelling foley catheter. This affected one of one sampled residents utilizing a foley catheter. Findings Include: A review of the facility's policy titled: "Care Plans" with an effective date of 10/1/2010 documented, "...PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to the federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timelines to meet a resident's medical, nursing and mental/psychosocial needs, that are identified in the comprehensive assessment..." RI #9 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Physician order [REDACTED]. "...12/15/14 Insert #16 Fr (French) foley cath (catheter) q (every) 3rd Wednesday..." RI #9's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2014 documented RI #9 scored a 14 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact for decision making. The MDS documented: "Section H-Bladder and Bowel...Urinary continence...Not rated, resident had a catheter (indwelling)..." On 1/23/14 at 10:30 AM, RI #9's care plan was reviewed by the surveyor. There was no care plan in RI #9's medical record regarding the catheter. On 1/23/15 at 10:40 AM, Employee Identifier (EI) #3 (Care Plan Coordinator) was asked to look at RI #9's chart to see if there was a care plan for RI #9's catheter. EI #3 replied, "I don't see one in the chart." EI #3 was asked if she was responsible for all care plans. EI #3 said, "Yes." The surveyor asked EI #3 what was the facility's policy on care plans. EI #3 said care plans were done on admission, quarterly and if there was a change. The surveyor asked EI #3 how did staff know what to do regarding the catheter if it was not care planned. EI #3 said the nursing standard was to empty the foley cath bag and staff had been trained on cath care. EI #3 was asked should there have been a care plan on the catheter and cath care for RI #9. EI #3 said, "Yes." On 1/23/15 at 10:50 AM, EI #2 (Assistant Director of Nursing), was asked if she was responsible for the catheter care plans. EI #2 said, "Yes." EI #2 was asked to look at RI #9's chart to see if there was a catheter care plan. EI #2 looked at the chart and said she did not see one. EI #2 was asked if she knew why there was not one. EI #2 said. "Oversight." The surveyor asked EI #2 if there should have been a care plan for the catheter and she said yes. EI #2 was asked who was responsible for the catheter care plans. EI #2 replied, "I would say me, I do the bowel and bladder section." EI #2 was asked what was the facility's policy on care plans. EI #2 said they were done annually and reviewed quarterly. On 1/23/15 at 1:55 PM, EI #4 (Medical Director) was asked if RI #9 was admitted to the facility with a catheter. EI #4 said "Yes." EI #4 was asked if he would have expected the facility to have a care plan for the catheter. EI #4 said, "Yes." On 1/23/15 at 2:15 PM, EI #1 DON (Director of Nursing) was asked if RI #9 had a catheter and she said she did. EI #1 was provided RI #9's medical chart to review. The surveyor asked her if there was a care plan for RI #9's catheter. EI #1 looked at the chart and replied, "No, not in this chart." EI #1 was asked if she knew why RI #9 did not have a care plan for the catheter. EI #1 said she was not sure. EI #1 was asked if there should have been a care plan in the chart and she said, "Yes." EI #1 was asked who was responsible for doing care plans. EI #1 said Medical Records made a copy of the care plans and a copy was supposed to be put on the old chart and the original on the current chart. EI #1 was asked what was the facility's policy on care plans. EI #1 said they do care plans on admission and as needed.

Based on interviews and record reviews, the facility failed to ensure: 1) written authorization was obtained to manage residents' personal funds deposited in the facility; 2) quarterly statements were distributed to residents or their legal representative; 3) residents were given receipts for withdrawals from their trust fund accounts; and 4) the residents' petty cash fund was safeguarded from theft. These deficient practices affected Resident Identifier (RI) #2, RI #4, RI #6, RI #8, RI #9, RI #10, RI #12, RI #13, RI #17, RI #22, RI #23, RI #24, RI #25, RI #26, RI #27, RI #28, RI #29, RI #30, RI #31,and RI #32, 20 of 32 sampled residents with the potential to affect the remaining 29 residents whose accounts are managed by the facility. Findings include: WRITTEN AUTHORIZATION The facility's policy titled "Resident Trust Funds" with an effective date of August 1, 2005 revealed: "PURPOSE: Each resident has the right to manage his/her personal funds, and to have the facility assist with that management, when needed. STANDARD: ...Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility ... ." According to the facility's "Investigative Summary" dated 04/18/14, "... (RI #18's) family came to the office on 4-10-14 to get money from her trust fund. When the family saw the amount in her trust, they questioned us on her recent transactions. We gave them the signature pages and they refuted her signature. We interviewed (RI #18) and obtained her signature and it was found to be different on some of the transactions. (Employee Identifier (EI) #5/Social Service Designee), Social Services Director was interviewed 4-11-14 and she admitted to forging signatures ... ." In an interview on 05/16/14 at 9:00 AM, Employee Identifier (EI) #6, the facility's Business Office Manager, was asked who is responsible for handling resident funds within the facility. EI #6 stated EI #1, the Administrator. A typed form labeled "Residents with Trust Accounts" signed by EI #1 and dated 05/17/14, indicated the facility managed the trust accounts of 49 residents. The "Trust Fund Trial Balance" dated 05/17/14, also indicated the facility managed the trust fund of 49 residents. The facility was unable to provide evidence that authorization was received to manage the account of Resident Identifier (RI) #2, RI #4, RI #6, RI #22, RI #23 and RI #24. Also, the "Resident Fund Authorization" provided by the facility for RI #9, RI #12, RI #13, RI #25, RI #26, RI #27, RI #28, RI #29, RI #30, RI #31 and RI #32 were not signed by either the resident and/or resident's responsible party. The "Trust Fund Trail Balance" dated 05/17/14, revealed the above mentioned residents's accounts had a balance to indicate the facility was managing the residents' monies. In an interview on 05/16/14 at 10:10 AM, EI #1, the Administrator, was asked who monitored to make sure the "Resident Fund Authorization" forms were signed and dated. EI #1 replied nobody was doing that. QUARTERLY STATEMENTS According to Centers for Medicare & Medicaid Services' State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities " ... The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. During an interview on 05/17/14 at 3:37 PM, RI #17, a self-sponsored resident, was asked how often he received quarterly statements. RI #17 stated he had never gotten a statement since he had been there. RI #17 was admitted to the facility on [DATE]. In an interview on 05/17/14 at 4:23 PM, RI #6's responsible party stated she doesn't get quarterly statements. When asked the last time she received a quarterly statement, she stated that she had never received one. In an interview on 05/18/14 beginning at 9:40 AM, EI #1, the Administrator and EI #2, the Corporate Business Office Manager, was asked who was responsible for sending out quarterly statements. EI #1 said EI #6. When asked has she been sending out quarterly statements, EI #1 said yes. EI #2 explained that EI #6 was not sending out quarterly statements. According to EI #2, EI #6 printed the statements and gave to EI #5, the former Social Service Designee (SSD) to mail to the sponsors and distribute to the residents. When asked who was responsible for monitoring to ensure the quarterly statements were distributed, EI #2 said the facility did not have a system. EI #1 stated she didn't even know EI #5 was getting the quarterly statements to mail. PETTY CASH WITHDRAWALS The facility's policy titled "Resident Trust Funds" with an effective date of August 1, 2005 revealed: " ... PROCESS: ... b) When money is needed for the purchase of personal items, the social service designee should assist the resident to access petty cash funds, from their account, as needed ... d) Any time funds are withdrawn from a trust account, in behalf of a resident; a receipt should be given to the resident. Copies of receipts from the vendor where the goods were purchased should be made a part of the trust account records ... ." During an interview on 05/17/14 at 3:37 PM, RI #17, a self-sponsored resident, was asked if he received a receipt when he got his money and he stated no, they never gave him a receipt. In an interview on 05/17/14 at 4:10 PM, RI #12 was asked if he got a receipt when he received money from his trust fund account. RI #12 replied no. In an interview on 05/17/14 at 4:20 PM, EI #1, the Administrator was asked who monitored EI #5, the former SSD, with the handling of the residents' trust fund account. EI #1 replied, "I don't think anyone monitored (EI #5), but it should've been me." In an interview on 05/17/2014 at 4:30 PM, RI #10 stated he did not get a receipt when he withdrawn $30.00 from his account every month. During an interview on 05/17/14 at 4:32 PM, RI #9 was asked if he received a receipt when he withdrew money from his trust fund account. RI #9 stated no. In an interview on 05/17/14 at 4:48 PM, RI #8 was asked if she received a receipt when she withdrew money from her trust fund account. RI #8 stated no and further explained that she never had to sign anything. In a telephone interview on 05/17/14 at 5:43 PM, EI #5, the former SSD, acknowledged that she was responsible for resident trust funds in the facility. When asked if she gave residents receipts when they withdrew money from their trust fund account, EI #5 said no. When asked why not, EI #5 stated she wasn't required to give receipts. EI #5 stated that is how she has always done it. In a follow-up interview on 05/18/14 at 9:40 AM, EI #1 explained she was alerted about an issue with petty cash, when the sponsor of RI #18 requested reimbursement for a TV that was purchased for the resident. A review of RI #18's account was not correct and that prompted a facility investigation. The surveyor asked prior to the incident, were residents receiving receipts when signing out for petty cash. EI #1 replied, "No." Since the conclusion of the facility's investigation, has the facility provided receipts when there are withdrawals from petty cash, EI #1 said no. When asked why not, EI #1 stated she doesn't give a receipt. EI #1 was asked should she. EI #1 replied obviously she should. During an interview on 05/18/14 at 10:05 AM, RI #20 was asked did the facility shop for him. RI #20 replied the facility did shop for him. When asked if he ever got a receipt for his purchases, RI #20 said he had never been given a receipt. SAFEGUARD PERSONAL FUNDS According to Centers for Medicare & Medicaid Services' State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities " ... the facility must hold, safeguard, ... the personal funds of the resident deposited with the facility ... ." In a telephone interview on 05/17/14 at 5:43 PM, EI #5, the former SSD, was asked why she resigned and she explained that her receipts and money went missing. When asked what she thought happened with the money, EI #5 said she thought an employee stole it. When asked what employee, EI #5 stated she didn't know. EI #5 was asked who all deals with petty cash and she stated just her. EI #5 explained that she thought the money was taken when she was out of her office. When asked if she had a key to her office, EI #5 said yes. When asked who all had a key, EI #5 said herself and EI #1, the Administrator, but stated a key was not needed. When asked the location of the petty cash box, EI #5 said it was locked in a file cabinet at all times, but someone could use a gem clip to open the file cabinet. When asked how she knew this, EI #5 stated because she had done it before when she didn't have her keys. According to EI #5, EI #1 was aware of this. When asked if the petty cash box was easily accessible, EI #5 said yes. In an interview on 05/18/14 at 9:40 AM, EI #1 was asked if she was aware the file cabinet in the office that contained the petty cash could be opened with a gem clip. EI #1 said no. According to EI #1, the file cabinet could be opened with a butter knife. When asked who else knew, EI #1 said she didn't know. EI #1 was asked what she did about this and she stated she did nothing (to safeguard the file cabinet containing petty cash).

Based on interviews, review of the facility's abuse policy, and investigation file, the facility failed to ensure $10,774.00 was not withdrawn from the Residents' Trust Fund Accounts from March 2013 to April 2014, without the residents' consent. This deficient practice affected 22 of the 49 residents currently residing in the facility whose funds are managed by the facility, with the potential to affect the remaining 27 residents whose funds are managed by the facility. On 05/18/14/at 4:46 PM, Employee Identifier (EI) #1, the Administrator; EI #14, the Chief Operating Officer; EI #15, the Vice President of Clinical Operations and EI #3, the Director of Nurses were informed that Substandard Quality Care had been identified in the areas of Resident Behavior & Facility Practices, F224. Findings include: The facility's policy and procedure titled, "Abuse, Neglect and Exploitation (NM.II-20)" dated 08/01/05, revealed the following: "... PURPOSE: ... The resident has the right to be free from ... misappropriation of property ... STANDARD: ... "Misappropriation of Resident Property" means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent ... ." According to the facility's "Investigative Summary" dated 04/18/14, "Attached are all of the documents related to the allegation of misappropriation of resident property by (Employee Identifier (EI) #5), Social Services Director. (Resident Identifier (RI) #18's) family came to the office on 4-10-14 to get money from her trust fund. When the family saw the amount in her trust, they questioned us on her recent transactions. We gave them the signature pages and they refuted her signature. We interviewed (RI #18) and obtained her signature and it was found to be different on some of the transactions. (Employee Identifier (EI) #5), Social Services Director was interviewed 4-11-14 and she admitted to forging signatures on 4-9-14 ... She resigned her position immediately. We noted the (local) Police Department ... SUMMARY: A review of all resident trust fund transactions beginning in January 2012 was started on 4-11-14 ... We found a pattern of questionable activity that started in March of 2013. We obtained signatures from our residents who were able to sign and began to reconcile these signatures and transactions. We identified questionable signatures and transactions with 22 residents ... CONCLUSION: There is evidence to support substantiation of misappropriation of resident property by (EI #5) ... ." A typed form labeled "Residents with Trust Accounts" signed by EI #1 and dated 05/17/14, indicated the facility managed the trust accounts of 49 residents. The "Trust Fund Trial Balance" dated 05/17/14, also indicated the facility managed the trust fund of 49 residents. In an interview on 05/18/14 at 10:10 AM, RI #18 stated sometimes she would ask for 10 or 15 dollars and EI #5 would tell her that she didn't have that much in her account. RI #18 stated but she knew she did. RI #18 stated she felt like EI #5 was trying to get over on her and keep her money. In a telephone interview on 05/17/14 at 5:43 PM, EI #5, the former SSD, acknowledged that she was responsible for resident trust funds in the facility. EI #5 was asked why she resigned and she explained that her receipts and money went missing. EI #5 stated she did not take any money and that was all she had to say. During an interview on 05/17/14 at 3:37 PM, RI #17, a self-sponsored resident, stated that when he came to the facility about two years ago he put $1,000.00 into his account and it was gone. He stated they fired the lady (EI #5) who was stealing the money and they have been trying to pay people back. He stated that they had paid him $80.00 of his money that she stole. During an interview with EI #1, the Administrator, and EI #2, the Corporate Business Office Manager, on 05/18/14 at 9:40 AM, EI #1 explained she was alerted about an issue with petty cash, when the sponsor of RI #18 requested reimbursement for a TV that was purchased for the resident. A review of RI #18's account was not correct and that prompted a facility investigation. EI #1 stated when they realized this happened and EI #5 admitted to forging residents' signatures, they went back to the beginning of 2013. EI #1 stated the facility staff felt like they saw a pattern in March 2013, so they went back further to 2012 to see if there was any questionable transactions. EI #1 stated the team consisted of EI #3, the Director of Nursing (DON), EI #2, and EI #14, the Chief Operating Officer. According to EI #1, the facility staff believe the exact amount of resident loss was $10,774.00. EI #1 stated the investigation took one week and during that week residents were interviewed who signed out for money on 04/09/14. EI #1 stated when she realized signatures did not match, that's when they pulled the trust fund signatures out to review. The surveyor asked how did they know the signatures. EI #1 stated she obtained new signatures for all residents that EI #5 had a signature on. EI #1 stated residents who signed by making an "X" on EI #5's records, actually were not even able to make a mark.

Based on interviews, review of the facility's abuse policy and investigation file, the facility failed to ensure Employee Identifier (EI) #5, the former Social Service Designee (SSD) was supervised to ensure the facility's abuse policy and procedure was implemented to prevent misappropriation of residents' property. According to the facility's investigation, EI #5 withdrawn $10,774.00 from residents' trust fund withouth the permission of the residents or residents' responsible party. This deficient practice affected 49 of 69 current residents in the facility, whose accounts are managed by the facility. On 05/18/14/at 4:46 PM, Employee Identifier (EI) #1, the Administrator; EI #14, the Chief Operating Officer; EI #15, the Vice President of Clinical Operations and EI #3, the Director of Nurses were informed that Substandard Quality Care had been identified in the areas of Resident Behavior & Facility Practices, F226. Findings include: Refer to F224 The facility's policy and procedure titled, "Abuse, Neglect and Exploitation (NM.II-20)" dated 08/01/05 documented " ... PURPOSE: ... The resident has the right to be free from ... misappropriation of property ... STANDARD: ... "Misappropriation of Resident Property" means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent ... TIPS FOR PREVENTION OF ABUSE, NEGLECT AND EXPLOITATION ... *Supervise staff to identify inappropriate behaviors ... ." According to the facility's "Investigative Summary" dated 04/18/14, "Attached are all of the documents related to the allegation of misappropriation of resident property by (Employee Identifier (EI) #5), Social Services Director. ... (Employee Identifier (EI) #5), Social Services Director was interviewed 4-11-14 and she admitted to forging signatures on 4-9-14 ... She resigned her position immediately. We noted the (local) Police Department ... CONCLUSION: There is evidence to support substantiation of misappropriation of resident property by (EI #5) ... ." In an interview on 05/17/14 at 4:20 PM, EI #1, the Administrator was asked who monitored EI #5, the former SSD, with the handling of the residents' trust fund account. EI #1 replied, "I don't think anyone monitored (EI #5), but it should've been me."

fBased on interviews and record reviews, the facility's Administrator, Employee Identifier (EI) #1, who is responsible for the overall operation of the facility failed to ensure: 1) written authorization was obtained to manage residents' personal funds deposited in the facility; 2) quarterly statements were distributed to residents or their legal representative; 3) residents were given receipts for withdrawals from their trust fund accounts; and 4) the residents' petty cash fund was safeguarded from theft. According to the facility's investigation, $10,774.00 was withdrawn from the Residents' Trust Fund Accounts from March 2013 to April 2014, without the residents' consent. These deficient practices affected Resident Identifier (RI) #2, RI #4, RI #6, RI #8, RI #9, RI #10, RI #12, RI #13, RI #17, RI #22, RI #23, RI #24, RI #25, RI #26, RI #27, RI #28, RI #29, RI #30, RI #31,and RI #32, 20 of 32 sampled residents and with the potential to affect the remaining 29 residents whose accounts are managed by the facility. Findings include: Refer to F159, F224 and F226 EI #1's undated "Position Description Administrator" documented "BASIC FUNCTION Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state and local standards, guidelines and regulations ... ESSENTIAL FUNCTIONS 1. Establish and direct the implementation of written policies and procedures ... 2. Assist in the ... implementation of departmental policies and procedures, ... 3. Ensure that all personnel, ... follow established policies and procedures. ... 5. ... ensure compliance with current regulations are being continually maintained. ... ." 1) The facility was unable to provide evidence that authorization was received to manage the account of Resident Identifier (RI) #2, RI #4, RI #6, RI #22, RI #23 and RI #24. Also, the "Resident Fund Authorization" provided by the facility for RI #9, RI #12, RI #13, RI #25, RI #26, RI #27, RI #28, RI #29, RI #30, RI #31 and RI #32 were not signed by either the resident and/or resident's responsible party. The "Trust Fund Trail Balance" dated 05/17/14, revealed the above mentioned residents's accounts had a balance to indicate the facility was managing the residents' monies. In an interview on 05/16/14 at 10:10 AM, EI #1, the Administrator, was asked who monitored to make sure the "Resident Fund Authorization" forms were signed and dated. EI #1 replied nobody was doing that. 2) In an interview on 05/18/14 beginning at 9:40 AM, EI #1, the Administrator and EI #2, the Corporate Business Office Manager, was asked who was responsible for sending out quarterly statements. EI #1 said EI #6, the facility's Business Office Manager. When asked has she been sending out quarterly statements, EI #1 said yes. EI #2 explained that EI #6 was not sending out quarterly statements. According to EI #2, EI #6 printed the statements and gave to EI #5, the former Social Service Designee (SSD) to mail to the sponsors and distribute to the residents. When asked who was responsible for monitoring to ensure the quarterly statements were distributed, EI #2 said the facility did not have a system. EI #1 stated she didn't even know EI #5 was getting the quarterly statements to mail. 3) In an interview on 05/17/14 at 4:20 PM, EI #1, the Administrator was asked who monitored EI #5, the former SSD, with the handling of the residents' trust fund account. EI #1 replied, "I don't think anyone monitored (EI #5), but it should've been me." 4) During an interview with EI #1, the Administrator, and EI #2, the Corporate Business Office Manager, on 05/18/14 at 9:40 AM, EI #1 explained she was alerted about an issue with petty cash, when the sponsor of RI #18 requested reimbursement for a TV that was purchased for the resident. A review of RI #18's account was not correct and that prompted a facility investigation. EI #1 stated when they realized this happened and EI #5 admitted to forging residents' signatures, they went back to the beginning of 2013. EI #1 stated the facility staff felt like they saw a pattern in March 2013, so they went back further to 2012 to see if there was any questionable transactions. EI #1 stated the team consisted of EI #3, the Director of Nursing (DON), EI #2, and EI #14, the Chief Operating Officer. According to EI #1, the facility staff believe the exact amount of resident loss was $10,774.00. EI #1 stated the investigation took one week and during that week residents were interviewed who signed out for money on 04/09/14. EI #1 stated when she realized signatures did not match, that's when they pulled the trust fund signatures out to review. The surveyor asked how did they know the signatures. EI #1 stated she obtained new signatures for all residents that EI #5 had a signature on. EI #1 stated residents who signed by making an "X" on EI #5's records, actually were not even able to make a mark. EI #1 was asked if she was aware the file cabinet in the office that contained the petty cash could be opened with a gem clip. EI #1 said no. According to EI #1, the file cabinet could be opened with a butter knife. When asked who else knew, EI #1 said she didn't know. EI #1 was asked what she did about this and she stated she did nothing (to safeguard the file cabinet containing petty cash).