Every finding on record at The Grandview Nursing and Rehabilitation Facility

Based on observation, interview, record review, and review of the facility's policies and the Centers for Disease Control and Prevention (CDC) related to enhanced-barrier precautions (EBP) and transmission-based precautions (TBP), it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 2 of 39 sampled residents, Residents (R) 7, and R52. The findings include: Review of the CDC Guidelines titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. The Guidelines stated staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials. Review of the facility's policy titled, Contact Precautions, no date, revealed the facility staff would utilize contact precautions in addition to standard precautions for residents known or suspected to have an illness, which is easily transmitted by direct resident contact or contact with the resident's environment. According to the policy, hand hygiene should be performed before donning (putting on) and after doffing (taking off) PPE, gloves should be removed before leaving the rooms, and PPE should be donned prior to entering the room. Review of the facility's policy titled, Enhanced Barrier Precautions, revised 07/27/2022, revealed the facility would use EBP for high-contact resident care activities to include dressing, bathing/showering, transferring, and changing linens. Review of the facility policy, Standard Precautions, not dated, revealed staff will follow standard precautions for all residents, regardless of infection or colonization status. According to the policy, staff should wear a gown and gloves to provide high-contact resident care. 1. Observation on 09/02/2025 at 6:34 PM revealed State Trained Nursing Aide (STNA) 1 entered room [ROOM NUMBER], a Contact Precaution room, without donning (putting on) the appropriate personal protective equipment (PPE) to include a gown and gloves before entering. The CDC and the facility's policy require staff to don a gown and gloves upon entry to a room under Contact Precautions. Additional observation revealed STNA1 did not perform hand hygiene after exiting the room. 2. Observation on 09/02/2025 at 6:55 PM revealed STNA1 sitting on a chair in R52's room, an EBP room, and assisting the resident with her meal. STNA1 failed to don gloves and a gown before performing high-contact resident care. The STNA was observed with her body up against the bedframe with her elbow resting on top of the resident's bed linen. 3. During an observation of STNA2 on 09/03/2025 at 8:30 AM, revealed the STNA changed bed linen and made up a bed without wearing any PPE. room [ROOM NUMBER]B, an EBP room. STNA2 was making up a bed without wearing gloves and a gown. During an interview with STNA2 at this time, she stated that wearing PPE was not necessary for making up the bed for a resident in EBP. Further interview revealed STNA2 was unable to clearly explain which tasks were consider as direct care under EBP. Further interview revealed the STNA verbalized understanding that touching a resident's environment under EBP without proper PPE or hand hygiene could cause cross contamination. The STNA stated she received infection control training upon hire and during multiple educational sessions throughout the year. 4. During an observation on 09/03/2025 at 10:15 AM, Housekeeper (HSK) 2 placed two contaminated trash bags from room [ROOM NUMBER], an EBP room, in the housekeeping cart receptacle. She did not perform hand hygiene before exiting the room. HSK2 then put on gloves, reentered the room, and replaced a trash can liner. She again, exited the room without doffing her gloves. The housekeeper placed her hands in her pockets and retrieved her keys to open the housekeeping cart. During an immediate interview with HSK2 she stated she used alcohol-based hand rub (ABHR) prior to exiting the room but later stated that she had not. HSK1 could not explain the importance of hand hygiene. Additionally, when asked by SSA surveyor the importance of removing PPE and using hand hygiene prior to leaving the room, the housekeeper could not articulate cross-contamination. HSK2 stated further that she did not know she was required to close bags before leaving the room. Furthermore, HSK2 stated she received infection control training upon hire and periodically by her supervisor. 5. During an observation on 09/04/2025 at 11:30 AM, Registered Nurse (RN) 3 was in an EBP room and performed a blood glucose fingerstick on R7. RN3 was observed wearing gloves, but she did not don a gown to provide direct care for R7. Review of the admission Record in R7's electronic health record (EHR) revealed the facility admitted the resident on 08/02/2024 with diagnoses to include type 2 diabetes, asthma, and cerebral vascular disease. Review of the quarterly Minimum Data Set [MDS], in R7's EMR with an assessment reference date (ARD) of 06/30/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 of indicating the resident was cognitively intact. Review of the Order Summary Report, dated 09/2025, in R7's EHR, revealed on 07/08/2025 the physician ordered that the resident be placed in EBP for diagnosis of a multi-drug-resistant organism (MDRO). Review of the admission Record found in R52's EHR, revealed the facility admitted the resident on 10/12/2020 with diagnoses to include hemiplegia of dominant side, chronic obstructive pulmonary disease, and history of multi-drug-resistant organism (MDRO). Review of R52's quarterly MDS, with an ARD of 07/21/2025, revealed that the resident had a BIMS score of 02/15 indicating the resident was severely impaired. Review of the Order Summary Report, dated 09/2025, in R52's EHR, revealed on 07/16/2025 the physician ordered that the resident be in EBP for diagnosis of extended-spectrum beta-lactamase (ESBL). During an interview with STNA1 on 09/02/2025 at 8:01 PM, she stated she did not provide direct care to the resident in contact precautions but was just checking for dinner trays. When asked by the State Survey Agency (SSA) what the facility policy was regarding the donning of PPE prior to entering a TBP room, STNA1 stated she only needed PPE when providing direct care. The STNA could not articulate the difference between EBP and contact precautions. Additionally, the STNA could not clarify what was meant by direct resident care; however, she verbalized understanding that direct contact with the resident's environment and bed linen without proper PPE could result in cross-contamination. STNA1 stated she should have worn the appropriate personal protective equipment when providing direct care to a resident under enhanced-barrier precautions. The STNA stated further she had received training and education on infection prevention and control upon hire. During an interview with the Housekeeping Supervisor (HS) on 09/04/2025 at 8:52 AM, she stated housekeeping staff received training from the Staff Development Coordinator (SDC) and the Infection Preventionist (IP) upon hire and periodically throughout the year. She stated trash bags should be tied before coming out of a room. Additionally, she stated staff should perform hand hygiene prior to entering and exiting the residents' rooms. The HS further stated housekeeping staff should adhere to the posted signage regarding the proper donning of PPE while in TBP rooms. Additionally, they must doff PPE and perform hand hygiene before exiting the room. The HS stated it was her expectation staff follow the facility policy and procedure for infection control. During an interview with the Infection Preventionist (IP) on 09/03/2025 at 10:45 AM, she stated it was her expectation that staff follow the facility policy and procedure for infection control. She stated all staff received education upon hire and periodically throughout the year regarding infection control. The IP stated staff should know infection prevention and control practices (IPCP) and follow protocols 100% of the time. The IP stated it was important for staff to know the resident's condition, and stated her expectation was for staff to follow the posted CDC signage. The IP stated all staff should follow facility policies and procedures related to infection control to provide a safe and healthy environment for residents, staff, and visitors. Per interview the IP stated she performed periodic audits for staff compliance related to infection control. The IP stated that she had not observed any non-compliance with IPCP when performing the audits. Further interview revealed the Infection Control committee meets every month and as needed to discuss infection surveillance and stated they have found no concerns. During an interview with the Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC) on 09/04/2025 at 8:42 AM, she stated all employees received education and training on infection control to include hand hygiene, PPE, EBP, and TBPs. She stated that employees receive a post- education test to assess understanding. The ADON/SDC stated that the facility provided an annual skills workshop to ensure skills were maintained. Per interview, the SDC stated it was her expectation that staff follow the facility policy and procedure for IPCP. She stated it was important for the safety and welfare or residents, staff, and visitors. During an interview with the Administrator on 09/03/2025 at 10:45 AM, she stated it was her expectation that staff adhere to facility policy related to infection control. She stated the facility followed the recommendation of the CDC for PPE use and isolation precautions. The Administrator stated it was important to ensure the safety and health of the residents and staff.

Based on interview, record review, and facility document and policy review, the facility failed to protect 1 (Resident #286) of 7 residents reviewed for abuse from resident-to-resident abuse. Specifically, the facility failed to protect Resident #286's right to be free from physical abuse perpetrated by Resident #284 on 08/19/2023. Findings included: The facility's Resident Protection Plan, dated 09/15/2022, included a policy titled, Reporting Abuse to Facility Management that indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. An Admission Record revealed the facility admitted Resident #284 on 02/17/2023. According to the Admission Record, the resident had a medical history that included diagnoses of moderate dementia with anxiety, need for assistance with personal care, depression, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2023, revealed Resident #284 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. According to the MDS, the resident had no physical, verbal, or other behavioral symptoms directed towards others and wandered one to three days during the assessment look-back period. Resident #284's care plan included a focus area, initiated on 02/17/2023, that indicated the resident exhibited physical and verbal behaviors, refused medications at times, and had a history of physical aggression towards others. Resident #284's Progress Notes revealed an Incident Note, dated 08/19/2023 at 8:13 PM, that indicated Resident #284 hit Resident #286 across the face and then in the leg as Resident #286 was propelling around them. Per the note, Kentucky Medication Aide (KMA) #21 witnessed the altercation. An Admission Record revealed the facility admitted Resident #286 on 02/13/2013. According to the Admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, post-traumatic stress disorder (PTSD), major depressive disorder, and dementia in other diseases classified elsewhere with mood disturbance. A Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2023 revealed Resident #286 had a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident had severe cognitive impairment. According to the MDS, the resident had no physical, verbal, or other behavioral symptoms directed towards others and wandered daily during the assessment look-back period. Resident #286's care plan included a focus area, initiated on 10/17/2022, that indicated the resident's psychosocial wellbeing was at risk due to dementia, confusion, and a new environment. Resident #286's Progress Notes revealed an Incident Note, dated 08/19/2023 at 6:10 PM, that indicated Resident #286 was propelling themselves in their wheelchair on the North Unit when one of the residents on the unit (Resident #284) hit Resident #286 on the right side of their face and kicked their right leg. A Facility Investigation-5 Day Final Report, dated 08/23/2023, revealed on 08/19/2023 at approximately 6:10 PM, Kentucky Medication Aide (KMA) #21 notified Licensed Practical Nurse (LPN) #23 that Resident #284 struck and kicked at Resident #286 as they passed them in the hallway. Per the report, KMA #21 and State Registered Nursing Assistant (SRNA) #24 witnessed the altercation, and the facility concluded the incident was verified and that it did occur. On 07/11/2024 at 12:02 PM, a call was placed to KMA #21. A voicemail was left, but no return call was received. During a telephone interview on 07/11/2024 at 12:09 PM, SRNA #24 stated she no longer worked at the facility. She stated she witnessed the incident between Resident #284 and Resident #286. She stated Resident #284 was in their wheelchair next to the day room doors, and Resident #286 rolled by, close to Resident #284, who swung and hit Resident #286. She stated Resident #284 slapped Resident #286's shoulder, but she did not see Resident #284 kick at Resident #286. SRNA #24 stated she immediately separated the residents and the incident occurred at the nurse's station so she called for the nurse to report what happened. SRNA #24 stated she could not recall who she reported the incident to. She further stated she had received abuse training from the facility while she was employed there and covered the different types of abuse and whom to report to. During an interview on 07/11/2024 at 4:22 PM, Registered Nurse (RN) #1 stated she was the Director of Nursing (DON) between July 2023 and October 2023, and had been with the facility since 2016 and had held various roles. She stated the facility provided abuse training frequently, the most recent being a couple months ago. She continued to state she recalled the incident between Resident #284 and Resident #286 and she stated the Administrator completed most of the investigation. RN #1 stated Resident #284 was placed on increased monitoring after the incident, specifically 1:1 supervision for a few days following the incident, followed by every 15-minute checks for a week. She stated the behavior and incident was odd and out of character for Resident #284, who had never done anything similar prior to the incident. She stated the physician came to examine Resident #284 and reviewed their medications for possible adjustments and Resident #286 had not been involved in any type of incident prior to or since the incident with Resident #284. RN #1 further stated she expected staff to follow the facility's abuse policy, and the floor staff acted appropriately during this incident, and the management team met to discuss the incident after the investigation. During an interview on 07/12/2024 at 3:27 PM, the Administrator stated Resident #284 was sitting in their wheelchair when Resident #286 passed by them, and Resident #284 smacked Resident #286. The Administrator further stated she expected staff to follow the facility's policy and abuse should be reported to the DON or herself immediately per policy.

Based on interview, record review, and facility document and policy review, the facility failed to ensure a pharmacy recommendation was addressed by the physician in a timely manner for 1 (Resident #34) of 5 residents reviewed for unnecessary medications. In addition, once the physician responded to the pharmacy recommendation, facility staff failed to immediately implement the physician's recommendation. Findings included: A facility policy titled, Consultant Pharmacist Reports, dated 11/2021, revealed Documentation and Communication of Consultant Pharmacist Recommendations included Policy The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion. Procedures A. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team. This should include: 1) Documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated manner. The policy revealed, 3) The consultant pharmacist documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for prescriber and/or nursing review. The policy revealed, B. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review and C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within a reasonable time period, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. An Admission Record revealed the facility admitted Resident #34 on 10/12/2019 and most recently readmitted the resident on 03/12/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of gastroesophageal reflux disease (GERD). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/04/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #34's care plan revealed a focus area, initiated on 10/28/2019, that indicated the resident was at risk for malnutrition/dehydration related to multiple diagnoses, including the resident's diagnosis of GERD. An intervention initiated on 11/30/2021 and revised on 02/13/2024 instructed staff to administer medications for GERD as ordered by the physician. A Note to Attending Physician/Prescriber, with a medication regimen review (MRR) date of 10/02/2023, revealed a note that indicated, [Resident #34] receives two or more medications with similar mechanism of actions which may represent duplicate therapy. The note identified the medications in question as famotidine (a medication used to treat GERD) 20 milligram (mg), to be taken every night, and pantoprazole (a medication used to treat GERD) 40 mg, to be taken every day. The note recommended the physician consider discontinuing one medication if clinically appropriate due to risk of adverse effects and to avoid polypharmacy. A Consultant Pharmacist's Medication Regimen Review, dated 11/05/2023, revealed that a consultant pharmacist sent a pharmacy recommendation for Resident #34 the previous month regarding a possible duplication of therapy. The review indicated the consultant pharmacist was unable to find a response to the recommendation and requested the facility follow up. A Note to Attending Physician/Prescriber, with a MRR date of 12/03/2023, revealed a note that indicated, [Resident #34] receives two or more medications with similar mechanism of actions which may represent duplicate therapy. The note identified the medications in question as famotidine 20 mg, to be taken every night, and pantoprazole 40 mg, to be taken every day. The note recommended the physician consider discontinuing one medication if clinically appropriate due to risk of adverse effects and to avoid polypharmacy. Resident #34's MRR records revealed the physician's first documented response to these recommendations was dated 12/08/2024, over two months from the date of the pharmacist's original recommendation. Per documentation on the 12/03/2023 Note to Attending Physician/Prescriber, the physician agreed with the recommendation on 12/08/2023 and provided a verbal order to decrease Resident #34's pantoprazole to 20 mg every day. Resident #34's Order Recap [recapitulation] Report, reflecting all orders during the timeframe from 12/01/2023 to 07/31/2024, revealed the resident's order for pantoprazole 40 mg, one tablet by mouth one time a day for GERD, was not decreased to 20 mg per the physician's verbal order until 12/14/2023, five days after the physician provided the verbal order to decrease the dose. The order to decrease the dosage was entered on 12/13/2023 with a start date of 12/14/2023. Resident #34's medication administration record (MAR), for the timeframe from 12/01/2023 to 12/31/2023, revealed documentation that indicated staff did not implement the physician's verbal order to decrease the dose of Resident #34's pantoprazole until 12/14/2023. During an interview on 07/10/2024 12:36 PM, the Director of Nursing (DON) confirmed Resident #34's pantoprazole was not decreased until 12/13/2023 and it went unaddressed from the 10/02/2023 pharmacy recommendation until the new order was entered on 12/13/2023. She indicated that her expectation was for the pharmacy recommendations to come directly to her as soon as they were completed. She stated she reviewed and sorted the recommendations, had medical records staff take them to the prescribing physician that day, then sent the staff back the next day to pick them up and the responses were given back to her, and they were addressed immediately at that time. During an interview on 07/12/2024 at 9:03 AM, the Administrator stated she was the DON and the Administrator at the time Resident #34's pharmacy recommendation was not addressed by the prescribing physician in a timely manner. She stated that she did not know why there was a delay in addressing the recommendation. She indicated that all pharmacy recommendations needed to be addressed as soon as possible, but no longer than a week. During an interview on 07/12/24 01:25 PM with R# 34's Medical Provider, he/she stated typically the facility would bring the pharmacy rec. to his/her office once a month and he/she would go over them and fax them back to the facility with a reason for not agreeing with the recommendation or any medication and/or lab orders. He/she stated he would expect medication and/or lab orders be acted on within a day or two after receiving them. He/she continued to state the resident had some other medication changes back in Nov. of 2023 due to dealing with a DVT. The Medical Provider stated he/she did not know why there was a lag in responding to the pharmacy recommendation.

Based on interview, record review, and policy review, the facility failed to ensure that an allegation of abuse for one (1) of six (6) sampled residents (Resident #1) was thoroughly investigated. On 06/21/19, the facility initiated an investigation of abuse when a hospital reported bruising to Resident #1's back. The facility policy directed that staff members who had contact with the resident during the period of the alleged incident should be interviewed. However, the facility failed to ensure that direct care staff who worked with the resident before the bruise was discovered were interviewed regarding the possible cause of the bruise. The findings include: Review of the facility policy, Abuse Investigations, dated 08/01/13, revealed All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility staff .2. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; .g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . Review of Resident #1's medical record revealed the facility admitted the resident on 05/01/18. The resident's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which meant the resident was not able to complete the interview. Further review of the MDS revealed the resident was assessed to require extensive to total assistance with activities of daily living and bed mobility. Review of a facility investigation revealed on 06/21/19, Resident #1 was at the local hospital when the hospital reported to Adult Protective Services (APS) that the resident had bruising. Per the investigation, the facility reported the allegation to APS, the state survey agency, and the ombudsman on 06/21/19. However, according to the investigation, a bruise was discovered on the resident's back on 06/17/19, and staff believed the cause of the bruise was from lying on a draw sheet that was turned incorrectly. The facility unsubstantiated the abuse allegation. Continued review of the investigation revealed the facility interviewed and obtained written statements from staff who cared for the resident on 06/17/19 when the bruise was discovered; however, there was no documented evidence that the facility interviewed the staff who provided care for the resident during the previous shift or staff who provided care for the resident from 06/18/19 through 06/21/19. Interview with State Registered Nurse Aide (SRNA) #4 revealed she had cared for Resident #1 on night shift around the time the bruise was discovered to the resident's back. SRNA #1 stated no one had questioned her as to the possible cause or if she knew anything about the bruise. Interview with the Administrator on 07/11/19 at 2:00 PM revealed the facility completed an incident report when the bruise to Resident #1's back was discovered on 06/17/19, but did not report the bruise to state agencies because they knew the cause of the bruise. The Administrator stated when an abuse allegation was reported to APS on 06/21/19 regarding the bruising, the facility initiated an investigation. The Administrator stated they attempted to contact all staff to ask about unreported abuse allegations, but confirmed that the facility did not interview staff who cared for Resident #1 regarding the cause of the injury.

Based on interview, record review, and review of facility policy, it was determined that the facility failed to ensure one (1) of six (6) sampled residents (Resident #1) was monitored after a change in condition. On 06/17/19, during morning care, staff discovered a large purple bruise to Resident #1's upper back. The facility suspected the cause of the bruise was the resident lying on a folded draw sheet corner. However, the facility failed to assess and monitor the bruise to the resident's back. The next documentation related to the bruise was 06/20/19 (three days later) when staff documented that the bruise was black. On 06/21/19, the resident was sent to the hospital, and the hospital described the bruise as a fourteen (14) centimeter by two (2) centimeter bruise with an open area in the skin at the bottom. The findings include: Review of the facility's Change in Resident Condition policy, revised on 09/01/18, revealed the facility would promptly notify the resident/resident's representative and the resident's physician of a change in the resident's condition. Although the facility policy did not address follow-up or monitoring after a change in condition, interview with facility staff revealed after a change in condition nursing staff would monitor/assess the resident every shift for 72 hours and document the assessment. Review of Resident #1's medical record revealed the facility admitted the resident on 05/01/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required extensive to total staff assistance with activities of daily living, including two (2) staff members for bed mobility. Review of a Situation Background Assessment Request (SBAR) note and incident report both dated 06/17/19 at 10:30 AM revealed Resident #1 was assessed to have a large purple area to the left upper back with a smaller half dollar sized area to the mid back. Further review of the note revealed the facility notified the resident's physician of the areas. Interview with State Registered Nurse Aide (SRNA) #1 at 10:37 AM revealed she had cared for Resident #1 on 06/17/19 and discovered the bruise to the resident's back. SRNA #1 stated her shift began at 6:00 AM on 06/17/19; however, Resident #1 required the assistance of two staff members for bed mobility, and she had to wait for the assistance of another staff member. Therefore, SRNA #1 stated she was unable to provide care to the resident until approximately 9:00 AM. SRNA #1 stated while providing care to the resident, she observed the resident's bed linens to be bundled up under the resident, and when she repositioned the resident she discovered a bruise that appeared to be approximately 6 inches by 3 inches to the resident's left upper back. Interview on 07/10/19 at 1:12 PM, with Licensed Practical Nurse (LPN) #4, who completed the SBAR note and Incident Report for Resident #1, revealed the area to the resident's back was approximately 6 inches long by 0.5 inches wide and dark purple in color. The LPN stated the area was not open and staff thought the area was caused by the resident lying on a folded square of the bed linens. Continued interview with the nurse revealed it was the facility's protocol to complete an assessment and document on the resident after a change in the resident's condition at a minimum every shift for seventy-two (72) hours. Review of the facility's Acute Monitoring Log, utilized by the facility to identify residents that need to be monitored/assessed after an incident/accident, revealed LPN #4 added Resident #1 to the log on 06/17/19, for monitoring of the bruising to the resident's back. However, further review of Resident #1's medical record revealed no evidence of any further assessment or documentation of the resident's bruising until 06/20/19 at 1:22 AM, when a nursing note stated, Monitoring bruise to upper back found prior to this shift. Bruise remains black. Review of the hospital record for Resident #1 dated 06/21/19, revealed the resident was sent to the hospital to have his/her feeding tube replaced. Further review of the hospital record revealed hospital staff documented the area to the resident's back as being bruised with a skin tear and the area measured fourteen (14) centimeters by two (2) centimeters. Interview with LPN #1 on 07/10/19 at 10:00 AM revealed she had been the nurse who had cared for Resident #1 on day shift, 06/19/19 and 06/20/19. The LPN stated she remembered that the resident had a tube feeding, but did not remember seeing an area to the resident's back. Interview on 07/10/19 at 5:28 PM with the former DON (who was employed at the facility when the incident occurred) revealed she remembered seeing Resident #1 on 06/17/19 and the bruise to the resident's back. The former DON stated an incident report was completed and the physician was notified. The former DON stated the facility believed the area to the resident's back was caused by the turn sheet. However, the former DON stated that after a change in the resident's condition or incident, nursing staff were to assess the resident at least every shift related to the change or incident and document the assessment in the nurse's notes.

Based on interview, record review, and policy review, the facility failed to ensure medical records for two (2) of six (6) residents (Residents #4 and #2) were accurate. Resident #4 had physician's orders to receive tube feeding and water flushes via the gastrostomy tube (feeding tube). However, facility staff failed to document that the tube feedings and water flushes were administered as ordered. Resident #2 had physician's orders for wound care and dressing changes daily. However the facility staff failed to document that the wound care was performed as ordered. The findings include: Review of the facility policy, Daily Work Assignments, dated 08/01/19, revealed all nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy .All licensed nursing personnel and other support staff must perform all assigned duties in accordance with their respective job description and facility policy. 1. Review of Resident #4's medical record revealed the facility admitted the resident on 08/08/15 and the resident's [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed the resident was rarely/never understood and required extensive assistance of staff for eating. Review of Resident #3's plan of care initiated on 04/12/17 revealed staff were required to administer the resident gastrostomy tube feedings as ordered and to check residuals as ordered. Review of Resident #3's physician orders dated 06/06/19 revealed an order for [REDACTED].#3 revealed the resident was to receive 300 ML of free water flushes per gastrostomy tube five (5) times per day. Continued review of Resident #3's TAR revealed staff were required to document that the resident's tube feeding was administered as ordered on the 7:00 AM to 7:00 PM shift and on the 7:00 PM to 7:00 AM shift. However, review of the TAR revealed no documented evidence that tube feeding was administered to the resident for seven (7) shifts from 07/01/19 through 07/10/19. Further review revealed no documented evidence that the facility provided water flushes as ordered by the resident's physician 27 times from 07/01/19 through 07/10/19. In addition, further review of Resident #3's TAR revealed no documented evidence that tube feeding was administered on day shift (7:00 AM - 7:00 PM) on 07/09/19. However, observation of Resident #3 on 07/09/19 at 11:10 AM, 12:40 PM, 1:05 PM, 2:03 PM, and 3:15 PM revealed tube feeding was infusing at 45 ML per hour as ordered by the resident's physician. Interview on 07/10/19 at 10:00 AM with Licensed Practical Nurse (LPN) #1 revealed she checked tube feedings to ensure it was administered as ordered, but did not always get everything documented due to being so busy. Interview with the Director of Nursing (DON) on 07/11/19 at 10:15 AM revealed administrative staff had not identified the omissions on the resident's TAR. The DON stated the Kentucky Medication Aides (KMAs) gave medications on one hallway on the North Unit. The DON stated the nurse had to administer/monitor tube feeding for the KMAs' patients, and may forget to document because the TARs were not on the nurse's medication cart. Interview with the Administrator on 07/11/19 at 2:00 PM revealed the Unit Managers and Director of Nursing monitored to ensure Medications and Treatments were administered as ordered. The Administrator stated the facility had not identified blanks on the TARs and there was not a current Quality Improvement Monitor related to medication or treatment administration. 2. Review of Resident #1's medical record revealed the facility admitted the resident on 05/01/18. The resident's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which meant the resident was not able to complete the interview. The resident was assessed to require extensive to total assistance with activities of daily living, requiring assistance of two (2) staff members for bed mobility. Resident #1 could not be observed as the resident was no longer a resident of the facility. Continued review of the record revealed Resident #1 had physician orders dated 06/14/19 to clean the pressure ulcers to the resident's buttocks with normal saline and apply a comfort form dressing to the area every day and as needed. However, review of the Treatment Administration Record (TAR) for Resident #1 revealed the daily treatment to the resident's pressure ulcer had not been documented as completed on 06/19/19 and 06/20/19 for the 7:00 AM to 7:00 PM shift. Interview with Licensed Practical Nurse (LPN) #1 on 07/10/19 at 10:00 AM revealed she had cared for the resident during the timeframe in question and remembered the resident having a nasogastric tube feeding, but did not remember seeing the resident's pressure ulcers or remember completing the resident pressure ulcer treatment on 06/19/19 or 06/20/19. Interview with the Director of Nursing on 07/11/19 at 10:15 AM revealed she had reviewed the resident's chart and TARs and could find no documentation that Resident #1's treatments were completed on 06/19/19 and 06/20/19. 3. A review of the medical record for Resident #2 revealed the facility admitted the resident on 03/12/19 with [DIAGNOSES REDACTED]. Review of Resident #2's physician orders dated 05/30/19 revealed an order for [REDACTED]. A review of Resident #2's TAR for (MONTH) 2019 revealed no documented evidence that wound care was provided to Resident #2's right heel on 07/01-04/19 or 07/06-08/19. Interview with Licensed Practical Nurse (LPN) #1 on 07/10/19 at 2:15 PM revealed she was the nurse assigned to care for Resident #2 on 07/02/19, 07/04/19, and 07/05/19, and was not sure why she did not document that wound care was provided. An interview with Registered Nurse (RN) #1 on 07/10/19 at 1:40 PM revealed she provided wound care for Resident #2 on 07/08/19. RN #2 stated she had gotten busy and failed to document the wound care. Interview with LPN #6 on 07/10/19 at 2:35 PM revealed she provided wound care for Resident #2 on 07/01/19, but failed to document that the care was provided on the resident's TAR. Interview with the Director of Nursing (DON) on 07/11/19 at 4:00 PM revealed nurses were required to document wound care on the resident's TAR when the care was provided. According to the DON, she was new to the facility, but made daily rounds to identify concerns with resident care and was not aware that nurses were not documenting wound care as required.

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations, on 04/23/19, revealed dust accumulation on a fan used in the dish room and the ceiling above the production area. In addition, the dish machine temperatures were missing and not documented throughout the month of (MONTH) 2019. The findings include: Review of the facility's Policy, titled Water Temperatures for Dish Washing Machines, undated, revealed facility should maintain adequate dishwashing machine temperatures to effectively wash and sanitize eating utensils and dishware. Continued review revealed the results of the temperatures must be recorded daily at each meal and the Dietary Manager would keep a written record of the results in the kitchen. Review of the facility form titled Dish Machine Log dated (MONTH) revealed the dish machine temperatures not recorded. The following dates not documented for Breakfast, Lunch, and Dinner on 04/03/19, Breakfast and Lunch for 04/06/19. Breakfast, Lunch and Supper for 04/07/19, 04/10/19, Breakfast, and Lunch for 04/12/19, Breakfast, Lunch for 04/15/19, Supper for 04/17/19, 04/18/19, and Breakfast and Lunch for 04/20/19, 04/21/19. Observation of the kitchen area, on 04/24/19 at 8:10 AM, revealed a fan near dish room. Continued observation revealed there was dust on the blades of the fan. Further observation revealed the fan was on and the air was directed into the dish room. Observation of the kitchen area, on 04/25/19 at 1:23 PM, revealed the fan was on and directed into the dish room. Continued observation revealed there was dust on the ceiling over the production area. Interview with Dietary Aide #4, on 04/25/19 at 1:02 PM, revealed the temperatures for the dish machine should be documented in the morning and at lunch to make sure the dishes are cleaned. Interview with Diet Aide #1, on 04/25/19 at 1:06 PM, revealed the temperature on the dish machines should be documented three (3) times a day with each meal. Per interview, this is done to make sure the dishes get clean. Interview with Dietary Aide #2, on 04/25/19 at 1:16 PM, revealed the dish machine temperatures were recorded every day to know the dish machine was working correctly so the dishes would be sanitized. Continued interview revealed should notify the manager for the dust on the fan and ceiling. Per interview, dust could get into the food. Interview with Dietary Aide #3, on 04/25/19 at 1:19 PM, revealed the dish machine temperatures should be checked three (3) times a day. Continued interview revealed the temperatures were documented daily to ensure the dish machine was running correctly and sanitizing the dishes for the safety of the residents. Per interview, the dust on the fan and the ceiling can get on the dishes and into the food and contaminate the food. Interview with Cook #1, on 04/25/19 at 1:08 PM, revealed the temperatures for the dish machine should be recorded for breakfast, lunch and supper to ensure the dish machine is washing and sanitizing the dishes correctly. Continued interview revealed maintenance was responsible for cleaning the dust from the ceiling. Further interview revealed dietary staff should check the fan and ceiling for dust and report this to maintenance because the dust could fall into the food and onto the dishes. Interview with the Certified Dietary Manager (CDM), on 04/25/19 at 1:23 PM, revealed recording of the dish machine temperature was required to be completed and documented three (3) times a day at meal times to ensure the dish machine cleans and sanitize the dishes correctly to ensure resident safety. Continued interview revealed the fan and ceiling should be cleaned appropriately and without dust. Per interview, dust will contaminate the dishes and food. Interview with Director of Nursing (DON), on 04/25/19 at 1:49 PM, revealed the dish machine temperatures should be recorded daily, per the facility's policy, to provide sanitization of dishware, infection control, and to ensure the equipment is operating properly. Continued interview revealed the fan and ceiling should be clean and dusted to prevent cross contamination of dishes, utensils and food for the safety of the residents. Interview with Administrator, on 04/25/19 at 3:09 PM, revealed the dish machine temperatures should be recorded daily to ensure the dish machine was holding the proper temperatures to sanitize and provide clean plates and dishware for resident safety. Continued interview revealed the fan and ceiling should be cleaned regularly to remove dust for sanitary conditions for the health and safety of the residents.

Based on observation, interview, record review, and review of facility's Policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (1) of twenty-three (23) sampled residents (Resident #4). Observation on 04/24/19 during the morning mealtime revealed Resident #4 was being assist by a SRNA who was standing next to and over top of the resident. The findings include: Review of the facility's Policy, titled Resident Rights, undated, revealed the resident has the right to be treated with consideration, respect and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs. Review of Resident #4's clinical record revealed the facility admitted the resident on 05/01/18 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 01/26/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15), indicating severe cognitive impairment. Observation of the morning meal, on 04/24/19 at 8:06 AM, revealed Resident #4 was being assisted with his/her meal. Continued observation revealed SRNA #5 was standing beside the resident while she was feeding him/her. Interview with State Registered Nurse Aide (SRNA) #5, on 04/24/19 at 8:10 AM, revealed she had worked at the facility for two (2) months. Continued interview revealed she normally stands to feed Resident #4 because he/she is in a high back wheelchair. She further stated she was supposed to pull up a chair to assist feeding residents; however, it was easier for her to stand to assist Resident #4. Further interview revealed it was a dignity issue to stand and feed residents. She stated she should have been at the resident's eye level. Interview with Certified Medical Assistant #9, on 04/25/19 at 10:30 AM, revealed she had worked at the facility for six (6) years. She stated the process to assist with feeding residents was to wash her hands, set up the tray and ensure the resident was sitting upright. She further stated she would pull up a chair and sit with the resident while she assisted the resident with their meal. She stated it is a dignity issue to stand up to feed a resident. Interview with Kentucky Medication Aide (KMA), on 04/25/19 at 10:42 AM, revealed, she had worked at the facility for two years. She stated she would wash her hands prior to assist feeding a resident, she would check the tray card for accuracy and pull up a chair to sit in while feeding the resident. She stated it was never okay to stand and feed a resident because that was a dignity issue for the resident. Interview with SRNA #6, on 04/25/2019 at 10:50 AM, revealed she had worked at the facility since (MONTH) (YEAR). Per interview she stated the process to assist a resident with their meal was to get a tray off the cart, check the meal card, wash her hands and grab a folding chair to set beside the resident. She stated it would not be okay to stand beside them and feed them. Further interview revealed staff sit beside them to be at eye level. She stated, if you stand up, it could make the resident not feel at ease, and it is also a dignity issue. Interview with Registered Nurse #1, on 04/25/2019 at 10:55 AM, revealed she was the charge nurse and had worked at the facility for about seven (7) months. Continued interview revealed when she assisted a resident with their meal, she pulled up a chair and sat next to them. She stated you always wanted to be eye-to-eye with the resident before assisting with the meal. She stated standing up is a dignity issue and would be over powering to the resident, she further stated you could not converse with them if you are standing over them. Interview with Director of Nursing (DON), on 04/25/2019 at 1:35 PM, revealed she had worked for the company for twelve (12) years in different roles; this was her first DON role. Per interview, it was her expectation for all residents to be treated with respect and dignity. She further stated when staff are assisting dependent residents with feeding it is her expectation that staff to make sure the tray is correct and matches the resident's diet. Continued interview revealed she expects staff to wash their hands and explain to the resident what they have to eat. She stated it is her expectation for the staff to sit in a chair while feeding the resident. She stated standing is not our practice and it would be a dignity issue to be standing while feeding the resident. She stated staff need to be at eye level with the residents. Interview with Administrator, on 04/25/19 at 2:15 PM, revealed she had been working at the facility for six (6) weeks. She stated it was her expectation for staff to assist residents in a dignified manner. She stated under normal circumstances it would not be appropriate to stand beside a resident, unless they are care planned for the staff to stand. She stated they should pull up a chair and sit down next to the resident to assist them with their meal. She stated sitting would be keeping with their dignity. Continued interview revealed it was her expectation staff ensure the residents' rights and treat them in a dignified manner and sit along beside them to assist with dining.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for three (3) of twenty two (22) sampled residents (Resident #8, Resident #49 and Resident 51). 1. Resident #8 had unwitnessed fall events in his/her room, during unassisted transfers, on 12/28/18 and 04/03/19. However, there was no documented evidence the Comprehensive Care Plan (CCP) was revised to include interventions related to the Root Cause of the fall events to prevent further falls of the same nature. 2. Per record review and interviews, Resident #49 sustained a fall, on 04/23/19 at the bedside during an unassisted transfer from the wheelchair to the bed. However, there was documented evidence the CCP was revised to include an intervention status [REDACTED]. 3. Per observation and interviews, Resident #51 was re-admitted to the facility on [DATE] after a hospitalization , with a urinary catheter. However, there was no documented evidence the Comprehensive Care Plan was revised to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). The findings include: Review of the facility's Policy, titled Care Plan, dated 08/01/13, revealed the individualized CCP would be developed to include measurable objectives and timetables to meet the medical, nursing, mental and psychological resident needs. Additionally, the CCP would identify care needs based on ongoing thorough assessment of the resident. Continued review revealed each resident's CCP would incorporate identified problem areas; incorporate risk factors; reflect treatment; aide in preventing declines in functional status; and reflect currently recognized standards of practice for problem areas and conditions. Further, when a resident was readmitted to the facility from a hospital stay, the Care Planning/Interdisciplinary team would revise the CCP as necessary to changes in the resident's condition. Review of the facility's Policy, titled Fall Program Guide, undated revealed it was the facility's responsibility to ensure the residents care, treatment and the environment was assessed, care planned and implemented. Additional review revealed the facility Fall Protocol included documenting interventions and identified fall risk in the CCP. 1. Review of Resident #8's medical record revealed the facility admitted the resident on 05/26/18, with primary [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly MDS Assessment, dated 01/25/19 revealed the facility assessed the resident to have a BIMS score of nine (9) out of fifteen (15), indicating moderated cognitive impairment. Additional review revealed the facility assessed the resident to required limited assistance of one (1) staff for bed mobility, transfers, walking, and locomotion. Continued review revealed the Resident required extensive assistance of one (1) staff for dressing, toileting and personal hygiene. Per Assessment, the resident was not steady but could stabilize by themselves from sit to stand, walking, turning and surface to surface transfer; however, required assistance to stabilize on and off the toilet. Further, the resident was frequently incontinent of bladder and continent of bowel. Per review, Resident #8 had two (2) or more falls since the last assessment with injury. Continued review revealed the resident had received the following medications seven (7) days during the assessment period: insulin, antipsychotic, antidepressant and a diuretic. Further, the resident had not received therapy of Restorative programs. Further review revealed the resident used a bed and chair alarm daily. Review of the Comprehensive Care Plan, dated 06/05/18 revealed the Resident #8 was at risk for falls related to Confusion, Gait/balance problems, Psychoactive drug use, Unaware of safety needs, and wandering. The goal was for the resident not to sustain serious injury. Interventions included to anticipate and meet the needs of the resident, initiated on 06/05/18 and bed alarm, initiated on 06/20/18. Continued review revealed interventions to place the walker directly in front of the resident, initiated on 10/16/18; nonskid strips on the floor at bedside, initiated on 11/29/18; nonskid socks while in bed, initiated on 12/04/18; and nonskid strips to floor in front of recliner, initiated on 12/21/18. Additional review revealed interventions included a sensor alarm to the chair, initiated on 02/26/19; scheduled toileting, initiated on 03/19/19; therapy screen for transfer, initiated on 03/21/19; and nonskid strips on floor in front of guest chair, and initiated on 03/29/19. However, there is no documented evidence the CCP was revised after fall events on 12/28/18 and 04/03/19 with interventions to prevent falls of the same nature. Review of Nurse's Notes, dated 12/28/18 at 2:45 AM, revealed a Situation Background Assessment Request (SBAR) related to an unwitnessed fall. Additional review revealed Resident # 8's alarm was sounding and staff noted the resident sitting on the floor in front of the recliner at bedside. Further review revealed the resident stated he/she sat down on the chair and slid to the floor. Review of Resident Accident/Incident Report, dated 12/28/18 at 2:45 AM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid off the recliner to the floor during an unassisted transfer to the chair. Continued review revealed the personal alarm was in use and functioning properly and the assistive device, walker was not used because the resident walked from the bed to the chair. Further review revealed the recommended action taken was to add dycem to the recliner. However there was no documented evidence the CCP, Risk for Falls, dated 06/05/18 was revised to include the addition of dycem to prevent falls of the same nature. Review of the Fall Scene Investigation Report, dated 12/28/18, revealed Resident #8 stated he/she was going to sit in the chair and slid in the floor. Additional review revealed the walker was not in use but was in reach, and the resident was wearing nonskid socks. Further, the alarm was working correctly. Review of the Root Cause Analysis (RCA), dated 12/28/18, revealed Resident #8 got out of bed and attempted to sit in the recliner; sat on the edge of the seat and slid onto the floor. Additional review revealed the resident transferred self from bed to chair, the alarm was sounding and staff immediately responded to the resident. Continued review revealed the resident had slid to the floor from the recliner seat. Review of SRNA #9's Witness Statement, dated 12/28/1,8 revealed Resident #8 stated he/she was attempting to go to the restroom. Interview with State Registered Nursing Assistant (SRNA) #9, on 04/25/19 at 1:17 PM, revealed she did not recall when Resident #8 was last toileted prior to the fall on 12/28/18 or the placement of the walker status [REDACTED]. Review of Nurse's Notes, dated 04/03/19 at 9:45 PM, revealed a Situation Background Assessment Request (SBAR) related to an unwitnessed fall. Per the SBAR, Resident # 8 was noted lying on the floor in front of his/her wheelchair at the doorway with the wheelchair behind them. The resident was wearing street clothes and shoes. Per the resident, he/she slid out of the chair and was OK. Additional review revealed the resident had no injuries and the family and physician were notified of the fall event. Further, there were no new order received by the physician. Review of Resident Accident/Incident Report, dated 04/03/19 at 9:45 PM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid out of the wheelchair. Continued review revealed the personal alarm not used at the time of the fall; however, it was functioning properly. Further review revealed the recommended action taken was to add dycem to the wheelchair. However, there was no documented evidence the CCP or Risk for Falls assessment was revised to include placement of dycem to the recliner after the 04/03/19 fall event. Review of the Fall Scene Investigation Report, dated 04/03/19, revealed the resident stated he/she slid out of the wheelchair. Additional review revealed the chair alarm was not in use and the resident was wearing shoes at the time of the fall. Further, the alarm was working correctly. Review of the RCA, dated 04/03/19, revealed Resident #8 self-transferred into the wheelchair and slid out of the wheelchair at the doorway. Additional review revealed the resident was unaware of safety and risk for falls and enjoyed sitting and watching visitors and staff. Further review revealed the intervention was to add dycem to the wheelchair to reduce risk of sliding out. However, there was no documented evidence the CCP or Risk for Falls was revised to include placement of dycem to the recliner after the 04/03/19 fall event. Review of SRNA #7's Witness Statement, dated 04/03/19, revealed after the fall, she realized the resident's chair alarm was not in the wheelchair. Interview with SRNA #7, on 4/25/19 at 9:01 AM, revealed she did not recall when she last noticed the chair alarm in Resident #8's wheelchair prior to the fall on 12/28/18 or why it was not in the wheelchair per the CCP. However, the CCP was the guide she used to know what fall precautions each resident required. Continued interview revealed she checked resident rooms at the beginning of her shift and ongoing throughout her shift to ensure all fall precautions were in place per the CCP. 2) Review of Resident #49's medical record revealed the facility admitted the resident on 03/15/19, with primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed Resident #49 had difficulty with visions and wore glasses. Continued review revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), indicating severe cognitive impairment. Per the MDS, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfer and toileting; walking did not occur, and required total assistance with locomotion and assistance from one (1) staff for personal hygiene. Per the MDS, the resident had impaired balance between surfaces and impaired range of motion in the both lower extremities. Further, the resident had one (1) fall in the previous month and received seven (7) days of antidepressant and antibiotic medication during the assessment period. Further review the resident received Physical, Occupational, and Speech therapy minutes during the assessment period. Review of Resident #49's Comprehensive Care Plan, dated 04/09/19, revealed the resident was at risk for falls related to impaired cognition, use of [MEDICAL CONDITION] medication, limited range of motion of the bilateral lower extremities, and unable to ambulate. The goal was for the resident not to sustain any falls. Interventions included educated the resident and provide reminders for safety; keep the room free of clutter and obstruction and for staff to provide assistance with transfer. Review of the Admission Nursing Evaluation, dated 03/15/19, revealed Resident #49 required assistance of two (2) staff for mobility and transfers. Further review revealed he/she was confused and oriented to person. Review of Fall Risk Evaluation, dated 03/15/19, revealed the facility assessed Resident #49 as high risk for falls, with a total score of fourteen (14). Additional review revealed the resident had intermittent confusion, had two (2) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of Fall Risk Evaluation, dated 03/24/19, revealed the facility assessed Resident #49 as high risk for falls, with a total score of sixteen (16). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of a SBAR, dated 04/23/19 at 5:15 PM, revealed Resident #49 sustained an unwitnessed fall without injury. Per review, the Resident was sitting in the floor on their buttocks beside the bed. Additional review revealed the Resident stated they got up without assistance from the wheelchair and forgot to lock the wheels; the wheelchair rolled and the resident fell to the floor. Further review revealed a reminder was posted in the room to Ask for Assistance. However, there was no documented evidence the CCP was revised, by LPN #2, with the intervention until the morning of 04/25/19. Attempted to call LPN #2 on 04/25/19 at 1:12 PM. Message was left to return call; however, no returned call was received. Review of a Resident Accident/Incident Report, dated 04/23/19 at 5:15 PM, revealed Resident #49 was observed in the room, sitting in the floor beside the bed and wheelchair post fall event. Additionally, the resident stated they had forgot to lock the wheelchair brakes and was trying to get in the bed. Further review revealed signage was posted in the room to Ask for Assistance Review of a Fall Scene Investigation Report, dated 04/23/19 at 5:15 PM, revealed Resident #49 stated he/she was trying to self-transfer to bed from the wheelchair. Additional review revealed the resident was wearing shoes at the time of the fall. Further review revealed the wheelchair slid out from under the resident during the attempted transfer. Review of a Summary of Root Cause Analysis (RCA), dated 04/23/19, revealed Resident #49 attempted to self-transfer into the bed from the wheelchair and slid out of the wheelchair into the floor. Additional review revealed the resident had a [DIAGNOSES REDACTED]. The intervention was to place signage in the room to Ask for Assistance prior to attempting transfer. Review of Nurse's Notes, for (MONTH) 2019, revealed no documented evidence of a fall on 04/23/19 at approximately 6:00 PM. Review of a physician's orders [REDACTED]. Interview with Resident #49, on 04/24/19 at 8:11 AM, revealed the resident had sustained a fall on 04/23/19 around 6:00 PM when he/she was trying to go back to bed to rest. Per interview, Resident #49 stated he/she attempted to get in bed by themselves and forgot to lock the wheelchair and when he/she stood from the wheelchair, it rolled backwards causing them to lose their balance and fall to the floor. Additional interview revealed the resident did not have an injury with the fall. Further interview revealed the nursing staff told him/her not to get in or out of bed by themselves. 3. Review of Resident #51's medical record revealed the facility admitted the resident on 03/02/19 with a primary [DIAGNOSES REDACTED]. Secondary admitting [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/22/19, revealed the facility assessed Resident #51 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognitive response. Additionally, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfers, and toilet use. Continued review revealed the resident required extensive assistance of one (1) staff with personal hygiene and ambulation in the room. Further review revealed the resident had seven (7) or more episode of urinary incontinence, but had at least one (1) episode of continent voiding during the assessment period. Review of the Comprehensive Care Plan (CCP), dated 04/09/19, revealed Resident #51 had toileting elimination deficit related to impaired mobility, and frequent incontinence of bladder. The goals included remaining clean and odor free and show signs of improvement in bladder continence while on scheduled toileting. Interventions included assess toilet patterns and needs, staff assistance with toileting needs, scheduled toileting every one (1) and half-hours. However, there was no documented evidence the CCP was revised on 04/16/19 or after to include an indwelling catheter. Review of Resident #51's Nurse's Notes, dated 04/10/19 at 8:00 AM, revealed a Situation Background, Assessment/appearance, Request (SBAR) assessment related to shortness of air and [MEDICAL CONDITION]. Additional review revealed the Resident was noted with tremors and was struggling to breathe with oxygen on at four (4) liters per nasal cannula, wheezes were auscultated in the lungs, and [MEDICAL CONDITION] was noted in bilateral lower extremities. The physician and resident representative were notified and the Resident was sent to the emergency room for further evaluation. Further, review of physician's orders [REDACTED]. Additional review of Nurse's Notes, dated 04/16/19 at 3:00 PM revealed Resident #51 returned to the facility and was taken to his/her room. However, there was no documented evidence the CCP was not developed to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the Resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). Review of the State Registered Nursing Assistant (SRNA) Kardex/Care Plan, dated 04/16/19, revealed Resident #51 had a catheter, required a leg strap, and catheter care. However, there was no documented evidence to resident's Comprehensive Care Plan was the CCP, was revised to include the indwelling catheter indication for use, ongoing care and removal protocols. Interview with Resident #51, on 04/23/19 at 4:00 PM, revealed he/she had a recently hospitalization related to excess fluid and trouble breathing. Per interview, while at the hospital an indwelling catheter was placed to help get the fluid off. Additional interview revealed he/she cleaned the catheter when on the toilet at least daily and night shift nursing staff had communicated to the Resident, by doing so would prevent infection related to the catheter. Further interview revealed the Resident was curious to know when the catheter would be removed since he/she had been back to the facility for a week now and was feeling better. Interview with SRNA #7, on 04/25/19 at 9:01 AM, revealed she has been at the facility for two (2) month. Per interview, Resident #51 had a catheter for almost two (2) weeks now after returning from the hospital. Additionally, she knew what care to provide to each resident per the CCP. Further, it was important for the CCP to be updated and revised to ensure necessary care was provided to a catheter to ensure it was clean, there was output, and the resident was not experiencing pain associated to the catheter. Interview with Kentucky Medication Aide (KMA), on 04/25/19 at 8:58 AM revealed she had worked at the facility for six (6) years. Interview revealed she knew how to provide care to each resident per the CCP. Per interview, Resident #51 returned to the facility after a hospitalization [DATE] with an indwelling catheter. However, she was not aware the CCP had been revised to include the indwelling catheter. Per KMA, it was important to provide catheter care each shift to decrease the risk for infection and or trauma to the Resident. It was also important to see the catheter each shift and documented the output and let the nurses know any changes to ensure a resident received care for their catheter; care that only a nurse could provide, like flushes or changing it, if the catheter was blocked. Further, she was not aware why the Resident had the catheter but knew the Resident was curious about when it was due to be changed or removed because she had never had a catheter before. Continued interview with KMA revealed the CCP should be revised after each fall to ensure resident remain safe and do not get hurt. Additionally, the revision of the CCP was the responsibility of the nurses including the MDS and DON. Further, she was not aware that Resident #8's CCP did not include dycem to the wheelchair seat and recliner seat. Per interview, she was not aware of any intervention implemented related to Resident #49's recent fall from the wheelchair. Interview with LPN #3, on 04/24/19 10:58 AM, revealed the she was responsible to review and revise the CCP with newly identified problem areas on re-admission. Per interview, it was the responsibility of the nurse to ensure the CCP identified all resident needs based on a thorough assessment of the resident. Additional interview revealed the nurse re-admitting Resident #51 on 04/16/19 failed to revise the CCP to include the indicated use of the urinary catheter, ongoing care, and interventions to decrease the risk for infection and trauma. Further, it was important for the CCP to be revised and to include all resident care needs to ensure resident were provided quality care to meet their needs. Continued interview with LPN #3 revealed the licensed nurse was responsible to complete a thorough assessment of the resident and events prior to a fall event. Per interview, it was the responsibility of the nurse to ensure the CCP was revised to include an intervention based on a RCA of the fall event, at the time of the fall to prevent further falls of the same nature. Additionally, the CCP for Resident #8 should have been revised on 12/28/18 and 04/03/19 to include the placement of dycem to the recliner and wheelchair seats. Further, the CCP should have been revised for Resident #49, on 04/23/19 to include the sign placed in the Resident's room to Call for Assistance. Continued interview revealed it was important that the direct care staff complete a thorough assessment of all fall events to determine the true RCA and to implement an intervention that was sufficient and effective. Interview with Minimum Data Set (MDS) Coordinator, on 04/25/19 at 10:00 AM, revealed she gathered information to revise the CCP per record review to include hospital discharge summaries, physician orders, diagnosis, and nursing assessments. Additionally, she would talk with the nursing staff and the residents, and attending Monday through Friday IDT clinical meetings to review the twenty-four (24) hour reports. Continued interview revealed she was unaware Resident #51 re-admitted to the facility on [DATE] with an indwelling catheter. Per the MDS coordinator, nursing staff did not communicate the information to her and the assessments and discharge summary did not note the indwelling catheter. Per interview, the CCP should have been revised to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the Resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). Continued interview revealed it was important for the CCP to be revised with catheter care to ensure staff are providing the appropriate catheter care to reduce the risk for infection and trauma. Further, to complete ongoing assessment to determine when the catheter could be removed as necessary. Further interview revealed in addition to the Monday through Friday Clinical meeting, the facility had a Falls Committee meeting, after the morning meeting. Per interview, during this meeting, the IDT reviewed immediate interventions direct care nurses had implemented status [REDACTED]. The attendees at the meeting included: the activities director, unit managers, DON, MDS, Social Services, SRNA off the floor, and the Administrator. Additional interview revealed a thorough review of the fall paper work was completed for each fall including the Incident Report, Witness Statement, Fall Scene investigation, the SBAR, Nurses Notes, etc. Continued interview revealed the RCA was determined after review and any revisions were made to the CCP at that time to prevent another fall of the same nature. Per interview, the interventions were made based on the RCA and the individual resident's strengths and weaknesses, and should be effective and sufficient to prevent falls. Further, the SRNA care plan as well as the CCP should have been updated immediately status [REDACTED].#8 and Resident #49. However, she was not aware Resident #49 had sustained a fall on 04/23/19 during an unassisted transfer from the wheelchair to the bed. Per the MDS Coordinator, CCPs and SRNA Kardex revisions should be legible writing with initials of the staff making the revision and dated with the current date to ensure the IDT are aware of the Resident care needs to keep them safe. Interview with the Director of Nursing (DON), on 04/25/19 at 2:30 PM, revealed she had been at the facility as the DON since 10/01/18. Per interview, it was the responsibility of the assigned direct care nurse to revise the CCP based on a face-to-face assessment for each resident on admission and re-admission to the facility. Continued interview revealed the direct care nurse assigned to Resident #51, on 04/16/19 failed to revise the CCP to include the use of an indwelling catheter. Additionally, the CCP should have been revised to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). Further, it was important for the CCP to be revised with changes in a resident's status because it was a guide used by the interdisciplinary team to ensure individualized quality care was provided to the resident to meet their needs. Continued interview revealed the DON did not have a current process in place to audit care plans and ensure revisions were made as necessary. Further interview with the DON revealed status [REDACTED]. Additionally, the nurse should do their due diligence to determine the root cause of the fall and implement an appropriate intervention related to the resident's individualized needs and the RCA, to prevent further falls of the same nature. Per interview, the CCP should have been revised immediately after the falls for Resident #8 on 12/28/19 and 04/03/19 for dycem to the recliner and wheelchair seats and for Resident #49 on 04/23/19 for the sign placed in the Resident's room. Further, the facility's fall follow up process should have been maintained and Resident #49's interventions should have been revised on the CCP before the evening of 04/24/19. After review of the SBAR, it was determined the best intervention for Resident #49 was anti roll back brakes to the wheelchair to prevent further falls if the Resident were to attempt to self-transfer to bed again; which was revised on 04/25/19. Per interview, she updated the CCP for Resident #49 on 04/24/19 after 5:00 PM. Continued interview revealed she backdated the intervention of Signage in the resident's room for 04/23/19 because the SBAR stated LPN #2 placed the sign in the room then. However, the CCP should have been revised at the time of the fall or during the Clinical meeting the morning of 04/24/19. Further interview revealed the Clinical meeting on 04/24/19 did not occur because surveyors were in the building. She expected the facility policy and protocols to be upheld related to fall management to ensure all resident's safety. Interview with the Administrator, on 04/25/19 at 3:00 PM, revealed she expected the direct care nursing staff to revise the CCP after re-admission assessments of residents to ensure any changes in a resident's status were identified and necessary care was provided. Per interview, she expected nursing leadership (DON and MDS) to audit the CCP to ensure necessary revisions are made after a re-admission. Additionally, she expected the CCP to include the indicated use of indwelling catheters, ongoing catheter care, and criteria for discontinuation of the catheter for all Resident's with catheters. Further, the CCP was the guide used by all staff to ensure a resident received necessary quality care to meet their needs and ensure their safety. Further interview with the Administrator revealed she expected the direct care nursing staff to maintain the facility's Care Plan policy. Per interview, it was the responsibility of the direct care nurse to revise the CCP immediately with an intervention to reduce the risk of further falls and at the latest within twenty-four (24) hours. Per interview, she expected the IDT to ensure the facility policy and protocols were followed after each resident fall through review of the fall event documentation. Additionally, she expected interventions to be based on the RCA and the residents needs and be effective in maintaining the resident's safety and meeting their needs.

Based on interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for three (3) of twenty-two (22) sampled residents; Resident #8, Resident #49 and Resident #53. 1. Resident #8 was assessed by the facility to be at High Risk for falls and to require the limited assist of one (1) staff for transfers and ambulation, and extensive assist of two (2) for toileting. However, record review revealed on [DATE], the resident self-transferred from the bed to the recliner while alone in the bedroom without supervision. Resident #8 sustained a fall when sliding from the recliner seat to the floor. Additionally, per SRNA #7's Witness Statement, on [DATE], the resident stated he/she was trying to go to the restroom. Further record review revealed on [DATE], the resident self-transferred into the wheelchair while alone in the bedroom without supervision. Resident #8 sustained a fall when sliding from the wheelchair seat to the floor. Continued review revealed SRNA #9's Witness Statement, on [DATE] revealed the wheelchair sounding alarm was not in the resident's wheelchair at the time of the fall. The facility failed to complete thorough investigation, as there was no documented evidence the Root Cause Analysis (RCA) of the falls addressed the causative factors related to why the Resident slid out of the chair. 2. Resident #49 was assessed by the facility to be at High Risk for fall and to require extensive assistance of tow (2) for transfers. However, interviews and record review revealed on [DATE], the resident self-transferred from the wheelchair to the bed while alone in the bedroom without supervision. Resident #49 sustained a fall, when the wheelchair rolled away, to the floor. Continued review revealed SRNA #10's Witness Statement, on [DATE] revealed the resident was assisted to and from the toileting and left in his/her room in the wheelchair prior to the fall. There was no documented evidence of a facility assessment related to the fall event in the medical record on [DATE] or [DATE]. Further, the facility failed to complete a thorough investigation, as there was no documented evidence the CCP was revised with an intervention related to the RCA until [DATE]. 3. Observation of Resident #53, on [DATE] at 4:10 PM, revealed an over the counter medication bottle, opened on the bedside table. Continued observation revealed the bottle was labeled Cayenne four hundred (400) milligram (mg). Interview with Resident #53 revealed his/her daughter brought the medication to the facility on [DATE] and it was supposed to help with his/her legs. Continued interview with the resident revealed he/she does not self-administer his/her own medications. The findings include: Review of the facility's Policy, titled Fall Program Guide, undated revealed it was the facility's responsibility to ensure the resident care, treatment and the environment was assessed, care planned and implemented. Additional review revealed the facility Fall Protocol included determinations of deficient practice to reduce falls and fall risk. Continued review revealed deficient practice was identified through record review and interviews of each fall, including what Fall Risk Factors (FRFs) were not identified as a problem; which FRF were known by staff and not communicated through documentation; were interventions and identified fall risk documented in the Comprehensive Care Plan (CCP); and were interventions taken sufficient. Further, review revealed an assessment of the resident would be performed at the time of the incident, by a licensed nurse to attempt to determine causative factors of the incident. 1. Review of Resident #8's medical record revealed the facility admitted the resident on [DATE], with primary [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated [DATE] revealed the facility assessed Resident #8 to have a Brief Interview of Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severe cognitive impairment. Additional review revealed the facility assessed the resident to require limited assistance of one (1) staff for bed mobility, transfers, walking, and locomotion. Continued review revealed the Resident required extensive assistance of one (1) staff for dressing, toileting and personal hygiene. Per Assessment, the Resident was not steady but could stabilize by themselves from sit to stand, walking, turning and surface to surface transfers; however, required assistance to stabilize on and off the toilet. Further, the resident was frequently incontinent of bladder and continent of bowel. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #8 to have a BIMS score of nine (9) out of fifteen (15), indicating the resident had moderate cognitive impairment. Continued review revealed the facility assessed the resident to require one (1) person physical assistance for bed mobility, transfers, walking in the room or corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Further review revealed the facility assessed the resident to have had two (2) or more falls without injury since admission or the last assessment. Per the MDS the resident had received the following medications seven (7) days during the assessment period: insulin, antipsychotic, antidepressant and diuretic. Review of Resident #8's Quarterly MDS Assessment, dated [DATE] revealed the facility assessed the resident to have a BIMS score of nine (9) out of fifteen (15), indicating moderated cognitive impairment. Additional review revealed the facility assessed the resident to required limited assistance of one (1) staff for bed mobility, transfers, walking, and locomotion. Continued review revealed the Resident required extensive assistance of one (1) staff for dressing, toileting and personal hygiene. Per Assessment, the resident was not steady but could stabilize by themselves from sit to stand, walking, turning and surface to surface transfer; however, required assistance to stabilize on and off the toilet. Further, the resident was frequently incontinent of bladder and continent of bowel. Per review, Resident #8 had two (2) or more falls since the last assessment with injury. Continued review revealed the resident had received the following medications seven (7) days during the assessment period: insulin, antipsychotic, antidepressant and a diuretic. Further, the resident had not received therapy of Restorative programs. Further review revealed the resident used a bed and chair alarm daily. Review of a physician's orders [REDACTED]. Review of a Fall Risk Evaluation, dated [DATE], revealed the facility assessed the resident as high risk for falls, with a total Score of twenty-two (22). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, had gait/balance problems and received medication that caused lethargy or confusion. Per the evaluation, a total score of ten (10) or above represented High Risk for falls and should be considered for potential falls. Review of Resident #8's Comprehensive Care Plan, dated [DATE] revealed the resident was at risk for falls related to Confusion, Gait/balance problems, psychoactive drug use, Unaware of safety needs, and wandering. The goal was for the resident not to sustain serious injury. Interventions included to anticipate and meet the needs of the Resident, initiated on [DATE] and to have a bed alarm, initiated on [DATE]. Continued review revealed interventions to place the resident's walker directly in front of the resident, initiated on [DATE]; nonskid strips on the floor at bedside, initiated on [DATE]; nonskid socks while in bed, initiated on [DATE]; and nonskid strips to the floor in front of the recliner, initiated on [DATE]. Additional review revealed interventions included sensor alarm to chair, initiated on [DATE]; scheduled toileting, initiated on [DATE]; therapy screen for transfer, initiated on [DATE]; and nonskid strips on the floor in front of the guest chair, initiated on [DATE]. Review of a Nurse's Notes, dated [DATE] at 2:45 AM, revealed a Situation Background Assessment Request (SBAR) for Resident #8 related to an unwitnessed fall. Per the SBAR, Resident # 8's alarm was sounding and staff noted the resident sitting on the floor in front of the recliner at bedside. The resident stated he/she sat down on the chair and slid to the floor. Additional review revealed the resident had no injuries and the family and physician were notified of the fall event. Further, there were no new order received by the physician. Review of Resident Accident/Incident Report, dated [DATE] at 2:45 AM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid off the recliner to the floor during an unassisted transfer to the chair. Continued review revealed the personal alarm was in use and functioning properly and the assistive device walker was not used because the resident walked from the bed to the chair. Further, the recommended action taken was to add dycem to the recliner. However, there was no documented evidence the CCP, Risk for Falls, dated [DATE] was revised to include placement of dycem to the recliner after the [DATE] fall event. Review of the Fall Scene Investigation Report, dated [DATE], revealed Resident #8 stated he/she was going to sit in the chair and slid in the floor. Additional review revealed the walker was not in use but was in reach, and the resident was wearing nonskid socks. Further, the alarm was working correctly. Review of SRNA #9's Witness Statement, dated [DATE], revealed Resident #8 stated he/she was attempting to go to the restroom. Interview with SRNA #9, on [DATE] at 1:17 PM, revealed she did not recall when Resident #8 was last toileted prior to the fall on [DATE] or the placement of the walker status [REDACTED]. Review of the Root Cause Analysis (RCA), dated [DATE], revealed Resident #8 got out of bed and attempted to sit in the recliner; sat on the edge of the seat and slid onto the floor. Additional review revealed the resident transferred self from bed to chair, the alarm was sounding and staff immediately responded to the resident. Continued review revealed the resident had slid to the floor from the recliner seat; however, there was no documented evidence the RCA addressed the Resident's toileting needs. Review of Fall Risk Evaluation, dated [DATE], revealed the facility assessed Resident #8 as high risk for falls, with a total score of twenty-two (22). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, had gait/balance problems and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of Nurse's Notes, dated [DATE] at 9:45 PM, revealed a Situation Background Assessment Request (SBAR) related to an unwitnessed fall. Per the SBAR, Resident # 8 was noted lying on the floor in front of his/her wheelchair at the doorway with the wheelchair behind them. The resident was wearing street clothes and shoes. Per the resident, he/she slid out of the chair and was OK. Additional review revealed the resident had no injuries and the family and physician were notified of the fall event. Further, there were no new order received by the physician. Review of Resident Accident/Incident Report, dated [DATE] at 9:45 PM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid out of the wheelchair. Continued review revealed the personal alarm was not in use at the time of the fall; however, it was functioning properly. Further, the recommended action taken was to add dycem to the wheelchair; however there was no documented evidence the CCP or the Risk for Falls assessment was revised to include placement of the dycem to the recliner after the [DATE] fall event. Review of the Fall Scene Investigation Report, dated [DATE], revealed the resident stated he/she slid out of the wheelchair. Additional review revealed the chair alarm was not in use and the resident was wearing shoes at the time of the fall. Further, the alarm was working correctly. Review of SRNA #7's Witness Statement, dated [DATE], revealed after Resident #8 fell , she realized the Resident's chair alarm was not in the wheelchair. Interview with SRNA #7, on [DATE] at 9:01 AM, revealed she did not recall when she last noticed the chair alarm in the Resident's wheelchair prior to the fall on [DATE] or why it was not in the wheelchair per the CCP. Review of the RCA, dated [DATE], revealed Resident #8 self-transferred into the wheelchair and slid out of the wheelchair at the doorway. Additional review revealed the resident was unaware of safety and risk for falls and enjoyed sitting and watching visitors and staff. Further, the intervention was to add dycem to the wheelchair to reduce risk of sliding out. However, there was no documented evidence the RCA addressed the wheelchair alarm not being in place at the time of the fall. Interview with Resident #8, on [DATE] at [DATE] at 1:00 PM, revealed he/she had sustained falls in the recent past mostly related to trying to go to the restroom. Additional interview revealed the resident choose not to wait for assistance with transfers and going to the restroom at times because he/she did not want to wait for help. Further interview revealed the resident was not concerned or bothered by the alarming devices on his/her bed and chair. 2) Review of Resident #49's medical record revealed the facility admitted the resident on [DATE], with primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed Resident #49 had difficulty with visions and wore glasses. Continued review revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), indicating severe cognitive impairment. Per the MDS, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfer and toileting; walking did not occur, and required total assistance with locomotion and assistance from one (1) staff for personal hygiene. Per the MDS, the resident had impaired balance between surfaces and impaired range of motion in the both lower extremities. Further, the resident had one (1) fall in the previous month and received seven (7) days of antidepressant and antibiotic medication during the assessment period. Further review the resident received Physical, Occupational, and Speech therapy minutes during the assessment period. Review of Resident #49's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for falls related to impaired cognition, use of [MEDICAL CONDITION] medication, limited range of motion of the bilateral lower extremities, and unable to ambulate. The goal was for the resident not to sustain any falls. Interventions included educated the resident and provide reminders for safety; keep the room free of clutter and obstruction and for staff to provide assistance with transfer. Review of Fall Risk Evaluation, dated [DATE], revealed the facility assessed Resident #49 as high risk for falls, with a total score of fourteen (14). Additional review revealed the resident had intermittent confusion, had two (2) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of the Admission Nursing Evaluation, dated [DATE], revealed Resident #49 required assistance of two (2) staff for mobility and transfers. Further review revealed he/she was confused and oriented to person. Review of Fall Risk Evaluation, dated [DATE], revealed the facility assessed Resident #49 as high risk for falls, with a total score of sixteen (16). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of a SBAR, dated [DATE] at 5:15 PM, revealed Resident #49 sustained an unwitnessed fall without injury. Per review, the Resident was sitting in the floor on their buttocks beside the bed. Additional review revealed the Resident stated they got up without assistance from the wheelchair and forgot to lock the wheels; the wheelchair rolled and the resident fell to the floor. Further review revealed a reminder was posted in the room to Ask for Assistance. Review of a Resident Accident/Incident Report, dated [DATE] at 5:15 PM, revealed Resident #49 was observed in the room, sitting in the floor beside the bed and wheelchair post fall event. Additionally, the resident stated they had forgot to lock the wheelchair brakes and was trying to get in the bed. Further review revealed signage was posted in the room to Ask for Assistance Review of a Fall Scene Investigation Report, dated [DATE] at 5:15 PM, revealed Resident #49 stated he/she was trying to self-transfer to bed from the wheelchair. Additional review revealed the resident was wearing shoes at the time of the fall. Further review revealed the wheelchair slid out from under the resident during the attempted transfer. Review of a Summary of Root Cause Analysis (RCA), dated [DATE], revealed Resident #49 attempted to self-transfer into the bed from the wheelchair and slid out of the wheelchair into the floor. Additional review revealed the resident had a [DIAGNOSES REDACTED]. However, the intervention was to place signage in the room to Ask for Assistance prior to attempting transfer. Review of Nurse's Notes, for (MONTH) 2019, revealed no documented evidence of a fall on [DATE] at approximately 6:00 PM. Review of a physician's orders [REDACTED]. Interview with Resident #49, on [DATE] at 8:11 AM, revealed the resident had sustained a fall on [DATE] around 6:00 PM when he/she was trying to go back to bed to rest. Per interview, Resident #49 stated he/she attempted to get in bed by themselves and forgot to lock the wheelchair and when he/she stood from the wheelchair, it rolled backwards causing them to lose their balance and fall to the floor. Additional interview revealed the resident did not have an injury with the fall. Further interview revealed the nursing staff told him/her not to get in or out of bed by themselves. Interview with SRNA # 6, on [DATE] at 9:07 AM, revealed she was aware Resident #49 had fallen the evening of [DATE] around 6:00 PM however; she was unaware of any fall precautions implemented after the fall. Continued interview revealed the nurses revised the CCP after each fall with interventions to prevent future falls. Further interview revealed Resident #49 had a new sign in his/her room at the foot of the bed by the bathroom that reminded the resident to call for assistance. Per interview, today was the first day she had seen this sign. Further interview revealed the sign was not a sufficient intervention to prevent future falls from transferring back to bed, because it was across the room from his/her bed and he/she would have their back to the sign, and the Resident had poor eyesight. Interview with SRNA #8, on [DATE] at 9:07 AM, revealed she was aware Resident #49 had fallen on [DATE] around 6:00 PM. Continued interview revealed she was not aware of any fall precautions implemented after the fall to prevent additional falls. Per interview, there was a new sign in the resident's room that advised him/her to call for assistance; however, the resident's vision was poor and the sign was placed across the room. Interview with Kentucky Medication Aide (KMA), on [DATE] at 8:58 AM, revealed she had worked at the facility for six (6) years. Continued interview revealed she assisted the nurse after falls by taking the resident's vital signs and giving her statement related to what the resident was doing before the fall. Further interview revealed she was not aware Resident #49's CCP had been revised to include signage in the resident's room or that the CCP for Resident #8 did not include dycem to the wheelchair and recliner. Further, it was important to complete a thorough investigation of falls and revise the care plan with a purposeful intervention to decrease the resident's risk for more falls and injury. Interview with LPN #3, on [DATE] at 10:58 AM, revealed the nurse was responsible for completing a thorough assessment of the resident and events prior to the fall and documented the assessment in the medical record, per the facility policy and protocols. Per interview, it was the responsibility of the nurse to determine an immediate intervention based on what the resident was trying to do at the time of the fall event, to prevent another occurrence/fall of the same nature. Additionally, the RCA should be determined by talking to the staff, the resident involved in the event and reviewing the resident record. Further interview revealed the interventions should be effective and reasonable. The interventions should assist the resident in meeting their needs and remain safe. Interview with Minimum Data Set (MDS) Coordinator, on [DATE] at 10:00 AM, revealed it was important direct care nurses documented thorough fall investigations at the time of a fall because she utilized that information to completed assessments and to revise the CCP to meet the resident's needs. She stated the CCP was used by the IDT as a guide to provide care to each resident. Additionally, documented post fall assessments were reviewed in the IDT clinical meetings and the Falls Committee meeting, after the morning meeting, to ensure the RCA had been identified and revision to the CCP were made as necessary. Per interview, the fall follow up should have been documented in the medical record. Continued interview revealed it was important for the CCP to be revised immediately with an intervention related to the RCA status [REDACTED]. Further interview revealed a thorough review of the fall paper work was completed for each fall including the Incident Report, Witness Statement, Fall Scene investigation, the SBAR, Nurses Notes, etc. She stated, the RCA was determined after review and any revisions were made to the CCP at that time to prevent another fall of the same nature. Per interview, the interventions were made based on the RCA and the individual resident's strengths and weaknesses, and should be effective and sufficient to prevent falls. Further interview revealed the CCP should have been updated immediately after Resident #8 and Resident #49's fall. However, she was not aware Resident #49 had sustained a fall on [DATE] during an unassisted transfer from the wheelchair to the bed because nursing staff did not communicate the information to her and the assessments was not in the medical record. Interview with the Director of Nursing (DON), on [DATE] at 2:30 PM, revealed after a fall, the nurse should assess the resident and fall scene immediately and document the findings in the medical record. Per interview, the nurse should do their do diligence to determine the root cause of the fall and implement an appropriate intervention related to the resident's individualized needs and the RCA, to prevent further falls of the same nature. Continued interview revealed the CCP should have been revised immediately after the falls for Resident #8 on [DATE] and [DATE] for dycem to the recliner and wheelchair seats and for Resident #49 on [DATE] for the sign placed in the Resident's room. Further, the facility's fall follow up protocol should have been maintained and Resident #49's interventions should have been in place before the evening of [DATE]. She stated, after review of the SBAR, it was determined the best intervention for Resident #49 was anti roll back brakes to the wheelchair to prevent further falls if the resident were to attempt to self-transfer to the bed again; which was revised on [DATE]. She expected the facility policy and protocols to be upheld related to fall management to ensure all resident's safety Interview with the Administrator, on [DATE] at 3:00 PM, revealed she expected the direct care nursing staff to maintain the facility's Fall Management Policy and Protocols. Per interview, it was the responsibility of the direct care nurse to documented a thorough post fall assessment in the medical record and implement an immediate intervention to reduce the risk of further falls, at the latest within twenty-four (24) hours. Per interview, she expected the IDT to ensure the facility policy and protocols were followed after each resident fall through review of the fall event documentation. Additionally, she expected interventions to be based on the RCA and the residents needs and be effective in maintaining the residents safety and meeting their needs. Further, the RCA should be determined based on statements and assessments of the fall event and the resident's needs. Review of the facility's Policy, titled Storage of Medications, undated, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Continued review revealed medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 3. Review of Resident #53 medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #53's Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating cognitively intact. Continued review revealed the facility assessed the resident to have vision impairment, sees large print, but not regular print in newspapers or books and does not wear corrective lens. Review of Resident #53's Evaluation of Resident's Ability to Safely Self-Administer Medication, dated [DATE], revealed the resident lacked upper body strength to safely self-administer medications. Continued review of the document revealed the resident does not know when his/her medications are due. Review of Resident #53's Monthly physician's orders [REDACTED]. Observation of Resident #53, on [DATE] at 4:10 PM, revealed an over the counter medication bottle opened on the bedside table. Continued observation revealed the medication was labeled Cayenne four hundred (400) mg. Interview with Resident #53, on [DATE] at 4:10 PM, revealed his/her daughter brought the medication in. Continued interview revealed the medication was supposed to help his/her legs. Further interview with the resident revealed he/she does not self-administer his/her own medications Interview with Certified Medical Assistant (CMA) #9, on [DATE] at 10:30 AM, revealed, she had been employed by the facility for six (6) years. Per interview, Resident #53 does not administer his/her own medications. She stated the residents do not self-administer their own medications. Per interview, she is not aware of any resident that would be able to safely self-administer medication. She stated if she observed medications in a room, she would remove the medications and notified the charge nurse immediately. Continued interview revealed all medications should be stored in the medication cart and it must be locked. Further interview revealed the facility does have residents that wander and it could have been harmful to them. Per interview Resident #53 could have taken too much of the medication and that would have endangered his/her safety. Interview with Kentucky Medication Aide (KMA) #10, on [DATE] at 10:42 AM, revealed she had been working at the facility for two (2) years. Continued interview revealed she was not aware of any resident in the facility that had been safely assessed to self-administer their own medications. She stated Resident #53 is not safe to self-administer his/her own medications. She stated all medications must be locked in medication room in medication carts. Further interview revealed they have residents that wander in and out of rooms, one could have taken that medication, and it would not have been safe. Per Interview, she stated if she found a medication in a resident's room, she would remove the medication and notify the nurse in charge. She further stated it would be hazardous for Resident #53 and all other residents because they could have choked, got sick and possibly died . Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 4:15 PM, revealed, she was assigned to Resident #53. Continued interview revealed Resident #53 should not have any medications in the room. Per interview, nursing staff administer all medications to Resident #53. She stated she removed the medication from the resident's bedside table and explained to the resident why the medication cannot be on the bedside table. She further stated she explained to the resident that she would need to get an order from the physician for the medication and would lock it up in the med cart until she obtained the order. Further interview revealed it could have been dangerous if another resident wandered in the room and got the medication. Per interview, Resident #53 could have taken more than the appropriate dose and there could be side effects of the medication or it could interact with a medication the resident was prescribed. Additional interview revealed the facility performs an assessment quarterly on residents to assess for self-administration of medications; however, to her knowledge, there were no residents able to self-administer medications. She further stated all medications should be stored in a locked drawer or medication cart. She stated the safety of the residents comes first and the facility's Policy should be followed. Interview with Director of Nursing (DON), on [DATE] at 1:35 PM, revealed she had been working

Based on observation, interview, and record review, it was determined the facility failed to ensure that resident who enters the facility with an indwelling catheter or subsequently receives one was assessed for removal of the catheter as soon as possible and received appropriate treatment and services to prevent urinary tract infections and to restore continence, for one (1) of three (3) sampled residents observed for indwelling urinary catheter care out of twenty-two (22) sampled residents (Resident #51). Observation and interview with Resident #51, on 04/23/19 revealed the resident had an indwelling urinary catheter placed during a recent hospital stay related to excess fluid. However, review of the medical record review revealed no documented evidence of timely and appropriate assessments related to the indication for use of an indwelling catheter or documentation of clinical indications for the use of a catheter. In addition, the medical record did not include criteria for the discontinuation of the catheter when the indication for use was no longer present. Per record review, there was no documented evidence related to ongoing care and catheter removal protocols. Further, there was no documented evidence of the Resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). The findings include: Interview with the Registered Nurse (RN) Consultant, on 04/25/19 at 4:27 PM, revealed the facility did not have an indwelling urinary catheter policy that addressed catheter care and services based on professional standards of practice. Review of Resident #51's medical record revealed the facility admitted the resident on 03/02/19 with a primary [DIAGNOSES REDACTED]. Secondary admitting [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/22/19, revealed the facility assessed Resident #51 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognitive response. Additionally, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfers, and toilet use. Continued review revealed the resident required extensive assistance of one (1) staff with personal hygiene and ambulation in the room. Further review revealed the resident had seven (7) or more episode of urinary incontinence, but had at least one (1) episode of continent voiding during the assessment period. Review of Resident #51's Baseline Care Plan, dated 03/02/19, revealed the resident had bladder incontinence. The goal was to establish an individualized bladder routine. Interventions included perineal care per policy; keep call light in reach and the use of adult briefs. Further review revealed the resident had Activities of Daily Living (ADL) Functional/Rehab Potential. The goal was to achieve/maintain maximum functional mobility. Interventions included therapy referrals; assist with toileting, transfers, and hygiene. Review of the State Registered Nursing Assistant (SRNA) Kardex/Care Plan, dated (MONTH) 2019 and revised 03/20/19, revealed Resident #51 required assistance for transfers and toileting needs. Additional review revealed the resident had incontinent bladder episodes and was on a one (1) and half-hour schedule toileting plan. Review of the Comprehensive Care Plan (CCP), dated 04/09/19, revealed Resident #51 had toileting elimination deficit related to impaired mobility, and frequent incontinence of bladder. The goals included remaining clean and odor free and show signs of improvement in bladder continence while on scheduled toileting. Interventions included to assess the toilet patterns and needs, staff assistance with toileting needs and to schedule toileting every one (1) and half-hours. Review of Resident #51's Nurse's Notes, dated 04/10/19 at 8:00 AM, revealed a Situation Background, Assessment/appearance, Request (SBAR) assessment, related to shortness of air and [MEDICAL CONDITION]. Additional review revealed the resident was noted with tremors and was struggling to breathe with oxygen on at four (4) liters per a nasal cannula, wheezes were auscultated in the lungs, and [MEDICAL CONDITION] was noted in bilateral lower extremities. The physician and resident representative were notified and the resident was sent to the emergency room for further evaluation. Review of physician's orders [REDACTED].#51 to the hospital for evaluation and treatment. Continued review of the medical record revealed Resident #51 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. However, there was no documented evidence of a [DIAGNOSES REDACTED]. Review of Resident #51's Nurse's Notes, dated 04/16/19 at 3:00 PM, revealed Resident #51 returned to the facility and was taken to his/her room. However, there was no documented evidence of a re-admission assessment including assessment of the indwelling catheter. Review of the State Registered Nursing Assistant (SRNA) Kardex/Care Plan, dated 04/16/19, revealed Resident #51 had a catheter, required a leg strap, and catheter care. However, there was no documented evidence the CCP was revised to include the indwelling catheter indication for use, ongoing care and removal protocols. Further review of Resident #51's Physician Orders, dated 04/16/19, revealed no documented evidence of re-admission orders [REDACTED]. Review of Resident #51's Treatment Administration Record (TAR), dated 04/16/19, revealed no documented evidence of orders related to an indwelling catheter or ongoing care. Review of the Provider's New Admit History and Physical, dated 04/18/19, revealed Resident #51 returned from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Further review revealed no documented evidence of review of the [MEDICAL CONDITION] (GU) system or urinary catheter. Review of Resident #51's Physician order [REDACTED]. Review of the Nurse's Notes and Assessments, dated 04/19/19 through 04/24/19 revealed no documented evidence of an assessment of Resident #51's indwelling catheter. Interview with Resident #51, on 04/23/19 at 4:00 PM, revealed he/she had a recently hospitalization related to excess fluid and trouble breathing. Per interview, while at the hospital an indwelling catheter was placed to help get the fluid off. Additional interview revealed he/she cleaned the catheter when on the toilet at least daily and night shift nursing staff had communicated to the resident, by doing so would prevent infection related to the catheter. Further interview revealed the resident was curious to know when the catheter would be removed since he/she had been back to the facility for a week now and was feeling better. Interview with LPN #3, assigned to Resident #51's hallway, on 04/24/19 10:58 AM, revealed the LPN #3 was responsible to complete and document an assessment of a resident returning to the facility on re-admission. Per interview, it was the responsibility of the nurse to ensure an assessment was thorough and the assessment findings were communicated to the physician. Additional interview revealed the re-admitting nurse was responsible to obtain necessary orders from the physician. Continued interview revealed the nurse re-admitting Resident #51, on 04/16/19, failed to document an assessment including the indwelling catheter and failed to obtain an order from the physician related to the indicated use for the indwelling catheter, ongoing care and removal criteria. Further, it was her expectation that residents receive care in accordance to professional standards for urinary catheters to decrease their risk for CAUTI's and trauma related to catheters. Interview with Kentucky Medication Aide (KMA), assigned to Resident #51 on 04/25/19 at 8:58 AM, revealed she had worked at the facility for six (6) years. Per interview, Resident #51 returned to the facility after a hospitalization on [DATE] with an indwelling catheter. However, the KMA had not provide catheter care to the Resident since returning to the facility, because it was not on the TAR; it was the responsibility of the SRNAs to provide catheter care every shift. Per KMA, it was important to provide catheter care each shift to decrease the risk for infection and or trauma to the Resident. It was also important to see the catheter each shift and documented the output and let the nurses know any changes to ensure a resident received care for their catheter; care that only a nurse could provide, like flushes or changing it, if the catheter was blocked. Further, she was not aware why the Resident #51 had the catheter but knew the resident was curious about when it was due to be changed or removed because he/she had never had a catheter before. Interview with SRNA #7, assigned to Resident #51, on 04/25/19 at 9:01 AM, revealed she has been at the facility for two (2) month. Per interview, Resident #51 had a catheter for almost two (2) weeks now after returning from the hospital. Additionally, she provided catheter care each shift and emptied urine from the catheter bag as necessary. Further, it was important to provide care to a catheter to ensure it was clean, there was output, and the resident was not experiencing pain associated to the catheter. Interview with SRNA #9, assigned to Resident #51's hallway, on 04/25/19 at 9:07 AM, revealed she had worked in the facility for a few months. Per interview, Resident #51 had a catheter after returning from the hospital recently. Additional interview revealed she had provided catheter care each shift and emptied the catheter bag every two (2) hours. Further, it was important to provide necessary care to the residents with catheters to reduce their risk for infections. Interview with SRNA #8, assigned to Resident #51's hallway, on 04/25/19 at 9:07 AM revealed she had worked in the facility for a couple months. Per interview, Resident #51 had a catheter after returning from the hospital. Additional interview revealed she had provided urinary catheter care each shift and emptied the catheter bag every two (2) hours. Further interview revealed it was important to provide necessary care to the residents with catheters to reduce the risk for infections. Interview with the Director of Nursing (DON), on 04/25/19 at 2:30 PM, revealed she had been at the facility as the DON since 10/01/18. Per interview, it was the responsibility of the assigned direct care nurse to complete a face-to-face assessment for each resident on admission and on re-admission to the facility, and to communicate the assessment findings to the physician to ensure necessary orders for care and treatment are obtained for the resident. Additionally, the direct care nurse was responsible to documented a Nursing Evaluation Assessment and chart a Nurse's Note related to the admission or re-admission. Continued interview revealed the direct care nurse assigned to Resident #51, on 04/16/19, failed to complete a thorough assessment of the resident to include the newly placed urinary catheter. Per the DON, the nurse should have assessed the catheter (type and size, signs and symptoms of infection) and obtained orders from the physician related to the indicated use for the catheter, criteria for discontinuation and ongoing care. Per the DON, the nurse should have documented the assessment and placed orders related to the catheter on the Treatment Administration Record (TAR). Per interview, it was the DON's expectation nursing staff maintain standards of practice related to indwelling urinary catheters to ensure the catheter was necessary, and the facility provided care to decrease the risk for infection and trauma, resident safety, quality of care and to ensure resident needs are met. Further interview revealed the facility had a Quality Assurance Performance Improvement (QAPI) plan related to re-admissions; to ensure assessments are thorough and completed and that necessary physician orders [REDACTED].#51's re-admission on 04/16/19. Interview with the Administrator, on 04/25/19 at 3:00 PM, revealed she expected the nursing staff to complete re-admission assessments timely and thoroughly. Additional interview revealed she expected Physician orders [REDACTED]. Per interview, she expected the nursing assessment findings to be documented and communicated to the physician and necessary orders to be implemented. Continued interview revealed she expected documented evidence for the indicated use of indwelling catheters, ongoing catheter care, and criteria for discontinuation of the catheter for all residents with catheters. Further interview revealed the licensed nurse failed to ensure Resident #51 had a thorough re-admission assessment to include an assessment of the indwelling catheter and related physician's orders [REDACTED].

Based on interview, record review, and review of facility's Policy, it was determined the facility failed to protect one (1) of four (4) sampled residents (Resident #1) from abuse. On 03/17/19, multiple staff witnessed State Registered Nursing Assistant (SRNA) #1 telling Resident #1 to hurry up and push the poop out that he/she was not the only resident and that his/her[***]stinks like a skunk. The findings include: Review of the facility's Policy, titled Reporting Abuse to Facility Management, dated 11/02/17, revealed it was the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Continued review revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. It includes verbal, sexual, physical and mental abuse; including abuse enabled and facilitated through the use of technology. Continued review revealed verbal abuse was defined as any use of oral, written or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Review of the facility's Policy, titled Policy for Adult Protection, signed by State Registered Nursing Assistant (SRNA) #1, on 02/28/19, revealed it was the policy of the facility that any employee who has reasonable cause to believe or even suspect that a resident or child has suffered abuse or neglect must report the incident immediately. Continued review revealed abuse or suspicion of abuse includes rough physical treatment, abusive or disrespectful language, neglect or failure to respond to a resident's needs or misappropriation of property. Review of the facility's initial Long Term Care Facility Self-Reported Incident Form, dated 03/17/19, revealed Resident #1 was pulling at his/her brief and SRNA #1 swatted at her hand and told him/her to hurry up we have other residents to take care of. Continued review revealed SRNA #1 was suspended pending the facility's investigation. Review of the facility's investigation, dated 03/18/19, revealed there were three (3) staff witnesses to the event. Continued review of the facility's investigation revealed the facility interviewed all three (3) staff witnesses. Per the witness interview, SRNA #1 was in Resident #1's room. Resident #1 had removed his/her own brief prior to staff arrival. Per interviews, SRNA #1 was in the process of putting the brief on the resident when the resident stated, I have to have a bowel movement. Per the interviews, Resident #1 was on the bedpan and SRNA #1 was heard saying hurry up we have other residents to take care of. Further review of the investigation revealed after the resident had a bowel movement, SRNA #1 made the comment that Resident #1's[***]smelled like skunk. Per interview, Resident #1 was reaching to get into the feces when SRNA #1 brushed her hand away, making contact. Additional review revealed the facility substantiated that SRNA #1 was abusive toward Resident #1. Review of the facility's Termination Form, dated 03/19/19, revealed SRNA #1 was involuntarily terminated. Review of Resident #1's clinical record revealed the resident was admitted by the facility on 03/15/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 3/21/19, revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. Telephone interview with SRNA #1, on 03/28/19 at 12:05 PM, revealed at approximately 3:30 AM on 03/17/19, Resident #1 started taking his/her brief off, SRNA #1 stated she put the brief back on Resident #1. SRNA #1 stated she asked Resident #1 are you done, we can't leave you in poop, you need to push it out. SRNA #1 further stated Resident #1 asked her to stay with the Resident, SRNA #1 revealed she replied No, we can't because there is more people here than just you. SRNA #1 then stated lord, that smells like skunk referring to Resident #1's bowel movement. Telephone interview with SRNA #2, on 03/28/19 at 12:30 PM, revealed she was standing in the doorway to Resident #1's room on 03/17/19 at approximately 3:30 AM when she heard SRNA #1 state to Resident #1 Hurry up and push your poop out, you are not the only one here. Continued interview revealed Resident #1 reached for his/her brief and SRNA #1 swiped the Resident's hand away and said, Leave that alone, that[***]smells like skunk. Further interview revealed, SRNA #2 immediately reported the incident to Registered Nurse (RN) #1. Telephone interview with SRNA #3, on 03/28/19 at 12:45 PM, revealed on 03/17/19 at approximately 3:30 am, she was in Resident #1's room assisting with perineal care. Continued interview revealed Resident #1 had removed his/her brief. Per interview, SRNA #1 was putting a new brief under the resident when SRNA #1 tapped Resident #1 on the left hand. Further interview revealed, Resident #1 stated I have to poop, SRNA #1 then stated to the resident, hurry up, I have other residents, you are not the only one here, his/her[***]stinks like a skunk. Interview with Registered Nurse (RN) #1, on 03/28/19 at 1:00 PM, revealed on 03/17/19 at approximately 3:30 AM, SRNA #2 reported the allegation of abuse. She stated she immediately escorted SRNA #1 to the time clock, and sent her home. Continued interview revealed she called the Administrator and reported the allegation after ensuring the safety of the resident. Interview with the Courtesy Aide (CA) #1, on 03/28/19 at 11:45 AM, revealed on 03/17/19 at approximately 3:30 AM, she was sitting in the doorway of a resident's room across the hall from Resident #1's room, when she heard SRNA #1 state, Hurry up and push it out, we are about to clean you up, you are not the only resident in here. Your[***]smells like skunk. CA #1 further stated SRNA #2 reported the incident to RN #1 immediately, and RN #1 immediately sent SRNA #1 home. Interview with the Director of Nursing (DON), on 03/28/19 at 2:25 PM, revealed facility staff receive abuse prevention, abuse reporting, and Resident rights training upon hire, monthly, and as needed. She stated the Administrator terminated SRNA #1 via telephone due to the findings of the facility investigation. Per interview, residents have a right to be free from abuse and it was her expectation that staff follow the facility's policy related to abuse. Interview with the Administrator, on 03/28/19 at 2:30 PM, revealed the allegation of abuse was reported to her on 03/17/19 at approximately 3:30 AM. Continued interview revealed she was responsible for the facility's investigation into the allegation. Further interview revealed as a result of the investigation, the facility substantiated the abuse allegation. She further revealed there were no previous warnings or incidents involving SRNA #1. She stated SRNA #1 was terminated following the findings of the investigation, and all staff were educated on abuse prevention, reporting, and Resident rights. Additional interview revealed the residents had a right to be free from abuse and the facility had an abuse policy. Per interview, it was her expectation that all staff follow the facility's abuse policy.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to have an effective system to ensure the resident's physician was notified when the resident experienced a change in condition and there was a need to alter treatment for one (1) of eighteen (18) sampled residents (Resident #19). From the morning of 08/10/18 until the evening of 08/11/18, Resident #19 intermittently complained of not feeling well, having increased weakness, feeling confused, and being unable to hold objects in his/her right hand. Resident #19's Responsible Party (RP) also reported that the resident was acting weird and was complaining of increased weakness, confusion and had witnessed the resident drop objects out of his/her right hand. In addition, the Social Worker (SW) assessed the resident's mental status on 08/10/18, which had significantly declined. However, there was no documented evidence the resident's physician was notified of these changes in condition. On 08/11/18, at approximately 6:20 PM, Resident #19 was found unable to speak or follow commands, and was experiencing facial drooping. Subsequently, Resident #19 was transferred to the hospital and diagnosed with [REDACTED]. Interview with the physician revealed she was not aware the resident had been transferred to the hospital and diagnosed with [REDACTED]. The facility's failure to have an effective system to ensure the resident's physician was notified of a change of condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/24/18, and determined to exist on 08/09/18 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F657), and 483.25 Quality of Care (F684 and F689). The facility was notified of the Immediate Jeopardy on 08/24/18, and the Immediate Jeopardy is ongoing. The findings include: Review of the facility's Change in a Resident's Condition Policy, dated 08/01/13, revealed the facility would promptly notify the resident's attending physician of changes in the resident's medical/mental condition and /or status. The policy stated the physician would be notified when the resident experienced an incident that had the potential for requiring physician intervention or a need to transfer the resident to a hospital. Review of Resident #19's medical record revealed the facility admitted the resident on 12/22/17, with [DIAGNOSES REDACTED]. Review of Resident #19's Minimum Data Set Assessment (MDS) assessment dated [DATE], revealed Resident #19 had a BIMS score of 15 indicating the resident had no cognitive impairment and displayed no behavioral disturbance. However, review of Social Services documentation dated 08/10/18 (no time recorded) revealed a subsequent BIMS assessment on 08/10/18, indicated the resident's cognitive status had declined to a score of eleven (11). The Social Services documentation also revealed Resident #19 was complaining that his/her blood pressure has been high the last couple of days. However, there was no documented evidence the SW reported the resident's complaints or decline in cognitive functioning to the nursing staff nor that the resident's physician was notified. Review of a COTA (Certified Occupational Therapy Assistant) note dated 08/10/18, and interview with the COTA on 08/21/18, at 11:58 AM, revealed she had worked with Resident #19 on the morning (exact time unknown) of 08/10/18. Review of the COTA note revealed Resident #19 presented with increased bilateral upper and bilateral lower extremity fatigue and weakness, and was complaining of confusion, which impacted the resident's participation and safety. The note also stated the resident was tearful, had a depressed mood, and was complaining of feeling confused since the previous night. Although the COTA note stated the resident's complaints and behaviors were reported to the nursing staff, there was no documented evidence that Resident #19 was assessed by nursing staff or that the resident's physician was notified of the concerns. Interview with the Resident #19's RP on 08/20/18 at 5:35 PM revealed she visited the resident daily, and was at the facility on the evening of 08/10/18. The RP stated she reported to the nursing staff that Resident #19 was unable to hold cards in his/her right hand without dropping them, was complaining of confusion and increased weakness, and appeared to be acting weird. Review of the Nursing documentation dated 08/10/18, at 6:00 PM, revealed LPN #7 documented that Resident#19 was complaining of not feeling well and complaining of weakness with occasional confusion. However, the nurse also documented that the resident was alert and oriented at that time, and that the resident's grips were equal and strong, and vital signs were WNL (within normal limits), but the nurse failed to document the resident's vital signs and failed to report the resident's and RP's complaints to the physician. Interview with LPN #11 on 08/18/18 at 3:03 PM revealed she was Resident #19's nurse on 08/11/18, from 7AM-7PM. LPN #11 stated she was not notified of any concerns with Resident #19, by the previous off going nurse, and did not assess the resident until 6:30 PM. Per interview, she was summonsed to Resident #19's room, around 6:30 PM, because the resident had been found sitting up in a wheelchair unable to speak, flaccid on the right side, and had facial drooping. Emergency Medical Services was notified and Resident #19 was transferred to the hospital. Review of a Hospital record for Resident #19 dated 08/11/18, revealed the resident arrived to the hospital on [DATE], at 6:46 PM, and the resident's blood pressure was 190/126. Resident #19 was diagnosed with [REDACTED]. Interview with the Acting Director of Nursing (DON) on 08/21/18 at 4:50 PM revealed she was out of the State when Resident #19 experienced a change in condition. However, she stated based on the resident's complaints of increased weakness, increased confusion, dropping items, and the resident stating to the Social Worker that his/her blood pressure had been elevated for a couple of days on 08/10/18, the resident's physician should have been notified. Interview with Physician #1 on 08/20/18 at 4:23 PM revealed she had been unaware that Resident #19 had been transported from the facility on 08/11/18 and was diagnosed and hospitalized with an [MEDICAL CONDITION] informed by the surveyor at the time of the interview. In addition, the Physician stated that if she had been notified on 08/10/18 that the resident had complaints of increased weakness, confusion, and dropping things, she would have given staff an order to send the resident to the emergency room for evaluation.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the care plan was revised for one (1) of eighteen (18) residents (Resident #21) to prevent falls. Resident #21 sustained six (6) falls from [DATE] to [DATE], one (1) fall with injury, and the facility failed to revise the resident's care plan with individualized interventions to prevent further falls. Resident #21 fell again on [DATE] and sustained multiple fractures. On [DATE], Resident #21 sustained a fall and an x-ray report, dated [DATE], revealed the resident had a wrist fracture. In addition, Resident #21 sustained a fall on [DATE], resulting in a fractured T12 ([MEDICATION NAME] vertebrae/upper back) severe burst type compression fracture with posterior cortical buckling, chronic C2 (cervical vertebrae/neck) fracture, and displaced subcapital [MEDICAL CONDITION] femoral neck (left [MEDICAL CONDITION]) as a result of the fall. The resident was not a surgical candidate for repairs of the fractures and the resident was placed on palliative care for pain control. Resident #21 expired on [DATE]. The facility's failure to ensure care plans were revised to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F657), and 483.25 Quality of Care (F684 and F689) The facility was notified of the Immediate Jeopardy on [DATE], and the Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy, Care Plans - Comprehensive, dated [DATE], revealed an individualized comprehensive care plan that included measurable objectives and timetable to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The policy stated assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. Review of the facility's Fall Program Guide (undated) revealed it was the responsibility of the facility to determine what increased the likelihood of a fall for each resident and to ensure that all identified risk factors had been assessed, care planned, and implemented. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not able to complete the interview process to assess cognitive impairment. The facility assessed Resident #21 to have moderately impaired cognition, unclear speech, poor decision-making, required cues and supervision, and was unsteady. Continued review of Resident #21's MDS revealed the facility assessed the resident to require limited assistance of one person for ambulation in the resident's room and for transfers, and required extensive assistance of one person for toileting and hygiene. The MDS revealed the resident had sustained two or more falls with injury since the prior assessment. The MDS also revealed Resident #21 utilized a wheel chair a bed and chair alarm daily (an alarm that monitors the resident's movement and alerts staff when movement is detected). Review of Resident #21's care plan initiated [DATE], revealed the facility identified the resident had the potential for trauma related to falls. According to the care plan, the facility implemented interventions that included one-half bed rails for positioning and mobility, responding to the call light promptly, and observing for complications in mobility. Further review of Resident #21's care plan revealed on [DATE], the facility revised the care plan to include an intervention to transfer the resident with the assistance of one to two persons as needed. Further review revealed on [DATE], the facility implemented a sensor alarm (a pad that alarms when the resident stands) to resident's bed and a safety alarm (a string that attaches to the resident and alarms when the string detaches from an alarming box) to the resident's chair. Staff were required to check the placement and function of the alarms every shift. On [DATE], the facility revised the resident's care plan to include a two hour scheduled toileting program. Continued review of the resident's care plan revealed on [DATE], the facility placed the resident on the Falling Star program, and indicated staff were to check every hour. A review of Resident #21's fall risk evaluations dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the facility assessed the resident on all six occasions to be at high risk for falls due to disorientation; had sustained three or more falls in the previous three months; was chair bound, had balance problems while standing and walking; had an unsteady gait, utilized a wheel chair and walker; and, took medications and had predisposing diseases which could contribute to a fall. However, review of the resident's plan of care revealed the facility failed to revise the care plan to include individualized interventions to address these risk factors. Review of an Accident/Incident Report dated [DATE] at 2:30 PM, revealed Resident #21 slid off edge of recliner onto the floor. The report indicated the reason the resident fell was that the resident was getting up to BR (bathroom). According to the report, the accident was reviewed during the morning meeting. However, review of the report revealed no documented evidence interventions were discussed to prevent further falls. In addition, continued review of the resident's care plan dated [DATE] revealed the facility documented Continue current plan of care. Review of an Accident/Incident Report dated [DATE], at 7:35 PM, revealed the resident's alarm was sounding, and the resident was found sitting on the floor between the beds. The report indicated the resident was in a chair prior to falling and it appeared the resident had the urge to go to the bathroom, got up, and fell . Review of Resident #21's care plan dated [DATE], revealed that although alarms had not been effective in preventing falls, the facility changed the alarm to the resident's chair from a safety alarm to a sensor alarm, and there was no documented evidence the facility revised the care plan with interventions to supervise the resident to prevent falls. Further review of Resident #21's [DATE], Accident/Incident Report revealed staff documented the resident had no injuries; however, review of nurse's notes dated [DATE] at 6:25 AM, revealed the resident complained of right wrist pain, the resident's right hand was purple, and an x-ray was ordered. A review of the x-ray report for Resident #21 dated [DATE] revealed the resident had a fractured distal radius with fragmentation of the basal joint (wrist). Review of Accident/Incident Reports dated [DATE] at 2:00 PM, and 2:30 PM, and review of a facility timeline, revealed Resident #21 sustained another fall after getting up from a chair and getting a cord around the resident's neck/draped on the shoulders. The report stated the resident had been more anxious and restless, and had more weakness and unsteadiness that day. Review of Resident #21's care plan revealed on [DATE], the facility documented staff should continue the resident's current plan of care, and no new interventions were implemented to prevent further falls. Even though the report, dated [DATE], stated the resident had been more anxious and restless, and had more weakness and unsteadiness that day, the facility failed to assess these risk factors and revise the resident's care plan to address these risk factors, per the facility's Fall Program Guide. Further review of Resident #21's care plan revealed on [DATE], the same day the resident's physician reviewed a [DATE] x-ray report and discovered the resident had a fractured wrist; the facility revised the resident's care plan to include placing gripper strips on the floor. In addition, the facility revised the resident's physical mobility care plan to include interventions for the Falling Star program with hourly checks and the need for staff to assist with transfers as needed. However, the interventions for the Falling Star program had been on the resident's care plan since [DATE] and assisting the resident with transfers had been on the resident's care plan since [DATE]; both of which had not been effective at preventing falls. Further review of Accident/Incident Reports dated [DATE] at 3:40 PM, revealed Resident #21 got out of the recliner with the foot piece up, and sustained another fall. The report stated the recommendation action taken was to remind the resident to stay seated, even though the resident was cognitively impaired. In addition, the facility revised the resident's care plan to included Grippy strips to the floor beside the resident's bed, even though this interventions had already been implemented on [DATE], and had not been effective to prevent further falls. The facility also documented an intervention to conduct a therapy screen. Review of physical therapy recommendations dated [DATE], revealed that due to Resident #21's continued mental status and medical decline, the resident was currently in best positioning and chair at that time. However, on [DATE], the facility revised the resident's care plan with interventions to keep the lift recliner unplugged (motor was removed), and to keep the chair footrest down. The facility also revised Resident #21's care plan on [DATE], to include a chair pad sensor to chair and bed pad sensor alarm to the bed and staff were required to check the sensor every shift. However, according to the care plan, the resident should have already had the sensor alarms in place. Review of an Accident/Incident Report dated [DATE] at 4:30 PM, revealed staff heard the resident's alarm sound and found the resident getting out of bed unassisted, and staff assisted the resident to a recliner. According to the report, approximately ,[DATE] minutes later, staff heard the alarm sound again and found the resident sitting on the floor next to recliner. A review of the resident's care plan revealed on [DATE] the facility documented that staff should continue the resident's current plan of care, even though the plan of care had not been effective in preventing the resident from falling. The facility failed to revise the resident's plan of care to address the resident's behavior of getting up without assistance. Further review of Accident/Incident Reports dated [DATE] at 9:05 PM, revealed Resident #21's alarm sounded, and the resident was found sitting on the floor. The report indicated the resident fell from bed and the causative factor was the resident attempting to self-transfer. The facility documented the recommended actions were to place non-skid strips on the floor and on [DATE], and the facility revised the resident's care plan to include non-skid strips. However, there was no evidence the facility recognized that the intervention to place non-skid strips to prevent further falls had already been implemented on two other occasions and had not been effective to prevent the resident from falling. Review of an Accident/Incident report for Resident #21 dated [DATE] at 9:35 AM, revealed a SRNA (State Registered Nurse Aide) found the resident on the floor, hollering Oh! Oh! According to the report, the sensor alarm in the recliner did not sound and review of a facility timeline referencing video surveillance footage for [DATE], revealed staff were in Resident #21's room at 8:04 AM on [DATE], and no one was in the resident's room again until 9:29 AM, one hour and twenty-five minutes later, when the resident was observed to have sustained a fall. Review of nursing notes dated [DATE] at 10:10 AM, revealed Resident #21 was transferred to the hospital on [DATE] at 10:10 AM. Review of hospital records revealed Resident #21 sustained a T12 ([MEDICATION NAME] vertebrae) severe burst type compression fracture with posterior cortical buckling, chronic C2 (cervical spine) fracture, and a displaced subcapital [MEDICAL CONDITION] femoral neck (left [MEDICAL CONDITION]) from the fall at the facility on [DATE]. The resident was transferred back to the facility on [DATE], for Palliative Care and the resident expired on [DATE]. Interview with the MDS Coordinator on [DATE] at 5:30 PM, revealed staff reviewed care plans during morning meetings after a resident fell to discuss what interventions were in place and go from there. The team discusses what interventions need to be done. If the team cannot determine other interventions, then that is when we put continue current P[NAME] (plan of care). An interview with the Acting Administrator and the Acting Director of Nursing on [DATE] at 11:45 AM, revealed that although the facility had identified that the majority of the resident's falls were due to the resident wanting to stand/get out of the recliner, there was no documented evidence the facility implemented increased supervision or assistive devices when the facility's interventions failed to prevent falls. An interview with the Acting Director of Nursing (DON) on [DATE] at 4:50 PM, revealed she was not the Acting DON on [DATE], when the resident fell and was transferred to the hospital. The Acting DON also stated she was not sure about repeat interventions for the resident because she was not at the facility to review the resident's medical record. Interview with the Acting Administrator on [DATE] at 5:29 PM, revealed resident falls were reviewed during the morning meeting. The Acting Administrator stated if a resident fell and had no injury, the care plan was effective and the facility would state, continue plan of care. According to the Acting Administrator, the facility would not implement a new intervention if there was no injury from a fall because the care plan was effective.

Based on interview, record review, review of the facility's policy and procedures, and review of the American Heart Association/American Stroke Association Guidelines, it was determined that the facility failed to have an effective system to ensure one (1) of eighteen (18) sampled residents (Resident #19) received treatment and care in accordance with professional standards of practice. On 8/10/18 and 08/11/18, Resident #19 complained to a minimum of four (4) facility staff that he/she was exhibiting symptoms including not feeling well, having increased weakness, confusion, and the inability to hold items in his/her right hand. In addition, the resident's Responsible Party (RP) also reported the resident's complaints and her observation that Resident #19 was not acting like him/herself to nursing staff. However, the facility failed to act on the resident's and RP's complaints, despite Resident #19 having multiple risk factors that increased the resident's chances of suffering a [MEDICAL CONDITIONS]. On the morning of 08/10/18, a Certified Occupational Therapy Assistant (COTA) reported to the resident's nurse that the resident had complained of increased bilateral upper and lower extremity weakness, confusion that was affecting the resident's ability to participate in therapy, tearfulness, and displayed a depressed mood. However, the nurse failed to document the COTA's report and failed to assess Resident #19. On 08/10/18, Social Worker (SW) #2 completed a Brief Interview for Mental Status (BIMS) assessment on Resident #19, but failed to identify that the resident's cognitive status had significantly decreased or report the resident's complaints of not feeling well to the resident's nurse. At 6:30 PM on 08/10/18, Resident #19's RP and the resident reported to Licensed Practical Nurse (LPN) #7 that the resident was dropping cards and had increased weakness and confusion. Although LPN #7 assessed Resident #19, and reported to the oncoming nurse to monitor the resident due to the complaints, LPN #7 failed to document the resident's vital signs. Interview with LPN #5, revealed that LPN #7 did report Resident #19's complaints to her, but LPN #5 failed to complete any assessment of the resident on her shift from 7PM to 7AM on the night of 08/10/18 and the early morning of 08/11/18. State Registered Nurse Aide (SRNA) #7, who cared for Resident #19 during the night of 08/10/18 and early morning of 08/11/18, reported that the resident complained to her of increased weakness, but the SRNA stated she did not report the resident's complaints to the nurse because the resident had complained of that before. Interview with LPN #11 revealed that she had cared for Resident #19 on the 7AM to 7PM shift on 08/11/18, but had received no information in report that the resident had made complaints or was not feeling well. Therefore, LPN #11 did not assess the resident until approximately 6:30 PM when she was summoned to Resident #19's room and assessed the resident to be unable to speak, unable to follow commands, be flaccid on the right side, and display facial drooping. Subsequently, Emergency Medical Services was called and Resident #19 was transferred to the hospital on [DATE] at approximately 6:40 PM and diagnosed with [REDACTED]. Resident #19 was then transferred to a Regional Medical Center's Stroke Unit on 08/11/18 at 7:41 PM. The facility's failure to ensure residents received care and treatment in accordance with professional standards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/24/18, and determined to exist on 08/09/18 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F657), and 483.25 Quality of Care (F684 and F689). The facility was notified of the Immediate Jeopardy on 08/24/18, and the Immediate Jeopardy is ongoing. The findings include: Review of the facility's Job Description Licensed Practical Nurse, undated, revealed the LPN would monitor all aspects of resident care and accurately take and record vital signs. The LPN would also be responsible to communicate with co-workers at all levels to adequately meet the needs of residents. The job description also indicated that all changes in a resident's condition would be documented in the resident's medical record. Review of the facility's policy, Change in a Resident's Condition, dated 08/01/13, revealed the Nurse Supervisor/Charge Nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the American Heart Association/American Stroke Association Guidelines, revealed several risk factors have been identified that can lead to an increased risk of a [MEDICAL CONDITION] including Hypertension, Smoking, Obesity, Decreased Physical Activity, and [MEDICAL CONDITION]. Further review of the guidelines revealed a [MEDICAL CONDITION] (TIA), was defined as a minor or mini stroke that manifests the same symptoms of a [MEDICAL CONDITION], but usually only last a few minutes. However, the guidelines stated that TIAs were often predecessors to a [MEDICAL CONDITION] should never be ignored and emergency medical assistance should be sought immediately. In addition, the guidelines state that time was critical when experiencing [MEDICAL CONDITION] immediate treatment could minimize the long-term effects of a stroke and/or even prevent death. The guidelines emphasized that any individual, or care giver of an individual, who had increased risk factors for [MEDICAL CONDITION] be familiar with and recognize the signs and symptoms of a [MEDICAL CONDITION], including sudden numbness or weakness of the extremities or face, confusion or trouble understanding, and loss of balance and coordination. The Guidelines further stated that emergency medical treatment should be obtained if individuals exhibit some or all of the warning signs, and they should never be ignored even if they go away. Review of Resident #19's medical record revealed the facility admitted the resident on 12/22/17, with [DIAGNOSES REDACTED]. Review of Resident #19's Care Plan dated 04/11/18, revealed the resident had an alteration in Cardiac output related to Hypertension and Hypomagnesium. Interventions initiated included observing the resident for increased intolerance to activities, fatigue and or weakness. The care plan also directed staff to measure and obtain vital signs per policy and as needed. Interview with the Acting Director of Nursing on 08/21/18 at 4:50 PM, revealed the facility's practice was to obtain resident vital signs weekly, unless the residents clinical condition indicated otherwise. Review of Resident #19's Minimum Data Set Assessment (MDS) assessment dated [DATE], revealed the resident had no hearing or visual difficulty, had clear speech and was able to understand and be understood, displayed no symptoms of behavioral disturbance, had no neurological [DIAGNOSES REDACTED]. In addition, the assessment revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) indicating the resident had no cognitive impairment. In addition, the facility assessed Resident #19 required assistance with all Activities of Daily Living (ADL) and utilized a wheelchair for mobility. Review of Resident #19's MDS dated [DATE], revealed the Resident had been assessed to have no changes from the previous assessment conducted on 05/17/18, in the areas of vision, hearing, speech, neurological status, medications, ADL's or mobility. However, the resident did have a decline in cognitive status from a BIMS of fifteen (15) to a BIMS of eleven (11). Further review of Social Services notes, dated 08/10/18, and interview with SW #2 on 08/09/18 at 3:35 PM, revealed the PHQ-9 (screening which determines BIMS score) had been conducted on 08/10/18. SW #2, who conducted the assessment, documented that Resident #19 had been tearful during the assessment and reported blood pressure has been high the last couple of days. However, review of Resident #19's medical record revealed no documentation that the resident's behavior or complaints of an increased blood pressure were reported to the nursing staff. Review of Resident #19's medical record revealed vital signs had not been recorded for the resident since 08/06/18. SW #2 stated that she did not notify the resident's nurse of the resident's statements that he/she was not feeling well or that his/her blood pressure had been high. In addition, the SW stated she had failed to recognize that Resident #19's BIMS score had decreased significantly from fifteen (15) to eleven (11). Review of a Certified Occupational Therapist Assistant (COTA) note dated 08/10/18, and interview with the COTA on 08/21/18, at 11:58 AM, revealed she had worked with Resident #19 on the morning (exact time unknown) of 08/10/18. Review of the COTA note revealed Resident #19 presented with increased bilateral upper and bilateral lower extremity fatigue and weakness, and was complaining of confusion, which affected the resident's participation and safety. The note also stated the resident was tearful, had a depressed mood, and was complaining of feeling confused since the previous night. The note also stated the COTA notified the resident's nurse regarding the resident's behaviors and complaints. However, review of Resident #19's nurses notes, dated 08/10/18 prior to 6:00 PM, revealed no documentation on Resident #19 since 08/02/18, and there was no evidence to indicate that Resident #19 was assessed after the COTA had made the nurse aware of the resident's behavior and complaints. Interview with the Resident #19's Responsible Party (RP), on 08/20/18 at 5:35 PM, revealed she visited the resident daily, and was at the facility on the evening of 08/10/18. The RP stated that she was playing cards with the resident around 6:00 PM, which was customary for the resident and RP. The RP stated the resident began to drop the cards and complained of feeling weird. The RP stated that Resident #1 was not acting like (him/herself), was unable to hold the cards in his/her right hand, and the resident's thinking was clouded. The RP stated she reported the change in the resident to LPN #7. The RP stated the nurse came to the room and assessed Resident #19. According to the RP, the nurse told her that the Resident's handgrip on the right side was not as strong as the handgrip on the left side. The RP stated LPN #7 told her that she would report the resident's condition to the oncoming nurse, and that Resident #19 would be monitored throughout the night. Review of a Nurses' Notes for Resident #19 on 08/10/18 at 6:00 PM, revealed LPN #7 documented that Resident#19 was complaining of not feeling well and complaining of weakness with occasional confusion. Although the Nurse documented that Resident #1's vital signs were WNL (within normal limits), there was no documentation of the resident's vital signs in the medial record. The nurse also documented that the resident was alert and oriented at that time, and that the resident's grips were equal and strong. However, per interview with the RP, the nurse had reported to her the resident's handgrip on the right side was not as strong as the handgrip on the left side. Further review revealed the note stated will pass on for 7PM-7AM nurse to follow up. However, there is no further assessment of Resident #19 in the nurses' notes or medical record until 08/11/18 at 6:35 PM. Interview with LPN #7, on 08/18/18 at 2:39 PM and 7:27 PM, and on 08/20/18 at 4:55 PM, revealed that she was Resident #19's nurse during the evening of 08/10/18. The LPN stated the resident's RP was at the facility visiting the resident and had reported to her that Resident #19 was dropping his/her playing cards, which was not normal for the resident. LPN #7 stated she assessed Resident #19, and the resident complained of increased weakness and confusion. The LPN stated she assessed the resident's vital signs and that they were within normal limits; however, she could not recall what the vital signs were, and stated she failed to document the vital signs in the resident's medical record. Continued interview with LPN #7 revealed she assessed the resident's handgrips to be equal and strong and the resident's bilateral lower extremity strength was equal. LPN #7 stated that she reported the resident's complaints and assessment to LPN #5, the oncoming nurse during shift report, and instructed LPN #5 to keep an eye on the resident because he/she was not feeling well. She stated that both the resident and the RP were concerned about the resident not feeling well. Interview with LPN #5 on 08/18/18 at 6:30 PM, the nurse who was caring for Resident #19 during the 7PM-7AM shift on the evening of 08/10/18 and the early morning of 08/11/18, revealed that LPN #7 reported to her that Resident #19 had complained of not feeling well. She stated LPN #7 reported that the resident's vital signs were within normal limits and that the resident's speech was fine. LPN #5 denied being told by LPN #7 to monitor the resident or check on the resident more frequently because of the resident's complaints. LPN #5 stated she did not assess the resident, instruct the SRNA to obtain the resident's vital signs, or enter the resident's room during her shift. However, LPN #5 stated she had visualized the resident on at least two (2) occasions, and the resident appeared to be in no distress. LPN #5 stated that Resident #19 was independent and could use his/her call light to alert staff if he/she was not feeling well, therefore, she did not feel that she needed to check on Resident #19 during her shift. In addition, LPN #5 stated that she was very busy on the night of 08/10/18, and was working short on the unit. Review of facility staffing and the census for Resident #19's unit on the night of 08/10/18 and early morning of 08/11/18, revealed there were forty-one (41) residents on the unit, and the unit was staffed with one nurse and one SRNA. Interview with SRNA #7 on 08/18/18 at 7:41 PM revealed she had worked with Resident #19 during the night shift on 08/11/18. The SRNA stated she had assisted Resident #19 with a bedpan one time on 08/11/18 (exact time unknown). The resident was a two staff assist for toileting, but the SRNA stated there was no available staff to assist the resident to the toilet. SRNA #7 stated the resident complained of increased weakness; however, the SRNA did not report this to the nurse because the resident had complained of that before. Further interview with SRNA, revealed she was not told during shift report that Resident #19 had complained of not feeling well or been instructed to check on the resident more frequently. Further interview with SRNA #7 revealed she had checked and changed Resident #19's roommate two (2) to three (3) times during the shift, and that Resident #19 appeared to be sleeping each time she had been in the room. Further interview with SRNA #7 revealed she had been unable to check on the residents more frequently, because she was the only SRNA on the unit working from 10:00 PM to 6:00 AM. Interview with LPN #11, on 08/18/18 at 3:03 PM revealed she was Resident #19's nurse on 08/11/18 from 7AM-7PM. LPN #11 stated she was not notified of any concerns with Resident #19 by the previous off going nurse. The nurse stated she had visualized the resident several times on 08/11/18 and the resident did not appear to be acting abnormal. Therefore, according to LPN #11, she did not assess Resident #19 on 08/11/18 until approximately 6:30 PM when she was called to the resident's room. Review of Nurses' Note dated 08/11/18 at 6:35 PM, revealed LPN #11 entered Resident #19's room and the resident was sitting up in a wheelchair unable to speak, had no gripping ability in the right hand, the resident's right side was flaccid and the resident was exhibiting facial drooping on the right side. The note also stated the resident's vital signs were unstable and the resident's blood pressure was documented to be 170/80. (Review of Resident #19's documented blood pressures from 6/18/18-08/06/18 revealed the highest systolic pressure recorded was 145). Further review of the nurses' note revealed Emergency Medical Services was contacted and Resident #19 was transferred to the hospital. Review of Resident #19's hospital record dated 08/11/18, revealed the resident arrived to the hospital on [DATE] at 6:46 PM, and the resident's blood pressure was 190/126. Resident #19 was diagnosed with [REDACTED]. Continued interview with Resident #19's RP on 08/20/18 at 5:35 PM, revealed Resident #19 remained hospitalized , was unable to communicate and had no movement on the right side. In addition, the RP stated that Resident #19 had also experienced new onset [MEDICAL CONDITION] since suffering [MEDICAL CONDITION] 08/11/18. Interview with the Regional Director of Clinical Services, on 08/21/18 at 5:50 PM, revealed she was made aware of Resident #19's change in condition and hospitalization on [DATE] during the morning clinical meeting. She stated based on the resident's assessment that was documented on 08/10/18 by LPN #7 that she did not see a cause for concern or any red flags. However, interview with Physician #1, on 08/20/18 at 4:23 PM, revealed if she had been notified on 08/10/18 that the resident had complaints of increased weakness, confusion, and dropping things, she would have given staff an order to send the resident to the emergency room for evaluation.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to have an effective system to provide supervision to prevent accidents for (1) of eighteen (18) residents (Resident #21). Resident #21 had a history of [REDACTED]. The facility failed to determine what increased the likelihood of Resident #21's falls and failed to ensure that all identified risk factors had been assessed, care planned, and implemented per the facility's policy and procedures. Resident #21 sustained a fall on [DATE], and an x-ray report obtained on [DATE] revealed the resident had a wrist fracture. However, the facility failed to identify the injury and the injury was not treated until [DATE], when the resident's physician identified the injury. The facility changed the resident's alarm after the fall, but failed to implement new interventions to supervise the resident to prevent further falls, and the resident sustained [REDACTED]. On [DATE], Resident #21's staff failed to supervise the resident hourly as per the resident's plan of care. Staff found Resident #21 on the floor beside the resident's chair, on [DATE]. The resident sustained [REDACTED]. Resident #21 expired on [DATE]. The facility's failure to have an effective system to provide supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F657), and 483.25 Quality of Care (F684 and F689) The facility was notified of the Immediate Jeopardy on [DATE], and the Immediate Jeopardy is ongoing. The findings include: Review of the facility's Fall Program Guide (undated) revealed fall prevention maintained or improved the quality of life for residents. The policy also stated that fall prevention required a comprehensive and interdisciplinary approach that considered every aspect of the resident, the resident's care and treatment, and the environment. In addition, the policy stated that it was the responsibility of the facility to determine what increased the likelihood of a fall for each resident and to ensure that all identified risk factors had been assessed, care planned, and implemented. The facility identified that factors that placed residents at an increased risk for falls included confusion, lack of safety awareness, agitation, unsafe behavior, and a history of falls. Review of the facility's Fall Program (undated) revealed the Director of Nursing (DON) and Administrator would review fall incident reports, and falls would be tracked by the facility designee. The policy indicated that any resident who sustained two (2) falls in thirty (30) days would be placed on the Falling Stars Program. Residents identified to be Falling Stars by the facility would be checked every hour, and that interventions would be documented and personalized. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not able to complete the interview process to assess cognitive impairment. However, the facility assessed Resident #21 to have moderately impaired cognition, unclear speech, poor decision making, and required cues and supervision. Continued review of Resident #21's MDS revealed the facility assessed the resident to require limited assistance of one person for ambulation in the resident's room and for transfers, and required extensive assistance of one person for toileting and hygiene. According to the MDS, Resident #21 was not steady with balancing, transitions, or walking, and utilized a wheel chair. The MDS revealed the resident had sustained two or more falls with injury since the prior assessment, but had no major injuries, such as fractures, joint dislocations, or head injuries. The MDS also revealed Resident #21 utilized a bed and chair alarm daily (an alarm which monitors the resident's movement and alerts staff when movement is detected). A review of Resident #21's fall risk evaluations dated [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the facility assessed the resident on all six occasions to be at high risk for falls due to disorientation, had sustained three or more falls in the previous three months, was chair bound, had balance problems while standing and walking, had an unsteady gait, utilized a wheel chair and walker, and took medications and had predisposing diseases which could contribute to a fall. A review of Resident #21's care plan initiated [DATE], revealed the facility identified the resident had the potential for trauma related to falls. According to the care plan, the facility implemented interventions that included one-half bed rails for positioning and mobility, responding to the call light promptly, and observing for complications in mobility. Further review of Resident #21's care plan revealed on [DATE], the facility revised the care plan to include an intervention to transfer the resident with the assistance of one to two persons as needed. Further review revealed on [DATE], the facility implemented a sensor alarm (a pad that alarms when the resident stands) to resident's bed and a safety alarm (a string that attaches to the resident and alarms when the string detaches from an alarming box) to the resident's chair. Staff was required to check the placement and function of the alarms every shift. On [DATE], the facility revised the resident's care plan to include a two hour scheduled toileting program. Continued review of the resident's care plan revealed on [DATE], the facility placed the resident on the Falling Star program, and indicated staff were to check every hour. Review of Accident/Incident Reports for Resident #21, revealed the resident sustained [REDACTED]. The reports indicated the falls occurred after the resident attempted to ambulate unassisted, and six of the seven falls occurred when the resident either slid from his/her chair or when the resident got up from the chair unassisted. Further review of Accident/Incident Reports dated [DATE] at 2:30 PM, revealed Resident #21 slid off edge of recliner onto the floor. The report indicated the reason the resident fell was because the resident was getting up to BR (bathroom). According to the report, the accident was reviewed during a morning meeting and no other interventions were implemented to prevent further falls. There was no documented evidence the facility ensured that all identified risk factors had been assessed per the facility's policy and procedure. In addition, continued review of the resident's care plan dated [DATE] revealed the facility documented Continue current plan of care. Review of an Accident/Incident Report dated [DATE], at 7:35 PM, revealed the resident's alarm was sounding, and the resident was found sitting on the floor between the beds. The report indicated the resident was in a chair prior to falling and it appeared the resident had the urge to go to the bathroom, got up, and fell . The resident stated, I gotta pee. The report further stated the resident could not use the call light related to decreased cognition and the resident did not understand that he/she needed to take or use his/her walker/wheelchair. The report indicated there were no injuries and staff escorted (the resident) to bathroom. However, review of nurse's notes dated [DATE] at 6:25 AM, revealed the resident complained of right wrist pain, the resident's right hand was purple, and an x-ray was ordered. A review of the x-ray report for Resident #21 dated [DATE], revealed the resident had a fractured distal radius with fragmentation of the basal joint (wrist). However, a review of nursing notes dated [DATE] at 2:30 PM, revealed the resident's physician was notified that the resident had no fractures, and no further action was taken. On [DATE] at 12:15 PM, 12:39 PM and 3:43 PM, a telephone interview was attempted with LPN #9, the nurse who received the initial x-ray report on [DATE], and notified the resident's physician that the resident did not have a fracture. However, LPN #9 could not be reached and the LPN did not return the phone calls. Further review of nurse's notes dated [DATE], [DATE], and [DATE], revealed staff documented that Resident #21's right wrist and hand continued to be bruised/purple. However, interview with LPN #1 on [DATE] at 3:45 PM revealed the facility was not aware the resident's wrist was broken until [DATE], when the resident's physician reviewed the x-ray results from [DATE], which indicated that the resident had a wrist fracture. LPN #4 stated the facility became aware when the LPN received a fax from the resident's physician on [DATE], for a splint to the resident's right wrist and for a referral for an orthopedic consult. Interview with Unit Manager #2 on [DATE] at 3:20 PM, revealed nursing staff was responsible for ensuring x-ray reports were received and the physician was notified of the results. The Unit Manager further stated she did not monitor to ensure x-ray results were reported accurately to the resident's physician. Continued review of Resident #21's care plan revealed the facility revised the resident's care plan on [DATE], and changed the alarm to the chair from a safety alarm to a sensor alarm. Further review revealed on [DATE], the facility clarified that staff should check placement and function of the sensor alarm to bed and chair every shift. There was no documented evidence the facility revised the care plan with interventions to supervise the resident while going to the bathroom to prevent falls per the Accident/Incident Report date [DATE]. Review of Accident/Incident Reports dated [DATE] at 2:00 PM and 2:30 PM, revealed at 2:00 PM, the resident's alarm sounded and when staff entered the resident's room, the resident was standing next to a dresser with a walker in front of the resident. The resident's knees suddenly went out and the resident fell . The report stated the resident had been more anxious and restless, and had more weakness and unsteadiness that day. The report for 2:30 PM on [DATE], stated the resident was found with a TV cord around (the resident's) neck. According to the report, prior to the incident, the resident was in a chair. A review of a facility timeline dated [DATE], revealed the fall and the incident with the cord occurred at the same time. The timeline revealed the resident was found by a housekeeper on the floor with a TV cord draped on shoulders. There was no documented evidence the facility ensured that all identified risk factors had been assessed per the facility's policy and procedure. Review of Resident #21's care plan revealed the facility documented on [DATE], staff should continue the resident's current plan of care, and no interventions were implemented to prevent further falls. On [DATE], the facility revised the resident's care plan to include placing gripper strips on the floor. In addition, the facility revised the resident's physical mobility care plan to include interventions for the Falling Star program with hourly checks and the need for staff to assist with transfers as needed. However, these interventions were already listed on the resident's care plan for falls. The intervention to transfer the resident with the assistance of one to two persons as needed was added to the falls care plan on [DATE] and the Falling Star program was added on [DATE]. Neither had not been effective at preventing the resident's falls. Further review of Accident/Incident Reports dated [DATE] at 3:40 PM, revealed Resident #21 got out of the recliner with the foot piece up. The report stated when the resident attempted to stand, the resident fell . According to the report, the resident was attempting to get out of the chair and get a walker. The report stated the recommendation action taken was to remind the resident to stay seated, even though the resident was cognitively impaired. There was no documented evidence the facility ensured that all identified risk factors had been assessed per the facility's policy and procedure. Review of Resident #21's care plan dated [DATE], revealed the facility revised the resident's care plan to include Grippy strips to the floor beside the resident's bed; however, this intervention had already been implemented on [DATE], and did not prevent further falls. The facility also documented an intervention to conduct a therapy screen. Further review of Resident #21's medical record revealed on [DATE] a therapy evaluation was requested for Resident #21 due to a recent fall. The request stated a physical therapy evaluation was needed due to the resident being unable to lower the foot piece of the recliner related to the resident's cognition. The therapy request stated the resident had crawled out of recliner with the foot rest up. The note stated that Physical therapy evaluated the resident and stated that due to continued mental status and medical decline, the resident was currently in best positioning and chair at that time. However, on [DATE], the facility revised the resident's care plan with interventions to keep the lift recliner unplugged (motor was removed), and to keep the chair foot rest down. The facility also revised Resident #21's care plan on [DATE], to include a pad sensor to the chair and bed pad sensor alarm to the bed and staff was required to check the sensor every shift. However, according to the care plan, the pad sensor alarm to the bed was added on [DATE] and the pad sensor to the chair was added on [DATE]. In addition, checking the alarms for placement and functioning had been an intervention since [DATE]. Review of an Accident/Incident Report dated [DATE] at 4:30 PM, revealed staff heard the resident's alarm sound and found the resident getting out of bed unassisted, and staff assisted the resident to a recliner. According to the report, approximately ,[DATE] minutes later, staff heard the alarm sound again and found the resident sitting on the floor next to recliner. A review of the resident's care plan revealed the facility documented on [DATE] that staff should continue the resident's current plan of care. There was no documented evidence the facility ensured that all identified risk factors had been assessed, care planned, and implemented per the facility's policy and procedures. Further review of Accident/Incident Reports dated [DATE] at 9:05 PM, revealed Resident #21's alarm sounded, and the resident was found sitting on the floor. The report stated the resident kept saying, I don't know. The report indicated the resident fell from bed and the causative factor was the resident attempting to self-transfer. The facility documented the recommended actions were to place non-skid strips on the floor and on [DATE], and the facility revised the resident's care plan to include non-skid strips. However, there was no evidence the facility recognized that the intervention to place non-skid strips to prevent further falls had already been implemented on two other occasions and had not been effective at preventing falls. Furthermore, interviews with Certified Medication Technician (CMT) #1 on [DATE] at 3:44 PM, State Registered Nurse Aide (SRNA) #32 on [DATE] at 3:21 PM, CMT #3 on [DATE] at 11:52 AM, and SRNA #30 on [DATE] at 12:10 PM, revealed when they provided care to Resident #21, they only checked on the resident every two hours, and were not aware the resident required hourly checks per the plan of care. Despite Resident #21 requiring hourly checks per the resident's facility developed care plan, review of a facility timeline referencing video surveillance footage for [DATE], revealed that staff was noted to be in Resident #21's room at 8:04 AM, on [DATE], and no one was in the resident's room again until 9:29 AM, one hour and twenty-five minutes later, when the resident was observed to have sustained a fall. Review of an Accident/Incident report dated [DATE] revealed at 9:35 AM, for Resident #21 revealed a SRNA looked into the resident's room and observed the resident sitting on his/her buttocks, beside the bed with his/her knees bent toward the chest. The resident was grasping at the staff's uniform, hollering Oh! Oh! The report stated staff lowered the resident's bilateral extremities, and the resident continued to yell, Oh! Oh! and continued yelling with movement to left lower extremity. According to the report, the facility determined the causative factor for the fall was the resident was up unassisted and his/her walker not in use. The sensor alarm in the recliner did not sound. There was no documented evidence the facility identified the resident was no longer assessed to utilize a walker independently and required assistance from staff. Review of a nursing note dated [DATE], at 9:35 AM revealed after the fall, Unit Manager #2 examined and assessed the resident and noted no redness or bruising, and the resident was able to move bilateral lower extremities once assisted to chair. However, the resident was holding the right groin area saying, Oh! Oh! Further review of nursing notes dated [DATE] at 9:45 AM, revealed the nurse called the resident's physician and received an order to transfer the resident to the hospital. The nursing notes stated Resident #21 was transferred to the hospital on [DATE] at 10:10 AM. Interview with Unit Manager (UM) #2 on [DATE] at 12:08 PM, revealed she found Resident #21 sitting on the floor on [DATE], and the alarm was not sounding. UM #2 stated the resident was sitting on the floor with his/her bilateral lower extremities bent with his/her knees to the chest, hollering Oh! Oh! Once the resident was assisted to the chair, the resident was holding the right groin area, voicing Oh! Oh! She stated she called the physician and resident was sent to the Emergency Department (ED) for evaluation. According to the Unit Manager, staff was required to check alarms to ensure they functioned once per shift, and she did not know if the alarm had been checked that shift. Interview with SRNA #13 on [DATE] at 12:16 PM revealed on [DATE], she was the nurse aide assigned to provide care for the resident. The SRNA stated she checked on the resident at approximately 7:15 AM, and was giving another resident a shower when the resident fell . Interview with CMT #3 on [DATE] at 11:52 AM revealed she was the medication aide that morning and the resident was in the recliner. The CMT stated the alarm did not sound when the resident fell , but when someone picked it up after the fall, and the alarm worked. Interview with MDS nurse #1 on [DATE] at 4:15 PM, revealed she was assigned to care for Resident #21 on [DATE]. She stated when she entered the resident's room after the resident was found on the floor, the alarm was not sounding. She stated they always checked alarms once per shift, but could not remember if she had checked Resident #21's alarm that morning. MDS nurse #1 stated since she had not signed off on it, she probably had not checked it that morning. An interview with the Acting Administrator and the Acting Director of Nursing on [DATE] at 11:45 AM, revealed that although the facility had identified that the majority of the resident's falls were due to the resident wanting to stand/get out of the recliner, there was no documented evidence the facility implemented increased supervision or assistive devices when the facility's interventions failed to prevent falls. Review of Resident #21's hospital record from Facility #1 revealed the resident arrived at the hospital's (ED) on [DATE] at 10:39 AM. According to the physician documentation, the resident had left lower extremity and hip pain that started after the resident fell at the facility. The record revealed the resident had a T12 ([MEDICATION NAME] vertebrae/upper back) compression fracture, subacute cervical (neck) spine fracture that was unstable, and a [MEDICAL CONDITION] hip. The resident was transferred to another acute care hospital (Facility #2), on [DATE] at 12:22 PM, due to the fractures. A review of Resident #21's medical record from Facility #2 revealed the resident sustained [REDACTED]. Review of an orthopedic progress note date [DATE], revealed the physician spoke at length with Resident #21's family regarding risks and benefits of surgery and the consequences of not proceeding with surgery. It was noted the patient was very uncomfortable and experienced significant pain upon movement. Review of a Neurosciences Consult Note dated [DATE], revealed the physician did not recommend surgery for [REDACTED]. The physician discussed removing the resident's C-collar (a brace to support and protect the neck) with the family, specifically, that it could potentially result in a high spinal cord injury with minor trauma, resulting in death. The family acknowledged the risk and wanted the collar removed. The family decided to pursue palliative care only to ensure the patient's pain and anxiety were controlled. A review of the discharge summary revealed Facility #2 transferred Resident #21 back to the facility on [DATE], with orders for palliative care and orders for pain medication that included administering [MEDICATION NAME] on a scheduled and as needed basis. Review of a nursing note dated [DATE] at 4:00 PM, revealed Resident #21 arrived back to the facility. The note stated the resident was awake and alert, unable to follow commands, and repeatedly called out Oh! Further review of nursing notes dated [DATE] at 10:15 AM, revealed Hospice was present to admit the resident into the program. The Hospice nurse assessed that the resident's head/neck was hyperextended, and the resident's eyes were open with a blank stare. Continued review of nursing notes dated [DATE] at 8:15 PM, revealed the resident's color was ashen with no respirations, a faint heart beat for a couple of minutes then stopped, and no blood pressure or visible signs of life. Review of a physician progress notes [REDACTED].#21 expired on evening of [DATE]. Interview with Resident #21's physician on [DATE] at 10:18 AM, revealed the Falling Star program was good in theory but would not prevent a fall. The physician would not speculate whether the injuries from the fall caused the resident's death.

Based on interview, record review, review of the facility's policies, previous Statements of Deficiencies, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of Statements of Deficiencies dated [DATE] and [DATE], revealed Immediate Jeopardy was identified at the facility on [DATE], [DATE], and [DATE] related to failures that included the failure to supervise residents to prevent accidents; failure to ensure care plans were revised to prevent accidents; failure to administer medications based on residents' Medication Administration Records (MARs)/Physician orders; and failure to ensure sufficient staffing to meet residents' needs. The facility submitted A[NAME]s on [DATE] and [DATE], alleging Immediate Jeopardy was removed; however, the Administrator failed to ensure Immediate Jeopardy was removed and Immediate Jeopardy was identified to exist again on [DATE]. The facility's failure to ensure the facility was administered in an effective manner has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F657), and 483.25 Quality of Care (F684 and F689) The facility was notified of the Immediate Jeopardy on [DATE], and the Immediate Jeopardy is ongoing. The findings include: Review of the Administrator's Job Description (not dated) revealed the Administrator's essential job function was to plan, develop, and implement all aspects of the facility's operations. The Administrator was to ensure staff was able to interpret and follow established policies and procedures. The policy also stated the Administrator's principal concern would be for the delivery of quality care to all residents of the facility. The facility submitted A[NAME]s on [DATE] and [DATE], alleging that Immediate Jeopardy was removed and the facility was monitoring to ensure removal. A review of the A[NAME] submitted by the facility on [DATE] revealed the Administrator would be present in a morning meeting to review Accidents/Incidents from the previous day. If a concern was identified, the appropriate interventions and the care plan would be revised as needed. The A[NAME] further stated that staffing levels were reviewed daily by the Administrator and Director of Nursing to ensure there were sufficient numbers to meet the care needs and acuity levels for residents. Review of the A[NAME] dated [DATE], revealed the Administrator would review the audit results from medication administration daily after each observation to confirm that any issues had been addressed including employee training, physician notification, and resident monitoring. The A[NAME] stated the Administrator would report the monitoring results and at QA meeting weekly until substantial compliance was achieved. Further review revealed the [DATE] A[NAME], also stated the corporate nurse consultant would provide oversight of the Administrator daily and review all incident reports, all investigations, etc. The A[NAME] stated the corporate nurse consultant would then report the results of the audits of the Administrator to the QA Committee weekly until substantial compliance was achieved. However, interview and record review revealed the facility failed to address Resident #21's risk factors for falls and revise the resident's care plan to prevent falls. The resident sustained [REDACTED]. Resident #21 expired on [DATE] (Refer to F657 and F689). An interview with the Acting Administrator, who was a corporate staff member serving as the Acting Administrator, and the Acting Director of Nursing on [DATE] at 11:45 AM, revealed that although the facility had identified that the majority of Resident #21's falls were due to the resident wanting to stand/get out of the recliner, there was no documented evidence the facility implemented increased supervision or assistive devices when the facility's interventions failed to prevent falls. Further interview with the Acting Administrator on [DATE] at 5:29 PM, revealed resident Accident/Incident Reports (falls) were reviewed during a morning meeting as stated in the facility's A[NAME]. However, even though the care plan was not effective in preventing falls, according to the Acting Administrator, the facility would not implement a new intervention if there was no injury from a fall because they believed the care plan was effective. In addition, observation of medication administration on [DATE] and [DATE] with Licensed Practical Nurse (LPN) #10 (the same LPN who committed Medication Errors during the [DATE] survey), and Certified Medication Aide (CMA) #4 revealed the staff made three (3) medication errors out of twenty-seven (27) opportunities, resulting in a medication error rate of 11.1 percent. Further, staff failed to document that Resident #4 and #26's Intravenous (IV) antibiotic medication was administered as ordered. In addition, staff transcribed the stop date for an IV antibiotic medication onto a MAR indicated [REDACTED]. Interview with the Acting Administrator on [DATE] at 6:10 PM revealed pharmacy staff continued to conduct medication observations with the staff as stated in the A[NAME]s; however, the interview revealed they had not identified any concerns with medication administration, and there was no evidence the facility had identified the medication errors for Resident #32. Further, interview and record review revealed on [DATE] and [DATE], revealed there was not enough staff to provide care for residents. Interview with the Acting Administrator on [DATE] at 5:27 PM, revealed even though the [DATE] A[NAME] alleged the Administrator would review staffing daily to ensure there were sufficient staff to provide care, the Administrator stated the issues with staffing were not brought to her attention.

Based on interview, record review, review of the facility's policy and procedures, and review of the facility's Allegations of Compliance (A[NAME]), it was determined that the Governing Body failed to ensure policies were implemented regarding operation of the facility. Immediate Jeopardy (IJ) was identified in the facility on [DATE], [DATE], and [DATE]. As of [DATE], the IJ was determined to be removed from the facility. However, on [DATE] an abbreviated standard survey was initiated and concluded on [DATE]. The investigation determined that IJ was again identified in the facility on [DATE] and was determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F580 J), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F657 J), and 483.25 Quality of Care (F684 J and F689 J). The IJ was determined to be ongoing. The findings include: Review of the facility's Administrative Management Policy dated [DATE], revealed the governing board shall be responsible for the management and operation of the facility. The policy stated the governing board was responsible for protection of the residents' personal and property rights, provision of facility services and quality resident care in accordance with professional standards of practice and principles, and provision of a safe physical environment equipped and staffed to maintain the facility and services. Review of a statement issued to the State Agency revealed effective [DATE], a corporate staff member became the Acting Administrator. Further review of the A[NAME] dated [DATE], revealed the facility terminated the Director of Nursing (DON) on [DATE], and oversight of nursing would be conducted by a Corporate Nurse Consultant until a new DON could be recruited. Observation and interview revealed a Corporate staff members continued to function in the roles of Acting DON and Acting Administrator at the time of exit on [DATE]. Review of an A[NAME] submitted on [DATE], revealed a Corporate Representative would provide daily oversight along with the Administrator in person for thirty days, then via phone for 90 days thereafter. Review of an A[NAME] submitted by the facility on [DATE], revealed the facility alleged Immediate Jeopardy would be removed effective [DATE]. The A[NAME] revealed the facility's Governing Body was comprised of the Chief Executive Officer (CEO), Chief Financial Officer (CFO), and Senior Vice President. According to the A[NAME], the Governing Body had been informed of the ongoing IJ and provided guidance and resources as necessary to correct the deficiencies. The A[NAME] stated the Administrator and the acting Director of Nursing would participate in daily meetings, weekly QA, and would regularly report to the Governing Body regarding achieving and maintaining ongoing substantial compliance. The A[NAME] also stated the Governing Body would receive updates from the facility's weekly QA meetings directly from the Administrator and would consult with the Compliance Officer weekly until substantial compliance was achieved. However, interview and record review revealed the facility failed to address Resident #21's risk factors for falls and revise the resident's care plan to prevent falls. The resident sustained [REDACTED]. Resident #21 expired on [DATE]. Interview with the Vice President of Operations (VPO) on [DATE] at 6:50 PM revealed that the facility had reviewed Resident #21's falls and that they had implemented every fall intervention that they could for him/her. She stated if the facility had placed fall mats next to the resident's bed that the resident would have fell over them when he/she ambulated without assistance. She further stated there was nothing more they could have done to prevent the resident from continued falls. However, there was no evidence the facility recognized that Resident #21's wrist was fractured on [DATE], but not identified or treated by the facility until [DATE]. Additionally, the facility also failed to identify that Resident #21 had not been provided the appropriate supervision the resident had been assessed to require prior to the fall on [DATE]. In addition, interview and record review revealed from the morning of [DATE] until the evening of [DATE], Resident #19 experienced a change in condition, and the resident voiced complaints to a minimum of four (4) facility staff. The resident's Responsible Party (RP) also reported the resident was not acting like him/herself to nursing staff. However, the facility failed to act on the resident's and RP's complaints, and failed to notify the resident's physician of the complaints. On [DATE], at approximately 6:20 PM, Resident #19 was found unable to speak or follow commands, and was experiencing facial drooping. Subsequently, Resident #19 was transferred to the hospital on [DATE], at approximately 6:40 PM and diagnosed with [REDACTED]. Continued interview with the Vice President of Operations (VPO) on [DATE] at 6:50 PM revealed she had reviewed Resident #19's medical record and that facility had taken appropriate action and did everything they could. The VPO stated Resident #19 did not experience a change in condition until [DATE] at which time the resident was transferred to the emergency room . However, there was no evidence to indicate that the facility had identified that the resident had initially displayed possible signs and systems of a stroke as early as the morning of [DATE], and failed to take appropriate action. In addition there was no evidence to indicate that the facility had identified that the Unit where Resident #19 was located had inadequate staffing in place on the night of [DATE], and that the nurse had failed to assess the resident or that the SRNA failed to report the resident's complaints to the nurse. Further interview with the Vice President of Operations (VPO) on [DATE] at 6:50 PM revealed she served as a member of the facility's Governing Body. The VPO stated that she had been in the facility consistently (exact days unknown) since approximately [DATE].

Based on observation, interview, record review, review of the facility's policy and procedures, review of Statements of Deficiencies (SOD) issued to the facility on [DATE] and [DATE], and review of Allegations of Compliance (A[NAME]) submitted by the facility on [DATE] and [DATE], it was determined the facility failed to ensure the Quality Assurance Committee identified quality deficiencies and implemented actions to correct quality deficiencies. Immediate Jeopardy was identified and SODs were issued on [DATE] and [DATE] related to the following: failure to administer medications based on residents' Medication Administration Records (MARs)/Physician orders; failure to ensure sufficient staffing to meet residents' needs; failure to supervise residents to prevent accidents; and failure to ensure care plans were revised to prevent accidents. The facility submitted A[NAME]s on [DATE] and [DATE], alleging that Immediate Jeopardy was removed and the facility was monitoring to ensure removal. However, the facility failed to address Resident #21's risk factors for falls and revise the resident's care plan to prevent falls. The resident sustained [REDACTED]. Resident #21 expired on [DATE] (Refer to F657 and F689). In addition, the facility alleged Licensed Practical Nurse (LPN) #10 was educated after making medication errors during the [DATE] survey, and all other staff were also educated and were competent. However, observation of medication administration on [DATE] and [DATE], revealed the LPN #10 made two additional medication errors and CMT #4 made a medication error, out of twenty-seven (27) opportunities, resulting in a medication error rate of 11.1 percent medication error rate. Further, the facility alleged that medication administration was being observed and monitored in the facility Quality Assurance (QA) program; however, the facility failed to identify medication errors and potential medication omissions (Refer to F759). Further, the facility alleged the Administrator and Director of Nursing would monitor staffing to ensure sufficient staff were available to provide resident care. However, on [DATE] and [DATE], there were not enough staff to provide care for residents (Refer to F725). The facility's failure to ensure an effective Quality Assurance Program was in place has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F657), and 483.25 Quality of Care (F684 and F689) The facility was notified of the Immediate Jeopardy on [DATE], and the Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy, Continuous Quality Improvement Policy Statement, not dated, revealed the facility's Quality Improvement process is comprehensive (involving all departments and key facility practices) and includes monitoring, evaluation, and appropriate follow-up action to continually improve and provide excellence in service. The policy stated the ultimate objective of Continuous Quality Improvement (CQI) was Quality Service for every resident, every day. Further review of the CQI policy revealed categories that made up the quality control component of the CQI process included Clinical, Environmental, Operations, etc. The policy revealed each CQI category had a calendar to be utilized by the CQI Committee as a guideline for the frequency of performing the specific indicator studies. The policy stated, however, that this was only a guide and the Committee was responsible for determining the frequency and need. According to the policy, the CQI Indicator studies that had the most significant impact on resident care and outcomes, or that reflected problem areas, must be examined more frequently. The policy further stated that in addition to the CQI Quality Indicator Studies, and the Quality Indicator/Quality Measure facility reports, information obtained from many other sources assisted in identifying potential problems that needed to be further reviewed. The policy indicated the sources could be satisfaction surveys, regulatory surveys, consultant reports, resident council concerns, family complaints, etc. The policy stated monitoring was ongoing and a log of CQI meetings, committee members, and topics discussed would be maintained as a ready reference of ongoing CQI activities and for sharing with surveyors as needed. 1. Review of an A[NAME] submitted by the facility on [DATE] revealed all resident care plans had been reviewed to reflect the residents' current care needs and all accident/incident reports for the last six months were reviewed on [DATE], with no new issues identified. The A[NAME] also stated staff had been educated daily revision of care plans to reflect residents' current care needs. According to the A[NAME], if a concern was identified, it would be discussed in the morning meeting to ensure the care plan was revised as needed. The A[NAME] stated staff would discuss appropriate interventions and the MDS Nurse would revise the care plan as needed. The A[NAME] also revealed that all Accident/incident reports, would be reviewed in a morning meeting, to ensure all reports were followed up on, and the resident care plan was revised as needed. Further review of the A[NAME] revealed the facility would audit ten percent of care plans each week to ensure appropriate additions/revisions had been made, and the audit would be presented to the QA Committee. According to the A[NAME], the QA Committee would meet weekly for six weeks and then monthly to review audits and determine compliance. However, Resident #21 had a history of [REDACTED].#21's falls and failed to ensure that all identified risk factors had been assessed, care planned, and implemented per the facility's policy and procedures. Resident #21 sustained a fall on [DATE], and an x-ray report obtained on [DATE] revealed the resident had a wrist fracture. The facility failed to identify the injury and the injury was not treated until [DATE], when the resident's physician identified the injury. The facility changed the resident's alarm after the fall, but failed to implement new interventions to supervise the resident to prevent further falls, and the resident sustained [REDACTED].#21's staff failed to supervise the resident hourly as per the resident's plan of care. Staff found Resident #21 on the floor beside the resident's chair, on [DATE]. The resident sustained [REDACTED]. Resident #21 expired on [DATE]. An interview with the Acting Administrator and the Acting Director of Nursing on [DATE] at 11:45 AM, revealed they were reviewing Accident/Incident reports in their morning meetings as alleged in an ACO, and had identified that the majority of the resident's falls were due to the resident wanting to stand/get out of the recliner; however, there was no documented evidence the facility revised the resident's care plan with interventions to prevent further falls. The Acting Administrator further stated in interview on [DATE] at 5:29 PM, that the facility did not revise a resident's care plan after a non-injury fall because she believed the care plan was effective, even though the care plan was not effective at preventing a fall. 2. Review of an SOD issued to the facility revealed on [DATE], Immediate Jeopardy was identified related to the medication error rate. The facility failed to evaluate the competency and skill level of LPN #9 when the LPN was hired, during the orientation process, or after being notified by orientation staff that LPN #9 was not following standards of practice related to medication administration. LPN #9 failed to utilize residents' Medication Administration Record [REDACTED]. Review of the facility's A[NAME] submitted on [DATE], revealed the facility conducted an in-service for all nursing staff on [DATE] related to medication administration technique and common errors and alleged all staff were competent. The facility also alleged that at least one medication audit would be conducted per week on alternating shifts with a different nurse or medication aide to identify any deficient practice. The A[NAME] also stated a pharmacy representative or a Corporate Nurse Consultant would observe at least ten medication opportunities every day, each shift, to identify any deficient practice. The A[NAME] alleged the audit results would be reported to the facility's Quality Assurance Committee. However, review of an SOD dated [DATE], revealed Immediate Jeopardy was determined to exist again, when staff (LPN #10) failed to review residents' MARs when administering medications. The facility had a medication error rate of 7.1 percent. The facility submitted an A[NAME] on [DATE], and alleged Immediate Jeopardy was removed on [DATE]. The facility alleged LPN #10 was re-educated and competency was evaluated by pharmacy staff on [DATE], and LPN #10 made no medication errors. The facility also alleged that all licensed nursing staff and certified medication aids were re-educated regarding MAR utilization by the acting DON on [DATE] and [DATE]. The education included the five Medication Rights, Triple Checking for accuracy and the MAR, and consistently checking the MAR. The facility alleged competency was confirmed through daily observation. The facility also alleged that beginning [DATE] and continuing daily until Immediate Jeopardy was removed, a pharmacy representative would be present to observe, monitor, and audit medication administration throughout the building. According to the A[NAME], any issues observed would be immediately addressed by the pharmacy staff and the staff member would be removed if necessary. The audit results would be provided to the Administrator daily after each observation, and the Administrator would review the audit results to confirm that any issues had been addressed including employee training, physician notification, and resident monitoring. The facility alleged the Administrator would report the monitoring results and any follow-up at the QA meeting on [DATE], and weekly thereafter until substantial compliance was achieved. However, observation of medication administration on [DATE] and [DATE] with Licensed Practical Nurse (LPN) #10, and Certified Medication Aide (CMA) #4 revealed the staff made three (3) medication errors out of twenty-seven (27) opportunities, resulting in a medication error rate of 11.1 percent. Interview with LPN #10 on [DATE] at 8:04 PM, revealed she had been educated regarding medication administration and ensuring medication was administered based on the MAR. However, LPN #10 revealed both medication errors were committed because the nurse failed to carefully review each resident's Medication Administration Record [REDACTED] Interview with the Pharmacist on [DATE] at 4:16 PM, and with the Administrator on [DATE] at 6:10 PM, revealed pharmacy staff continued to do medication observations with the staff as stated in the facility's A[NAME]s, and had not identified any concerns with medication administration. In addition, review of Resident #4 and #26's Medication Administration Records (MARs) revealed staff failed to document the resident's Intravenous (IV) antibiotic medication was administered as ordered. In addition, staff transcribed the stop date for an IV antibiotic medication onto a MAR indicated [REDACTED]. Interview with the acting Director of Nursing (DON) on [DATE] at 4:47 PM revealed she had been checking residents' MARs and physician's orders [REDACTED]. However, there was no evidence the facility identified that Resident #32's MAR indicated [REDACTED]. 3. Review of an SOD dated [DATE], revealed Immediate Jeopardy was identified due to the facility's failure to provide sufficient numbers of nursing staff to answer call lights and supervise residents. Resident #3 was left on a bedpan for approximately two (2) hours, Resident #8 did not receive incontinence care for approximately six (6) hours, and sustained skin breakdown to his/her perineal area, and Resident #1 was being placed in a reclining Geri-chair, which he/she could not voluntarily get out of, to facilitate staff in getting their work done. Review of A[NAME] dated [DATE], revealed the facility alleged that staffing was monitored each shift by the Staffing Coordinator with daily oversight by the Administrator and Director of Nursing to ensure there were competent staff in sufficient numbers to meet the care needs and acuity levels for the resident, which included number of admissions and residents with behaviors. The A[NAME] stated the Administrator and DON would monitor staffing and if there were increased nursing requirements, additional staff would be allocated to ensure resident needs were met. If staffing levels were not adequate, incentives were offered to employees who were not working to ensure staffing levels are adequate. The A[NAME] alleged that if staffing could not be covered by offering an incentive, an administrative nurses would cover the shift to ensure sufficient staffing. Further review of an SOD dated [DATE], revealed Immediate Jeopardy at staffing was removed; however, deficient practice remained while the facility monitored the effectiveness of systemic changes and quality assurance activities. Review of most current staffing levels provided to the surveyor was for [DATE] which revealed the facility's staffing levels were as follows for a census of seventy-seven (77) residents: ten (10) State Registered Nurse Aides (SRNA) for day shift; seven (7) SRNAs for evenings, and five (5) SRNAs for nights; two (2) nurses, or one (1) nurse and one (1) Certified Medication Technician (CMT) for the North Unit on days (7 AM to 7 PM), and for the night shift (7 PM to 7 AM) on the North Unit one (1) nurse and one (1) CMT; on the South Unit three (3) nurses, or two (2) nurses and one (1) CMT for days, and two (2) nurses, or one (1) nurse and one (1) CMT for nights. However, based on observation, interview, and record review, on [DATE] from 12:00 AM to 6:00 AM, and on [DATE] for the day shift, the facility failed to ensure there were sufficient numbers of staff to provide care for residents. There was not enough staff to provide one to one supervision (staff supervision at all times) on [DATE], for Resident #6 to ensure the resident's safety transfer residents from bed/chair. In addition, on [DATE], there were not enough staff to transfer residents from bed/chair per staff interview. Interview with the Acting Administrator on [DATE] at 5:27 PM, and the Acting Director of Nursing (DON) on [DATE] at 5:50 PM, revealed the issues with staffing were not brought to their attention, and there was no evidence the Administrator/DON monitored staffing daily to ensure there were sufficient staff to provide resident care as alleged in the A[NAME]s.

Based on interview, record review, and review of a facility job description, it was determined the facility failed to provide services that met professional standards of quality for one (1) of seven (7) sampled residents (Resident # 34). Resident #34's physician ordered neurological examinations to be completed after the resident sustained [REDACTED]. However, Licensed Practical Nurse (LPN) #10 failed to act on the physician's orders [REDACTED]. The findings include: Review of the facility's Job Description for a Licensed Practical Nurse (LPN) revealed the LPN was responsible for transcribing and taking appropriate action on physician's orders [REDACTED]. Review of Resident #34's medical record revealed the resident sustained [REDACTED]. Review of the resident's physician's orders [REDACTED]. Further review revealed the resident's physician gave an order on 09/11/18, to conduct neurological examinations for 72 hours. Review of Resident #34's care plan, dated 03/06/18 revealed the facility identified the resident was at risk for falls related to confusion and gait/balance problems. Further review revealed the facility revised the resident's care plan on 09/11/18, with interventions that included conducting neurological examinations for 72 hours to ensure the resident did not have major injury related to the fall. Review of the facility's Neurological Flow Sheet revealed the facility was required to conduct vital signs and neurological examinations every 15 minutes for the first hour, every 30 minutes the second hour, then hourly for six (6) hours, every four (4) hours for eight (8) hours, then every eight (8) hours for fifty-six hours, for a total of seventy-two hours. Review of Resident #34's Neurological Flow Sheet on 09/12/18, at 4:30 PM, revealed no documented evidence staff conducted a neurological examination for Resident #34 on 09/12/18 at 12:00 AM. Interview with LPN #10 on 09/13/18 at 6:40 PM, revealed she was the nurse responsible for Resident #34's care on 09/12/18, at 12:00 AM. LPN #10 stated she did not complete Resident #34's neurological examination. Further interview with LPN #10 revealed when she reviewed the resident's Neurological Flow Sheet on 09/12/18, the resident did not have a neurological exam due at 12:00 AM. She stated at that time, the flow sheet indicated the exam was required to be conducted at 12:00 PM. After reviewing the flow sheet on 09/13/18, LPN #10 stated it appeared the document had since been altered to reflect the need to conduct the exam at 12:00 AM.

The facility failed to provide sufficient numbers of nursing staff to provide care to all residents. On 05/29/18, Resident #3 was left on a bedpan for approximately two (2) hours. On 03/18/18, Resident #8 did not receive incontinence care for approximately six (6) hours, and sustained skin breakdown to his/her perineal area. Residents #3 and #8 stated they activated their call lights; however, their needs were not met. Interviews with nine (9) other residents (Residents #1, #3, #5, #12, #19, #20, B, C, and G) revealed there was not enough staff at the facility They stated they had waited up to one and one-half hours for staff to respond to call lights. Residents also reported they had incontinence accidents waiting for staff to respond. In addition, interviews conducted with Resident #1 and staff revealed the resident was being placed in a reclining Geri-chair, which he/she could not voluntarily get out of, to facilitate staff in getting their work done. The facility's failure to ensure sufficient numbers of staff were available to provide care for residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy titled Staffing, dated 08/01/13, revealed the facility would maintain staffing to ensure that the residents' needs and services would be met. 1. Review of Resident #4's medical record revealed the facility admitted the resident on 08/22/17, with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) Score of fifteen (15) indicating the resident was interviewable. Interview with Resident #4 on 06/27/18 at 4:00 PM and 4:30 PM revealed he/she had been left on a bedpan too long on several occasions. Resident #4 stated, One time I was left on a bedpan for a very long time and I was told I should have rung my call light. I did, but nobody came. Further interview with Resident #4 revealed that recently (exact date unknown) staff came in at 4:00 AM for a bladder treatment. The resident stated he/she was required to hold the medication in his/her bladder for thirty minutes for treatment of [REDACTED].#4 stated after waiting thirty minutes, he/she pushed the call light, but staff failed to respond. The resident then stated that finally before breakfast a staff member entered his/her room, but told the resident that she could not assist because she was passing breakfast trays. Resident #4 stated, I finally had to pee on myself. The resident stated he/she believed the cause of his/her frequent Urinary Tract Infections was due to having to hold his/her urine because, They don't have enough staff here. Further interview revealed no one returned to assist the resident to the bathroom until 8:00 AM, but it was too late. The resident stated it bothers me when he/she is incontinent. Review of a Care Conference Note dated 05/29/18, revealed Resident #4 and his/her family voiced concerns that the resident's call light was taking too long to be answered. The resident stated it had previously taken up to four (4) hours for staff to answer the call light. The facility's response to the concern was that they had reviewed video footage and determined that Resident #4's call light had not been on any longer than one hour. The resident also voiced concerns that he/she had been left on a bedpan. Further review of the Notes revealed that the facility explained during that time that the night shift aide failed to communicate to the day shift aide that the resident had been placed on a bedpan. The Notes also stated Resident #4 .did not put on call light during this time. The resident responded, I just waited for them to come get me off, I thought they knew. 2. Review of Resident #8's medical record revealed the facility admitted the resident on 04/11/12, with [DIAGNOSES REDACTED]. Review of Resident #8's MDS assessment dated [DATE], revealed the resident had a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of a facility Grievance Complaint Form dated 03/20/18, revealed Resident #8 voiced a grievance to the Social Services Director that the weekend staff was awful, and there was not enough help on both Saturday and Sunday of the previous weekend. According to the Grievance Complaint Form, the resident reported that he/she was changed on Sunday morning, 03/18/18, at 5:15 AM, and was not changed again until 11:05 AM, just before going to lunch. According to the resident's report to the Social Worker, he/she was soaked with urine and the resident's bottom was raw, had a sore on my ass, and a rash between my legs. Interview with Resident #8 on 06/28/18 revealed the resident remembered filing the grievance complaint because there was hardly no staff in the building. According to interview with Resident #8, staff changed the resident's incontinence brief at approximately 5:00 AM (exact date unknown, but recalled it was a weekend in March), and it was not changed again until lunchtime. Further interview with the resident revealed the area was setting me on fire. According to the interview, the resident reported ringing his/her call light several times and no one answered. Resident #8 further stated staff often came in and turned off the call light, but they did not meet the resident's needs. The resident stated it made him/her mad when there was not enough staff to answer call lights. 3. Review of Resident #1's medical record revealed the facility admitted the resident on 05/16/17, with [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #1 was cognitively intact. Interview with Resident #1 on 06/27/18 at 6:20 PM, revealed it .doesn't do any good to ring the call light because they don't come. 4. Review of Resident #3's medical record revealed the facility admitted the resident on 12/31/13, with [DIAGNOSES REDACTED]. Review of the resident's MDS dated [DATE], revealed the facility assessed Resident #3 to have a BIMS score of fifteen (15), which indicated Resident #3 was cognitively intact. Interview with Resident #3 on 06/26/18 at 4:20 PM, revealed on average it would take staff thirty-five (35) minutes to respond to his/her call light, and it was often worse on the weekends. The resident stated staffing at the facility had been discussed in the Resident Council, with SRNAs, Nurses, the DON, and the Administrator. Resident #3 stated it makes him/her sad, because he/she has been in the facility over five (5) years and they treat him/her this way. 5. Review of Resident #5's medical record revealed the facility admitted the resident on 03/25/15, with [DIAGNOSES REDACTED]. Review of the resident's MDS dated [DATE], revealed the facility assessed Resident #5 to have a BIMS score of nine (9), which indicated Resident #5 was cognitively intact. Interview with Resident #5 on 06/26/18 at 6:15 PM, revealed staff often did not respond to the resident's call light for up to one and one-half hours. The resident stated, I have a clock on my wall. Resident #5 also stated staff fusses at him/her because he/she liked to go to bed early. The resident stated that staff told him/her that they were busy doing other things. Resident #5 further stated that he/she has activated the call light in the past and staff did not respond for thirty (30) minutes. Resident #5 stated he/she was incontinent of urine because staff did not respond. The resident stated, It upsets me when I have to pee on myself. 6. Interview with Resident #1 on 06/27/18 at 6:20 PM, revealed sometimes they put me in the mean chair so he/she could not get up. Resident #1 stated that staff have made me sit in the chair all day. Interview with SRNA #15 on 07/01/18 at 6:00 PM, revealed staff had been placing Resident #1 in the reclined Geri-chair in order to answer call lights or when other residents were needing assistance. SRNA #15 also stated that the nurses placed Resident #1 in the reclined Geri-chair in order to get medications passed and to conduct nursing rounds. Interview with LPN #10 on 06/29/18 at 5:45 PM, revealed Resident #1 was placed in the reclined Geri-chair when nurses needed to get medications passed, or when staff needed to get their rounds made, stating You are unable to get anything done. Interview with SRNA #17 on 07/03/18 at 10:05 AM, revealed she had placed Resident #1 in the reclined Geri-chair at times because the resident would continually push his/her call light requesting to go to the bathroom. SRNA #17 stated staff would put the resident in the reclined Geri-chair anytime they needed to do rounds, answer call lights, or complete paperwork. 7. Review of Resident #12's medical record revealed the facility admitted the resident on 03/13/18, with [DIAGNOSES REDACTED]. Review of Resident 12's MDS assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of fifteen (15), which indicated the resident was interviewable. Interview with Resident #12 on 07/19/18 at 4:30 PM, revealed he/she had to wait on assistance and there was never enough staff. The resident stated there was too much work and not enough people. 8. Review of Resident #19's medical record revealed the facility admitted the resident on 12/22/17, with [DIAGNOSES REDACTED]. Review of the resident's MDS dated [DATE], revealed the facility assessed Resident #19 to have a BIMS score of fifteen (15), which indicated Resident #19 was cognitively intact. Interview with Resident #19 on 07/19/18 at 2:50 PM, revealed staff were slow to answer call lights. Resident #19 stated he/she tried to ring ahead of time if he/she knew they were short-staffed so he/she would not have to wait as long. 9. Review of Resident #20's medical record revealed the facility admitted the resident on 10/11/17, with [DIAGNOSES REDACTED]. Review of the resident's MDS dated [DATE], revealed the facility assessed Resident #20 to have a BIMS score of fifteen (15), which indicated Resident #20 was cognitively intact. Interview with Resident #20 on 06/26/18 at 6:25 PM, revealed he/she has timed staff before and it would take staff up to ninety (90) minutes to answer his/her call light. The resident stated he/she wears a watch and has a clock in his/her room and that was how he/she knew how long it took staff to respond. Resident #20 stated he/she had reported that there were not enough staff, but he/she could not recall specific dates and times it was reported. 10. Review of Resident B's medical record revealed the facility admitted the resident on 01/25/18, with [DIAGNOSES REDACTED]. Review of Resident B's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS score of fifteen (15). Interview with Resident B on 06/26/18 at 9:15 AM, revealed that the resident resided in the room with his/her spouse, who was dependent on staff. Resident B stated he/she rang the call light when the spouse required assistance, and often staff came into the room, turned off the light, but did not provide care for the resident. 11. Review of Resident C's medical record revealed the facility admitted the resident on 06/19/17, with [DIAGNOSES REDACTED]. Review of Resident C's MDS assessment dated [DATE], revealed the resident had a BIMS score of fifteen (15) and was interviewable. Interview with Resident C on 06/26/18 at 9:50 AM, revealed that he/she had timed staff on how long it took staff to answer his/her call light and at times it took up to one and one-half hours for staff to answer his/her call light. 12. Review of Resident G's medical record revealed the facility admitted the resident on 01/29/15 with [DIAGNOSES REDACTED]. Review of Resident G's MDS assessment dated [DATE], revealed the resident had a BIMS score of fifteen (15) and was interviewable. Interview with Resident G on 07/19/18 at 2:55 PM, revealed staff were slow to answer call lights, especially in the mornings. Interview with the facility Ombudsman on 07/05/18 at 9:30 AM, revealed she spoke to the Resident Council President on 01/11/18 and on 02/08/18. The Ombudsman stated the residents had concerns that call lights were not answered timely and there was not enough staff. Interview with State Registered Nurse Aide (SRNA) #1 on 06/26/18 at 12:04 PM, revealed residents had told her that they were not receiving bed baths or showers on weekends, because there was no staff available. She also stated residents were having incontinence accidents while they were waiting for somebody to answer their call lights. Interview with SRNA #2 on 06/26/18 at 12:23 PM, revealed residents had also told her that there was not enough staff to assist residents on weekends. Interview with SRNA #5 on 06/26/18 at 1:15 PM, revealed one week ago she worked on one unit by herself and it was hard to take care of all the residents. SRNA #5 stated staffing on weekends was terrible. SRNA #5 stated residents often complained because staff could not answer call lights in a timely manner. Interview with SRNA #4 on 06/26/18 at 2:00 PM, revealed she worked on weekends at times, and the facility was very short-staffed on weekends. She stated residents stated that they had incontinence episodes, waiting for their call lights to be answered. SRNA #4 stated there were more residents on the South Hall of the facility and the residents required more care. The SRNA stated when the South Hall was short-staffed, it took longer to answer the call lights. Interview with SRNA #6 on 06/26/18 at 4:50 PM, revealed the facility was very short-staffed on weekends. She stated when she returned to work on Mondays, she could tell that the male residents had not been shaved and the residents complained that staff took way too long to answer their call lights. Interview with SRNA #7 on 06/26/18 at 5:55 PM, revealed she has worked when there was only one SRNA on each unit of the facility and residents had to wait for call lights to be answered. SRNA #7 stated residents have had incontinence accidents waiting for someone to answer their call lights. Interview with SRNA #9 on 06/27/18 at 5:30 PM, revealed residents had told her that they had to wait for over an hour for her to answer their call lights. She stated she tried to get to residents timely, but there were not enough staff. SRNA #9 stated she always apologized to the residents, and explained to them how the facility was short-staffed. Interview with SRNA #15 on 07/01/18 at 6:00 PM, revealed residents had told her that they had incontinence accidents waiting for staff to answer the call lights. According to SRNA #15, Administrative staff was aware of the residents' concerns with short-staffing. Interview with SRNA #22 on 07/02/18 at 6:23 PM, revealed the facility was very understaffed. The SRNA revealed he had residents complain that they have had incontinence accidents on themselves, waiting for him to answer their call lights. He stated he has to stay over at times, when his shift ends, in order to get all his work done. Interview with Licensed Practical Nurse (LPN) #1 on 06/27/18 at 11:50 AM, revealed she had worked at the facility with only (1) SRNA on each hall, which was not enough staff. LPN #1 stated the facility had several residents who required a lift for transfers and two (2) SRNAs were needed. The LPN also stated that residents who needed assistance to go the bathroom had complained that they had incontinence episodes waiting for staff to answer their call lights. Interview with LPN #3 on 06/28/18 at 3:31 PM, revealed staff had reported that residents were having incontinence episodes waiting for staff to answer their call lights. She further stated residents who were alert and oriented, and who could tell time, had complained that it sometimes took hours for staff to answer their call lights. LPN #3 stated Administrative staff was aware of the residents' concerns. Interview with the Director of Nursing (DON) on 07/03/18 at 10:48 AM, revealed residents and staff had complained that there was not enough staff at the facility. The DON stated he was aware that staff were not able to complete resident showers, and he had told them just give them bed baths. The DON stated the more SRNAs they have in the facility, the less the SRNAs want to work. He stated, I told them, just give them bed baths. The Administrator also stated that residents should not place Resident #1 into a reclined Geri-chair in order to get their work completed. Interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM revealed they were aware the facility had been short-staffed at times. They further stated staff had worked a twenty-four (24) hour shift a couple of times to ensure the needs of the residents were met. They further stated they had tried to give sign-on bonuses, gift cards for working extra shifts, and pulled staff from their sister facilities, but they had not considered using agency staff. However, there was no evidence the facility had taken other action to ensure resident care needs were met.

Based on interview, record review, review of facility policies, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's failure to ensure the facility was Administered in an effective manner has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the Administrator's Job Description (not dated) revealed the Administrator's essential job function was to plan, develop, and implement all aspects of facility operations. The Administrator was to ensure staff were able to interpret and follow established policies and procedures. The policy also stated the Administrator's principal concern would be for the delivery of quality care to all residents of the facility. Record review revealed Resident #8 filed a grievance with the facility that he/she was left wet for approximately six (6) hours on 03/18/18, which resulted in excoriation. Interview with Resident #8 revealed he/she activated his/her call light several times, but due to a lack of staff in the facility, no one responded. The Administrator and Social Services Director reviewed video footage and determined that staff were in the resident's room during the time the resident alleged he/she was not cared for; however, the Administrator did not ensure an investigation was conducted to determine whether staff provided care for the resident while in the resident's room and failed to take action to prevent the incident from recurring. The Administrator also failed to report these allegations of neglect to the appropriate State Agencies as required. On 04/06/18, staff placed Resident #3 on a bedpan after lunch. However, the facility failed to monitor the resident every five (5) minutes as required by the facility's protocol and staff did not remove the bed pan from underneath Resident #3 until 04/07/18 at approximately 2:30 PM. Interviews with staff revealed the bedpan was indented into the resident's skin and the resident developed pressure ulcers to the buttocks as a result of being on the bedpan for a prolonged period of time. Interview with the Administrator revealed she was aware staff reported that Resident #3 had been left on a bedpan for an extended amount of time, however, the Administrator stated she did not believe the incident had occurred and therefore did not investigate the neglect or take further action. An interview with staff revealed State Registered Nurse Aide (SRNA) #17 slammed Resident #5 onto a toilet. SRNA #5 stated she reported the incident to the Administrator during the week of 06/18/18. However, there was no evidence to indicate the Administrator initiated an investigation related to the allegation when she became aware of it. Interviews with Resident #7 and review of documentation revealed Resident #7 reported on 06/13/18 that LPN #9 shoved medications and tried to pour water in the resident's mouth, hurting the resident's mouth. Resident #7 stated LPN #9 also hit Resident #6 on the back and fussed at the resident after Resident #6 spit out his/her medications. Interview and record review revealed LPN #2 reported the allegations to the facility's Administrator. However, the Administrator failed to ensure an investigation was conducted, that residents were protected, and that the allegations were reported as required. Staff failed to monitor Resident #4 while on a bedpan in accordance with facility policy and the resident was left on a bedpan for approximately two (2) hours on 05/29/18. The Administrator was notified of the incident by Resident #4's family on 05/29/18 during a care conference. The Administrator acknowledged that the resident was left on the bedpan for an extended amount of time, and determined the cause of the neglect was that SRNAs had failed to communicate. However, there was no documented evidence that the Administrator took action to determine why the facility's policy and procedure in place to check residents placed on a bedpan every five minutes was not followed or to ensure it would be implemented in the future. On 06/18/18, Resident #2 was diagnosed with [REDACTED].#2 was cognitively impaired and interviews with staff revealed they were not aware how the injury occurred. However, there was no documented evidence the Administrator reported the injury of unknown source to state agencies and there was no documented evidence the Administrator ensured a thorough investigation of the resident's injury of unknown source was conducted. While conducting an investigation related to an allegation involving Resident #3, the Administrator made Resident #3 feel as though he/she was lying about the allegation. Resident #3 stated he/she was intimidated and belittled. Staff interviews confirmed Resident #3 was upset and had cried for several days. Although the Administrator was aware that Resident #3 was upset and crying, she took no action to ensure the resident's emotional well-being was addressed. On 06/13/18 and 06/19/18, Resident #9 removed his/her code alert bracelet without staff knowledge and exited the facility without staff supervision. Interviews with the Administrator revealed she was aware that Resident #9 had exited the facility without staff knowledge. However, the Administrator failed to identify the resident's elopement as a concern to be addressed in the facility Quality Assurance Program. Interviews with facility residents and staff revealed there was not enough staff working at the facility to meet the needs of residents. Although the Administrator acknowledged in interview that the facility was short-staffed at times, no action had been taken to ensure resident needs were being met and that facility residents were not experiencing adverse outcomes as a result of the facility being short-staffed. Interview with the Administrator on 07/02/18 at 5:13 PM, 07/08/18 at 2:45 PM, and 07/20/18 at 12:28 PM, revealed she was aware of all the abuse/neglect/injury of unknown origin allegations; however, she did not report or investigate the allegations or protect the residents from further potential abuse/neglect because the Administrator either did not believe the allegations occurred, were not suspicious, or were accidents. The Administrator stated if there was a logical explanation for an injury, the facility did not report or investigate the injury. Further interview with the Administrator revealed she had not identified that staff were restraining Resident #1 for convenience; and had not identified any concerns regarding nurse or nurse aide trainings for competency related to medication administration. The Administrator stated she was aware that Resident #9 had left the facility without staff knowledge, but had not identified that Resident #9's care plan had not been revised when displaying exit-seeking behavior and/or elopement. Continued interview with the Administrator revealed the facility had identified an ongoing concern with staffing; however, the Administrator stated staffing had not been addressed in the facility's CQI program. In addition, because the facility had not identified the concerns with abuse/neglect/injuries of unknown origin protection, reporting, and investigating, and had not identified a concern with elopement, the facility had not identified the quality deficiencies and developed action plans to address the concerns in the CQI program. The Administrator stated, I take good care of these residents. I take it personally. It's insulting.

Based on interview, record review, review of facility policy, and review of an Allegation of Compliance submitted by the facility, it was determined that the Governing Body failed to ensure policies were implemented regarding operation of the facility. Immediate Jeopardy was identified on 07/06/18. The facility submitted an acceptable Allegation of Compliance (AOC) on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the AOC could not be verified, and Immediate Jeopardy was identified again on 07/20/18. The Immediate Jeopardy is ongoing. The facility submitted a second AOC on 07/27/18, which alleged removal of the Immediate Jeopardy on 07/26/18. According to the AOC, a representative of the Governing Body would be in attendance at the monthly Quality Assurance meetings to ensure that systems and policies were being monitored appropriately by Administration. However, based on observation, interview, and record review, the AOC submitted on 07/27/18 could not be verified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), 42 CFR 483.45 Pharmacy Services (F759), 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). Additional Immediate Jeopardy was identified at 42 CFR 483.70 Administration (F837). The facility was notified of the Immediate Jeopardy on 08/03/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Administrative Management Policy dated 08/01/13, revealed the governing board shall be responsible for the management and operation of the facility. The policy stated the governing board was responsible for protection of the residents' personal and property rights, provision of facility services and quality resident care in accordance with professional standards of practice and principles, and provision of a safe physical environment equipped and staffed to maintain the facility and services. Review of an AOC submitted by the facility on 07/27/18, revealed a representative of the Governing Body would be in attendance at the monthly Quality Assurance meetings to ensure that systems and policies were being monitored appropriately by Administration. The facility alleged Immediate Jeopardy was removed effective 07/26/18. However, review of a Resident Accident/Incident report dated 07/28/18 at 11:30 AM, revealed Resident #23 had a dark purple bruise to the right inner thigh that measured 1.5 centimeters (cm) by 2 cm. Further review revealed the facility documented that the causative factor for the bruise was that the resident throws his/her legs over the arms of a Geri-chair and attempted to crawl over the bed rail. According to the report, the facility reviewed the incident in the morning meeting on 07/29/18, two days after the injury was identified. There was no documented evidence the facility reported the injury to State agencies or conducted an investigation of the injury in accordance with the facility's Resident Protection Plan and the AOC. Review of the facility's training dated 07/09/18, 07/11/18, and 07/12/18, revealed staff were trained, as stated in the facility's AOCs, regarding injuries of unknown origin. However, facility and corporate staff failed to recognize the injury as an injury of unknown source, and failed to report and investigate the injury as required by the facility's policy (Refer to F600, F609, F610, F835, and F868). In addition, observation of medication administration on 07/30/18, revealed twenty-eight (28) medication opportunities with two (2) errors, resulting in a 7.1 percent error rate. Review of the facility's training and interview with Licensed Practical Nurse (LPN) #10 revealed the LPN was trained and passed competency in medication administration on 07/21/18, as stated in the facility's AOC dated 07/27/18. However, observation revealed LPN #10 administered medication to two (2) residents (unsampled Residents G and H) based on memory. LPN #10 did not read the entire physician's orders [REDACTED]. The LPN administered [MEDICATION NAME]/[MEDICATION NAME] nebulizer inhalation medication at 7:40 PM to Resident G. However, the medication had already been administered by another nurse at 6:00 PM and was not due again until 1:00 AM on 07/31/18. In addition, LPN #10 administered one Tylenol 500 milligram (mg) tablet to Resident H; however, the resident had physician's orders [REDACTED]. On 08/02/18 at 5:26 PM, an interview with the Chief Executive Officer (CEO), a member of the facility's Governing Body, revealed he was aware of the deficient practices cited and he was working closely with the management company to get the facility back in compliance. He stated he spoke with the Executive Vice President of the management company daily and often met as a team related to compliance, regulatory issues, and complaints. The CEO stated the management company had also reported there were concerns with Resident #23's bruising and he was involved in helping to correct the issues.

Based on interview, record review, review of facility policy, and review of an Allegation of Compliance submitted by the facility, it was determined that the Governing Body failed to ensure policies were implemented regarding operation of the facility. Immediate Jeopardy was identified on 07/06/18. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified, and Immediate Jeopardy was identified again on 07/20/18. The Immediate Jeopardy is ongoing. The facility submitted a second A[NAME] on 07/27/18, which alleged removal of the Immediate Jeopardy on 07/26/18. According to the A[NAME], a representative of the Governing Body would be in attendance at the monthly Quality Assurance meetings to ensure that systems and policies were being monitored appropriately by Administration. However, based on observation, interview, and record review, the A[NAME] submitted on 07/27/18 could not be verified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), 42 CFR 483.45 Pharmacy Services (F759), 42 CFR 483.70 Administration (F835), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). Additional Immediate Jeopardy was identified at 42 CFR 483.70 Administration (F837). The facility was notified of the Immediate Jeopardy on 08/03/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Administrative Management Policy dated 08/01/13, revealed the governing board shall be responsible for the management and operation of the facility. The policy stated the governing board was responsible for protection of the residents' personal and property rights, provision of facility services and quality resident care in accordance with professional standards of practice and principles, and provision of a safe physical environment equipped and staffed to maintain the facility and services. Review of an A[NAME] submitted by the facility on 07/27/18, revealed a representative of the Governing Body would be in attendance at the monthly Quality Assurance meetings to ensure that systems and policies were being monitored appropriately by Administration. The facility alleged Immediate Jeopardy was removed effective 07/26/18. However, review of a Resident Accident/Incident report dated 07/28/18 at 11:30 AM, revealed Resident #23 had a dark purple bruise to the right inner thigh that measured 1.5 centimeters (cm) by 2 cm. Further review revealed the facility documented that the causative factor for the bruise was that the resident throws his/her legs over the arms of a Geri-chair and attempted to crawl over the bed rail. According to the report, the facility reviewed the incident in the morning meeting on 07/29/18, two days after the injury was identified. There was no documented evidence the facility reported the injury to State agencies or conducted an investigation of the injury in accordance with the facility's Resident Protection Plan and the A[NAME]. Review of the facility's training dated 07/09/18, 07/11/18, and 07/12/18, revealed staff were trained, as stated in the facility's A[NAME]s, regarding injuries of unknown origin. However, facility and corporate staff failed to recognize the injury as an injury of unknown source, and failed to report and investigate the injury as required by the facility's policy (Refer to F600, F609, F610, F835, and F868). In addition, observation of medication administration on 07/30/18, revealed twenty-eight (28) medication opportunities with two (2) errors, resulting in a 7.1 percent error rate. Review of the facility's training and interview with Licensed Practical Nurse (LPN) #10 revealed the LPN was trained and passed competency in medication administration on 07/21/18, as stated in the facility's A[NAME] dated 07/27/18. However, observation revealed LPN #10 administered medication to two (2) residents (unsampled Residents G and H) based on memory. LPN #10 did not read the entire physician's orders [REDACTED]. The LPN administered [MEDICATION NAME]/[MEDICATION NAME] nebulizer inhalation medication at 7:40 PM to Resident G. However, the medication had already been administered by another nurse at 6:00 PM and was not due again until 1:00 AM on 07/31/18. In addition, LPN #10 administered one Tylenol 500 milligram (mg) tablet to Resident H; however, the resident had physician's orders [REDACTED]. On 08/02/18 at 5:26 PM, an interview with the Chief Executive Officer (CEO), a member of the facility's Governing Body, revealed he was aware of the deficient practices cited and he was working closely with the management company to get the facility back in compliance. He stated he spoke with the Executive Vice President of the management company daily and often met as a team related to compliance, regulatory issues, and complaints. The CEO stated the management company had also reported there were concerns with Resident #23's bruising and he was involved in helping to correct the issues.

Based on observation, interview, record review, policy review, and review of the Facility Assessment, it was determined the facility failed to ensure the Quality Assurance Committee identified quality deficiencies and implemented actions to correct quality deficiencies. Interviews with the Administrator, who was the facility's Continuous Quality Improvement Coordinator, revealed she was aware of allegations that Residents #5 and #6 were abused, that Residents #3, #4, and #8 were neglected, and that Resident #2 had a fractured shoulder. However, the Administrator stated she did not feel the allegations should have been reported to State agencies, investigated, or that staff should have been suspended in accordance with the facility's policy. Therefore, the facility failed to identify that reporting/investigation/resident protection was a concern that should be addressed in the facility's Quality Assurance Program (Refer to F600, F609, and F610). In addition, interviews with the Administrator revealed she was aware that Resident #9 had exited the facility without staff knowledge. However, the facility failed to identify the resident's elopement as a concern to be addressed in the facility Quality Assurance Program (Refer to F657, F689, and F758). The facility failed to identify that staffing and staff competencies were a concern; subsequently, the facility failed to identify that the concern should be addressed in the facility's Quality Assurance Program. The facility failed to ensure the competency of a newly hired nurse (Licensed Practical Nurse #9) and the nurse committed two significant medication errors (06/04/18 and 07/20/18) and 14 errors during the medication pass observations on 07/20/18 (Refer to F725, F726, F759, and F760). The facility's failure to ensure the Quality Assurance Program identified quality deficiencies has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy, Continuous Quality Improvement Policy Statement, not dated, revealed the facility's Quality Improvement process is comprehensive (involving all departments and key facility practices) and includes monitoring, evaluation, and appropriate follow-up action to continually improve and provide excellence in service. The policy stated the ultimate objective of Continuous Quality Improvement (CQI) was Quality Service for every resident, every day. Further review of the CQI policy revealed categories that made up the quality control component of the CQI process included Clinical, Environmental, Operations, etc. The policy revealed each CQI category had a calendar to be utilized by the CQI Committee as a guideline for the frequency of performing the specific indicator studies. The policy stated, however, that this was only a guide and the Committee was responsible for determining the frequency and need. According to the policy, the CQI Indicator studies that had the most significant impact on resident care and outcomes, or that reflected problem areas, must be examined more frequently. The policy further stated that in addition to the CQI Quality Indicator Studies, and the Quality Indicator/Quality Measure facility reports, information obtained from many other sources assisted in identifying potential problems that needed to be further reviewed. The policy indicated the sources could be satisfaction surveys, regulatory surveys, consultant reports, resident council concerns, family complaints, etc. The policy stated monitoring was ongoing and a log of CQI meetings, committee members, and topics discussed would be maintained as a ready reference of ongoing CQI activities and for sharing with surveyors as needed. Interview with the Administrator on 07/20/18 at 12:28 PM revealed she had been serving as the Continuous Quality Improvement Coordinator and was currently training the Minimum Data Set (MDS) Coordinator to serve as CQI Coordinator. Per the Administrator, the facility's CQI Committee met on a monthly basis and reviewed quality indicators as directed by the CQI calendar. The Administrator stated they also went through the Quality Measures every month and also used Minimum Data Set (MDS) reviews and Grievances to identify problems. The Administrator stated when the CQI Committee identified a problem the following occurs: an action plan is developed by the committee, the action plan is implemented, and then an evaluation of the action plan is reviewed. A request for any indicators or monitors the CQI Committee had addressed on the following concerns and the dates addressed were requested from the Administrator: Abuse, Neglect, Injury of Unknown Source, Reporting and Investigating Abuse/Neglect, Elopements, and Grievance. 1. Interviews with Residents #3, #4, #5, #7, and #8 and interviews with staff revealed Residents #3, #4, #5, #6, #7, and #8 were abused/neglected by staff at the facility. The residents and/or staff stated they reported the allegations to the Administrator; however, there was no evidence the facility implemented the facility's Resident Protection Plan and took action to protect the residents from further potential abuse/neglect; the facility failed to report the allegations to state agencies timely; and the facility failed to conduct a thorough investigation of the allegations (Refer to F600, F609, and F610). In addition, on 06/18/18, Resident #2, a resident who was cognitively impaired and dependent upon staff for all activities of daily living, was diagnosed with [REDACTED]. There was no documented evidence the facility reported the allegation to state agencies as required by the facility policy or conducted a thorough investigation of the injury (Refer to F609 and F610). 2. The facility assessed Resident #9 to be at risk for elopement and developed a care plan with interventions to address elopement. Resident #9 exhibited exit-seeking behavior; however, the facility failed to revise the resident's care plan to address the exit-seeking behavior. On 06/13/18, Resident #9 removed his/her code alert bracelet and exited the facility without staff knowledge. The facility failed to revise the resident's care plan with interventions to prevent recurrence and on 06/19/18, Resident #9 exited the facility again without staff knowledge (Refer to F657, F689, and F758). 3. Interviews with Residents #3 and #8 revealed staff did not answer their call lights timely. On 05/29/18, Resident #3 was left on a bedpan for approximately two hours. On 03/18/18, Resident #8 did not receive incontinence care for approximately six hours, and sustained skin breakdown to his/her perineal area. Residents #3 and #8 stated they activated their call lights; however, their needs were not met. In addition, interviews with nine (9) other residents (Residents #1, #3, #5, #19, #20, B, C, G, and H) revealed there was not enough staff at the facility. Residents stated they had waited up to one and one-half hours for staff to respond to call lights and meet the residents' needs, often resulting in incontinence episodes. 4. The facility failed to evaluate the competency and skill level of Licensed Practical Nurse (LPN) #9 upon hire (05/22/18). On 06/04/18, LPN #9 administered Insulin (medication used to lower blood sugar levels) in error to Resident #21, and no formal retraining or counseling was provided to the LPN after the error, or even after being notified by orientation staff that LPN #9 was not following standards of practice related to medication administration. The facility allowed LPN #9 to continue to provide resident care and administer resident medications. On 07/20/18, LPN #9 was observed during the morning medication pass to administer medications to five residents. Numerous errors were observed during the medication pass, which resulted in a 31.8 percent error rate. An additional significant error also occurred on 07/20/18 when LPN #9 administered in error a [MEDICATION NAME] Patch (pain medication) to Resident #21. (Refer to F726, F759, and F760.) Further interview with the Administrator on 07/20/18 at 12:28 PM, revealed the facility had identified an ongoing concern with staffing. Per the Administrator, there were no nursing applications since (MONTH) (YEAR) and very few nurse aide applications. The Administrator stated the facility had attempted several interventions to address the staffing shortage, but staffing was still a problem. When asked if staffing had been addressed in the CQI program, the Administrator stated it had not been addressed recently and she would get the dates of the last time staffing had been brought to the CQI Committee as a problem in the facility. At 4:50 PM, the Administrator stated the facility had last looked at staffing in the CQI program in (MONTH) (YEAR). The Administrator stated the facility had a weekly meeting where problems were discussed and resident elopements or residents at risk for elopement were looked at weekly. However, even though resident elopement and elopement risks were discussed weekly, resident elopements had not been addressed in CQI Committee, prior to the survey. According to the Administrator, the facility had not taken abuse to CQI lately, and there was no evidence abuse/neglect/injuries of unknown source were on the facility's CQI calendar. A second request was made for any indicators or monitors the CQI Committee had addressed related to: Abuse, Neglect, Injury of Unknown Origin, Reporting and Investigating Abuse/Neglect, Elopements, and Grievances. A third request for information was made on 07/20/18 at 8:10 PM; however, no documented evidence was received that the facility had identified the quality deficiencies and developed action plans to address the concerns.

Based on observation, interview, record review, and review of the facility's abuse policy, it was determined the facility failed to protect six (6) of twenty-two (22) sampled residents from abuse/neglect (Residents #3, #4, #5, #6, #7, and #8). An interview with staff revealed State Registered Nurse Aide (SRNA) #17 slammed Resident #5 onto a toilet (exact date unknown, but prior to 05/06/18). Resident #5 was also able to recall the incident and stated it frightened him/her and caused pain. SRNA #5 stated she reported the incident to Licensed Practical Nurse (LPN) #8 immediately after the incident occurred and reported the allegation to the Administrator during the week of 06/18/18. In addition, interviews with staff revealed other staff were mean to Resident #5. Interview with the Unit Manager revealed she had knowledge of the abuse allegations and Resident #5 had also reported to her directly that staff did not like him/her and would not answer the resident's call light. However, the facility failed to ensure the facility's abuse policy was implemented and no action was taken to protect the resident from further potential abuse (Refer to F609 and 610). Interviews with Resident #7 and review of documentation revealed Resident #7 reported on 06/13/18 that LPN #9 shoved medications and tried to pour water in the resident's mouth, hurting the resident's mouth. Resident #7 stated LPN #9 also hit Resident #6 on the back and fussed at the resident after Resident #6 spit out his/her medications. Interview and record review revealed LPN #2 reported the allegations to the facility's Administrator. However, the facility failed to suspend LPN #9, as required by the facility's policy, and failed to ensure residents were protected from further potential abuse (Refer to F609 and 610). The facility further failed to protect Resident #3 from neglect. Staff placed Resident #3 on a bedpan after lunch on 04/06/18. The facility failed to monitor the resident every five (5) minutes as required by the facility's protocol and staff did not remove the bed pan until 04/07/18 at approximately 2:30 PM. Interviews with staff revealed the bedpan was indented into the resident's skin and the resident developed pressure ulcers to the buttocks as a result of being on the bedpan for a prolonged period of time (Refer to F606, F610, F656, and F686). In addition, staff failed to monitor Resident #4 while on a bedpan in accordance with facility policy and the resident was left on a bedpan for approximately two (2) hours on 05/29/18. Furthermore, Resident #8 wrote a grievance that he/she was left wet for approximately six (6) hours, which resulted in excoriation. Interviews with Residents #4 and #8 revealed they activated their call lights and staff did not respond (Refer to F609 and F610). The facility's failure to ensure residents were protected from abuse/neglect has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Resident Protection Plan, dated 11/12/17, revealed it was the facility's policy that each resident had the right to be free from abuse and neglect. The policy stated the facility did not condone abuse by anyone, including staff members. The policy further stated residents should be protected from any harm during the course of an investigation. According to the policy, employees of the facility who had been accused of resident abuse would be suspended immediately pending investigation or until the results of the investigation had been reviewed by the Administrator. Continued review of the facility's Resident Protection Plan revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, and included verbal, physical, and mental abuse. The facility defined verbal abuse as .any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Further review revealed the facility defined physical abuse as .hitting, slapping, pinching, kicking, etc. The facility defined mental abuse as .not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. According to the facility's policy, willful was defined as .an individual acting in a deliberate way; not that the individual must have intended to inflict injury or harm. Further review of the facility's Resident Protection Plan revealed the facility defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental or emotional anguish. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 07/01/16, and the resident had [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be nine (9), indicating the resident was interviewable. The MDS indicated the resident had no behaviors, and had mood indicators of feeling depressed and having little energy. The resident required extensive assistance of staff with activities of daily living, including walking and transferring, and the resident utilized a walker and a wheelchair. The MDS further revealed the resident had minimal difficulty in hearing, could be understood, and usually understood others, comprehending most of the conversation. Interview with Resident #5 on 06/26/18 at 6:15 PM, revealed the resident recalled an incident when a staff member grabbed him/her by the arm and shoved me on the commode. The resident stated the staff member was hateful, but he/she was unable to recall exactly what she (the staff member) said. Resident #5 stated it frightened him/her and hurt when he/she hit the commode (toilet). Interview with State Registered Nurse Aide (SRNA) #5 on 06/27/18 at 4:35 PM, revealed approximately one month ago, she and SRNA #17 were assisting Resident #5 to the bathroom. SRNA #5 stated SRNA #17 told her to let go of the resident. SRNA #17 then picked up the resident and slammed the resident down onto a commode and stated to the resident, I'm tired of this bullshit. You're going to learn to walk the right way. According to SRNA #5, Resident #5 stated, I wish you wouldn't be so mean to me. I can't help it. SRNA #5 stated she immediately reported the abuse to LPN #8, and not long after the incident, SRNA #17 quit working at the facility. However, SRNA #5 stated she was notified last week (week of 06/18/18) that SRNA #17 was coming back to the facility to work. SRNA #5 stated this concerned her because of the incident with Resident #5, so she reported the abuse to the Administrator. However, SRNA #5 stated the Administrator told her that she should report the incident up the chain of command even though SRNA #5 told the Administrator that she already had reported this. Interview with LPN #8 on 06/27/18 at 4:00 PM revealed she worked with Resident #5; however, no one had reported anything to her about a SRNA pushing/slamming the resident onto a commode. Interview with SRNA #17 on 07/03/18 at 10:24 AM revealed she denied shoving Resident #5 onto a commode and stated she was not hateful with the resident. SRNA #17 stated she did tell the resident he/she needed to walk flat on his/her feet. SRNA #17 stated the resident was one of them on the call light all the time. The SRNA further stated that at one time she monitored how often the resident rang his/her call light, stating, it went off thirty to forty times in an eight-hour period. Review of SRNA #17's personnel file revealed the SRNA voluntarily left employment at the facility on 05/06/18. Interview with SRNA #3 on 06/28/18 at 11:15 AM, revealed she worked on the unit where Resident #5 resided. She stated staff were mean to the resident and did not want to answer the resident's call light. Interview with LPN #3 on 06/28/18 at 3:02 PM, revealed staff often stated they did not like to work with Resident #5. She stated that Resident #5 had also reported to her that someone had pushed him/her onto the commode. LPN #3 stated the resident often reported that staff were hateful and mean to him/her. She stated that the resident did not know names of staff, but he/she could describe them. LPN #3 stated she reported the incidents to the Unit Manager; however, the Unit Manager always told her to write it up but it ends there and nothing happens. Interview with Unit Manager #1 on 06/29/18 at 11:11 AM, revealed she heard someone talking about Resident #5 being pushed onto a toilet, but she was not sure when it happened. The Unit Manager stated it was not reported to her, but if the allegation had been reported to her directly, she would have removed SRNA #17 from resident care. The Unit Manager stated that Resident #5 also had reported to her that staff did not like him/her and that they would not answer his/her call light. The Unit Manager stated she had not been able to identify the staff member, and took no further action to protect the resident from further potential abuse. She stated the resident tends to fabricate things. Interview with the DON on 07/03/18 at 10:50 AM, revealed he was not aware of the incident involving Resident #5 being slammed onto a commode until the weekend of 06/30/18. The DON stated it was his understanding that a nurse aide reported the allegation to the Administrator and the Administrator was taking care of the incident. Interview with the Administrator on 07/05/18 at 2:45 PM revealed on 06/21/18, SRNA #5 reported that SRNA #17 had cursed in front of Resident #5 saying, This is bullshit. However, there was no documented evidence the Administrator investigated the allegation at that time. Further interview revealed the Administrator denied that SRNA #5 reported that SRNA #17 slammed Resident #5 until she interviewed SNRA #5 again on 06/30/18, after the survey was initiated. 2. Review of Resident #6's medical record revealed the facility admitted the resident on 10/21/17, with [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was severely cognitively impaired. The MDS revealed the resident had no behaviors and required extensive assistance with all Activities of Daily Living (ADLs). Review of Resident #6's care plan, revised on 05/02/18, revealed the facility developed a care plan related to the resident's impaired thought process due to [MEDICAL CONDITION] and Activities of Daily Living (ADL) deficit. The facility developed interventions that included administering medications as ordered, utilizing reality orientation without agitating the resident, allowing time to process information and respond, offering reassurance and comfort when the resident became agitated or confused, assisting with ADLs, and allowing the resident to do as much as possible for him/herself. Interview with Resident #7 on 06/27/18 at 5:56 PM, revealed Resident #6 came into Resident #7's room and LPN #9 gave medication to Resident #6 (date unknown). Resident #7 stated Resident #6 spit out the medication and LPN #9 hit the resident on the back and said something to the resident, but he/she could not heare what the nurse said. Resident #7 stated he/she reported the incident to the nurse (LPN #2) the next day. Review of Resident #7's medical record revealed the facility admitted the resident on 06/12/14, and the resident had [DIAGNOSES REDACTED]. Review of Resident #7's Minimum Data Set assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating the resident was interviewable. Further review revealed the facility assessed the resident to have depressed mood and trouble sleeping, but exhibited no other mood symptoms. The MDS also revealed the facility assessed the resident to have organized thinking and clear comprehension; and exhibited no [MEDICAL CONDITION] or behavioral symptoms. Review of Resident #7's care plan revealed the facility developed a care plan related to the resident's risk for decline in psychosocial well-being. The facility developed interventions to prevent decline that included allowing the resident to participate in daily care and decision-making, listening carefully to the resident and being nonjudgmental, and allowing the resident to express his/her feelings. Review of Resident #6 and Resident #7's Medication Administration Records (MARs) for (MONTH) (YEAR) revealed LPN #9 administered medications to the residents on 06/01/18, 06/04/18, 06/05/18, 06/12/18, 06/18/18, 06/19/18, and 06/26/18. Interview with Resident #7 on 06/27/18 at 5:56 PM, revealed LPN #9 came into his/her room (date unknown) to administer his/her medications and shoved the medication in his/her mouth. The resident further stated the nurse also tried to pour water in his/her mouth. Then, Resident #6 came into the resident's room and LPN #9 gave medication to Resident #6. Resident #7 stated Resident #6 spit out the medication and LPN #9 hit the resident on the back and said something to the resident, but he/she could not hear what the nurse said. Resident #7 stated he/she reported the incidents to the nurse (LPN #2) the next day. Resident #7 further stated that he/she would prefer that the nurse not provide care for him/her anymore. Interview with LPN #2 on 06/27/18 at 12:40 PM, and review of a Nurse's Note dated 06/13/18, revealed Resident #7 reported that he/she didn't like that older nurse that LPN #2 was training the other day, which was (LPN #9). Resident #7 reported that LPN #9 was hateful speaking and she hurt my mouth giving my medicines. She put it all in my mouth at one time. The resident stated, She tried to pour my water in my mouth but I stopped her and told her I can get my own water. According to the documentation, Resident #7 also reported that lady who wheels in my room and bumps my bed with (his/her) wheelchair came in here, which would be (Resident #6). Resident #7 stated LPN #9 brought Resident #6's medicine in Resident #7's room and gave the medication to the resident. Resident #7 reported that Resident #6 spit out the medication on the floor and LPN #9 smacked the resident and yelled at (the resident) not to spit out (the resident's) meds (medications). Further review/interview with LPN #2 revealed Resident #7 reported LPN #9 forced what looked like orange juice in (Resident #6's) mouth. Further review of documentation revealed LPN #9 smacked Resident #6 on the right shoulder. LPN #2 assessed Resident #6 and the resident had no injuries. According to the documentation and interview with LPN #2, she reported the incidents immediately to the Administrator. Further interview with LPN #2 revealed she had not witnessed LPN #9 abuse a resident, but it wouldn't surprise me if it happened because she (LPN #9) had a bad attitude. During interview with LPN #9 on 07/02/18 at 7:04 PM, she stated, I do not remember hitting (Resident #6) and she did not recall Resident #7 stating that he/she had mouth pain. LPN #9 stated the Administrator called her and asked about the residents last week. LPN #9 stated she had not been suspended from the facility. Interview with SRNA #7 on 06/27/18 at 5:45 PM, revealed after the incident occurred, Resident #7 asked her if LPN #9 was going to be working because he/she did not want the LPN providing care for him/her. SRNA #7 stated she had not observed LPN #9 hit a resident, but stated the LPN sometimes got in a hurry and got smart with residents. Interview with the Social Services Director on 07/19/18 at 4:55 PM revealed she was aware of the allegation involving LPN #9. The Social Services Director stated she had seen LPN #2's chicken scratch dated 06/13/18, regarding the incident. In addition, she stated the Administrator sent her an email regarding the allegation. She stated that she and the Administrator discussed the allegation with LPN #9 during the week of 06/26/18, but they had taken no further action. The Social Services Director provided the email and stated she received the email on her personal email from the Administrator on 06/26/18. Review of the email printed 06/27/18 at 4:31 PM, revealed LPN #2 reported that Resident #7 told her that he/she had observed an older nurse with gray hair hit (the resident), that wheels around, on (the resident's) shoulder when the resident was in (Resident #7's) room. The email stated that LPN #2 assumed Resident #7 was referring to Resident #6 because Resident #6 wheeled about the facility. It was also assumed that the nurse Resident #7 was referring to was LPN #9, because she had gray hair and had worked on the hallway where the residents resided. Resident #7 reported that the nurse gave Resident #6's medicines, the resident began to spit out the medication, and the nurse hit Resident #6 on the shoulder and told the resident not to do that. Resident #7 also reported to LPN #2 that LPN #9 hurt his/her mouth when she gave his/her medications. Resident #7 was not able to give the date when the incident occurred. LPN #2 stated she assessed Resident #6 and no injuries were noted. According to the email, LPN #9 denied hitting Resident #6 on the shoulder and stated she did not recall Resident #7 saying anything about his/her mouth hurting. Interview with the Administrator on 07/05/18 at 2:45 PM, revealed she was aware of the allegation involving Residents #6 and #7. However, further interview revealed no action was taken to ensure residents were protected because she did not have an exact date or time that the incident allegedly occurred, or the name of the nurse who was the alleged perpetrator. The Administrator stated that LPN #2, the nurse who reported the allegation, assumed that the alleged perpetrator was LPN #9, because Resident #7 stated it was a new nurse. The Administrator stated she talked to LPN #9, who stated she did not hit Resident #6. She stated she had known LPN #9 for a long time and Resident #6 was the kind of resident that is like poor pitiful me. The Administrator stated she was not aware of the allegation that LPN #9 hurt Resident #7's mouth. She stated she did not talk to Resident #7 because he/she was asleep. According to the Administrator, she did not suspend LPN #9, as required by the facility's policy, because a specific date or time was not given. There was no evidence the facility took action to protect residents from further abuse. 3. Review of a facility procedure titled Giving the Bedpan, not dated, revealed after assisting a resident onto a bedpan, staff were required to return when the resident signaled, or to check on the resident every five (5) minutes. Review of Resident #3's medical record revealed the facility admitted the resident on 12/31/13, and the resident had [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. Further review of the assessment revealed Resident #3 required the assistance of two (2) or more staff persons for bed mobility and toilet use, which included bedpan use. The MDS revealed the resident was occasionally incontinent of bowel and bladder, and was at risk for developing pressure ulcers. However, Resident #3 had no pressure ulcers. Review of Resident #3's care plan dated 01/16/14, revealed the resident had a toileting deficit related to generalized weakness, [MEDICAL CONDITIONS], and bowel incontinence. The facility developed interventions that included providing privacy, responding promptly to the call light, and providing total care with Activities of Daily Living. Review of the Department of Nursing Clinical Flowsheet for (MONTH) (YEAR) revealed Resident #3 utilized an indwelling urinary catheter for bladder elimination and was continent of bowel. Review of Resident #3's Weekly Nurse's Notes and Body Audit dated 04/03/18, revealed the resident had areas to the lower extremities that the facility was treating, had multiple bruises from a previous fall, and no pressure ulcers were documented. Further review of the resident's care plan (not dated) revealed the resident had a potential for impaired skin integrity and had red and opened areas to the buttocks due to being stuck to bedpan. Further review of the Weekly Nurse's Notes and Body Audits revealed on 04/10/18, the facility documented that the resident had a 6.5-inch lateral abrasion to the left buttock with a quarter-sized abrasion to the right buttock, and a 4-inch lateral abrasion to the right upper buttock. Interview with Resident #3 on 06/26/18 at 4:20 PM, revealed that over a month ago, staff left him/her on a bedpan for too long. The resident stated he/she did not recall the incident because just prior to the incident he/she had been in the hospital and was sick. However, the resident stated staff told him/her about the incident and stated the bedpan had broken causing the areas on his/her bottom. Resident #3 stated he/she did not feel well and did not allow the State Agency Surveyor to observe his/her skin. However, Resident #3 stated he/she continued to receive treatment to the areas on his/her bottom and the areas caused pain. Interview with SRNA #23 on 07/02/18 at 5:22 PM, revealed that she and SRNA #25, who were staff preceptors and were helping to assist residents, placed Resident #3 on a bedpan after lunch on 04/06/18. She stated they told SRNAs #20 and #21, who were the SRNAs assigned to work the unit, that Resident #3 was on a bedpan and that they needed to take the resident off the bedpan. Interview with SRNA #20 on 07/02/18 at 6:02 PM, revealed she provided care for Resident #3 on 04/06/18 from 6:00 AM until 3:00 PM. She stated she did not assist the resident on or off a bedpan on 04/06/18. SNRA #20 also stated that she did not recall SRNA #23 or SRNA #25 reporting to her that Resident #3 had been assisted onto a bedpan after lunch on 04/06/18. Interview with SRNA #21 on 07/02/18 at 7:55 PM revealed on 04/06/18, she was assigned to provide care for Resident #3 from 6:00 AM to 3:00 PM. SRNA #21 stated no one notified her that Resident #3 had been placed on a bedpan. She stated when she returned to work on Monday, 04/09/18, she was shocked when she saw Resident #3's bottom. Interview with SRNA #22 on 07/02/18 at 6:23 PM, revealed he was assigned to provide care for Resident #3 on 04/06/18 at 10:00 PM until 6:00 AM on 04/07/18, and did not assist Resident #3 with a bedpan during this time. Continued interviews with SRNAs #20, #21, and #22 revealed they turned and repositioned Resident #3 during their shifts on 04/06/18 and/or 04/07/18; however, due to the resident's weight and use of a draw sheet (a linen placed underneath a resident to move the resident in bed), they would not have been able to see a bedpan. The SRNAs further stated that because Resident #3 was continent of bowel and had a urinary catheter, they had no reason to check for a bedpan. Interview with SRNA #7 on 06/26/18 at 5:55 PM, revealed she did not assist the resident onto a bedpan during her shift from 6:00 AM to 3:00 PM on 04/07/18. However, she and Registered Nurse (RN) #1 discovered a bedpan under Resident #3 at approximately 2:30 PM on 04/07/18. SRNA #7 stated when staff removed the bedpan from the resident's bottom, the resident had a red ring on (his/her) bottom, and had two areas that opened up on the resident's bottom, after the incident happened. Interview with RN #1 on 06/26/18 at 5:08 PM, revealed on the afternoon of 04/07/18, a bedpan was discovered underneath Resident #3, when she and SRNA #7 were preparing to wash Resident #3's back. RN #1 stated, (The resident's) bottom was indented in the shape of a bed pan and was red. The RN stated she did not complete an incident report because the resident's skin was not open at that time; however, she left a note for the Wound Care Nurse to report that the incident had occurred. Interview with the Wound Care Nurse on 07/03/18 at 5:50 PM, revealed she assessed Resident #3's bottom on 04/09/18, two days after the bedpan was removed, and she could see the indention of the bedpan and redness on the resident's bottom. The Wound Care Nurse stated the next day, 04/10/18, the red areas opened. Interview with LPN #1 on 06/27/18 at 11:50 AM, revealed she provided care for Resident #3 on 04/06/18 during the day shift, and she did not return to work until 04/09/18. LPN #1 stated that on 04/09/18, the indention of the bedpan remained on Resident #3's bottom. LPN #1 further stated that she asked the DON and the Administrator about the bedpan incident and they told her they were looking into it. Interview with Minimum Data Set (MDS) Nurse #2 on 06/27/18 at 3:20 PM, and the DON on 07/03/18 at 10:48 AM, revealed the bedpan incident involving Resident #3 was briefly discussed in the morning meeting on 04/09/18. However, during the meeting, the Administrator stated she was in the facility on 04/07/18 and reported she did not observe a bedpan underneath the resident; therefore, no further action was taken. An interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM, revealed the Administrator was aware of the bedpan incident involving Resident #3. The Administrator stated she did not believe a bedpan was left underneath Resident #3 for an extended length of time. They stated if a bedpan had truly been left underneath Resident #3 for a long length of time, the incident would have been investigated and reported to state agencies. 4. Review of Resident #4's medical record revealed the facility admitted the resident on 08/22/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was not cognitively impaired and was interviewable. Further review revealed Resident #4 had no [MEDICAL CONDITION] or behaviors, and required total assistance with activities of daily living, including bed mobility and toileting. The assessment also revealed Resident #4 was occasionally incontinent of bladder and always continent of bowel. Review of Resident #4's care plan dated 09/12/17, revealed the facility identified the resident was at risk for toileting/elimination deficit related to impaired mobility, left-sided weakness, bowel incontinence, and occasional bladder incontinence. The facility developed interventions that included providing scheduled toileting every two hours, ensuring toileting needs were met by staff, encouraging the resident to use the call light and respond promptly, and assisting with toileting needs including mobility on and off the toilet. Review of a Care Conference Note dated 05/29/18, revealed Resident #4 and his/her family voiced concerns that the resident had been left on a bedpan. The Notes further stated that the facility explained during that time the night shift aide failed to communicate to the day shift aide that the resident had been placed on a bedpan. The Notes also stated Resident #4 did not put on call light during this time. The resident responded, I just waited for them to come get me off, I thought they knew. Review of a Weekly Nurse's Notes and Body Audit form dated 05/29/18, revealed Resident #4 was assessed related to bedpan left under resident for approximately 2 hours this AM. The facility documented no redness or bruising was noted and the resident voiced no pain. Interview with Resident #4 on 06/27/18 at 4:00 PM, revealed he/she had been left on a bedpan too long on several occasions. Resident #4 stated, One time I was left on a bedpan for a very long time and I was told I should have rung my call light. I did, but nobody came. Resident #4 further stated that being left on the bedpan was uncomfortable, painful, and made him/her feel bad, because they forgot about me. Review of an in-service for SRNAs dated 05/30/18 and titled Walking Rounds, revealed the facility trained staff on the importance of making walking rounds because, We do not always remember everything that may have happened during our shift. The in-service detailed the importance of making rounds. The in-service did not include names of staff in attendance. Further review revealed the facility provided an example of a resident that may have been placed on bedpan during last round and needs to be removed. However, the information provided in the training was not in accordance with the facility's policy of checking residents every five (5) minutes after being placed on a bedpan. Interview with SRNA #3 on 06/29/18 at 11:17 AM, revealed she recalled that Resident #4 had been left on a bedpan, but she did not remember the date. SRNA #3 stated that staff on third shift had placed Resident #4 on a bedpan at approximately 5:15 AM, but forgot to report the information to her during shift report. SRNA #3 stated when she entered the resident's room at approximately 7:30 AM, the resident reported he/she was on a bedpan. The SRNA stated she could not remember if Resident #4 had any redness as a result of being on the bedpan. In addition, SRNA #3 stated she did not report the incident because at that time she did not know the resident had been on the bedpan for more than two (2) hours. SRNA #3 further stated, Staff do not do walking rounds to give report to the oncoming staff, because they are running out of the doors when oncoming staff arrive for work. Furthermore, SRNA #3 stated she had never been trained on the facility's bedpan policy and had received no retraining since the incident. Interview with Unit Manager (UM) #1 on 06/29/18 at 10:50 AM, revealed she found out about Resident #4 being left on a bedpan at a Resident Care Conference on 05/29/18. The UM stated a bedpan was placed under Resident #4 at approximately 5:00 AM, when a medication was given to the resident for his/her bladder. She stated Resident #4 reported that the bedpan was not removed until SRNA #3 removed the bed pan at approximately 7:00 AM,

Based on observation, interview, record review, and review of the facility's abuse policy, it was determined the facility failed to ensure allegations of abuse/neglect/injury of unknown source were reported to the State protection agency and the State Survey Agency for seven (7) of twenty-two (22) sampled residents (Residents #2, #3, #4, #5, #6, #7, and #8). Residents and/or staff reported allegations to the Administrator that Residents #5, #6, and #7 were abused; Residents #3, #4, and #8 were neglected; and Resident #2 had an injury of unknown source. However, the facility failed to report the allegations to the state survey agency and Adult Protective Services. (Refer to F600 and F610.) The facility's failure to report allegations of abuse, neglect, and an injury of unknown source has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Resident Protection Plan, dated 11/12/17, revealed it was the policy of the facility that any employee who had reasonable cause to believe or even suspect that a resident had suffered abuse, neglect, or injuries of unknown source must report the incident immediately. The policy stated the Administrator or designee would then promptly notify (verbally and written) the state agency, Adult Protective Services, and the Ombudsman of the incident immediately, but not later than two (2) hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. In addition, the policy stated that the Administrator, or designee, would provide the appropriate state agencies with a written report of the findings of the facility's investigation within five working days of the occurrence of the incident. 1. Interview with Resident #5 on 06/26/18 at 6:15 PM, revealed a staff member grabbed the resident by the arm and shoved me on the commode (could not recall exact date). The resident stated the staff member was hateful, but he/she was unable to recall exactly what the staff member said. Resident #5 stated it frightened him/her and hurt when he/she hit the commode (toilet). Interview with State Registered Nurse Aide (SRNA) #5 on 06/27/18 at 4:35 PM revealed approximately one month ago, she and SRNA #17 were assisting Resident #5 to the bathroom. SRNA #5 stated that SRNA #17 picked up Resident #5, slammed the resident down onto a commode, and stated, I'm tired of this bullshit. You're going to learn to walk the right way. According to SRNA #5, Resident #5 stated, I wish you wouldn't be so mean to me. I can't help it. SRNA #5 stated she immediately reported the abuse to Licensed Practical Nurse (LPN) #8, and reported the allegation to the Administrator during the week of 06/18/18. Interview with LPN #8 on 06/27/18 at 4:00 PM, revealed she did not recall SRNA #5 reporting that a SRNA pushed/slammed Resident #5 onto a commode. Interview with LPN #3 on 06/28/18 at 3:02 PM, revealed Resident #5 had also reported to her that someone had pushed him/her onto the commode. LPN #3 stated the resident often reported that staff were hateful and mean to the resident. According to LPN #3, she reported the incidents to the Unit Manager; however, the Unit Manager always told her to write it up and it ends there and nothing happens. Interview with Unit Manager #1 on 06/29/18 at 11:11 AM revealed she heard someone talking about Resident #5 being pushed on a toilet, but she was not sure when it happened. The LPN stated it was not reported to her, but if the allegation had been reported to her directly, she would have removed SRNA #17 from care and would have reported the allegation to Administrative staff. Interview with the Director of Nursing (DON) on 07/03/18 at 10:50 AM, revealed he was not aware of the incident involving Resident #5 being slammed on a commode until the weekend of 06/30/18. The DON stated it was his understanding that a nurse aide reported the allegation to the Administrator and the Administrator was taking care of the incident. According to the DON, any allegation that a staff member was mean or rude to a resident would automatically be investigated as abuse and reported to state agencies. Interview with the Administrator on 07/05/18 at 2:45 PM revealed on 06/21/18, SRNA #5 reported that SRNA #17 had cursed in front of Resident #5 saying, This is bullshit. Further interview revealed the Administrator denied that SRNA #5 reported that SRNA #17 slammed Resident #5 until the Administrator interviewed SNRA #5 again on 06/30/18, after the survey was initiated. The Administrator stated that cursing in front of a resident did not generate an incident report and the facility did not report those incidents. The Administrator stated they would have investigated the incident if the allegation was that staff were cursing at the resident. 2. Interview with Resident #7 on 06/27/18 at 5:56 PM revealed the resident stated that a nurse (LPN #9) came in to administer the resident's medications and shoved the medication in the resident's mouth. In addition, the nurse tried to pour water in the resident's mouth. Further interview with Resident #7 revealed the nurse gave Resident #6's medication and Resident #6 spit out the medication. According to Resident #7, the nurse hit Resident #6 on the back and said something to the resident, but he/she could not recall what the nurse said. Resident #7 stated he/she reported the incident to LPN #2 and he/she had not spoken to anyone else about the incident. Interview with LPN #2 on 06/27/18 at 12:40 PM, review of the LPN's documentation made on a Nurse's Note dated 06/13/18, and review of an email dated 06/29/18, revealed the Administrator was aware of the incident that occurred on 06/13/18. According to the Nurse's Note, Resident #7 doesn't like that older nurse (the nurse) was training the other day which was LPN #9. Resident #7 reported the nurse was hateful speaking and she hurt my mouth giving my medicines. She put it all in my mouth at one time. and She tried to pour my water in my mouth but I stopped her and told her I can get my own water. Resident #7 also reported the nurse smacked Resident #6, yelled at the resident, and forced what looked like orange juice in Resident #6's mouth. According to the email from the Administrator, Resident #7 was not able to give the date as to when the incident occurred, LPN #9 denied hitting Resident #6 on the shoulder, and LPN #9 did not recall Resident #7 saying anything about mouth pain. There was no documented evidence the facility conducted an investigation of the incident in accordance with the facility's policy. Interview with the Administrator on 07/05/18 at 2:45 PM, revealed the allegation was not reported because she did not have an exact date or time the incident occurred and she did not know the other resident's name (Resident #6). The Administrator stated she had known LPN #9 for years and I can't imagine (LPN #9) ever doing anything like that. 3. Review of Resident #3's care plan (not dated) revealed the resident had red and opened areas to the buttocks due to being stuck to bedpan. Review of a Weekly Nurse's Notes and Body Audit form dated 04/10/18, revealed Resident #3 had a 6.5-inch lateral abrasion to the left buttock with a quarter-sized abrasion to the right buttock, and a 4-inch lateral abrasion to the right upper buttock. Interview with Resident #3 on 06/26/18 at 4:20 PM, revealed that over a month ago, staff told the resident that they left him/her on a bedpan for too long. The resident did not recall the incident because the resident had just returned from the hospital and was sick. The resident stated staff told him/her that the bedpan had broken while it was under the resident causing the areas on his/her bottom. Resident #3 stated he/she continued to receive treatment to the areas on his/her bottom and the areas caused pain. Interview with Registered Nurse (RN) #1 on 06/26/18 at 5:08 PM, revealed on the afternoon of 04/07/18, a bedpan was discovered underneath Resident #3. RN #1 stated the bedpan had been under the resident so long that the resident's bottom was indented in the shape of a bed pan and was red. Interview with Minimum Data Set (MDS) Nurse #2 on 06/27/18 at 3:20 PM, and the Director of Nursing (DON) on 07/03/18 at 10:48 AM, revealed the bedpan incident involving Resident #3 was briefly discussed in the morning meeting on 04/09/18. However, during the meeting, the Administrator stated she was in the facility on 04/07/18, and reported she did not observe a bedpan underneath the resident; therefore, no further action was taken. An interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM, revealed the Administrator did not report the allegation that Resident #3 was left under a bedpan because she knew it had had not been left there that long. 4. Review of a Care Conference Note dated 05/29/18, revealed Resident #4 and his/her family voiced concerns that the resident had been left on a bedpan. The Notes further stated that the facility explained that the night shift aide failed to communicate to the day shift aide that the resident had been placed on a bedpan. The Notes also stated Resident #4 did not put on call light during this time. The resident responded, I just waited for them to come get me off, I thought they knew. Interview with Resident #4 on 06/27/18 at 4:00 PM, revealed he/she had been left on a bedpan too long on several occasions, but one time I was left on a bedpan for a very long time and I was told I should have rung my call light. I did, but nobody came. Interview with the Director of Nursing (DON) on 07/03/18 at 10:48 AM, revealed he was aware of the bedpan incident with Resident #4. The DON revealed since there was no injury to Resident #4, he did not think the incident required any action. Interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM, revealed that because they believed the incident was an accident and not an intentional act, they did not report the allegation to State Agencies. 5. Review of a facility grievance complaint form dated 03/20/18, revealed Resident #8 voiced a grievance that he/she received incontinence care on 03/18/18 at 5:15 AM and did not receive incontinence care again until 11:05 AM. According to the resident's report to the Social Worker, he/she was soaked and raw in the groin area. Interview with Resident #8 on 06/28/18 revealed the resident remembered filing the grievance complaint because there was hardly no staff in the building. According to interview with Resident #8, staff changed the resident's incontinence brief at approximately 5:00 AM (exact date unknown, but recalled it was a weekend in March) and it was not changed again until lunchtime. Further interview with the resident revealed that he/she was already red and raw between his/her legs and the urine was setting me on fire. According to the interview, the resident reported ringing his/her call light several times and no one answered. Interview with the Director of Social Services (DSS) on 07/03/18 revealed Resident #8 came to her office on 03/20/18 to report that he/she was upset about the number of weekend staff and the staff had not changed the resident as they should. Further interview with the DSS revealed that Resident #8 visited her office frequently and the resident did not usually complain. The DSS revealed she and the Administrator reviewed the video footage of the hallway and determined there were several staff members in and out of the resident's room during that time. There was no evidence the facility conducted any further investigation or reported the allegation to State Agencies. Interview with the DON on 07/03/18 at 10:45 AM, revealed if a resident voiced a concern, the facility looked to see if something is being done, but it was the Unit Coordinator's responsibility to follow up on concerns. There was no evidence the facility reported the allegation to State Agencies. 6. Review of a Radiology Report signed on 06/18/18 at 11:10 PM for Resident #2 revealed the resident had a moderately displaced fracture through the surgical neck of the right humerus (shoulder). Interviews with Licensed Practical Nurse (LPN) #4 on 06/27/18 at 6:35 PM, LPN #8 on 06/27/18 at 4:00 PM, State Registered Nurse Aide (SRNA) #1 on 06/28/18 at 10:17 AM, SRNA #2 on 06/28/18 at 10:37 AM, SRNA #12 on 06/28/18 at 11:15 AM, LPN #3 on 06/28/18 at 3:02 PM, SRNA #15 on 07/02/18 at 6:00 PM, SRNA #22 on 07/02/18 at 6:45 PM, and LPN #5 on 07/03/18 at 6:14 PM, revealed they provided care for Resident #2 but could not explain how the resident's injury occurred and they stated Resident #2 was not capable of stating how the injury occurred. The staff stated the resident had contractures and could not move on his/her own. Review of a Resident Accident/Incident Report dated 06/09/18, revealed the resident's right arm had yellowish/purple/green discoloration that extended from the elbow up under the resident's arm and to the resident's upper back, and a knot below the elbow. The report stated the resident had an elbow x-ray on 06/07/18 that did not show a fracture. A review of the Follow-Up Assessment form for Resident #3 dated 06/09/18, revealed that the facility determined the causative factor for the resident's injury was listed as on [MEDICATION NAME] (blood thinner). The assessment form also noted that the incident was reviewed on 06/11/18 in the morning meeting. There was no documented evidence the facility investigated the resident's bruising which was identified on 06/07/18, and subsequently determined to be a fracture on 06/19/18, or reported the injury of unknown source to state agencies as required by the facility's policy. Interview with the Administrator on 07/05/18 at 2:45 PM revealed when a resident had an injury of unknown source, she answered questions that she felt like needed to asked to determine if it should be reported, and if a logical explanantion could be found, she does not report the incident. The Administrator stated she did not report that Resident #2 had a shoulder fracture because she did not believe the injury was suspicious and believed there was a causative factor.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure allegations of abuse/neglect/injury of unknown source were thoroughly investigated for seven (7) of twenty-two (22) residents (Residents #2, #3, #4, #5 #6, #7, and #8). State Registered Nurse Aide (SRNA) #5 reported to Licensed Practical Nurse (LPN) #8 prior to 05/06/18, and to the Administrator during the week of 06/18/18, that SRNA #17 slammed Resident #5 onto a toilet (Refer to F600 and F609). Interviews with Resident #7 and review of documentation revealed Resident #7 reported on 06/13/18 that LPN #9 shoved medications and tried to pour water in the resident's mouth, hurting the resident's mouth. Resident #7 also stated LPN #9 hit Resident #6 on the back and fussed at the resident after Resident #6 spit out his/her medications (Refer to F600 and F609). Interviews revealed staff placed Resident #3 on a bedpan and did not remove the bedpan until approximately twenty-four hours later. The bedpan was indented into the resident's skin and the resident developed pressure ulcers to the buttocks as a result of being on the bedpan for a prolonged period of time. In addition, Resident #4 was left on a bedpan for approximately two (2) hours on 05/29/18 (Refer to F600 and F609). On 06/18/18, Resident #2 was diagnosed with [REDACTED]. Interviews with staff revealed they were not aware how the injury occurred (Refer to F609). Interviews with the Administrator revealed the facility failed to ensure each allegation was thoroughly investigated to ensure residents were protected from further abuse/neglect/injuries of unknown source. The facility's failure to ensure the investigations of allegations of abuse, neglect, and an injury of unknown source has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Resident Protection Plan, dated 11/12/17, revealed it was the facility's policy that each resident had the right to be free from abuse and neglect. The policy stated the facility did not condone abuse by anyone, including staff members. The policy stated all reports of abuse or neglect would be promptly and thoroughly investigated by facility management. According to the policy, the administrator or his/her designee would conduct the investigation. Further review of the policy revealed that at a minimum the following documentation would be reviewed: documentation of the incident, the medical record to determine events leading up to the incident, and all events leading up to the alleged incident would be reviewed. The policy also stated the following interviews would be conducted: the person reporting the incident; witnesses; the resident as appropriate; staff members from all shifts who had contact with the resident during the period of the alleged incident; the resident's roommate, family members, and visitors if applicable; other residents to whom the accused employee provides care or services; and consult the resident's attending physician. The policy also stated witness reports would be obtained in writing and witnesses were required to sign and date the reports. Further review revealed employees of the facility involved in the allegation would be suspended immediately pending investigation results. The policy also stated the administrator would keep the resident and his/her representative informed of the progress of the investigation and the results of the investigation would be recorded on an approved documentation form. In addition, the administrator would inform the resident and his/her representative of the results of the investigation and any corrective action taken. 1. Interview with Resident #5 on 06/26/18 at 6:15 PM, revealed a staff member grabbed him/her by the arm and shoved me on the commode (could not recall exact date). The resident stated the staff member was hateful, but he/she was unable to recall exactly what the staff member said. Resident #5 stated it frightened him/her and hurt when he/she hit the commode (toilet). Interview with State Registered Nurse Aide (SRNA) #5 on 06/27/18 at 4:35 PM, revealed approximately one month ago, she and SRNA #17 were assisting Resident #5 to the bathroom. SRNA #5 stated that SRNA #17 picked up Resident #5, slammed the resident down onto a commode, and stated, I'm tired of this bullshit. You're going to learn to walk the right way. According to SRNA #5, Resident #5 stated, I wish you wouldn't be so mean to me. I can't help it. SRNA #5 stated she immediately reported the abuse to Licensed Practical Nurse (LPN) #8, and reported the allegation to the Administrator during the week of 06/18/18 Interview with LPN #8 on 06/27/18 at 4:00 PM, revealed she did not recall SRNA #5 reporting that a SRNA pushed/slammed Resident #5 onto a commode. Interview with SRNA #3 on 06/28/18 at 11:15 AM, revealed she did not recall the incident with SRNA #5, but stated staff were mean to Resident #5. Interview with LPN #3 on 06/28/18 at 3:02 PM, revealed Resident #5 had also reported to her that someone had pushed the resident onto the commode. LPN #3 stated the resident often reported that staff were hateful and mean to him/her. According to LPN #3, Resident #5 did not know names of staff, but he/she could describe them. LPN #3 stated she reported the incidents to the Unit Manager; however, the Unit Manager always told her to write it up but .it ends there and nothing happens. Interview with Unit Manager #1 on 06/29/18 at 11:11 AM revealed she heard someone talking about Resident #5 being pushed onto a toilet, but she was not sure when it happened. The Unit Manager stated it was not reported to her, but if the allegation had been reported to her directly, she would have removed SRNA #17 from care and would have reported the allegation to Administrative staff so an investigation could have been conducted. The Unit Manager stated that Resident #5 also had reported to her that staff did not like him/her and would not answer his/her call light, but the resident had not been able to identify the staff member. The Unit Manager further stated the resident tends to fabricate things. Interview with the Director of Nursing (DON) on 07/03/18 at 10:50 AM, revealed he was not aware of the incident involving Resident #5 being slammed onto a commode until the weekend of 06/30/18. The DON stated it was his understanding that a nurse aide reported the allegation to the Administrator and the Administrator was taking care of the incident. According to the DON, any allegation that a staff member was mean or rude to a resident would automatically be investigated as abuse. He stated that during an investigation the resident involved, staff involved, and anyone working that shift were interviewed. Interview with the Administrator on 07/05/18 at 2:45 PM, revealed on 06/21/18, SRNA #5 reported that SRNA #17 had cursed in front of Resident #5 saying, This is bullshit. However, there was no evidence the Administrator investigated the allegation at that time. Further interview revealed the Administrator denied that SRNA #5 reported that SRNA #17 slammed Resident #5 until she interviewed SNRA #5 again on 06/30/18, after the survey was initiated. 2. Interview with Resident #7 on 06/27/18 at 5:56 PM, revealed the resident stated that a nurse (LPN #9) came in to administer his/her medications and shoved the medication in his/her mouth. In addition, the nurse tried to pour water in the resident's mouth. Further interview with Resident #7 revealed the nurse gave Resident #6's medication and the resident spit out the medication. According to Resident #7, the nurse hit Resident #6 on the back and said something to the resident, but he/she could not recall what the nurse said. Resident #7 stated he/she reported the incident to LPN #2 and he/she had not spoken to anyone else about the incident. Interview with LPN #2 on 06/27/18 at 12:40 PM, and review of the LPN's documentation made on a Nurse's Note dated 06/13/18, and review of an email dated 06/29/18, revealed the Administrator was aware of the incident that occurred on 06/13/18. According to the Nurse's Note, Resident #7 doesn't like that older nurse (the nurse) was training the other day, which was LPN #9. Resident #7 reported the nurse was hateful speaking and she hurt my mouth giving my medicines. She put it all in my mouth at one time. and She tried to pour my water in my mouth but I stopped her and told her I can get my own water. Resident #7 also reported the nurse smacked Resident #6, yelled at the resident, and forced what looked like orange juice in Resident #6's mouth. According to the email from the Administrator, Resident #7 was not able to give the date as to when the incident occurred, LPN #9 denied hitting Resident #6 on the shoulder, and LPN #9 did not recall Resident #7 saying anything about mouth pain. There was no documented evidence the facility conducted an investigation of the incident in accordance with the facility's policy. Interview with the Administrator 07/05/18 at 2:45 PM, revealed the facility did not conduct an investigation of the allegation. The Administrator stated she talked to LPN #9, who stated she did not hit Resident #6, and there was no evidence that any further action was taken. She stated she had known LPN #9 for a long time and Resident #6 was the kind of resident that is like poor pitiful me. 3. Review of Resident #3's care plan (not dated) revealed the resident had red and opened areas to the buttocks due to being stuck to bedpan. Review of a Weekly Nurse's Notes and Body Audit form dated 04/10/18, revealed Resident had a 6.5-inch lateral abrasion to the left buttock with a quarter-sized abrasion to the right buttock, and a 4-inch lateral abrasion to the right upper buttock. Interview with Resident #3 on 06/26/18 at 4:20 PM, revealed that over a month ago, staff told the resident that they left him/her on a bedpan for too long. The resident did not recall the incident because the resident had just returned from the hospital and was sick. The resident stated staff told him/her that the bedpan had broken while it was under him/her causing the areas on his/her bottom. Resident #3 stated he/she continued to receive treatment to the areas on his/her bottom and the areas caused pain. Interview with Registered Nurse (RN) #1 on 06/26/18 at 5:08 PM, revealed on the afternoon of 04/07/18, a bedpan was discovered underneath Resident #3. RN #1 stated the bedpan had been under the resident so long that the resident's bottom was indented in the shape of a bedpan and was red. The RN she left a note for the Wound Care Nurse to report the incident. Interview with LPN #1 on 06/27/18 at 11:50 AM, revealed on 04/09/18, two days later, the indention of the bedpan remained on Resident #3's bottom. LPN #1 stated she asked the Director of Nursing (DON) and the Administrator about the bedpan incident and they told her that they were looking into it. Interview with Minimum Data Set (MDS) Nurse #2 on 06/27/18 at 3:20 PM, and the DON on 07/03/18 at 10:48 AM, revealed the bedpan incident involving Resident #3 was briefly discussed in the morning meeting on 04/09/18. However, during the meeting, the Administrator stated she was in the facility on 04/07/18 and reported she did not observe a bedpan underneath the resident; therefore, no further action was taken. An interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM, revealed the Administrator was aware of a bedpan incident involving Resident #3, but she stated she did not believe a bedpan was left underneath Resident #3 for an extended length of time, and an investigation was not conducted. The Administrative staff stated if a bedpan had truly been left underneath Resident #3 for a long length of time, the incident would have been investigated. 4. Review of a Care Conference Note dated 05/29/18, revealed Resident #4 and his/her family voiced concerns the resident had been left on a bedpan. The Notes further stated that the facility explained that the night shift aide failed to communicate to the day shift aide that the resident had been placed on a bedpan. The Notes also stated Resident #4 did not put on call light during this time. The resident responded, I just waited for them to come get me off, I thought they knew. Interview with Resident #4 on 06/27/18 at 4:00 PM, revealed he/she had been left on a bedpan too long on several occasions, but one time I was left on a bedpan for a very long time and I was told I should have rung my call light. I did, but nobody came. Resident #4 stated being left on the bedpan was uncomfortable, painful, and made him/her feel bad, because they forgot about me. Review of an in-service for State Registered Nurse Aides (SRNAs) dated 05/30/18 titled Walking Rounds, revealed the facility trained staff on the importance of making walking rounds because, We do not always remember everything that may have happened during our shift. The in-service detailed the importance of making rounds. The facility provided an example of a resident that may have been placed on bedpan during last round and needs to be removed; however, staff who attended the in-service was not documented and the information provided in the training was not in accordance with the facility's policy of checking residents every five (5) minutes after being placed on a bedpan. Interview with the Director of Nursing (DON) on 07/03/18 at 10:48 AM, revealed he was aware of the bedpan incident with Resident #4. The DON stated since there was no injury to Resident #4, he did not think the incident required any action. Interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM, revealed they did not believe this was an allegation of neglect, stating it was an accident and there was no evidence the facility investigated the allegation. Both staff members agreed that a resident should be checked every five (5) to ten (10) minutes, after being placed on a bedpan. However, the Administrator stated Resident #4 was an alert and oriented resident and should have rung (his/her) call light. 5. Review of the facility's grievance complaint form dated 03/20/18, revealed Resident #8 voiced a grievance to the Social Services Director that staff did not provide incontinence care for him/her on 03/18/18 for approximately six hours. According to the resident's report to the Social Worker, he/she was soaked and raw in the groin area. Interview with Resident #8 on 06/28/18 revealed the resident remembered filing the grievance complaint because during a weekend in (MONTH) there was hardly no staff in the building. According to Resident #8, staff changed the resident's incontinence brief at approximately 5:00 AM, and it was not changed again until lunchtime. The resident stated he/she was already red and raw between his/her legs and the urine was setting me on fire. Further review of the grievance complaint form revealed that the Administrator and the Quality Assurance Nurse were notified of the complaint. The form revealed staff reviewed video footage for the morning of Sunday, 03/18/18, that showed staff going in and out of the resident's room on several different occasions. According to the grievance summary, the DON, Administrator, and Social Services Director believed that the resident had possibly reported the wrong date because the video footage clearly showed staff tending to the resident's room. According to the summary, the Administrator directed the DON to verify the dates with the resident. However, the resident reported the same date, time, and complaint to the DON. Review of the grievance form revealed the conclusion was that the resident's grievance was not confirmed. There was no documented evidence that the facility conducted an investigation in accordance with the facility's policy and collected interviews and reviewed documents as required by the policy. Interview with the Director of Social Services (DSS) on 07/03/18 revealed she and the Administrator reviewed videotapes for the time period that Resident #8 complained of not being changed and there were several staff members in and out of the resident's room during that time. The DSS revealed that no other investigation was conducted and no interviews were conducted with the staff to ensure they provided care for the resident while in the resident's room. 6. Review of the facility's Resident Protection Plan, dated 11/12/17, revealed it was the responsibility of employees to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, to facility management. Further review of the policy revealed that an injury of unknown source was defined as an injury that meets both of the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: (a) the extent of the injury; or (b) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or (c) the number of injuries observed at one particular point in time; or (d) the incidence of injuries over time. The policy further stated that should an injury of unknown source be reported, the Administrator or his/her designee, would investigate the alleged incident. Observation of Resident #2 on 06/26/18 at 12:55 PM, revealed the resident was in bed with his/her right arm in a sling. Review of Resident #2's medical record revealed the facility admitted the resident on 05/10/12 with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set ((MDS) dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) assessment and was severely cognitively impaired. The MDS also revealed the resident was nonambulatory and totally dependent on staff for activities of daily living. Further review of the MDS revealed the resident had limited range of motion to the lower extremities and to one of the upper extremities. Review of Nurse's Notes and Physician order [REDACTED].#2 revealed the physician ordered an x-ray of the right elbow related to bruising and a knot-like area. Further review of Nurse's Notes dated 06/08/18 at 12:05 AM, revealed the x-ray results noted no [MEDICAL CONDITION] elbow and [MEDICAL CONDITION] changes were present. Continued review of the Nurse's Notes dated 06/09/18 at 12:50 PM, and 06/10/18 at 10:00 AM, revealed Resident #2 continued to have various shades of bruising to the right arm extending from the elbow up the resident's arm and spreading to the resident's back. The Nurse's Notes dated 06/17/18, at 6:00 PM, revealed a physician's orders [REDACTED]. A review of a Radiology Report signed on 06/18/18 at 11:10 PM for Resident #2 revealed the resident had a moderately displaced fracture through the surgical neck of the right humerus (shoulder). Interview with the Medical Director on 07/03/18 at 2:37 PM revealed Resident #2 had [MEDICAL CONDITION] and that the fracture to the resident's right shoulder had to have occurred when care was being provided. Interviews with Licensed Practical Nurse (LPN) #4 on 06/27/18 at 6:35 PM, LPN #8 on 06/27/18 at 4:00 PM, State Registered Nurse Aide (SRNA) #1 on 06/28/18 at 10:17 AM, SRNA #2 on 06/28/18 at 10:37 AM, SRNA #12 on 06/28/18 at 11:15 AM, LPN #3 on 06/28/18 at 3:02 PM, SRNA #15 on 07/02/18 at 6:00 PM, SRNA #22 on 07/02/18 at 6:45 PM, and LPN #5 on 07/03/18 at 6:14 PM, revealed they provided care for Resident #2, but they could not explain how the resident's injury occurred. Further interview revealed the staff stated Resident #2 was not capable of stating how the injury occurred. The staff stated the resident had contractures and could not move on his/her own. Review of a Resident Accident/Incident Report dated 06/09/18, revealed the resident's right arm from the elbow to under the arm was yellowish/purple/green and extended to the resident's upper back. The report also stated the resident continued to have a knot below the elbow. The report stated the resident's physician was in the facility on 06/07/18, and ordered the resident to have an x-ray of the right elbow. A review of the Follow-Up Assessment form for Resident #3 dated 06/09/18, revealed that the facility determined the causative factor for the resident's injury was listed as on [MEDICATION NAME] (a blood thinner). The assessment form also noted that the incident was reviewed on 06/11/18 in the morning meeting. However, there was no documented evidence that the facility investigated the resident's bruising which was identified on 06/07/18, and subsequently determined to be a fracture on 06/19/18. Interview with the Administrator on 07/05/18 at 2:45 PM revealed she did not conduct an investigation of the injury/fracture of Resident #2's shoulder because she did not believe the injury was suspicious. She stated she was aware the resident's injury was not observed, but she had spoken to the resident's physician sometime after the resident was diagnosed with [REDACTED].

Based on observation, interview, record review, and policy review, it was determined the facility failed to ensure that one (1) of twenty-two (22) sampled residents (Resident #1) remained free from physical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. Interviews conducted with Resident #1, five (5) State Registered Nursing Assistants (SRNAs), two (2) Licensed Practical Nurses (LPNs), and the Director of Nursing (DON) all revealed that Resident #1 was being placed in a reclining Geri-chair, which he/she could not voluntarily get out of, to facilitate staff getting their work done, retaliation for sustaining falls, using the call light excessively, requesting to use the bathroom, and as punishment for not being good. The facility's failure to ensure residents were free from physical restraints imposed for the purposes of discipline or convenience has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Restraint Policy, dated 08/01/13, defined physical restraints as any method or device attached or adjacent to the resident's body that the individual cannot remove easily, restrains the resident's freedom of movement, or restricts the resident's access to his/her body. The policy listed examples of devices that were/may be considered physical restraints which included Geri-chairs. The policy further stated the facility would only utilize restraints after other alternatives had been tried unsuccessfully and only used for the safety and well-being of residents. The policy further revealed restraints would only be used to treat the resident's medical symptom(s) and never be used for discipline, staff convenience, or for the prevention of falls. Review of Resident #1's medical record revealed the facility admitted the resident on 05/16/17, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14). The facility also assessed the resident to have no hearing impairment and to display no behavioral symptoms. Further review of Resident #1's MDS revealed it was very important for the resident to be able to make choices related to daily preferences and activities. The facility also assessed Resident #1 to be nonambulatory, to utilize a wheelchair for mobility, and to require staff assistance for activities of daily living including transfers/bed mobility. In addition, the MDS assessment revealed the resident had no physical restraints or alarms in use. Review of Resident #1's Care Area Assessments (CAAs) dated 04/11/18, revealed the resident had poor balance and a history of frequent falls in the facility. Review of Resident #1's care plan, dated 07/21/17, revealed the facility identified that the resident was at risk for trauma related to falls due to an unsteady gait, [MEDICAL CONDITION] disorder, left-sided weakness, and attempts to be independent. In addition, the care plan stated that staff has questioned possible attention seeking behaviors. Interview with Resident #1 on 06/27/18 at 6:20 PM, revealed sometimes they put me in the mean chair. Resident #1 went on to say that one day last week after he/she sustained a fall in the bathroom, staff placed him/her in the mean chair and would not allow or assist him/her to go back to bed. Resident #1 stated that staff made me sit in the chair all day, despite him/her complaining of back pain after the fall. Resident #1 stated he/she referred to the Geri chair as the mean chair because staff get upset and angry with him/her because of him/her sustaining frequent falls; and if the staff placed him/her in the chair he/she is unable to get out of it, and therefore will not fall. Resident #1 stated it made him/her mad when staff make me sit in the mean chair. Review of a Resident Accident/Incident report for Resident #1 revealed the resident had sustained a fall on 06/20/18. Review of a Department of Nursing Clinical Flow Sheet (nurse aide care plan) dated (MONTH) (YEAR) revealed nursing assistants had the option of placing Resident #1 in a wheelchair, Geri-chair, or recliner, but gave no specific criteria for the staff to use when deciding on the most appropriate choice of which chair to utilize for the resident based on the resident's functional status. In addition, there was no evidence found to indicate that the facility had performed any restraint assessments to determine if the choices given to the nursing assistants would be a restraint for Resident #1. Interview with State Registered Nursing Assistant (SRNA) #5 on 06/26/18 at 1:15 PM, revealed she had observed Resident #1 in a reclined Geri-chair on numerous occasions when staff were making rounds or passing medications. SRNA #5 stated that Resident #1 refers to the Geri-chair as the mean chair. The SRNA further stated she had witnessed other SRNAs threaten Resident #1, telling him/her that if you do not be still, we will put you in the chair. SRNA #5 stated Resident #1 gets very upset when staff make him/her sit in the reclined Geri-chair. Interview with SRNA #19 on 06/29/18 at 3:47 PM, revealed Resident #1 was placed in the reclined Geri-chair on 06/25/18, after supper, at approximately 7:00 PM, while staff were passing out medications and was not removed from the chair until approximately 10:30 PM (three and one-half hours later). SRNA #19 stated that Resident #1 was placed in the chair so staff could get their work completed. Interview with SRNA #15 on 07/01/18 at 6:00 PM, revealed staff had been placing Resident #1 in the reclined Geri-chair more lately, because the resident will not sleep. SRNA #15 stated she has placed the resident in the reclined Geri-chair before, in order to answer call lights when other residents were needing assistance. SRNA #15 also stated that the nurses place Resident #1 in the reclined Geri-chair also, to facilitate getting medications passed and to conduct nursing rounds. SRNA #15 stated Licensed Practical Nurse (LPN) #10 had instructed her in the past to place Resident #1 in the reclined Geri-chair so the SRNAs could complete their rounds. Interview with LPN #10 on 06/29/18 at 5:45 PM, revealed Resident #1 was placed in the reclined Geri-chair after a fall, when nurses need to get medications passed, or when staff needed to get their rounds made, because otherwise, You are unable to get anything done. LPN #10 also stated, When (Resident #1) is being 'good,' there is no need to put (Resident #1) in the chair. LPN #10 stated she had not considered the Geri-chair to be a restraint for Resident #1, despite the fact that the resident cannot get out of the chair voluntarily. Interview with SRNA #22 on 07/02/18 at 6:23 PM, revealed she had placed Resident #1 in the reclined Geri-chair before due to the resident not going to sleep at night. The SRNA stated she had heard staff refer to the chair as the mean or crazy chair when referring to Resident #1, but she had only heard staff refer to the chair like that to each other and not in front of Resident #1. Interview with SRNA #17 on 07/03/18 at 10:05 AM, revealed she had placed Resident #1 in the reclined Geri-chair at times because the resident would continually push his/her call light requesting to go to the bathroom. SRNA #17 stated staff would put the resident in the reclined Geri-chair anytime they needed to do rounds, answer call lights, or complete paperwork. SRNA #17 stated Resident #1 did not like the chair because (Resident #1) cannot get out of it. Interview with LPN #3 on 06/28/18 at 3:31 PM, revealed she had heard SRNA staff threaten to place Resident #1 in the reclined Geri-chair, because (Resident #1) would not be still. LPN #3 stated Resident #1 would become very upset about having to sit in the reclined Geri-chair and would say, Why do you have to be so mean to me? However, LPN #3 stated she had never considered the chair to be a restraint for Resident #1 and she had taken no action related to the staff threatening the resident with the chair. LPN #3 also stated that it was not up to her to decide which chair staff placed a resident in, that information was developed and included on the nurse aide care plans. Interview with the Director of Nursing (DON) on 07/03/18 at 10:48 AM, revealed SRNAs should not be making the decision on which chair is appropriate for residents. The DON stated the Unit Managers should be making the decision if a resident needs to be placed in a reclined Geri-chair. He further revealed staff should not be threatening Resident #1, to put him/her in a Geri-chair, just because the resident would not be still. However, the DON also stated he did not consider the reclined Geri-chair to be a restraint for Resident #1 while staff were doing rounds and passing out medications. The DON further stated that a restraint assessment had never been completed for Resident #1 related to the Geri-chair because it had never been identified to be a restraint for the resident. Interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM, revealed it would be the responsibility of the Charge Nurse to decide if a resident was placed in a reclining Geri-chair, but stated the staff should not be placing the resident in the reclining Geri-chair in order to get medications passed or their work completed.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for three (3) of twenty-two (22) sampled residents (Resident #1, Resident #3, and Resident #4). The facility developed care plans for Residents #3 and #4 that addressed assisting the resident with activities of daily living/toileting. However, the facility failed to identify that Resident #3 was left on a bedpan for an extended period of time, and Resident #4 was left on a bedpan for approximately two (2) hours. Resident #3 developed pressure ulcers on his/her bottom. In addition, Resident #1's care plan stated staff had the option of placing the resident in a wheelchair, Geri-chair, or recliner; however, the facility failed to develop criteria for utilizing the most appropriate device for the resident. Resident #1 was assessed to require the assistance of two or more staff members for transferring; however, the resident's care plan gave staff the option of utilizing one or two staff members for transfers. The facility's failure to ensure that residents' comprehensive person-centered care plans were developed and implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Care Planning-Interdisciplinary Team Policy, dated 08/01/13, revealed the facility's Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. The policy stated the care plan would be based on the resident's comprehensive assessment and developed utilizing the resident's daily care routines and would be available for staff who were responsible for providing care and services to the resident. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 12/31/13, and the resident had [DIAGNOSES REDACTED]. A review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. Further review of the assessment revealed Resident #3 required assistance of two or more staff members for bed mobility and toilet use, which included bedpan use. The MDS revealed the resident was occasionally incontinent of bowel and bladder, and was at risk for developing pressure ulcers; however, Resident #3 had no pressure ulcers. Review of Resident #3's care plan dated 01/16/14, revealed the resident had a toileting deficit and staff were required to provide total care for all the resident's Activities of Daily Living. Further review of the resident's care plan (not dated) revealed the resident had a potential for impaired skin integrity and had red and opened areas to the buttocks due to being stuck to bedpan. Interview with Resident #3 on 06/26/18 at 4:20 PM, revealed that over a month ago, staff left the resident on a bedpan for too long. The resident stated he/she did not recall the incident because just prior to the incident he/she had been in the hospital and was sick. However, the resident stated staff told him/her about the incident and stated the bedpan had broken causing the areas on his/her bottom. Resident #3 stated he/she did not feel well and did not allow the Surveyor to observe the resident's skin. However, Resident #3 stated he/she continued to receive treatment to the areas on his/her bottom and the areas caused pain. Interview with State Registered Nurse Aide (SRNA) #23 on 07/02/18 at 5:22 PM, revealed that she and SRNA #25, who were staff preceptors and were helping to assist residents, placed Resident #3 on a bedpan after lunch on 04/06/18. She stated they told SRNAs #20 and #21, who were the SRNAs assigned to work the unit, that Resident #3 was on a bedpan and that they needed to take the resident off the bedpan. Interview with SRNA #20 on 07/02/18 at 6:02 PM, SRNA #21 on 07/02/18 at 7:55 PM, and SRNA #22 on 07/02/18 at 6:23 PM, revealed they provided care for Resident #3 on 04/06/18 and 04/07/18. The SRNAs stated they turned and repositioned the resident utilizing a draw sheet (a linen placed underneath a resident to move the resident in bed) and provided other resident care; however, the SNRAs stated they would not have been able to see a bedpan because of the resident's obesity. The SRNAs stated they were not aware staff placed Resident #3 on a bedpan on 04/06/18, and they did not remove the bedpan from underneath the resident. Interview with Registered Nurse (RN) #1 on 06/26/18 at 5:08 PM, revealed on the afternoon of 04/07/18, a bedpan was discovered underneath Resident #3, when she and SRNA #7 were preparing to wash Resident #3's back. RN #1 stated, (The resident's) bottom was indented in the shape of a bedpan and was red. Review of a Weekly Nurse's Notes and Body Audit form for Resident #3 dated 04/10/18, revealed the resident had a 6.5-inch lateral abrasion to the left buttock with a quarter-sized abrasion to the right buttock, and a 4-inch lateral abrasion to the right upper buttock. 2. Review of Resident #4's medical record revealed the facility admitted the resident on 08/22/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was not cognitively impaired and was interviewable. Further review revealed Resident #4 required total assistance with activities of daily living, including bed mobility and toileting. The assessment also revealed Resident #4 was occasionally incontinent of bladder and always continent of bowel. Review of Resident #4's care plan dated 09/12/17 revealed the facility identified the resident was at risk for toileting/elimination deficit related to impaired mobility, left-sided weakness, bowel incontinence, and occasional bladder incontinence. The facility developed interventions that included providing scheduled toileting every two hours, ensuring toileting needs were met by staff, encouraging the resident to use the call light and respond promptly, and assisting with toileting needs including mobility on and off the toilet. Review of a Care Conference Note dated 05/29/18 revealed Resident #4 and his/her family voiced concerns that the resident had been left on a bedpan. The Notes further stated that the facility explained during that time that the night shift aide failed to communicate to the day shift aide that the resident had been placed on a bedpan. Interview with Resident #4 on 06/27/18 at 4:00 PM, revealed he/she had been left on a bedpan too long on several occasions. Resident #4 stated, One time I was left on a bedpan for a very long time and I was told I should have rung my call light. I did, but nobody came. Resident #4 further stated being left on the bedpan was uncomfortable, painful, and made the resident feel bad, because they forgot about me. Interview with SRNA #3 on 06/29/18 at 11:17 AM, revealed SRNA #3 stated when she entered the resident's room at approximately 7:30 AM (date unknown) Resident #4 reported he/she was on a bedpan. SRNA #3 stated third shift staff had placed Resident #4 on a bedpan at approximately 5:15 AM, but forgot to report the information to her during shift report. 3. Review of Resident #1's medical record revealed the facility admitted the resident on 05/16/17, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14). The facility also assessed Resident #1 to be nonambulatory, to utilize a wheelchair for mobility, and to require extensive assistance of two or more staff persons for transfers. Review of Resident #1's care plan dated 07/21/17 and the Department of Nursing Clinical Flow Sheet (nurse aide care plan) dated (MONTH) (YEAR) revealed staff had the choice of placing the resident in a wheelchair, Geri-chair, or recliner. However, the care plan gave no specific criteria for the staff to use when deciding on which chair to utilize for the resident based on the resident's functional status. The care plan also indicated the resident required the assistance of one or two staff persons for transferring, even though the facility had assessed the resident to require the extensive assistance of two or more persons for transfers. Interviews with SRNA #5 on 06/26/18 at 1:15 PM, SRNA #19 on 06/29/18 at 3:47 PM, SRNA #17 on 07/03/18 at 10:05 AM, SRNA #22 on 07/02/18 at 6:23 PM, SRNA #15 on 07/01/18 at 6:00 PM, and Licensed Practical Nurse (LPN) #10 on 06/29/18 at 5:45 PM revealed it was their choice for placing the resident in a Geri-chair and for how many staff persons the resident needed for transfers. The staff stated there was no specific criteria to utilize when making the decision; however, all the staff verbalized that Resident #1 was often placed in the reclined Geri-chair in order to facilitate staff in completing their work. Interview with Resident #1 on 06/27/18 at 6:20 PM, revealed staff placed him/her in a Geri-chair and would not allow or assist him/her out of the chair. Resident #1 stated he/she referred to the Geri-chair as the mean chair because staff got upset and angry with him/her and placed him/her in the reclining Geri-chair. Interview with the MDS Nurse on 06/28/18 at 3:20 PM, revealed she developed resident care plans and revised care plans with any change in condition or new physician orders. The MDS Nurse further stated when she developed care plan interventions, she documented that a resident needed one to two staff members for transferring regardless of what the resident was assessed to require. The MDS Nurse stated she developed care plans in that manner to allow the SRNAs to make a decision depending on how a resident was doing on a specific day or time. The Nurse further stated SRNAs had been trained and should know how much assistance the resident needed. The MDS Nurse stated SNRAs had also been trained and could decide which chair to utilize for a resident. Interview with the Director of Nursing (DON) on 07/03/18 at 10:48 AM, revealed resident care plans should match the assessment that had been conducted on the resident so the appropriate care and services could be provided. The DON stated that SRNAs should not have to make decisions on care requirements for residents.

Based on interview, record review, and facility policy review it was determined the facility failed to revise the care plan for one (1) of twenty-two (22) sampled residents (Resident #9) when the resident exhibited changes in behavior. The facility admitted Resident #9 on 05/26/18 and developed a comprehensive care plan dated 06/05/18 that included interventions for the risk for elopement that included a code alert device (device utilized to alarm when a resident gets close to an exit). On 06/13/18, Resident #9 removed the code alert bracelet without staff knowledge and followed another resident outside of the facility. The resident was outside without staff knowledge for approximately five (5) minutes. On 06/17/18, Resident #9's spouse was exiting the facility when the code alert alarm sounded. It was found that Resident #9 removed the code alert bracelet and put it in his/her pants pocket that the spouse was taking home to launder. On 06/19/18 at 5:15 AM, Resident #9's code alert bracelet was found broken on the bedside table and the alarm device could not be found. The nurse documented that she would pass it along in shift report. Although it was documented on the shift report log, there was no evidence the alarm was replaced and at 9:00 AM on 06/19/18, Resident #9 exited the facility without staff knowledge. The facility failed to review and revise the care plan to include interventions to prevent the resident from exiting the facility. The facility's failure to ensure the care plan was revised to prevent the resident from eloping from the facility has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy, Care Planning - Interdisciplinary Team, dated 08/01/13, revealed the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Review of the facility's policy, Care Plans - Comprehensive, dated 08/01/13, revealed an individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. A review of Resident #9's medical record revealed the facility admitted the resident on 05/26/18, with [DIAGNOSES REDACTED]. Review of Resident #9's Baseline Care Plan dated 05/26/18, revealed the facility completed a Falls/Safety Risk/Elopement Risk care plan with a goal to remain free of injuries and elopement. The facility developed interventions that included to keep the call light within reach, instruct on safety measures, assess footwear for non-skid soles, therapy referrals, and bed and chair alarm. However, the facility did not indicate that a code alert bracelet or hourly checks were indicated on the Baseline Care Plan. Review of an Elopement Risk assessment dated [DATE], revealed the facility assessed Resident #9 to be at risk for elopement because the resident was physically able to leave the facility on his/her own; was cognitively impaired with poor decision-making skills and had intermittent confusion; had dementia, anxiety, and depression; verbally expressed the desire to go home; wandered aimlessly; and was a new admission and not accepting the new situation. A review of physician's telephone orders dated 05/28/18 (no time) revealed an order for [REDACTED]. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was cognitively impaired. The MDS revealed the resident had disorganized thinking, exhibited signs and symptoms of depression, had trouble concentrating, and was fidgety and/or restless. The facility assessed the resident to wander; however, the facility assessed that the wandering did not place the resident at a significant risk of getting to a potentially dangerous place. Further review revealed on 06/01/18, the facility updated Resident #9's Elopement Risk Assessment and the resident remained at risk for elopement, and the facility implemented a code alert bracelet. Review of Resident #9's Comprehensive Care Plan dated 06/05/18, revealed the facility developed a care plan for elopement risk due to confusion, being in a new environment, and wandering. The facility initiated interventions including functional alarmed exits, a code alert device, elopement risk assessments, involving family/responsible party, keeping the environment free of clutter and obstruction, monitoring for wandering and behavior indicators, redirecting and reassuring the resident, and encouraging him/her to remain in the facility, keeping an elopement book, and being aware that the resident wanders. There was no evidence that the care plan had been revised since 06/05/18. There were no specific interventions that addressed Resident #9's exit-seeking behavior. Review of the Daily Skilled Nurse's Notes and Nurse's Notes revealed documentation that Resident #9 exhibited exit-seeking behavior, removed code alert bracelet, or made statements related to going home or leaving on 05/28/18, 05/29/18, 05/31/18, 06/02/18, 06/04/18, 06/17/18, 06/19/18, 06/21/18, 06/24/18, 06/25/18, 07/02/18, and 07/03/18. Interview with State Registered Nurse Aide (SRNA) #2 on 07/03/18 at 2:06 PM revealed Resident #9 had attempted to leave the building numerous times. SRNA #2 further stated that during every shift she worked, the resident exhibited exit-seeking behavior. Review of the Psychoactive Medication Monthly Flow Record for (MONTH) (YEAR) revealed that the behavioral symptoms that facility staff were monitoring were delusions, hitting, paranoia, and restlessness. There was no evidence that the facility was monitoring the resident's exit-seeking behaviors. Further review of Resident #9's Nurse's Notes dated 06/13/18 at 3:01 PM, revealed the resident removed his/her code alert bracelet and wheeled himself/herself outside the facility with another resident. The Nurse's Note stated staff assisted the resident back inside and placed a new code alert bracelet on the resident. Interview with Housekeeper #1 on 07/03/18 at 6:03 PM, revealed as she was leaving work for the day on 06/13/18 at approximately 3:00 PM, she observed Resident #9 in the parking lot beside the Administrator's car with no staff supervision. Housekeeper #1 stated the resident told her that he/she was looking for his/her car. The housekeeper stated an alarm was not sounding when the resident was found unsupervised in the parking lot. Review of the Nurse's Notes dated 06/19/18 at 9:00 AM, revealed the resident exited the facility and required multiple attempts to keep the resident out of road and assist the resident into the building. Interview with SRNA #11 on 07/03/18 at 2:29 PM, revealed the resident got out into the parking lot on 06/19/18 at approximately 9:00 AM. The resident went out the front door and she was unsure if the resident's code alert alarm sounded. SRNA #11 further stated she was unsure how long the resident was outside of the facility. Interview with MDS Nurse #2 on 06/28/18 at 3:20 PM revealed that she writes the comprehensive care plan. She stated staff should be revising the care plan any time there is a change in the resident's condition. Interview with Unit Manager (UM) #1 on 07/02/18 at 6:48 PM revealed that the nurses should look at the comprehensive care plans daily for changes in the residents' care. She further stated that staff should update the comprehensive care plan when there was a change in the resident's condition, but was unable to state why Resident #9's care plan was not revised. Interview with the Director of Nursing on 07/03/18 at 10:48 AM, revealed that the comprehensive care plans should match the residents' assessments. He stated that the Unit Managers ensured that the comprehensive care plans were up to date.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #3) received care consistent with professional standards of practice to prevent pressure ulcers and failed to ensure that residents with pressure ulcers received treatment and services to prevent the pressure ulcers from declining. On 04/06/18 after lunch (exact time unknown), staff assisted Resident #3 onto a bedpan. However, staff failed to remove the bedpan from underneath the resident until 04/07/18 at approximately 2:30 PM. The bedpan was indented into the resident's skin and the skin was red. On 04/10/18, the facility assessed the resident to have open areas to the buttocks. According to the resident's care plan, the red and opened areas to the buttocks were due to being stuck to bedpan. However, there was no evidence the resident's physician was notified of the pressure areas that had developed on Resident #3's buttocks due to being left on the bedpan until 04/12/18, at which time, a treatment to the areas was ordered. However, the pressure ulcers to Resident #3's buttocks declined and on 05/01/18, the resident was diagnosed to have [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA), Pseudomonas Aeruginosa, and Gram Positive Cocci bacteria in the wounds. The facility's failure to ensure residents received care and services to prevent pressure ulcers from developing and declining has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the Protocol for Early Intervention to Prevent Skin Breakdown, undated, revealed the facility would utilize an early intervention plan for all residents identified to be at risk for skin breakdown. In addition, review of the facility's policy, Assisting with Activities of Daily Living, not dated, revealed staff were required to monitor residents who had been placed on a bedpan every five (5) minutes. Review of Resident #3's medical record revealed the facility admitted the resident on 12/31/13, and the resident had [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. Further review of the assessment revealed Resident #3 was occasionally incontinent of bowel/bladder and required the assistance of two or more staff persons for bed mobility and toilet use, which included bedpan use. The MDS also revealed Resident #3 was at risk for developing skin breakdown, but had no pressure ulcers. Interview with Resident #3 on 06/26/18 at 4:20 PM, revealed several weeks ago she developed painful skin breakdown to the coccyx area as a result of being left on a bedpan for too long. The State Survey Agency Surveyor was unable to observe the resident's skin breakdown as Resident #3 declined to have a skin assessment. Review of a Weekly Nurse's Notes and Body Audit form dated 04/03/18, revealed Resident #3 had areas to his/her lower extremities which the facility was treating and multiple bruises from a previous fall. However, Resident #3 had no areas of skin breakdown to the buttocks or coccyx area. Review of Resident #3's care plan revealed the facility developed a care plan for Resident #3 on 01/16/14, related to the potential for impaired skin integrity due to the resident's history of [MEDICAL CONDITION] and incontinence episodes. The goal identified was for Resident #3 to have intact skin. Further review of Resident #3's skin integrity care plan revealed an undated entry that identified Resident #3 to have red and open areas to the buttocks due to being stuck to bedpan. Interview with State Registered Nurse Aide (SRNA) #23 on 07/02/18 at 5:22 PM, revealed she and SRNA #25 placed Resident #3 on a bedpan after lunch on 04/06/18. However, interview with Registered Nurse (RN) #1 on 06/26/18 at 5:08 PM, revealed the bedpan was not removed from under Resident #3 until roughly 2:30 PM on 04/07/18. RN #1 stated the shape of the bedpan was indented into Resident #3's buttocks and the area was reddened. However, RN #1 stated she did not notify the resident's physician of the incident because the resident's skin was not opened. Further interview with RN #1 revealed she did leave a note for the Wound Care Nurse that the resident had been left on a bedpan which had caused indentation and redness to the skin. Interview with the Wound Care Nurse on 07/03/18 at 5:50 PM, revealed she could not remember receiving a note from RN #1, but she conducted a skin assessment of Resident #3's skin on 04/09/18 (two days after the bedpan was removed). The nurse stated at that time the indention of the bedpan was visible to the resident's buttocks, and the area was red. Further interview with the Wound Care Nurse revealed on 04/10/18, she again assessed the area to Resident #3's buttocks, and review of a Weekly Nurse's Notes and Body Audit form dated 04/10/18, revealed Resident #3 was assessed to have a 6.5-inch lateral abrasion to the left buttock, a quarter-sized abrasion to the left upper buttock, and a 4-inch lateral abrasion to the right upper buttock. However, the Wound Care Nurse stated that Resident #3's Physician was not notified of the areas to Resident #3's buttocks until 04/12/18, when the nurse again assessed the buttocks and determined the areas appeared to look worse. Review of physician's orders [REDACTED]. buttocks three (3) times a day until healed, due to red and open areas. Further review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. In addition orders were also received to begin [MEDICATION NAME] (an Antibiotic) and [MEDICATION NAME] (an Anti-fungal) medications and to culture the wounds on Resident #3's buttocks. Review of a culture report dated 05/01/18, revealed the wounds to Resident #3's buttocks contained a heavy growth of Staphylococcus Aureus (a Gram-positive Bacteria) and a light growth of Pseudomonas Aeruginosa (a Gram-negative Bacteria). Interview with Resident #3's Physician on 07/20/18 at 10:30 AM, revealed she had been made aware that Resident #3 had developed skin breakdown to the coccyx area, and had given treatment orders to the staff related to the areas. However, Resident #3's Physician did not assess the resident's buttocks until 04/25/18.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide supervision to prevent accidents for one (1) of twenty-two (22) sampled residents (Resident #9). The facility assessed Resident #9 to be at risk for elopement and implemented a code alert bracelet (device utilized to alarm when a resident attempts to open an exit door). On 06/13/18 and 06/19/18, Resident #9 removed his/her code alert bracelet without staff knowledge and exited the facility without staff supervision. Per facility staff, Resident #9 was outside of the facility without staff supervision for approximately five (5) minutes. Resident #9 exhibited exit-seeking behavior (saying he/she wanted to go home and went to the exit doors attempting to leave). The facility failed to develop specific interventions for Resident #9 to prevent the resident from removing the code alert bracelet and exiting the facility without staff knowledge; and failed to develop specific interventions to address the resident's exit-seeking behavior. The facility's failure to ensure residents received supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Elopements/Missing Residents policy, dated 03/23/18, revealed the facility would investigate and report all cases of missing residents. The policy stated staff would promptly report to the Charge Nurse or Director of Nursing (DON) when any resident tried to leave the premises or was suspected to be missing. The policy further stated that when an alarm sounded, staff should check the alarm and surrounding area, get help from staff if necessary, and instruct another staff member to inform the Charge Nurse or DON that a resident had left the premises. Further review revealed when the resident returned to the facility, staff should examine the resident for injuries, contact the physician and legal representative, document relevant information in the resident's medical record, and complete and file an Incident Report. The policy did not address exit-seeking behaviors or monitoring of code alert bracelets. Review of Resident #9's medical record revealed the facility admitted the resident on 05/26/18, with [DIAGNOSES REDACTED]. Review of Resident #9's Baseline Care Plan dated 05/26/18, revealed the facility completed a Falls/Safety Risk/Elopement Risk care plan with a goal to remain free of injuries and elopement. The facility developed interventions that included keeping the call light within reach, instruct on safety measures, assess footwear for non-skid soles, therapy referrals, and bed and chair alarm. However, the facility did not indicate that a code alert bracelet or hourly checks were indicated on the Baseline Care Plan. Review of an Elopement Risk assessment dated [DATE], revealed the facility assessed Resident #9 to be at risk for elopement because the resident was physically able to leave the facility on his/her own; was cognitively impaired with poor decision-making skills and had intermittent confusion; had dementia, anxiety and depression; verbally expressed the desire to go home; wandered aimlessly; and was a new admission and not accepting the new situation. Review of Physician's Telephone Orders dated 05/28/18 (no time) revealed an order for [REDACTED]. Review of Resident #9's Daily Skilled Nurse's Notes and Nurse's Notes revealed the resident began attempting to exit the facility on 05/28/18. Facility staff documented on 05/28/18 that the resident was exit seeking throughout the day. At 9:00 PM, the resident exited the building through the dining room door, and a SRNA assisted the resident back into the building. The resident stated he/she wanted to go home. Further review of the Nurse's Notes revealed on 05/29/18 at 1:30 PM, Resident #9 pushed the door at the ambulance entrance until the door opened, and the resident went outside. The resident was tearful and combative and refused to return inside the building. The Note stated it was raining and staff attempted to get the resident back into the building; however, the resident continued to pull away and came close to falling several times. The resident began to walk down the grass and away from the building and was redirected to a parking lot under an awning. The resident's daughter arrived and was able to convince the resident to sit on the front porch. At 2:50 PM on 05/29/18, the nurse also documented that the resident had periods of confusion and delusions. The resident threw a flower pot at the window and said, I'm getting out. Continued review of Resident #9's Daily Skilled Nurse's Notes and Nurse's Notes revealed on 05/31/18 (no time documented) nursing staff documented that the resident required multiple attempts of redirection related to trying to go outdoors; however, redirection had failed. The Note stated the staff called the resident's family to come and sit with the resident. Further review of Daily Skilled Nurse's Notes and Nurse's Notes revealed documentation that Resident #9 exhibited exit-seeking behavior, removed the code alert bracelet, or made statements related to going home or leaving on 05/28/18, 05/29/18, 05/31/18, 06/02/18, 06/04/18, 06/17/18, 06/19/18, 06/21/18, 06/24/18, 06/25/18, 07/02/18, and 07/03/18. Interview with State Registered Nurse Aide (SRNA) #2 on 07/03/18 at 2:06 PM revealed Resident #9 had attempted to leave the building numerous times. SRNA #2 further stated that during every shift that she worked, the resident exhibited exit-seeking behavior. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was cognitively impaired. The MDS stated the resident had disorganized thinking, exhibited signs and symptoms of depression, had trouble concentrating, and was fidgety and/or restless. The facility assessed the resident to wander; however, the facility assessed that the wandering did not place the resident at a significant risk of getting to a potentially dangerous place. Further review revealed on 06/01/18, the facility updated Resident #9's Elopement Risk Assessment and determined the resident remained at risk for elopement. The facility implemented a code alert bracelet. Review of the facility's shift report dated 06/04/18, on the 7:00 PM to 7:00 AM shift, revealed Resident #9 went out the front door after a physician opened the door and let the resident out. Interview with Licensed Practical Nurse (LPN) #5 on 07/03/18 at 6:14 PM, revealed the resident exited the facility on 06/04/18 when a physician at the facility opened the door for the resident and let him/her out the front door. She stated that the resident was barefoot and had his/her code alert bracelet on and the alarm was sounding. LPN #5 stated that she immediately went outside and found the resident and brought him/her into the building. Review of Resident #9's Comprehensive Care Plan dated 06/05/18, revealed the facility developed a care plan for elopement risk due to confusion, being in a new environment, and wandering. The facility initiated interventions including functional alarmed exits, a code alert device, elopement risk assessments, involving family/responsible party, keeping the environment free of clutter and obstruction, monitoring for wandering and behavior indicators, redirecting and reassuring the resident, and encouraging him/her to remain in the facility, keeping an elopement book, and being aware that the resident wanders. Review of the Treatment Record (TAR) for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that the code alert bracelet for Resident #9 was not monitored to ensure it was on the resident until 06/19/18. There was no documented evidence that the facility staff was assessing the placement of the resident's code alert bracelet daily during each shift to ensure it was in place from 05/28/18 through 06/18/18. Continued review of the TAR revealed that staff did not initial on 06/24/18 and 06/30/18 during the 7:00 AM - 7:00 PM shift that the resident was checked to ensure his/her code alert bracelet was in place. Review of the Psychoactive Medication Monthly Flow Record for (MONTH) (YEAR) revealed that the behavioral symptoms that facility staff were monitoring were delusions, hitting, paranoia, and restlessness. There was no evidence that the facility was monitoring the resident's exit-seeking behaviors. Further review of Resident #9's Nurse's Notes dated 06/13/18 at 3:01 PM, revealed the resident removed his/her code alert bracelet and wheeled himself/herself outside the facility with another resident. The Nurse's Note stated staff assisted the resident back inside and placed a new code alert bracelet on the resident. Interview with Housekeeper #1 on 07/03/18 at 6:03 PM revealed as she was leaving work for the day on 06/13/18 at approximately 3:00 PM, she observed Resident #9 in the parking lot beside the Administrator's car with no staff supervision. The resident stated he/she was looking for his/her car. The Housekeeper stated an alarm was not sounding when the resident was found unsupervised in the parking lot. Further interview revealed the Housekeeper stated she turned her car around and went inside to notify LPN #11, leaving Resident #9 in the parking lot unsupervised. Housekeeper #1 stated while she and LPN #11 were still in the facility, they called out for more help and when assistance arrived, she left. She further stated that she had observed Resident #9 outside of the facility approximately four (4) other times; however, staff were already with the resident. Interview with LPN #11 on 07/03/18 at 4:37 PM and 07/05/18 at 11:30 AM, revealed Resident #9 was not wearing a code alert bracelet when he/she left the building unsupervised on 06/13/18. She stated the resident often removed/cut his/her bracelets off without staff knowledge. Further interview with LPN #11 revealed the Housekeeper reported the resident was out no more than 5 to 10 minutes and was in the parking lot looking for his/her car. LPN #11 stated she did not hear the resident's code alert bracelet alarm. She stated she and other staff assisted the resident back inside the facility. Review of the Fifteen Minute Elopement Monitoring dated 06/13/18 at 4:00 PM, revealed the facility initiated every fifteen (15) minute monitoring of the resident. The monitoring continued until 06/14/18 at 4:00 PM, without any evidence that the facility assessed the resident to ensure discontinuation of the supervision was appropriate. In addition, there was no evidence the facility revised the resident's care plan with interventions to prevent further elopement. Further review of the Daily Skilled Nurse's Notes and Nurse's Notes revealed on 06/17/18 at 1:30 PM, and 06/19/18 at 5:15 AM, staff found that Resident #9 had removed his/her code alert bracelet. On 06/17/18, the resident's code alert bracelet sounded when the resident's spouse left the facility with the resident's laundry. The bracelet was found in the pants pocket of the resident's dirty clothes. On 06/19/18 at 5:15 AM, staff found the resident's code alert bracelet lying on the bedside table, broken. Staff documented they were unable to find another code alert bracelet and would pass along to day shift. However, the facility failed to ensure the resident's code alert bracelet was replaced and failed to implement interventions to address the resident removing the code alert bracelet. Review of the Nurse's Notes dated 06/19/18 at 9:00 AM, revealed the resident exited the facility and required multiple attempts to keep the resident out of road and assist the resident into the building. Interview with SRNA #11 on 07/03/18 at 2:29 PM, revealed the resident got out in the parking lot on 06/19/18 at approximately 9:00 AM. The resident went out the front door and she was unsure if the resident's code alert alarm sounded. SRNA #11 further stated she was unsure how long the resident was outside of the facility. Interview with LPN #8 on 07/05/18 at 10:45 AM revealed that Resident #9 went out of the EMS (Emergency Medical Services) doors which was at the end of the 313 Hall on 05/29/18. She stated the resident was able to push the door open and exit the building; however, staff was with the resident the entire time. She stated SRNA #22 attempted to get the resident back into the building, but the resident refused. She stated it was raining outside and she had to walk around with the resident, along with SRNA #22, and they finally were able to get the resident onto the porch. She further stated that the DON, LPN #12, the resident's daughter, and the resident's granddaughter were able to get the resident back into the facility. LPN #8 stated the resident was wearing a code alert bracelet when he/she exited the facility. Further interview revealed that nursing staff checked the resident daily to ensure his/her code alert bracelet was in place and documented it on the TAR. She stated whoever wrote the order for the code alert bracelet was expected to place the order on the TAR. Interview with the Director of Nursing (DON) on 07/05/18 at 1:50 PM revealed Nursing staff was supposed to check the code alert bracelets daily to ensure residents that required them had them in place and then document on the Treatment Record (TAR). He stated the Unit Manager should check to make sure that the code alert bracelet was on the TAR. Furthermore, he stated that the nurse that wrote the order should have placed the order on the TAR. The DON stated he was aware of the incident on 06/13/18 when the resident was found outside in the parking lot. He stated, There was an alert and oriented resident outside that was keeping an eye on the resident. The DON stated that Housekeeper #1 informed him that the resident was outside. He stated video surveillance was reviewed and it was concluded that the resident was outside for approximately five (5) minutes without staff. Further interview with the DON revealed that the alarm was not sounding to alert staff that a resident wearing a code alert bracelet was outside of the facility. He stated that he went outside along with other staff and the resident's daughter and granddaughter and assisted the resident back into the facility. The DON stated that on 06/19/18, the resident followed staff out the front door when they were assisting another resident outside of the facility. Continued interview revealed that incident reports were not completed on the elopements. He stated interviews were conducted and video footage was reviewed when the elopements occurred. Interview with the Administrator and the Senior Director of Clinical Services on 07/05/18 at 2:45 PM, revealed Resident #9 had a code alert bracelet placed on 05/28/18 due to his/her initial admission assessment. They stated that the nurses were responsible to check the resident's code alert bracelet every shift to ensure it was in place and document on the TAR that the code alert bracelet was in place. They stated they were sure that nursing staff was checking the resident's code alert bracelet every shift even though they were not documenting it on the TAR. Continued interviews revealed physician's orders [REDACTED]. They stated that when the resident exited the building on 06/13/18 he/she was with an alert and oriented resident and that although this was not an optimal situation, the other resident could provide supervision for Resident #9. She stated that the resident had removed his/her code alert bracelet and after that incident, staff placed a code alert bracelet on the resident's wheelchair and the resident's shoe. They stated on 06/13/18 and 06/19/18 they assumed staff wrote on the shift report that the resident needed a code alert bracelet because the resident kept taking it off.

Based on observation, interview, record review, policy review, and review of the Facility Assessment, it was determined the facility failed to ensure nursing staff (Licensed Practical Nurse #9) had appropriate competencies and skills to safely administer medications. The facility failed to evaluate the competency and skill level upon hire or during the orientation process even after being notified by orientation staff that Licensed Practical Nurse (LPN) #9 was not following standards of practice related to medication administration. The LPN administered Insulin (medication used to regulate blood sugar) in error to Resident #21 on 06/04/18 and no formal retraining or counseling was provided to the LPN after the error. The facility allowed LPN #9 to continue to provide resident care and administer residents' medications. On 07/11/18, Resident #20 alleged that LPN #9 attempted to give him/her the incorrect/unprescribed medication and that the LPN used unprofessional language. Although the facility investigated the allegation of verbal abuse, the facility failed to evaluate the LPN's competency regarding medication administration. On 07/20/18, LPN #9 was observed during the morning medication pass to administer medications to five (5) residents (Resident A, Resident D, Resident E, Resident F, and Resident #22). Numerous errors (14 errors out of 44 opportunities) were observed during the medication pass which resulted in a 31.8 percent error rate. An additional significant error also occurred on 07/20/18 when LPN #9 administered a [MEDICATION NAME] Patch (pain medication) to Resident #21. The facility failed to ensure LPN #9 was competent in acceptable infection control practices. On 07/20/18, LPN #9 was observed to administer medications to Resident #22, who required contact precautions. LPN #9 failed to utilize the appropriate personal protective equipment (PPE) required when delivering care to Resident #22. The facility's failure to ensure sufficient numbers of staff were available to provide care for residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy, Staff Development Program, dated 08/01/13, revealed Staff development is defined as initial orientation followed by regularly scheduled in-service training classes .The primary objectives of our facility's Staff Development Program are: .b. To develop in each employee an awareness of his/her abilities and limitation in providing care for residents g. To teach each employee specific policies and procedures of our facility. Review of the Facility Assessment completed in (MONTH) (YEAR) revealed licensed staff competencies would be assessed upon hire, annually, and as needed. The assessment included a staff competency checklist for licensed nurse orientation. Per the checklist, the preceptor will evaluate the skills of the licensed nurse and indicate whether the skill level was met or unmet. The checklist had a section for evaluation of the nurse's ability to administer resident medications. 1. Review of LPN #9's personnel record revealed a hire date of 05/22/18. The file did not contain the competency checklist that is to be completed for each new employee. The personnel file contained no work performance concerns or counseling. Interview with LPN #2 on 07/19/18 at 6:30 PM and 07/20/18 at 11:45 AM, revealed that she had provided orientation to LPN #9 on the North Hall when LPN #9 first started working. LPN #2 stated after working with LPN #9, she expressed to the Director of Nursing (DON) several times that she was concerned that LPN #9 could not perform the job duties. LPN #2 stated she reported that LPN #9 did not follow the Medication Administration Record [REDACTED]. While she was observing LPN #9 administering medications during the one-day orientation, LPN #9 would have made eight (8) medication errors had she not intervened. LPN #2 stated she brought her concerns regarding LPN #9 to the DON's attention and was advised to take this concern to the Scheduler for her to schedule the LPN for more orientation. LPN #2 said when she notified the Scheduler, the Scheduler said she would tell LPN #9 to read the MAR. LPN #2 said she told the Scheduler and the DON that she had already told LPN #9 to read the MAR, but it had done no good. LPN #2 stated she was not asked to complete a competency checklist regarding LPN #9's work performance. Interview with LPN #4 on 07/21/18 at 3:00 PM, revealed she had oriented LPN #9 for a couple of days after the LPN started work. LPN #4 stated she was not asked to complete a competency checklist regarding LPN #9's work performance. The LPN stated that she did not feel LPN #9 was ready to work independently as she did not understand the facility's policies and procedures. The LPN stated no one asked her about LPN #9's work performance. Review of the Medication Discrepancy Report dated 06/04/18, revealed LPN #9 had administered 40 units of [MEDICATION NAME] Insulin to Resident #21 at 6:50 PM, which was not prescribed for the resident. The LPN documented the reason for the error was the Certified Medication Aide had documented the incorrect room number by Resident #21's name. Review of Resident #21's record revealed the resident was to receive sliding scale insulin if the resident's blood sugar was greater than 200; however, the resident's blood sugar was 116 at 4:00 PM on 06/04/18. The allegation of verbal abuse dated 07/11/18 revealed Resident #20 alleged that LPN #9 had attempted to give him/her the wrong medications and allegedly the LPN said, I don't have time for this s--t. Review of the facility's investigation related to this allegation reported on 07/11/18 revealed the facility found the allegation of verbal abuse to be unsubstantiated; however, the investigation revealed no actions documented related to the allegation that LPN #9 gave the resident the wrong medication. Review of Resident #20's medical record revealed the facility admitted the resident on 10/11/17 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was interviewable. Interview with Resident #20 on 07/19/18 at 4:55 PM revealed the resident remembered the incident that occurred on 07/11/18. Resident #20 stated that he/she always counted his/her medications before taking them and noticed that LPN #9 had not given him/her the correct number of pills. The resident stated the LPN had also brought in two (2) large orange pills which did not look like any medication he/she had ever taken. Resident #20 stated he/she did not take the medication when it was first offered. The LPN then discarded the original medications, obtained the Medication Administration Record [REDACTED]. Resident #20 stated the nurse went back and forth to the cart five (5) times, but she finally got his/her medications. The resident stated he/she was disappointed because, She (LPN #9) could have killed someone, if she gave the wrong medication. Observation of the morning medication pass on 07/20/18 on the North 100 Hall with LPN #9 revealed the LPN was observed to administer medications to five (5) residents (Resident A, Resident D, Resident E, Resident F, and Resident #22). There were 44 opportunities (44 medications) observed administered to these residents. There were 14 errors observed including omitted doses, incorrect doses, and expired medications. During the medication pass observation on 07/20/18 the following medications were omitted (ordered by not given): Leflunomide 10 milligrams (mg); [MEDICATION NAME] Inhaler; [MEDICATION NAME] 0.2 % eye drops; [MEDICATION NAME] 325 mg; [MEDICATION NAME] 10 mg; [MEDICATION NAME] 10 mg; [MEDICATION NAME] 40 mg; [MEDICATION NAME] 0.5 % Ophthalmic Solution; and [MEDICATION NAME] 50 MCG spray suspension. The incorrect dose of the following medications were administered: Senna Laxative 8.6 mg, two (2) tablets were administered instead of one (1) tablet, and [MEDICATION NAME] two (2) grams were administered instead of one (1) gram. Two (2) medications ([MEDICATION NAME] 75 mg and [MEDICATION NAME]) were ordered to be administered before meals but were given with the meal. (Refer to F759.) Review of the Medication Discrepancy Report dated 07/20/18 at 10:00 AM, revealed Resident #21 was to receive a [MEDICATION NAME] every 12 hours and the patch was due to be applied at 10:00 PM on 07/20/18. However, the patch was applied at 10:00 AM on 07/20/18 by LPN #9. Interview with LPN #9 on 07/20/18 at 5:10 PM revealed she had retired from nursing five (5) or more years ago and was employed by the facility in (MONTH) (YEAR). LPN #9 said that she had orientation with LPN #4 for about seven to ten days and with LPN #2 for one day. The LPN stated that the orientation consisted of watching the orientating LPN passing meds and completing treatments and then LPN #9 administered meds and performed resident treatments. The LPN stated that she did have some apprehension about starting to work independently but the facility was short-staffed and she felt like she needed to go to work. LPN #9 said that the medication had changed, stating that even Tylenol is called something else. When asked if she was referring to [MEDICATION NAME] or APAP, she replied Yes. LPN #9 said, I know I'm out of compliance in giving the meds on time, because I'm real slow. The LPN said she made a few medication errors, had filled out the medication error report, and notified the doctor and the family. The LPN stated that no one at the facility had counseled her regarding her work performance, nor had she received any retraining. LPN #9 stated she guessed she was just nervous today and that was why she made the medication errors on 07/20/18. Interview with the Administrator, Director of Nursing, and Senior Director of Clinical Services on 07/20/18 at 3:33 PM revealed that the DON did not get involved with hands-on training related to medication administration. The DON stated the facility did have a competency check-off sheet, but this form was not being completed or returned to him. He stated LPN #2 had come to him with concerns regarding LPN #9 being slow with the medication pass and passing medications using the medication boxes instead of the MAR. The DON stated he had not formally counseled LPN #9. Further interview with the DON revealed he had met with the LPN in the hall and advised her to be more careful. The DON stated no additional training was provided after LPN #9 had made the significant Insulin medication error in (MONTH) (YEAR). Continued interview with the DON revealed he was aware LPN #9 had made another medication error today. During further interview with the Administrative staff, they were asked if they had a concern regarding the allegation by Resident #21 that he/she had been given incorrect medications. The DON stated that it was a conflict of personalities and that LPN #9 had been told not to go back into Resident #21's room. The Senior Director of Clinical Services stated the facility usually had pharmacy staff observing new nurses pass medications and planned to ask the pharmacist to come in Monday to observe LPN #9 (the error was observed on Friday). The DON stated LPN #9 was scheduled to work the weekend. Around 4:30 PM, Administrative staff advised that LPN #9 had been suspended. 2. Observation of the morning medication pass on 07/20/18 revealed a contact isolation sign on Resident 22's door. The signage indicated that staff or visitors were to wash hands, don gloves, and wear a gown when entering the room. LPN #9 donned gloves but failed to sanitize her hands or put on a gown prior to entering Resident #22's room. The LPN was observed from the doorway to brush up against the resident's bed linens while administering medications to the resident. Interview with LPN #9 on 07/20/18 at 5:10 PM revealed that her infection control training during orientation consisted of watching videos. She stated there were no tests or competency checks after she watched the training videos. The LPN said, I'm aware I did not wash my hands enough today. Interview with the DON on 07/20/18 at 8:30 PM revealed that he did not participate in infection control trainings for staff. The Infection Control Nurse and Human Resources (HR)/Payroll Personnel were responsible to complete infection control trainings with staff. Per the DON, the Infection Control Nurse should have initiated the staff competency check-off list. The DON said he relied on emails from staff to let him know when training and other duties were completed. Per the DON, everyone was just covered up with work at the present time. Interview with the Infection Control Nurse on 07/20/18 at 8:10 PM, revealed she had no formal training prior to assuming the role of Infection Control Nurse. She stated she assumed the role of Infection Control Nurse about one (1) year ago. The nurse said she did get boot camp infection control training in the fall of (YEAR). The Infection Control Nurse said that she was not responsible for new employee infection control training and that the HR staff person showed new staff a video related to infection control. In addition, the Infection Control Nurse stated she was not responsible for initiating the Licensed Nurse Competency Checklist. An interview with the Administrator on 07/20/18 at 12:00 PM revealed the DON was responsible for ensuring the orientation check-off sheet was completed for staff. Per the Administrator, if a problem was identified, the preceptor would report this to the Scheduler who would schedule the new hire for more orientation. The Administrator stated the facility had not identified any concerns regarding nurse or nurse aide trainings.

Based on observation, record review, interview, and policy review, and the Geriatric Dosage Handbook, 12th Edition, it was determined the facility failed to ensure the medication error rate was not five (5) percent or greater. The facility failed to evaluate the competency and skill level of License Practical Nurse (LPN) #9 when the LPN was hired (05/22/18), during the orientation process, or after being notified by orientation staff that LPN #9 was not following standards of practice related to medication administration. On 06/04/18, LPN #9 administered Insulin (diabetic medication) in error to Resident #21 resulting in a significant medication error. No formal retraining or counseling was provided to LPN #9 after the error. LPN #9 continued to provide resident care and administered resident medications. Observations during medication administration on 07/20/18 revealed LPN #9 failed to compare the Medication Administrator Record (MAR) to the medication label when administering medications. On 07/20/18 during the morning medication pass, LPN #9 was observed to administer medications to five (5) residents (Residents #22, A, D, E, and F) on one (1) hallway of the North Unit. There were 44 medication opportunities with 14 errors observed during this medication pass, resulting in a 31.8 percent error rate. An additional significant error also occurred on 07/20/18 when LPN #9 administered a [MEDICATION NAME] Patch (pain medication) to Resident #21. (Refer to F726.) The facility's failure to the facility's medication error rate was not greater than five percent has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's policy, Preparation and General Guidelines, related to Medication Administration, dated 12/18/12, revealed Medications are administered as prescribed in accordance with good nursing principles and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Medications are administered within 60 minutes of the scheduled time except before or after meal orders, which are administered based on meal times. Review of the Medication Discrepancy Report Policy, dated 08/16/11, revealed medication errors and drug reactions must be reported immediately to the Director of Nursing (DON) or his/her designee, the resident's attending physician, and the resident's responsive party, following a thorough assessment of the resident. Review of the Facility Assessment completed in (MONTH) (YEAR) revealed licensed staff competencies would be assessed upon hire, annually, and as needed. The assessment included a staff competency checklist for licensed nurse orientation. Per the checklist, the preceptor will evaluate the skills of the licensed nurse and indicate whether the skill level was met or unmet. The checklist had a section for evaluation of the nurse's ability to administer resident medications. Review of LPN #9's personnel record revealed a hire date of 05/22/18. The file did not contain the competency checklist that was to be completed for each new employee, per policy. The personnel file contained no work performance concerns or counseling. 1. During the morning medication pass on 07/20/18 on the North Unit, LPN #9 was observed to administer medication to unsampled Resident E at 7:45 AM. The LPN failed to compare the medications removed from the cart with the MAR and proceeded to administer [MEDICATION NAME] Diskus Inhaler 100-50 Micrograms (MCG) one puff by mouth to Resident E. After the medication was administered, LPN #9 failed to offer water for the resident to rinse his/her mouth. Review of the physician's orders [REDACTED]. Resident E had a physician's orders [REDACTED]. The medication was scheduled on the MAR for 8:00 AM. LPN #9 failed to administer this medication during the AM medication pass. Resident E had a physician's orders [REDACTED]. LPN #9 failed to administer this medication during the AM medication pass. Resident E had a physician's orders [REDACTED]. LPN #9 administered the incorrect dose; she administered Senna Laxative 8.6 mg, two tablets. Resident E had a physician's orders [REDACTED]. The medication was scheduled for 6:00 AM and was documented on the MAR as given at 6:00 AM. However, LPN #9 was observed to administer [MEDICATION NAME] 75 mg at 7:45 AM while the resident was eating breakfast. 2. On 07/20/18, during the morning medication pass, LPN #9 was observed to administer medications to unsampled Resident D. The LPN failed to compare the medications removed from the cart with the MAR. Resident D had a physician's orders [REDACTED]. LPN #9 circled the medication as not given and informed the State Survey Agency Surveyor that the medication was unavailable. However, observation of the medication cart at approximately 11:15 AM, revealed the medication was in the cart. Further review of the MAR revealed the medication was given the evening before at 8:00 PM, and interview with LPN #2 on 07/20/18 at 11:30 AM revealed routine pharmacy delivery time was every day in the afternoon/evening. 3. On 07/20/18 during the morning medication pass, LPN #9 was observed to administer medications to Resident #22 at 8:10 AM. The LPN failed to compare the medications removed from the cart with the MAR. Resident #22 had a physician's orders [REDACTED]. The LPN administered 2 grams of the [MEDICATION NAME] to Resident #22 while the resident was eating breakfast. According to the Geriatric Dosage Handbook, 12th Edition, [MEDICATION NAME] should be administered on an empty stomach. Resident #22 had a physician's orders [REDACTED]. LPN #9 signed/initialed the MAR that the medication was given but failed to administer this medication to Resident #22. Resident #22 had a physician's orders [REDACTED]. LPN #9 signed/initialed the MAR that the medication was given but failed to administer this medication to Resident #22. Resident #22 had a physician's orders [REDACTED]. The LPN circled the MAR and stated the medication was not available. However, review of the medication cart revealed approximately half a bottle of [MEDICATION NAME] medication was in the cart, labeled with the resident's name, and available for use. 4. On 07/20/18 during the morning medication pass, LPN #9 was observed to administer medications to unsampled Resident F at 8:25 AM. The LPN failed to compare the medications removed from the cart with the MAR. Resident F had a physician's orders [REDACTED]. The medication was scheduled for 8:00 AM; however, LPN #9 failed to administer the medication during the morning medication pass. 5. On 07/20/18 during the morning medication pass, LPN #9 was observed to administer medications to unsampled Resident A at 10:40 AM. The LPN failed to compare the medications removed from the cart with the MAR. The resident had a physician's orders [REDACTED]. The LPN failed to administer this medication during the morning medication pass; however, observation at approximately 11:15 AM revealed [MEDICATION NAME] eyes drops were available for Resident A. Resident A had a physician's orders [REDACTED]. This medication was scheduled for 9:00 AM. The LPN failed to administer this medication during the morning medication pass. Observation of Resident A's medication storage revealed [MEDICATION NAME] nasal spray was available Interview with LPN #9 on 07/20/18 at 5:10 PM revealed she had retired from nursing five or more years ago but was employed by the facility in (MONTH) (YEAR). LPN #9 stated that she had received orientation with two separate LPNs for appropriately seven to ten days. She stated that the orientation consisted of watching the nurse who was with her passing meds and completing treatments and then she administered meds and did resident treatments. The LPN stated that she did have some apprehension about starting to work independently, but the facility was short-staffed and she felt like she needed to work independently. LPN #9 stated that the medications had changed and stated, Even Tylenol is called something else now. When asked if she was referring to [MEDICATION NAME] or APAP, she replied Yes. During further interview with LPN #9, she stated, I know I'm out of compliance in giving the meds on time because I'm real slow. The LPN stated she made a few medication errors since starting work at the facility. Continued interview with LPN #9 revealed that no one at the facility had counseled her regarding her work performance, nor had she received any retraining. LPN #9 stated she guessed she was just nervous today and that was why she made the medication errors on 07/20/18. Interview with the Administrator, Director of Nursing (DON), and Senior Director of Clinical Services on 07/20/18 at 3:33 PM revealed that the DON did not get involved with hands-on training related to medication administration. The DON stated the facility did have a competency check-off sheet but that this form was not being completed or returned to him. The DON stated LPN #2 had come to him with concerns regarding LPN #9 being slow with the medication pass and passing medications using the medication boxes instead of the MAR; however, the DON stated he had not formally counseled LPN #9. The DON said he had met with the LPN in the hall and advised her to be more careful. The DON stated no additional training was provided after LPN #9 had committed the significant Insulin medication error in (MONTH) (YEAR). The DON said he was aware LPN #9 had made another significant medication error today. Review of the Policy on Medication Discrepancies revealed staff were required to notify the DON immediately of any medication error. Further interview with the DON on 07/20/18 at 8:30 PM revealed he did not recall when he was notified of the second medication error which occurred on 07/20/18. Review of the Medication Discrepancy Report revealed the error occurred at 10:00 AM. An interview with the Administrator on 07/20/18 at 12:00 PM revealed the DON was responsible for ensuring the orientation check-off sheet was completed for staff. Per the Administrator, if a problem was identified, the preceptor would report this to the Scheduler, who would then schedule the new hire for more orientation. Even though the Administrator had signed the Medication Discrepancy Report dated 06/04/18 when LPN #9 administered Insulin to the wrong resident, the Administrator stated the facility had not identified any concerns regarding nurse competency related to medication administration.

Based on observation, record review, interview, and policy review, it was determined the facility failed to ensure the facility was free from significant medication errors. The facility failed to evaluate the competency and skill level of Licensed Practical Nurse (LPN) #9 when she was hired (05/22/18), during the orientation process, or after being notified by orientation staff related to medication administration. On 06/04/18, LPN #9 administered 40 units of [MEDICATION NAME] Insulin (used to lower blood sugar levels) to Resident #21 in error. No formal retraining or counseling was provided to LPN #9 after the error. LPN #9 continued to provide resident care and administered resident medications. On 07/20/18, during the morning medication pass, LPN #9 committed 14 medication errors while administering medications to five (5) residents. An additional significant error also occurred on 07/20/18 when LPN #9 administered in error a [MEDICATION NAME] Patch (pain medication) to Resident #21. The facility's failure to ensure residents were free from significant medication errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/06/18 and determined to exist on 04/06/18 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F604, F609, and F610), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656 and F657), 42 CFR 483.25 Quality of Care (F686 and F689), 42 CFR 483.35 Nursing Services (F725), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 07/06/18. An acceptable Allegation of Compliance was received on 07/19/18, which alleged removal of the Immediate Jeopardy on 07/19/18. However, the A[NAME] could not be verified based on observations, staff interviews, and review of facility documentation. Additional Immediate Jeopardy was identified at 42 CFR 483.35 Nursing Services (F726), 42 CFR 483.45 Pharmacy Services (F759 and F760), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F868). The facility was notified of the Immediate Jeopardy on 07/20/18. The Immediate Jeopardy is ongoing. The findings include: Review of the Medication Discrepancy Report policy, dated 08/16/11, revealed that All medication discrepancies and drug reactions will be recorded on the Medication Discrepancy Form. 1. Medication errors and drug reactions must be reported immediately to the Director of Nursing or her designee, resident's attending physician and the resident's responsible party, following a thorough assessment of the resident 4. The Director of Nursing will review the error for any follow-up, i.e. completeness, educational, referral, etc. Review of the Facility Assessment completed in (MONTH) (YEAR) revealed licensed staff competencies would be assessed upon hire, annually, and as needed. The assessment included a staff competency checklist for licensed nurse orientation. Per the checklist, the preceptor will evaluate the skills of the licensed nurse and indicate whether the skill level was met or unmet. The checklist had a section for evaluation of the nurse's ability to administer resident medications. Review of LPN #9's personnel record revealed a hire date of 05/22/18. The file did not contain the competency checklist that is to be completed for each new employee. The personnel file contained no work performance concerns or counseling. Interview with LPN #2 on 07/19/18 at 6:30 PM and 07/20/18 at 11:45 AM revealed that she had provided orientation to LPN #9 on the North Hall when the LPN first started working (end of (MONTH) (YEAR)). LPN #2 stated after working with LPN #9, she expressed to the Director of Nursing (DON) several times that she was concerned that LPN #9 could not perform the job duties. LPN #2 stated she reported that LPN #9 did not follow the Medication Administration Record [REDACTED]. While she was observing LPN #9 administering medications during the one-day orientation, LPN #2 stated that LPN #9 would have made eight (8) medication errors had she not intervened. Interview with LPN #4 on 07/21/18 at 3:00 PM revealed she had oriented LPN #9 for a couple of days after the LPN started work. LPN #4 stated she was not asked to complete a competency checklist regarding LPN #9's work performance. She stated that she did not feel LPN #9 was ready to work independently as she did not understand the facility's policies and procedures. Review of the working schedule for LPN #9 revealed the LPN had worked seven shifts prior to working on 06/04/18. Based on interviews with LPN #2 on 07/19/18 at 6:30 PM and 07/20/18 at 11:45 AM, LPN #4 on 07/21/18 at 3:00 PM, and LPN #9 on 07/20/18 at 5:10 PM, it was unclear how many days of orientation LPN #9 received. Review of LPN #9's personnel file revealed no documented orientation information. 1. Review of the Medication Discrepancy Report dated 06/04/18 revealed LPN #9 had administered [MEDICATION NAME] Insulin 40 units to Resident #21 at 6:50 PM. The form was filled out by LPN #9 and the LPN had checked no to the following questions: Did you follow the THREE RULES? - LOOK at the medicine as you removed it from the cart? - COMPARE it with the MAR? - LOOK at it as you replaced it in the cart? Continued review of the report revealed the LPN documented measures to prevent further occurrences as Review and always follow the 3 rules (1) Look at med as you remove from the cart. (2) Compare it (with) MAR. (3) Look at it as you replace it in cart. The LPN documented that the reason for the error was the Certified Medication Aide had documented the incorrect room number by Resident #21's name. Review of Resident #21's record revealed the facility admitted the resident on 12/16/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 99 which indicated the resident was unable to complete the interview. The assessment also revealed that the resident's ability was limited in making requests. Review of the physician's orders [REDACTED]. Per the physician's orders [REDACTED].#21 was to receive sliding scale insulin if the resident's blood sugar was greater than 200 milligrams per deciliter (mg/dL). However, the resident's blood sugar was 116 mg/dL at 4:00 PM on 06/04/18. The physician was notified of the error and ordered to give orange juice with sugar every one to two hours and do accu-checks every two hours throughout the night. Per the physician's orders [REDACTED]. Review of the documentation revealed none of the resident's blood sugar levels were below 120 mg/dL. Interview with the Director of Nursing (DON) on 07/20/18 at 3:33 PM revealed that he did not get involved with hands-on training related to medication administration. The DON stated the facility did have a competency check-off sheet but that this form was not being completed or returned to him. He stated LPN #2 had come to him with concerns regarding LPN #9 being slow with the medication pass and passing medications using the medication boxes instead of the MAR. The DON stated he had not formally counseled LPN #9 after the significant medication error. He stated he had met with the LPN in the hall and advised her to be more careful. The DON stated no additional training was provided after LPN #9 had committed the significant Insulin medication error in (MONTH) (YEAR). The DON stated he reviewed each medication error but the facility did not have a high medication error rate. 2. Review of the Medication Discrepancy Report dated 07/20/18 revealed LPN #9 had administered [MEDICATION NAME] 12 Microgram (MCG) patch to Resident #21 at 10:00 AM. The form was filled out by LPN #9 and the LPN had checked no to the following questions: Did you follow the THREE RULES? - LOOK at the medicine as you removed it from the cart? - COMPARE it with the MAR? - LOOK at it as you replaced in in the cart? Continued review of the report revealed the LPN documented measures to prevent further occurrences as Review and always follow the 3 rules (1) Look at med as remove from cart. (2) Compare it (with) MAR. (3) Look @ it as you replace it in cart. The LPN documented that the pain patch was incorrectly administered at 10:00 AM instead of 10:00 PM. The measures to prevent recurrence (documented by LPN #9) said to pass on to next shift that already been given - It was scheduled for today anyway. LPN #9 had documented on the Medication Discrepancy Report that the physician was notified at 10:00 AM. Review of Resident #21's record revealed the facility admitted the resident on 12/16/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 99 which indicated the resident was unable to complete the interview. The assessment also revealed that the resident's ability was limited in making requests. Review of the physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the Nurse's Notes revealed no documented evidence of the physician notification or if any orders were received regarding the incident. Continued review of the Nurse's Notes revealed the last entry documented on Resident #21 was 07/19/18 at 4:20 PM. Interview with the DON on 07/20/18 at 8:30 PM revealed he was aware of the second medication error involving LPN #9. Per the DON, pharmacy staff came to the facility on ce per month and would observe one nurse on day shift pass medications to residents. The DON said night shift staff was not observed by pharmacy staff. He stated that the pharmacy did a yearly training on medication administration and this was the only training provided to nursing staff on medication administration. Further interview revealed after the [MEDICATION NAME] error, there should have been a physician's orders [REDACTED]. The DON said he did not remember any one nurse in the past having two (2) errors in such a short timeframe. The DON stated medication error reports are taken to the Quality Assurance Meeting every month for review by the Medical Director.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #3) was treated with respect and dignity. While conducting an investigation related to an allegation involving Resident #3, members of the facility's administrative team upset the resident and made the resident feel like he/she was being intimidated and belittled. On 07/16/18, the Administrator and Director of Nursing (DON) were suspended from the facility when Resident #3 reported that they had made the resident feel as though he/she was lying when they questioned the resident related to an allegation that had been reported. Interviews with Resident #3 revealed he/she had been intimidated and felt that he/she could no longer remain in the facility. The resident stated he/she had received emotional scars as a result of the incident, and had contacted other facilities to inquire about being transferred. Interviews with facility staff confirmed Resident #3 had been upset and cried for several days after the incident. The findings include: Review of the facility's policy, Dignity, dated 08/01/13, revealed each resident residing in the facility would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. The facility's policy stated residents would be treated with dignity and respect at all times. The policy defined treated with dignity as each resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The policy also stated that demeaning practices were prohibited and staff would not challenge or contraindicate the resident's beliefs or statements. Review of the facility's self-reported mental abuse allegation received on 07/17/18 revealed on 07/16/18, the Administrator and Director of Nursing (DON) were suspended because Resident #3 had reported to the Social Worker that the Administrator and DON had interviewed him/her about an incident that had been reported. The resident reported that he/she felt like they (the Administrator and DON) had called him/her a liar. The report stated the resident was upset and tearful when reporting the incident. Interview with the Operations Director on 07/18/18, at 11:43 AM, revealed the facility had conducted an investigation related to the Administrator and DON's actions. The Operations Director stated the allegation was determined to be unsubstantiated and the Administrator and DON returned to work on 07/18/18. Review of Resident #3's medical record revealed the facility admitted the resident on 12/31/13, with [DIAGNOSES REDACTED]. A review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. The facility assessed Resident #3 to have no [MEDICAL CONDITION] or behavioral symptoms. Interview and observation of Resident #3 on 07/20/18, at 3:30 PM, revealed the resident was crying and stated they (the Administrator and DON) have been in here several times and made him/her feel like they believed he/she was lying. The resident stated they had interviewed him/her about a bedpan incident several times. Resident #3 also stated that he/she had been told by a staff member (would not name) that the Administrator and DON were upset with him/her because he/she had reported them. Further interview with Resident #3 revealed the last time the Administrator and DON had been in his/her room was yesterday or the day before. The resident stated they came into his/her room and asked the therapist to leave and shut the door behind them. Resident #3 stated the Administrator stated to him/her, We need to get all of this straight. The resident stated that the Administrator and DON told him/her that he/she was telling one story and others were telling another story. Resident #3 stated he/she was very intimidated by the demeanor of the Administrator and DON, and felt as though he/she could no longer stay in the facility which until recently had felt like my home. The resident stated, The scars on my butt are healing, but the emotional scars will take longer to heal. Resident #3 went on to state, I am really, really hurt and upset and would like to tell them I am a human, not a dog. Interview with Certified Medication Technician (CMT) #1 on 07/19/18, at 6:00 PM, revealed she worked in the facility on 07/17/18 and 07/18/18, and Resident #3 had cried all day on both days. The CMT stated, I'm afraid (he/she) is going to have a [MEDICAL CONDITION]. CMT #1 stated on 07/17/18, the resident was shaking and stated, I got to get out of here, I can't stand it anymore. The CMT stated Resident #3 told her that he/she had contacted staff at other facilities trying to get transferred. The CMT stated that the Administrator and DON had made the resident feel like a liar and were intimidating him/her. Interview with Licensed Practical Nurse (LPN) #1 on 07/19/18, at 5:03 PM, revealed she had not witnessed the Administrator or DON go into Resident #3's room, but that she had been told about it by other staff. LPN #1 stated that Resident #3 had also discussed the incident with her, and had stated to her that it had really upset (him/her). LPN #1 also stated that Resident #3 told her that the Administrator and DON had called him/her a liar, and it had hurt his/her feelings. The LPN stated that the last time she observed Resident #3 the resident was in his/her room crying. Interview with LPN #2 on 07/19/18, at 6:20 PM, revealed that she had walked by Resident #3's room earlier in the day and observed the resident sobbing. LPN #3 stated she went in the resident's room, and the resident requested that she shut the door. She stated the resident told her that the Social Worker had called his/her family and told them that I was making false accusations. The LPN stated Resident #3 was crying and upset and stated that the DON used to stop by and speak to him/her every day, and now he does not speak to him/her. LPN #2 stated that Resident #3 told her that the Administrator, DON, and Social Worker were all intimidating him/her and accusing him/her of lying about the incident related to a bedpan. Interview with Resident #3's Family/Power of Attorney (POA) on 07/19/18, at 3:30 PM, revealed the Social Worker had never contacted him previously, but had called him four to five times this week, reporting things that Resident #3 had stated, such as, he/she had been neglected, he/she reported an incident that occurred with a bedpan, and he/she was telling inconsistent stories. The POA stated he went to the facility earlier in the week and visited Resident #3. He stated that the resident was crying and was upset over how he/she was being treated. The POA stated that Resident #3 had been in contact with other facilities and was trying to find another facility to transfer to. Interview on 07/20/18, at 10:53 AM, with a Director of Nursing at another facility (Facility #2) revealed she had visited the resident earlier in the day. The DON at Facility #2 stated the resident had been through a lot of turmoil and was wanting to transfer to another facility and was asking questions related to our facility being able to meet his/her needs. Interview on 07/19/18 at 2:00 PM, with a DON at another facility (Facility #3) revealed that she had previously been employed at the facility and had cared for Resident #3 in the past. The DON at Facility #3 stated that Resident #3 had telephoned her at work on 07/17/18, and was crying and very upset asking her how he/she could get transferred to another facility. Resident #3 stated to Facility #3's DON that he/she .was about to lose (his/her) mind, because Administration at the facility kept coming into his/her room and asking questions about things the resident had reported. Interview with the Administrator, DON, and the Senior Director of Clinical Services on 07/20/18, at 3:30 PM, revealed the Administrator and DON went to Resident #3's room on 07/17/18, because the resident had said a bedpan had broken under him/her. The Administrator stated that the incident was discussed with the resident, and that they asked the resident a few questions but she did not feel like they were intimidating or belittling him/her. The Administrator stated that she was aware that Resident #3 wanted to be transferred to another facility. The Administrator also stated the day after we talked to (Resident #3) the Social Worker had told us (he/she) was tearful. However, there was no evidence found to indicate that the facility took any further action related to the resident's emotional or mental well-being.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure interventions were in place to manage pain for one (1) of twenty-two (22) sampled residents (Resident #2). Resident #2 experienced untreated pain for eleven (11) days from 06/07/18 until 06/18/18. On 06/07/18, Resident #2 was noted to have bruising to his/her right arm and to be in pain. On 06/08/18, an x-ray revealed negative results for fracture of Resident #2's elbow. Interviews with staff revealed the resident continued to experience pain; however, the resident's physician was not contacted again until 06/17/18, at which time another x-ray was ordered. The x-ray was conducted on 06/18/18 and revealed Resident #2 had a fractured humerus. Resident #2 was ordered [MEDICATION NAME] as needed for pain. Resident #2 received one (1) dose of [MEDICATION NAME] from 06/07/18 thru 06/18/18. The findings include: Review of the facility's policy titled Pain Protocol, undated, revealed on an every shift basis, the residents would have their pain levels assessed during routine medication or care delivery. Further review of the policy revealed a comprehensive pain assessment would be performed on a minimum of once per quarter with the Resident Assessment Instrument (RAI) schedule, but would also be done any time the resident experienced an increase in pain that was significant and/or persistent. Observations of Resident #2 on 06/26/18 at 12:05 PM, revealed the resident in bed with his/her right arm in a sling. Review of Resident #2's medical record revealed the facility admitted Resident #2 on 05/10/12 with [DIAGNOSES REDACTED]. Review of Resident #2's Annual Minimum Data Set ((MDS) dated [DATE] revealed the facility had assessed Resident #2 to not be able to complete the Brief Interview for Mental Status (BIMS) interview. Continued review of Resident #2's MDS revealed the facility had determined a pain assessment interview should not be conducted because Resident #2 is rarely/never understood. Review of Resident #2's Comprehensive Care Plan dated 07/25/12 revealed the resident was at risk for alteration in comfort related to [MEDICAL CONDITION] and orthopedic surgery. Continued review of Resident #2's care plan revealed the resident to have chronic left shoulder and back pain. Further review of Resident #2's care plan revealed interventions to include: observe for signs/symptoms of pain (non-verbal expressions of pain), and report complaints of pain. Resident #2's care plan revealed the resident would be kept as comfortable as possible. Review of Resident #2's Nurse Aide Care Plan revealed no interventions related to observing for pain. Review of Nurse's Notes for Resident #2 revealed on 06/07/18, the resident was noted to have a bruised and knot-like area to his/her right elbow. The physician ordered an x-ray to the resident's right elbow and the results indicated there was no acute fracture. Continued review of Resident #2's Nurse's Notes revealed on 06/09/18, the resident was noted to have bruising in various shades to his/her right arm from the elbow up to his/her back and to have a knot-like area present to his/her right elbow. On 06/10/18, Resident #2 was noted to continue to have yellowish, purple, green bruising to his/her right arm from just below the elbow to the upper arm around to the small area on his/her back. Continued review of the Nurse's Note dated 06/10/18, revealed Resident #2 grimaced in pain when his/her arm was moved. Further review of Resident #2's Nurse's Notes revealed an x-ray to his/her right shoulder was ordered on [DATE]; and on 06/19/18 the results of the x-ray indicated Resident #2 had a shoulder (humerus) fracture. Review of Resident #2's physician progress notes [REDACTED].#2's Physician indicated the resident was stable but exhibited pain with joint motion during care. Review of a Comprehensive Pain assessment dated [DATE] revealed the resident had not complained of or been assessed to have experienced pain in the last seven (7) days. Review of Resident #2's skin assessment dated [DATE] revealed the resident had bruising to his/her right elbow and upper arm. Review of Resident #2's radiology report with a date of service of 06/18/18 revealed Resident #2 had a moderately displaced fracture through the surgical neck of the right humerus. Continued review of the radiology report revealed Resident #2's bones were subjectively osteopenic. Interview with Licensed Practical Nurse (LPN) #8 on 06/27/18 at 4:00 PM revealed she had noticed that Resident #2 had a bruise to his/her elbow, and the resident moaned when he/she was moved. LPN #8 stated she reported the resident's condition to Resident #2's Physician. Interview with State Registered Nurse Aide (SRNA) #5 on 06/27/18 at 4:35 PM revealed Resident #2 always yelled out with movement and she had reported to the nurses that Resident #2 was in pain. Further interview with SRNA #5 revealed LPN #4 was the only nurse who would check on the resident when she would report to them that the resident was in pain. Interview with SRNA #10 on 06/28/18 at 10:06 AM revealed one day while she was caring for Resident #2 his/her shoulder was moving around back and forth and he/she moaned when being moved. SRNA #10 stated she notified Resident #2's nurse of what she had observed. Interview with SRNA #2 on 06/28/18 at 10:37 AM revealed she had noticed Resident #2 had swelling in his/her right elbow area and reported this to LPN #4. Further interview with SRNA #2 revealed Resident #2 appeared to be in pain when his/her arm was moved. Interview with SRNA #12 on 06/28/18 at 1:46 PM revealed on 06/05/18 or 06/07/18 she noticed Resident #2 had bruising on his/her right elbow and notified the nurse. Continued interview with SRNA #12 revealed she tried not to touch the resident's arm too much because the resident appeared to be in some pain. Interview with LPN #3 on 06/28/18 at 3:02 PM, revealed after the first x-ray was conducted on Resident #2's elbow she had noticed that the bruising to the resident's right elbow was yellow, purple, and went up his/her arm in front, up his/her shoulder, and onto his/her back. Further interview with LPN #3 revealed Resident #2 also had a small bruise/knot to his/her forearm. LPN #3 reported Resident #2 would grimace when she touched his/her arm. Continued interview with LPN #3 revealed after a couple of days of grimacing she notified Resident #2's physician and asked for an x-ray of the resident's shoulder. Continued interview with LPN #3 on 06/28/18 at 3:40 PM revealed Resident #2 moaned and grimaced any time he/she was moved. However, there was no evidence LPN #3 assessed the resident's pain or administered pain medication to the resident. Interview with SRNA #11 on 06/28/18 at 3:52 PM revealed whenever Resident #2 was moved in bed he/she moaned. Interview with SRNA #19 on 06/29/18 at 3:47 PM revealed she noticed bruising to Resident #2's right elbow and up his/her arm on 06/16/18. Continued interview with SRNA #19 revealed Resident #2 moaned when his/her right arm was moved. The SRNA stated she reported this to the nurse. Interview with SRNA #22 on 07/02/18 at 6:45 PM revealed Resident #2 appeared to be in more pain than usual after the bruising was discovered to the resident's right arm. Interview with Certified Medication Technician (CMT) #2 on 07/02/18 at 5:37 PM revealed Resident #2 appeared to be in more pain since the shoulder fracture occurred. There was no documented evidence the CMT administered pain medication to the resident. Interview with SRNA #15 on 07/02/18 at 6:00 PM revealed Resident #2 had moaned and appeared to be in pain since the bruising to the right arm was discovered. Review of Resident #2's Medication Administration Record [REDACTED]. Although direct care staff and the nurses stated the resident was in pain when moved, continued review of Resident #2's MAR indicated [REDACTED]. Continued review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The nurse was to rate the resident's pain 0-10 (0 - no pain to 10 - weeping in agony) and document on the MAR. Further review of the documentation from 06/07-18/18 revealed all assessments of Resident #2's pain were 0 (indicating the resident had no pain). According to the schedule provided by the facility, LPN #3 and LPN #8 worked with Resident #2 between 06/07-18/18 and both stated the resident moaned and/or grimaced when moved. However, both failed to document on the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 07/03/18 at 10:50 AM revealed the bruise and knot to Resident #2's right elbow should have been looked into. Interview with the facility's Medical Director on 07/03/18 at 2:37 PM revealed he had been told by staff that Resident #2 was always in pain when he/she was moved. Continued interview with the Medical Director revealed the facility had never contacted him to request any additional pain medication for Resident #2. Interview with the facility's Administrator on 07/05/18 at 2:45 PM, revealed on 06/10/18 the color of Resident #2's bruising changed and the resident was noted to have increased pain. Continued interview with the Administrator revealed the facility conducted pain assessments on residents every shift, but could not explain why the resident's pain was not treated.