Every finding on record at Western State Nursing Facility

Number of residents sampled: 20Number of residents cited: 2The facility failed to provide a dignified existence for two residents by not ensuring lap covering for two residents, R35 and R18. Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for two (2) of twenty (20) sampled residents (Resident 18 and 35). The findings include: Review of facility policy dated October 2000, item 21 titled Dignity revealed, the facility must promote care for residents in a manner that maintains or enhances each individual's dignity and respects his or her dignity.A review of MDS information revealed R35 was admitted on [DATE] with a diagnosis of unspecified symptoms and signs involving cognitive functions and awareness and does not have a BIMS score and is not interviewable. R18 was admitted on [DATE] with a diagnosis of schizophrenia and psychotic disorder, and has a BIMS score of 99 and is not interviewable. An observation at 12:45 PM on 12/08/2025, Resident (R)18 and R35 are sitting in the hallway outside their rooms in wheelchairs. Each was wearing only a short gown with underwear and no pants. R18 was playing with her gown's tail and exposing herself. There were no lap covering or blanket on R18 or the floor near the Broda chair.An observation at 2:20 PM on 12/08/2025 revealed that R35 was sitting in a wheelchair in the hall with her legs exposed, wearing only a gown and underwear without pants and no lap cover or blanket around. An interview with CNA#2 on 12/10/2025 at 3:43 PM revealed that R18, who was sitting in the hall in a wheelchair, throws her blanket off her and that she likes to flash at times. CNA#2 also stated that an intervention for her is to put pants on her and blankets, but she does not like those. No blanket or lap covering was covering R18, who was in the hall at that time.In an interview with LPN #1 on 12/10/2025 at 3:50 PM, it was revealed that they put a blanket on R18 in the past to help cover her, but she doesn't keep a blanket on her, and they must continually cover her back up to maintain privacy. In an interview with the ADON on 12/10/2025 at 6:30 PM, she revealed that she expected residents in gowns to have their legs covered with a lap cover or blanket while in the hall.In an interview with the DON on 12/10/2025 at 6:40 PM, she revealed that her expectations were that the staff monitor the residents in the hall and that they be covered by a blanket, and depending on the time of day, the resident should be dressed to avoid a privacy or dignity issue.In an interview with the Administrator on 12/10/2025 at 7:00 PM, she revealed that she expected residents to be covered for dignity and privacy while in the hall. Her expectation for a resident with behavioral difficulty is to maintain dignity and privacy, to redirect the resident, and if behavior persists, to remove the resident to their room.

Based on observation, interview, and review of facility policy, the facility failed to follow standard precautions to be followed to prevent the spread of infection. Appropriate infection prevention and control practices were not implemented during medication administration. Hand hygiene was not performed while administering medications to one of two residents, Resident (R) 28. The findings include:Review of facility policy, titled Psychobiological/Pharmacological Interventions Medication Administration and Documentation, revised January 2023, revealed all medication will be prepared and administered as per manufacturer's specifications and accepted professional standards.Review of facility policy, titled Infection Prevention and Control, revised October 2022, revealed Western State Nursing Facility will maintain an Infection Prevention and Control Program intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/2025 revealed the facility admitted R28 on 03/27/2013 with the primary reason for admission of non-traumatic brain dysfunction. Diagnoses active within seven (7) days of the ARD included cancer, anemia, Parkinson's Disease, and schizophrenia. A Brief Interview for Mental Status (BIMS) of 99 indicated the interview for R28 could not be completed.Observation of medication administration with Registered Nurse (RN) 1 on 12/10/2025 at 9:15 AM revealed RN1 wearing gloves while preparing medications for R28 at the medication cart. Wearing the same pair of gloves, RN1 placed a finger inside the medication cup prior to placing medication in the same cup, she typed on the computer keyboard and handled the drawers of the cart. Continuing to wear the same pair of gloves, RN1 entered R28's room and picked up the fall mat from the floor and placed it against the wall, she then used the bed control to adjust height of the bed. While still wearing the same pair of gloves, she moved the blanket away from R28's face and began to administer medications. Because she had a question regarding the need to thicken liquid medications, RN1 exited the resident's room, returned to the medication cart computer, and then went to the end of the hall to add thickener to the liquid medication. Upon return to the medication cart, RN1 removed her gloves, used hand sanitizing gel, and re-gloved before typing on the computer keyboard then knocking on resident's door, adjusting the bed height, administering the liquid medication and wiping R28's face. She then replaced the fall mat, exited the room, and returned to the medication cart to type information into the computer before removing her gloves.In an interview with RN1 on 12/10/2025 at 9:40 AM, she stated nothing should be inside a medication cup and she was unaware she had placed a finger inside the cup. She further stated it is the facility policy to wear gloves during medication administration so that the meds are not touched. I guess we need to figure it out because there are no gloves or hand sanitizer in the resident rooms and that would be a lot of in and out of a room she stated regarding wearing gloves and the lack of hand hygiene.In an interview on 12/10/2025 at 6:38 PM with Assistant Director of Nursing (ADON), she stated that she was not sure it was in the policy for nurses to wear gloves while administering medication. She further stated that a lot wear them and change in between residents. If gloves are worn, staff are to remove and perform hand hygiene between residents. Additionally, she stated that touching multiple objects, including a fall mat on the floor and the resident's face, while wearing the same gloves was not appropriate. Staff is educated that hand hygiene should be performed prior to and after the administration of medications. She stated that possible negative outcomes of a lack of hand hygiene could be that residents become sick or the possibility of spreading anything after touching so many things. In an interview with Director of Nursing (DON) on 12/10/2025 at 6:55 PM, she stated it was not policy for staff to wear gloves while administering oral medication, but they should perform proper hand hygiene between residents. Additionally, she stated that staff is educated on hand hygiene. She added that the educator left back in June so herself and the ADON have educated new staff on hire and others annually and as needed. She stated that she saw no concerns with the morning medication pass because RN1 did not touch the medicine. She expected staff to wash hands between residents and that there could be a potential for illness or something could happen to make the residents sick if proper hand hygiene was not performed. In an interview with Administrator on 12/10/2025 at 7:11 PM, she stated she had a social work background but was familiar with hand hygiene. She would not expect gloves to be worn for oral medication administration. She knows some may prefer to wear gloves. She would expect that if something was touched that was contaminated, hands would be washed prior to administering medication. Administrator stated that she did not believe that the morning's medication administration was appropriate. A potential negative outcome could be infection.

Number of residents sampled: 20Number of residents cited: 1The facility failed to ensure that one resident could access the call light R46. Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the call system was accessible to residents while in their bed, chair, or other sleeping accommodations for one (1) of twenty (20) sampled residents (R46). The findings include: Review of MDS information on 12/08/2025 revealed that R46 was admitted on [DATE] and had a BIMS of 99 with a diagnosis of schizophrenia and is not interviewable. Review of functional abilities (GG0130A1) shows partial to moderate help needed for using eating utensils. Review of care plan dated 10/20/2025, an intervention for high risk of fall was to ensure the call light is within reach. An observation made on 12/08/2025 at 2:00 PM revealed that Resident 46 was sitting in a Broda chair 2 feet from her bed with a call light wedged behind the recliner at the foot of her bed. An observation made on 12/10/2025 at 3:33 PM revealed that R46 was sitting in a Broda chair with the call light on the floor between the recliner and the bed, out of reach. In an interview, CNA#2 on 12/10/2025 at 3:43 PM, she revealed that R46 will hold her drinking cups and can use a call light. In an interview, LPN #1 on 12/10/2025 at 3:50 PM, she revealed that R46 can operate a call light and, at times, feed herself. In an interview with the ADON on 12/10/2025 at 6:30 PM, she revealed that they trained all staff to place the call light on the resident's lap when they do not see it within reach. In an interview with the DON on 12/10/2025 at 6:40 PM, she revealed that the expectation was that all residents who can use call lights have them. In an interview with the Administrator on 12/10/2025 at 7:00 PM, she expected the call light to be within the reach of all residents, and if a resident cannot operate a call light, that it be recorded and addressed in the care plan. If the resident cannot push a button, they would receive a pressure pad alternative.

Based on observation, interview, review of the facility's policy and resident's medical record, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections for one of two sampled residents (Resident #22 (R22)). Staff failed to perform hand hygiene when indicated; contaminated residents' clothing and bed linens; and, failed to prevent the contamination of clean dressings. The findings include: Review of the facility's policy titled, Infection Control Practices in Maintaining Sanitary Environment in the Prevention of Development and Spread of Contagious Viruses and Pathogens, dated 12/2006 and revised 03/2019 revealed the facility will maintain infection control practices that promote a sanitary environment to prevent the development and spread of contagious viruses and pathogens. Review of the facility's policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 revised 08/2022 revealed the facility would ensure that optimal skin care was provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and The National Pressure Ulcer Advisory Panel. Further review revealed the clean technique would be utilized for dressing changes, unless otherwise indicated per physician's order. The facility would follow Standard Precautions in regards to wound care. Steps included: 1. Bring equipment to resident room; . 3. Prepare a clean, dry work area at bedside, use disinfectant solution to prepare the work surface, cover work surface with clean dry paper or cloth towel to prevent contamination of supplies; 4. Place a trash bag at the end of the bed or within easy reach of the work area; 5. Wash hands, apply gloves; 6. Prepare/open dressing items on table; 9. Remove soiled dressing and place in trash bag; 10. Remove gloves, wash hands, and apply new gloves; 12. Clean the wound with normal saline or prescribed cleanser; 13. Pat the tissue surrounding the wound dry with a 4 x 4. 15; Apply prescribed topical agent to wound; 16. Apply wound dressing, cover the entire wound; 20. Discard gloves and all used supplies in trash bag. Remove Equipment; 21. Wash hands; and 22. Discard trash bag in bio-hazardous waste receptacle. 1. (a.) Review of the Electronic Medical Record (EMR) revealed the facility admitted R 22 on 09/16/2015 with diagnoses which included: eating disorder, impaired cognitive status, chronic schizophrenia, erratic behavior leading to multiple falls with fractures, and Stage IV pressure wound to the left gluteal area. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 99. This score indicated the resident had moderate cognitive impairment. During an observation of wound care, performed by Licensed Practical Nurse #3 (LPN3) on 08/08/2024 at 8:53 AM, of R22's left gluteal area, revealed she had covered an over bed table with clean towels. LPN3 stopped and washed her hands and donned gloves. She then opened a sterile cup and poured Dakin's solution into the cup. LPN3 then opened 2 sterile four by fours and placed them into the Dakin's solution for the wound packing. She placed a plastic trash bag beside her dressings and solution. Further review revealed she removed the dirty dressing and placed it in the trash bag on top of her clean table beside her packing. She then took off her dirty gloves and donned clean gloves without washing her hands. She cleaned the wound with wound cleanser, a sterile gauze and a Q-tip. She took the dirty Q-tip and gauze and put them in the trash bag sitting beside her clean dressings. The trash bag at this time was laying over the top of the open Dakin's soaked gauze in the sterile cup. After placing the dressing on the wound, she pulled up the resident's pants and placed the resident in her broda chair with help from an aide with her. Prior to starting the dressing change, LPN #3 unhooked the resident's Gastric-tube feeding. She removed the gastric tube cap which was stuck to the top of the IV fluid pole. An interview with LPN3 on 08/08/2024 at 9:30 AM, after the dressing change, she stated she should have washed her hands more. She stated she was unaware she had contaminated the dressing with the trash bag on the clean table. LPN3 stated it was her practice to secure the cap of the G-tube on the IV pole for safe keeping. During an interview with the Infection Control Registered Nurse (IP/RN) on 08/07/2024 at 11:33 AM, she stated there was ongoing education regarding hand washing and infection control. The IP/RN stated on 08/08/2024 at 10:00 AM that she expected all staff to follow the hand washing and wound care policies as written. She further stated she expected the nurses to use clean technique and not contaminate the wound during the dressing change. During the interview, she stated she expected the cap of the feeding tube to be placed in a place where it would not be contaminated. During an interview with the Director of Nursing (DON) on 08/07/2024 at 3:40 PM she stated she expected all nursing staff to use proper handwashing practices and to follow the facility's polices regarding wound care and hand washing. She stated she expected nursing staff to place the cap of the feeding tubing in a clean area when removed for feeding. During an interview with the Administrator on 08/07/2024 at 4:40 PM she stated she expected all staff to use proper handwashing practices and provide wound care per policies.

Based on observation, interview, record review, and facility policy, the facility failed to maintain a quality assessment and assurance (QAA) committee consisting of the Medical Director or his/her representative. The facility failed to ensure or encourage real-time alternative methods of participation, such as videoconferencing and teleconference calls to include the Medical Director or his/her representative. The findings include: Review of the facility's policy titled, Quality Assessment and Assurance Committee, dated 10/2022, revealed the facility would maintain a QAA committee consisting of a minimum of the Administrator or representative, Director of Nursing (DON) or representative, Physician, Infection Preventionist or representative, and three facility staff. Further review revealed the QAA committee must meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance Performance Improvement (QAPI) program. During an interview with the Administrator, on 08/08/2024 at 4:30 PM, she stated the Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist (IP), Social Services Director (SSD), and Clinical Coordinator, Medical Director, and she were members of the QAA committee. She stated that the Medical Director or his representative had not attended the quarterly meetings. She stated the Medical Director had been provided the results of those meetings and would make recommendations as needed. She further stated the Medical Director was invited by the ADON prior to the QAPI meetings but since she had been in the Administrator position the Medical Director or his representative had not attended any meetings via phone, video-conferencing, or in-person. In an interview with the Medical Director, on 08/08/2024 at 5:16 PM, he stated he was not aware of the terms regarding QAA or QAPI. He further stated after he was provided a definition of what QAPI was and entailed, he had not understood what the QAA committee was or what his role was on the committee. He stated he was not aware of the quarterly meetings, but if the facility had invited him to a meeting he would generally have gone to the facility to attend. The Medical Director stated he was not aware of receiving any email or letter regarding QAA or QAPI meetings. In an interview with the ADON (Assistant Director of Nursing) on 08/08/2024 at 5:30 PM, she stated she had emailed the Medical Director for the last quarterly QAPI meeting (copy of email provided). She stated the prior two letters for the invitation for the previous two quarterly QAPI meetings were sent via postal mail (facility had not retained copies of those letters to provide). She stated she had never received a confirmation email or phone call that the Medical Director was planning to attend. The ADON stated she was not aware of any staff following up with the Medical Director related to attending the meetings. In an interview with the Administrator, on 08/08/2024 at 5:40 PM, she stated she was only aware that the Medical Director had been notified but had not understood the regulatory requirement for the Medical Director or his representative to attend the meeting because he was active in reviewing and making recommendations. She stated she was astonished when informed that the Medical Director stated he not aware of the QAA committee or the QAPI program. She stated she would ensure moving forward that the Medical Director was fully informed of the QAA committee and QAPI so that he understood his role and the importance of his participation in those meetings.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to distribute and serve food in accordance with professional standards for food service safety related to staff not washing hands or changing gloves after leaving the meal tray prep area and prior to returning to area. Review of the Census and Condition, dated 11/19/19, revealed eighty-three (83) of ninety-three (93) residents received their meals from the kitchen. The findings include: Review of the facility's policy titled, Handwashing, last reviewed 10/2018, revealed routine hand washing should be completed after situations during which microbial contamination of hands is likely to occur and after touching inanimate sources that are likely to be contaminated with virulent or epidemiological important microorganisms of special clinical or epidemiological significance; for example: multiple drug resistant bacteria. Observation on 11/19/19 at 11:30 AM, revealed the dietary cook left the tray line three (3) times, once she touched a tray cart, the second time she touched the handles of drawers, and the third time she left the kitchen area and returned; however, she did not wash her hands or change gloves and returned to the tray line to handle food with the same gloves. Interview with the Dietary Cook and the Dietary Manager on 11/19/19 at 11:51 AM, revealed the Dietary Cook stated she should have changed her gloves and washed her hands after each time she left the tray line. The Dietary Manager revealed she expected the dietary staff to wash their hands and change their gloves.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure to help prevent the development and transmission of communicable diseases and infections for two (2) of twenty-two (22) sampled residents (Residents #30, and #89). In addition, the facility failed to ensure linens were transported so as to prevent the spread of infection. Observation revealed staff failed to perform handwashing to prevent infections during pressure ulcer care and catheter care for Resident #30 and catheter care and gastrostomy care for Resident #89. In addition, observation revealed staff carried a resident's clothing protector under his arm prior to placing it around a residents neck during meal service. The findings include: Review of the facility policy titled, Handwashing, last revised (MONTH) (YEAR) revealed, handwashing is considered the single most important procedure for preventing infection or the spread of infection. Indications: when you arrive at work, before and after touching wounds, after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or body fluids, secretions, or excretions, after touching inanimate sources that are likely to be contaminated with virulent or epidemiological important microorganisms of special clinical or epidemiologic significance; for example: multiple drug resistant bacteria, between resident contact, after handling soiled or used linens, bed pans, catheters, and urinals and after handling soiled equipment or utensils. Gloves should be used for hand contamination activities. Gloves should be removed to prevent contamination of hands during removal. Hands should be washed when the activity is completed. Gloves should be changed between residents, and may need to be changed during the care of a single resident. 1. Record review revealed the facility admitted Resident #30's on 03/16/18 with [DIAGNOSES REDACTED]. Observation of wound care on 11/21/19 at 9:14 AM revealed License Practical Nurse (LPN) #1 failed to wash hands prior to opening dressings, and failed to wear gloves; did not wash hands after removing the dirty wound dressing on left hip; and, cleaned the wound with normal saline, wearing the same dirty gloves. Further observation revealed LPN #1 removed her gloves to go out in the hallway to obtain skin prep and returned putting on clean gloves without washing his/her hands, then she applied skin prep to wound. LPN #1 went to sink to wet wash cloth, then removed gloves and replaced them without washing hands. There was stool on the gloves she removed. She then prepared for the coccyx dressing. She cleaned the wound with normal saline and applied dressing. Further observation revealed dirty soiled wash cloths were still under resident touching clean dressings. Interview with LPN #1 on 11/21/19 at 2:00 PM revealed she should have washed hands during, before, and after wound care. She stated she also should have stopped dressing change when resident had a BM and completely cleaned before continuing with wound care so that the wound would not have been contaminated. Interview with the Wound Care Nurse on 11/21/19 at 1:57 PM revealed she expected the nurse to wash hands and don gloves and not touch the dressings with bare hands. Observation of catheter care by Certified Nurse Aide (CNA) #2 and #3 on 11/21/19 at 1:25 PM revealed the catheter bag was laying on the floor. Further observation revealed the CNA's failed to wash hands between soiled glove changes and did not use appropriately good hygiene practices. Interview with CNA #2 and CNA #3 on 11/21/19 at 1:42 PM revealed they should have washed hands in between soiled glove changes. CNA #2 stated the catheter bags should not be on the floor. 2. Record review revealed the facility admitted Resident #89 on 07/29/19 with [DIAGNOSES REDACTED]. Observation of incontinent care for Resident #89 by CNA #1 with the assistance from LPN#1 on 11/21/19 10:35 AM revealed CNA #1 did not wash her hands prior to peri care, nor did she wash hands between glove changes. She then cleaned the front and placed all laundry in a trash bag on top of bed. Observation of gastrostomy tube care on 11/21/19 at 10:35 PM revealed LPN #1 failed failed to wash her hands during the procedure and after glove changes and also contaminated the dressing when she placed it on the resident's bedding prior to putting it at the site. Further observation revealed she also placed the soiled dressing on the bedding and the wound cleanser on the resident's bedding with no barrier in place. Interview with CNA #1 on 11/25/19 at 10:50 AM revealed she should have cleaned Resident #89 from clean to dirty. She revealed she did not realize she did not wash her hands. She revealed she should not have placed her dirty linen on the bed as the dirty linen fell out of the bag onto the bedding. Interview with LPN #1 on 11/25/19 at 1:55 PM revealed she should have used proper hand washing and knows to change gloves when they are soiled. She also revealed she should have not contaminated the resident's bedding by placing the soiled dressing on the bed. She revealed she needed a couple more hands to help since the resident was contracted and difficult to keep the area clean. Interview with the Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the nurse to wash her hands between glove changes and not to contaminate the bedding. The DON stated she also expected good hand hygiene to be used during wound care, gastostomy tube care, catheter care, and peri care. 3. Interview with the Director of Nursing (DON) on 11/21/19 at 3:03 PM, revealed the facility did not have a policy that addressed handling of linens. She stated the facility followed state and federal regulations related to the handling of clean linens. Observation of a meal service on 11/19/19 at 12:28 PM, revealed CNA #5 transported a clothing protector under his right arm prior to placing it around a residents neck prior to meal service. Interview with CNA #5 on 11/21/19 at 2:51 PM, revealed he should not have carried the clothing protector under his arm. CNA #5 stated he should have held the clothing protector away from his body to keep it clean. Further interview with the DON on 11/21/19 at 3:03 PM, revealed she would have expected CNA #5 to carry linens away from his body as to not contaminate it.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents received the appropriate care and services to prevent urinary tract infections to the extent possible (Resident #30) related to poor hand hygiene during indwelling catheter care. The findings include: Review of the facility policy Care of the Indwelling Catheter to Prevent Infections dated (MONTH) 2001 and revised (MONTH) (YEAR) revealed the facility will closely monitor all residents with long term indwelling catheter placement for signs and symptoms of infection and urosepsis. A resident will not be catheterized unless their clinical coneition demonstrates that the catheterization is necessary. Residents with an indwelling catheter will receive perineal and catheter care every shift and following every bowel movement. Catheter care includes cleaning at least the first four inches of the catheter closest to the insertion site plus the perineal area with soap and water. The tubing will be assessed after care to ensure it is not kinked, clamped, and ensure tubhing is not touching the floor and the appropriate drainage bag is in place. Review of the procedure for Giving Female Perineal Care revealed to perform hand hygiene, put on disposable gloves, separate the labia and clean downward from front to back with one stroke. Repeat steps until area is clean. Use a clean part of the washcloth for each stroke. Rinse and pat dry. Assist resident on side away from you. Wash from the vagina to the anus with one stroke. Repeat as necessary until clean with a clean area of the washcloth. Rinse and pat dry. Remove and discard the gloves. Perform hand hygiene and report and record observations. Record review revealed the facility admitted Resident #30 on 03/16/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/09/19 revealed the faciltiy coded the Brief Interview of Mental Status score (BIMS) as ninty-nine (99) which indicated the resident had severe cognitive impairment and was unable to be interviewed. Further review of the MDS found the resident to be totally dependent of care for Activities of Daily Living. Observation of Resident #30's catheter care by Certified Nurse Aide (CNA) #2 and #3 on 11/21/19 at 1:25 PM revealed the resident's catheter bag was laying on the floor. Further observation revealed the CNA's failed to wash hands between soiled glove changes. Interview with CNA #2 and CNA #3 on 11/21/19 at 1:42 PM revealed they should have washed hands in between soiled glove changes. CNA #2 stated she knew the catheter bag should not be on the floor. Interview with Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the staff to followthe facility policy and procedures. She stated she expected catheter bags to not be touching the floor.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with pressure ulcers in the selected sample of twenty-two (22) residents received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Licensed staff failed to provide pressure ulcer care for Resident #30 according to professional standards of practice which resulted in the Nurse contaminating the wound with feces. The findings include: Review of the facility policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 and reviewed (MONTH) (YEAR) revealed, The facility will ensure that optimal skin care is provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and the National Pressure Ulcer Advisory Panel. Any resident identified with an actual skin care problem or identified as a high risk for pressure injury or skin injury with have an individualized plan of care developed and initiated per the licensed nurse to address specific goals and treatment protocols which implements individualized interventions, monitors effectiveness of interventions, and modifies interventions and approaches. An individualized monitoring or interventions for skin care will be according to the physician/clinician's order or resident's plan of care. Clean technique will be utilized for dressing changes unless otherwise indicated per physicians's orders. Record review revealed the facility admitted Resident #30's on 03/16/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/09/19 revealed the facility coded the Brief Interview of Mental Status score (BIMS) as ninety-nine (99) which indicated the resident had severe cognitive impairment and was unable to be interviewed. Further review of the MDS found the resident to be totally dependent of care for Activities of Daily Living. Review of the Comprehensive Care Plan for Impaired Skin Integrity dated 03/19/18 with an interventions for wound treatments as ordered; however, observation of wound care on 11/21/19 at 9:14 AM revealed License Practical Nurse (LPN) #1 failed to provide wound care according to professional standards of practice. LPN #1 failed to clean table prior to laying down barrier, opened dressings without washing hands nor did she have gloves on, did not wash hands after removing the dirty wound dressing on left hip, and cleaned the wound with normal saline, with same dirty gloves. LPN #1 then stated she forgot to get skin prep so she removed her gloves, obtained the skin prep out in hallway, then put on clean gloves without washing his/her hands, then put on skin prep. She placed the clean dressing on with stool surrounding area where resident had a BM. LPN #1 then removed the dressing to coccyx with that had stool on it and contaminated the coccyx wound with feces. LPN #1 went to sink to wet wash clothe to clean and removed gloves and replaced without washing hands. There was stool on the gloves she removed. She then prepared for the coccyx dressing. She cleaned the wound with normal saline and applied dressing. Further observation revealed dirty soiled wash cloths were still under resident touching clean dressings. Interview with LPN #1 on 11/21/19 at 2:00 PM revealed she should have washed hands during, before, and after wound care. She stated she also should have stopped dressing change when resident had a BM and completely cleaned before continuing with wound care so that the wound would not have been contaminated. Interview with the Wound Care Nurse on 11/21/19 at 1:57 PM revealed she expected the over bed table to be cleaned prior to placing barrier. She stated she expected the nurse to wash hands and don gloves and not touch the dressings with bare hands. She also revealed she expected all staff to follow the resident's care plan as written. Interview with the Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the nurse to wash her hands between glove changes and not to contaminate the bedding. The DON stated she also expected good hand hygiene to be used during wound care and staff to follow care plans as written.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with wounds in the selected sample of twenty-two (22) residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan (Resident #41). Licensed staff failed to provide wound care in accordance with professional standards of practice for Resident #41. The findings include: Review of the facility policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 and reviewed (MONTH) (YEAR) revealed, The facility will ensure that optimal skin care is provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and the National Pressure Ulcer Advisory Panel. Any resident identified with an actual skin care problem or identified as a high risk for pressure injury or skin injury with have an individualized plan of care developed and initiated per the licensed nurse to address specific goals and treatment protocols which implements individualized interventions, monitors effectiveness of interventions, and modifies interventions and approaches. An individualized monitoring or interventions for skin care will be according to the physician/clinician's order or resident's plan of care. Dressing and Treatment: Clean technique will be utilized for dressing changes unless otherwise indicted per physician orders. Routine injury cleaning is to be done with all dressing changes and as per physician orders. Normal saline will be used for cleansing unless otherwise indicated per the physician. Record review revealed the facility admitted Resident #41 on 01/10/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/25/19 revealed the facility coded the BIMS score as ninety-nine (99) which indicated the resident was severely cognitively impaired and unable to be interviewed. Further review of the MDS revealed the resident was totally dependent of care with ADL's. Review of the Comprehensive Care Plan for Impaired Skin Integrity dated 04/25/17 revealed an interventions to provide wound care as ordered.; however, observation of wound care to Resident #41's skin tear/wound/surgical wound on 11/21/19 at 9:00 AM revealed LPN #1 failed to clean over bed table prior to laying down barrier or after care, to wash hands between glove changes, and to wear gloves when she opened and removed dressings with fingers and placed on abdomen prior to placing on leg. Interview on 11/21/19 at 2:00 PM with LPN #1 revealed she should have washed her hands between glove changes and used clean gloves to open dressings. She stated she also should have put clean dressing on a barrier. Interview with the Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the nurse to use good hand hygiene during wound care and dressing changes.

Based on interview, record review and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for two (2) of twenty-two (22) sampled residents (Residents #80 and #88 ) Record review for Residents #80 and #88, revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident transfers. The finding include: Review of the facility policy titled, Placement, Discharge, Planning, and Transfers, last reviewed (MONTH) (YEAR), revealed while on leave/bed hold, the facility will notify the resident and/or representative of the transfer or discharge and the reasons for the move. 1. Record review revealed the facility admitted Resident #80 on 08/15/13, with [DIAGNOSES REDACTED]. Review of a Nurses Note dated 09/10/19, revealed Resident #80 was sent to the emergency room (ER) for evaluation and treatment. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. 2. Record review revealed the facility admitted Resident #88 on 08/04/09, with [DIAGNOSES REDACTED]. Review of a Nurses Note dated 10/01/19, revealed Resident #88 was sent to the emergency room (ER) for evaluation and treatment. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. Interview with Social Service Director on 11/21/19 at 11:05 AM, revealed the Ombudsman requested to only be notified if a resident was officially discharged from the facility. She stated the facility had failed to follow the regulation, as they were not notifying the Ombudsman of all transfers. Interview with the Director of Nursing (DON) on 11/21/19 at 3:03 PM, revealed she was not aware the facility was to notify a representative of the Office of the State Long-Term Care Ombudsman office of all transfers and discharges. The DON further stated the facility would ensure this misunderstanding would be corrected.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents' right to privacy was honored (Resident #93). Staff were observed to walk by Resident #93's room while he/she was up in his/her wheelchair, in his/her doorway, with his/her gown pulled up exposing his/her incontinent brief; however, the staff failed to assist Resident #93 in covering him/herself up to ensure the resident's privacy per facility policy. The findings include: Review of the facility policy, Resident Rights, last revised (MONTH) (YEAR), revealed the facility will protect and promote the rights of each resident. Resident rights will be recognized and honored to insure a dignified existence and self-determination. The policy further revealed the facility must promote care for residents in a manner that maintains and enhances each individuals dignity and respects his/her individuality. Record review revealed the facility admitted Resident #93 on 10/15/08, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the facility coded Resident #93's Brief Interview of Mental Status (BIMS) score as ninety-nine (99) and was unable to assess Resident #93's cognition level. Observations on 11/21/19 at 9:13 AM and 9:28 AM, revealed Resident #93 was sitting up in his/her wheelchair in the doorway of his/her room, with his/her shirt pulled up, and incontinent brief exposed. Continued observation revealed one (1) resident and two (2) staff members passed by the resident's room; however, neither staff took any action to ensure the resident's privacy. Interview with Certified Nurse Aide (CNA) #4 on 11/21/19 at 9:39 AM, revealed staff should assist in covering the resident up or change the resident's clothes. CNA #4 stated she had put pants on the resident after noticing he/she was in a gown. Interview with Licensed Practical Nurse (LPN) #2 on 11/21/19 at 9:40 AM revealed all staff should honor a resident's privacy. LPN #2 stated Resident #93 was care planned to have pants on when up because he/she leans forward so much causing a gown to slide upward, exposing his/her leg and brief. Interview with the Director of Nursing (DON) on 11/21/19 at 3:03 PM, revealed she expected staff to ensure residents have their right to privacy. She stated if staff noticed a resident was uncovered and possibly exposing themselves, staff should cover the resident or change his/her clothing.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure eye drops and ear drops used in the facility were labeled in accordance with currently accepted professional principles, on two (2) of four (4) units at the facility. The findings include: Review of the facility's policy titled, Psychobiological /Pharmacological Interventions Medication Administration and Documentation, last revised (MONTH) (YEAR), revealed all multi-dose medications must bear an expiration date. At the time a multi-dose medication is opened it must be labeled with the date and staff initials. Observation of Unit 331 and Unit 332 medication carts on 08/29/18 at 8:15 AM, revealed the following medications had been opened with no date as to when they were opened: Medication Cart A for Unit 332: Ear Drops: NeoPolyDex ear ointment Eye Drops: Dorzolanide Opth Solution x 2 bottles [MEDICATION NAME] Opth Sol Lantanoprost x 2 bottles Medication Cart A Unit for 331: [MEDICATION NAME] eye drops Interviews on 08/29/18 with Licensed Practical Nurse (LPN) #2 at 8:30 AM, LPN #1, at 9:50 AM, Registered Nurse (RN) #1 at 8:15 AM, and RN #2 at 10:00 AM, revealed medications were to be dated when opened and all nurses were responsible for dating the medications when they were opened. Interview with the Director of Nursing (DON), on 08/30/18 at 3:15 PM, revealed she expected the medication to be dated when opened by whichever nurse opened it.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one (1) of twenty-one (21) sampled residents (Resident #27). Observation on 08/29/18 revealed Registered Nurse (RN) #2 failed to wash her hands and change her gloves after removing the soiled dressing and before applying the new dressing during wound care for Resident #27's pressure ulcer. The findings include: Review of facility policy titled, Skin/Wound Care Protocol. last reviewed (MONTH) (YEAR) revealed the facility will ensure optimal skin care is provided to all residents according to Clinical Practice guidelines per the Agency for Health Care Research and Quality (AHRQ) and the National Pressure Ulcer Advisory Panel (NPUAP). #15-d revealed clean technique will be utilized for dressing changes unless otherwise indicated per physician's orders [REDACTED]. Record review revealed the facility admitted Resident #27 on 03/16/18 with [DIAGNOSES REDACTED]. Review of Resident #27's Quarterly Minimum Data Set (MDS) assessment, dated 06/18/18, revealed the facility assessed Resident #27's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. Further review revealed the resident has a stage III pressure area on admission. Observation on 08/29/18 at 10:00 AM revealed Registered Nurse (RN) #2 performed a dressing change to the sacral area. RN #2 washed her hands and don clean gloves, removed the old dressing that was soiled with feces, and then applied the clean dressing without washing her hands or changing her gloves. Interview with RN #2 on 08/29/18 at 10:30 AM revealed she realized she did not use proper hand hygiene during the dressing change but thought she had uses one gloved hand to remove the dirty dressing and the other gloved hand to apply the clean dressing. Interview with the Director of Nursing (DON) and the Infection Control Nurse on 08/30/18 at 3:16 PM revealed RN #2 should have changed gloves and washed her hands when going from the dirty dressing to the clean dressing.

Based on interview, record review, and review of the facility's Incident Management/Abuse Protocol, it was determined the facility failed to implement the facility policy related to reporting suspected abuse for one (1) of three (3) sampled residents (Resident #1). On 05/28/18, the Therapeutic Recreation Aide (TRA) #1 observed Resident #1 tied to a wheelchair with a sheet while sitting in the Restorative Dining Room on Unit 332. TRA #1 failed to report the alleged abuse to administration immediately. The findings include: Review of the facility's policy and procedures titled, Incident Management/Abuse Protocol, last revised (MONTH) (YEAR), revealed the facility Director or designated representative shall follow KRS 209, KRS 620, 42 CFR 483.13, and 42 CFR 483.420 for immediately reporting of harm or potential for harm following the identification of a condition or situation that has a potential to cause harm to a person's psychological and/or physical health and safety, or following an incident that causes harm to a person's psychological and/or physical health and safety. It is the responsibility of the facility to immediately secure the safety of the individual(s) or person(s) by removing the threat. Review of the facility's policy, Resident Rights, last revised (MONTH) (YEAR), revealed the facility will protect and promote the rights of each resident. The resident has the right to be free from any physical and/or chemical restraints administered for the purpose of discipline of convenience. Record review revealed the facility admitted Resident #1 on 06/24/15 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Inventory of Mental Status (BIMS) score of twelve (12). Interview with TRA #1, on 06/13/18 at 9:40 AM, revealed on 05/28/18 she went to Unit 332. She stated she observed RN #4 bring Resident #1 in the small dining area to attend an activity. She stated, RN#4 asked me to keep an eye on Resident #4. TRA #1 stated when she approached Resident #1, she noted the resident attempted to get up from wheelchair; however, he/she was not able to stand. TRA #1 stated, I noticed Resident #1 was tied to the wheelchair with a sheet. TRA #1 revealed at this time RN #4 returned and she asked her, who tied him/her to the wheelchair? and RN #4 responded you don't see anything, repeating the statement two (2) more times, you don't see anything. TRA #1 stated RN #4 did not reveal why Resident #1 was tied to the wheelchair and she did not report the resident was tied in the wheelchair with a sheet. Interview with Resident #1, on 06/12/18 at 3:00 PM, revealed the Resident did not remember being tied to her wheelchair with a sheet on 05/28/18. Attempts to interview RN #4 on 06/13/18 at 10:27 AM, on 06/13/18 at 1:30 PM, and on 06/14/18 at 2:30 PM were unsuccessful. Interview with State Registered Nurse Aide (SRNA) # 2, on 06/13/18 at 11:30 AM, revealed at approximately 12:30 PM, she transported Resident #1 to his/her bedroom. SRNA #2 stated Resident #1 was tied in the wheelchair with a sheet. SRNA #1 stated, I removed the sheet, and told RN #1 someone had tied the resident in the wheelchair with a sheet and RN #1 revealed she used the sheet to secure Resident #1 in the wheelchair. SRNA #1 stated she did not report RN #1 had tied Resident #1 to the wheelchair to the Skilled Facility Charge Nurse (SFCN). Interview with RN #1, on 06/13/18 at 3:10 PM, revealed she used a sheet as a seat belt to secure Resident #1 to the wheelchair, on 05/28/18 at approximately 11:45 AM. RN #1 stated Resident #1 had been restless for over a month and a staff member remained with the resident while awake due to the resident's unsteady gait. RN #1 stated, I made a judgement call to secure the resident in the wheelchair with a sheet, not as a restraint, but like a seat belt for his/her safety. RN #1 further stated, I know restraint policies are in place but I did not take the time to find out what process to follow. Interview with the SFCN, on 06/12/18 at 5:30 PM, revealed on 05/28/18 she was the SFCN during the hours of 7:00 AM to 5:00 PM. The SFCN stated RN #1 failed to report she tied Resident #1 to the wheelchair with a sheet and she would expect any staff to report an unusual occurrence, condition, or activity involving a resident. Interview with the Director of Nursing (DON), on 06/14/18 at 3:20 PM, revealed the facility promotes a restraint free environment but if a resident requires the use of a restraint the facility has policies and procedures to follow. She stated she expected staff to report if a resident was seen tied with a sheet to a wheelchair. She further stated RN #1 should not have used a sheet to tie the resident to a wheelchair and she would not expect any nurse to use a sheet as a restraint. The facility implemented the following actions to correct the deficient practice: 1. The licensed nurse (RN #1) was removed from patient care on 05/29/18 after Administration was made aware she restrained Resident #1 to wheelchair on 05/28/18. The facility conducted an investigation related to the use of a restraint. At conclusion of the investigation, RN #1 was terminated by the facility on 05/31/18 related to failure to follow the facility's Medical Physical Restraint policies and procedures. 2. The facility interviewed residents with a BIMS score of eight (8) or greater; and performed skin assessments on residents with BIMS score below (8) on 05/29/18 to identify other residents potentially affected by the use of a restraint. 3. The facility re-educated facility staff on 05/29/18 through 06/05/18 regarding Abuse/Neglect and Restraints. Staff members received copies of the policies and signed attestation indicating acknowledgement of understanding the policies 4. The Staff Facility Charge Nurse (SFCN) will make rounds twice a shift for each shift to assess for any concerns on the units and document any concerns identified for one (1) month. After one (1) month, (1) interview (staff and resident) and (1) skin assessments (resident with BIMS less than {8}) will be conducted for five (5) months. 5. The Administrative Nurses which consist of the (DON), Clinical Coordinator, Safety Coordinator, Incident Management Coordinator, and Infection Control Nurse, will monitor to ensure the deficient practice will not recur by conducting daily interviews with two (2) interviewable residents on each unit. Additionally, (2) staff members on each unit will be interviewed daily to to ensure they are aware of what constitutes abuse, neglect, and restraints. Any lack of knowledge will be identified immediately and addressed with the staff member. The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with RN #1 on 06/13/18 at 3:10 PM revealed the facility suspended her on 05/29/18 pending the outcome of an investigation. RN #1 stated she used a sheet as a seat belt to secure Resident #1 in a wheelchair for the resident's safety on 05/28/18. RN #1 revealed she was contacted on 05/31/18, informed the investigation revealed she failed to follow the facility's policy regarding use of a physical restraint, and her employment with the facility was terminated effective as of 05/31/18. 2. Interview with Resident #1 (BIMS score 12), on 06/12/18 at 3:00 PM, revealed he/she had no concerns with the care and treatment received at the facility. Resident #1 stated resident care needs were met and he/she denied ever being hurt by staff or another resident at the facility. Review of body skin audits conducted by the Clinical Coordinator on 05/29/18 and on 06/05/18 revealed no concerns. 3. Review of the facility's Inservice Training sign in sheet, dated 05/29/18, revealed the following topics were reviewed; Abuse, Neglect, and Restraints. The in-service was conducted by the DON, Clinical Coordinator, and Incident Management Coordinator to direct care staff on all shifts. Interviews were conducted with the following staff members to validate inservice on abuse, neglect, and restraints; RN #2 (Skilled Facility Charge Nurse (SFCN) on 06/12/18 at 5:30 PM; RN #3 (SFCN) on 06/14/18 at 4:30 PM, RN #4 (SFCN) on 06/14/18 at 4:40 PM, Nurse Aide State Registered (NASR) #1 on 06/12/18 at 5:30 AM, NASR #2 on 06/13/18 at 11:30 AM, and Therapeutic Recreation Aide (TRA) #1 on 06/13/18 at 9:40 AM. Interviews revealed the facility was a restraint free environment, any identified abuse, neglect, and use of restraint(s) should be reported to the facility's (SFCN). In addition, the staff were able to identify forms of abuse, neglect, and any device or material attached to a resident's body that cannot be removed easily, and restricts freedom of movement is a restraint. 4. Interviews with the following (SFCN's): RN #2 on 06/12/18 at 5:30 PM; RN #3 on 06/14/18 at 4:30 PM; and RN #4 on 06/14/18 at 4:50 PM, revealed they are required to make rounds twice during the shift to all four (4) units in the facility. The staff stated the (SFCN) was required to complete an audit sheet per unit on each round; any concerns identified should be addressed and documented on the audit form; and corrective action should be initiated immediately. The audit sheets should be forwarded to the DON at the end of each shift. 5. Interview with the Clinical Coordinator, on 06/14/18 at 2:50 PM, revealed she randomly selects (2) staff members on each unit to interview daily (Monday through Friday) regarding abuse, neglect, reporting of abuse and/or neglect, and knowledge of restraint use. She stated any lack of knowledge determined during the interview process will result in immediate education. She revealed these interviews will be conducted by the Unit Charge Nurse on weekends and holidays. A questionnaire will be conducted with staff and residents, body audits will be conducted on (2) randomly selected residents with a BIMS score less than (8). Interview with RN #4, on 06/14/18 at 4:50 PM, revealed she is required to randomly select (2) staff members and (2) residents with a BIMS score of (8) or greater to interview when working the 6:00 PM to 7:00 AM shift, weekends, and holidays. She revealed she quizzes the staff and residents regarding abuse, neglect, reporting abuse/neglect, and use of restraints. She stated the information obtained is forwarded to the DON. Interviews with the following; Nurse Aide State Registered (NASR) #1 on 06/12/18 at 5:30 AM, NASR #2 on 06/13/18 at 11:30 AM, and Therapeutic Recreation Aide (TRA) #1 on 06/13/18 at 9:40 AM, revealed each day at least (2) staff and (2) residents are interviewed regarding abuse, neglect, reporting abuse/neglect, and restraints. Interview with the DON, on 06/14/18 at 4:10 PM, revealed corrective action will be monitored for one (1) month. Additionally, after (1) month (1) interviews (staff and resident) and (1) skin assessments (resident with BIMS less than {8})will be conducted for five (5) months. She stated she will present the audits and monitoring to the Quality Assurance Committee for six (6) months with any performance plans necessary. She stated the corrective action was completed on 06/06/18.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (1) of three (3) sampled residents (Resident #1). Registered Nurse (RN) #1 used a sheet to secure Resident #1 in the wheelchair on 05/28/18 at approximately 11:45 AM. RN #1 failed to identify the use of the sheet as a physical restraint when Resident #1's mobility was restricted to a seated position and the resident was not able to remove the sheet independently. The findings include: Review of the facility's policy, Resident Rights, revised (MONTH) (YEAR), revealed the facility will protect and promote the rights of each resident. Resident rights will be recognized and honored to ensure a dignified existence and self-determination. The resident has the right to be free from any physical and/or chemical restraints administered for the purpose of discipline of convenience. Review of the facility's policy, High Risk Situations: Medical Physical Restraint, last revised (MONTH) (YEAR), revealed the facility will provide resident safety through the utilization of physical restraint to prevent a resident from injury to self or others when all other less restrictive measures have failed. Restraints are to be used only for residents' medical symptoms or emergencies and are not to be used in a manner that causes undue physical discomfort, harm or pain to the resident, nor are restraints to be used for discipline or staff convenience. Further review of the policy revealed the definition of a Physical Restraint - Any physical or mechanical device, material or equipment attached or adjacent to the resident's body that cannot be removed easily, consistently, and which restricts freedom of movement or normal access to one's body. Restraints are implemented only after a complete physical assessment of the resident by a licensed nurse is completed. The least restrictive intervention will be utilized to provide safety/prevent injury to self or others. The nursing assessment will include how the use of a restraint might worsen the resident's medical condition, how the physical restraint will protect the resident's safety and assist the resident in attaining or maintaining his/her practical level of physical and psychosocial wellbeing. Record review revealed the facility admitted Resident #1 on 06/24/15, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/07/18, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Inventory of Mental Status (BIMS) score of twelve (12). which indicated the resident was interviewable. Further review of the MDS section G: Functional Status, revealed the facility assessed Resident #1's ambulation at 0/0; which indicated the resident was ambulatory independently without any assistive devices. Review of the MDS Section P: Restraints, revealed the facility identified Resident #1 did not use any type of restraint. Interview with Therapeutic Recreation Aide (TRA) #1, on 06/13/18 at 9:40 AM, revealed on 05/28/18 she went to Unit 332 and observed RN #4 bring Resident #1 in the small dining area to attend an activity. She stated, RN#4 asked me to keep an eye on Resident #4. TRA #1 stated when she approached Resident #1, she noted the resident attempted to get up from wheelchair; however, he/she was not able to stand. TRA #1 stated, I noticed Resident #1 was tied to the wheelchair with a sheet. TRA #1 revealed at this time RN #4 returned and she asked her, who tied him/her to the wheelchair? and RN #4 responded you don't see anything, repeating the statement two (2) more times, you don't see anything. Review of Resident #2's Nurses Notes, dated 05/28/18 at 5:54 PM, revealed the resident has been awake since before lunch. Resident not following verbal cues. Staff must constantly press down on resident shoulders to remind him/her her to sit back down or remain seated. Resident tends to throw herself forward and backwards in the wheelchair. Resident becomes very rigid with this behavior. Staff is concerned that she may injure herself, Verbalized concerns with Psychiatry and she said she would look further into the resident's history. However, further review revealed no documented evidence the resident was assessed for the use of a restraint. Review of Resident #2's Physician Orders, dated 05/28/18, revealed no order for the use of [REDACTED] Interview with State Registered Nurse Aide (SRNA) #2, on 06/13/18 at 11:30 AM, revealed at approximately 12:30 PM, she transported Resident #1 to his/her bedroom. SRNA #2 stated Resident #1 was tied in the wheelchair with a sheet. SRNA #1 stated, I removed the sheet, and told RN #1 someone had tied the resident in the wheelchair with a sheet and RN #1 revealed she used the sheet to secure Resident #1 in the wheelchair. SRNA #2 stated she knew the facility had a restraint free policy however, she failed to report the incident to the Skilled Facility Charge Nurse (SFCN). Interview with RN #1, on 06/13/18 at 3:10 PM, revealed Resident #1 had been restless for over the past month. RN #1 stated a staff member remained with the resident while awake at all times because the resident's gait was unsteady. Further interview with RN #1 on 05/28/18 at approximately 11:45 AM, revealed Resident #1 was constantly moving about in wheelchair, moving self forward and backward, and attempting to get out of wheelchair. RN #1 stated, I made a judgement call to secure the resident in the wheelchair with a sheet, not as a restraint, but like a seat belt for his/her safety. I felt if I did not do something the resident was going to get hurt. The sheet did keep the resident from getting out of the wheelchair and the resident was not able to remove the sheet; however, she stated I did not use the proper device or protocol prior to using the sheet, nor did I call the Doctor. RN #1 further stated, I know restraint policies are in place but I did not take the time to find out what process to follow. I know the facility does not use restraints, I used the sheet as a seat belt for the resident's safety. She stated Resident #1 was in the restraint for approximately an hour. Interview with the SFCN, on 06/12/18 at 5:30 PM, revealed on 05/28/18 she was the SFCN during the hours of 7:00 AM to 5:00 PM. She stated RN #1 failed to report the use of a restraint on Resident #1. Interview with the Director of Nursing (DON), on 06/14/18 at 3:20 PM, revealed the facility promoted a restraint free environment and if a resident required the use of a restraint, the facility had policies and procedures to follow. The DON stated RN #1 should have notified the doctor to obtain a physician's orders [REDACTED].#1's condition warranted the use of a restraint. The DON further stated, this facility does not use restraints, if so, only in the event of an emergency, as a last resort. I would not expect any nurse to use a sheet as a restraint. I would have expected RN #1 to follow the facility's policy. The facility implemented the following actions to correct the deficient practice: 1. The licensed nurse (RN #1) was removed from patient care on 05/29/18 after Administration was made aware she restrained Resident #1 to wheelchair on 05/28/18. The facility conducted an investigation related to the use of a restraint. At conclusion of the investigation, RN #1 was terminated by the facility on 05/31/18 related to failure to follow the facility's Medical Physical Restraint policies and procedures. 2. The facility interviewed residents with a BIMS score of eight (8) or greater; and performed skin assessments on residents with BIMS score below (8) on 05/29/18 to identify other residents potentially affected by the use of a restraint. 3. The facility re-educated facility staff on 05/29/18 through 06/05/18 regarding Abuse/Neglect and Restraints. Staff members received copies of the policies and signed attestation indicating acknowledgement of understanding the policies 4. The Staff Facility Charge Nurse (SFCN) will make rounds twice a shift for each shift to assess for any concerns on the units and document any concerns identified for one (1) month. After one (1) month, (1) interview (staff and resident) and (1) skin assessments (resident with BIMS less than {8}) will be conducted for five (5) months. 5. The Administrative Nurses which consist of the (DON), Clinical Coordinator, Safety Coordinator, Incident Management Coordinator, and Infection Control Nurse, will monitor to ensure the deficient practice will not recur by conducting daily interviews with two (2) interviewable residents on each unit. Additionally, (2) staff members on each unit will be interviewed daily to to ensure they are aware of what constitutes abuse, neglect, and restraints. Any lack of knowledge will be identified immediately and addressed with the staff member. The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with RN #1 on 06/13/18 at 3:10 PM revealed the facility suspended her on 05/29/18 pending the outcome of an investigation. RN #1 stated she used a sheet as a seat belt to secure Resident #1 in a wheelchair for the resident's safety on 05/28/18. RN #1 revealed she was contacted on 05/31/18, informed the investigation revealed she failed to follow the facility's policy regarding use of a physical restraint, and her employment with the facility was terminated effective as of 05/31/18. 2. Interview with Resident #1 (BIMS score 12), on 06/12/18 at 3:00 PM, revealed he/she had no concerns with the care and treatment received at the facility. Resident #1 stated resident care needs were met and he/she denied ever being hurt by staff or another resident at the facility. Review of body skin audits conducted by the Clinical Coordinator on 05/29/18 and on 06/05/18 revealed no concerns. 3. Review of the facility's Inservice Training sign in sheet, dated 05/29/18, revealed the following topics were reviewed; Abuse, Neglect, and Restraints. The in-service was conducted by the DON, Clinical Coordinator, and Incident Management Coordinator to direct care staff on all shifts. Interviews were conducted with the following staff members to validate inservice on abuse, neglect, and restraints; RN #2 (Skilled Facility Charge Nurse (SFCN) on 06/12/18 at 5:30 PM; RN #3 (SFCN) on 06/14/18 at 4:30 PM, RN #4 (SFCN) on 06/14/18 at 4:40 PM, Nurse Aide State Registered (NASR) #1 on 06/12/18 at 5:30 AM, NASR #2 on 06/13/18 at 11:30 AM, and Therapeutic Recreation Aide (TRA) #1 on 06/13/18 at 9:40 AM. Interviews revealed the facility was a restraint free environment, any identified abuse, neglect, and use of restraint(s) should be reported to the facility's (SFCN). In addition, the staff were able to identify forms of abuse, neglect, and any device or material attached to a resident's body that cannot be removed easily, and restricts freedom of movement is a restraint. 4. Interviews with the following (SFCN's): RN #2 on 06/12/18 at 5:30 PM; RN #3 on 06/14/18 at 4:30 PM; and RN #4 on 06/14/18 at 4:50 PM, revealed they are required to make rounds twice during the shift to all four (4) units in the facility. The staff stated the (SFCN) was required to complete an audit sheet per unit on each round; any concerns identified should be addressed and documented on the audit form; and corrective action should be initiated immediately. The audit sheets should be forwarded to the DON at the end of each shift. 5. Interview with the Clinical Coordinator, on 06/14/18 at 2:50 PM, revealed she randomly selects (2) staff members on each unit to interview daily (Monday through Friday) regarding abuse, neglect, reporting of abuse and/or neglect, and knowledge of restraint use. She stated any lack of knowledge determined during the interview process will result in immediate education. She revealed these interviews will be conducted by the Unit Charge Nurse on weekends and holidays. A questionnaire will be conducted with staff and residents, body audits will be conducted on (2) randomly selected residents with a BIMS score less than (8). Interview with RN #4, on 06/14/18 at 4:50 PM, revealed she is required to randomly select (2) staff members and (2) residents with a BIMS score of (8) or greater to interview when working the 6:00 PM to 7:00 AM shift, weekends, and holidays. She revealed she quizzes the staff and residents regarding abuse, neglect, reporting abuse/neglect, and use of restraints. She stated the information obtained is forwarded to the DON. Interviews with the following; Nurse Aide State Registered (NASR) #1 on 06/12/18 at 5:30 AM, NASR #2 on 06/13/18 at 11:30 AM, and Therapeutic Recreation Aide (TRA) #1 on 06/13/18 at 9:40 AM, revealed each day at least (2) staff and (2) residents are interviewed regarding abuse, neglect, reporting abuse/neglect, and restraints. Interview with the DON, on 06/14/18 at 4:10 PM, revealed corrective action will be monitored for one (1) month. Additionally, after (1) month (1) interviews (staff and resident) and (1) skin assessments (resident with BIMS less than {8})will be conducted for five (5) months. She stated she will present the audits and monitoring to the Quality Assurance Committee for six (6) months with any performance plans necessary. She stated the corrective action was completed on 06/06/18.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for one (1) of three (3) sampled residents (Resident #1). On 02/16/18, the Podiatrist treated Resident #1 and recommended Triple Antibiotic Ointment (TAO) to the left second (2nd) toe twice a day for fourteen (14) days and was referred to the Medical Doctor (MD) for further evaluation/management; however, the nursing staff failed to notify the MD and/or the facility's Advanced Practice Registered Nurse (APRN) of the Podiatry recommendations. The findings include: Review of the facility's Policy: IV SOP 5, Nursing Interventions: Skin/Wound Care Protocol, effective 12/1998, reviewed (MONTH) (YEAR), revealed monitoring of skin is to include inspection of nails and feet, any identified skin care problems to include bruises, abrasions, burns, [MEDICAL CONDITION], rashes, reddened areas, skin tears, or open areas are to be reported immediately to the assigned licensed nurse for assessment. Review of the facility's Policy IV SOP 4-F, Nursing Interventions: Health Maintenance Promotion; Performing Nail and Foot Care, effective 07/1999; reviewed (MONTH) (YEAR), revealed residents at the facility will be assessed and monitored daily with routine care to ensure that proper nail and foot care are given to prevent the risk of infection/injury. Nail and foot care of residents with Diabetes Mellitus, Peripheral or Vascular Disease is done by licensed staff only (unless referred to a specialist per physician's orders [REDACTED]. Any noted problems with trimming of nails, noted signs or symptoms of infection, or noted injuries to the nails or surrounding areas will be assessed per the licensed nurse with referrals made to the Physician as necessary. Record review revealed the facility admitted Resident #1 on 07/23/09 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 03/13/18, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was not interviewable. Further review revealed the resident did not bear weight to stand or ambulate. Review of Resident #1's Comprehensive Care Plan Impaired Skin Integrity, dated 05/17/17, revealed interventions for all staff to monitor skin integrity at all times. Any changes in skin integrity should be reported to the Charge Nurse, Skin Care Nurse, and Healthcare Practitioner/MD. Further review revealed a Comprehensive Care Plan for Hypertension, Heart Failure, and Diabetes Mellitus related to foot care and assessment (after the Podiatry visit) which revealed interventions for heels to be elevated off the bed and a heel lift boot to the right foot at all times for preventative measures. Daily skin audit by one (1) licensed nurse for all residents with [DIAGNOSES REDACTED]. Review of Resident #1's Monthly Progress Note by the APRN, dated 02/13/18 at 1:53 PM, revealed a physical examination within normal limits, and overview of systems revealed no reported changes. Review of Resident #1's Skin Assessment, completed on 02/20/18 at 6:32 AM, by Licensed Practical Nurse (LPN) #3, revealed no skin issues were identified. Review of the Podiatrist's Service Note, dated 02/16/18, revealed the Podiatrist was unable to feel a posterior tibial pulse point (bilateral ankles), and dorsalis pedis pulse bilaterally. The toenails were thickened, and there was diminished temperature of the skin of the left foot, as well as Rubor (redness) of the skin. Further review of the Podiatrist's Service documentation revealed elongated toenails manual and/or electric debridement of toenails using sterile heat, autoclaved instruments to all toenails on both feet. Further medical complications [REDACTED]. The Podiatrist Services Note, dated 02/16/18, revealed dressed left second (2nd) toe with Mupirocin Ointment 2% and gauze dressing. Recommend Triple Antibiotic Ointment to left (2nd) toe twice daily (BID) for fourteen (14) days, then re-evaluate. Refer to the MD for further evaluation/management. Interview with the Podiatrist, on 04/11/18 at 9:02 AM, revealed he examined Resident #1's toenails, on 02/16/18, at the facility. The Podiatrist stated, I am not so familiar with the physical findings of the resident's feet/toenails as I do not have the medical record to review. I have been made aware of the resident's outcome. My recommendation was to apply TAO to the left (2nd) toe BID for fourteen (14) days and to re-evaluate, but I also wanted the MD to further evaluate and manage care, given the resident's medical history. I would have expected the recommendation to be carried out especially, for the MD to assess and evaluate because there was no trauma to the toe, it just started bleeding. My documentation would indicate the findings of my assessment and treatment, it was obvious treatment was needed beyond the Podiatry visit. Further interview revealed the Podiatrist was not familiar with the facility's Computerized Physician order [REDACTED]. For future instances, given the outcome of this specific resident, I will speak with the Charge Nurse and/or DON before I exit to inform of my recommendations, and hopefully this will produce a more positive outcome. Interview with Certified Nursing Assistant (CNA) #4, on 04/10/18 at 3:30 PM, revealed she was assigned to round with the Podiatrist on 02/16/18. Interview revealed CNA #4 removed Resident #1's socks for the Podiatrist to trim his/her toenails when she noticed Resident #1's 2nd toe on the left foot was extremely dry and looked darker than the other toes. CNA #4 revealed the Podiatrist had not touched Resident #1's foot; however, the 2nd toe on the left foot started to bleed, not gushing but more than a drop. CNA #4 revealed she went to get a nurse to assess the resident but the nurse covering the Unit was at lunch, so she got the nurse that was orienting on the Unit. Further interview revealed the Nurse (orientee) looked at Resident #1's toe, cleaned the toe, and the Podiatrist put some ointment on it and wrapped it. Interview revealed CNA #4 did not recall the Podiatrist telling the Nurse (orientee) any specific treatment to be done. An attempt to interview the Nurse (orientee) was unsuccessful as she no longer worked at the facility. Attempts to contact her by phone, on 04/11/18 at 12:16 PM and 3:28 PM, and on 04/12/18 at 8:09 AM, were unsuccessful. Interview with Registered Nurse (RN) #1, on 04/10/18 at 4:00 PM, revealed she was aware of the Podiatrist's visit to the facility on [DATE]; however, she was at lunch when the Podiatrist was on the Unit. She revealed CNAs typically round with the Podiatrist; however, if the Podiatrist has a recommendation for treatment, he typically will notify the nurse. RN #1 revealed on 02/22/18, Resident #1 was in the shower when CNA #3 and Certified Medication Technician (CMT) #2 informed her something was wrong with the resident's foot. RN #1 revealed she noticed Resident #1's 2nd toe on the left foot was black, and the left heel had a large necrotic circular area, no bleeding or drainage, but had a smell of rotting flesh, even after showering. RN #1 revealed she notified the facility's APRN about the condition of Resident #1's left foot and an order was obtained to transfer him/her to a local hospital emergency room (ER) for evaluation/treatment. RN #1 revealed she became aware of the Podiatrist's 02/16/18 recommendations for Resident #1, on 02/22/18; the Podiatry recommendations were uploaded in the computer. Review of Resident #1's medical record (Assessment Report) from the local hospital ER, dated 02/22/18 at 6:03 PM, revealed the ER Nurse assessment of the resident's left heel was described as a necrotic heel wound with black eschar, an assessment of the (2nd) toe on the left foot as necrotic; and pedal pulses unable to be dopplered. Review of the Computed Tomography (CT) [MEDICATION NAME] of the abdomen, pelvis, and lower extremities, dated 02/22/18 at 9:20 PM, revealed the common femoral artery was patent, stenosis at the origin of the common femoral artery with stenosis estimated at greater than 90% with minimal flow in the popliteal artery, and the anterior tibial artery is occluded. Clinical Impression: significantly degraded flow in the left lower extremity (LLE) originating at the origin of the superficial femoral artery. Review of the ER Physician Assessment Report revealed necrotic toe, deep heel ulcer, vascular compromise, needed specialized level of Vascular Surgery care. Review of the EMTALA Transfer Acceptance or Denial form revealed Resident #1 was accepted as a transfer to the hospital ER in another state due to requiring a higher level of care. Interview with the APRN, on 04/11/18 at 10:25 AM, revealed she noted the Podiatrist's recommendations of care for Resident #1's left 2nd toe around 02/21/18, in the computer. Interview with the APRN revealed she signed recommendations; however, she revealed staff should have called her or the facility's MD to obtain an order regarding the Podiatrist's recommendations. Further interview with the APRN revealed she saw Resident #1 on 02/16/18 before the Podiatrist's visit on this date and revealed the resident had no wounds to his/her left foot at that time. Interview revealed the APRN was contacted on 02/22/18 by RN #1 related to the condition of Resident #1's left foot and toe. The APRN stated, I gave the order to transfer to the ER for evaluation/treatment. Further interview revealed the APRN did not see the condition of the resident's foot/toe before he/she was transferred to the ER. The APRN stated, Resident #1's left foot was vascular and not infected; TAO would not have made a difference in the resident's outcome. Interview with the Medical Director, on 04/11/18 at 11:56 AM, revealed Resident #1 had artherosclerotic [MEDICAL CONDITION] indicating blood flow to other parts of the resident's body was compromised. Further interview revealed Resident #1's bleeding toe may have been an indication of early stages of gangrene. Further interview revealed the Podiatrist's recommendation for TAO to the toe would not have had any results on the outcome (condition) of the toe because Resident #1 had very bad vascular insufficiency, as well as other co-morbidities that would not classify the resident as a surgical candidate. The Medical Director stated, the outcome (condition) was all related to compromised blood flow that was determined after the resident was transferred to the local ER, and then on to a Medical Center in another state. Interview with the Director of Nursing (DON), on 04/12/18 at 11:35 AM, revealed the Podiatrist recommendations of care for Resident #1's toe may have been filed by the Nurse (orientee). Interview revealed the facility had generated a bath sheet to use when the residents were bathed, and any skin issues identified were recorded on the bath sheet and given to the nurse for follow-up. The DON revealed the facility had also purchased a doppler to use in assessing the residents' pulses, and that pedal pulses will be assessed on all new admissions as well. The DON stated, I feel these actions will allow a better process to ensure care needs are met for the residents and better checks to ensure nothing is missed. The facility implemented the following actions to correct the deficient practice: 1. The facility re-implemented the Stop and Watch forms, on 03/05/18, for reporting concerns on the unit, such as new bruising, skin tears, etc. The CNAs make a copy of the Stop and Watch form, giving the original to the Unit Nurse and a copy to the Administrative Nurse to follow-up and ensure any identified concerns were addressed. 2. The DON revised the facility Policy 1V SOP 2B, Resident Assessment and Documentation, on 02/21/18. The revision was added under, Resident Documentation; C. 1. Weekly skin assessments will be completed each week per the assigned day and shift for each resident. Weekly skin assessments will include head to toe resident assessments. These assessments will continue as long as the resident is in the facility, to include pulses to the lower extremities. 3. A Bath-Skin Audit Form was developed and put in place for CNAs to use during baths for reporting concerns. The form will be routed to the DON after identified concerns are addressed by the Unit Nurse. This was implemented on 03/05/18. 4. All residents with [DIAGNOSES REDACTED]. The Administrative Nurses will also assess pulses on at least two (2) residents per day and conduct a body audit. The Clinical Coordinator and Wound Care/Infection Control Nurse will compile and store all assessments for review. 5. The Skilled Facility Charge Nurse (SFCN)and a CNA will be assigned to round with the Podiatrist, starting on 03/05/18. 6. The Clinical Coordinator provided education on 02/27/18 to the staff who were responsible for direct care of the residents. The staff was educated on implementation of New Skin Monitoring For Residents. Staff on leave and/or staff who did not receive the education will be educated upon return to work. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview with the DON, on 04/12/18 at 11:35 AM, revealed the Stop-and-Watch form have been a tool the CNAs have been encouraged to use. However, as of 03/05/18, it was made mandatory for the Stop-and-Watch form and the Bath-Skin Audit Form to be used. Interviews with CNA #3 on 04/10/18 at 4:25 PM, CMT #1 on 04/10/18 at 4:40 PM, CMT #2 on 04/10/18 at 4:50 PM, RN #1 on 04/10/18 at 4:00 PM, and LPN #6 on 04/10/18 at 5:00 PM, revealed Stop-and-Watch and Bath-Skin Audit Form were now mandatory for staff to use if a concern was identified when providing resident care. Interviews revealed the staff members were to utilize the forms for documentation, then forward to the Nurse on the Unit. Interviews revealed a copy of the Stop-and-Watch and Bath-Skin Body Audit Forms were to be forwarded to the Clinical Coordinator and the Wound Care/Infection Control Nurse daily to follow-up and ensure the unit nurse notified the facility's APRN and/or MD of any identified concerns. The facility provided the following information: Stop-and-Watch Form, Bath-Skin Audit Form, and Assessment of all residents with [DIAGNOSES REDACTED]. The review was consistent with compiled information for Units 311, 312, 331, and 332, which was conducted daily starting 03/05/18. Review revealed there were not any residents on Unit 311 with documented [DIAGNOSES REDACTED]. Interview with Unsampled Resident A, on 04/12/18 at 2:20 PM, revealed a nurse checked his/her feet and assessed his/her pedal pulses daily. 2. Review of revision to Policy lV SOP 2B, revised 02/26/18, Resident Documentation, C. 1, revealed weekly skin assessments will be completed each week per the assigned day and shift for each resident. Weekly skin assessment will include a head to toe resident assessment. These assessments will continue as long as the resident is in the facility, to include pulses to the lower extremities. Review of education provided by the Clinical Coordinator to the nursing staff, on 02/27/18, revealed the following topics; Reporting of Skin Issues, New Skin Monitoring for Residents, INTERACT: Stop-and-Watch, Daily Lower Extremity Skin/Pulse Check for residents with [DIAGNOSES REDACTED]. Interviews with CNA #3 on 04/10/18 at 4:25 PM, CMT #1 on 04/10/18 at 4:40 PM, CMT #2 on 04/10/18 at 4:50 PM, RN #1 on 04/10/18 at 4:00 PM, and LPN #6 on 04/10/18 at 5:00 PM, revealed education provided by the Clinical Coordinator with an implemented date of 03/05/18. 3. Interviews with CNA #3 on 04/10/18 at 4:25 PM, CMT #1 on 04/10/18 at 4:40 PM, CMT #2 on 04/10/18 at 4:50 PM, RN #1 on 04/10/18 at 4:00 PM, and LPN #6 on 04/10/18 at 5:00 PM, revealed education was provided by the Clinical Coordinator with an implemented date of 03/05/18. 4. Interviews with RN #1 on 04/10/18 at 4:00 PM, Clinical Coordinator on 04/12/18 at 1:44 PM, LPN #6 on 04/10/18 at 5:00 PM, and LPN #2 on 04/12/18 at 2:10 PM, revealed all residents with a [DIAGNOSES REDACTED]. The Administrative Nurses which consist of the Clinical Coordinator, Wound Care/Infection Control Nurse, and the Incident Manager/Investigator will also assess pulses on at least two (2) residents per day and conduct a body audit. The Clinical Coordinator and Wound Care/Infection Control Nurse will compile and store all assessments for review. Review of the requested assessments; Stop-and-Watch Form, Bath-Skin Audit Form, and Assessment of all residents with [DIAGNOSES REDACTED]. The review was consistent with compiled information for Units 311, 312, 331, and 332, which was conducted daily starting 03/05/18. Review revealed there were not any residents on Unit 311 with documented [DIAGNOSES REDACTED]. Interview with Unsampled Resident A, on 04/12/18 at 2:20 PM, revealed a nurse checked his/her feet and assessed his/her pedal pulses daily. 5. Interviews with SFCN #2, on 04/11/18 at 3:30 PM, and SFCN #3, on 04/12/19 at 2:30 PM, revealed as of 03/05/18, the SFCN and a CNA will make rounds with the Podiatrist and/or other ancillary Healthcare Professionals. Interviews revealed the SFCN will gather healthcare documents and/or recommendations if any and turn over to the Nurse covering the Unit. Interviews revealed any recommendations will be forwarded to the facility's APRN and/or Medical Director by the Unit Nurse. 6. Review of education provided by the Clinical Coordinator to the nursing staff, on 02/27/18, revealed the following topics: Reporting of Skin Issues, New Skin Monitoring for Residents, INTERACT: Stop-and-Watch, Daily Lower Extremity Skin/Pulse Check for Residents with [DIAGNOSES REDACTED]. Interviews with CNA #3 on 04/10/18 at 4:25 PM, CMT #1 on 04/10/18 at 4:40 PM, CMT #2 on 04/10/18 at 4:50 PM, RN #1 on 04/10/18 at 4:00 PM, and LPN #6 on 04/10/18 at 5:00 PM, revealed education provided by the Clinical Coordinator with an implemented date of 03/05/18.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure care was provided in accordance with the resident's written plan of care for two (2) of three (3) sampled residents (Resident #1 and #2). Resident #1 was care planned to receive bolus tube feedings at 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM and Resident #2 was care planned to receive bolus tube feeding at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; however, on 06/23/17 the licensed staff failed to administer the resident's bolus tube feedings at 8:00 AM and 12:00 PM. The findings include: Review of the facilities policy titled Interdisciplinary Plan of Care, last reviewed April 2017, revealed specific interventions will be addressed on the Plan of Care based on expected outcomes. The provision of care will be in accordance with intervention outlines. 1. Record review revealed the facility admitted Resident #1 on 04/25/16 with [DIAGNOSES REDACTED]. Review of a Comprehensive Care Plan, dated 05/01/17, revealed the facility had identified Resident #1 to be at risk for altered nutritional status with an intervention to administer flushes and nutritional feedings as ordered. [MEDICATION NAME] 1.5 350 cc bolus five (5) times a day at 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM per [DEVICE] plus 250 cc H20 flush five (5) times a day as tolerated. However, interview with Registered Nurse (RN) #1, on 07/11/17 at 4:04 PM, revealed he failed to administer Resident #1's 8:00 AM and 12:00 PM bolus tube feedings per the resident's care plan. 2. Record review revealed the facility admitted Resident #2 on 09/01/16 with [DIAGNOSES REDACTED]. Review of a Comprehensive Care Plan, dated 03/08/17, revealed the facility had identified Resident #2 to be at risk for altered nutritional status with an intervention to administer flushes and nutritional feedings as ordered. [MEDICATION NAME] 1.5 240 cc bolus six (6) times a day at per [DEVICE] plus 300 cc H20 flush six (6) times a day as tolerated. However, interview with Registered Nurse (RN) #1, on 07/11/17 at 4:04 PM, revealed he failed to administer Resident #2's 8:00 AM and 12:00 PM bolus tube feedings per the resident's care plan. Further interview with Registered Nurse (RN) #1, on 07/11/17 at 4:04 PM, revealed he discovered at the end of his shift that Resident #1's and Resident #2's tube feedings were missed because the Electronic Medication Administration Records (EMARs) did not highlight the tube feeding orders for his shift. RN #1 stated he immediately reported he missed the feedings and the failure of the EMAR to the Clinical Coordinator. Interview with the Clinical Coordinator, on 07/11/17 at 1:16 PM, revealed she started an investigation when notified of the EMAR failure. She stated it was determined any order with a frequency greater than four (4) times a day did not populate to highlight the order on the EMAR for the ordered interventions. Interview with the Director of Nursing, on 07/13/17 at 2:44 PM, revealed she was made aware feedings were missed because the EMAR did not populate expected interventions the way staff were taught to use the EMAR system. She stated the Clinical Coordinator notified all nursing staff the EMAR may not populate all expected interventions so nursing staff providing care and services will have to review the interventions ordered to ensure they are being provided. She stated the problem identified was reported to the proper Information Technology (IT) staff to correct the next business day.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure ordered feedings were provided for two (2) of three (3) sampled residents (Resident #1 and #2). Resident #1 was assessed, care planned, and had physician's orders [REDACTED]. Resident #2 was assessed, care planned, and had physician's orders [REDACTED]. The findings include: Review of the facilities policy titled Care of Residents with Gastrointestinal Tube, last reviewed June 2017, revealed any discrepancy between the required and actual feeding intake will be assessed per the licensed nurse with documentation in the nurses note to state the discrepancy and the identified reason, along with any referral to the dietician or Health Care Plan Professional for further assessment. 1. Record review revealed the facility admitted Resident #1 on 04/25/16 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/01/17, revealed the facility assessed the Resident #1's cognition as severely impaired as the resident was not able to complete the Brief Interview of Mental Status (BIMS) which indicated the resident was not intervieweable. Further review revealed the resident was assessed as having a feeding tube. The assessment did not indicate the amount of calories or fluids received via tube feeding daily. Review of the Nutrition Risk Data Collection and Assessment, dated 08/01/16, revealed the resident required two-thousand four hundred (2400) calories, seventy-eight (78) grams of protein, and one-thousand nine-hundred fifty to two-thousand two-hundred seventy-five cc (1950-2275) of fluid a day. The residents [MEDICATION NAME] and flushes provided two-thousand six hundred twenty-five (2625) total calories, one-hundred-eighteen (118) grams of protein, and two-thousand three-hundred sixty-two (2362) cc. of fluid including flushes which meets the residents assessed needs. Review of a Physicians Order, dated 03/01/17, revealed an order for [REDACTED]. Review of a Comprehensive Care Plan, dated 05/01/17, revealed the facility had identified Resident #1 to be at risk for altered nutritional status with an intervention to administer flushes and nutritional feedings as ordered. [MEDICATION NAME] 1.5 350 cc bolus five (5) times a day at 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM per [DEVICE] plus 250 cc H20 flush five (5) times a day as tolerated. Interview with Registered Nurse (RN) #1, on 07/11/17 at 4:04 PM, revealed he failed to administer Resident #1's 8:00 AM and 12:00 PM bolus tube feedings because Resident #1's Electronic Medication Administration Record [REDACTED]. 2. Record review revealed the facility admitted Resident #2 on 09/01/16 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 06/05/17, revealed the facility assessed Resident #2's cognition as severely impaired as the resident was unable to completed the BIMS which indicated the resident was not interviewable. Further review revealed the resident was assessed as having a feeding tube. The assessment did not indicate the amount of calories or fluid received via tube feeding daily. Review of the Nutrition Risk Data Collection and Assessment, dated 09/02/16, revealed the resident required two-thousand two-hundred fifty-eight (2258) calories, seventy-three to eighty-eight (73-88) grams of protein, and two-thousand one-hundred-ninety (2190) cc of fluid a day. Review of a dietary/Nutrition Note, dated 06/21/17, revealed the [MEDICATION NAME] provided one-thousand five-hundred calories, sixty-eight (68) grams of protein, and two-thousand-four hundred fifty-five (2455) cc of water including flushes along with oral intake of meals and snacks which meets the residents assessed needs. Review of a Physicians Order, dated 03/01/17, revealed an order for [REDACTED]. Review of a Comprehensive Care Plan, dated 03/08/17, revealed the facility had identified Resident #2 to be at risk for altered nutritional status with an intervention to administer flushes and nutritional feedings as ordered. [MEDICATION NAME] 1.5 240 cc bolus six (6) times a day at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM per [DEVICE] plus 300 cc H20 flush six (6) times a day as tolerated. Interview with RN #1, on 07/11/17 at 4:04 PM, revealed he did not administer Resident #2's 8:00 AM and 12:00 PM feedings because the EMAR did not highlight the ordered feedings for Residents #2 during his shift so he would have been made aware of the required feedings. Further interview with Registered Nurse (RN) #1, on 07/11/17 at 4:04 PM, revealed he immediately reported the missed feedings to the Clinical Coordinator at the end of his shift when he realized the feedings had been missed for Resident #1 and Resident #2. Interview with the Clinical Coordinator, on 07/11/17 at 1:16 PM, revealed she started an investigation when notified of the EMAR failure. She stated it was determined that any order with a frequency greater than four (4) times a day did not populate to notify staff of ordered interventions. She also notified Licensed Practical Nurse (LPN) #1 to assess Residents #1 and #2 and notify the Provider on call. Interview with LPN #1, on 07/11/17 at 1:16 PM, revealed he assessed Residents #1 and #2 then notified the Advanced Practice Registered Nurse (APRN) and orders were received to provide a one (1) time feeding to Resident #1 at 12:00 AM to make up for one of the feedings missed. In addition, he stated the APRN gave no new orders for Resident #2 because the resident still eats and drinks at meal and snack times. Interview with the Director of Nursing (DON), on 07/13/17 at 2:44 PM, revealed she was made aware feedings were missed because the EMAR did not populate expected interventions the way staff were taught to use the EMAR system. She stated the Clinical Coordinator notified all nursing staff that the EMAR may not populate all expected interventions and nursing staff providing care and services would have to review the interventions ordered to ensure they are being provided. The DON also stated the problem identified was reported to the proper Information Technology (IT) staff to correct the next business day and they continue to monitor the EMAR system and report problems as they arise to IT as it is a new system and unexpected glitches have occurred.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure privacy for one (1) of twenty-one (21) sampled residents (Resident #1) during completion of a full body skin audit, perineal care and wound care. On 06/22/17, staff failed to pull the privacy curtain prior to providing care for Resident #1. Another staff member opened the door and entered the room while the resident's buttocks were exposed. The findings include: Review of the facility's policy titled, Resident Rights, last revised March of 2017, revealed the facility will protect and promote the rights of each resident. Residents' rights will be recognized and honored to insure a dignified existence and self determination. It further stated the resident has the right to personal privacy. The policy stated, personal privacy means accommodations, medical treatment, written and telephone communications, personal care visits, meetings of family and resident groups. Record review revealed the facility admitted Resident #1 on 12/13/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 03/22/17, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) not completed due to resident being rarely/never understood, which indicated the resident was not interviewable. Observation of a full body skin assessment, perineal care and a wound dressing change by Licensed Practical Nurse (LPN) #5 and State Registered Nurse Aide (SRNA) #1, on 06/22/17 at 8:55 AM, revealed LPN #5 and SRNA #1 failed to close the privacy curtain around the resident to ensure privacy was provided. At 9:00 AM, a second SRNA knocked on the door and opened it slightly to see if her help was needed. LPN #5 and SRNA #1 yelled resident care but the second SRNA still opened the door and entered the room. At that time, the resident was being positioned on his/her left side and his/her buttocks were exposed. Interview with LPN #5 and SRNA #1, on 06/22/17 at 9:20 AM, revealed they failed to close the privacy curtain around the resident. Both stated they knew to close the privacy curtain and usually did. Interview with the Director of Nursing (DON), on 06/22/17 at 10:40 AM, revealed she expected the staff to close the privacy curtain around residents during provision of care to ensure privacy.

Based on observation, interview, record review, and review of an emergency room Diagnostic Imaging Report and the facility's Nursing Service Standards of Operation, it was determined the facility failed to provide care in accordance with each resident's plan of care for one (1) of twenty-three (23) sampled residents (Resident #11); and, one (1) unsampled resident (Resident A). On 03/04/14, Resident #11 sustained a fall when attempting to transfer unassisted from the bed. The resident was care planned for a bed sensor alarm; however, the alarm was not turned on and did not sound to alert staff the resident was attempting to transfer. Resident #11 fell from the bed and sustained a fracture to the right fifth finger and a laceration to the right hand that required stitches and a splint. Review of the February and March 2014 Medication Administration Records (MARs) revealed the resident required an increase in pain medication from twice a month to everyday, but one day, from 03/04/14 through 03/19/14. In addition, Resident #11 was care planned for a seat belt alarm; however, observation, on 03/18/14 at 9:22 AM, revealed the resident was sitting in the dining room in a Broda chair with a seat belt alarm that was not turned on and not functional. Resident A was care planned for a clip alarm at all times; however, observations on 03/18/14 revealed Resident A's clip alarm was not attached to the resident. The findings include: Review of the facility's Nursing Service Standards of Operation, last revised 06/08, revealed the care plan would reflect necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Review of the facility's Risk Management Program (Section: IV Provision of Clinical Professional Service), last revised 10/13, revealed the Falls Reduction Program would be noted on the assigned staff's Unit Staff Assignment Sheet, bed sensor alarm to be placed on the resident's bed, chair alarm if the resident was chair bound, and other interventions according to resident's individual needs to prevent falls. 1. Record review revealed the facility admitted Resident #11 on 08/20/13 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 12/12/13, revealed the facility assessed Resident #11's cognition as severely impaired with the Brief Interview for Mental Status (BIMS) coded at ninety-nine ("99"). The resident was assessed as requiring the limited assist of one (1) staff for transfers and extensive assist of one (1) staff for ambulation. Observation, on 03/18/14 at 9:22 AM, revealed Resident #11 sitting in the dining room in a Broda chair with a seatbelt alarm; however, further observation revealed the seatbelt alarm was not turned on. Interview with CNA #1, on 03/18/14 at 9:22 AM, revealed she had turned the alarm on and she did not know why the alarm was not on at this time. CNA #1 stated the resident was not able to turn the seatbelt alarm off. Review of the Comprehensive Care Plan for "Potential Risk for Injury or Falls", dated 12/18/13, and the Unit Staff Assignment Sheet, dated 03/03/14, revealed interventions for a bed sensor alarm and seatbelt alarm. Review of Resident #11's Unit Staff Assignment Sheet, dated 03/03/14, which was in effect on the morning of 03/04/14, revealed the alarm was checked and initialed by the Certified Nurse Aide (CNA) that it was on and functioning at 3:00 AM. Review of a Post Fall Assessment, dated 03/04/14 at 3:50 AM, revealed the resident had an unwitnessed fall resulting in a laceration to the right hand, and an abrasion to the right knee with the suspected cause of fall as unknown. At 4:07 AM, the physician gave an order to send the resident to the emergency room for treatment. Review of the emergency room Diagnostic Imaging Report, dated 03/04/14, revealed a fracture to the proximal fifth (5th) phalanx (finger). Review of the Nurse's Notes, dated 03/04/14 at 9:30 AM, revealed the resident returned to the facility with a splint to the right hand and four (4) sutures. Review of the February and March 2014 Medication Administration Records (MARs) revealed the resident required an increase in pain medication (Tylenol 650 milligrams (mg) as needed for pain) from twice a month to everyday, but one, from 03/04/14 through 03/19/14. Interview with CNA #2, on 03/19/14 at 1:45 PM, revealed the resident was care planned for the bed alarm and it should have been turned on to alert staff when the resident attempted to get up unassisted. CNA #2 stated she had checked Resident #11's bed alarm at 3:00 AM prior to going to lunch and it was on and functioning. When she returned from lunch, the resident had fallen from the bed and it was reported to her by the Charge Nurse the alarm did not sound because it was not turned on. She stated she had no idea how the alarm got turned off because the resident was unable to turn the alarm off. Interview with CNA #3, on 03/19/14 at 1:10 PM, revealed she was in the room next door to Resident #11's room and heard Resident #11 yelling. She stated when she came around the corner, the resident was sitting on the mat beside the bed on the floor with blood on his/her hand and the bed alarm was not sounding. She revealed she went to the door and yelled for help and the Charge Nurse came to assess the resident. The physician was called, and the resident was sent to the hospital for evaluation. Interview with Licensed Practical Nurse (LPN) #3, on 03/19/14 at 10:50 AM, revealed the resident was care planned for risk of falls and the care plan should have been followed for the bed sensor alarm. LPN #3 stated when she entered the room, the resident was sitting on the floor, on the mat, beside the bed and had blood on his/her hand. She stated she asked CNA #3 if the bed alarm sounded and was told the alarm was turned off. The resident was assessed and noted to have a laceration to the right hand, abrasion to the right knee, and complained of pain in the right hand. 2. Record review revealed the facility admitted Resident A on 07/31/13 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 08/06/13, revealed the facility assessed Resident A's cognition as cognitively intact with a BIMS score of fifteen (15) and requiring extensive assistance with transfer and ambulation. Review of the Comprehensive Care Plan for Potential Risk for Falls, dated 02/12/14, revealed an intervention for a clip alarm on at all times. Observation, on 03/18/14 at 6:17 AM and 11:20 AM, revealed Resident A was in bed with a clip alarm that was not attached to the resident. Interview, on 03/18/14 at 11:25 AM with LPN #4, revealed Resident A should have a clip alarm on at all times. Interview, on 03/18/14 at 11:25 AM with CNA #1, revealed she had put Resident A back to bed and she thought she had put the clip alarm on the resident. She stated LPN #4 had told her the clip alarm was not attached to the resident. Interview with the Director of Nursing (DON), on 03/19/14 at 1:05 PM, revealed the care plans should be followed by the CNAs. She stated the alarms were checked by the CNAs and signed off on the Unit Staff Assignment Sheet by the CNAs. She revealed the Charge Nurse on duty should confirm the alarms were on and functioning properly.

Based on observation, interview, record review, and review of the emergency room Diagnostic Imaging Report, the facility's Nursing Service Standards of Operation (Section: IV Provision of Clinical Professional Services: Subject Assistive/Safety Devices for Resident Safety), and the facility's Risk Management Program, it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (1) of twenty-three sampled residents (Resident #11). On 03/04/14, Resident #11 had an unwitnessed fall from the bed. The resident attempted an unassisted transfer; the staff was not alerted due to the staff's failure to ensure the resident's bed sensor alarm was on and functioning. The resident sustained [REDACTED]. In addition, the resident required an increase in pain medication related to the injuries. Refer to F282 The findings include: Review of the Nursing Service Standards of Operation (Section: IV Provision of Clinical Professional Services: Subject Assistive/Safety Devices for Resident Safety), last revised 08/12, revealed the facility would assess the resident's individual needs for assistive/safety devices, utilizing an interdisciplinary approach, to promote maximum independence for movement and positioning while providing optimal comfort and safety. Utilization of all assistive/safety devices would be addressed on the resident's plan of care and on the Unit Staff Assignment Sheet. The assigned care giver would monitor the resident's assistive/safety devices to ensure they are in place and functioning properly and denote the same by their signature on the Unit Staff Assignment Sheet. Review of the facility's Risk Management Program (Section: IV Provision of Clinical Professional Service), last revised 10/13, revealed the Falls Reduction Program would be noted on the assigned staffs' Unit Staff Assignment Sheet, bed sensor alarm to be placed on the resident's bed, chair alarm if the resident was chair bound, and other interventions according to resident's individual needs to prevent falls. Record review revealed the facility admitted Resident #11 on 08/20/13, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 12/12/13, revealed the facility assessed Resident #11's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) coded as ninety-nine (99), and as requiring the limited assist of one (1) staff for transfers and extensive assistance of one (1) staff for ambulation. Review of the Comprehensive Care Plan for Potential for Injury, dated 12/18/13, and the Unit Staff Assignment Sheet, dated 03/03/14, revealed the resident was care planned for a bed sensor alarm and a seatbelt alarm. Observation, on 03/18/14 at 9:22 AM, revealed Resident #11 was sitting in the dining room in a Broda chair with a seatbelt alarm; however, further observation revealed the seatbelt alarm was not in the on position and was not functional. Review of the Post Fall Assessment, dated 03/04/14 at 3:50 AM, revealed Resident #11 had an unwitnessed fall from the bed which resulted in a laceration to the right hand and an abrasion to the right knee. The resident's bed sensor alarm was in place but was not turned on to alert staff when the resident attempted to transfer. The physician was called and an order was received to send the resident to the emergency room for treatment. Review of the emergency room Diagnostic Imaging Report, dated 03/04/14, revealed the resident sustained [REDACTED]. Review of a Nurse's Note, dated 03/04/14 at 9:30 AM, revealed the resident returned to the facility with a splint to the right hand and four (4) sutures, fracture to the right fifth (5th) phalanx (finger) with hand tender to touch and pain which required Tylenol (pain medication) 650 milligrams (mg) to be given. Review of the February and March 2014 Medication Administration Records (MARs) revealed the resident required an increase in Tylenol administration for pain from twice a month to everyday, but one day, from 03/04/14 through 03/19/14. Interview with Certified Nurse Aide (CNA) #2, on 03/19/14 at 1:45 PM, revealed she had checked Resident #11's bed alarm at 3:00 AM prior to going to lunch and it was on and functioning. She stated when she returned from lunch the resident had fallen from the bed. She stated the Charge Nurse informed her that the alarm did not sound because it was not turned on. CNA #2 stated she had no idea how the alarm got turned off because the resident was unable to turn the alarm off. Additionally, she revealed she had made rounds to check the resident's alarms a total of five (5) times during her shift and the alarm was on every time. Interview with CNA #3, on 03/19/14 at 1:10 PM, revealed she was doing rounds and checks on the alarms and was in the room next door to Resident #11 and heard the resident yelling. She stated when she came around the corner, the resident was sitting on the mat, beside the bed, on the floor with blood on his/her hand. She stated she went to the door and yelled for help and the Charge Nurse came to assess the resident. The Charge Nurse called the physician, and sent the resident to the hospital for evaluation. She revealed the resident was unable to explain what had happened related to his/her impaired cognition. Interview with Licensed Practical Nurse (LPN) #3, on 03/19/14 at 10:50 AM, revealed when she entered the room the resident was sitting on the floor, on the mat, beside the bed and had blood on his/her hand. She stated she asked CNA #3 if the bed alarm sounded and was told the alarm was turned off. She revealed she assessed the resident and noted a laceration to the right hand; an abrasion to the right knee; and, the resident complained of pain in the right hand. She stated she called the physician and received an order to send the resident to the emergency room . Interview with the Medical Director/Resident #11's physician, on 03/20/14 at 12:32 PM, revealed the bed sensor alarm should have been on because it would have alerted staff that something was going on with the resident. He stated that he would not prescribe stronger pain medication for the resident related to an injury unless the current pain regimen was not effective. He stated in this case the Tylenol was effective even though there was an increased need for it after the injury. Interview with CNA #4 and CNA #5, on 03/20/14 at 8:30 AM and 8:35 AM, respectively, revealed they do not turn the alarms off for any reason including providing incontinent care. Both stated there was a silencer button on the alarm, if the alarm goes off during care it resets itself after the resident was stable on the sensor pad. The CNAs stated they should check the alarms every two (2) hours to ensure the alarms were in place and functioning. Interview with the Director of Nursing (DON), on 03/19/14 at 1:05 PM, revealed the alarms were checked by the CNAs and signed off on the Unit Staff Assignment Sheet by the CNA. She stated the Charge Nurse on duty should confirm the alarms were on and functioning properly every two (2) hours.

Based on observation, interview, record review, and a review of facility's policy and procedure it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for four (4) of five (5) sampled residents (Residents #1, #2, #3 and #5). Resident #3 was being provided incontinent care while standing in the shower with two (2) staff and when one (1) staff left to get a towel the resident lunged falling to the floor. The resident sustained [REDACTED]. Staff failed to transfer Resident #1 to bed from a care foam chair prior to providing incontinent care. When the staff turned the resident to his/her side the resident fell off the chair to the floor and sustained a fractured knee and laceration to the left upper forehead. Resident #1 required pain medication two to three times a day to control the pain to his/her knee. Resident #2 was ambulated by one person and no gait belt instead of two (2) staff with a gait belt per care plan which resulted in the one staff having to lower the resident to the floor. The resident raised his/her head off the floor and slammed his/her face on the floor, which resulted right black eye and a laceration above the right eye. Staff failed to ensure Resident #5's room was kept uncluttered per care plan, by having an unused "Broda" chair stored in front of the sink. Resident #5 attempted to move the Broda chair and he/she slid out of the wheel chair to the floor which resulted in redness to his/her shins and minor pain. The findings include: Review of the Standard Operating Procedure #7A High Risk Situations: Resident High Risk Medical Needs, Falls Risk, last revised 07/2013, revealed the facility will utilize transfer and positioning techniques to promote optimal resident and staff safety. Residents will be assessed at the time of admission regarding areas of potential high risks per the licensed nurse and within twenty-one (21) days per the interdisciplinary overall plan of care team. Reassessment will be completed quarterly thereafter and with any change in status or as otherwise identified with each risk area as follows: residents assessed as high risk for falls will have an individualized plan of care developed and implemented to address specific interventions to prevent falls and provide safety. The licensed nurse will monitor resident fall prevention interventions each shift to ensure interventions are in place as per the resident's individualized plan of care so to prevent accident hazards of falls. 1. Record review revealed the facility admitted Resident #3 on 06/07/11, with [DIAGNOSES REDACTED]. Record review revealed Resident #3 was in the hospital after sustaining a fall on 10/04/13 with latent injuries noted. Further record review revealed the resident was assessed, on 10/06/13, to have sustained a right hip fracture and swelling and bruising to the penis; and, a right elbow fracture which was identified on 10/08/13. Review of the facility's "FINAL INVESTIGATIVE REPORT", dated 10/11/13, revealed the resident had a witnessed fall on 10/04/13 with no apparent injury noted at that time. On 10/06/13, the resident exhibited swelling to his/her right hip and discoloration (bruising and swelling) to the penis. Prior to 10/06/13, there had been no documented reports of pain or abnormalities. The resident was sent to the hospital on [DATE], and was diagnosed with [REDACTED]. On 10/08/13, a right elbow fracture was also identified as having occurred from the fall on 10/04/13. Review of the Quarterly MDS assessment, dated 07/30/13, revealed the facility assessed Resident #3 as needing extensive assistance of two (2) persons for transfers and ambulation. Review of the Comprehensive Care Plan titled "Self-care Deficit", dated 08/06/13, revealed the resident was able to transfer and ambulate with one (1) staff assistance and a gait belt. However, review of the CNA flow sheet, dated 10/04/13, revealed the resident required ambulation with two (2) person assistance using a gait belt, as well as to ambulate two-hundred (200) feet with a rolling walker and one person assistance using a gait belt twice a day on the 3-11 shift plus once on the 11-7 shift. Further review of the Comprehensive Care Plan revealed two (2) staff should assist the resident if he/she became resistive to care or exhibited combative behaviors Interview with CNA #3, on 10/10/13 at 2:45 PM, revealed he and another CNA were giving Resident #3 a shower. The resident was sitting on a shower chair and when CNA #5 stood him/her up to dry him/her off the resident began to have a bowel movement and CNA #5 asked the other CNA to get her a towel. When CNA #3 turned to get a towel the resident lunged toward the door resulting in CNA #5 losing control over the resident causing both the resident and the CNA to fall. CNA #5 stated she attempted to break the resident's fall with her body and the resident pinned her between the shower wall by falling on her legs and ankle. Interview with CNA #6, on 10/11/13 at 4:05 PM, revealed she had taken care of Resident #3 and did not notice any bruising or swelling to the resident's hip until she was called into the room to clean the resident and then she noticed swelling to the resident's right hip and swelling and bruising to the penis. She further stated she did not know that the resident had fallen on October 4th and would not have moved him/her if she had known. Interview with Medication Technician #1, on 10/11/13 at 4:10 PM, revealed she had given medication to Resident #3 on this date and did not notice anything unusual about the resident's behavior and did not have to administer him/her any pain medication. Interview with MDS Coordinator #1, on 10/11/13 at 1:47 PM, revealed if a resident required extensive assistance with two (2) persons, and a gait belt, then that was what should be on the care plan and the CNA flow sheet. Further interview revealed the care plans were supposed to be updated with changes. She stated the nurses that worked the units were supposed to let her know if there was a change in the resident's status. Interview with MDS Coordinator #2, on 10/11/13 at 11:35 PM, revealed if she completed an MDS assessment and the resident was assessed to require extensive assistance with two (2) persons then the care plan should reflect the correct status. She stated if the CNA flow sheet needed to be updated to reflect the resident's status she would do that as needed. She indicated the Comprehensive Care Plan, CNA flow sheet, and MDS assessment should match the resident's status. Interviews with Registered Nurse (RN) #1 and RN #2, on 10/10/13 at 3:25 PM and 3:49 PM and on 10/11/13 at 1:25 PM and 1:33 PM respectively, revealed Resident #3 had fallen and was lowered to the floor. Both RNs stated the resident did not exhibit any signs of pain and when the resident was in pain he/she revealed it by facial grimacing and wincing. RN #2 stated after the resident was up and dressed, he/she was ambulated out of the shower room to the wheelchair with no concerns noted. The RNs stated it was the responsibility of the nurse on each shift to check the CNA flow record to assure accuracy and sign that it had been reviewed and updated if needed. RN #2 revealed he checked the flow sheet at the beginning and end of the shift for accuracy and if there was any changes he would update them on paper and in the computer. RN #2 stated the Comprehensive Care Plan, CNA flow sheet and MDS assessment should match the resident's status. 2. Record review revealed the facility admitted Resident #1 on 06/12/12 with [DIAGNOSES REDACTED]. Observation, on 10/09/13 at 10:30 AM, revealed Resident #1 was sitting in a care foam chair in his/her room with a laceration to the left forehead and complaints of pain to the right knee. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/06/13, revealed the facility assessed Resident #1's cognition as cognitively intact and required extensive assistance of two (2) staff for transfer, bed mobility and incontinent care. In addition, the resident was not ambulatory. Review of the Comprehensive Care Plan for "Self-care Deficit", dated 09/09/13, and the CNA Flow Sheet, dated 09/19/13, revealed staff should use a mechanical lift with a blue sling for all transfers. The resident is incontinent of bowel and bladder, totally dependent for incontinent care, and on a check and change program every two (2) hours and, as needed. Review of the Nurse's Note, dated 09/19/13 at 8:20 AM, revealed the licensed staff was called to Resident #1's room and the resident was found lying on his/her back on the floor with a laceration to the left forehead, redness to both knees and facial grimacing. Further review revealed Resident #1 verbalized pain with movement of the right knee. The Advanced Practitioner Registered Nurse was called and the resident was transferred to the emergency room . Review of the facility's Final Investigation Report, dated 09/26/13, revealed Resident #1 had an assisted fall on 09/19/13 at 8:20 AM. However, further record review revealed the resident rolled out of the chair to the floor while two (2) Certified Nursing Assistants (CNAs) were providing incontinent care to the resident in a care foam chair instead of placing the resident in the bed. This fall resulted in injuries. Review of an x-ray report, dated 09/19/13, revealed Resident #1 had a fracture to the right knee. Review of the Emergency Department Report, dated 09/19/13, revealed the resident presented with a laceration to his/her left forehead as well. Review of the physician's orders [REDACTED].) five (5) mg. every six (6) hours as needed. A review of Nursing Notes, dated 09/19/13 through 09/23/13, and review of the October Medication Administration Record, revealed Resident #1 was given Lortab two to three time a day in September 2013 and three times a day from 10/01/13 to 010/09/13 for complaints of pain of the right knee. Interview with Resident #1, on 10/09/11 at 10:30 AM, revealed he/she had fallen out of the care foam chair while having his/her adult brief changed. He/She stated he/she was not sure how the CNAs let him/her fall because one was on each side of the chair. Further interview on 10/10/13 at 11:30 AM revealed Resident #1 preferred to be transferred to the bed with the Hoyer (mechanical) lift for incontinent care and felt safer in the bed. Interview with CNA #1, on 10/10/13 at 11:15 AM and CNA #2 on 10/10/13 at 11:30 AM, revealed they were involved in caring for the resident when the fall occurred. Both CNAs stated the two (2) of them were changing the resident's brief when CNA #2 rolled the resident too far causing him/her to roll out of the chair. CNA #1 stated the resident had requested to be left in the care foam chair to be changed due to the Hoyer lift hurting his/her legs. CNA #1 and #2 stated they had been trained to transfer a resident with a Hoyer lift back to the bed from a chair before providing incontinent care. Interview with Resident #1's roommate, on 10/09/13 at 10:25 AM, revealed the CNAs were going to change Resident #1 and when they turned him/her on his/her side he/she fell . She stated the CNAs did not pull the curtain so she saw everything that happened. ===Interview with Resident #1's roommate, on 10/09/13 at 10:25 AM, revealed Resident #1 was being changed and when staff turned the resident to his/her side, the resident rolled out of the chair onto the floor. When the resident was asked how he/she saw what was happened with Resident #1, he/she stated the curtain was not pulled and he/she saw everything. Interview with the Staffing Director on, 10/11/13 at 11:00 AM, revealed during orientation and training the first thing she trained staff was to follow the care plan for a resident. She stated the facility had skills check lists for all employees and it was re-emphasized that a mechanical lift required two (2) person assist and if a care plan stated a resident required two persons assistance for ambulation or standing then the staff should follow it. She further revealed she provided training regarding providing incontinent care in the bed and never in any kind of a chair. Interview with the Director of Nursing (DON), on 10/11/13 at 5:00 PM, revealed the CNAs had been trained on transferring residents as well as how and where to provide incontinent care. The training included transferring a resident to bed from a chair to provide incontinent care. She further stated that all staff had been inserviced on safe transfers and ambulation. 3. Record review revealed the facility admitted Resident #2 on 02/06/79 with [DIAGNOSES REDACTED]. Observation of the resident, on 10/09/13 at 11:00 AM, revealed Resident #2 sitting in a wheel chair in the television lounge with a sheep skin gait belt around his/her waist. Further observation revealed the resident's right eye was black with a cut above the right eye that resulted from a fall on 09/27/13. Review of Nursing Notes, dated 09/27/13 revealed Resident #2 was being ambulated in the hallway with one (1) person assist and no gait belt when the resident's knees buckled resulting in CNA #4 assisting the resident to the floor. While Resident #2 was struggling to get up after being lowered to the floor, he/she bumped his/her brow ridge above his/her right eye causing a 1/4 inch cut to the area. Review of the facility's Resident Transfer Form, dated 09/30/13, revealed the resident was sent to the hospital for an x-ray to the right eye to rule out a fracture related to the fall on 09/27/13. Review of the Emergency Department Discharge instructions, dated 09/30/13, revealed a [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 08/19/13, revealed the resident required limited, two (2) person assist for ambulation. Review of the Comprehensive Care Plan titled "Injury, risk for", last revised 08/26/13 and the Certified Nursing Assistant (CNA) flow sheet, dated 09/27/13, related to ambulation revealed the resident was to be ambulated to and from all destinations with a gait belt and two (2) staff assistance. Interview with CNA #4, on 10/10/13 at 2:30 PM, revealed she was ambulating Resident #2 down the hallway without a gait belt. She stated the resident's knees buckled and he/she began to fall and she lowered the resident to the floor. She further revealed when she was satisfied the resident was completely on the floor she took a step back and the resident lifted his/her head up off the floor and then slammed it back on the floor causing a bump to his/her head. Further review revealed she knew the care plan was specific in addressing the resident was to have a gait belt and two (2) person assistance for ambulation. She stated she was ambulating the resident alone and without a gait belt because staffing was one less than normal and she did not want to take the time to find a gait belt and another person to assist her in ambulating the resident. Interview with the Staffing Director, on 10/11/13 at 11:00 AM, revealed during orientation and training the first thing she trained staff on was to follow the care plan for a resident. She stated they had skills check off lists for all employees and it was re-emphasized if a care plan stated a resident required two (2) person assistance for ambulation or standing then the staff should follow it. Interview with the Director of Nursing (DON), on 10/11/13 at 5:00 PM, revealed the CNAs had been trained on transferring residents as well as using a gait belt for all residents who required assist with ambulation and transfers. 4. Record review revealed the facility admitted Resident #5 on 06/22/12 with [DIAGNOSES REDACTED]. Review of a Nursing Note, dated 09/20/13 written at 6:30 PM, revealed Resident #5 experienced a fall on 09/20/13 while attempting to get to the sink in his/her room to brush his/her teeth. The sink was blocked by a Broda chair causing the resident to attempt to move the chair to get to the sink. As a result, he/she slid out of the wheel chair to the floor and complained of pain to his/her shin areas with redness noted to the shins. Observation, on 10/11/13 at 4:40 PM, revealed Resident #5 was sitting up in a wheel chair in his/her room with no concerns noted. Interview with Resident #5, on 10/11/13 at 4:40 PM, revealed he/she was trying to get to the sink to brush his/her teeth and fell on his/her knees because a chair was blocking the sink. He/She stated "it hurt a little bit and he/she has some pain with the incident." Review of the Quarterly MDS assessment, dated 08/27/13, revealed the facility assessed Resident #5 to require total assistance of two (2) persons for transfer and was non-ambulatory related to bilateral below the knee amputations. Review of the Comprehensive Care Plan titled, "Impaired Cognition and Impaired Mobility", dated 06/11/13, revealed staff should provide extensive assistance with personal hygiene, oral care by staff, and the resident's room should be kept clutter free. Review of the CNA Flow Sheet, dated 10/11/13, revealed the resident was to be assisted with bathing, dressing, and grooming as well as make sure the resident's room was free of clutter and the resident was able to get to the sink to brush his/her teeth. Interview with Licensed Practical Nurse (LPN) #3, on 10/11/13 at 4:50 PM, revealed the Broda chair belonged to another resident who had been moved out of the room approximately two (2) weeks ago or longer. She stated it was moved out into the hall after the incident on 09/20/13 at least on her shift and she did not know if it was left out in the hall on the other shifts. Interview with the Director of Nursing (DON), on 10/11/13 at 5:00 PM, revealed the CNAs had been trained on keeping the residents' rooms uncluttered to assist in preventing accidents. She agreed the Broda chair should not have been blocking the sink.

Based on observation, interview, record review and facility's policy and procedure review it was determined the facility failed to ensure services were provided in accordance with each resident's written plan of care for three (3) of five (5) sampled residents (Resident #2, #3 and #5). Resident #3 was provided incontinent care while standing in the shower with two (2) Certified Nurse Aides (CNAs) per care plan; however, one (1) CNA left to get a towel, leaving the resident with one CNA, and the resident lunged falling to the floor. The resident sustained [REDACTED]. Resident #2 was care planned to receive two (2) person assistance with ambulation to and from all destinations with a gait belt. However, on 09/26/13, Resident #2 was ambulated by one (1) staff with no gait belt which resulted in a fall. Resident #2 sustained a blackened right eye with a laceration above the right brow area. Staff failed to ensure Resident #5's room was kept uncluttered, per care plan, by having an unused "Broda" chair stored in front of the sink. Resident #5 attempted to move the "Broda" chair and he/she slid out of the wheel chair to the floor which resulted in redness to his/her shins and minor pain. The findings include: Review of the facility's Nursing Service Standard of Operation No 3 titled: Assignment/Provision of Resident Care According to the Resident's Comprehensive Plan of Care, last revised 03/2013, revealed the assigned Unit Nurse would be responsible for the supervision of the provision of resident care according to the Comprehensive Plan of Care. Staff will carry out specific resident care assignments through the utilization of the resident's care plan and unit staff assignment sheet (CNA flow sheet) which designates care plan interventions to be provided. 1. Record review revealed the facility admitted Resident #3 on 06/07/11 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 07/30/13, revealed the facility assessed Resident #3 as needing extensive assistance of two (2) persons for transfers and ambulation. Review of the Comprehensive Care Plan titled "Self-care Deficit", dated 08/06/13, revealed the resident was able to transfer and ambulate with one (1) staff assistance and a gait belt. Further review of the Comprehensive Care Plan revealed two (2) staff should assist the resident if he/she became resistive to care or exhibited combative behaviors. Review of the CNA flow sheet, dated 10/04/13, revealed the resident required ambulation with two (2) person assist using a gait belt as well as to ambulate two-hundred (200) feet with a rolling walker and one person assistance using a gait belt twice a day on the 3-11 shift plus once on the 11-7 shift. Review of the facility's "FINAL INVESTIGATIVE REPORT", dated 10/11/13, revealed the resident had a witnessed fall on 10/04/13 with no apparent injury noted at that time. On 10/06/13, the resident exhibited swelling to his/her right hip and bruising and swelling to the penis. Prior to 10/06/13, there had been no documented reports of pain or abnormalities. The resident was sent to the hospital on [DATE] and was diagnosed with [REDACTED]. Interview with CNA #3, on 10/10/13 at 2:45 PM, revealed he and another CNA were giving Resident #3 a shower. The resident was sitting on a shower chair and when CNA #5 stood him/her up to dry him/her off the resident began to have a bowel movement and CNA #5 asked the other CNA to get her a towel. When CNA #3 turned to get a towel the resident lunged toward the door resulting in CNA #5 losing control over the resident causing both the resident and the CNA to fall. CNA #5 stated she attempted to break the resident's fall with her body and the resident pinned her between the shower wall by falling on her legs and ankle. Interview with MDS Coordinator #1, on 10/11/13 at 1:47 PM, revealed if a resident required extensive two (2) person assist with a gait belt, then that was what should be on the care plan and the CNA flow sheet. Further interview revealed the care plans were supposed to be updated with changes. She stated the nurses that worked the units were supposed to let her know if there was a change in the resident's status. Interview with MDS Coordinator #2, on 10/11/13 at 11:35 PM, revealed if she completed an MDS assessment and the resident was assessed to require extensive assistance with two (2) persons then the care plan should reflect the correct status. She stated if the CNA flow sheet needed to be updated to reflect the resident's status she would do that as needed. She indicated the Comprehensive Care Plan, CNA flow sheet, and MDS assessment should match the resident's status. Interviews with Registered Nurse (RN) #1 and RN #2, on 10/10/13 at 3:25 PM and 3:49 PM and on 10/11/13 at 1:25 PM and 1:33 PM respectively, revealed Resident #3 had fallen and was lowered to the floor. Both RNs stated the resident did not exhibit any signs of pain and when the resident was in pain he/she revealed it by facial grimacing and wincing. RN #2 stated after the resident assisted to get up and dressed, he/she was ambulated out of the shower room to the wheelchair with no concerns noted. The RNs stated it was the responsibility of the nurse on each shift to check the CNA flow record to assure accuracy and sign that it had been reviewed and updated if needed. RN #2 revealed he checked the flow sheet at the beginning and end of the shift for accuracy and if there were any changes he would update them on paper and in the computer. RN #2 stated the Comprehensive Care Plan, the CNA Flow sheet and MDS assessment should match the resident's status. 2. Record review revealed the facility admitted Resident #2 on 02/06/79 with [DIAGNOSES REDACTED]. Observation, on 10/09/13 at 11:00 AM, revealed Resident #2 was sitting in a wheel chair in the television lounge with a sheep skin gait belt around his/her waist. The resident had a blackened right eye with a laceration above the right eye. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/19/13, revealed the facility assessed the resident's cognition as severely impaired. Further review revealed the facility assessed the resident as being ambulatory with limited, two (2) person assist. Review of the Comprehensive Care Plan titled "Injury, risk for", last revised 08/26/13, and the Certified Nurse Aide (CNA) flow sheet, dated 09/27/13, revealed Resident #2 should be ambulated to and from all destinations with a gait belt and two (2) staff assist. Review of the Nursing Note, dated 09/27/13 at 7:15 PM, revealed Resident #2 was being ambulated by CNA #4 from the dining room and the resident's knees buckled causing the CNA to lose control over the resident, which resulted in a fall. While Resident #2 was struggling to get up after being lowered to the floor, the resident bumped his/her brow ridge above the right eye causing a one quarter (1/4) inch cut to the area. Review of the Facility Resident Transfer form, dated 09/30/13, revealed the resident was sent to the hospital for an x-ray to the right eye to rule out a fracture related to the fall on 09/27/13. Review of the Emergency Department Discharge instructions, dated 09/30/13, revealed a [DIAGNOSES REDACTED]. Interview with CNA #4, on 10/10/13 at 2:30 PM, revealed she was ambulating Resident #2 down the hallway without a gait belt. CNA #4 stated the resident's knees buckled and he/she began to fall and she lowered the resident to the floor. She stated when she was satisfied the resident was completely on the floor she took a step back and the resident lifted his/her head up off the floor and then slammed it back on the floor causing a bump to the head. The CNA revealed she knew the care plan had been written to be specific in addressing that the resident was to have a gait belt and two (2) person assist for ambulation. Interview with the Staffing Director, on 10/11/13 at 11:00 AM, revealed the staff should follow the care plan and the CNA Flow Sheet when providing care to the residents. The Staffing Director stated CNA #4 should have used a gait belt and ambulated the resident with the assistance of another staff member. Interview with the Director of Nursing (DON), on 10/11/13 at 5:00 PM, revealed the CNA should have followed the resident's care plan utilizing a gait belt and having another staff member assist her. 3. Record review revealed the facility admitted Resident #5 on 06/22/12 with [DIAGNOSES REDACTED]. Review of a Nursing Note, dated 09/20/13 written at 6:30 PM, revealed Resident #5 experienced a fall on 09/20/13 while attempting to get to the sink in his/her room to brush his/her teeth. The sink was blocked by a Broda chair causing the resident to attempt to move the chair to get to the sink. As a result, he/she slid out of the wheel chair to the floor and complained of pain to his/her shin areas, with redness noted to his/her shins. Observation, on 10/11/13 at 4:40 PM, revealed Resident #5 was sitting up in a wheel chair in his/her room with no concerns noted. Interview with Resident #5, on 10/11/13 at 4:40 PM, revealed he/she was trying to get to the sink to brush his/her teeth and fell on his/her knees because a chair was blocking the sink. He/She stated "it hurt a little bit" and (he/she) has some pain with the incident. Review of the Quarterly MDS assessment, dated 08/27/13, revealed the facility assessed Resident #5 as requiring total assistance of two (2) persons for transfer and was non-ambulatory related to bilateral [MEDICAL CONDITION]. Review of the Comprehensive Care Plan titled, "Impaired Cognition and Impaired Mobility", dated 06/11/13, revealed the resident's room should be kept clutter free. Review of the CNA Flow Sheet, dated 10/11/13, revealed staff should make sure the resident's room was free of clutter and the resident was able to get to the sink to brush his/her teeth. Interview with Licensed Practical Nurse (LPN) #3, on 10/11/13 at 4:50 PM, revealed the Broda chair belonged to another resident who had moved out of the room approximately two (2) weeks ago or longer. She stated the chair was moved out into the hall after the incident on 09/20/13 at least on her shift and she did not know if it was left out in the hall on the other shifts. Interview with the Director of Nursing (DON), on 10/11/13 at 5:00 PM, revealed the CNAs had been trained on keeping the residents' rooms uncluttered to assist in preventing accidents and to follow the care plans. She agreed the Broda chair should not have been blocking the sink.

Based on interview, review of the facility's Standard of Operating Procedures, and the Final Investigative Report, it was determined the facility failed to ensure written policies and procedures were implemented that prohibit abuse of residents for one resident (#10), in the selected sample of twenty-three residents. Certified Medication Technician (CMT) #1 witnessed Certified Nurse Aide (CNA) #1 hit Resident #10 across the face with a shoe, but failed to report the allegation immediately to his supervisor. Resident #10 was crying after the incident and CNA #1 remained in the dining room for approximately 10-15 minutes. (Refer to F223) A final investigative report, completed 12/27/11, did not address the delay in reporting by CMT #1. The findings include: A review of the facility's Standard Operating Procedure "Incident Management/Abuse Protocol", revised 07/01/07, revealed the facility would immediately report and respond to any involvement, observation of, report of, or potential for an incident or event that indicated a resident injury, harm, abuse, neglect, or exploitation. The protocol revealed it was the responsibility of any staff person to make an immediate verbal report about an incident to the immediate supervisor and/or facility administrator or designee as soon as it was discovered. Any staff failing to report an incident immediately upon suspicion of abuse or neglect were considered in violation of the facility's policy and subject to appropriate disciplinary action, up to and including dismissal. A review of the Final Investigative Report, completed 12/27/11, revealed CNA #1 was removed from direct care on 12/20/11 at 3:00 PM and terminated 12/22/11; however, there was no information regarding the delayed reporting by CMT #1. An interview with CMT #1, on 01/05/12 at 2:20 PM and on 01/06/12 at 2:00 PM, revealed he witnessed an incident of verbal and physical abuse on 12/20/11 between CNA #1 and Resident #10. CMT #1 revealed he did not report the incident as soon as it happened as he was "nervous." He revealed it was emotional and he could not believe the incident happened. He had been employed at the facility for six years, but never had to report an allegation of abuse. He revealed he reported the incident to RN #2, "10-15 minutes" after the incident was witnessed. CMT #1 revealed he should have reported the incident as soon as it occurred. With the delay in reporting, he revealed it was possible for CNA #1 to have further contact with Resident #10 and other residents in the facility. An interview with CNA #7, on 01/05/12 at 3:30 PM and on 01/06/12 at 1:45 PM, revealed she worked second shift on 12/20/11. At the beginning of the shift, she noticed Resident #10 was sitting in the dining room with CNA #1. The resident was visibly upset. She revealed CMT #1 was in the doorway of the television room, but did not say anything at that time. She called RN #2 to the dining room for assistance with the resident. Upon questioning by RN #2, CMT #1 gave a report of the witnessed incident. An interview with RN #2, on 01/05/12 at 3:55 PM, revealed he was the day shift nurse working on 12/20/11. He revealed CNA #7 called him to the dining room that day because Resident #10 was "really upset." He revealed CMT #1 was in the doorway of the television room and appeared to be "flushed" and "shaky." At that time, CMT #1 reported the alleged abuse to Resident #10 by CNA #1. An interview with the facility's Certified Investigator, on 01/06/12 at 2:25 PM, revealed she investigated the allegation of abuse on 12/20/11. She revealed she was aware CMT #1 did not report the incident as soon as it was witnessed. She stated CMT #1 was not exactly sure how long he waited to report, but CMT #1's best guess at the time of the investigation was five (5) minutes. She revealed CMT #1 was passing medications at the time of the incident and could not leave the medication cart. Per interview, CNA #1 was not "repeatedly hitting" the resident; she had stopped and walked away. She revealed the facility considered CMT #1's timeline of events adequate, so the investigative report did not conclude there was a delay in CMT #1 reporting the incident. An interview with the Director of Nursing, on 01/06/12 at 2:45 PM, revealed CMT #1 was passing medications and witnessed the incident between CNA #1 and Resident #10. She revealed CMT #1 did "to the best of his ability" report the incident immediately. She revealed she expected staff to keep the residents safe, from every aspect. A review of an employee schedule for CMT #1, dated December 2011, revealed he worked in the facility on 12/21/11, 12/22/11, 12/25/11, and 12/26/11. A review of an inservice related to abuse revealed CMT #1 was not inserviced until 12/27/11. Review of the personnel file for CMT #1 revealed no disciplinary action related to the delay in reporting abuse.

Based on interview, record review, review of the facility's Standard of Operating Procedures, and the Investigative Report, it was determined the facility failed to ensure residents were free from verbal, physical, and mental abuse for one resident (#10), in the selected sample of twenty-three residents. Certified Medication Technician (CMT) #1 witnessed Certified Nurse Aide (CNA) #1 hit Resident #10 across the face with a shoe, but failed to report the incident immediately to his supervisor. (Refer to F226) Resident #10 was crying after the incident and stated to CNA #1 "Don't hit me." CNA #1 remained in the dining room with Resident #10 for 10-15 minutes before the incident was reported, causing psychosocial harm to the resident. The findings include: A review of the facility's Standard Operating Procedure "Incident Management/Abuse Protocol", revised 07/01/07, revealed adult abuse was defined as the willful infliction of injury, intimidation, or punishment that resulted in physical pain or injury, including mental injury or anguish. A review of the Final Investigative Report, completed 12/27/11, revealed CNA #7 reported to RN #1, on 12/20/11 at approximately 2:55 PM, that Resident #10 was crying. When the resident was questioned by RN #2, the resident reported someone had hit him/her. CMT #1 approached RN #2 at that time, and reported he witnessed CNA #1 hit Resident #10. An interview with CMT #1, on 01/05/12 at 2:15 PM, revealed the incident had occurred between 2:00 PM and 2:30 PM. CNA #1 was removed from direct care on 12/20/11 at 3:00 PM and terminated 12/22/11. An interview with CMT #1, on 01/05/12 at 2:20 PM, and on 01/06/12 at 2:00 PM, revealed he witnessed an incident on 12/20/11 between CNA #1 and Resident #10. Resident #10 was sitting in a chair between the dining room and television room, kicking his/her shoes across the hall. CNA #1 assisted Resident #10 to sit at a table in the dining room. He revealed CNA #1 took the resident's house shoe and "swiped" it across the resident's face, back and forth two times. He revealed the first "swipe" was loud enough to hear a "smack" from the plastic on the bottom of the shoe. He stated the resident was crying after the incident and stated to CNA #1 "Don't hit me." He revealed CNA #1 stated to the resident "There is no excuse for it, is there?" CMT #1 revealed he did not report the incident as soon as it happened. CNA #1 walked away from the resident, but was stayed in the dining room. CMT #1 revealed, approximately "10-15 minutes" later, an employee from the next shift, CNA #7, noticed the resident was crying and she informed Registered Nurse (RN) #2 that something was going on with the resident. At that time, CMT #1 stated that he then reported the incident to RN #2. CMT #1 revealed he should have reported the incident as soon as it occurred, and should have asked CNA #1 to leave the situation. With the delay in reporting, he revealed it was possible for CNA #1 to have further contact with Resident #10 and other residents in the facility. An interview with CNA #7, on 01/05/12 at 3:30 PM, and on 01/06/12 at 1:45 PM, revealed she worked second shift on 12/20/11. At approximately 2:38 PM, she stated that she clocked in for her shift and put her purse behind the nurse's desk. She walked down the hallway and observed her resident rooms, as usual. She revealed Resident #10 was sitting in the dining room with CNA #1 sitting in front of the resident. She revealed the resident's eyes were red and he/she was visibly upset. She revealed the resident began to cry when spoken to, and was unable to express what was wrong. She stated "I had never seen him/her like this before." She revealed she asked the dayshift staff if anyone knew what was wrong with Resident #10, but no information was provided. She revealed CMT #1 was in the doorway of the television room, but did not say anything at that time. She called RN #2 to the dining room for assistance with the resident, and RN #2 asked staff to stay in the building until it was determined what happened with the resident. Upon questioning by RN #2, CMT #1 gave a report of the witnessed incident. An interview with RN #2, on 01/05/12 at 3:55 PM, revealed he was the day shift nurse working on 12/20/11. He revealed CNA #7 called him to the dining room that day because Resident #10 was "really upset." He revealed the resident told him he/she was hit by someone, but did not want to say who hit him/her. He stated that CNA #1 was in the back of the dining room, on the opposite side of Resident #10. He notified his supervisor by phone. He revealed CMT #1 was in the doorway of the television room and appeared to be "flushed" and "shaky." RN #2 stated that CMT #1, at that time, reported the alleged abuse to Resident #10 by CNA #1. RN #2 revealed he called CNA #1 to the nurse's desk and she was taken off the floor. An interview with CNA #8, on 01/05/12 at 4:10 PM, revealed he was sitting in the dining room on 12/20/11 between 2:00 PM-2:30 PM. He revealed his back was to Resident #10 and CNA #1, and he heard a "pop," but did not turn around to see what caused the sound. He revealed the resident was upset about something, but he did not witness anything. An interview with CNA #1, on 01/05/12 at 11:45 PM, revealed on 12/20/11 Resident #10 was kicking his/her shoes off and she walked the resident to the dining room to calm down. She revealed the resident's shoes were taken away. She told the resident he/she could have them back after the resident calmed down. She denied hitting the resident with the shoe. An interview with the Administrator and Assistant Administrator, on 01/06/12 at 2:45 PM, revealed a time frame, from the time the incident occurred to the time it was reported, could not be verified as the incident occurred at shift change. A review of Resident #10's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired. An attempt to interview Resident #10, on 01/05/12 at 9:00 AM, revealed the resident was hard to understand at times, during the interview. He/She stated repeatedly "Everybody loves me" and "I love it here."