Every finding on record at Woodcrest Nursing and Rehabilitation Center

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure proper control, accountability, reconciliation, and safeguarding of controlled substances in accordance with professional standards of practice and facility policy when staff did not accurately complete and reconcile the Controlled Narcotic Record sheets or sign the Controlled Medication Shift Change Log, for 4 of 6 sampled medication carts.The findings include:Review of the facility's policy titled, Medication Administration Standard of Practice, reviewed 03/2026, revealed the facility required medications to be administered safely and as prescribed. The policy further requires medications to be administered in accordance with physician orders. The policy stated documentation must be completed for each medication administered.The State Survey Agency (SSA) Surveyor requested all medication administration policies, including a controlled substance administration policy, on 06/18/2026 at 11:15 AM; however, the facility did not provide the SSA Surveyor with a controlled substance administration policy.1a. Observation and review of the medication administration documentation and controlled substance logs for the first floor East Medication Cart 1, on 06/18/2026 at 9:45 AM, revealed R82's Gabapentin 300 mg was documented in the Medication Administration Record (MAR) as administered at 8:24 AM; however, the controlled substance had not been signed out on the Controlled Narcotic Record sheet, as given. Review of R82's admission Face Sheet, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 01/27/2025 with diagnoses to include type 2 diabetes with neuropathy, intracranial hemorrhage, and back pain.Review of R82's quarterly MDS, with an ARD of 05/06/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating he was cognitively intact.Review of R82's Physician's Orders Form, dated 06/18/2026, found in the resident's EMR under the Orders tab, revealed an order for Gabapentin 300 mg, one capsule by mouth three times daily.1b. Observation and review of the medication administration documentation and controlled substance logs for the first floor East Medication Cart 1, on 06/18/2026 at 9:50 AM, revealed R9's Lyrica 200 mg was documented in the MAR as administered at 7:46 AM; however, the controlled substance had not been signed out on the Controlled Narcotic Record sheet, as given. Review of R9's admission Face Sheet, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 05/13/2026 with diagnoses to include chronic hepatic encephalopathy, pain syndrome, and spondylosis (spinal osteoarthritis).Review of R9's admission MDS, with an ARD of 05/19/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, indicating moderate cognitive impairment.Review of R9's Physician's Orders Form, dated 06/18/2026, found in the resident's EMR under the Orders tab, revealed an order for Lyrica 200 mg, one capsule by mouth twice daily.During an interview on 06/18/2026 at 9:45 AM with Licensed Practical Nurse (LPN) 6, she stated she typically documented the removal of a controlled substance on the corresponding Controlled Narcotic Record sheet immediately after removing the medication from the blister packet. LPN6 stated she failed to document the administration of the controlled substance for R9 and R82 after she administered the medications to the residents. LPN6 stated accurate documentation of controlled substance administration was important to maintain accountability and prevent medication diversion.2. Observation of the first floor South Hall Medication Cart 1, on 06/18/2026 at 10:01 AM, revealed R5's Controlled Narcotic Record sheet for lacosamide (a seizure medication) 100 mg tablet was signed out as administered on 06/18/2026 at 9:31 AM. However, the record review revealed Registered Nurse (RN) 1 did not administer the medication to R5.Review of Resident (R) 5's admission Face Sheet, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 10/30/2025 with diagnoses to include chronic pain, metabolic encephalopathy (brain dysfunction), and seizures.Review of R5's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/09/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating he was cognitively intact.Review of R5's Physician's Orders Form, dated 06/18/2026, found in the resident's EMR under the Orders tab, revealed an order for lacosamide 100 milligrams (mg), one tablet by mouth twice daily.During an immediate interview with RN1 on 06/18/2026 at 9:31 AM, she stated she signed R5's lacosamide 100 mg tablet out on the corresponding Controlled Narcotic Record sheet at 9:31 AM. She stated R5 was asleep at the scheduled medication administration time and therefore she did not administer the medication. RN1 further stated she did not remove the controlled substance from the blister pack despite documenting it on the corresponding Controlled Narcotic Record sheet. She stated that because the medication remained in the blister pack after it had been signed out, the quantity of lacosamide 100 mg tablets on hand did not reconcile with the documented account on the narcotic record sheet. RN1 stated proper documentation of controlled substances helped maintain an accurate inventory and reduced the risk of diversion.3. Observation of the first floor [NAME] Hall Medication Cart 1, on 06/18/2026 at 10:15 AM, revealed on the Controlled Medication Shift Change Log, there was no oncoming nurse's signature documenting the narcotic count for 06/18/2026.During an interview with LPN7 on 06/18/2026 at 10:15 AM, he stated the facility's policy requires both the off going and oncoming nurses to count controlled medications at shift change. LPN7 was unsure why he did not sign the Controlled Medication Shift Change Log, on 06/18/2026, after he verified the count. Furthermore, he stated he should have completed and documented the narcotic drug count immediately upon accepting the keys to the medication cart to ensure accountability for narcotic medications.4a. Observation of the second floor South Medication Cart 2, on 06/18/2026 at 10:30 AM, revealed on the Controlled Medication Shift Change Log, there was no off going nurse's signature documenting the narcotic count for 06/18/2026.4b. Observation of the second floor South Medication Cart 2 on 06/18/2026 at 10:35 AM, revealed R67's pregabalin (a nerve pain medication) 100 mg was documented in the MAR as administered at 8:21 AM; however, the controlled substance had not been signed out on the Controlled Narcotic Record sheet, as given. Review of R67's admission Face Sheet, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 03/04/2024 with diagnoses to include type 2 diabetes with neuropathy (damage to nerves), chronic pain, and chronic kidney disease.Review of R67's quarterly MDS, with an ARD of 04/15/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 13 out of 15, indicating she was cognitively intact.Review of R67's Physician's Orders Form, dated 06/18/2026, found in the resident's EMR under the Orders tab, revealed an order for pregabalin 100 mg, one capsule by mouth three times daily.During an interview with LPN8 on 06/18/2026 at 10:30 AM, she stated both the off going and oncoming nurse are supposed to count the controlled medication cards and document the count was correct by signing their name on the Controlled Medication Shift Change Log at each shift change. She stated she verified the count and signed the log but could not say why the off going nurse did not.Furthermore, LPN8 stated her process was to document the removal of a controlled substance on the corresponding Controlled Narcotic Record sheet immediately after removing the medication from the blister packet. LPN8 stated she failed to document the administration of the controlled substance for R67 after she administered the medication to the resident. She stated proper documentation of controlled substances was important to maintain an accurate inventory and reduce the risk of diversion.During an interview with the Director of Nursing (DON) on 06/18/2026 at 4:36 PM, she stated documentation should be completed when the nurse administers medication to the resident to ensure the controlled substance record remains accurate. The DON stated nurses were expected to do a narcotic count at each change of shift, document the number of cards in the lock box, and sign the Controlled Medication Shift Change Log. She stated she expected nursing staff to follow the facility's Medication Administration policy consistently. Furthermore, the DON stated maintaining complete and accurate documentation ensured each controlled substance was accounted for and reduced the risk of medication diversion.During an interview with the Administrator on 06/18/2026 at 5:05 PM, she stated she expected clinical nursing staff to comply with all policies and procedures related to controlled substance accountability and documentation. Additionally, she stated controlled substance records should accurately reflect medication administration to maintain an accurate inventory. Furthermore, she stated thorough and accurate documentation was essential to account for each controlled substance and minimize the potential for controlled medication diversion.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to follow infection prevention and control policies to help prevent the development and transmission of communicable diseases and infection for 3 of 4 residents with reusable medical equipment, Resident (R) 32, R59, and R78.Additionally, the facility failed to follow infection control policies for 3 of 8 residents observed for medication administration, R97, R99, and R121. Review of the facility's policy entitled, Infection Control, dated October 2018, revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the facility's policy entitled, Cleaning and Disinfection of Resident Care Items and Equipment, revised 4/2025, revealed non-critical items are those that come in contact with intact skin but no mucous membranes. This includes non-critical resident-care items like blood pressure cuffs and most non-critical reusable items can be decontaminated where they are used. Review of the facility's Nurse Skills Checks Standards revealed a satisfactory mark is given if a staff member does not touch medication. 1. During an observation on 06/16/2026 at 10:53 AM, State Trained Nurse Aide (STNA) 1 entered room [ROOM NUMBER] and immediately removed a shower chair. STNA1 did not clean or disinfect the shared equipment before taking the chair into R32's room. STNA1 did not have disinfectant wipes available. Further observation revealed STNA1 transferred R32 into the contaminated shower chair. During an interview with STNA1 on 06/16/2026 at 4:00 PM, STNA1 stated she cleaned the chair before she removed it from room [ROOM NUMBER]. When asked by the State Survey Agency (SSA) Surveyor where the disinfectant wipes were kept, she stated they were kept in the locked medication carts. She stated it was important to clean and disinfect shared equipment between residents to prevent the spread of germs. 2. During an observation on 06/16/2026 at 3:10 PM, Kentucky Medication Aide (KMA) 1 exited room [ROOM NUMBER] after she used a mechanical lift to transfer R59, who was on Enhanced Barrier Precautions (EBP). She placed the mechanical lift in the hallway without cleaning or disinfecting it after use. During an interview with KMA1 on 06/16/2026 at 3:17 PM, she stated she was helping another STNA who stated she would clean the lift. KMA1 stated following the facility's infection control policies and procedures was important to prevent cross-contamination. 3. During an observation on 06/16/2026 at 3:12 PM, STNA2 stripped R59's bed and bagged dirty clothing and bed linens. STNA2 did not wear a gown or gloves when she handled the linen and clothing. R59 was on EBP due to a gastrostomy tube. During an interview with STNA2 on 06/16/2026 at 3:18 PM, she stated she did not provide direct care to R59, but only bagged soiled linen and clothing. She stated she had worn gloves but had taken them off and placed them in the bag containing the linen and clothing. STNA2 stated if she needed to wear a gown while in a resident's room, they would be available at the door. When asked by the SSA Surveyor when staff were expected to wear gloves and a gown in a resident's room under EBP, STNA2 stated staff should put on personal protective equipment (PPE) during direct resident care; however, STNA2 stated she did not believe changing linens was considered direct resident care. 4. During an observation of LPN6 taking R76's blood pressure on 06/17/2026 at 9:17 AM, she removed the blood pressure cuff from the top of the medication cart and went into R76's room. She took his blood pressure on his left wrist and then went back to the cart and laid the blood pressure cuff on the top of the cart. She did not sanitize or clean the blood pressure cuff. Continued observation revealed the blood pressure cuff was on top of the medication cart from 9:17 AM to 9:40 AM. Observation on 06/17/2026 at 9:40 AM revealed LPN6 took the blood pressure cuff from the top of the medication cart and took R78's blood pressure and checked the resident's oxygen saturation with a finger devise. She placed the blood pressure cuff and the oxygen devise on top of the medication cart. She did not sanitize the blood pressure cuff or the oxygen saturation devise. During an immediate interview with LPN6 after the observation, when asked what the facility policy said about sanitizing reuseable medical equipment she stated, I don't know. 5. During an observation on 06/17/2026 at 9:00 AM of Licensed Practical Nurse (LPN) 2 during a medication administration for R99, LPN2 removed five separate medications from a multi-dose blister card located in the medication cart. LPN2 held each blister card, pushed the medication into the palm of her ungloved hand, then placed it into the medication cup. During an immediate interview with LPN2 on 06/17/2026 at 9:00 AM, she stated she intended to waste the medication because the cup had tipped over. LPN2 then tipped the medication cup over in the presence of the SSA Surveyor, causing the five pills to spill onto the top of the medication cart. She picked up the pills and discarded them into a sharps container located on the cart. LPN2 stated she wasted the medication because the medication cup had been knocked over. 5. During an observation on 06/17/2026 at 9:10 AM of KMA1 during medication administration for R121, KMA1 removed 21 separate medications from blister packs in the medication cart. KMA1 held each blister pack, pushed each medication into her hand, and placed it into the medication cup. KMA1 did not wear gloves while handling the medications. During an immediate interview with KMA1 on 06/17/2026 at 9:10 AM, she stated, I've never seen any nurse here wear gloves while passing pills. When asked by the SSA Surveyor whether she believed there was a concern with breaching infection control protocols, KMA1 stated she used hand sanitizer before each medication pass. When the SSA Surveyor further asked whether touching the card packs, paperwork, the medication cart, and equipment after performing hand hygiene and before handling the medications with her ungloved hands could have re-contaminated her hands, KMA1 stated, Yes. KMA1 stated following infection control practices was important to prevent the spread of infection and to keep residents and staff safe. 6. Observation on 06/17/2026 at 7:55 AM revealed LPN2 gave medications to R97. She sanitized her hands then opened the medication drawer and scrolled through medication cards to find R97's medication. She then punched out the medication into her hand and put the medication in a medication cup. She then went into R97's room and gave the medication to the resident. During an immediate interview with LPN2 after the observation, she stated she did not think it would hurt to touch medications with her bare hands. She further stated it would potentially contaminate food but not medications. During an interview with the Infection Preventionist (IP) on 06/17/2026 at 11:10 AM, she stated staff were expected to pop medications directly from the blister card into the medication cup and not handle medications with their bare hands. She stated if a medication missed the cup or came into contact with another surface, it should be discarded. The IP stated she did not perform routine audits or maintain documentation to monitor staff compliance with medication administration practices. The IP further stated the facility policy required staff to clean and disinfect shared resident care equipment, including mechanical lifts, shower chairs, and other reusable equipment, after each resident's use, using bleach wipes. She stated she did not routinely monitor staff compliance with cleaning and disinfecting shared equipment outside of annual competency validation. The IP further stated staff were expected to review the precaution signage posted outside resident rooms before providing care. She stated PPE stations containing gowns were located throughout the hallways, gloves were readily available, and residents on Transmission-Based Precautions (TBP) had PPE carts or bins located outside their rooms. She stated staff were expected to wear the appropriate PPE and perform hand hygiene before and after resident care. Furthermore, the IP stated staff were instructed to review the precaution signage outside the resident's rooms before providing care and to wear the required PPE depending on the care provided. She further stated PPE stations were located throughout the hallways, and gloves were available inside the rooms. Outside rooms for residents on contact or droplet precautions, she stated staff were instructed if they were unsure of the required precautions, they should gown and glove. When asked by the SSA Surveyor whether staff would be expected to wear a gown and gloves while handling or changing bed linens after the resident had been transferred out of bed, the IP stated, Enhanced barrier precautions really is more about patient contact. The linen shouldn't be. The IP stated infection prevention procedures were important to prevent the spread of infectious disease among residents and staff. During additional interview on 06/17/2026 at 1:07 PM, the IP approached the SSA Surveyor and stated she had misspoken in her earlier interview about changing linen. She stated staff were required to wear PPE when changing a resident's linen under EBP. The IP further stated, That's why we hang it [signage] outside the room as a reminder. During an interview on 06/17/2026 at 11:10 AM with the Assistant Director of Nursing (ADON), she stated staff were expected to pop medications directly from the blister card into the medication cup without touching the medications with their bare hands. She stated contaminated medications should be discarded and replaced. The ADON stated the facility policy required staff to clean and disinfect shared equipment, including mechanical lifts and shower chairs, after each resident's use, using bleach wipes. Additionally, the ADON stated staff were expected to follow the precaution signage and were to wear the appropriate PPE. She further stated staff were expected to wear a gown and gloves when changing the linens of a resident on EBP. Furthermore, the ADON stated more frequent audits would identify staff noncompliance sooner and allow the facility to implement corrective interventions. During an interview on 06/18/2026 at 4:36 PM with the Director of Nursing (DON), she stated she expected staff to dispense medications directly from the blister card into the medication cup without handling the medication with their bare hands. She stated staff were expected to disinfect shared equipment, including mechanical lifts and shower chairs, after each resident's use, in accordance with the facility's policy. The DON stated staff should wear appropriate PPE, including a gown and gloves, when providing care or changing linens for residents on EBP. Furthermore, she stated it was important to follow the facility's medication administration and infection control policies to reduce the risk of cross-contamination and the transmission of infectious organisms, and to protect the health and safety of residents and staff. During an interview on 06/18/2026 at 5:05 PM with the Administrator, she stated she ensured staff adhered to the facility's infection control policies by providing ongoing education. She stated she expected nursing staff to perform hand hygiene before and after medication administration and follow the facility's medication administration policies. She stated it was not appropriate to touch medication with bare hands. The Administrator further stated management conducted audits of medication administration practices to ensure compliance. Furthermore, the Administrator stated she expected staff to clean and disinfect shared equipment after each use in accordance with facility policy. The Administrator stated following infection control policies and procedures was important for the safety and well-being of residents and staff.

Based on interview and record review, the facility failed to ensure each resident had been screened for a mental disorder or intellectual disorder prior to admission for 1 of 6 sampled residents reviewed, Resident (R) (12).The findings include:Review of the facility's policy entitled, Preadmission Screening and Resident Review (PASARR), reviewed on 03/2026, revealed the purpose is to determine if an individual seeking admission has a serious mental illness (SMI), intellectual disability (ID), or related condition (RC), and determine eligibility for nursing facility placement.Review of the facility's policy entitled, Resident Rights Standard of Practice, reviewed on 3/2026, revealed the purpose is to ensure each resident is treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his/her quality of life.Review of R12's Face Sheet revealed the facility admitted the resident on 05/13/2025 with diagnoses to include alcohol abuse, uncomplicated, anemia unspecified, and benign prostatic hyperplasia without lower urinary tract symptoms cough. Review of R12's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/13/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 of 15, indicating he was moderately cognitively impaired.Review of R12's Personal Self Center Comprehensive Care Plan, dated 05/13/2025, revealed R12 triggered for post-traumatic stress disorder (PTSD), unspecified. This was related to a risk for alteration in psychosocial well-being related to PTSD and a history of alcohol abuse.During an interview with the Director of Nursing (DON) on 06/18/2026 at 12:01 PM, she stated it was a requirement in the regulations for residents to be screened for SMI, ID, and RC prior to the resident being placed in a nursing facility. She stated if the resident was not screened, the resident could possibility not be getting the best care they needed.During an interview with the Regional Quality Manager on 06/18/2026 at 4:50 PM, she stated she agreed residents should be screened for SMI, ID, and RC prior to placement in a nursing facility.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections affecting all facility residents, with a current census of 110 residents. 1. Observation of the Laundry Room on 05/20/2025 revealed the facility laundry area was not maintained in a clean and sanitary manner. 2. Observation of Housekeeper (HSK) 1 on 05/20/2025 revealed she walked into the dirty utility room carrying a bag of contaminated linen slung over her shoulder and up against her person. 3. Observation of HSK2 on 05/20/2025 revealed she transported clean linen against her person and through the clean area and into the dirty utility room. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], undated, revealed the facility maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Per the policy, all staff was responsible for adhering to IPCP policies, including the use of PPE and hand hygiene according to established procedures. Review of the facility's Housekeeping/Laundry Management and Procurement Agreement, dated 08/31/2018, revealed the facility entered into an agreement with Healthcare Service Group (HSG), to provide all housekeeping and laundry services at the facility. 1. Observation of the facility's Laundry Room on 05/20/2025 at 8:32 AM revealed the dirty utility room had two trash bins pushed against the sink, one of which was overflowing with both bagged and unbagged trash. There were two large utility bins filled with dirty laundry. The sink was blocked by the dirty laundry bins and a trash barrel, preventing staff from accessing it for hand hygiene. Furthermore, the sink was filled with clean mop heads. Further observation revealed no personal protective equipment (PPE) was available for staff to use when sorting contaminated laundry. Further observation on 05/20/2025 at 8:32 AM revealed a wall-mounted utility sink was located in the dirty utility room. It contained dirty, stagnant water. A gallon container of chemicals was sitting on the right rim of the sink, while various cleaning tools and chemicals were also nearby. Additional observation revealed a yellow mop bucket, heavily stained and containing an unwashed wet mop, was present in the room. Directly under the sink, there was a black milk crate filled with tools. Cleaning brushes and brooms leaned against the wall, and a dirty red floor scrubber pad hung from the faucet of the sink. Per observation, the floor itself was visibly stained and scattered with dirt and debris. Furthermore, there were three pillows and multiple large shipping boxes full of linen stacked on top of each other and pushed up against the dirty trash bin. The room also contained brooms and a dustpan, both full of debris and multiple bags of trash and laundry were on the floor. Continued observation on 05/20/2025 at 8:32 AM of the washroom revealed the floor area between two large industrial washing machines appeared heavily worn and stained from water and detergent residue. There was evidence of rust and grime around the bases of the machines. The rest of the washroom floor was similarly stained and contained dirt and debris. There were two utility bins full of dirty laundry obstructing a handwashing sink and eyewash station. Several brooms were present, along with a dustpan that was filled with debris. In one corner of the room, debris had been swept up and pushed to the side. A clean Hoyer lift sling was hanging next to the brooms, with its straps touching the ground and resting in the dirt and debris. Additionally, a face shield was lying on the floor on top of one of the brooms, and gloves were stored on top of a bucket of washing chemicals. Additionally, observation of the laundry area on 05/20/2025 at 8:32 AM revealed the dryer room area was unkempt. The floor was visibly stained and contained dirt, debris and trash. The counter was overflowing with clothing, and the space underneath it was used for storage of clothing and linens not protected from contact with the floor. 2. Observation of the laundry area on 05/20/2025 at 8:45 AM revealed HSK1 walked into the dirty utility room carrying a bag of contaminated linen slung over her shoulder and up against her person. During an interview with HSK1 on 05/20/2025 at 8:45 AM, she stated she did not have a bin to transport the dirty linen, and it was too heavy to carry. She stated she was unaware that carrying contaminated linen against her person was an infection control issue. She stated she was employed by HSG and had been provided infection control training upon hire. She stated it was important to follow infection control policies to prevent the spread of germs. 3. Observation of HSK2 on 05/20/2025 at 8:50 AM revealed she transported clean linen against her person and through the clean area and into the dirty utility room. During an interview with HSK2 on 05/20/2025 at 8:50 AM, she stated she should not walk clean linen through the dirty areas of the laundry room. She stated doing so could contaminate the clean laundry. She stated she had received infection control training through HSG. During an interview with the Assistant Manager of Environmental Services (EVS AM1) on 05/20/2025 at 8:55 AM, she stated she worked for HSG. She stated she was concerned about the cleanliness of the room, and it was dirty and it shouldn't look this way. The EVS AM1 stated the laundry attendant was responsible for maintaining cleanliness in the area, and she worked for the contracted laundry service. She stated linen should be transported away from the body, and clean mops, Hoyer lift (mechanical lift used to transport residents from one surface to another) slings, and other supplies must not be stored in a dirty laundry area to avoid cross-contamination. Additionally, she stated keeping the laundry area clean was essential to prevent the spread of infection. During an interview with EVS AM2 on 05/20/2025 at 8:55 AM, she stated linen should be transported away from the body to avoid cross-contamination. She stated HSK1 and HSK2 had been educated to transport linen away from their person. She stated clean clothing and linen should be taken out through the clean area and not back through the dirty utility room. During an interview with HSG's Housekeeping Account Manager (AM) on 05/21/2025 at 11:35 AM, he stated HSG had a contract with the facility to provide housekeeping and laundry services. He stated he was responsible for overseeing the housekeeping and laundry departments. He stated the area was in a bad state because there was very little storage space for the washing supplies, resulting in a cluttered area. The AM further stated his team had been working on cleaning up the space. He stated it was important for his staff to adhere to IPCPs to prevent the spread of infection. He stated clean and dirty items should never be mixed, and staff should not carry linens against their bodies. Additionally, he stated housekeeping staff should not transport clean linens through the area designated for dirty linens. He stated his staff had received education regarding the proper handling and transportation of laundry and linens. The AM stated it was his expectation that staff maintained a clean and sanitary laundry area to help prevent the spread of germs. During an interview with the Infection Preventionist (IP) on 05/21/2025 at 11:15 AM, she stated the facility adhered to the Centers for Disease Control and Prevention (CDC) guidelines for infection control. The IP stated staff should not carry linen against their bodies, as this practice could lead to cross-contamination. She stated it was her expectation that all staff members, including contracted vendors, complied with the facility's infection prevention and control policies (IPCP). The IP stated following these policies was important for the prevention of infectious disease and to ensure a safe home for the residents. During an interview with the Director of Nursing (DON) on 05/21/2025 at 11:25 AM, she stated it was her expectation that all staff members, including contracted vendors, adhered to the facility's IPCP. She stated all staff received infection control training upon hire and periodically throughout the year. In addition, the DON stated staff was updated on current CDC guidelines when they changed. The DON stated, if nursing leadership observed any lapses in infection control practices, immediate intervention would take place, including on-the-spot education for staff and a review of their competencies. Furthermore, she stated following facility policy and CDC guidelines was important for preventing disease and ensuring the safety of both staff and residents. During an interview with the Administrator on 05/21/2025 at 11:00 AM, he stated the facility had contracted with HSG to manage the facility's housekeeping and laundry services. When asked who had oversight over the management company, he stated, I oversee them. He stated he frequently audited the laundry, but he had not been in there recently. He stated it was important to maintain a clean and sanitary laundry environment to prevent cross contamination and the spread of infections. He stated it was his expectation that HSG staff followed the facility's infection control policies and kept the laundry areas clean. He further stated that maintaining infection control measures was crucial for the safety of the residents.

Based on observation, interview, record review, and review of the facility's job description, the facility failed to ensure that its medication error rate was less than five percent. Two errors out of 33 opportunities resulted in a 6.06% error rate. The findings include: Record review of the Licensed Practical Nurse (LPN) job description, updated 4/19/2024, listed essential functions of this position, including administration of medications and treatments, following approved nursing techniques. Review of the May 2025 Medication Administration Record (MAR) for Resident (R) 1 revealed Atorvastatin 20 milligrams (mg) and Loratadine 10 mg was ordered for administration between 7:00 PM and 10:59 PM. Observation on 05/20/2025 at 9:10 AM revealed LPN3 prepared two medications ordered for R1 that were scheduled for bedtime administration. Atorvastatin 20 mg was a low dose of a drug intended to lower cholesterol and triglycerides, and Loratadine 10 mg was an antihistamine medication used to treat seasonal allergies. During interview on 05/20/2025 at 9:12 AM with LPN3, she stated she understood that these medications were scheduled at night, and they were pulled in error. She stated she did not feel there would be any adverse effect. However, she stated had it been another type of medication, it could have caused the resident a problem. During interview on 05/21/2025 at 11:47 AM with the contracted Pharmacist, he stated that while he did not expect the incident would cause harm, the efficacy of the Atorvastatin given in the morning would be questionable since lipid production was typically higher in the evening and therefore more likely to have the intended result. In addition, he stated the potential of the resident drinking grapefruit juice would be higher in the morning with breakfast, and that could also decrease the desired outcome. Regarding the loratadine 10 mg, he stated because it had the potential to cause drowsiness, it could adversely affect the resident's activity level during the daytime. He also stated the maximum daily dose of this medication was 10 mg. He stated, if the medication was inadvertently given again, at bedtime, as originally scheduled, it could increase the drying effect of the medication, which in some residents could cause dizziness, dry oral mucosa, or similar anticholinergic responses. During interview on 05/21/2025 at 10:22 AM with the Director of Nursing (DON), she stated it was her expectation that medications would be administered according to the physician's orders. During interview on 05/22/2025 at 9:46 AM with the Administrator, he stated it was his expectation that physician orders would be followed as written and that facility policies would be followed. He added that it was important to follow these orders to decrease potential harm to the resident.

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for two (2) of forty-two (42) total sampled residents (Resident #11 and Resident #55). Observations during the lunch meal service, on 09/10/19, revealed staff used labels to identify residents requiring assistance with meals during meal service and ignored resident requests for assistance with meals. The findings include: Review of the facility's Policy titled, Resident's Rights, undated, revealed the facility believed residents had the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. Further review revealed the facility would ensure residents were treated with respect and dignity and would promote and facilitate resident self-determination through support of resident choice. Continued policy review revealed the facility would support each resident in exercising his/her rights. Review of the facility's Policy titled, Abuse, Neglect and Misappropriation of Property, revised on 06/2019, revealed the facility prohibited the abuse, neglect and/or misappropriation of property of residents/patients by anyone, which included staff, family, and/or visitors. Further review revealed the facility worked proactively to establish an environment of safety and protection for residents/patients. 1. Review of the clinical record revealed the facility readmitted Resident #11, on 07/06/18 with [DIAGNOSES REDACTED]. Review of Resident #11's Annual Minimum Data Set (MDS) Assessment, dated 06/11/19, revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of zero (0) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review of the Annual MDS Assessment revealed the facility assessed the resident to require extensive physical assistance of two (2) staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Continued review of the MDS revealed the facility assessed Resident #11 as requiring extensive physical assistance of one (1) staff with eating. Observations during lunch meal service, on 09/10/19 at 12:27 PM, revealed Certified Nursing Assistant (CNA) #1, standing at the entrance of the second floor dining room, shouting out, Who's got the feeder table? Further observations revealed Resident #11 was seated at the assisted table located just behind CNA #1 with his/her head hanging down towards his/her lap. Continued observations revealed staff members seated at the assisted table directing Resident #11 and other residents in the dining room to sing. However, when Resident #11 and others were unable to properly recite the words to the song staff had directed him/her to sing, CNA #1, CNA #3, and Kentucky Medication Aide (KMA) #1 began laughing and making jokes about the funny words residents had used. Additional dining room observations revealed Resident #11 and other residents not laughing along with staff members. 2. Review of the clinical record revealed the facility readmitted Resident #55 on 03/01/19 with [DIAGNOSES REDACTED]. Review of Quarterly MDS Assessment, dated 07/28/19, revealed the facility assessed Resident #55 as having a BIMS score of four (4) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review of Quarterly MDS Assessment revealed the facility assessed the resident to require extensive physical assistance of two (2) staff for bed mobility, transfers, dressing and toilet use. Continued review of the MDS revealed the facility assessed Resident #55 as requiring extensive physical assistance of one (1) staff with eating and personal hygiene. 2) Observations during lunch meal service, on 09/10/19 at 12:27 PM, revealed Resident #55 having difficulty getting food items from his/her plate, onto the eating utensil and to his/her mouth related to shaking and dropping the food back onto the plate or into his/her lap. Further observations revealed Resident #55 raised his/her hand, as if to request staff assistance with the meal, on three (3) separate occasions with no staff response. Continued observations revealed staff directing residents to sing instead of assisting Resident #55 with his/her request. Interview with CNA #1, on 09/11/19 at 10:35 AM, revealed she should not have referred to the assisted dining table as feeder table but was not aware this was a dignity issue as she had not received education or training related to this topic. Further interview with CNA #1 revealed she never thought about it before now but could see how it could make the residents that required assistance with meals feel humiliated, degraded or embarrassed. Continued interview revealed staff should be talking with residents and not amongst themselves during the resident meal service. CNA #1 revealed staff should engage the resident and have resident focus on dining experience while encouraging and assisting the resident to eat. Additional interview with CNA #1 revealed staff should never laugh or make jokes about the residents as this could cause feelings of humiliation, embarrassment and violate the resident's dignity. Interview with CNA #2, on 09/11/19 at 2:24 PM, revealed it was never appropriate to say feeder table because it was degrading and could be humiliating to the residents. Further interview revealed staff should always respect residents and maintain the resident's right to dignity. Continued interview with CNA #2 revealed staff were to communicate with and engage residents during the dining experience. Additional interview revealed staff were never to request that residents perform for them and should allow residents to initiate if they wished to sing. CNA #2 added if staff are aware residents have dementia or other memory problems, staff should not request residents to do things that the staff are aware they may be unable to do. In addition, staff should never laugh when residents are not able to do things they are asked to do. She stated this could be humiliating, frustrating or make our residents feel bullied. Staff were to assist residents as needed and as requested. Interview with CNA #3, on 09/13/19 at 10:00 AM, revealed it was not acceptable or appropriate to request residents to sing, laugh at residents when they were not able to sing, or to use feeder table to describe the assist to dine table. Further interview with CNA #3 revealed staff were to respect the resident's right to dignity at all times. CNA #3 added laughing when residents were unable to sing songs staff had directed residents to sing could have been perceived as humiliating, degrading or embarrassing to the residents, which was a violation of each resident's right. Continued interview revealed staff were to assist residents as needed and as requested. Interview with KMA #1, on 09/13/19 at 10:15 AM, revealed staff were to engage residents in the dining experience and involve residents in activities such as singing if the residents initiate it and not make it appear as though staff were having residents perform for them, as this was a dignity and respect issue. Further interview with KMA #1 revealed staff were to assist residents as needed and as requested. Interview with the Unit Manager, on 09/13/19 at 10:55 AM, revealed her expectation was for staff to respect and engage residents in a dignified manner. Further interview with Unit Manager revealed she was disappointed to learn her staff had requested confused residents to sing and when resident no longer understanding or remembering the words, staff laughing at them. Continued interview revealed she expected staff to speak with/about resident needs and engage resident in the dining experience. Additional interview revealed residents should not have to raise his/her hand to request assistance, staff should make rounds in the dining room to ensure all resident's needs were being met. The Unit Manager added staff have been educated and were expected to never use feeder table to identify an assisted dining table. Staff were expected to provide excellent customer service at all times while maintaining the resident's dignity and privacy and providing respect at all times. Interview with Director of Nursing (DON), on 09/13/19 at 11:22 AM, revealed the facility had no policy on Assistance with Meals, Activities of Daily Living for Dependent Resident or Dementia Care. The DON revealed the nursing assistants were trained on all these subjects during their training classes and were provided quiz exams to determine each staff member's levels of understanding following the training. In addition, the DON added the nursing assistants were given quizzes annually on Dementia care to ensure understanding. Further interview with DON revealed the expectation was for staff to maintain resident dignity and privacy at all times. Staff were expected to engage residents in the dining experience. Staff were expected to anticipate and meet resident needs. A resident should never have to raise his/her hand when having difficulty with a meal in the dining room. Per interview, this was a dignity issue and could be demeaning, embarrassing and a safety concern for the resident. Continued interview revealed staff were never to identify the assisted dining table as a feeder table as this too was demeaning and degrading for residents and a violation of Resident Rights. The DON stated staff were expected to follow the guidelines and honor the Resident's Rights. My expectations are that Resident's Rights are honored and dignity preserved. Interview with Licensed Nursing Home Administrator, on 09/13/19 at 11:35 AM, revealed it was her expectation that staff preserve the resident's dignity while honoring and respecting the Resident's Rights at all times.

Based on observation, interview, and record review, it was determined the facility failed to ensure comfortable and safe water temperature levels that minimize resident's susceptibility to loss of body heat and risk of hypothermia, or hyper-thermia, and is comfortable for residents, as determined through observations of Unit 2 Residents' bathroom sink water temperatures. Observations of temperatures 02/05/19-02/06/19 on Unit 2 ranging from seventy-eight (78) degrees Fahrenheit to one hundred (100) degrees Fahrenheit and through resident interviews with eleven (11) of fifty-three (53) sampled Residents (Resident #2, Resident #3, Resident #10, Resident #11, Resident #18, Resident #22, Resident #34, Resident #46, Resident #75, Resident #86 and Resident #87). Observations of Unit 2 on 02/05/19 at 11:00 AM revealed room [ROOM NUMBER] had a water temperature of ninety (90) degrees Fahrenheit, at 11:15 AM room [ROOM NUMBER] water temperature ninety-eight (98) degrees Fahrenheit. Continue observations of Unit 2 on 02/06/19 at 1:05 PM in room [ROOM NUMBER] revealed water temperature was ninety-eight (98) degrees Fahrenheit rose to one hundred (100) degrees Fahrenheit within a minute then dropped to eighty-four (84) degrees Fahrenheit within three (3) minutes. Further observations on Unit 2 at 1:10 PM revealed room [ROOM NUMBER] water temperatures ninety-eight (98) degrees Fahrenheit dropped to eighty-four (84) degrees Fahrenheit within three (3) minutes and at 2:07 PM room [ROOM NUMBER] water temperatures one hundred (100) degrees Fahrenheit and declined to seventy-eight (78) degrees Fahrenheit within three (3) minutes. The findings include: Interview on 02/07/19 at 9:13 AM with Maintenance Assistant revealed the facility had no policy for water temperatures; however, the facility followed the state guidelines of one-hundred one (101) to one-hundred ten (110) degrees Fahrenheit for resident areas. Interview further revealed he performed random checks of residents' rooms and to measure the water temperature he turned on the sink and the shower at the same time. An interview with the Maintenance Director on 02/07/19 at 3:30 PM revealed the facility follows regulatory guidelines for maintaining water temperatures for bathing and showers between one-hundred (101) degrees to one-hundred and ten (110) degrees. The facility does not have their own policy for water temperature safety but he kept a log of the temperatures. 1. Observation on 02/05/19 at 11:10 AM in room [ROOM NUMBER], Resident #75's room revealed the bathroom sink water temperature was ninety (90) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #75 on 09/15/18 and review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15), indicating the resident had no cognitive impairment. Interview on 02/05/19 at 11:12 AM with Resident #75 revealed the resident's bathroom shower was ice cold; however, the water in the general shower room warmer. Resident #75 said he/she wished the water was warmer. 2. Observation on 02/05/19 at 11:15 AM in room [ROOM NUMBER], Resident #22 bathroom sink revealed water temperature of ninety-eight (98) degrees Fahrenheit. Observation on 02/06/19 at 2:40 PM with Maintenance revealed the hot water temperatures in room [ROOM NUMBER] eighty-three (83) to eighty-four (84) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #22 on 12/16/18 and review of the Admission MDS assessment dated [DATE] revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Interview on 02/05/19 at 11:32 PM with Resident #22 revealed he/she waits 15 minutes to heat water to shave. 3. Observation on 02/05/19 at 11:15 AM in room [ROOM NUMBER], Resident #3 bathroom sink revealed water temperature of ninety-eight (98) degrees Fahrenheit. Observation on 02/06/19 at 2:40 PM with Maintenance revealed the hot water temperatures in room [ROOM NUMBER] eighty-three (83) to eighty-four (84) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #3 on 10/15/18 and review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15), indicating no cognitive impairment. Interview on 02/05/19 at 11:15 AM with Resident #3 revealed his/her showers were sometimes hot and sometimes cold. The hot water in the shower was off and on, but he/she preferred the water to be warmer. 4. Observation on 02/06/19 at 1:40 PM in Resident #87's bathroom sink revealed, water temperature at eighty-five (85) degrees Fahrenheit. Observation on 02/06/19 at 1:46 PM at the bathroom sink revealed water temperature at eighty-five (85) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #87 on 06/28/18 and review of the Quarterly MDS assessment dated [DATE] revealed, the facility assessed the resident as having a BIMS of ten (10) out of fifteen (15) indicating moderate cognitive impairment. Interview with Resident #87 on 02/05/19 at 10:30 AM revealed, at times the his/her water was too cold to take a shower. The water will be warm then turn cold while he/she is completing the shower with assistance. 5. Observation on 02/06/19 at 1:46 PM in Resident #2's bathroom sink revealed, water temperature in the same room as resident #87 was one-hundred and eight (108) degrees Fahrenheit checked a few minutes later the temperature dropped to eight-three (83) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #2 on 01/04/13 and review of the Quarterly MDS assessment dated [DATE] revealed, the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) indicating resident was cognitively intact. Interview with Resident #2 on 02/05/19 at 4:13 PM revealed, Resident #2 was independent taking his/her shower. The resident stated while in the shower, the water may be very warm then turns cold suddenly. Resident #2 stated this was horrible when the water turned cold all at once. 6. Observation with Maintenance Director on 02/06/19 at 2:45 PM revealed, the temperature of the water in the sink in Resident #11's room was ninety-five (95) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #11 on 01/07/15 and review of the Quarterly MDS dated [DATE] revealed, the facility assessed the resident as having a BIMS of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #11 on 02/06/19 at 11:00 AM revealed the resident received two showers a week on Wednesdays and Saturdays and the aides were very kind and caring. The resident stated when they help me in the shower it will be a little hot, then it will run cold. When the water runs cold, the aides shut it off. 7. Observation on 02/06/19 at 2:06 PM Resident #34's bathroom sink revealed, water temperature on ninety-one (91) degrees Fahrenheit. Further observation with Maintenance Director on 02/06/19 at 2:51 PM revealed the follow up temperature by the Maintenance Director was one-hundred (100) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #34 on 12/10/07 and review of the Quarterly MDS dated [DATE] revealed, the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #34 on 02/05/19 at 11:10 AM revealed, the shower water was cold last night on 02/04/19. The resident further stated the water will be warm, and then after you are in the shower it turns ice cold. 8. Observation on 02/06/19 at 1:55 PM Resident #18's bathroom sink revealed, water temperature at ninety-nine (99) degrees Fahrenheit. Review of the medical record revealed the facility admitted Resident #18 on 10/05/17 and review of the Quarterly MDS assessment dated [DATE] revealed, the facility assessed the resident as having a BIMS of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #18 on 02/05/19 at 10:50 AM revealed, when in the shower, the water turns cold, the aide has to adjust the water. They turn on the sink to make the shower water warmer, sometimes it does not become warm again and we hurry. 9. Observation on 02/06/19 at 2:13 PM revealed Resident #46 was sitting up in a wheelchair. Review of the medical record revealed the facility admitted Resident #46 on 08/02/19 and review of the Quarterly MDS dated [DATE] revealed, the facility assessed the resident as having a BIMS of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #46 on 02/05/19 at 10:55 AM, revealed, he/she had a shower today, the water was hot during the shower and then it became cold. The resident revealed, the temperature in the shower got hot and then ice cold during the shower. The resident further said when it got cold he/she had to get out. 10. Observation on 02/06/19 at 1:10 PM of room [ROOM NUMBER] bathroom sink water temperature revealed ninety-eight (98) degrees Fahrenheit and the temperature changed in three (3) minutes to eighty-four (84) degrees Fahrenheit. Observation on 02/06/19 at 2:07 PM of room [ROOM NUMBER] bathroom sink revealed water temperature one-hundred (100) degrees then dropped to seventy-eight (78) degrees Fahrenheit in three (3) minutes. Observation on 02/06/19 at 2:09 PM to 2:14 PM with the Maintenance Director revealed the hot water temperatures in room [ROOM NUMBER] was ninety-(90) degrees Fahrenheit and room [ROOM NUMBER] was eighty-six (86) degrees Fahrenheit, dropping to eighty-three (83)degrees Fahrenheit. 11. Review of the medical record revealed the facility admitted Resident #10 on 04/15/17 and review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident as having a BIMS of ten (10) out of fifteen (15) indicating the resident was moderately cognitively impaired. Interview on 02/05/19 at 11:20 AM in room [ROOM NUMBER] with Resident #10 revealed the hot water extreme very hot and then went to very cold. The water temperature had no happy medium. The water was cool last night in shower. 12. Review of the medical record revealed the facility admitted Resident #86 on 10/08/18 and review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident as having a BIMS of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Interview on 02/05/19 at 11:30 AM in room [ROOM NUMBER] with Resident #86 revealed he/she receives showers and the water is not hot. The resident said it made the shower uncomfortable. Review of the water temperature logs for (MONTH) (YEAR) revealed, water temperatures were maintained between one-hundred and four (104) degrees to one-hundred and five (105) degrees Fahrenheit. Review of the water logs for (MONTH) 2019 revealed, water temperatures were maintained between one-hundred and four degrees (104) degrees to one-hundred and nine (109) degrees Fahrenheit. Further review of the (MONTH) water temperature logs between (MONTH) 1, 2019 and (MONTH) 5, 2019 revealed, the water temperature was maintained between one-hundred and one (101) degrees to 108 degrees Fahrenheit. Continued review for focused water temperature audit completed by maintenance on (MONTH) 7, 2019 revealed water temperatures ranged between one-hundred and one degrees (101) to one-hundred and six (106) degrees Fahrenheit. Interview with the Unit Manager of the second floor on 02/07/19 at 2:43 PM revealed, she was informed the resident showers had become cold while they were showering for the past two weeks. The Unit Manager was unaware of any specific time the temperatures become cold in the shower. She was unaware of any resident not taking a shower due to warm temperatures. Further interview revealed the Unit Manager would expect the staff assisting the resident with a shower to remove the resident from the shower if the water became cold. Staff have been instructed to turn the hot water on in the sink and that helps the water warm up, it pulls more water to the bathroom. I have heard the residents complaining about the water temperatures for a couple of weeks. I notified maintenance and made my chain of command aware. My direct supervisor is the Assistant Director of Nursing (ADON and the Director of Nursing (DON) whom I informed. Interview with SRNA #4 on 02/0719 at 2:36 PM revealed, she usually works on two (2) south. Everyone has an individual shower in his or her room; they have certain shower days, such as Monday/Thursday, Tuesday/Friday, and Wednesday/Saturday. Further interview revealed, the water must run unit it gets hot, it has taken longer this week. It does not seem related to how many residents are taking showers. When residents are in the shower, the water does go from warm to cold; it happens with no regularity, it can happen at any time. When it does happen, I stop the shower, and then rinse the resident off as soon as possible. The water will not get warm again when the resident is still in the shower. Some residents have complained to me about the water getting cold in the shower. Early in the morning, the water is less likely to become cold. Interview on 02/07/19 at 1:26 PM with Licensed Practical Nurse (LPN ) #2, who worked on Unit 2 revealed some residents would not take a shower in cold water and some residents have stated the water was too cold. She stated she had contacted maintenance when water was cold. Interview on 02/07/19 at 1:37 PM State Registered Nursing Assistant (SRNA) #3, who worked on Unit 2 revealed residents refused showers sometimes and he tells the nurse. Interview on 02/07/19 at 1:40 PM with SRNA #4 revealed residents sometimes refused showers due to cold water temperatures. Further interviewing with the Maintenance Director on 02/07/19 at 10:55 AM revealed, to maintain resident safety, water temperatures are-checked each morning. Lines are-flushed if there are any temperatures above the state guidelines greater than one-hundred and ten (110) degrees. Further interview revealed, during walking rounds to check water temperatures, maintenance verified several temperatures out of range this morning on 02/07/19. Someday's the water temperatures become hotter when it is cold outside, some days it is colder. Maintenance normally will check temperatures in the morning doing random checks and again in the afternoon. Residents have not complained about water temperatures since (MONTH) 2019. This morning on 02/07/19, maintenance received a text from a staff member with a concern the water temperatures were too cold. Continued interview revealed the Maintenance Director was puzzled about the fluctuations in the water temperatures on the second floor. Interview on 02/07/19 at 4:23 PM with Director of Nursing (DON) revealed staff is trying to address the concern of water temperatures. Assisting residents with options to accommodate residents with bathing. Maintenance is aware of the concerns of the water temperatures and addressing the concerns. The water temperature adjusted to [MEDICAL CONDITION] too low or cold temperatures could be uncomfortable for the residents. Interview with the DON on 02/08/19 at 9:57 AM revealed, she expects the residents to have warm water. As expected, the staff informed maintenance if the water was running too hot or too cold and carried out interventions to make the resident comfortable. Interview on 02/07/19 at 4:47 PM Administrator revealed showers provided to resident by preference. Staff try to honor resident preference and reschedule if the resident allows. Staff offer perineal care, bed baths or re-approach if a resident refuses or does not want to take a shower due to the temperature of the water. If the water temperature too hot the resident could receive a burn, and if the water temperature was too cold it would make the resident uncomfortable. Interview with the Administrator on 02/08/19 at 10:15 AM revealed, she would expect staff to notify maintenance, the Unit Manager, DON and herself if there were issues with resident's water temperatures in the shower. If the water was too cold, the aides could offer a bed bath, blankets if the water turned cold in the middle of the shower.

Based on observation, interview, record review and review of facility policy, it was determine that the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, were provided by qualified persons in accordance with each resident's written plan of care for three (3) of twenty (20) sampled residents (Resident #45, Resident #82, and Resident #90). Resident #45 received medications via Gastrostomy Tube (Gtube); however, the facility failed to follow Physician order [REDACTED]. Resident #82 was in Contact Precautions and the facility failed to follow Resident #82's Physician Orders, Comprehensive Care Plan, and facility Policies and Procedures when staff entered the resident's room and touched the Resident #82 without donning proper PPE (Personal Protective Equipment). Resident #90 was ordered nutrition via Gtube feedings. The facility failed to follow Physician order [REDACTED].#90's tube feeding. The findings include: Interview with the Director of Nursing (DON) revealed the facility did not have a care plan policy; however, the facility followed the Resident Assessment Instrument(RAI) manual guidelines per Centers for Medicare and Medicaid Services. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. 1. Interview with the Director of Nursing (DON) during request for facility policy or procedure for administering medications via tube revealed the facility had no policy regarding this except instructions for crushing medications to be administered via tube. Observation of the narcotic book on the medication cart on the unit revealed a facility document titled PharMerica Proper Administration of Medications Via Enteral Tube Audit Tool. Review of this document revealed documentation Verify tube placement. Unclamp tube and insert small amount of air into tube with the syringe and listen to stomach with stethoscope for gurgling sounds. Aspirate stomach content with syringe. Check residual. Allow stomach contents to go back into stomach. Follow nursing care center policy addressing residual volume. Record review revealed the facility admitted Resident #45 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed an additional physician's orders [REDACTED]. Review of Resident #45's Comprehensive Care Plan revealed a problem dated 04/02/15 which documented Resident #45 was at risk for aspiration related to dysphagia. tube feed related [MEDICAL CONDITION](cerebravascular accident) dysphagia. Further review of the plan of care revealed a goal documented as Resident #45 would be free from S/S (signs/symptoms) of aspiration as disease process will allow with a goal date of 04/10/19. Continued review of the plan of care revealed an intervention dated 11/06/18 which documented check GT (gtube) placement as ordered. Observation of a medication pass on 02/06/19 at 12:29 PM revealed Licensed Practical nurse (LPN) #6 inserted the syringe drew back and stated no residual. No residual was observed in the syringe. LPN #6 was not observed to insert small amount of air into tube with the syringe and listen to stomach with stethoscope for gurgling sounds per facility procedure PharMerica Proper Administration of Medications Via Enteral Tube Audit Tool. Interview with LPN #6 revealed when asked how she checks tube placement, she indicated checking residual was how she checked for placement, and LPN #6 continued to administer Resident#45 water and medications via the Gtube. Medications administered were [MEDICATION NAME] 20 MG (milligrams); [MEDICATION NAME] 100 MG; Calcium 1250 MG/5ML (milliliters) with dosage of 5 ML; [MEDICATION NAME]/Levadopa 25-100 and [MEDICATION NAME] 90 MG. Interview with the Unit Manager of the 100 unit on 02/08/19 at 10:10 AM revealed to check G tube placement by administering air into tube and listening with stethoscope. The unit Manager reviewed Resident #45's Physician order [REDACTED].#6 did not follow the physician's orders [REDACTED]. The Unit Manager further stated a potential problem with not checking for placement of the G tube prior to administering fluids or medication could be Resident #45 could aspirate the medications. The Unit Manager 100 unit stated the expectation was that facility staff follow Physician Orders, Care Plans and facility policy. Interview with the facility Assistant Director of Nursing (ADON) on 02/07/19 at 04:57 PM revealed to check G tube placement, put tube in and pull it out and check residual. If there was residual, notify the resident's physician and recheck in 1 hour. The ADON further stated if there was no residual, use syringe and insert approximately 10 cc's air while listening with stethoscope for sound over stomach area. Interview on 02/07/19 at 05:15 PM with the facility DON (Director of Nursing) revealed to check for G tube placement there were two ways to check. The DON stated the two ways were to use air with a stethoscope and listen, and check residual. The DON stated if you check for residual and there is none, there is no option but to check with air bolus. The DON stated she was unaware that placement with air bolus wasn't checked for Resident #45 during med pass on 02/06/18. The DON stated the resident may prefer not to have the air bolus. Continued interview with the DON revealed she reviewed PharMerica Proper Administration of Medications Via Enteral Tube Audit Tool. Further interview with the DON revealed the document says insert small amount of air into tube with the syringe and listen to stomach with stethoscope for gurgling sounds and check residual, The DON stated is says check both. The DON stated she expects staff to follow facility policy unless physician order [REDACTED].#45 prefers not to have bolus but stated, she would not put med in of didn't check placement. The DON stated LPN #6 should have used air bolus and stethoscope to check placement. The DON reviewed Resident #45's Physician orders [REDACTED].#6 did not follow the Physician order [REDACTED]. The DON stated the Procedure in back of book on med cart stated insert small amount of air into tube with the syringe and listen to stomach with stethoscope for gurgling sounds and check residual. Continued interview with the DON revealed her expectation is that staff follow resident Physician order [REDACTED]. Interview with the facility Administrator on 02/08/19 at 11:04 AM revealed it is her expectation that staff follow the facility policy and procedures, Physician order [REDACTED]. The Administrator indicated she is not a nurse but stated she is aware air is used to check placement to make sure med's go to correct spot. She reviewed the document PharMerica Proper Administration of Medications Via Enteral Tube Audit Tool and Resident #45's Physician order [REDACTED].#45. Continued interview with the Administrator revealed that by not checking for placement of the G tube, the outcome could be if the tube was in the wrong place, med's would not be delivered to the right place. 2) Review of the facility document [MEDICAL CONDITION] which was not dated, revealed a Standard of Practice (SOP) Statement Preventive measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile (to prevent transmission of [DIAGNOSES REDACTED]icile to others). The policy [MEDICAL CONDITION] further documented Residents with diarrhea associated [DIAGNOSES REDACTED]icile (i.e., residents who are colonized and symptomatic) will be placed on Contact Precautions. Healthcare workers will wear gloves and gowns upon entering the room of a resident with C.difficile infection, and will remove gowns and gloves prior to exiting the room. Additional review of the document revealed [DIAGNOSES REDACTED]icile is transmitted via the fecal-oral route and The primary reservoirs for [DIAGNOSES REDACTED]icile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to common cleaning and disinfection methods. Record review revealed Resident #82 was admitted by the facility on 03/03/18. Review of the current [DIAGNOSES REDACTED].#82 had [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set (MDS) assessment, a Quarterly assessment dated [DATE], revealed the facility assessed Resident #82 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15). Review of the resident's plan of care revealed a problem with onset date 03/13/18 documented as Resident #82 was at risk for fluctuating incontinence as evidenced by occasionally incontinent of bladder with further risk for infection, constipation, and skin breakdown. Additional review of the problem section revealed documentation stated 07/18/18 nocturnal incont; 01/15/19[DIAGNOSES REDACTED] and 01/31/19[DIAGNOSES REDACTED]. The goals were documented as will continue to have episodes of continence x 90 days through 03/03/19; will have soft formed BM (bowel movement) at least every 3 days through 03/03/19; will be free of s/s (signs or symptoms) of infection x 90 days through 03/03/19. Additional review of goals revealed a goal dated 01/15/19 will remain free from s/s (signs/symptoms) complications from[DIAGNOSES REDACTED] x 90 days and a goal dated 01/31/19[DIAGNOSES REDACTED] will resolve without further complications x 90 days. Interventions included antibiotics as ordered dated 01/15/19 and 01/31/19 and bedside commode as ordered. Further review of the Plan of care for Resident #82 revealed an intervention of contact precautions dated 01/31/19. Review of Resident #82's physician's orders [REDACTED]. Observations of Resident #82 on 02/06/19 at 10:00 AM revealed a sign on the resident's door to see nurse before entering. Further observation revealed there were gowns, gloves, and face masks attached to Resident #82's room door. Observations revealed the resident was sitting in his wheelchair near his bed and dresser. Resident #82 asked for his tissues which were not in his reach as I was exiting the room and I advised him I would request his staff to assist. I reported to facility staff in the hall and the facility staff stated they would tell Resident #82's aide. Further observation revealed the aide was observed to enter the room without donning any PPE, although the resident was on contact precautions. The aide did not apply a gown, gloves, nor mask and asked what resident needed. Resident #82 requested tissues and the aide was observed to obtain Resident #82's tissues and provided them to the resident. Continued observation revealed the aide touched/rubbed/patted the resident on the back and spoke to the resident. The aide was observed to enter the resident's bathroom and then exited the room. Interview with State Registered Nursing Assistant (SRNA) #7 immediately after she exited the Resident #82's room revealed SRNA #7 stated Resident #82 had contact precautions and when I asked about following the precautions the SRNA stated I forgot my gloves. Continued interview with SRNA #7 revealed it was his/her understanding that they only had to use mask and gown if Resident #82 had a bowel movement and there was a risk something may be splashed. SRNA #7 stated Resident #82 tested positive for[DIAGNOSES REDACTED] and this was the reason Resident #82 was on contact precautions. Further interview with SRNA #7 revealed these precautions were important so you don't take it home with you. Interview with the Unit Manager of the 100 unit on 02/08/19 at 10:10 AM revealed the facility policy was that PPE (Personal Protective Equipment) would be worn for any contact with Resident #82, due to the resident was on contact precautions. The Unit Manager was informed of the incident with SRNA #7 not using PPE as documented above, when SRNA #7 had physical contact with Resident #82. The Unit Manager reviewed Resident #82's physician's orders [REDACTED]. Further interview with the Unit Manager 100 unit revealed Resident #82's Physician order [REDACTED].#82 was to have Contact Precautions, and this was not followed, when SRNA #7 had physical contact with Resident #82 without using PPE. Interview with the facility ADON on 02/07/19 at 05:08 PM revealed it was facility policy that if staff provided direct care to a resident on contact precautions, staff were to wear gown and gloves. She stated Resident #82 has a bedside commode and doesn't share the bathroom for toileting; although resident did have a roommate and the shower would be shared. She stated Resident #82's roommate was mobile. Continued interview with the ADON revealed SRNA #7 should have worn PPE when direct care is provided. Interview on 02/07/19 at 05:50 PM, with the facility Director of Nursing (DON), who is also the facility Infection Control Nurse, revealed Resident #82 had tested positive for [MEDICAL CONDITION] and was on the second dose of medications, but was not symptomatic. The DON stated residents with [MEDICAL CONDITION] were kept on contact precautions until after they complete medications. The DON stated SRNA #7 should have applied PPE if she went in Resident #82's room and touched the resident. The DON further stated Resident #82 was on contact precaution, and the DON stated she expected staff to follow facility policy and use precautions when touching a resident on contact precautions. Additional interview with the DON/Infection Control Nurse, on 02/08/19 at 10:47 AM, revealed Resident #82 was in contact precautions and contact precautions should have been followed. The DON reviewed Resident #82's Physician orders [REDACTED]. Further interview with the DON revealed Resident #82's physician's orders [REDACTED].#7 did not use PPE when providing care for Resident #82. The DON stated she expected staff to follow physician's orders [REDACTED]. Further interview with the DON/Infection Control Nurse revealed staff not following contact precautions could spread infection throughout the building. Interview on 02/08/19 at 11:27 AM with the facility Administrator revealed it was her expectation that staff follow the facility policy and procedures for contact precautions for any resident in contact precautions. The facility Administrator stated if staff provided direct care or touched Resident #82, staff should have used PPE per the facility policy. Continued interview with the Administrator revealed she reviewed Resident #82's Physician order [REDACTED].#82's Physician order [REDACTED]. The Administrator stated she expected staff to follow facility Policies and Procedures. The Administrator indicated cross contamination would be a potential outcome of not following contact precautions, Physician order [REDACTED].#82. 3) Review of the medical record revealed the facility admitted Resident #90 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission MDS assessment, dated 12/31/18, revealed the facility assessed Resident #90 to have a Brief Interview for Mental Status (BIMS) score of zero zero (00) out of fifteen (15). Resident #90 was assessed by the facility as never/rarely understanding and assessed in Cognitive skills for daily decision making as severely impaired. Further review of the assessment revealed the resident was not able to complete the interview for mood and staff assessment of resident mood score was zero zero (00) out of thirty (30). The facility further assessed Resident #90 as having a feeding tube and receiving 51 or more percent of calories received through feeding tube and 501 cc/day or more fluid received intravenously or by feeding tube. Review of Resident #90's Comprehensive Plan of care revealed a problem dated 01/02/19 which stated Resident #90 is a risk for complications associated with tube feeding. Further review of the plan of care revealed a goal that the resident will be free from complications associated with tube feeding x 90 days through 04/02/19. An additional goal was documented the resident would be free from SX (symptoms) Aspiration AEB (as evidenced by): lungs will remain clear, afrebile x 90 days through 04/02/19. Continued review of the plan of care for Resident #90 revealed approaches which were TF (tube feeding) as ordered. See current MAR (Medication Administration Record) and flushes as ordered. Record review revealed physician's orders [REDACTED].#90. Further review revealed a physician's orders [REDACTED]. Change every AM at 5am. Observation on 02/05/19 at 04:17 PM revealed Resident #90 had [MEDICATION NAME] 1.5 at 54 cc per hr and at the time of observation, there was 1300 ml remaining. Observation of the [MEDICATION NAME] container revealed it was dated 02/05/19 at 5:00 AM. The kangaroo flush bag was observed with no label and no date and was observed with approximately 500 cc/ml in the bag. Observation on 02/07/19 at 02:25 PM revealed tube feeding [MEDICATION NAME] 1.5 cal via pump at 54 cc per hour Further review revealed the bottle is 1.5 liter bottle and was dated 02/07/19 at 5 AM. Kangaroo Fluid bag observed with no date or label. Observation of the feeding pump revealed the pump documented feeding at 54 cc hour and fluid at 30 ml fluid every 2 hours. Further observation on 02/07/19 at 04:31 PM revealed tube feeding [MEDICATION NAME] 1.5 cal via pump at 54 cc per hour Further review revealed the bottle is 1.5 liter bottle and was dated 02/07/19 at 5 AM. Kangaroo Fluid bag observed with no date or label. Observation of the feeding pump revealed the pump documented feeding at 54 cc hour and fluid at 30 ml fluid every 2 hours. Further observation revealed there were 1300 ml in the [MEDICATION NAME] feeding remaining of the 1500 ml which is the amount packaged in the container. Resident #90's assigned nurse observed the feeding with the surveyor. Interview with LPN #5 revealed Resident #90 should have about 960 cc/ml remaining in the [MEDICATION NAME] container if the feeding was administered per physician's orders [REDACTED]. LPN #5 indicated she was unsure why the remaining feeding in the container was 1300 ml. Continued interview with LPN #5 revealed the nurse was asked how the facility ensures the correct amount of feeding was administered to residents who receive nutrition via tube feeding and LPN #5 indicated third shift should be able to tell. Continued interview with LPN #5 revealed the (Kangaroo) water flush bags were to be completed by night shift and that night shift were to hang new ones. LPN #5 indicated she was unsure if there is a facility policy regarding the labeling or dating the fluid bags but if there is no date or label, she would be unable to know how long it had been there. Interview on 02/07/19 at 04:42 PM with the facility Assistant Director of Nursing (ADON), revealed she observed the [MEDICATION NAME] container for Resident #90 and stated it was hung at 5am 02/07/19. She stated there was 1500 ml when the feeding began and at the time of the interview it should have approximately 900 cc/ml. The ADON stated the pump should monitor the feeding on the history. Regarding the facility policy for monitoring tube feeding and how the facility monitors to ensure resident's receiving tube feeding receive the ordered amount, she indicated she would have to check on a policy. Continued interview with the ADON revealed there is no way on the feeding pump to show how much Resident #90 received since 5 AM. The ADON stated the pump documented over 6662 ml since the last reset but stated she cannot determine when the reset occurred. The ADON stated the pump does indicate Resident #90 received 54 cc's in the last 1 hour. The ADON stated Resident #90 should have received approximately 621 cc/ml from 5 AM to the time of observation/interview 02/07/19 at 04:42 PM but only 200 is showing as having been administered per the bottle of [MEDICATION NAME] feeding. Subsequent interview with the ADON on 02/07/19 at 5:20 PM revealed the ADON stated the pump/machine says Resident #90 is receiving feeding as ordered but she thought the bottle may have been mislabeled. The ADON indicated Resident #90 should receive 1188 ml tube feeding over the 22 hour period and there would be 312 left in the [MEDICATION NAME] container and thought at 5AM staff used the remaining feeding on the container prior to starting the new container of [MEDICATION NAME] and didn't change the time from 5:00 AM to the time it was hung to start being administered. Interview with the facility DON on 02/07/19 at 5:20 PM revealed if staff used the remaining feeding on the container prior to starting the new [MEDICATION NAME] container, the staff should have correctly labeled and dated the bottle of [MEDICATION NAME] feeding with the actual date and time it was hung to be administered. Interview with the Unit Manager of the 100 hall on 02/08/19 at 10:10 AM revealed she was unaware of Resident #90 having an issue with the amount of feeding received on 02/07/19 or with date/time the [MEDICATION NAME] tube feeding was administered. The Unit manager reviewed Resident #90's Physician order [REDACTED]. The Unit Manager further stated if the container was not labeled correctly with the date and time, there was no way to know how much feeding the resident received. Subsequent interview with the DON on 02/08/19 at 10:47 AM revealed she was still trying to contact staff to determine what happened regarding Resident #90's tube feeding. The DON stated she thought the resident received her feeding but doesn't think a new container of [MEDICATION NAME] was hung at 5am. The DON reviewed Resident #90's physician's orders [REDACTED]. Continued interview with the DON revealed Resident #90's [MEDICATION NAME] 1.5 via tube feeding was supposed to be turned off at 3:00 AM and changed at 5AM. When asked about consequence of not following physician's orders [REDACTED].#90's nutrition, the DON stated it's nutrition-its imperative. Interview with the facility Administrator on 02/08/19 at 11:04 AM revealed it was her expectation that staff follow facility policy and procedures and that staff should follow physician's orders [REDACTED]. Further interview with the Administrator revealed she reviewed Resident #90's Physician order [REDACTED]. [REDACTED].#90 regarding tube feeding which could cause a negative outcome to the resident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for two (2) of four (4) residents who receive enteral feeding and for two (2) of twenty (20) sampled residents (Resident #90 and Resident #350). The facility failed to follow physician orders [REDACTED].#90, and the kangaroo fluid bag had no date or label during the survey process. Resident #350's kangaroo fluid bag had no date or label during the survey process. The findings include: Review of facility policy titled Administration of Enteral Tube Feedings: Intermittent or Continuous, which was not dated, revealed For continuous tube feeding, fill bag with four (4) hours of tube feeding )or prepare ready-to hang container), flush tubing, attach to volume control infuser according to manufacturer's instructions, attach distal end to feeding tube, and start. Flush with 30-60 ml (milliliters) of water every four (4) hours after first checking residual. Interview with the facility Director of Nursing (DON) on 02/07/19 at 05:36 PM revealed the facility has no policy regarding labeling or dating bags (kangaroo) of fluid separately, that are used to provide resident's fluids who are receiving tube feeding. Review of the documentation provided by the facility titled How to use the kangaroo(NAME)Pump, with no date, revealed the documentation stated the following: Throw the bag out if it has been used for 24 hours. Review of the document/package insert provided by the facility titled Kangaroo Epump ENPlus Spike with Flush Bag revealed the documentation stated Note: This set is intended for enteral feeding only. It is recommended that this device be replaced every 24 hours. Review of the copy of the label provided by the facility for [MEDICATION NAME] Complete, Balanced Nutrition With Fiber 1.5 CAL (calorie) 2250 Cal/1500 ml (milliliters) 1.5 Liter Ready-to-Hang enteral feeding container, revealed Hang product up to 48 hours after initial connection when clean technique and only one new feeding sets are used. Otherwise , hang no longer than 24 hours. 1. Review of the medical record revealed the facility admitted Resident #90 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 12/31/18, revealed the facility assessed Resident #90 to have a Brief Interview for Mental Status (BIMS) score of zero zero (00) out of fifteen (15) indicating the resident was severly cognitively impaired. Resident #90 was assessed by the facility as never/rarely understanding and assessed in Cognitive skills for daily decision making as severely impaired. Further review of the assessment revealed the resident was not able to complete the interview for mood and staff assessment of resident mood score was zero zero (00) out of thirty (30). The facility further assessed Resident #90 as having a feeding tube and receiving 51 or more percent of calories received through feeding tube and 501 cc/day or more fluid received intravenously or by feeding tube. Review of Resident #90's Comprehensive Plan of care revealed a problem dated 01/02/19 which stated Resident #90 is a risk for complications associated with tube feeding. Further review of the plan of care revealed a goal that the resident will be free from complications associated with tube feeding x 90 days through 04/02/19. An additional goal was documented the resident would be free from SX (symptoms) Aspiration AEB (as evidenced by): lungs will remain clear, afrebile x 90 days through 04/02/19. Continued review of the plan of care for Resident #90 revealed approaches which were TF (tube feeding) as ordered. See current MAR (Medication Administration Record) and flushes as ordered. Record review revealed Resident #90's weights were reviewed and the resident was documented with weight of 169.4 on 12/25/18 and on 1/21/19 Resident #90's weight was 146.2 pounds. Interview with the facility dietitian on 02/07/19 at 03:01 PM revealed she stated the admission weight was incorrect and this is noted in resident record. The Dietitian further indicated she reviewed Resident #90's nutrition and hydration today, 02/07/19, and stated there were no concerns. Further interview with the Dietitian revealed she increased fluid although she stated Resident #90 was meeting fluid needs, due to Resident #90 had a Urinary Tract Infection [MEDICAL CONDITION] last month. The dietitian further stated she increased the fluid from 225 cc every 4 hours to 250 cc every 4 hours. Record review revealed physician's orders [REDACTED].#90. Further review revealed a physician's orders [REDACTED]. Change every AM at 5am. Observation on 02/05/19 at 04:17 PM revealed Resident #90 had [MEDICATION NAME] 1.5 at 54cc per hr and at the time of observation, there was 1300ml remaining. Observation of the [MEDICATION NAME] container revealed it was dated 02/05/19 at 5:00AM. The kangaroo flush bag was observed with no label and no date and was observed with approximately 500 cc/ml in the bag. Observation on 02/07/19 at 02:25 PM revealed tube feeding [MEDICATION NAME] 1.5 cal via pump at 54 cc per hour Further review revealed the bottle is 1.5 liter bottle and was dated 02/07/19 at 5 AM. Kangaroo Fluid bag observed with no date or label. Observation of the feeding pump revealed the pump documented feeding at 54 cc hour and fluid at 30 ml fluid every 2 hours. Further observation on 02/07/19 at 04:31 PM revealed tube feeding [MEDICATION NAME] 1.5 cal via pump at 54 cc per hour Further review revealed the bottle is 1.5 liter bottle and was dated 02/07/19 at 5 AM. Kangaroo Fluid bag observed with no date or label. Observation of the feeding pump revealed the pump documented feeding at 54 cc hour and fluid at 30 ml fluid every 2 hours. Further observation revealed there were 1300 ml in the [MEDICATION NAME] feeding remaining of the 1500 ml which is the amount packaged in the container. Resident #90's assigned nurse observed the feeding with the surveyor. Interview with LPN #5 revealed Resident #90 should have about 960 cc/ml remaining in the [MEDICATION NAME] container if the feeding was administered per physician's orders [REDACTED]. LPN #5 indicated she was unsure why the remaining feeding in the container was 1300 ml. Continued interview with LPN #5 revealed the nurse was asked how the facility ensures the correct amount of feeding was administered to residents who receive nutrition via tube feeding and LPN #5 indicated third shift should be able to tell. Continued interview with LPN #5 revealed the (Kangaroo) water flush bags were to be completed by night shift and that night shift were to hang new ones. LPN #5 indicated she was unsure if there is a facility policy regarding the labeling or dating the fluid bags but if there is no date or label, she would be unable to know how long it had been there. Interview on 02/07/19 at 04:42 PM with the facility Assistant Director of Nursing (ADON), revealed she observed the [MEDICATION NAME] container for Resident #90 and stated it was hung at 5:00 AM on 02/07/19. She stated there was 1500ml when the feeding began and at the time of the interview it should have approximately 900 cc/ml. Further interview with the ADON revealed the (Kangaroo) water flush bag should be labeled and dated. The ADON stated the facility has a sticker for that. Continued interview with the ADON revealed that looking at the fluid bag for Resident #90, there is no way to know how long it had been there, since there was no label. The ADON stated the pump should monitor the feeding on the history. Regarding the facility policy for monitoring tube feeding and how the facility monitors to ensure resident's receiving tube feeding receive the ordered amount, she indicated she would have to check on a policy. Continued interview with the ADON revealed there is no way on the feeding pump to show how much Resident #90 received since 5 AM. The ADON stated the pump documented over 6662 ml since the last reset but stated she cannot determine when the reset occurred. The ADON stated the pump does indicate Resident #90 received 54 cc's in the last 1 hour. The ADON stated Resident #90 should have received approximately 621 cc/ml from 5 AM to the time of observation/interview 02/07/19 at 04:42 PM but only 200 is showing as having been administered per the bottle of [MEDICATION NAME] feeding. Subsequent interview with the ADON on 02/07/19 at 5:20 PM revealed the ADON stated the pump/machine says Resident #90 is receiving feeding as ordered but she thought the bottle may have been mislabeled. The ADON indicated Resident #90 should receive 1188 ml tube feeding over the 22 hour period and there would be 312 left in the [MEDICATION NAME] container and thought at 5 AM staff used the remaining feeding on the container prior to starting the new container of [MEDICATION NAME] and didn't change the time from 5:00 AM to the time it was hung to start being administered. Interview with the facility DON on 02/07/19 at 5:20 PM revealed if staff used the remaining feeding on the container prior to starting the new [MEDICATION NAME] container, the staff should have correctly labeled and dated the bottle of [MEDICATION NAME] feeding with the actual date and time it was hung to be administered. Continued interview with the DON on 02/07/19 at 05:36 PM revealed there was no policy about labeling or dating the (kangaroo) bags of fluid separately. Further interview with the DON revealed she thinks the nurses do what they are supposed to do and stated they have been educated to change the water bag when they change the feeding, that way both are changed at the same time. Interview with the Unit Manager 100 hall on 02/08/19 at 10:10 AM revealed she was unaware of Resident #90 having an issue with the amount of feeding received on 02/07/19 or with date/time the [MEDICATION NAME] tube feeding was administered. The Unit manager reviewed Resident #90's Physician order [REDACTED]. The Unit Manager stated unless they used remaining from prior container. The Unit Manager further if the container was not labeled correctly with the date and time, there was no way to know how much feeding the resident received. Further interview with the Unit Manager regarding the (Kangaroo) fluid bags revealed staff know to take fluids and feeding down together and as long as they are connected, they don't label the fluids, only the feeding. Continued interview revealed that one could be removed without both being changed at the same time as the fluids and feeding are not physically connected. The Unit Manager 100 hall stated she was confident in the system but was now questioning it. Further interview revealed if the (Kangaroo fluids) were not labeled or dated, there would be no way of knowing when it was hung to be administered or for how long the fluids had been there without being changed. Subsequent interview with the DON on 02/08/19 at 10:47 AM revealed she was still trying to contact staff to determine what happened regarding Resident #90's tube feeding. The DON stated she thought the resident received her feeding but doesn't think a new container of [MEDICATION NAME] was hung at 5am. The DON reviewed Resident #90's physician's orders [REDACTED]. Continued interview with the DON revealed Resident #90's [MEDICATION NAME] 1.5 via tube feeding was supposed to be turned off at 3:00 AM and changed at 5AM. When asked about consequence of not following physician's orders [REDACTED].#90's nutrition, the DON stated it's nutrition-its imperative. Interview with the facility Administrator on 02/08/19 at 11:04 AM revealed the facility has no policy regarding labeling (Kangaroo) fluid bags with tube feeding. The Administrator indicated the system is one system and was all connected and hung as one. When asked if the items are joined and could be hung separately she indicated there is a potential the (Kangaroo) fluid bag could be be there longer and not be replaced at the same time as the feeding. The Administrator indicated it was her expectation that staff follow facility policy and procedures and that staff should follow physician's orders [REDACTED]. Further interview with the Administrator revealed she reviewed Resident #90's Physician order [REDACTED]. [REDACTED].#90 regarding tube feeding which could cause a negative outcome to the resident. 2. Record review reveled the facility admitted Resident #350 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission MDS assessment, dated 01/31/19, revealed the facility assessed Resident #350 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15). Resident #350 was assessed by the facility as having a feeding tube and receiving 51 or more percent of calories received through feeding tube and 501 cc/day or more fluid received intravenously or by feeding tube. Further record review revealed Resident #350 had a Nursing Care Plan with a problem onset date documented 01/11/19 for risk for alteration in Nutrition related to [MEDICAL CONDITION];[MEDICAL CONDITION](Hypertension); [MEDICAL CONDITIONS]; Dysphagia; A-Fib; [MEDICAL CONDITIONS]; Gastrostomy status; NPO (Nothing by Mouth). Further review revealed Resident #350 had goals documented which included a goal the resident will be free of s/s (signs/symptoms) of dehydration/fluid imbalance with goal date documented 04/30/19. Further review of the plan of care revealed approaches which included Provide enteral nutrition feeding and flushes as ordered and report changes in TF (tube feeding) promptly. Observations during the survey on 02/05/19 at 10:55 AM; 02/05/19 at 04:09 PM; and 02/07/19 at 12:32 PM revealed Resident #350's (Kangaroo) fluid bag was observed with no label or date. Observation of Resident #350's (Kangaroo) fluid bag with the ADON on 02/07/19 at 04:56 PM and subsequent interview with the ADON revealed the (Kangaroo) fluid bag should be labeled and dated. Continued interview with the ADON revealed there is no way to know how long the (Kangaroo) fluid bag has been there since there was no label. The ADON indicated she would have to check on policy regarding labeling the fluid bags. Interview on 02/07/19 at 04:31 PM with LPN #5 revealed the (Kangaroo) water flush bags were to be completed by night shift and that night shift were to hang new ones. LPN #5 indicated she was unsure if there is a facility policy regarding the labeling or dating the fluid bags but if there is no date or label, she would be unable to know how long it had been there. Interview with the Unit Manager 100 hall on 02/08/19 at 10:10 AM regarding the (Kangaroo) fluid bags revealed staff know to take fluids and feeding down together and as long as they are connected, they don't label the fluids, only the feeding. Continued interview revealed that one could be removed without both being changed at the same time as the fluids and feeding are not physically connected. The Unit Manager 100 hall stated she was confident in the system but was now questioning it. Further interview revealed if the (Kangaroo fluids) were not labeled or dated, there would be no way of knowing when it was hung to be administered or for how long the fluids had been there without being changed. Interview with the facility DON on 02/07/19 at 05:36 PM revealed there was no policy about labeling or dating the (kangaroo) bags of fluid separately from the feeding. Further interview with the DON revealed she thinks the nurses do what they are supposed to do and stated they have been educated to change the water bag when they change the feeding, that way both are changed at the same time. Interview with the facility Administrator on 02/08/19 at 11:04 AM revealed the facility has no policy regarding labeling (Kangaroo) fluid bags with tube feeding. The Administrator indicated the system is one system and was all connected and hung as one. When asked if the items are joined and could be hung separately she indicated there is a potential the (Kangaroo) fluid bag could be be there longer and not be replaced at the same time as the feeding.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (1) of twenty (20) sampled residents. Resident #44 was administered ProStat on [DATE], after order was to be discontinued on [DATE]. The findings include: Review of the facility Medication Management Policy, dated ,[DATE], revealed, the facility would review each resident's drug regimen to ensure it is free from unnecessary drugs. This includes any drug in excessive dose (including duplicate drug therapy). Further policy review, revealed in order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. Review of Resident #44's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #44's Physician Order's, dated [DATE], revealed orders for Prostat 30 ml daily for 30 days to promote wound healing. The order was to be discontinued on [DATE]. Review of the Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 2:33 PM, revealed, the Electronic Medication Administration Record [REDACTED]. She stated she would not have given, if it didn't prompt me to give it. Further observation and interview with LPN #1 revealed whoever took the order did not put a stop date in our electronic record. She stated she was unaware that the ordered expired. Interview with the Director of Nursing (DON) on [DATE] at 2:36 PM, revealed she had been there for four months and when she took over the systems were broken here. She said she was working hard to get systems in place. She stated it was their process that whoever pulls the orders puts the order in the computer. The order was back in (MONTH) and it didn't get checked and entered correctly with the stop date into the system. We have recently instituted a new procedure, for triple check of any new orders. The physician agreed it should have been continued and a new order was obtained to continue medication on [DATE]. It is my expectation that whoever takes the orders off, enter them correctly into our electronic health care record, unfortunately the stop date was not entered for this order. Interview with the Administrator on [DATE] at 2:56 PM, revealed it was her expectation for the staff to follow physician orders. She stated she was made aware of the med error for Resident #44 on [DATE]. It is my expectation for the staff to enter the orders into the system correctly.

Based on interview and record review, it was determined the facility failed to ensure PRN orders for [MEDICAL CONDITION] dugs were limited to 14 days except when extended by the physician or prescribing practitioner beyond 14 days with documented rationale in the resident's medical record for two (2) of twenty (20) sampled residents, Resident #90 related to [MEDICATION NAME], and Resident #36 related to [MEDICATION NAME]. The findings include: Review of the facility's policy titled Medication Monitoring/Medication Management, dated 11/2017, revealed Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. The facility policy further documented Based on a comprehensive assessment of a resident, the facility must insure: Residents who use [MEDICAL CONDITION] drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Further review of the policy revealed New Admissions: The attending physician in collaboration with the consultant pharmacist must re-evaluate the use of the [MEDICAL CONDITION] medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. 1. Review of the medical record revealed the facility admitted Resident #90 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission MDS assessment, dated 12/31/18, revealed the facility assessed Resident #90 to have a Brief Interview for Mental Status (BIMS) score of zero zero (00) out of fifteen (15), indicating the resident was severely impaired. The assessment indicated the resident was rarely/never understood had no speech-absence of spoken words. Further review of the assessment revealed the resident was not able to complete the interview for mood and staff assessment of resident mood score was zero zero (00) out of thirty (30). The facility further assessed Resident #90 as having no behavioral symptoms. In addition, review of the assessment revealed the facility assessed Resident #90 as having received antianxiety medication one (1) day of the last seven (7) days. Review of Resident #90's Physician Orders, dated February, 2019 revealed an order for [REDACTED]. There was no stop date or date to discontinue the medication documented. Review of the Medication Administration Record (MAR) for Resident #90 dated December, (YEAR), revealed [MEDICATION NAME] 0.5 MG tablet Give one (1) tablet per tube every six (6) hours as needed for anxiety, with an Order date 12/24/18 and Start date 12/24/18. There was no stop date or date to discontinue the medication documented. Further review of the (MONTH) MAR revealed the resident was administered the medication on 12/26/18 at 8:45 AM. Review of the (MAR) for Resident #90 dated January, 2019, revealed [MEDICATION NAME] 0.5 MG tablet Give one (1) tablet per tube every six (6) hours as needed for anxiety, with an Order date 12/24/18 and Start date 12/24/18, and no stop date or date to discontinue the medication documented. Further review of the MAR revealed the resident received the medication on 01/05/19 at 4:29 PM. Review of the (MONTH) MAR revealed the medication [MEDICATION NAME] 0.5 MG tablet Give one (1) tablet per tube every six (6) hours as needed for anxiety, with an Order date 12/24/18 and Start date 12/24/18. Review of the Medication Regimen Review document revealed the resident's medication was reviewed by a Pharmacist on 01/11/19 and the documentation stated MD-prn [MEDICATION NAME]. ([MEDICATION NAME] is the generic form of [MEDICATION NAME]). Further review of the resident's medical record revealed [REDACTED]. Continued review of the progress note revealed no documentation regarding the [MEDICATION NAME]. The [MEDICAL CONDITION] medication, [MEDICATION NAME] 0.5 MG tablet Give one (1) tablet per tube every six (6) hours as needed for anxiety was ordered for Resident #90 on 12/24/18 with no documented discontinuation date, and was ordered for 44 days with no evidence of a documented rationale or duration to extend the medication order beyond 14 days for the PRN (as needed) [MEDICAL CONDITION] medication per the facility policy. Interview with Licensed Practical Nurse (LPN) #5 on 02/07/19 at 04:31 PM revealed Resident #90 had the PRN (as needed) [MEDICATION NAME] ordered for use if the resident gets agitated or has anxiety. The LPN stated she was not aware until today that the [MEDICAL CONDITION] PRN medications have a 14 day expiration on the order. Interview on 02/07/19 at 05:04 PM with the Assistant Director of Nursing, ADON, the ADON stated she knew it was a policy that that PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days and said facility physicians are aware and stated the facility has asked and given the physicians the GDR's (Gradual Dosage Reductions) to complete. The ADON stated the facility needs to be stricter with Physicians to ensure the regulation is met Interview on 02/07/19 05:42 PM with the facility Director of Nursing, the DON stated she was aware of the 14 day prn [MEDICAL CONDITION] medication order and stated the physician just chooses to continue it. She further stated the facility was working on the issue, and said I can't write the orders and change them but I can tell the physician and the physician has to do something with it. Interview with the facility Administrator on 02/08/19 at 11:04 AM, the Administrator was asked about the continued use of [MEDICATION NAME] for Resident #90. The Administrator stated she was aware of the 14 day only for the prn lorazapam and stated she is not sure why Resident #90's prn order for [MEDICATION NAME] continued on past the 14 days. The Administrator further stated she is aware of the regulation and stated the facility policy says for prn [MEDICAL CONDITION] medication it has to have a 14 day stop date. Further interview with the administrator revealed it is her expectation that facility policy and procedures are followed and that the [MEDICATION NAME] continuing past 14 days for Resident #90 could be an unnecessary medication. 2. Review of resident #36's clinical record revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/19/18, revealed the facility assessed Resident #36 to have a Brief Interview for Mental Status (BIMS) score of zero zero (00) out of fifteen (15), indicating the resident was severely impaired. Review of Resident #36's physician's orders [REDACTED]. Review of Resident #36's Medication Administration Record (MAR) for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019 and (MONTH) to 02/07/19 revealed [MEDICATION NAME] 5 mg PO PRN was given once on (MONTH) 16, 2019. Review of the Monthly physician's orders [REDACTED].#36 was to receive [MEDICATION NAME] 5 mg PRN as needed for psychotic agitation and was discontinued on 02/07/19. Continued review revealed, [MEDICATION NAME] was originally ordered on [DATE]. Further review revealed, no new order was received after the original PRN order was written on 10/31/18. Review of the MRR, signed by the Consulting Pharmacist on 11/16/18 with continued MRR reviews for (MONTH) (YEAR), (MONTH) 2019, revealed Resident #36 was receiving psychoactive medications including [MEDICATION NAME] 5 mg PO qd as needed. Continued review revealed the Consulting Pharmacist was aware the resident was actually receiving [MEDICATION NAME] 5 mg PO qd as needed and recommended the current diagnosis, behaviors and usage pattern and evaluate continued need. The Consulting Pharmacist advised PRN antipsychotic orders cannot exceed 14 days and require direct prescriber evaluation for continuation. Interview with Licensed Practical Nurse (LPN) #3 on 02/07/19 at 5:35 PM revealed, when the physician orders [REDACTED]. When the nurse takes off the order for an antipsychotic and there is a stop date by the physician we put that on the MAR with the start date. I was not aware nurses needed to obtain another order after 14 days for an antipsychotic PRN medication. If a medication has a stop date on it and the nurse enters it on the MAR at the end of the stop date it will not show up on the electronic MAR. Interview with LPN #4 on 02/07/19 at 5:42 PM revealed, if a resident is on an antipsychotic PRN medication, the doctor writes the stop date for 14 days. They count the 14 days and put that stop date on the electronic MAR and after the 14 days it automatically drops off. I was not aware an antipsychotic cannot be continued after 14 days without a new physician's orders [REDACTED]. Interview with the DON on 02/08/19 at 9:57 AM revealed, the physician should have reviewed Resident # 36's antipsychotic medication [MEDICATION NAME] 5 mg PO PRN within the 14 days it was originally ordered. The attending physician continued to say to the facility he/she wanted to continue the medication. Further interview with the DON revealed, per the facility policy the physician has to write the order after every 14 days and reevaluate the resident for the continued need of the antipsychotic medication. Interview with the Administrator on 02/08/19 at 10:15 AM revealed, the duration for antipsychotic medications order PRN is 14 days, the the physician would need to re-evaluate the resident and the Gradual Dose Reduction (GDR). Continued interview revealed, the physician would need to rewrite the order if it were to be continued, this is according to the facility's policy. Further interview revealed, the interdisciplinary team reviews PRN antipsychotics in the clinical meetings, however, this particular medication for resident #36 [MEDICATION NAME] 5 mg PO PRN was not caught. Whoever enters a PRN psychotic medication should put the 14 day stop date. All nurses who take off orders would do this. Interview on 02/11/19 at 2:14 PM with the Psycharist revealed she writes in the orders 14 days for any PRN [MEDICAL CONDITION] or anti-psychotic medication. The nurses call her when the medication is due to review and if she does not review the medication the medication should be dropped or discontinued. Interview on 02/11/19 at 3:36 PM with the Physician revealed he only writes antipsychotics for 14 days and then reevaluates the PRN medications in another 14 days. The nurse calls and asks for extension of the PRN anti-psychotic or recevies a stop order. The Psycharist makes recommendations to him concerning residents PRN anti-psychotic medication. The goal to keep residents on a low dose of the antipsychotics as PRN medication. He tries to not keep the resident long term on the PRN [MEDICAL CONDITION] medications and tries other non-anti-[MEDICAL CONDITION] medications.

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for two (2) of two (2) sampled resident's ordered contact precautions and two (2) of twenty (20) sampled residents (Resident #82 and Resident #351). Resident #82 was in contact precautions, and staff were observed to touch the resident without donning proper PPE (Personal Protective Equipment). Resident #351 was in contact precautions and soiled laundry was observed sitting on top of the red biohazard can in Resident #351's room. The findings include: Review of the Standards of Practice Policy, Revised 11/2017, revealed Preventive measures will be taken to prevent the occurrence of [MEDICAL CONDITION] (C. Difficile or [DIAGNOSES REDACTED].) infections among residents and precautions will be taken while caring for residents with [MEDICAL CONDITION]. The policy further stated, residents with diarrhea associated with [MEDICAL CONDITION] will be placed on contact precautions for the duration of the illness. Review of the document [MEDICAL CONDITION], undated, revealed a Standard of Practice (SOP) Statement that Preventive measures will be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile (to prevent transmission of [DIAGNOSES REDACTED]icile to others). The policy [MEDICAL CONDITION] further documented, Residents with diarrhea associated [DIAGNOSES REDACTED]icile (i.e., residents who are colonized and symptomatic) will be placed on Contact Precautions. Healthcare workers will wear gloves and gowns upon entering the room of a resident with [DIAGNOSES REDACTED]icile infection, and will remove gowns and gloves prior to exiting the room. Residents with [DIAGNOSES REDACTED]icile infection will be placed in a private room if available. If a private room is not available, residents will be cohorted with a dedicated commode for each resident. Additional review of the document revealed [DIAGNOSES REDACTED]icile is transmitted via the fecal-oral route and The primary reservoirs for [DIAGNOSES REDACTED]icile are infected people and surfaces. Further review revealed [DIAGNOSES REDACTED]icile Spores can persist on resident-care items and surfaces for several months and are resistant to common cleaning and disinfection methods. Review of the facility's Procedure for Removing Linen from Contact Precaution Rooms Policy, undated, revealed the purpose was to prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions; properly transport linens to minimize contamination. Personnel transport linens to prevent the spread of infection. Further review of the document revealed Procedure: When an employee is removing soiled linen from a precaution room, the linen must be bagged in yellow bags. Upon bagging, the linen it will be transferred to the soiled laundry room by a nursing aide or a nurse staff member. Linens are to be removed from the room with each change. 1) Record review revealed Resident #82 was admitted by the facility on 03/03/18. Review of the current [DIAGNOSES REDACTED].#82 had [DIAGNOSES REDACTED]. Difficile. Review of the resident's most recent Minimum Data Set (MDS) assessment, a Quarterly assessment, dated 11/24/18, revealed the facility assessed Resident #82 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15). Review of the resident's plan of care revealed a problem with the onset date 03/13/18 documented as Resident #82 was at risk for fluctuating incontinence as evidenced by occasionally incontinent of bladder with further risk for infection, constipation, and skin breakdown. Additional review of the problem section revealed documentation stated 07/18/18 nocturnal incont; 01/15/19 [DIAGNOSES REDACTED] and 01/31/19 [DIAGNOSES REDACTED]. The goals were documented as will continue to have episodes of continence for ninety (90) days through 03/03/19; will have soft formed BM (bowel movement) at least every three (3) days through 03/03/19; will be free of s/s (signs or symptoms) of infection for ninety (90) days through 03/03/19. Additional review of the goals revealed a goal dated 01/15/19 that Resident #82 will remain free from s/s (signs/symptoms) and complications from [DIAGNOSES REDACTED]. for ninety (90) days and a goal dated 01/31/19 that [DIAGNOSES REDACTED]. would resolve without further complications for ninety (90) days. Interventions included antibiotics as ordered dated 01/15/19 and 01/31/19 and bedside commode as ordered. Further review of the Plan of care for Resident #82 revealed an intervention of contact precautions dated 01/31/19. Review of the physician's orders [REDACTED]. Observations of Resident #82, on 02/06/19 at 9:30 AM, revealed a sign on resident's door to see nurse before entering. Attached to the resident's room door were gowns, gloves, and facemasks. Observations revealed the resident was sitting in his/her wheelchair near his/her bed and dresser. Continued observations revealed this resident has a roommate who shares the room. Observation revealed a red biohazard bin in the single bathroom of the room. The red bin is in the resident bathroom, which is used by Resident #82's roommate. Resident #82's roommate was observed to exit the bathroom on 02/06/19 at approximately 9:30 AM. Resident #82 asked for his tissues, which were not in his reach as I was exiting the room and I advised him I would request his staff to assist. I reported to facility staff in the hall and the facility staff stated they would tell Resident #82's aide. Further observation revealed the aide was observed to enter the room without donning any PPE, although the resident was on contact precautions. The aide did not apply a gown, gloves, nor mask and asked what the resident needed. Resident #82 requested tissues and the aide was observed providing the tissues to the resident. Continued observation revealed the aide touched/rubbed/patted the resident on the back and spoke to the resident. The aide was observed to enter the resident's bathroom and then exited the room. Interview with SRNA #7, on 02/06/19 at approximately 10:00 AM, revealed Resident #82 had contact precautions ordered. Per interview, SRNA #7 stated, I forgot my gloves. Continued interview with SRNA #7 revealed it was her understanding that they only had to use the mask and gown if Resident #82 had a bowel movement and there was a risk something may be splashed. Continued interview revealed Resident #82 tested positive for[DIAGNOSES REDACTED]. and this was the reason Resident #82 was on contact precautions. Further interview revealed these precautions were important so you do not take it home with you. Interview with the Unit Manager 100 unit, on 02/08/19 at 10:10 AM, revealed the facility policy was that PPE (Personal Protective Equipment) would be worn for any contact with Resident #82, due to the resident was on contact precautions. The Unit Manager reviewed Resident #82's physician's orders [REDACTED]. Further interview with the Unit Manager 100 unit revealed Resident #82's Physician order [REDACTED].#82 was to have Contact Precautions and this was not followed when SRNA #7 had physical contact with Resident #82 without using PPE. Interview with the facility Assistant Director of Nursing (ADON), on 02/07/19 at 05:08 PM, revealed it was facility's policy that if staff provided direct care to a resident that was on contact precautions, staff are to wear gown and gloves. She stated Resident #82 has a bedside commode and does not share the bathroom for toileting; although the resident does have roommate and the shower would be shared. Continued interview revealed SRNA #7 should have worn PPE when direct care was provided. Interview with the facility Director of Nursing (DON), who is also the facility Infection Control Nurse, on 02/07/19 at 5:50 PM, revealed Resident #82 had again tested positive for [MEDICAL CONDITION] and was on the second dose of medications, but was not symptomatic. The DON stated residents with [MEDICAL CONDITION] were kept on contact precautions until after they complete their medications. Continued interview revealed SRNA #7 should have applied PPE if she went in Resident #82's room and touched the resident. The DON further stated she expected staff to follow facility policy and use precautions when touching a resident on contact precautions. Further interview with the DON revealed the Resident #82 had a roommate and she stated the facility policy for a resident in contact precautions due to [DIAGNOSES REDACTED] would be in a private room if possible; but the facility was not required to do that. Further interview with the DON revealed Resident #82 was symptomatic initially and was in with the roommate. The DON stated, honestly, I could not tell you why we did not move Resident #82. Subsequent interview with the DON/Infection Control Nurse, on 02/08/19 at 10:47 AM, revealed Resident #82 was in contact precautions and contact precautions should have been followed. Per interview, Resident #82's physician's orders [REDACTED].#7 did not use PPE when providing care for Resident #82. The DON stated she expected staff to follow physician's orders [REDACTED]. Further interview with the DON/Infection Control Nurse revealed staff not following contact precautions could spread infection throughout the building. Interview with the facility Administrator, on 02/08/19 at 11:27 AM, revealed it was her expectation that staff follow the facility policy and procedures for contact precautions for any resident in contact precautions. The facility Administrator stated, if staff provided direct care or touched Resident #82, staff should have used PPE per the facility policy. Continued interview with the Administrator revealed she reviewed Resident #82's Physician order [REDACTED].#82's Physician order [REDACTED]. The Administrator stated she expected staff to follow facility Policies and Procedures. The Administrator indicated cross contamination would be a potential outcome of not following contact precautions, Physician order [REDACTED].#82. 2) Review of the medical record revealed the facility admitted Resident #351 on 01/17/19 with diagnoses, which included End Stage [MEDICAL CONDITION] and [MEDICATION NAME] due to [MEDICAL CONDITION], not specified as recurrent. Review of Resident #351's Comprehensive Care Plan revealed a problem, dated 01/21/19, which documented Resident #351 was being treated for [REDACTED]. ([MEDICAL CONDITION]) and was at further risk for alteration in fluid balance and skin breakdown. A goal was that infection would resolve without further complication for thirty (30) days with a target date of 03/02/19. Further review of Resident #351's Plan of Care revealed approaches to educate the resident and family on proper hand washing and other infection control as appropriate, isolation per CDC (Center for Disease Control) guidelines, provide adequate housekeeping measures related to disinfection/sterilization based on organism, location of infection and mode of transmission. Observation, on 02/05/19 at 10:35 AM, of Resident #351's room door revealed a sign on the door to see the nurse before entering the room and gloves, masks, and gowns were observed on the door of the resident's room. Observation, on 02/06/19 at 10:45 AM, revealed a large red biohazard plastic can with a red plastic lid on top of it, in Resident #351's room. Further observation revealed the lid must be manually moved to dispose of items in the can. Continued observation revealed there was a large yellow plastic bag with soiled linen sitting on top of the lid of the red biohazard can. Interview with SRNA #8, on 02/07/19 at 1:15 PM, revealed she saw the yellow biohazard bag with soiled laundry on top of the red biohazard plastic can on 02/06/19. SRNA #8 stated, it had soiled linen in the yellow bag and linen in a yellow bag was supposed to be taken straight to the laundry. Continued interview with SRNA #8 regarding the lid that has to be manually moved on the red biohazard can revealed she barely touches under the lid to lift and put soiled gloves, gown, and mask in and then washes her hands. Interview with the Unit Manager 100 unit, on 02/08/18 at 10:10 AM, revealed the facility policy is for soiled laundry of a resident on contact precautions for [MEDICAL CONDITION] was to be placed in a yellow bag and taken to the laundry immediately. The Unit Manager stated laundry in the yellow bag should not be left sitting on top of the red biohazard can. The Unit Manager indicated PPE should be removed and then the tub/can opened to put the items inside. Interview with the facility DON/Infection Control Nurse, on 02/07/19 at 5:44 PM, revealed when a resident is on contact precautions, staff should not be laying stuff on top of the red biohazard can. The DON/Infection Control Nurse stated staff were supposed to take soiled linen, place it in a yellow bag and take it directly to the laundry. Continued interview with the DON/Infection Control Nurse revealed possible cross-contamination could occur with the red biohazard lid you manually move on and off the can. Interview with the Administrator, on 02/08/19 at 11:04 AM, revealed if the yellow bag with soiled laundry was not too full, maybe staff left it in there, but the Administrator continued, and stated the best practice was to take it to the laundry. The Administrator further stated it was her expectation that staff follow facility policies and procedures and stated facility policy was to take soiled linen on to the laundry, and by not doing so could potentially cause cross contamination.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to have an effective system to ensure the Physician was notified when there was a need to alter treatment and when there was a significant change in the resident's physical status for sixteen (16) of fifty-two (52) sampled residents (Residents #1, #4, #9, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, #83, and one (1) unsampled resident (Unsampled Resident A). Observation on 02/05/18 at 6:40 PM, revealed the Acting Director of Nursing (DON) was the only nurse on the second floor unit assigned to sixty-one (61) residents. Interview on 02/06/18, 02/07/18 and 02/08/18 with the Acting DON, and with Licensed Practical Nurse (LPN) #7 and LPN #8, revealed the Acting DON was the only nurse on the second floor unit on 02/05/18 from approximately 3:45 PM until approximately 6:45 PM when LPN #7 and LPN #8 arrived on the unit. Interview with the Acting DON, LPN #7 and LPN #8 revealed the Sliding Scale Insulin medication which was ordered to be administered at 4:00 PM and 5:00 PM based on the results of the Accuchecks was not administered until between 7:00 PM and 8:00 PM on 02/05/18. The nurses further revealed they performed 8:00 PM and 9:00 PM Accuchecks, administered Sliding Scale Insulin coverage related to the Accuchecks, and administered routine long acting Insulin between 9:00 PM and 11:30 PM on 02/05/18, without notifying the Physician the 4:00 PM and 5:00 PM Insulin had been administered late. The nurses revealed they did not seek guidance from the physician related to the need for possible adjustment in Insulin dosage or delay in Insulin administration. Also, the nurses revealed they failed to notify the Physician of high and low Blood Glucose levels on the evening of 02/05/18, even though there were physician's orders [REDACTED]. This failure affected Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A. (Refer to F-760) Additionally, review of Weight Records revealed Resident #83 had a significant weight loss of 14.15 % in one (1) month and Resident #9 a significant weight loss of 7.21 % in one (1) month. However, there was no documented evidence the Physician was notified of the residents' significant weight loss. (Refer to F-692) The facility's failure to have an effective system in place to ensure Physician notification when there was a need to alter treatment, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 02/08/18, and was determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction (P(NAME)), and the facility Quality Assurance monitors to ensure compliance with systemic changes. The findings include: 1. Review of the facility's Change of Condition Process Policy, revised September 2015, revealed the Physician, Advanced Registered Nurse Practitioner (ARNP), or Physician's Assistant was to be notified of a medication error involving the potential for significant toxic side effects and any significant changes in condition that might be associated with one (1) or more medications. Observation and interview on 02/05/18 at 6:40 PM, with the Acting DON, confirmed she was the only nurse on the second floor unit for sixty-one (1) nurses. Per interview, she was running from hall to hall obtaining Accuchecks for the diabetic residents on the three (3) halls and she was late administering the 4:00 PM and 5:00 PM Sliding Scale (SS) Insulin coverage to the residents. Record review revealed fourteen (14) sampled residents and one unsampled resident (Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A) did not receive their scheduled Insulin or Sliding Scale (SS) Insulin as ordered the evening of 02/05/18, with medication administration being from two (2) to four (4) hours late. Record review revealed there was no documented evidence the residents' physician was notified of the late medication administration. Record review revealed Residents #13, #31, #40, #61, #64, #78, and Unsampled Resident A received both SS Insulin and scheduled Insulin at the same time. However, record review revealed no documented evidence the residents' physician was notified of the late medication administration to adjust the Insulin doses for these residents. In addition, Resident #22 received SS Insulin at 7:53 PM for a blood glucose reading of 65 at 9:00 PM; Resident #19 received SS Insulin coverage at 7:54 PM for a blood glucose reading of 405 and SS Insulin coverage at 11:25 PM for a blood glucose reading of 516 and Resident #64 received SS Insulin coverage for a blood glucose reading of 483 at 7:49 PM; however, there was no documented evidence the Physician was notified of these blood sugar readings. Further review of Resident #64 Physician orders [REDACTED].#64's 483 glucose reading per the physician's orders [REDACTED].>Further interview with the Acting DON, 02/07/18 at 4:00 PM, revealed when Licensed Practical Nurse (LPN) #7 arrived on the unit at approximately 6:45 PM, she started administering Insulin in accordance with the Accuchecks the Acting DON had obtained. Per interview, she and LPN #7 were performing Accuchecks and administering Insulin that was due at 4:00 PM and 5:00 PM, after 7:00 PM. She further stated the Physician should have been notified the Insulin was administered late as he may have wanted to adjust the next Insulin dose. The Acting DON stated she held off on administration of the 9:00 PM Accuchecks and Insulin until 10:00 to 10:30 PM due to giving the 4:00 PM and 5:00 PM Insulin late. She further stated she thought she had notified the physician of Resident #19's blood glucose reading of 405 and 516 and Resident #64's blood glucose reading of 483, and stated if she called the Physician, she should have documented it in the nurse's Notes. However, review of the nurse's notes for Residents #19 and 64 revealed no documented evidence the physician was notified. Interview with LPN #7, on 2/8/17 12:27 PM, revealed she arrived on the second floor unit about 6:45 PM and received a list of Accucheck readings which had been obtained by the Acting DON and started administering Insulin in accordance with the Accuchecks. She stated she gave Insulin that was due at 4:00 PM and 5:00 PM between 7:00 PM and 7:30 PM. Per interview, she did not notify the Physician the Insulin and medications were being administered late, but should have because he may have wanted to adjust the Insulin doses for the residents. Interview with LPN #8, on 02/06/18 at 3:15 PM, revealed she arrived at approximately 6:45 PM and received the keys to the East Hall second floor from the Acting DON. She further stated the Acting DON had already performed the 4:00 PM and 5:00 PM Accuchecks and she received the list of Accucheck readings from her. LPN #8 stated she started passing medications and administering Insulin's that were due at 4:00 PM and 5:00 PM between 7:15 PM and 7:20 PM. She stated by that time the residents had already had their supper meal so the Insulin was not given before the supper meal. Per interview, she had not notified the Physician that the medications and Insulin's were administered late, but should have in case the Insulin dosage would need to be adjusted. Interview on 02/08/18 at 3:00 PM, with the Attending Physician/Medical Director for Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident #A, revealed he was not notified of the Insulin being administered late on 02/05/18, but should have been notified due to the possible need to adjust the Insulin coverage for the next dose. Continued interview revealed if the residents' Accucheck and Insulin Administration was completed up to two (2) or four (4) hours late, this could cause the routine long acting Insulin and the Sliding Scale Insulin to be administered at the same time. He stated if he had been notified the Insulin's were administered late on 02/05/17, he would have advised the nurses related to the next dose of Insulin administration on a case by case basis for each of the residents. Further interview revealed he should have been notified of high and low blood glucose readings as per the physician's orders [REDACTED]. Interview with the Administrator, on 02/08/18 at 7:10 PM, revealed the nurses should have notified the Physician about the late administration of Insulin on 02/05/18 and he also should have been informed of this situation. Per interview, he expected the nurses to notify the Physician as per orders of high blood sugar readings. 2. Review of the facility's Change of Condition Process Policy, revised September 2015, revealed the Physician, Advanced Registered Nurse Practitioner (ARNP), or Physician's Assistant was to be notified of weight loss -five percent (5%) or more within thirty (30) days or ten percent (10%) or more within six (6) months. Review of Resident #83's Weight Record revealed Resident #83 weighed 106.0 pounds on 01/07/18 and weighed 91.0 pounds on 02/07/18. This was a significant weight loss of 14.15% in one (1) month. However, further review of the medical record revealed there was no documented evidence the Physician had been notified of the significant weight loss. Review of Resident #9's Weight Record revealed Resident #9 weighed 169.0 pounds on 01/03/18 and weighed 156.8 pounds on 02/07/18. This was a weight loss of 7.21% in one (1) month. However, further review of the medical record revealed there was no documented evidence the Physician had been notified of the significant weight loss. The Acting DON was unavailable for interview on 02/16/18 on the date of survey exit. Post Survey phone interview with the Acting DON on 02/20/18 at 12:00 PM, revealed the Physician should be notified anytime there was a significant weight loss or gain. She stated she was responsible for ensuring weekly and monthly weights were obtained and also for ensuring re-weights were obtained if weight discrepancies noted in order for the RD and the Physician to be notified of significant weight losses or gains. However, due to the facility being short staffed she had to work as a staff nurse all but a few days since 01/05/18, when the previous DON left. Per interview, she did not have time to ensure the weights were obtained and inputted into the electronic record timely. Further interview with the Attending Physician/Medical Director on 02/16/18 at 4:22 PM, revealed he expected staff to notify him of significant weight losses and if he had known of the significant weight losses for Resident #9 and Resident # 83, he would probably have ordered supplements or appetite stimulants. He stated it was important he was notified of significant weight losses in order to write orders to promote stable weights. Further interview with the Administrator, on 02/16/18 at 4:00 PM, revealed it was important for the Physician to be notified timely of significant weight losses and for orders to be obtained for supplements, appetite stimulants, or other interventions. He further stated it was important for the Physician to be notified of weight loss in order for the Physician to assess the residents for disease processes that could be contributing to the weight loss. The facility provided an acceptable credible Allegation of Compliance on (A(NAME)) 02/16/18, which alleged removal of the IJ effective 02/14/18. Review of the A(NAME) revealed the facility implemented the following: 1. On 02/08/18 the facility added additional staffing on the 3:00 to 11:00 PM shift to include one Licensed Practical Nurse (LPN) who clocked in at 6:30 PM and one LPN who clocked in at 6:45 PM. 2. On 02/09/18, a licensed nurse completed Medication Error Reports for each of the fifteen (15) residents (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33) identified in the deficient practice of insulin administration. 3. On 02/09/18, a licensed nurse verified no new orders or adverse outcomes were noted as a result of the medication errors for any of the identified fifteen residents, (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33). 4. On 02/06/18, the facility entered into a contract with a nursing staffing agency to supplement any staffing needs. 5. On 02/08/18, the Human Resource Manager/Staffing Coordinator validated that all open positions were posted for recruitment. Further interview revealed, the facility expanded the recruitment area for licensed nurses. 6. On 02/11/18, the Regional Quality Manager performed an audit of residents. Thirty-nine total residents were identified who received blood glucose monitoring and subsequent insulin orders. The audit validated blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. 7. On 02/09/18, the Administrator and Regional Director of Operations created and adopted a new Emergency Staffing Procedure to address actions to be taken during emergencies or where additional staffing is optional. 8. On 02/09/18, the Administrator and the Regional Director of Operations reviewed and updated the staffing component of the facility self-assessment. 9. On 02/09/18, re-education was provided by the Regional Quality Manager to the Acting Director of Nursing (DON) in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. On 02/09/18, re-education was provided by the Regional Director of Operations to the Administrator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. On 02/10/18, re-education was provided by the Regional Quality Manager to a licensed Staff Educator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 12. The Acting DON and/or the licensed Staff Educator and Regional Quality Manager provided education to licensed nurses. The education included notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Approximately 93% of the current facility licensed nursing staff completed education by 02/13/18. Those remaining will have completed education prior to assuming duties upon returning to work. 13. Agency nursing binder implemented with orientation reference steps and training information and copies to be given to any agency nurse. Any agency nurse will be required to complete education by Director of Nursing or Assistant Director of Nursing prior to assuming duties and will sign for received education. 14. Acting DON, Staff Educator and/or Regional Quality Manager provided validation of educational understanding by the licensed nursing staff with return verbal exchange. 15. Audits were to be done by the Acting DON, Nurse Manager, and/or the Regional Quality Manager daily beginning 02/09/18, for blood sugar test completion, physician follow up if indicated, physician orders [REDACTED]. 16. Quality Assurance (QA) Meetings were held on 02/09/18 to discuss the IJ allegation and develop an action plan. The Attendees included the Administrator, Regional Quality Manager, Acting DON, Social Services (2), Business Director, Human Resources/Staffing Coordinator, and the Regional Director of Operations. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action to be initiated. QA meetings were to be held at least weekly until substantial compliance was achieved and monthly thereafter. A member of the Regional Team will be in attendance in addition to the facility team for the weekly QA. The Team was to include at a minimum the Administrator, Acting DON, Social Services, State Registered Nursing Assistant and the Charge Nurse. 17. On 2/09/18, a Governing Body Meeting was held to officially document in the minutes the appointment of a replacement Administrator and outline the Administrative duties. The Administrator had received an official letter of appointment on 01/30/18. The Administrator, the Acting DON and the Regional Director of Operations were in attendance. The Medical Director was contacted by the Administrator on 02/09/18 and reviewed the Governing Body Meeting Minutes were reviewed with him. The State Survey Agency validated the implementation of the facility's A(NAME) as follows: 1. Reviewed facility staffing sheets for 02/05/18. LPN #7 clocked in at 6:30 PM and LPN #8 clocked in at 6:45 PM on 02/05/18. Interview with Administrator on 02/16/18 revealed he had verified LPN # 7 had clocked in at 6:30 PM and LPN #8 had clocked in at 6:45 PM on 02/05/18, per the Acting DON and time sheets. Interview with the Acting DON, during a post survey interview, on 02/22/18 at 10:10 AM, revealed on 02/05/18, she had been the only nurse on the second floor until LPN #7 and LPN #8 clocked in around 6:30 PM. Further interview revealed, the shift started at 3:00 PM. 2. Review of the Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33, identified with the deficient practice sliding scale insulin administered outside the time frame on 02/05/18. These reports were completed by the Acting DON. Interview with the Acting DON, during a post survey interview on 02/22/18 at 10:10 AM, revealed she had completed the Medication error reports on 02/09/18. 3. Review of Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, and Resident #33, revealed they were signed by the Acting DON. Further review revealed, the Acting DON notified the physician and documented there were no new orders or adverse outcomes related to the insulin administration errors made on 02/05/18. Post Survey Interview with the Acting DON, on 02/22/18 at 10:10 AM, revealed she notified physician and there were no adverse effects or orders from physician related to Medication Error Reports on 02/09/18. 4. Review of the facility's contract with the nurse staffing agency, dated 02/06/18, revealed the contract was signed by the Administrator. Further review revealed, the contact was to provide supplemental staffing and staffing placement options. Interview with the Administrator, on 02/16/18 at 1:00 PM, revealed he did sign the staffing agreement with the nursing staffing agency on 02/06/18. 5. Review of the Human Resource/Staffing Coordinator statement, dated 02/08/18, reported marketing strategies were reviewed and placed in surrounding areas for nurse recruitment purposes. Interview with the Human Resources/Staffing Coordinator, on 02/16/18 at 2:00 PM, validated marketing strategies were used in an attempt to recruit staff and expand recruitment areas on 02/08/18. 6. Review of the audit, dated 02/11/18, revealed thirty-nine (39) residents were identified to receive finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. Interview with Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she audited all residents in the facility. Continued interview revealed, she identified thirty-nine (39) residents that received finger glucose monitoring and subsequent blood sugar testing. Further interview revealed she audited areas to included: residents receiving finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and orders being followed with any discrepancies addressed. 7. Review of the Emergency staffing Procedure reveals, the procedure was dated effective 02/10/18. Continued review of the document revealed, during emergencies, scheduled staffing interruption, or other temporary situations, a supervisor may require an employee to work different workdays, additional shift(s), different shift(s), or extended shift(s) without advanced notice. 8. Review of the staffing component of the facility self-assessment, dated 02/09/18, revealed the Administrator and the Regional Director of Operations reviewed and updated the staffing component previously dated 11/28/17. Further review revealed, the document was reviewed by the Governing body, Acting DON, Medical Director and Maintenance Director on 02/09/18. Interview with Administrator, on 2/16/18 at 11:00 AM, revealed the staffing component was updated on 02/09/18. Interview with Medical Director, on 02/16/18 at 4:20 PM, revealed he was updated on the facility self-assessment updates in the Governing Body Meeting on 02/09/18. 9. Review of the facility Education sign in sheets, dated 02/09/18, revealed the Acting DON was re-educated on newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Further review revealed, the education was provided by the Regional Quality Manager. Post Survey Interview with the Acting DON, on 02/22/16 at 10:10 AM, revealed she had been re-educated by the Regional Quality Manager on the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. Review of Education sign in sheets, dated 02/09/18, revealed the Administrator was re-educated by the Regional Director of Operations. Continued review revealed the education consisted of: the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Interview with the Administrator, on 02/16/18 at 1:15 PM, revealed he had received training from the Regional Director of Operations regarding the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. Review of the Education sign in sheets revealed, the Regional Quality Manager provided education to the licensed Staff Educator, on 02/10/18, in regards to the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Interview with the Regional Quality Manager, on 02/16/18 at 2:30 PM, indicated she had provided the education to the Staff Educator to include the verbal return of information and her signature of understanding. 12. Review of the facility Education Sign in sheets, revealed the Acting DON, the licensed Staff Educator and the Regional Quality Manager provided re-education to the licensed staff nurses in regards to the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Review of the Education Staffing Rosters and sign in sheets revealed, approximately 93% of the facility's licensed nursing staff had received re-education by 02/13/18 with education provided to others prior to working a shift. Interview, on 02/16/18 with Licensed Practical Nurse (LPN) #3, LPN #10, LPN #11, LPN #12 and Registered Nurse (RN) #7 revealed, education was provided to them on 2/13/18. Interview with LPN# 10 and RN #6, on 02/16/18, revealed they had received education on the above topics on 02/14/18, prior to the start of their shift. Interview with the Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she reviewed the staffing rosters and compared them to the Education sign on sheets for completeness by 02/13/18. Continued interview revealed any staff that had not received the education by 02/13/18 was educated as they returned to work and prior to beginning their shift. 13. Review of the Agency Binder revealed, orientation reference steps and training Information was included in the binder. Interview with the Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she had compiled the Agency Binder to be a tool for Agency or outside facility employees in orientation and to be a reference tool for training information. 14. Review of the Education Sign in sheets indicated LPN #3, LPN #10, LPN #11, LPN #12, RN #7, LPN#10 and RN #6 had received the re-education regarding insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Interviews, on 02/16/18, with LPN #3, LPN #10, LPN #11, LPN #12 and RN #7 revealed education was provided to them on the 2/13/18 and during the education, they were expected to provide return verbal exchange and to sign they understood the training. Interviews, on 02/16/18, with LPN#10 and RN #6, revealed they received education on the above topics on 02/14/18 and they were required to provide return verbal exchange of the education and sign they understood the education. 15. Review of audits performed by the Regional Quality Manager, for blood sugar testing completion, physician follow up if indicated and physician orders [REDACTED]. Interview with Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she had performed the audits daily to monitor for blood testing completion, physician follow up if indicated, orders being followed with any discrepancies being addressed for the dates listed. She further stated she had performed all the audits to date; however, she had a system in place for the Acting DON or a Nurse Manager to perform the audits if she was not in the building. 16. Review of the Quality Assurance (QA) minutes, revealed the QA team met on 02/09/18 and 02/13/18. Review of the meeting minutes in the signature area, revealed signatures by the Medical Director, Administrator, Regional Quality Manager, Acting DON, Social Services, Business Director, Human Resources/Staffing/Coordinator and the Regional Director of Operations. Review of QA meeting, dated 02/13/18, revealed signatures of the Administrator, Social Services, a Licensed Practical Nurse, a State Registered Nursing Assistant, Regional Quality Manager, Regulatory Liaison, Divisional Nursing Consultant, Regional Director of Operations, and with the Medical Director's participation via phone. Interview with Medical Director, on 02/16/18 at 4:20 PM, revealed he had participated via phone, with the QA meeting and was updated regarding the issues to be discussed and the meeting agenda. Continued interview revealed, he was very active in the discussions. 17. Review of the Governing Body Meeting Minutes, dated 02/09/18, revealed the meeting was attended by the Administrator, Acting DON, Medical Director and Regional Director of Operations. Review of a Letter of Appointment for the Administrator, dated 01/30/18, appointed the facility's new Administrator. Interview with Administrator, on 02/16/18 at 1:00 PM, confirmed the Letter of Appointment was signed on 01/30/18 and reviewed with the Governing Body on 02/09/18. Interview with Medical Director, on 02/16/18 at 4:20 PM, validates the duties of the Administrator as discussed in the Governing Body meeting.

Based on observation, interview, record review, review of the facility's policy and procedures, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to have an effective system to ensure services provided met the standards of practice for medication administration for twenty-two (22) of fifty-two (52) sampled residents (Resident #1, #4, #6, #13, #14, #19, #20, #22, #29, #31, #40, #54, #61, #63, #64, #66, #72, #78, #79, #80, #90, #92, and one (1) unsampled resident (Unsampled Resident A). Observation and interview with the Acting Director of Nursing (DON), on 02/05/18 at 6:40 PM, revealed she was the only nurse on the second floor which had a census of sixty-one (61) residents, and she had been working as the only licensed nurse on the unit since approximately 3:45 PM when the day shift nurses left. The Acting DON further revealed she was behind on performing Accuchecks (procedure to determine Blood Glucose levels) which were ordered to be performed at 4:00 PM and 5:00 PM. Interview with Licensed Practical Nurse (LPN) #7 and LPN #8, revealed they arrived on the second floor unit to assist the Acting DON at approximately 6:45 PM on 02/05/18. LPN #7, LPN #8 and the Acting DON stated the Sliding Scale Insulin medication which was ordered to be administered to the second floor residents at 4:00 PM and 5:00 PM, in accordance with the Accuchecks, was not administered until between 7:00 PM and 8:00 PM on 02/05/18. Furthermore, the nurses revealed they performed 8:00 PM and 9:00 PM Accuchecks; administered Sliding Scale Insulin coverage; and administered routine long acting Insulin between 9:00 PM and 11:30 PM on 02/05/18, which was outside the scheduled medication times for these medications. This failure affected Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A. (Refer to F-760) Additionally, observation on 02/15/18 at 08:45 AM, revealed Licensed Practical Nurse (LPN) #11 had nine (9) unlabeled medication cups on the top of the first floor medication cart. The medication cups contained a total of fifty-six (56) medications. Interview with LPN #11 at the time of observation, revealed she had pulled the medication for eight (8) residents, and documented administration of the medication on the Medication Administration Record [REDACTED]. This affected Residents #6, #29, #54, #66, #72, #80, #90, and #92. The facility's failure to have an effective system to ensure services provided met the standards of practice for medication administration has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/08/18, and determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: 1. Interview with the Administrator on 02/16/18 at 4:00 PM, revealed the facility did not use a certain standards of practice for medication pass, but used KBN Guidelines. Review of the KBN, AOS #14, revised October 2015, Roles of Nurses in the implementation of Patient Care Orders, revealed in accordance with Kentucky Revised Statutes (KRS) 314.021 (2), nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (ARNP). This includes preparing and administering medications in the prescribed dosage, route, and frequency. Review of the facility's Medication Administration Policy, undated, revealed medications are administered in accordance with written orders of the prescriber and if necessary the nurse calls the prescriber for clarification. Medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. The individual who administers the medication dose, records the administration on the resident's Medication Administration Record [REDACTED]. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled and an explanatory note is entered on the reverse of the record. Further review of the policy revealed there was no clarification to state the procedure for documentation when a medication was given other than the scheduled time on the Electronic Medication Administration Record [REDACTED] Observation and interview, on 02/05/18 at 6:40 PM, revealed the Acting Director of Nursing (DON) was the only nurse on the South Hall unit for sixty-one (61) residents because two (2) nurses had called in for the 3:00 PM - 11:00 PM shift. She revealed she was just obtaining Accuchecks for the diabetic residents and was late administering the 4:00 PM and 5:00 PM Sliding Scale (SS) coverage. Per interview, two (2) nurses from another facility were coming in to help her; however, would not be there until approximately 7:00 PM. Interview with LPN #8 on 02/06/18 at 3:15 PM and with LPN #7 on 02/08/17 12:27 PM and revealed they arrived on the unit at approximately 6:45 PM. Both revealed they received a list of Accucheck results which had been obtained by the Acting DON and started administering Insulin in accordance with the Accuchecks. Per interview, they administered Insulin that was due at 4:00 PM and 5:00 PM between 7:00 PM and 7:30 PM. Additional interview on 02/07/18 at 4:00 PM, with the Acting DON revealed she held off on the administration of the 9:00 PM Accuchecks and Insulin until 10:00 to 10:30 PM due to giving the 4:00 PM and 5:00 PM Insulin late. Record review revealed fourteen (14) sampled residents and one unsampled resident (Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A) did not receive their scheduled Insulin or Sliding Scale (SS) Insulin as ordered the evening of 02/05/18, with medication administration being from two (2) to four (4) hours late. Record review revealed Residents #13, #31, #40, #61, #64, #78, and Unsampled Resident A received both SS Insulin and scheduled Insulin at the same time the evening of 02/05/18. In addition, per record review on the evening of 02/05/18, Resident #4 did not receive their SS Insulin as indicated for a blood glucose reading of 235; Residents #19 and #20 did not receive their scheduled Insulin; and, Residents #13, #31, #40, #61, #64, #78 and Unsampled Resident A received SS Insulin and scheduled insulin at the same time. Further interview with the Acting DON, 02/07/18 at 4:00 PM, revealed she should have documented in the Nurse's Notes the time the Accuchecks and Insulin's were actually administered, as there was no way to document this on the EMAR. Per interview, the Physician's orders related to Accuchecks and Insulin Administration were not followed as orders were carried out outside of the parameters of one (1) hour before and one (1) hour after the scheduled time for medication administration, per the facility's policy and procedures, and the Insulin was not given as ordered related to mealtime. She further revealed standards of practice related to Insulin administration were not met. Interview with LPN #8, on 02/06/18 at 3:15 PM, revealed she did not document the late administration of Insulin in the Nurse's Notes, but should have. Per interview, standards of practice related to Insulin administration were not followed as the Insulin was administered outside the timeframe's as per physician orders and the facility's policy and procedures. Interview with LPN #7, on 2/8/17 12:27 PM, revealed she did not document the Insulin's were administered late in the Nurse's Notes. She stated for some residents the routine Insulin and Sliding Scale Insulin were given at the same time because she was late giving the 4:00 PM and 5:00 PM Sliding Scale Insulin's. She further stated medication should be given one (1) hour before to one (1) hour after the scheduled time or at specific times according to meals. Per interview, standards of practice were not followed related to Insulin administration on 02/05/18. Interview on 02/08/18 at 3:00 PM, with the Attending Physician/Medical Director, for Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A, revealed he expected Accuchecks to be performed as per Physician's orders and Insulin to be administered on time as per the Physician's Orders. He stated there could be adverse consequences of not receiving Insulin as ordered or giving Insulin's out of the timeframe parameters. He stated it was a professional standard of practice to administer medication as ordered, and the professional standard was not met on 02/05/18 when the medications were not administered on time as ordered. Interview with the Administrator, on 02/08/18 at 7:10 PM, revealed residents could suffer negative consequences if Insulin was not being administered on time as per orders and per professional standards of practice. 2. Review of the facility Policy, titled Medication Administration dated 2007, revealed medications are to be administered at the time they are prepared; no medications are to be kept on top of the cart; and the individual who administers the medication dose records the administration on the residents Medication Administration Record [REDACTED]. Observation on 02/15/18 from 08:45 AM until 9:00 AM, with LPN #11, revealed there were nine (9) unlabeled medication cups on the top of the first floor medication cart. Further observation revealed the medication cups contained a total of fifty-six (56) medications. There were five (5) tablets in an unmarked medication cup on top of the medication cart which LPN #11 identified as belonging to Resident #6, by a written list she had to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered the medication to the resident as they were in the cup on top of the medication cart. There were eight (8) tablets in an unmarked medication cup on top of the medication cart which LPN #11 identified as belonging to Resident #29, by the written list she had to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered these medications to the resident as they were in the cup on top of the medication cart. There were five (5) tablets in an unmarked medication cup on top of the medication cart which LPN #11 identified as belonging to Resident #54 by a written list she had to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered these medications to the resident as they were in the cup on top of the medication cart. There were ten (10) tablets in an unmarked medication cup on top of the medication cart which LPN #11 identified as belonging to Resident #66 by a written list she had to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered these medications to the resident as they were in the cup on top of the medication cart. There were seven (7) tablets in an unmarked medication cup on top of the medication cart which LPN #11 identified as belonging to Resident #72 by a written list she had to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered these medications to the resident as they were in the cup on top of the medication cart. There were eight (8) tablets in an unmarked medication cup on top of the medication cart which LPN #11 identified as belonging to Resident #80, by a written list to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered these medications to the resident as they were in the cup on top of the medication cart. There were three (3) tablets in an unmarked medication cup and an unmarked medication cup with clear liquid on top of the medication cart which LPN #11 identified as belonging to Resident #90 by a written list she had to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered these medications to the resident as they were in the cup on top of the medication cart. There were nine (9) tablets in an unmarked medication cup on top of the medication cart which LPN #11 identified as belonging to Resident #92 by a written list she had to the right of the medication cups. Record review of the MAR indicated [REDACTED]. However, LPN #11 revealed she had not yet administered these medications to the resident as they were in the cup on top of the medication cart. Continued interview with LPN #11, on 02/15/18 at 09:00 AM, revealed she had pulled and documented all medications prior to administering them in an attempt to administer the medications in a timely manner. She stated she pulled the medications from the cart and placed them in medications cups and had a list to the right of the cup stating the resident who was to receive the medications, but had not labeled the cups with the resident's name. Further interview with LPN #11, revealed she knew it was against the facility's policy to administer and document medication in this manner, but she thought it would be a quicker way to complete medication pass so that she could proceed to her other duties. Per interview, she did see where there was a risk of administering the wrong medication to the residents which could lead to serious consequences. She further stated it was not policy to document the administration of medications before they were administered. Post-Survey interview with the Acting DON, on 02/28/18 at 11:32 AM, revealed she expected all staff to follow the facility's policy and prepare medications individually for each resident and to document the medications as administered on the MAR indicated [REDACTED]. Interview with the Regional Quality Manager, on 02/16/185 at 09:15 AM, revealed all staff were to follow the facility's policy regarding medication administration. Per interview, medications should be pulled from the medication cart for the individual resident at the time of delivery. Continued interview revealed medications should never be prepared or pre-documented and should always be documented after administration per the medication rights. She stated this was important because if medications were not administered correctly there could be medication errors that could have a negative impact on the residents. Interview with the Administrator, on 06/16/18 at 9:25 AM, revealed it was his expectation for staff to follow the facility's policy related to medication administration. He stated staff were to prepare medications individually for each resident and were not to document administration of the medication until the medication had actually been administered. He stated proper administration of medication was important to prevent medication errors and to prevent negative outcomes to the residents. He further stated the facility needed to re-educate staff and perform audits to address medication administration issues in the facility. The facility provided an acceptable credible Allegation of Compliance on (A(NAME)) 02/16/18, which alleged removal of the IJ effective 02/14/18. Review of the A(NAME) revealed the facility implemented the following: 1. On 02/08/18 the facility added additional staffing on the 3:00 to 11:00 PM shift to include one Licensed Practical Nurse (LPN) who clocked in at 6:30 PM and one LPN who clocked in at 6:45 PM. 2. On 02/09/18, a licensed nurse completed Medication Error Reports for each of the fifteen (15) residents (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33) identified in the deficient practice of insulin administration. 3. On 02/09/18, a licensed nurse verified no new orders or adverse outcomes were noted as a result of the medication errors for any of the identified fifteen residents, (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33). 4. On 02/06/18, the facility entered into a contract with a nursing staffing agency to supplement any staffing needs. 5. On 02/08/18, the Human Resource Manager/Staffing Coordinator validated that all open positions were posted for recruitment. Further interview revealed, the facility expanded the recruitment area for licensed nurses. 6. On 02/11/18, the Regional Quality Manager performed an audit of residents. Thirty-nine total residents were identified who received blood glucose monitoring and subsequent insulin orders. The audit validated blood sugar testing completion, physician follow up if indicated and physician's orders were being followed with any discrepancies being addressed. 7. On 02/09/18, the Administrator and Regional Director of Operations created and adopted a new Emergency Staffing Procedure to address actions to be taken during emergencies or where additional staffing is optional. 8. On 02/09/18, the Administrator and the Regional Director of Operations reviewed and updated the staffing component of the facility self-assessment. 9. On 02/09/18, re-education was provided by the Regional Quality Manager to the Acting Director of Nursing (DON) in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. On 02/09/18, re-education was provided by the Regional Director of Operations to the Administrator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. On 02/10/18, re-education was provided by the Regional Quality Manager to a licensed Staff Educator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 12. The Acting DON and/or the licensed Staff Educator and Regional Quality Manager provided education to licensed nurses. The education included notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Approximately 93% of the current facility licensed nursing staff completed education by 02/13/18. Those remaining will have completed education prior to assuming duties upon returning to work. 13. Agency nursing binder implemented with orientation reference steps and training information and copies to be given to any agency nurse. Any agency nurse will be required to complete education by Director of Nursing or Assistant Director of Nursing prior to assuming duties and will sign for received education. 14. Acting DON, Staff Educator and/or Regional Quality Manager provided validation of educational understanding by the licensed nursing staff with return verbal exchange. 15. Audits were to be done by the Acting DON, Nurse Manager, and/or the Regional Quality Manager daily beginning 02/09/18, for blood sugar test completion, physician follow up if indicated, physician orders followed with any discrepancies addressed. 16. Quality Assurance (QA) Meetings were held on 02/09/18 to discuss the IJ allegation and develop an action plan. The Attendees included the Administrator, Regional Quality Manager, Acting DON, Social Services (2), Business Director, Human Resources/Staffing Coordinator, and the Regional Director of Operations. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action to be initiated. QA meetings were to be held at least weekly until substantial compliance was achieved and monthly thereafter. A member of the Regional Team will be in attendance in addition to the facility team for the weekly QA. The Team was to include at a minimum the Administrator, Acting DON, Social Services, State Registered Nursing Assistant and the Charge Nurse. 17. On 2/09/18, a Governing Body Meeting was held to officially document in the minutes the appointment of a replacement Administrator and outline the Administrative duties. The Administrator had received an official letter of appointment on 01/30/18. The Administrator, the Acting DON and the Regional Director of Operations were in attendance. The Medical Director was contacted by the Administrator on 02/09/18 and reviewed the Governing Body Meeting Minutes were reviewed with him. The State Survey Agency validated the implementation of the facility's A(NAME) as follows: 1. Reviewed facility staffing sheets for 02/05/18. LPN #7 clocked in at 6:30 PM and LPN #8 clocked in at 6:45 PM on 02/05/18. Interview with Administrator on 02/16/18 revealed he had verified LPN # 7 had clocked in at 6:30 PM and LPN #8 had clocked in at 6:45 PM on 02/05/18, per the Acting DON and time sheets. Interview with the Acting DON, during a post survey interview, on 02/22/18 at 10:10 AM, revealed on 02/05/18, she had been the only nurse on the second floor until LPN #7 and LPN #8 clocked in around 6:30 PM. Further interview revealed, the shift started at 3:00 PM. 2. Review of the Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33, identified with the deficient practice sliding scale insulin administered outside the time frame on 02/05/18. These reports were completed by the Acting DON. Interview with the Acting DON, during a post survey interview on 02/22/18 at 10:10 AM, revealed she had completed the Medication error reports on 02/09/18. 3. Review of Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, and Resident #33, revealed they were signed by the Acting DON. Further review revealed, the Acting DON notified the physician and documented there were no new orders or adverse outcomes related to the insulin administration errors made on 02/05/18. Post Survey Interview with the Acting DON, on 02/22/18 at 10:10 AM, revealed she notified physician and there were no adverse effects or orders from physician related to Medication Error Reports on 02/09/18. 4. Review of the facility's contract with the nurse staffing agency, dated 02/06/18, revealed the contract was signed by the Administrator. Further review revealed, the contact was to provide supplemental staffing and staffing placement options. Interview with the Administrator, on 02/16/18 at 1:00 PM, revealed he did sign the staffing agreement with the nursing staffing agency on 02/06/18. 5. Review of the Human Resource/Staffing Coordinator statement, dated 02/08/18, reported marketing strategies were reviewed and placed in surrounding areas for nurse recruitment purposes. Interview with the Human Resources/Staffing Coordinator, on 02/16/18 at 2:00 PM, validated marketing strategies were used in an attempt to recruit staff and expand recruitment areas on 02/08/18. 6. Review of the audit, dated 02/11/18, revealed thirty-nine (39) residents were identified to receive finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and physician's orders being followed with any discrepancies addressed was completed by the Regional Quality Manager. Interview with Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she audited all residents in the facility. Continued interview revealed, she identified thirty-nine (39) residents that received finger glucose monitoring and subsequent blood sugar testing. Further interview revealed she audited areas to included: residents receiving finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and orders being followed with any discrepancies addressed. 7. Review of the Emergency staffing Procedure reveals, the procedure was dated effective 02/10/18. Continued review of the document revealed, during emergencies, scheduled staffing interruption, or other temporary situations, a supervisor may require an employee to work different workdays, additional shift(s), different shift(s), or extended shift(s) without advanced notice. 8. Review of the staffing component of the facility self-assessment, dated 02/09/18, revealed the Administrator and the Regional Director of Operations reviewed and updated the staffing component previously dated 11/28/17. Further review revealed, the document was reviewed by the Governing body, Acting DON, Medical Director and Maintenance Director on 02/09/18. Interview with Administrator, on 2/16/18 at 11:00 AM, revealed the staffing component was updated on 02/09/18. Interview with Medical Director, on 02/16/18 at 4:20 PM, revealed he was updated on the facility self-assessment updates in the Governing Body Meeting on 02/09/18. 9. Review of the facility Education sign in sheets, dated 02/09/18, revealed the Acting DON was re-educated on newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Further review revealed, the education was provided by the Regional Quality Manager. Post Survey Interview with the Acting DON, on 02/22/16 at 10:10 AM, revealed she had been re-educated by the Regional Quality Manager on the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. Review of Education sign in sheets, dated 02/09/18, revealed the Administrator was re-educated by the Regional Director of Operations. Continued review revealed the education consisted of: the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and (TRUNCATED)

Based on observation, interview, record review, review of facility's Policies, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, it was determined the facility failed to have an effective system to ensure services were provided by the facility in accordance with each resident's written plan of care for twenty-one (21) of fifty-two (52) sampled residents (Residents #1, #4, #9, #13, #14, #19, #20, #22, #23, #27, #31, #40, #52, #61, #63, #64, #70 #78, #79, #91, and #102) and one (1) unsampled resident (Unsampled Resident A). Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A's Comprehensive Care Plans were not followed related to monitoring Blood Glucose Levels, Insulin Administration as ordered, and notification to the Physician for high and low blood glucose levels. Observation and interview with the Acting Director of Nursing (DON), on 02/05/18 at 6:40 PM, revealed she had been working as the only licensed nurse for sixty-one (61) residents, since approximately 3:45 PM when the day shift nurses left and was performing Accuchecks (procedure to determine Blood Glucose levels). Interview on 02/06/18, 02/07/18, and 02/08/18 with Licensed Practical Nurse (LPN) #7, LPN #8, and the Acting DON, revealed LPN #7 and LPN #8 arrived on the second floor unit to assist the Acting DON at approximately 6:45 PM on 02/05/18. The three (3) nurses verified the Sliding Scale Insulin medication which was ordered to be administered to the second floor residents at 4:00 PM and 5:00 PM, in accordance with the Accuchecks, was not administered until between 7:00 PM and 8:00 PM on 02/05/18. Additionally, the nurses revealed they performed 8:00 PM and 9:00 PM Accuchecks; administered Sliding Scale Insulin coverage; and administered routine long acting Insulin between 9:00 PM and 11:30 PM on 02/05/18, without notifying the Physician the 4:00 PM and 5:00 PM Insulin had been administered late. Record review confirmed the Accuchecks were not performed as ordered, the Insulin's were not administered as ordered, and the Physician was not notified of high and low blood sugars per the Comprehensive Care Plans the evening of 02/05/18 (Refer to F-580, F-725 and F-760). In addition, Residents #1, #9, #27, #52, #70 and #91's Comprehensive Care Plans were not followed related to Weekly Skin Assessments. Interview and record review revealed the previous Director of Nursing's (DON) last day at the facility was 01/05/18, and the Assistant DON was placed in the Acting DON position on 01/05/18. However, the Acting DON was not able to fulfill the duties of the Acting DON, due to having to work in the role of staff nurse due to the staffing shortage. Interview further revealed due to the staffing shortage the nurses were unable to complete skin and wound documentation weekly as per protocol. (Refer to F-686 and F-725) Furthermore, Nutritional Comprehensive Care Plans were not followed related to monthly weights. Although for most residents' monthly weights were obtained, they were not verified to ensure they were accurate when there was a significant discrepancy in weights obtained from month to month. In addition, the Care Plans were not followed related to recording meal consumption and notification to the Physician related to weight loss. This affected Residents #9, #27, #70, #83, and #91's (Refer to F-580, and F-692, and F-725) Additionally, Activities Comprehensive Care Plans were not followed related to both group activities and one (1) on one (1) activities for Residents #23, #52, and #102. (Refer to F679) The facility's failure to have an effective system in place to ensure services were provided by the facility in accordance with each resident's written Comprehensive Plan of Care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/08/18, and determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of the facility's Comprehensive Care Plans Standard of Practice Policy, revised November 2017, revealed it is the practice of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The following examples demonstrate the facility's failure to ensure the Comprehensive Care Plans were implemented related to Blood Sugar Checks and Insulin administration: 1. Review of Resident #1's Medical Record revealed the facility admitted him/her on 01/30/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, dated 02/14/17, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Diabetic. The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included the following: Routine Insulin as ordered; Accuchecks QID (four times a day) and give Sliding Scale Insulin Injections as ordered; monitor of hypo/hyperglycemic episodes and document action taken; monitor blood glucose level with signs and symptoms of changes in mood, behaviors, lethargy, diarrhea, nausea and vomiting that is not customary; diet as ordered and offer substitute as indicated and encourage to consume snacks. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 02/05/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was severely cognitively impaired. Review of Section I of the MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #1's Electronic Medication Record (EMAR), revealed he/she was to receive [MEDICATION NAME] per SS coverage at 5:00 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 20 units at 9:00 PM. Additional review revealed Licensed Practical Nurse (LPN) #8 signed the EMAR at 5:00 PM and 9:00 PM, indicating the medications were given as scheduled. However, review of Resident #1's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #1 received the 5:00 PM dose of [MEDICATION NAME] SS coverage of 2 units at 8:34 PM for a blood sugar reading of 162, indicating the Insulin was administered three (3) hours and thirty-four (34) minutes late by LPN #8. Further review revealed the 9:00 PM Accucheck had been completed and the dose of [MEDICATION NAME] SS coverage was not administered. Additional review revealed the 9:00 PM dose of [MEDICATION NAME] 20 units, was administered as scheduled by LPN #8, twenty-six (26) minutes after the SS coverage was administered. Also, review revealed the 6:00 AM blood sugar reading was 106 at 7:54 AM on 02/06/18, which was done one (1) hour and fifty-four (54) minutes after the scheduled 6:00 AM time. 2. Review of Resident #4's Clinical Record revealed the facility admitted him/her on 08/16/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan revised 11/29/17, revealed the resident was at risk for alteration in blood glucose level related to Diabetes. The goal stated the resident would be free of hypo/[MEDICAL CONDITION] episodes. Interventions included: medications as ordered; notify physician of persistent low less than sixty (60) or elevated greater than four-hundred blood glucose; offer bedtime snack; diet as ordered; and update family and physician of changes as needed. Review of Resident #4's Quarterly MDS Assessment, dated 01/25/18, revealed the facility assessed the resident as having a BIMS score of fifteen (15), out of fifteen (15), which indicated the resident was cognitively intact. Review of Section I of Resident #4's MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #4's physician's orders [REDACTED]. Continued review revealed the resident did not have a routinely scheduled Insulin at bedtime. Review of Resident #4's EMAR, revealed the resident was to receive [MEDICATION NAME] 100 units/ml per SS coverage at 4:30 PM and 9:00 PM. Further review revealed the Acting DON signed the EMAR at 4:30 PM and 9:00 PM, indicating the Insulin had been given on time. However, review of Resident #4's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #4 received the 4:30 PM dose of [MEDICATION NAME] SS coverage of 4 units which was prescribed for a blood glucose reading of 235 at 7:38 PM, indicating it had been administered two (2) hours and eight (8) minutes late. Continued review revealed the 9:00 PM blood sugar reading was obtained at 10:51 PM, and the dose of [MEDICATION NAME] SS coverage had been held due to special requirements were not met. However, further review revealed the 9:00 PM blood sugar reading had been obtained at 10:51 PM, indicating it had been done one (1) hour and fifty-one (51) minutes past it's scheduled 9:00 PM time. 3. Review of Resident #13's Clinical Record revealed the facility readmitted him/her on 04/30/16 with [DIAGNOSES REDACTED]. Review of Resident 13's Comprehensive Care Plan with an onset date of 01/30/15, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Insulin Dependent Diabetes Mellitus (IDDM). The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included the following: monitor blood glucose levels per physician's orders [REDACTED]. Review of Resident #13's Quarterly MDS Assessment, dated 10/09/17, revealed the facility assessed the resident as having a BIMS score of seven (7) out of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Section I of Resident #13's MDS revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #13's physician's orders [REDACTED]. Review of Resident #13's EMAR, dated 02/05/18, revealed he/she was to receive [MEDICATION NAME] 100 units/ml, 20 units at 5:00 PM; [MEDICATION NAME] 100 units/ml per SS coverage at 5:00 PM and 9:00 PM; and [MEDICATION NAME] 100 units/ml, 55 units at 9:00 PM. Additional review revealed LPN #8 signed the EMAR at 5:00 PM and 9:00 PM, indicating all the Insulin medications had been given on time. However, review of Resident #13's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #13 received the 5:00 PM dose of [MEDICATION NAME] 100 units/ml, 20 units at 7:29 PM, indicating the Insulin was administered two (2) hours and twenty-nine (29) minutes late. Continued review revealed the 5:00 PM [MEDICATION NAME] 100 units/ml, 4 units per SS coverage for a blood glucose reading of 245 had also been administered at 7:29 PM, indicating this medication had been administered two (2) hours and twenty-nine (29) minutes after the scheduled 5:00 PM time and in conjunction with the scheduled Insulin of 20 units. Additional review of the EMAR Detailed Report, revealed the 9:00 PM [MEDICATION NAME] 100 units/ml, 55 units was administered at 10:49 PM, indicating the Insulin was administered one (1) hour and forty-nine (49) minutes late by LPN #8. Also, review revealed the resident had a blood sugar reading of 188 at 7:56 AM with 2 units SS coverage administered one (1) hour and fifty-six (56) minutes after the scheduled 6:00 AM SS coverage was due. 4. Review of Resident #14's Clinical Record revealed the facility readmitted him/her on 11/06/17 with [DIAGNOSES REDACTED]. Review of Resident 14's Comprehensive Care Plan dated 07/18/17, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Diabetes. The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included the following: oral meds as ordered; monitor blood glucose levels per physician's orders [REDACTED]. Review of Resident #14's Quarterly MDS Assessment, dated 11/13/17, revealed the facility assessed the resident as having a BIMS score of seven (7) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of Section I of Resident #14's MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #14's physician's orders [REDACTED]. Review of Resident #14's EMAR dated 02/05/18, revealed he/she was to receive Humalog 100 units/ml per SS at 5:00 PM and 9:00 PM. Continued review revealed LPN #8 signed Resident #14 had received Humalog 100 units/ml, two (2) units per SS at 5:00 PM, indicating the Humalog had been administered on time. Additional review revealed the Acting DON had signed Resident #14's 9:00 PM dose of Humalog 100 units/ml per SS coverage as not administered. However, review of Resident #14's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #14 received Humalog two (2) units for a blood sugar reading of 199 at 9:15 PM by LPN #8, four (4) hours and fifteen (15) minutes late. Further review of the EMAR Detailed Report, revealed no documented evidence the 9:00 PM blood sugar reading was obtained, and the SS coverage was not administered by the Acting DON. 5. Review of Resident #19's Clinical Record revealed the facility readmitted the resident on 11/16/17 with [DIAGNOSES REDACTED]. Review of Resident 19's Comprehensive Care Plan dated 11/29/17, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Diabetic (Insulin Dependent). The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included: monitor for signs and symptoms hypo/[MEDICAL CONDITION] and document action taken; routine insulin as ordered; and notify physician of persistent low (less than) sixty (60) or elevated (greater than) four hundred (400) blood glucose levels. Review of Resident #19's Quarterly MDS Assessment, dated 01/24/18, revealed the facility assessed him/her as having a BIMS score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of Section I of Resident #19's MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #19's physician's orders [REDACTED]. Review of Resident #19's EMAR, dated 02/05/18, revealed he/she was to receive Humalog 100 units/ml per SS coverage at 4:30 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 15 units at 8:30 PM. Additional review revealed the Acting DON signed the EMAR at 4:30 PM, 8:30 PM, and 9:00 PM, indicating the Insulin medications had been given on time. However, review of Resident #19's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #19 received the 4:30 PM dose of Humalog 100 units/ml, 12 units per SS coverage for a blood glucose reading of 405 at 7:54 PM, indicating the medication had been administered three (3) hours and twenty-four (24) minutes after the scheduled 4:30 PM time. Additional review of the EMAR Detailed Report, revealed no documented evidence the 8:30 PM [MEDICATION NAME] 100 units/ml, 15 units had been administered by the Acting DON. Continued review revealed Resident #19's 9:00 PM dose of Humalog 100 units/ml, 12 units per SS coverage had been administered at 11:25 PM for a blood sugar reading of 516, indicating the medication had been administered two (2) hours and twenty-five (25) minutes late. Review of Resident #19's Nurse's Note dated 02/05/18, revealed there was no documented evidence the Acting DON notified the physician of the high blood sugar readings of 405 and 516 on 02/05/18, per the plan of care. 6. Review of Resident #20's Clinical Record revealed the facility admitted him/her on 11/20/17 with [DIAGNOSES REDACTED]. Review of Resident #20's Admission MDS Assessment, dated 11/27/17, revealed the facility assessed him/her as having a BIMS score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of Section I of Resident #20's MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident 20's Comprehensive Care Plan dated 11/30/17, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Diabetic (Insulin Dependent). The goal stated the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included the following: monitor blood glucose levels with signs and symptoms of lethargy, changes in mental status, diarrhea, nausea, vomiting that is not customary; Humalog, give per sliding scale; routine insulin as ordered; and notify physician of persistent low (less than) sixty (60) or elevated (greater than) four hundred (400) blood glucose levels; offer snacks. Review of Resident #20's physician's orders [REDACTED]. Review of Resident #20's EMAR dated 02/05/18, revealed he/she was to receive Humalog 100 units/ml per SS coverage at 5:00 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 25 units at 8:00 PM. Continued review revealed LPN #7 had signed the EMAR at 5:00 PM, 8:00 PM, and 9:00 PM, indicating all the medications had been given on time. However, review of Resident #20's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #20 received the 5:00 PM dose of Humalog 100 units/ml, 6 units per SS coverage for a blood glucose reading of 251 at 8:57 PM, indicating the medication was administered three (3) hours and fifty-seven (57) minutes after the scheduled 5:00 PM time. Additional review of the EMAR Detailed Report, revealed there was no documented evidence the 8:00 PM [MEDICATION NAME] 100 units/ml, 25 units had been administered by LPN #7. Continued review of the EMAR Detailed Report, revealed the 9:00 PM Humalog 100 units/ml, 6 units per SS coverage for a blood sugar of 270, had been administered at 10:03 PM, indicating it was administered as scheduled. 7. Review of Resident #22's Clinical Record revealed the facility readmitted him/her on 11/17/17 with [DIAGNOSES REDACTED]. Review of Resident 22's Comprehensive Care Plan dated 02/27/15, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Insulin Dependent Diabetes Mellitus (IDDM). The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included the following: monitor blood glucose levels per physician's orders [REDACTED]. Review of Resident #22's Quarterly MDS Assessment, dated 11/24/17, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Section I of Resident # 22's MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #22's physician's orders [REDACTED]. Review of Resident #22's EMAR, dated 02/05/18, revealed he/she was to receive [MEDICATION NAME] 100 units/ml per SS coverage at 4:30 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 25 units at 8:00 PM. Further review revealed the Acting DON signed the EMAR at 4:30 PM, and 8:00 PM, indicating the medications had been given on time. However, review of Resident #22's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #22 received the 4:30 PM dose of [MEDICATION NAME] 4 units per SS coverage for a blood glucose reading of 214 at 7:53 PM, indicating the medication was administered three (3) hours and twenty-three (23) minutes after the scheduled 4:30 PM time. Continued review of the EMAR Detailed Report, revealed the 8:00 PM [MEDICATION NAME] 100 units/ml, 25 units had been administered at 11:18 PM, indicating it had been administered three (3) hours and eighteen (18) minutes late by the Acting DON. Also, review revealed Resident #22's 9:00 PM blood sugar reading was obtained at 11:18 PM, indicating it had been obtained two (2) hours and eighteen (18) minutes late and the 9:00 PM dose of [MEDICATION NAME] 100 units/ml per SS coverage was held due to a blood sugar reading of 65. 8. Review of Resident #31's Clinical Record revealed the facility readmitted him/her on 12/21/17 with [DIAGNOSES REDACTED]. Review of Resident 31's Comprehensive Care Plan dated 04/30/15, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Insulin Dependent Diabetes Mellitus (IDDM). The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included the following: monitor blood glucose levels per physician's orders [REDACTED]. Review of Resident #31's Annual MDS Assessment, dated 12/02/17, revealed the facility assessed him/her as having a BIMS score of fifteen (15), indicating the resident was cognitively intact. Review of Section I of the MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #31's physician's orders [REDACTED]. Review of Resident #31's EMAR dated 02/05/18, revealed he/she was to receive Humalog 100 units/ml, 20 units at 5:00 PM; Humalog 100 units/ml per SS coverage at 4:00 PM and 8:00 PM; and [MEDICATION NAME] 100 units/ml, 40 units at 8:00 PM. Additional review revealed the Acting DON signed for the Insulin's on the EMAR at 4:00 PM, 5:00 PM, and 8:00 PM, indicating all the medications had been given on time. However, review of Resident #31's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #31 received the 4:00 PM Humalog 100 units/ml, 4 unit's SS coverage for a blood sugar of 237, at 7:20 PM, indicating it was administered three (3) hours and twenty (20) minutes late. Continued review of the EMAR Detailed Report, revealed the scheduled 5:00 PM dose of Humalog 100 units/ml, 20 units was also administered at 7:20 PM, indicating the medication was administered two (2) hours and twenty (20) minutes late and in conjunction with the SS coverage. Further review revealed the 8:00 PM [MEDICATION NAME] 100 units/ml, 40 units was administered at 10:44 PM, indicating the medication was administered two (2) hours and forty-four (44) minutes late by the Acting DON. Additional review revealed the resident's blood sugar reading was 183 at 8:49 AM on 02/06/18, and the resident received two (2) units of SS coverage at 8:49 AM, indicating it had been obtained two (2) hours and forty-nine minutes after its scheduled 6:00 AM time. 9. Review of Resident #40's Clinical Record revealed the facility readmitted him/her on 11/26/17 with [DIAGNOSES REDACTED]. Review of Resident 40's Comprehensive Care Plan dated 03/26/15, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Insulin Dependent Diabetes Mellitus (IDDM). The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes. The interventions included: monitor blood glucose levels per physician's orders [REDACTED]. Review of Resident #40's Quarterly MDS Assessment, dated 12/05/17, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen, which indicated the resident was cognitively intact. Review of Section I of the MDS, revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of Resident #40's physician's orders [REDACTED]. Review of Resident #40's EMAR dated 02/05/18, revealed LPN #7 signed the EMAR at 4:00 PM, 5:00 PM, 8:00 PM, and 9:00 PM, indicating the Insulin medications had been administered on time. However, review of Resident #40's EMAR Detailed Report, dated 02/05/18, revealed the medications were not administered as ordered per the plan of care. Resident #40 received the 4:00 PM dose of [MEDICATION NAME] SS coverage of 4 units at 7:41 PM, indicating the medication had been administered two (2) hours and forty-one (41) minutes late. Continued review of the EMAR Detailed Report, revealed the 5:00 PM dose of scheduled [MEDICATION NAME], was administered at 7:41 PM, indicating the medication was administered two (2) hours and forty-one (41) minutes late, at the same time as the SS coverage, which was administered at the same time as the 5:00 PM dose of [MEDICATION NAME]. Ongoing review revealed the routine scheduled 8:00 PM dose of [MEDICATION NAME] 26 units was administered at 11:04 PM, indicating it was administered three (3) hours and four (4) minutes late. Additional review of the EMAR Detailed Report, dated 02/05/18, revealed the 8:00 PM [MEDICATION NAME] SS coverage of 2 units for a blood glucose reading of 183 was administered at 11:04 PM, (at the same time as the [MEDICATION NAME]), indicating it was administered three (3) hours and four (4) minutes late by LPN #7. The EMAR Detailed Report further revealed, LPN #7 administered the 9:00 PM dose of scheduled [MEDICATION NAME] at 11:04 PM (at the same time as the [MEDICATION NAME] and [MEDICATION NAME] SS coverage), indicating the Insulin was administered two (2) hours and four (4) minutes late. 10. Review of Resident #61's Clinical Record revealed the facility readmitted him/her on 12/18/17 with [DIAGNOSES REDACTED]. Review of Resident 61's Comprehensive Care Plan dated 11/12/15, revealed he/she was at Risk for Alteration in Blood Glucose Levels related to Insulin Dependent Diabetes Mellitus (IDDM). The goal revealed the resident would be free from signs and symptoms of hypo/hyperglycemic episodes for ninety (90) days. The interventions included the following: monitor blood glucose levels per physician's orders XREDACT

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to have an effective system in place to ensure sufficient numbers of nursing staff, including Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Registered Nurse Aides (SRNA), were available to provide nursing care on a twenty-four (24) hour basis for twenty-three (23) of fifty-two (52) sampled residents (#1, #4, #9, #13, #14, #19, #20, #22, #27, #31, #39, #40, #50, #52, #61, #63, #64, #70, #78, #79, #83, #91, #102) and one (1) unsampled resident (Unsampled Resident A). Observation on 02/05/18 at 6:40 PM, revealed the second floor unit of the facility had a census of sixty-one (61) residents and the Acting Director of Nursing (DON) was the only nurse on the unit. Interview with the Acting DON at the time of observation revealed she had been the only nurse on the unit since approximately 3:45 PM and was late performing Accuchecks (procedure to determine Blood Glucose levels) for the diabetic residents which were ordered to be performed at 4:00 PM and 5:00 PM. Interview with Licensed Practical Nurse (LPN) #7 and LPN #8, who arrived on the second floor unit at approximately 6:45 PM, and further interview with the Acting DON, revealed the Sliding Scale Insulin which was ordered to be administered at 4:00 PM and 5:00 PM based on the results of the Accuchecks for diabetic residents was not administered until between 7:00 PM and 8:00 PM on 02/05/18. Interview also revealed on 02/05/18, the nurses performed 8:00 PM and 9:00 PM Accuchecks; administered Sliding Scale Insulin coverage; and administered scheduled long acting Insulin to diabetic residents between 9:00 PM and 11:30 PM, without notifying the Physician the 4:00 PM and 5:00 PM Insulin had been administered late. This affected Resident #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A. (Refer to F-580, F-760, F-835 and F-837) In addition, the facility failed to ensure there was oversight related to skin management. There was no documented evidence Weekly Skin and Wound Assessments were completed in order to identify and treat Pressure Ulcers before they deteriorated. Actual Harm was identified related to residents' not having skin assessed for up to fifty-two (52) days. Residents' skin was documented as intact and then after long periods without a skin assessment, Stage II and Unstageable Pressure Ulcer were identified. Per interview with staff, the nurses did not have time to ensure the skin assessments were completed and there were more Pressure Ulcers noted due to the staffing shortage. This affected Residents #1, #9, #27, #52, #70 and #91. (Refer to F-686) Additionally, the facility failed to ensure monthly weights were obtained, and the Physician was notified for significant weight losses and gains. Also, when variances in weights were noted with significant weight gains or losses, there was no documented evidence re-weights were obtained. Furthermore, there was no documented evidence meal consumption was being consistently documented or monitored and no documented evidence resident's weights and nutritional status were consistently monitored by the Weight Committee. Interviews revealed this was due to the staffing shortage. This affected Residents #27, #70, #83, and #91 (Refer to F-692) Also, interview and record review, revealed Residents #19, #22, # 40, #50, and #64 were discharged from Therapy with recommendations for the Restorative Nursing Program; however, due to the staffing shortage, these residents were not receiving Restorative Nursing as per Therapy recommendations. (Refer to F-688) Furthermore, interview with residents and staff revealed baths/showers were not being completed due to the staffing shortage for Residents #1, #22, #39, #40, #50, #64, #83 and #102. Review of the Hygiene Reports for the months of December 2017, and January 2018, revealed baths/showers were not completed twice a week as scheduled and for some residents there was no documented evidence of baths/showers for the entire two (2) months reviewed. (Refer to F-677) The facility's failure to have an effective system in place to ensure sufficient numbers of nursing staff to provide care on a twenty-four (24) hour basis has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/08/18, and determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18, with remaining non-compliance at a Scope and Severity of a K while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Interview on 02/16/18 at 4:00 PM with the Interim Administrator, revealed the facility did not have a policy related to Sufficient Staffing. 1. Review of the facility's Medication Administration Policy, undated, revealed medications are administered in accordance with written orders of the prescriber and if necessary the nurse calls the prescriber for clarification. Medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Observation and interview, on 02/05/18 at 6:40 PM, revealed the Acting Director of Nursing (DON), was the only nurse on the South Hall unit for sixty-one (61) residents because two (2) nurses had called in for the 3:00 PM - 11:00 PM shift. Per interview, she was obtaining Accuchecks for the diabetic residents and was late administering the 4:00 PM and 5:00 PM Sliding Scale (SS) coverage. She further stated, two (2) nurses from another facility were coming in to help her; however, would not be there until approximately 7:00 PM. Interview with LPN #8 on 02/06/18 at 3:15 PM, and with LPN #7 on 02/08/17 at 12:27 PM, revealed they both arrived on the second floor unit at approximately 6:45 PM on 02/05/18. The nurses stated they received a list of Accucheck results which had been obtained by the Acting DON and started administering Insulin in accordance with the Accuchecks results. Per their interviews, they both administered Insulin that was due at 4:00 PM and 5:00 PM between 7:00 PM and 7:30 PM on 02/05/18. Additional interview with the Acting DON on 02/07/18 at 4:00 PM, verified on the evening of 02/05/18, she was the only nurse on the second floor unit for sixty-one (61) residents until approximately 6:45 PM when two (2) other nurses arrived on the unit. Per interview, she had informed the Staffing Scheduler and the Regional Quality Manager and they were aware she was the only nurse on the Unit. Per interview Record review of the Electronic Medication Administration Record [REDACTED]#14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A) did not receive their scheduled Insulin or Sliding Scale (SS) Insulin as ordered the evening of 02/05/18, with medication administration being from two (2) to four (4) hours late. Also, review of the EMAR Detailed Report, revealed Residents #13, #31, #40, #61, #64, #78, and Unsampled Resident A received both SS Insulin and scheduled Insulin at the same time the evening of 02/05/18. Additionally, per record review on the evening of 02/05/18, Resident #4 did not receive his/her SS Insulin as indicated for a blood glucose reading of 235; Residents #19 and #20 did not receive their scheduled Insulin; and, Residents #13, #31, #40, #61, #64, #78 and Unsampled Resident A received SS Insulin and scheduled insulin at the same time. Interview with the Staffing Scheduler, on 02/12/18 3:00 PM, revealed she didn't think she told the Administrator the evening shift was going to be short staffed on the second floor unit after two (2) nurses called in for that shift on 02/05/18. However, she stated the Acting DON was aware because both nurses called in within the two (2) hour window, and both she and the Acting DON tried to find coverage prior to the evening shift starting that day. She further stated there were two (2) nurses who arrived on 02/05/18 to assist the Acting DON on the second floor unit at approximately 6:30 PM to 7:00 PM. She stated she should have made sure the Administrator knew the unit would be left short staffed until the other nurses could arrive later in the evening for 02/05/18. 2. Review of the facility's Skin System Policy and Procedure, undated, revealed a skin assessment would be completed on admission/re-admission, with any fall, and weekly thereafter. The skin committee would meet at least weekly to review the care of residents with pressure ulcers, complex wounds and skin compromise; to include resident's nutritional status and response to healing. Staging and measuring would be done by the assigned nurse to maintain continuity in documentation of progression of wound healing. Further review of the Policy, revealed the assigned Nurse Manager would provide oversight of the resident's skin/wound care in collaboration with the nurse, and physician, and report changes to the Skin Committee on a weekly basis. Residents #70, #27, #91, #52, #9, and #1, acquired Pressure Ulcers in the facility from a Stage II to unstageable Pressure Ulcers after skin assessments/wound assessments were not completed for as long as fifty-two (52) days. There was no documented evidence the facility Policy was followed related to weekly Skin Assessments; staging and measuring by an assigned nurse to ensure continuity in documentation of progression of wound healing; or oversight of the resident's skin/wound care in collaboration with the nurse, and physician. Also, there was no documented evidence of consistent oversight of wounds through a Skin Committee on a weekly basis. Interview revealed the Unit Managers who were over the skin management for their units resigned as did several staff nurses after the resignation of the previous DON on 01/05/18. Interview and record review revealed the nurses were unable to complete skin and wound documentation and treatments as per protocol due to the staffing shortage. Actual Harm was identified for Residents #70, #91, and #52, related to lack of monitoring and acquisition of Pressure Ulcers. Interview was conducted on 02/06/18 at 2:00 PM, with LPN #3, who documented most of the Skin Assessments for Resident #70 for the months of November 2017 through February 2018. She revealed the nurses and State Registered Nurse Aides (SRNA) had been challenged recently as far as staffing, and patient care sometimes trumped skin assessments so some skin assessments may have been missed by the other nurses. She further stated, It's been rough and scary, referring to the staffing shortage. Interview on 01/31/18 at 9:10 AM, with Registered Nurse (RN) #2, revealed staffing had not been adequate and nurses who had been employed at the facility for many years were leaving because they were stressed and felt like their nursing license was on the line. She stated she had noticed there were more pressure sores at this time, and felt it was due to the staffing shortage of nurses and aides. Interview on 02/13/18 at 4:13 PM, with RN #4, revealed she had worked at the facility for five (5) years and there had been a staffing shortage at the facility since November 2017. She stated treatments and skin assessments were the last thing on her plate after administering medications. Per interview, sometimes some of the treatments such as powders or creams were not completed as a result of being short staffed; however, she tried to get the pressure ulcer treatments completed. Interview with the Acting DON, on 02/07/18 at 4:00 PM, revealed she had worked at the facility for nine (9) years and stepped into the role as Acting DON on 01/05/18, which was the same day the previous DON and the Staff Development resigned. Per interview, the Unit Managers who were responsible for skin management also resigned shortly afterward as did several other nurses. She further revealed she had worked in the staff nurse role passing medications, and performing treatments all but about three (3) days since 01/05/18, and was also working a lot of double shifts due to the staffing shortage. She stated she was aware skin assessments and wound assessments were not being completed because there was not enough time in the day due to being short staffed. I know for a fact some treatments are not being done because there is no time to do it. The Acting DON revealed, there used to be regular weekly Interdisciplinary Team (IDT) Meetings to talk about the residents' skin issues; however, due to the staffing shortage these meetings were not consistently conducted. 3. Review of the Weight Policy, revised August 2014, revealed the facility would ensure that a resident maintains, to the extent possible, acceptable parameters of nutritional status, unless the resident's clinical condition demonstrates that this is not possible; and receives a therapeutic diet when there is a nutritional problem. Weights and nutritional status are monitored by the Weight Committee and the Consultant Dietician. The Director of Nursing (DON) or designee is responsible to see that weights are obtained regularly for all residents. Any weights reflecting possible medical condition changes should be brought to the attention of the supervisor immediately. Notification of any variance along with recommended interventions must be communicated to the Physician and family according to regulatory requirement. Monthly weights will be obtained by nursing and entered into the Accunurse (computer system). Residents triggering a significant weight variance defined as 5% in one (1) month, 7.5 % in three (3) months, and /or 10% in six (6) months will be addressed by the Weight Variance Committee and placed on weekly weight monitoring. Review of the Weight Records revealed Resident #83 had a significant weight loss of 14.15% in one (1) month, from 01/07/18 until 02/07/18; and Resident #9 had a significant weight loss of 7.21 % in one (1) month, from 01/03/18 until 02/07/18. However, there was no documented evidence the Physician was notified of the significant weight losses; and no documented evidence of monitoring the residents' food consumption as evidenced by missing documentation for meal consumption as per facility Policy. Additionally, Residents #27, #70, #83, and #91 had significant weight losses or gains noted; however, there was no documented evidence of re-weights in order to verify the weight variances. Also, was no documented evidence of monitoring these residents nutritional status to evaluate if current interventions were effective or if there was a need for further recommendations. Interview with the Registered Dietician (RD), on 02/07/18 at 11:30 AM, and on 02/16/18 at 3:32 PM, revealed during her visits she would look at weight comparisons for residents in the computer to check for weight gains and losses. Per interview, it had been chaotic at the facility in recent months and she would recommend all residents at the facility to be on weekly weights because of the fluctuating weights obtained. Per interview, the facility had a history of [REDACTED]. Post Survey phone interview with the Acting DON, 02/20/18 at 12:00 PM, revealed the Physician should be notified anytime there was a significant weight loss or gain. She further stated she was responsible for ensuring weights and re-weights were obtained and inputted into the electronic computer system; however, due to having to work the role of staff nurse, she was unable to ensure this was done timely. The Acting DON further revealed the Interdisciplinary Team (IDT) had not been meeting on a regular basis to discuss residents with nutritional problems due to the staffing issues and the State Registered Nursing Assistants (SRNA) were not consistently documenting meal intakes due to staffing. 4. Review of the facility's Reliant Rehabilitation Policy, created 10/10/13, revealed that the facility managers shall establish and maintain a system to track residents in the facility. The system enhanced the management of the rehabilitation program throughout the facility, and ensured and monitored compliance with restorative and functional maintenance programs. Continued review revealed the following information would be collected and used to enhance the quality of the rehabilitation practices: screening date history and disciplines involved; functional problems; therapy equipment prescribed; record of residents on either /both functional maintenance and restorative programs; and the timeframe to screen, and the average amount of time spent per screening. Procedures included: the facility would choose one of the recommended methods of resident tracking; resident tracking systems would be updated every time a resident was screened; records of the resident tracking system would be maintained and accessible by members of the rehabilitation team and appropriate facility staff; and results of the resident tracking system would be regularly analyzed by the facility manager or designee for the purpose of reviewing outcomes and in order to make recommendations for quality improvement. Residents #22, #40, #50 and #64 were discharged from Physical Therapy or Occupational Therapy with recommendations and instructions for the Restorative Nursing Program in order to prevent decline related to transfers, ambulation, and Range of Motion. However, Resident and Staff interview revealed the Restorative Nursing Program (RNP) had no oversight, and there was no monitoring of compliance with restorative and functional maintenance programs as per Policy. Review of the Restorative Rosters for January and February 2018, verified residents were not consistently participating in the Restorative Nursing Program. In addition, the Restorative Aide (RA), was unable to complete her duties as RA due to having to having to work the floor in the capacity of a SRNA as a result of the staffing shortage. Interview on 02/13/18, at 11:30 AM, with the Restorative Aide (RA), revealed she had worked at the facility as a RA, approximately six (6) to seven (7) years. The RA stated the facility's Staff Development Nurse (SDN) who was over the RNP left the faciity on [DATE]. The RA further stated she had been working as the only Restorative Aide in the facility for over a year, and was assigned to work the floor as an aide to provide direct care to residents because of the staffing shortage. She stated she could not keep up with restorative nursing duties due to having to work as a floor aide. Further interview with the RA, revealed the Staff Development Nurse (SDN) was responsible for developing Restorative Nursing Care Plans and instructions for the residents after recommendations were received from the therapy department; making a monthly schedule for the residents on Restorative Nursing caseload; and charting routine progress for individual residents in the RNP. However, per interview, after the SDN left, restorative interventions could not be provided if there was not a Restorative Nursing Care Plan in place for those residents discharged from therapy. She stated she had not had an updated list of residents who were to receive Restorative Nursing Services since the SDN left on 01/05/18. Post Survey Interview, on 02/20/18 at 12:00 PM, with the Acting DON, revealed she was not aware of who was responsible for completing the restorative care plans after the Staff Development / Restorative Nurse left on 01/05/18. The Acting DON stated she did communicate her concerns to the Former Administrator about the RA working the floor and the fact that no one was over the RNP after the Staff Development Nurse resigned. The Acting DON stated each resident who required RNP services should have a care plan after discharge from therapy, and the care plan should be specific related to what type of therapy had been ordered. The Acting DON stated she expected all RNP residents to have a RNP care plan and those residents should be receiving RNP services as outlined by the care plan. 5. Interview on 02/16/18 at 4:00 PM with the Administrator, revealed the facility had no specific policy related to grooming and baths; however, per interview it was his expectation that the residents were groomed daily and received baths/showers twice a week as per their bath schedules. Resident and Staff interview revealed residents were not receiving baths/showers twice a week as per facility protocol due to the facility being short staffed. The Hygiene Reports revealed: Resident #1 received no baths or showers in January 2018 with no refusals documented; Resident #22 received two (2) baths/showers in December 2017 and none in January 2018 with no refusals documented; Resident #39 received one (1) bath/shower in December and two (2) baths/showers in January 2018 with no refusals documented; Resident #40 received four (4) baths/showers in December 2017 and one (1) bath/shower in January 2018; Resident #50 received one (1) bath/shower in January 2018; Resident #64 received (1) sponge bath and (1) shower in December 2017 and one (1) bath and one (1) shower for the month of January 2018; Resident #83 received two (2) baths in the month of December 2017 and one (1) bath for the month of January 2017; and Resident #102 received two (2) baths in December 2017 and one (1) bath in January 2018. Interview on 02/02/18 at 3:12 PM, with SRNA #2, who worked the second floor and cared for Resident #22, and Resident #1, revealed each resident had a scheduled bath/shower day but due to the facility being short staffed, it was very difficult to give all the residents their scheduled showers/baths. SRNA #2 revealed all care provided by the SRNA should be documented in the Kiosk every day, but due to the staffing shortage she had not been able to document the care. Interview on 01/30/18 at 1:00 PM, with SRNA #7, who cared for Resident #39 on the first floor South Hall 01/30/18, revealed, Resident #39 was alert and oriented and was able to communicate his/her needs. SRNA #7 further stated the resident had told her on several occasions, staff would not give him/her a bath or shower because of the shortage of staff. SRNA #7 revealed she had reported the incidents to the Former Administrator and to the Former DON whenever resident's complained to her about not getting baths; however, nothing was done. SRNA #7 stated she often had to come in one (1) hour before her shift started to ensure all her assigned residents received their baths and showers and she did not get paid overtime for this. She further revealed because of the staffing it was very hard to get charting done, so even if the resident did get a bath or shower, it might not be documented in the Kiosk because the aides didn't have time to chart. Interview on 01/30/18 at 4:10 PM, with LPN #1, revealed the facility had been working short staffed ever since she started there three (3) months ago. LPN #1 further stated all the staff were doing the best they could to make sure the residents were being cared for. However, she stated because they were all working short, residents had to wait for care, and staff were not always able to give baths and get charting done. Per interview, she complained about staffing but every time she did, she was told they had advertisements out and were working on the problem. Interview on 02/02/18 at 4:14 PM with LPN #5, who worked the 3:00 PM to 11:00 PM shift on the second floor and cared for Residents #40, Resident #50, and Resident #64, revealed it was impossible for two (2) SRNA's to care for sixty-one (61) residents. LPN #5 stated the aides could barely do their check and change to include incontinence care every two (2) hours, turn and reposition residents, and assist residents to bed. LPN #5 stated the aides had complained about working short, but nothing had been done about it. Interview on 02/06/18 at 11:20 AM, with SRNA #13, who worked on the second floor and cared for Resident #40, Resident #50, and Resident #64, revealed residents were not able to get their scheduled showers because the facility was short on SRNAs. SRNA #13 stated there were usually three (3) to four (4) SRNA's on day shift caring for sixty-one (61) residents when there should be six (6) SRNAs, two (2) for each hall. SRNA #13 further stated it was difficult to get all the residents up, give them a bath or shower, feed them two (2) meals, make rounds for check and change, and do the charting. Per interview, there was not enough time in the day to get all her assigned tasks done and even if a resident received a bath, it might not be documented because she didn't have time at the end of her shift to chart what she had done. Interview on 01/31/18 at 9:10 AM, with RN #2, who worked the 7:00 AM to 3:00 PM shift on the second floor, revealed she felt like the staffing was inadequate which was causing residents not to be turned and repositioned every two (2) hours. Per interview, baths and showers were not being done because of the facility being short staffed. Interview on 01/30/18 at 1:30 PM, with SRNA #9, who provided care to residents on the first floor, revealed the facility was short staffed all the time and she often heard residents complain staff members would not give them baths or showers. SRNA #9 stated, whenever she heard a resident complain, she would report it to the Former Administrator and Former DON, but no changes were made related to staffing. SRNA #9 stated residents should be able to get a bath or shower at least two (2) times a week and if they didn't, it could be a dignity issue. SRNA #9 further stated she tried hard to get her baths done, but sometimes just couldn't because she had too many residents and she worked short a lot. Per interview, even if she did get the baths done it might not show up in the Kiosk because she didn't have time to chart it. Interview on 01/31/18 at 9:20 AM with LPN #2, who typically worked the 11:00 PM to 7:00 AM shift on the first floor, revealed she didn't feel the residents were getting the care they needed because of the staffing situation. LPN #2 revealed the facility had only been scheduling two (2) nurses and one (1) SRNA to care for forty (40) to fifty (50) residents on the first floor; and two (2) nurses and one (1) SRNA on the second floor for sixty-one (61) residents on the night shift. LPN #2 stated she had worked the night shift last night with one (1) aide and herself on the first floor because there was a call in and the other nurse was pulled to the second floor. LPN #2 stated the priority was to turn and reposition and check and change the residents every two (2) to three (3) hours. Interview on 02/02/18 at 2:08 PM, with Licensed Practical Nurse (LPN) #4, who worked the 7:00 AM to 3:00 PM shift on the first floor, revealed when there were only three (3) aides on the floor, it was hard for to get showers and charting done. LPN #4 stated with three (3) aides, they had to focus more on turning and repositioning the residents, doing their check and change, and making sure the residents were assisted with meals. LPN #4 stated the Former DON and Former Administrator had been told on multiple occasions that they were working short and she was told not to worry about it because they were working on it. Interview on 02/02/18 at 4:28 PM, with LPN #6, who worked the 3:00 PM to 11:00 PM shift on the second floor, revealed it was a push for two (2) to three (3) aides to care for sixty-one (61) residents. LPN #6 stated the aides had complained to her but she told them to do what they could. Interview on 02/06/18 at 10:50 AM, with SRNA #12, who was assigned to residents on the first floor, revealed the first floor usually had two (2) to three (3) aides for the first and second shifts to care for forty (40) to fifty (50) residents. SRNA #12 stated when there were only two (2) to three (3) aides the baths and charting didn't always get done because it was more important to do rounds for check and change and turn and reposition the residents every two (2) hours. SRNA #12 stated when she was not able to complete her assigned tasks, she would report it to the nurse and the nurse would say, just get done what you can. SRNA #12 further stated she had complained to the Former DON and the Former Administrator about working short. Interview on 02/06/18 at 12:00 PM, with SRNA #14, who was assigned to residents on the first floor, revealed she was usually assigned twenty (20) residents to care for on day shift, and with that many residents, she was not able to complete her charting or give every resident a bath or shower when scheduled. SRNA #14 stated it was more important to turn and reposition residents and round for incontinence care and check and change. SRNA #14 stated most of the time she was only able to turn and reposition residents every three (3) to four (4) hours. SRNA #14 further stated when she was unable to complete her baths and showers, she reported it to the nurse and also would report it to the next shift, hoping they would be able to give the baths. Per interview, everyone had complained about not being able to get things done and they were told to do the best they could. Interview on 02/06/18 at 4:00 PM, with the Acting Director of Nurse's (Acting DON), revealed the Former Administrators last day at the facility was the same day the Office of Inspector General (OIG) Representatives walked into the facility on [DATE]. Per interview, she had complained to the Former DON and the Former Administrator about staffing and was told not to worry about it. The Acting DON stated she had talked to the Staffing Coordinator about getting agency staff and was told the Former Administrator said no to using a staffing Agency. Per interview, the SRNA's had complained about not being able to get all their baths and showers done and were being told to just do the best they could. Additional interview with the Acting DON, revealed the residents should be getting their baths and showers per schedule, but it was hard to do with the staffing shortage. The Acting DON stated when residents did not have their personal hygiene needs met, this could be a dignity and neglect issue. However, she stated she did not feel it was intentional neglect. Additional interview with the Medical Director, on 02/08/18 at 2:00 PM, revealed he was aware the building was short staffed and had addressed the situation with the Former Administrator and the Former Director of Nursing (DON). Per interview, he was told by both the Former Administrator and the Former DON, that they were working on it, and would get Agency staff in the building. He stated the Former Administrator told him they were offering bonuses and raises for nurses who would stay. He further stated he was aware several nurses had given their resignation and they decided to stay after he (Medical Director) asked them to stay. Per interview, he did not want to lose the nurses because they were good nurses. Continued interview revealed he was not sure what Corporate was allowing the Former Administrator to do towards the staffing situation, but he did not see any improvement in staffing until after the Survey started, and then sister facility staff as well as Agency staff came into the building. Interview with the Administrator, on 02/08/18 at 7:10 PM, revealed he was responsible for oversight of staffing and upon arriving to the facility his first day on 01/30/18, he was not aware of the staffing situation. Per interview, he quickly learned of the staffi (TRUNCATED)

Based on observation, interview, record review and review of facility Policy, it was determined the facility failed to have an effective system to ensure residents were free from significant medication errors related to Insulin administration for fourteen (14) of fifty-two (52) sampled residents (Resident #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and one (1) unsampled resident (Unsampled Resident A). Observation on 02/05/18 at 6:40 PM, revealed the second floor unit of the facility had sixty-one (61) residents and only one (1) licensed nurse working on the unit, who was also the Acting Director of Nursing (DON). Interview with the Acting DON at the time of observation confirmed she had been the only nurse on the unit since approximately 3:45 PM and was in the process of performing Accuchecks (procedure to determine Blood Glucose levels) for the diabetic residents which were ordered to be performed at 4:00 PM and 5:00 PM. Interview with Licensed Practical Nurse (LPN) #7 and LPN #8, who arrived on the second floor unit at approximately 6:45 PM, and further interview with the Acting DON, revealed the Sliding Scale Insulin which was ordered to be administered at 4:00 PM and 5:00 PM based on the results of the Accuchecks was not administered until between 7:00 PM and 8:00 PM on 02/05/18. Interview also revealed on 02/05/18, the nurses performed 8:00 PM and 9:00 PM Accuchecks; administered Sliding Scale Insulin coverage; and administered scheduled long acting Insulin between 9:00 PM and 11:30 PM, without notifying the Physician the 4:00 PM and 5:00 PM Insulin had been administered late, and without consulting with the Physician for guidance related to the need for possible adjustment in Insulin dosage or delay in Insulin administration. In addition, the nurses revealed they failed to notify the Physician of high and low Blood Glucose levels on the evening of 02/05/18. (Refer to F-580 and F-658) The facility's failure to have an effective system in place to ensure residents were free from significant medication errors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 02/08/18, and determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Medication Administration Policy, undated, revealed medications are administered in accordance with written orders of the prescriber and if necessary the nurse calls the prescriber for clarification. Medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. The individual who administers the medication dose, records the administration on the resident's Medication Administration Record [REDACTED]. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled and an explanatory note is entered on the reverse of the record. Further review revealed there was no clarification in the policy to state the procedure for documentation when a medication was given other than the scheduled time on the Electronic Medication Administration Record [REDACTED] Observation on 02/05/18 at 6:40 PM, on the second floor, revealed the Acting Director of Nursing (DON) was on the South Hall with two (2) Glucometers (device to measure blood glucose) in her hands. Interview on 02/05/18 at 6:40 PM with the Acting DON, revealed two (2) nurses had called in for the 3:00 PM - 11:00 PM shift and she was the only nurse on the second floor for sixty-one (61) residents. She stated she was in the middle of passing her 4:00 PM medications when a resident on another hall fell and she had to stop passing medications to administer aid to the resident. The Acting DON further stated she was running from hall to hall trying to obtain the blood glucose monitoring for all the diabetics on the three (3) halls because they were late getting their 4:00 PM and 5:00 PM Sliding Scale (SS) coverage. Per interview, the facility had called a sister facility and two (2) nurses from another facility were coming in to help her, but they would not be able to arrive until around 7:00 PM. The following are examples from record review of significant medication errors related to Insulin as a result of the Acting DON being left on the sixty-one (61) bed unit as the only licensed nurse from approximately 3:45 PM until the other two (2) licensed nurses arrived to the unit at approximately 6:45 PM. 1. Review of Resident #1's Clinical Record revealed the facility admitted the resident on 01/30/17 with [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's Electronic Medication Record (EMAR), revealed the resident was to receive [MEDICATION NAME] per SS coverage at 5:00 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 20 units at 9:00 PM. Further review revealed Licensed Practical Nurse (LPN) #8 signed the EMAR at 5:00 PM and 9:00 PM, indicating the medications were given as scheduled. However, review of Resident #1's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 5:00 PM dose of [MEDICATION NAME] SS coverage of 2 units at 8:34 PM for a blood sugar reading of 162, indicating the Insulin was administered three (3) hours and thirty-four (34) minutes late by LPN #8. Continued review revealed the 9:00 PM blood sugar reading had been done and the dose of [MEDICATION NAME] SS coverage was not administered. Further review revealed the 9:00 PM dose of [MEDICATION NAME] 20 units was administered as scheduled by LPN #8, twenty-six (26) minutes after the SS coverage was administered. Review of Resident #1's Nurse's Notes, revealed there was no documented evidence LPN #8 notified the resident's physician of the late SS Insulin administration or the need to adjust the Insulin dosage for 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 2. Review of Resident #4's Clinical Record revealed the facility admitted the resident on 08/16/17 with [DIAGNOSES REDACTED]. Review of Resident #4's physician's orders [REDACTED]. Continued review revealed the resident did not have a routinely scheduled Insulin at bedtime. Review of Resident #4's EMAR, revealed the resident was to receive [MEDICATION NAME] 100 units/ml per SS coverage at 4:30 PM and 9:00 PM. Further review revealed the Acting DON signed the EMAR at 4:30 PM and 9:00 PM, indicating the Insulin had been given on time. However, review of Resident #4's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 4:30 PM dose of [MEDICATION NAME] SS coverage of 4 units which was prescribed for a blood glucose reading of 235 at 7:38 PM, indicating it had been administered two (2) hours and eight (8) minutes late. Continued review revealed the 9:00 PM blood sugar reading was obtained at 10:51 PM, indicating it had been done one (1) hour and fifty-one (51) minutes past it's scheduled 9:00 PM time and SS Insulin coverage was not required. Review of Resident #4's Nurse's Notes, dated 02/05/18, revealed there was no documented the evidence the Acting DON notified the resident's physician of the late medication administration. In addition, there was no documented evidence in the Nurse's Notes the resident's Novalog SS Insulin coverage of four (4) units was administered late on that date. 3. Review of Resident #13's Clinical Record revealed the facility readmitted the resident on 04/30/16 with [DIAGNOSES REDACTED]. Review of Resident #13's physician's orders [REDACTED]. Review of Resident #13's EMAR, dated 02/05/18, revealed the resident was to receive [MEDICATION NAME] 100 units/ml, 20 units at 5:00 PM; [MEDICATION NAME] 100 units/ml per SS coverage at 5:00 PM and 9:00 PM; and [MEDICATION NAME] 100 units/ml, 55 units at 9:00 PM. Further review revealed LPN #8 signed the EMAR at 5:00 PM and 9:00 PM, indicating all the Insulin medications had been given on time. However, review of Resident #13's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 5:00 PM dose of [MEDICATION NAME] 100 units/ml, 20 units at 7:29 PM, indicating the Insulin had been administered two (2) hours and twenty-nine (29) minutes late. Further review revealed the 5:00 PM [MEDICATION NAME] 100 units/ml, 4 units per SS coverage for a blood glucose reading of 245 had also been administered at 7:29 PM, indicating this medication had been administered two (2) hours and twenty-nine (29) minutes after the scheduled 5:00 PM time and in conjunction with the scheduled Insulin of 20 units. Further review of the EMAR Detailed Report, revealed the 9:00 PM [MEDICATION NAME] 100 units/ml, 55 units was administered at 10:49 PM, indicating the Insulin was administered one (1) hour and forty-nine (49) minutes late by LPN #8. Review of Resident #13's Nurse's Notes, dated 02/05/18, revealed there was no documented evidence LPN #8 notified the resident's physician of the late medication administration or the need to adjust the scheduled Insulin dose based on the late administration on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 4. Review of Resident #14's Clinical Record revealed the facility readmitted the resident on 11/06/17 with [DIAGNOSES REDACTED]. Review of Resident #14's physician's orders [REDACTED]. Review of Resident #14's EMAR dated 02/05/18, revealed the resident was to receive Humalog 100 units/ml per SS at 5:00 PM and 9:00 PM. Further review revealed LPN #8 signed Resident #14 had received Humalog 100 units/ml, two (2) units per SS at 5:00 PM, indicating the Humalog had been administered on time. Continued review revealed the Acting DON had signed Resident #14's 9:00 PM dose of Humalog 100 units/ml per SS coverage as not administered. However, review of Resident #14's EMAR Detailed Report, dated 02/05/18, revealed the resident was administered Humalog two (2) units for a blood sugar reading of 199 at 9:15 PM by LPN #8, four (4) hours and fifteen (15) minutes late. Continued review of the EMAR Detailed Report, revealed no documented evidence the 9:00 PM blood sugar reading was obtained and the SS coverage was not administered by the Acting DON. Review of Resident #14's Nurse's Notes dated 02/05/18, revealed there was no documented evidence LPN #8 notified the resident's physician of the late Humalog SS coverage for 5:00 PM given at 9:15 PM on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. Continued review revealed no documented evidence the 9:00 PM blood glucose reading had been obtained and the SS coverage was not administered by the Acting DON. 5. Review of Resident #19's Clinical Record revealed the facility readmitted the resident on 11/16/17 with [DIAGNOSES REDACTED]. Review of Resident #19's physician's orders [REDACTED]. Review of Resident #19's EMAR, dated 02/05/18, revealed the resident was to receive Humalog 100 units/ml per SS coverage at 4:30 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 15 units at 8:30 PM. Further review revealed the Acting DON signed the EMAR at 4:30 PM, 8:30 PM, and 9:00 PM, indicating the Insulin medications had been given on time. However, review of Resident #19's EMAR Detailed Report, dated 02/05/18, revealed the resident was administered the 4:30 PM dose of Humalog 100 units/ml, 12 units per SS coverage for a blood glucose reading of 405 at 7:54 PM, indicating the medication had been administered three (3) hours and twenty-four (24) minutes after the scheduled 4:30 PM time. Further review of the EMAR Detailed Report, revealed no documented evidence the 8:30 PM [MEDICATION NAME] 100 units/ml, 15 units had been administered by the Acting DON. Additional review revealed Resident #19's 9:00 PM dose of Humalog 100 units/ml, 12 units per SS coverage had been administered at 11:25 PM for a blood sugar reading of 516, indicating the medication had been administered two (2) hours and twenty-five (25) minutes late. Review of Resident #19's Nurse's Note dated 02/05/18, revealed there was no documented evidence the Acting DON notified the resident's physician of the late medication administration. Continued review revealed there was no documented evidence the physician was notified of the high blood sugar readings of 405 and 516 on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late or not given on that date. 6. Review of Resident #20's Clinical Record revealed the facility admitted the resident on 11/20/17 with [DIAGNOSES REDACTED]. Review of Resident #20's physician's orders [REDACTED]. Review of Resident #20's EMAR dated 02/05/18, revealed the resident was to receive Humalog 100 units/ml per SS coverage at 5:00 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 25 units at 8:00 PM. Further review revealed LPN #7 had signed the EMAR at 5:00 PM, 8:00 PM, and 9:00 PM, indicating all the medications had been given on time. However, review of Resident #20's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 5:00 PM dose of Humalog 100 units/ml, 6 units per SS coverage for a blood glucose reading of 251 at 8:57 PM, indicating the medication had been administered three (3) hours and fifty-seven (57) minutes after the scheduled 5:00 PM time. Further review of the EMAR Detailed Report, revealed there was no documented evidence the 8:00 PM [MEDICATION NAME] 100 units/ml, 25 units had been administered by LPN #7. Additional review of the EMAR Detailed Report, revealed the 9:00 PM Humalog 100 units/ml, 6 units per SS coverage for a blood sugar of 270, had been administered at 10:03 PM, indicating it was administered as scheduled. Review of Resident #20's Nurse's Note dated 02/05/18, revealed there was no documented evidence LPN #7 notified the resident's physician of the late medication Insulin administration on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late or not given on that date. 7. Review of Resident #22's Clinical Record revealed the facility readmitted the resident on 11/17/17 with [DIAGNOSES REDACTED]. Review of Resident #22's physician's orders [REDACTED]. Review of Resident #22's EMAR, dated 02/05/18, revealed the resident was to receive [MEDICATION NAME] 100 units/ml per SS coverage at 4:30 PM and 9:00 PM, and [MEDICATION NAME] 100 units/ml, 25 units at 8:00 PM. Further review revealed the Acting DON signed the EMAR at 4:30 PM, and 8:00 PM, indicating the medications had been given on time. Additional review revealed the 9:00 PM blood sugar reading had been obtained on time. However, review of Resident #22's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 4:30 PM dose of [MEDICATION NAME] 4 units per SS coverage for a blood glucose reading of 214 at 7:53 PM, indicating the medication was administered three (3) hours and twenty-three (23) minutes after the scheduled 4:30 PM time. Further review of the EMAR Detailed Report, revealed the 8:00 PM [MEDICATION NAME] 100 units/ml, 25 units had been administered at 11:18 PM, indicating it had been administered three (3) hours and eighteen (18) minutes late by the Acting DON. Additional review revealed Resident #22's 9:00 PM blood sugar reading was obtained at 11:18 PM, indicating it had been obtained two (2) hours and eighteen (18) minutes late and the 9:00 PM dose of [MEDICATION NAME] 100 units/ml per SS coverage was held due to a blood sugar reading of 65. Review of Resident #22's Nurse's Notes dated 02/05/18, revealed there was no documented evidence the Acting DON notified the resident's physician of the late medication administration. Further review revealed no documented evidence the resident was offered a snack for the blood sugar reading of 65, nor was there documented evidence the resident's blood sugar had been rechecked to ensure the resident had not become hypoglycemic on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 8. Review of Resident #31's Clinical Record revealed the facility readmitted the resident on 12/21/17 with [DIAGNOSES REDACTED]. Review of Resident #31's physician's orders [REDACTED]. Review of Resident #31's EMAR dated 02/05/18, revealed the resident was to receive Humalog 100 units/ml, 20 units at 5:00 PM; Humalog 100 units/ml per SS coverage at 4:00 PM and 8:00 PM; and [MEDICATION NAME] 100 units/ml, 40 units at 8:00 PM. Further review revealed the Acting DON signed for the Insulin's on the EMAR at 4:00 PM, 5:00 PM, and 8:00 PM, indicating all the medications had been given on time. However, review of Resident #31's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 4:00 PM Humalog 100 units/ml, 4 unit's SS coverage for a blood sugar of 237, at 7:20 PM, indicating it was administered three (3) hours and twenty (20) minutes late. Further review of the EMAR Detailed Report, revealed the scheduled 5:00 PM dose of Humalog 100 units/ml, 20 units was also administered at 7:20 PM, indicating the medication was administered two (2) hours and twenty (20) minutes late and in conjunction with the SS coverage. Additional review revealed the 8:00 PM [MEDICATION NAME] 100 units/ml, 40 units was administered at 10:44 PM, indicating the medication was administered two (2) hours and forty-four (44) minutes late by the Acting DON. Ongoing review revealed the resident received the 8:00 PM dose of Humalog 4 units of SS coverage for a blood sugar reading of 212 at 10:44 PM, at the same time as the scheduled 8:00 PM dose of [MEDICATION NAME] 40 units, indicating the Humalog had been administered two (2) hours and forty-four (44) minutes late. Review of Resident #31's Nurse's Notes, dated 02/05/18, revealed there was no documented evidence the Acting DON notified the resident's physician of the late medication administration or the need to adjust the scheduled insulin dose on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 9. Review of Resident #40's Clinical Record revealed the facility readmitted the resident on 11/26/17 with [DIAGNOSES REDACTED]. Review of Resident #40's physician's orders [REDACTED]. Review of Resident #40's EMAR dated 02/05/18, revealed LPN #7 signed the EMAR at 4:00 PM, 5:00 PM, 8:00 PM, and 9:00 PM, indicating the Insulin medications had been given on time. However, review of Resident #40's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 4:00 PM dose of [MEDICATION NAME] SS coverage of 4 units at 7:41 PM, indicating the medication had been administered two (2) hours and forty-one (41) minutes late. Further review of the EMAR Detailed Report, revealed the 5:00 PM dose of scheduled [MEDICATION NAME] was administered at 7:41 PM, indicating the medication was administered two (2) hours and forty-one (41) minutes late and in conjunction with the SS Insulin coverage. Additional review revealed the routine scheduled 8:00 PM dose of [MEDICATION NAME] 26 units was administered at 11:04 PM, indicating it was administered three (3) hours and four (4) minutes late. Continued review of the EMAR Detailed Report, dated 02/05/18, revealed the 8:00 PM [MEDICATION NAME] SS coverage of 2 units for a blood glucose reading of 183 was administered at 11:04 PM, in conjunction with the scheduled [MEDICATION NAME] which was due at 8:00 PM, indicating it was administered three (3) hours and four (4) minutes late by LPN #7. The EMAR Detailed Report further revealed, LPN #7 also administered the 9:00 PM dose of scheduled [MEDICATION NAME] at 11:04 PM (at the same time as the [MEDICATION NAME] and [MEDICATION NAME] SS coverage), indicating it was administered two (2) hours and four (4) minutes late. The facility was unable to provide the resident's next blood sugar reading which was duet at 6:00 AM on 02/06/18. Review of Resident #40's Nurse's Notes dated 02/05/18, revealed there was no documented evidence LPN #7 notified the resident's physician of the late medication administration or the need to adjust the resident's insulin dosages. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 10. Review of Resident #61's Clinical Record revealed the facility readmitted the resident on 12/18/17 with [DIAGNOSES REDACTED]. Review of Resident #61's physician's orders [REDACTED]. Review of Resident #61's EMAR dated 02/05/18, revealed the resident was to receive Humalog 100 units/ml per SS coverage at 4:00 PM and 8:00 PM, and [MEDICATION NAME] 100 units/ml, 20 units at 8:00 PM. Further review revealed the Acting DON signed the EMAR at 4:00 PM and 8:00 PM, indicating all the Insulin medications had been given on time. However, review of Resident #61's EMAR Detailed Report. dated 02/05/18, revealed the resident received the 4:00 PM dose of Humalog 100 units/ml, 4 units per SS coverage for a blood glucose reading of 241 at 7:09 PM, indicating the medication had been administered three (3) hours and nine (9) minutes after the scheduled 4:00 PM time. Further review of the EMAR Detailed Report, revealed the 8:00 PM Humalog 100 units/ml, 6 units per SS coverage for a blood sugar of 267, was administered at 10:40 PM, indicating the medication was administered two (2) hours and forty (40) minutes late. Additional review revealed the 8:00 PM scheduled [MEDICATION NAME] 100 units/ml, 20 units was also administered at 10:40 PM (at the same time as the Humalog SS coverage), indicating the medication was administered two (2) hours and forty (40) minutes late by the Acting DON. Review of Resident #61's Nurse's Notes dated 02/05/18, revealed there was no documented evidence the Acting DON notified the resident's physician of the late medication administration or the need to adjust the insulin dose based on the late administration on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 11. Review of Resident #63's Clinical Record revealed the facility readmitted the resident on 01/05/18 with [DIAGNOSES REDACTED]. Review of Resident #63's physician's orders [REDACTED]. Further review revealed the resident was to receive [MEDICATION NAME] 100 Units per ml, 15 units SQ twice a day. Review of the February 2018 EMAR, revealed Resident #63 was to receive [MEDICATION NAME] 100 units/ml, fifteen (15) units SQ at 8:00 PM and [MEDICATION NAME] 100 units/ml, per Sliding Scale coverage at 4:00 PM, and 8:00 PM. Further review of the EMAR revealed the [MEDICATION NAME] 100 units/ml was administered at 4:00 PM and 8:00 PM, and the [MEDICATION NAME] 100 units/ml was administered at 8:00 PM, indicating both medications had been administered on time by the Acting DON. However, review of Resident #63's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 4:00 PM dose of [MEDICATION NAME] two (2) units for a blood sugar reading of 171 at 7:34 PM, indicating the Insulin medication had been given three (3) hours and thirty-four (34) minutes late. Further review of the EMAR Detailed Report, revealed the 8:00 PM blood glucose level was obtained at 10:55 PM, indicating the Accucheck was obtained two (2) hours and fifty-five (55) minutes late, and no SS coverage was indicated. Further review of the EMAR Detailed Report, revealed the Acting DON administered the scheduled 8:00 PM dose of [MEDICATION NAME] 100 units per ml, 15 units, at 10:55 PM, indicating it was administered two (2) hours and fifty-five (55) minutes late. Review of Resident #63's Nurse's Notes dated 02/05/18, revealed there was no documented evidence the Acting DON notified the resident's physician of the late insulin administration. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 12. Review of Resident #64's Clinical Record revealed the facility admitted the resident on 11/03/17 with [DIAGNOSES REDACTED]. Review of Resident #64's physician's orders [REDACTED]. Further review revealed for blood glucose reading greater than 450, notify the physician. Review of Resident #64's EMAR, dated 02/05/18, revealed the resident was scheduled to receive [MEDICATION NAME] 100 units/ml, 25 units at 9:00 PM and Humalog 100 units/ml, per SS coverage at 5:00 PM and 9:00 PM. Further review revealed the Acting DON signed the EMAR at 5:00 PM and 9:00 PM, indicating the Insulin medications was given on time. However, review of Resident #64's EMAR Detailed Report, dated 02/05/18, revealed the resident received the 5:00 PM dose of Humalog 100 units/ml, 14 units per SS coverage for a blood glucose reading of 483 at 7:49 PM, indicating the Insulin medication was administered two (2) hours and forty-nine (49) minutes after the scheduled 5:00 PM time. Further review of the EMAR Detailed Report, revealed the 9:00 PM Humalog 100 units/ml, 2 units per SS coverage for a blood sugar of 161, was administered at 11:10 PM, indicating it was administered two (2) hours and ten (10) minutes late. Additional review revealed the 9:00 PM [MEDICATION NAME] 100 units/ml, 25 units was also administered at 11:10 PM (at the same time as the Humalog SS coverage), indicating the medication had been administered two (2) hours and ten (10) minutes late by the Acting DON. Review of Resident #64's Nurse's Notes, dated 02/05/18, revealed there was no documented evidence the Acting DON notified the resident's physician the insulin's were given late and closer together than scheduled, and no documented evidence of notification of the resident's high blood glucose reading of 483 on 02/05/18. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. 13. Review of Resident #78's Clinical Record revealed the facility admitted the resident on 10/25/17 with [DIAGNOSES REDACTED]. Review of Resident #78's physician's orders [REDACTED]. Further review revealed the resident was to receive [MEDICATION NAME] Insulin 100 Units per ml, 42 units SQ at bedtime. Review of Resident #78's Electronic Medication Administration Record [REDACTED]. Further review of the EMAR, revealed Licensed Practical Nurse (LPN) #7 signed she administered the [MEDICATION NAME] SS coverage at 5:00 PM and 9:00 PM, and the [MEDICATION NAME] at 9:00 PM, indicating the [MEDICATION NAME] and the [MEDICATION NAME] were administered on time. However, review of Resident #78's EMAR Detailed Report, dated 02/05/18, revealed the resident received [MEDICATION NAME] four (4) units for a blood sugar reading of 209 at 9:05 PM by LPN #7. Continued review of the EMAR Detailed Report, revealed the 9:05 PM dose of [MEDICATION NAME] was scheduled to be administered at 5:00 PM, indicating the [MEDICATION NAME] Insulin was administered four (4) hours after the scheduled 5:00 PM time. Further review of the EMAR Detailed Report, revealed LPN #7 administered the scheduled 9:00 PM dose of [MEDICATION NAME] four (4) units, for a blood sugar reading of 215, at 9:41 PM, indicating the [MEDICATION NAME] was given thirty-six (36) minutes after the 9:05 PM dose. Continued review revealed LPN #7 administered Resident #78's scheduled 9:00 PM dose of [MEDICATION NAME] 100 units per ml, 42 units, at 9:41 PM, indicating it was given at the same time she administered the 9:41 PM dose of [MEDICATION NAME] SS coverage. Review of Resident #78's Nurse's Notes, dated 02/05/18, revealed there was no documented evidence LPN #7 notified the resident's physician of the [MEDICATION NAME] SS coverage, being administered late, or asked the physician's advice on adjusting the resident's 9:00 PM [MEDICATION NAME] SS coverage or [MEDICATION NAME]coverage scheduled at 9:00 PM, prior to administering the medications so close together. In addition, there was no documented evidence in the Nurse's Notes the resident's Insulin was administered late on that date. Review of Resident #78's Nurse's Notes, dated 02/05/18 revealed there was no documented evidence the resident's Insulin had been administered late. Review of the Nurse's Notes dated 02/06/18 at 6:11 AM, revealed the scheduled 6:00 AM [MEDICATION NAME] 100 units/ml SQ was held due to a blood glucose reading of sixty-five (65), and the resident received a snack per the resident's request. 14. Review of Resident #79's Clinical Record revealed facility readmitted the resident on 12/21/17 with [DIAGNOSES REDACTED]. Review of Resident #79's physician's orders [REDACTED]. Further review revealed the resident was to receive [MEDICATION NAME] 100 units/ml, twenty-five (25) units SQ every evening. Review of Resident #79's EMAR dated 02/05/18, revealed the resident

Based on observation, interview, record review, review of the Director of Nursing and Administrator's Job Descriptions, and review of the facility's Policies and Procedures, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and to ensure Insulin medication was administered as prescribed and diabetic residents were monitored to prevent serious hypo/hyperglycemic reactions. Observation and interview on 02/05/18 at 6:40 PM, with the Acting Director of Nursing (DON), revealed she was the only nurse on the second floor unit of the facility with a census of sixty-one (61) residents and was in the process of performing Accuchecks (procedure to determine Blood Glucose levels) for the diabetic residents which were ordered to be performed at 4:00 PM and 5:00 PM. Further interview on 02/06/18, 02/07/18 and 02/08/18, with Licensed Practical Nurse (LPN) #7 and LPN #8, and the Acting DON, revealed LPN #7 and LPN #8 arrived on the second floor unit at approximately 6:45 PM on 02/05/18. The nurses stated they administered the Sliding Scale Insulin which was ordered to be administered at 4:00 PM and 5:00 PM, based on the results of the Accuchecks, between 7:00 PM and 8:00 PM on 02/05/18. The nurses further revealed they performed the 8:00 PM and 9:00 PM Accuchecks; administered Sliding Scale Insulin coverage; and administered routine long acting Insulin between 9:00 PM and 11:30 PM on 02/05/18, without notifying the Physician the 4:00 PM and 5:00 PM Insulin was administered late, and without consulting with the Physician for guidance related to the need for possible adjustment in Insulin dosage, or delay in Insulin administration. Also, the nurses revealed they failed to notify the Physician of high and low Blood Glucose levels on the evening of 02/05/18. This failure affected fourteen (14) of fifty-two (52) sampled residents (Resident #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and one (1) unsampled resident (Unsampled Resident #A). (Refer to and F-725 and F-760) The facility's failure to have an effective system in place to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/08/18, and determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18 with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Job Description for Administrator, undated, revealed the Administrator directs the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. Further review revealed the Administrator's Essential Functions included: facility management; compliance management; facility staffing and retention; business management; and community relations. Per the Job Description, the Administrator responsibilities also included: developing, implementing, monitoring and evaluating programs to promote recruitment, retention, career development and continuing education of staff; hiring staff; coordinating with Regional Director and Human Resources; ensuring maintenance of accurate medical records for auditing and regulatory compliance with appropriate approved guidelines; and ensuring excellent care for residents was maintained by overseeing and monitoring patient care services delivered. Review of the facility's Job Description for Director of Nursing (DON), undated, revealed the DON plans, organizes, develops, and directs the overall operation of the facility's nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, as may be directed by the Administrator, to ensure the highest degree if quality care is maintained at all times. The Essential Functions include: responsible for the planning, organizing, direction, supervision, and evaluation of all the nursing services provided in the facility; ensures nursing department compliance with federal, state, and local regulations and implementation of nursing programs; ensures maintenance of records and reports concerning resident care; provides the Administrator with information relate to the nursing needs of the resident and the nursing service departments ability to meet those needs; serves on, participates in, and attends committees of the facility; determines the staffing needs of the nursing department necessary to meet the total nursing needs of the residents. Further review revealed the DON was responsible for, in conjunction with Human Resources, the recruitment and selection of nursing service personnel, and ensures development of work assignments and schedule duty hours of nursing service personnel. Review of the facility's Medication Administration Policy, undated, revealed medications are administered in accordance with written orders of the prescriber and if necessary the nurse calls the prescriber for clarification. Medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. The individual who administers the medication dose, records the administration on the resident's Medication Administration Record [REDACTED]. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled and an explanatory note is entered on the reverse of the record. Further review revealed there was no clarification in the policy to state the procedure for documentation when a medication was given other than the scheduled time on the Electronic Medication Administration Record [REDACTED] Interview with the Acting DON, on 02/07/18 at 4:00 PM, confirmed on the evening of 02/05/18, she was the only nurse on the second floor unit for sixty-one (61) residents from approximately 3:45 PM when the day shift nurses left until approximately 6:45 PM. She stated she had informed the Staffing Scheduler and the Regional Quality Manager and they were aware she was the only nurse on the Unit. Per interview, during the time she was the only nurse on the unit she had obtained some Accuchecks, but not all, and had not been able to administer Insulin. Continued interview with the Acting DON, revealed when Licensed Practical Nurse (LPN) #7 and LPN #8 arrived on the unit at approximately 6:45 PM, on 02/05/18, she gave them the keys to the other medication carts and the list of Accuchecks she had obtained and they started administering Insulin in accordance with the Accuchecks she had obtained. Further interview with the Acting DON, revealed she as well as LPN #7, and LPN #8, were performing Accuchecks and administering Insulin that was due at 4:00 PM and 5:00 PM, after 7:00 PM on 02/05/18. Per interview, the Physician was not notified the Insulin was administered late, but should have been notified as he may have wanted to adjust the next Insulin dose. She stated she held off on administration of the 9:00 PM Accuchecks and Insulin until 10:00 to 10:30 PM due to giving the 4:00 PM and 5:00 PM Insulin late. Per interview, she thought she had notified the physician of Resident #19's blood glucose reading of 516 and Resident #64's blood glucose reading of 483, and stated if she called the Physician, she should have documented it in the Nurse's Notes. The Acting DON, stated it was not safe for her to be the only nurse on the unit the evening of 02/05/18, and this placed residents at risk of harm to have only one (1) nurse on the floor. Additional interview with the Acting DON, revealed she stepped into the Acting DON role 01/05/18, the day the previous DON left. Per interview, the Staff Development Nurse left the same day as the previous DON left, and the Unit Managers as well as many other nurses left afterward. She stated she was only able to actually work in the role of the Acting DON about three (3) days since 01/05/18. Per interview, she told the Former Administrator staff could not take care of the residents, it was not safe, and asked him not to take new admissions. She said he told her, don't worry about that, I will take care of it. However, she stated he would leave every day on time and she would have stay to help due to the staffing shortage, often working double shifts. Per interview, many State Registered Nurse Aides (SRNA) also resigned and told her it was too short staffed. Interview with LPN #7, on 02/08/17 12:27 PM, revealed she had worked at the facility on the evening of 02/05/18 and came from the sister facility, arriving about 6:45 PM to the second floor unit. Per interview, she received a list of Accucheck results which had been obtained by the Acting DON and then administered Insulin in accordance with the Accuchecks. She verified she gave Insulin that was due at 4:00 PM and 5:00 PM between 7:00 PM and 7:30 PM. LPN #7 stated she did not notify the Physician the Insulin and medications were being administered late. Per interview, the Insulin's were given late because there was only one (1) nurse for the unit on the evening shift for three (3) halls upon her arrival. Continued interview revealed for some residents the routine Insulin and Sliding Scale Insulin were given at the same time because she was late giving the 4:00 PM and 5:00 PM Sliding Scale Insulin's. Interview with LPN #8, on 02/06/18 at 3:15 PM, revealed she worked PRN (as needed) and was called in on the evening of 02/05/18, arriving at approximately 6:45 PM. She stated the Acting DON had already performed the 4:00 PM and 5:00 PM Accuchecks and she received the list of Accucheck results from her and started passing medications and administering Insulin's that were due at 4:00 PM and 5:00 PM, between 7:15 PM and 7:20 PM. Per interview, she had not notified the Physician that the medications and Insulin's were administered late, but should have in case the Insulin dosage would need to be adjusted. Interview on 02/08/18 at 3:00 PM, with the Attending Physician/Medical Director, for Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident #A, revealed he expected Accuchecks to be performed as and Insulin to be administered on time as per the physician's orders [REDACTED]. Per interview, it was a significant medication error to administer Insulin outside of the time parameters as this posed a risk for [MEDICAL CONDITION] and [DIAGNOSES REDACTED], which could lead to serious consequences. Record review of the Electronic Medication Administration Record [REDACTED]#20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A) did not receive their scheduled Insulin or Sliding Scale (SS) Insulin as ordered on the evening of 02/05/18, due to the medication administration being from two (2) to four (4) hours late. Record review of the EMAR Detailed Report, further revealed Residents #13, #31, #40, #61, #64, #78, and Unsampled Resident A received both SS Insulin and scheduled Insulin at the same time on the evening of 02/05/18. Also, per record review on the evening of 02/05/18, Resident #4 did not receive his/her SS Insulin as indicated for a blood glucose reading of 235; Residents #19 and #20 did not receive his/her scheduled Insulin; and, Residents #13, #31, #40, #61, #64, #78 and Unsampled Resident A received SS Insulin and scheduled insulin at the same time. Further interview with the Medical Director, revealed he was aware the building was short staffed and had addressed the situation with the Former Administrator and the Former Director of Nursing (DON). He stated he was told by both the Former Administrator and the Former DON, that they were working on it and would get Agency staff in the building. He further stated the Former Administrator told him they were offering bonuses and raises for nurses who would stay. Per interview, the Medical Director was aware several nurses had given their resignation and they decided to stay after he (Medical Director) asked them to stay. He stated he did not want to lose the nurses because they were good nurses. He further stated he was not sure what Corporate was allowing the Former Administrator to do towards the staffing situation, but he did not see any improvement in staffing until after the Survey started, and sister facility staff as well as Agency staff came into the building. Interview with the Administrator, on 02/08/18 at 7:10 PM, revealed his role was to take care of the building for all departments, to make sure residents were taken care of and to make sure their rights were upheld. He further stated he was also responsible for oversight of staffing as well. Per interview, upon arriving to the facility his first day on 01/30/18, he was not aware of the staffing situation. He stated he quickly learned of the staffing problem and started taking actions to resolve the problem such as having staff from sister facilities come to help, and getting Agency staff in the building. He further stated he was unaware the Acting DON was the only nurse on the floor at the beginning of the evening shift on 02/05/18. Per interview, the facility should not have let the day shift nurses leave until there was coverage for the 3:00 PM-11:00 PM Shift. He stated he was aware two (2) nurses had called in on 02/05/17 for the second shift, but thought the Staffing Scheduler had found coverage until LPN #7 and LPN #8 arrived. He further stated he was not aware Accuchecks were not performed and Insulin was not administered as per physician's orders [REDACTED]. Per interview, insufficient staffing had played a large part in the deficiencies identified during this survey and there was leadership dysfunction prior to his arrival. Interview with the Former Administrator, on 02/15/18 at 8:40 AM, revealed his last day at the facility was 01/29/18. Per interview, he realized in March 2017, there was a lot of staff who would call in and the Former DON would have to work as a staff nurse sometimes to fill in when staff did not come to work. He stated the Former DON was not effective and was placed on a Performance Improvement Plan due not being professional at times and not ensuring care was provided to the residents. Per interview the Former DON resigned on 01/05/18. Further interview with the Former Administrator, revealed the Assistant DON took over as the Acting DON on 01/05/18, but could not fulfill her duties due to working the floor because of the staffing shortage. He stated he made it clear to the Regional Director of Operations that the Acting DON was working the floor and could not take over Interim DON duties as a result. He stated the Regional Quality Manager came and spent several weeks at the facility after the previous DON left due to the Acting DON having to work the floor, but did not make him aware of care not being provided except for the showers. He stated he used ancillary staff on the floor to pass ice and water pitchers, pass meal trays; and some of the ancillary staff who were certified would also work as SRNA's to give baths and showers. Further interview with the Former Administrator, revealed he asked the Regional Director of Operations if the building could have approval for Agency staff or staff to come from the sister facilities, but this never materialized and no one responded. Per interview, Corporate did offer bonuses for staff to pick up extra shifts and placed advertisements in the paper and on the website which was ineffective and staff would get aggravated and resign due to the staffing shortage. Continued interview revealed he told Corporate several times the building was in a staffing crisis and he tried to get the building to move in the right direction; however, he stated there were nine (9) open positions for nurses and seventeen (17) open positions for SRNA's when he left. Per interview, Quality of care was compromised during the staffing crisis and he and corporate were responsible. The facility provided an acceptable credible Allegation of Compliance on (A(NAME)) 02/16/18, which alleged removal of the IJ effective 02/14/18. Review of the A(NAME) revealed the facility implemented the following: 1. On 02/08/18 the facility added additional staffing on the 3:00 to 11:00 PM shift to include one Licensed Practical Nurse (LPN) who clocked in at 6:30 PM and one LPN who clocked in at 6:45 PM. 2. On 02/09/18, a licensed nurse completed Medication Error Reports for each of the fifteen (15) residents (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33) identified in the deficient practice of insulin administration. 3. On 02/09/18, a licensed nurse verified no new orders or adverse outcomes were noted as a result of the medication errors for any of the identified fifteen residents, (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33). 4. On 02/06/18, the facility entered into a contract with a nursing staffing agency to supplement any staffing needs. 5. On 02/08/18, the Human Resource Manager/Staffing Coordinator validated that all open positions were posted for recruitment. Further interview revealed, the facility expanded the recruitment area for licensed nurses. 6. On 02/11/18, the Regional Quality Manager performed an audit of residents. Thirty-nine total residents were identified who received blood glucose monitoring and subsequent insulin orders. The audit validated blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. 7. On 02/09/18, the Administrator and Regional Director of Operations created and adopted a new Emergency Staffing Procedure to address actions to be taken during emergencies or where additional staffing is optional. 8. On 02/09/18, the Administrator and the Regional Director of Operations reviewed and updated the staffing component of the facility self-assessment. 9. On 02/09/18, re-education was provided by the Regional Quality Manager to the Acting Director of Nursing (DON) in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. On 02/09/18, re-education was provided by the Regional Director of Operations to the Administrator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. On 02/10/18, re-education was provided by the Regional Quality Manager to a licensed Staff Educator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 12. The Acting DON and/or the licensed Staff Educator and Regional Quality Manager provided education to licensed nurses. The education included notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Approximately 93% of the current facility licensed nursing staff completed education by 02/13/18. Those remaining will have completed education prior to assuming duties upon returning to work. 13. Agency nursing binder implemented with orientation reference steps and training information and copies to be given to any agency nurse. Any agency nurse will be required to complete education by Director of Nursing or Assistant Director of Nursing prior to assuming duties and will sign for received education. 14. Acting DON, Staff Educator and/or Regional Quality Manager provided validation of educational understanding by the licensed nursing staff with return verbal exchange. 15. Audits were to be done by the Acting DON, Nurse Manager, and/or the Regional Quality Manager daily beginning 02/09/18, for blood sugar test completion, physician follow up if indicated, physician orders [REDACTED]. 16. Quality Assurance (QA) Meetings were held on 02/09/18 to discuss the IJ allegation and develop an action plan. The Attendees included the Administrator, Regional Quality Manager, Acting DON, Social Services (2), Business Director, Human Resources/Staffing Coordinator, and the Regional Director of Operations. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action to be initiated. QA meetings were to be held at least weekly until substantial compliance was achieved and monthly thereafter. A member of the Regional Team will be in attendance in addition to the facility team for the weekly QA. The Team was to include at a minimum the Administrator, Acting DON, Social Services, State Registered Nursing Assistant and the Charge Nurse. 17. On 2/09/18, a Governing Body Meeting was held to officially document in the minutes the appointment of a replacement Administrator and outline the Administrative duties. The Administrator had received an official letter of appointment on 01/30/18. The Administrator, the Acting DON and the Regional Director of Operations were in attendance. The Medical Director was contacted by the Administrator on 02/09/18 and reviewed the Governing Body Meeting Minutes were reviewed with him. The State Survey Agency validated the implementation of the facility's A(NAME) as follows: 1. Reviewed facility staffing sheets for 02/05/18. LPN #7 clocked in at 6:30 PM and LPN #8 clocked in at 6:45 PM on 02/05/18. Interview with Administrator on 02/16/18 revealed he had verified LPN # 7 had clocked in at 6:30 PM and LPN #8 had clocked in at 6:45 PM on 02/05/18, per the Acting DON and time sheets. Interview with the Acting DON, during a post survey interview, on 02/22/18 at 10:10 AM, revealed on 02/05/18, she had been the only nurse on the second floor until LPN #7 and LPN #8 clocked in around 6:30 PM. Further interview revealed, the shift started at 3:00 PM. 2. Review of the Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33, identified with the deficient practice sliding scale insulin administered outside the time frame on 02/05/18. These reports were completed by the Acting DON. Interview with the Acting DON, during a post survey interview on 02/22/18 at 10:10 AM, revealed she had completed the Medication error reports on 02/09/18. 3. Review of Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, and Resident #33, revealed they were signed by the Acting DON. Further review revealed, the Acting DON notified the physician and documented there were no new orders or adverse outcomes related to the insulin administration errors made on 02/05/18. Post Survey Interview with the Acting DON, on 02/22/18 at 10:10 AM, revealed she notified physician and there were no adverse effects or orders from physician related to Medication Error Reports on 02/09/18. 4. Review of the facility's contract with the nurse staffing agency, dated 02/06/18, revealed the contract was signed by the Administrator. Further review revealed, the contact was to provide supplemental staffing and staffing placement options. Interview with the Administrator, on 02/16/18 at 1:00 PM, revealed he did sign the staffing agreement with the nursing staffing agency on 02/06/18. 5. Review of the Human Resource/Staffing Coordinator statement, dated 02/08/18, reported marketing strategies were reviewed and placed in surrounding areas for nurse recruitment purposes. Interview with the Human Resources/Staffing Coordinator, on 02/16/18 at 2:00 PM, validated marketing strategies were used in an attempt to recruit staff and expand recruitment areas on 02/08/18. 6. Review of the audit, dated 02/11/18, revealed thirty-nine (39) residents were identified to receive finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. Interview with Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she audited all residents in the facility. Continued interview revealed, she identified thirty-nine (39) residents that received finger glucose monitoring and subsequent blood sugar testing. Further interview revealed she audited areas to included: residents receiving finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and orders being followed with any discrepancies addressed. 7. Review of the Emergency staffing Procedure reveals, the procedure was dated effective 02/10/18. Continued review of the document revealed, during emergencies, scheduled staffing interruption, or other temporary situations, a supervisor may require an employee to work different workdays, additional shift(s), different shift(s), or extended shift(s) without advanced notice. 8. Review of the staffing component of the facility self-assessment, dated 02/09/18, revealed the Administrator and the Regional Director of Operations reviewed and updated the staffing component previously dated 11/28/17. Further review revealed, the document was reviewed by the Governing body, Acting DON, Medical Director and Maintenance Director on 02/09/18. Interview with Administrator, on 2/16/18 at 11:00 AM, revealed the staffing component was updated on 02/09/18. Interview with Medical Director, on 02/16/18 at 4:20 PM, revealed he was updated on the facility self-assessment updates in the Governing Body Meeting on 02/09/18. 9. Review of the facility Education sign in sheets, dated 02/09/18, revealed the Acting DON was re-educated on newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Further review revealed, the education was provided by the Regional Quality Manager. Post Survey Interview with the Acting DON, on 02/22/16 at 10:10 AM, revealed she had been re-educated by the Regional Quality Manager on the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. Review of Education sign in sheets, dated 02/09/18, revealed the Administrator was re-educated by the Regional Director of Operations. Continued review revealed the education consisted of: the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Interview with the Administrator, on 02/16/18 at 1:15 PM, revealed he had received training from the Regional Director of Operations regarding the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. Review of the Education sign in sheets revealed, the Regional Quality Manager provided education to the licensed Staff Educator, on 02/10/18, in regards to the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Interview with the Regional Quality Manager, on 02/16/18 at 2:30 PM, indicated she had provided the education to the Staff Educator to include the verbal return of information and her signature of understanding. 12. Review of the facility Education Sign in sheets, revealed the Acting DON, the licensed Staff Educator and the Regional Quality Manager provided re-education to the licensed staff nurses in regards to the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Review of the Education Staffing Rosters and sign in sheets revealed, approximately 93% of the facility's licensed nursing staff had received re-educatio (TRUNCATED)

Based on interview, record review, review of the facility's Job Description for the Regional Quality Manager, review of the facility's Job Description for the Divisional Quality Manager, review of the facility's Job Description for the Regional Director of Operations, and review of the facility's Policies, it was determined the facility's Governing Body failed to ensure the facility's Policies were implemented regarding the management and operation of the facility for fourteen (14) of fifty-two (52) sampled residents and one (1) unsampled resident (Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A). Observation and interview with the Acting Director of Nursing (DON), on 02/05/18 at 6:40 PM, revealed she had been the only nurse working on the second floor with a census of sixty-one (61) residents since approximately 3:45 PM when the day shift nurses left. The Acting DON revealed she was behind on performing Accuchecks (procedure to determine Blood Glucose levels) which were ordered to be performed at 4:00 PM and 5:00 PM. Interview with Licensed Practical Nurse (LPN) #7 and LPN #8, revealed they arrived on the second floor unit at approximately 6:45 PM on 02/05/18 to assist the Acting DON. LPN #7, LPN #8 and the Acting DON revealed the Sliding Scale Insulin medication which was ordered to be administered to the second floor residents at 4:00 PM and 5:00 PM, in accordance with the Accucheck results, was not administered until between 7:00 PM and 8:00 PM on 02/05/18. Furthermore, the nurses revealed they performed 8:00 PM and 9:00 PM Accuchecks; administered Sliding Scale Insulin coverage; and administered routine long acting Insulin between 9:00 PM and 11:30 PM on 02/05/18, which was outside the scheduled medication times. This failure affected Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A. (Refer to F-725 and F-760) The facility's failure to have an effective Governing Body to ensure the facility's polices were implemented regarding the management and operation of the facility has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/08/18, and determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18 with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Job Description for Regional Quality Manager, undated, revealed the Essential Functions of the Position include: collaborate with the facility and regional teams to identify, prioritize and implement clinical intervention strategies; oversee clinical services within assigned long term care facilities; foster an environment of growth to develop the leadership skills of facility teams for improving staff retention; provide direct consultation to long term care facilities; relay and provide recommendations to help improve systems of nursing management and overall delivery of care; train and provide resources to nursing administration and staff nurses; monitor each facility and ensure they are in compliance with all state and federal regulations related to the nursing department; and promote continuity of quality care through the utilization of nursing process, resident assessment instrument process, disease management guidelines, quality assurance and assessment process, patient education, outcomes management and regulatory compliance. Review of the Job Description for the Divisional Quality Manager, undated, revealed the Essential Functions of the Position include: provide leadership, development, execution, clinical management, and strategy to communities within range of responsibility; management of regional clinical team based on current corporate organizational chart; responsibilities encompass all aspects of clinical operation including personnel management, implementation of clinical processes, policies and procedures, budge adherence and regulatory compliance; perform comprehensive site visits, conducting personal on site review of community operations to identify quality survey, reimbursement, clinical compliance and /or personnel issues; drives the clinical operations and performance of assigned communities and provides advice and direction for improvement/enhancement; performs regional clinical analysis and updates Directors, Administrators, and Directors of Nurses regarding facility clinical performance; analyzes regional staffing issues to assist communities and provides advice and direction for facility clinical performance; and analyzes regional staffing issues to assist communities with recruitment, training, and retention of staff. Review of the Job Description for the Regional Director of Operations, undated revealed the Essential Functions of the Position include: provide leadership, development, execution, business management, and strategy to communities within range of responsibility; management of regional team or other reports based on current corporate organizational chart; responsibilities encompass all aspects of operation including marketing, personnel management, census development, community relations, implementation of polices and procedures, budget adherence and regulatory compliance; perform comprehensive site visit; conducting personal on-site review of community operations to identify survey, quality, census and personnel issues; drives the operations and performance of assigned communities and provides advice and direction or improvement/enhancement; performs financial analysis and updates to Executive Directors and Administrators regarding financial performance; analyzes staffing issues to assist communities with recruitment, training and retention of staff; and assists in preparing annual budget recommendations and supports their success to meet or exceed performance. Review of the facility's Medication Administration Policy, undated, revealed medications are administered in accordance with written orders of the prescriber and if necessary the nurse calls the prescriber for clarification. Medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. The individual who administers the medication dose, records the administration on the resident's Medication Administration Record [REDACTED]. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled and an explanatory note is entered on the reverse of the record. Further review of the policy revealed there was no clarification to state the procedure for documentation when a medication was given other than the scheduled time on the Electronic Medication Administration Record [REDACTED] Observation and interview, on 02/05/18 at 6:40 PM, revealed the Acting DON was the only licensed nurse on the second floor unit with a census of sixty-one (61) residents due to two (2) nurses calling in for the 3:00 PM-11:30 PM shift. Per interview, she was late on obtaining Accuchecks for the diabetic residents and was also late administering the 4:00 PM and 5:00 PM Sliding Scale (S/S) coverage. She further stated two (2) nurses were coming in to assist her, but would not arrive until approximately 7:00 PM. Interview with LPN #8 on 02/06/18 at 3:15 PM and LPN #7 on 02/08/17 at 12:27 PM, revealed they arrived on the second floor unit at approximately 6:45 PM on 02/05/18. Per interview, they both received a list of Accucheck results which had been obtained by the Acting DON and started administering Insulin in accordance with the Accuchecks. They verified they administered Insulin that was due at 4:00 PM and 5:00 PM between 7:00 PM and 7:30 PM. Record review revealed fourteen (14) sampled residents and one unsampled resident (Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A) did not receive their scheduled Insulin or Sliding Scale (SS) Insulin as ordered on the evening of 02/05/18, due to the medication administration being from two (2) to four (4) hours late. Record review revealed Residents #13, #31, #40, #61, #64, #78, and Unsampled Resident A received both SS Insulin and scheduled Insulin at the same time on the evening of 02/05/18. Also, per record review on the evening of 02/05/18, Resident #4 did not receive his/her SS Insulin as indicated for a blood glucose reading of 235; Residents #19 and #20 did not receive his/her scheduled Insulin; and, Residents #13, #31, #40, #61, #64, #78 and Unsampled Resident A received SS Insulin and scheduled insulin at the same time. Interview on 02/08/18 at 3:00 PM, with the Attending Physician/Medical Director, for Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident #A, revealed he expected Accuchecks to be performed and Insulin to be administered as per the physician's orders [REDACTED]. Per interview, it was a significant medication error to administer Insulin outside of the time parameters as this posed a risk for [MEDICAL CONDITION] and [DIAGNOSES REDACTED], which could lead to serious consequences. Interview with the Regional Quality Manager (RQM) on 02/08/18 at 4:38 PM, revealed she visited her buildings once a month and her role was to sit through the morning clinical meetings to see if they were following facility processes and to see what concerns were brought up; audit through observation during walking rounds to see if any concerns; check rooms for any safety hazards; and complete chart reviews. She stated she was unaware there was only one (1) nurse on the evening of 02/05/17 after 3:00 PM for the second floor for sixty-one (61) residents and did not answer when asked if it would be possible for one (1) nurse to administer medications timely to that many residents. However, she did state there was no mandatory system in place to make staff stay over. Per interview, when staff called to say they would not be in, the Staffing Coordinator or the Acting DON were to try to call staff to see if they could get staff to come in or to ask staff to stay over. Further interview with the RQM, revealed in order to ensure there were no significant medication errors in the building, she would observe medication pass, and review transcriptions of orders at intervals. She stated she had not recently observed a medication pass at the facility, and as part of her audits she did not normally review the Medication Administration Record [REDACTED]. Per interview, it would be a medication error to give Insulin hours late and there could be negative consequences for the residents if Insulin's were not given as ordered. Continued interview with the RQM, revealed she had discovered the showers were not being documented and/or not being given at the facility and she implemented an action plan which involved setting up a shower sheet to include the State Registered Nursing Assistant (SRNA) and the Nurse to sign for each shower in order to ensure the showers were given and documented, but she had not yet in serviced all applicable staff on the process. Also, per interview she had identified there was a problem with the skin assessments /wound assessments being documented as completed on the Treatment Administration Record (TAR), but without documentation of wounds with descriptions and measurements. She stated she was in the process of implementing the action plan and had not yet in serviced all applicable staff related to this. Additional interview with the RQM, revealed facility staff brought concerns about the staffing shortage to her sometime in January and she brought the staff concerns to the Former Administrator, the Former Director of Nursing (DON) and the Regional Director of Operations. Per interview, the facility offered a sign on bonus; offered $50.00 to pick up an extra shift which was then increased to $100.00; and did Social Media Advertisements. She stated when the Regional Director of Operations spoke with the previous Administrator about staffing, he would say he had it covered. She further stated she received a call from the Medical Director who stated there were issues with nurses leaving and she notified the Regional Director of Operations herself, who started calling in nurses from other buildings to help. Per interview, she was not sure of the date the Medical Director spoke to her about this and was unsure of the date in which she had notified the Regional Director of Operations. Continued interview with the RQM, revealed the Acting DON was to audit charts as part of her job and to ensure care was provided as per the physician's orders [REDACTED]. When asked how she ensured there was adequate staff to meet the residents' needs, she stated she would review staffing sheets, and talk to the Staffing Coordinator, Acting DON and the Administrator. She further stated she was just now looking at staffing and needed to do a retrospective review of staffing. Interview on 02/15/18 at 10:00 AM, with the Divisional Quality Manager (DQM), revealed she was the direct Supervisor for the Regional Quality Manager in this building and other buildings as well. Per interview, during her visits to the facility she would review skin, weights, [MEDICAL CONDITION] medications, the core nursing system, and would check to ensure the facility was having daily meetings, reviewing new admissions, and following regulations. She stated the Regional Quality Managers were to identify issues that needed work from the morning clinical meetings and also had a check list of things to look at to ensure care was being provided. She further stated she and the Regional Quality Managers would complete mock surveys and complete a Score Card for each facility three (3) times a year related to nursing systems, weight management, skin management, infection control, quality of care and medication administration. Further interview with the (DQM), revealed in order to determine medication errors the Regional Quality Managers would observe medication pass, but would only look at the MAR's which revealed the times the medication was scheduled to be given and would not look at the Detailed Report which would state the actual time the medication was administered unless they had identified a problem with medication not given timely. Per interview, she was unsure if it was identified at this facility that medications were not given timely prior to the survey. However, she stated it was important for medications including Insulin to be given timely and per physician's orders [REDACTED]. Additional interview with the DQM, revealed this building is a focus facility for me as problems were identified starting in October due to turnover of staff, problems with the facility not following systems, and problems with Administration. Per interview, the Regional Quality Manager had identified skin assessments and treatments were not being completed and weights were not being obtained prior to the Survey and was in the process of carrying out action plans including audits through the Quality Assurance (QA) Process. However, she stated she was not sure in what month they had discussed this in the QA Meeting and was not sure where they were in the process related to education to staff. She stated we are still carrying out the action plans. Interview with the Regional Director of Operations (RDO), on 2/15/18 at 9:33 AM, revealed she had ten (10) buildings in which she was to oversee which included making sure policies and procedures were followed, and checking the financial operations of the facility. She stated she was the Immediate supervisor of the Administrator. Per interview, corporate was aware there were staffing issues at the facility for at least the last two (2) months Further interview with the RDO, revealed starting in December, she requested updates on a regular basis from the previous Administrator related to staffing and in December he was handling staffing pretty well. Per interview, then staff would no longer agree to overtime and corporate implemented bonuses for picking up extra shifts; a referral bonus; offered sign on bonuses to recruit for Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Registered Nurse Aides (SRNA); and asked staff from other building to come out and help. Per interview, the previous Administrator did not request agency staff which would have to be formally requested by the Administrator and would have to go through a corporate approval process. Additional interview with the RDO, revealed the Former Administrator did not let her know staffing was as low as it was and would tell her he had it covered right up until the day he left. She stated had she known staffing was in the crisis level that it was prior to the Former Administrator leaving, she would have utilized Agency staff and ensured there was more staff coming from the sister facilities to help. Per interview, a prudent Administrator should have made her aware there was a staffing crisis. She stated as a result of being short staffed, they realized weights were not being obtained, showers were not being given, and skin assessment/wound assessments were not being completed which were quality of care issues. However, she stated she was unaware the Acting DON was having to work the floor completing staff nurse duties and was unable to complete her Acting DON duties due to staffing. When asked about the situation which occurred on 02/05/18, where the physician's orders [REDACTED]. Continued interview with the RDO, revealed the Former Administrator left the facility, the same day the current Administrator started. She stated the current Administrator quickly realized there had been issues with the previous Administrators leadership style which contributed to staff resigning. Per interview, the current Administrator requested Agency Staff and also requested staff from the sister facilities to come help and at this time Agency staff and staff from a sister facility were in the building. The facility provided an acceptable credible Allegation of Compliance on (A(NAME)) 02/16/18, which alleged removal of the IJ effective 02/14/18. Review of the A(NAME) revealed the facility implemented the following: 1. On 02/08/18 the facility added additional staffing on the 3:00 to 11:00 PM shift to include one Licensed Practical Nurse (LPN) who clocked in at 6:30 PM and one LPN who clocked in at 6:45 PM. 2. On 02/09/18, a licensed nurse completed Medication Error Reports for each of the fifteen (15) residents (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33) identified in the deficient practice of insulin administration. 3. On 02/09/18, a licensed nurse verified no new orders or adverse outcomes were noted as a result of the medication errors for any of the identified fifteen residents, (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33). 4. On 02/06/18, the facility entered into a contract with a nursing staffing agency to supplement any staffing needs. 5. On 02/08/18, the Human Resource Manager/Staffing Coordinator validated that all open positions were posted for recruitment. Further interview revealed, the facility expanded the recruitment area for licensed nurses. 6. On 02/11/18, the Regional Quality Manager performed an audit of residents. Thirty-nine total residents were identified who received blood glucose monitoring and subsequent insulin orders. The audit validated blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. 7. On 02/09/18, the Administrator and Regional Director of Operations created and adopted a new Emergency Staffing Procedure to address actions to be taken during emergencies or where additional staffing is optional. 8. On 02/09/18, the Administrator and the Regional Director of Operations reviewed and updated the staffing component of the facility self-assessment. 9. On 02/09/18, re-education was provided by the Regional Quality Manager to the Acting Director of Nursing (DON) in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. On 02/09/18, re-education was provided by the Regional Director of Operations to the Administrator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. On 02/10/18, re-education was provided by the Regional Quality Manager to a licensed Staff Educator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 12. The Acting DON and/or the licensed Staff Educator and Regional Quality Manager provided education to licensed nurses. The education included notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Approximately 93% of the current facility licensed nursing staff completed education by 02/13/18. Those remaining will have completed education prior to assuming duties upon returning to work. 13. Agency nursing binder implemented with orientation reference steps and training information and copies to be given to any agency nurse. Any agency nurse will be required to complete education by Director of Nursing or Assistant Director of Nursing prior to assuming duties and will sign for received education. 14. Acting DON, Staff Educator and/or Regional Quality Manager provided validation of educational understanding by the licensed nursing staff with return verbal exchange. 15. Audits were to be done by the Acting DON, Nurse Manager, and/or the Regional Quality Manager daily beginning 02/09/18, for blood sugar test completion, physician follow up if indicated, physician orders [REDACTED]. 16. Quality Assurance (QA) Meetings were held on 02/09/18 to discuss the IJ allegation and develop an action plan. The Attendees included the Administrator, Regional Quality Manager, Acting DON, Social Services (2), Business Director, Human Resources/Staffing Coordinator, and the Regional Director of Operations. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action to be initiated. QA meetings were to be held at least weekly until substantial compliance was achieved and monthly thereafter. A member of the Regional Team will be in attendance in addition to the facility team for the weekly QA. The Team was to include at a minimum the Administrator, Acting DON, Social Services, State Registered Nursing Assistant and the Charge Nurse. 17. On 2/09/18, a Governing Body Meeting was held to officially document in the minutes the appointment of a replacement Administrator and outline the Administrative duties. The Administrator had received an official letter of appointment on 01/30/18. The Administrator, the Acting DON and the Regional Director of Operations were in attendance. The Medical Director was contacted by the Administrator on 02/09/18 and reviewed the Governing Body Meeting Minutes were reviewed with him. The State Survey Agency validated the implementation of the facility's A(NAME) as follows: 1. Reviewed facility staffing sheets for 02/05/18. LPN #7 clocked in at 6:30 PM and LPN #8 clocked in at 6:45 PM on 02/05/18. Interview with Administrator on 02/16/18 revealed he had verified LPN # 7 had clocked in at 6:30 PM and LPN #8 had clocked in at 6:45 PM on 02/05/18, per the Acting DON and time sheets. Interview with the Acting DON, during a post survey interview, on 02/22/18 at 10:10 AM, revealed on 02/05/18, she had been the only nurse on the second floor until LPN #7 and LPN #8 clocked in around 6:30 PM. Further interview revealed, the shift started at 3:00 PM. 2. Review of the Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33, identified with the deficient practice sliding scale insulin administered outside the time frame on 02/05/18. These reports were completed by the Acting DON. Interview with the Acting DON, during a post survey interview on 02/22/18 at 10:10 AM, revealed she had completed the Medication error reports on 02/09/18. 3. Review of Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, and Resident #33, revealed they were signed by the Acting DON. Further review revealed, the Acting DON notified the physician and documented there were no new orders or adverse outcomes related to the insulin administration errors made on 02/05/18. Post Survey Interview with the Acting DON, on 02/22/18 at 10:10 AM, revealed she notified physician and there were no adverse effects or orders from physician related to Medication Error Reports on 02/09/18. 4. Review of the facility's contract with the nurse staffing agency, dated 02/06/18, revealed the contract was signed by the Administrator. Further review revealed, the contact was to provide supplemental staffing and staffing placement options. Interview with the Administrator, on 02/16/18 at 1:00 PM, revealed he did sign the staffing agreement with the nursing staffing agency on 02/06/18. 5. Review of the Human Resource/Staffing Coordinator statement, dated 02/08/18, reported marketing strategies were reviewed and placed in surrounding areas for nurse recruitment purposes. Interview with the Human Resources/Staffing Coordinator, on 02/16/18 at 2:00 PM, validated marketing strategies were used in an attempt to recruit staff and expand recruitment areas on 02/08/18. 6. Review of the audit, dated 02/11/18, revealed thirty-nine (39) residents were identified to receive finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. Interview with Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she audited all residents in the facility. Continued interview revealed, she identified thirty-nine (39) residents that received finger glucose monitoring and subsequent blood sugar testing. Further interview revealed she audited areas to included: residents receiving finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and orders being followed with any discrepancies addressed. 7. Review of the Emergency staffing Procedure reveals, the procedure was dated effective 02/10/18. Continued review of the document revealed, during emergencies, scheduled staffing interruption, or other temporary situations, a supervisor may require an employee to work different workdays, additional shift(s), different shift(s), or extended shift(s) without advanced notice. 8. Review of the staffing component of the facility self-assessment, dated 02/09/18, revealed the Administrator and the Regional Director of Operations reviewed and updated the staffing component previously dated 11/28/17. Further review revealed, the document was reviewed by the Governing body, Acting DON, Medical Director and Maintenance Director on 02/09/18. Interview with Administrator, on 2/16/18 at 11:00 AM, revealed the staffing component was updated on 02/09/18. Interview with Medical Director, on 02/16/18 at 4:20 PM, revealed he was updated on the facility self-assessment updates in the Governing Body Meeting on 02/09/18. 9. Review of the facility Education sign in sheets, dated 02/09/18, revealed the Acting DON was re-educated on newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Further review revealed, the education was provided by the Regional Quality Manager. Post Survey Interview with the Acting DON, on 02/22/16 at 10:10 AM, revealed she had been re-educated by the Regional Quality Manager on the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. Review of Education sign in sheets, dated 02/09/18, revealed the Administrator was re-educated by the Regional Director of Operations. Continued review revealed the education consisted of: the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related t (TRUNCATED)

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to have an effective system to ensure clinical records were maintained on each resident which were complete, and accurately documented for nineteen (19) of fifty-two (52) sampled residents and one (1) unsampled resident (Residents #1, #4, #9, #13, #14, #19, #20, #22, #27, #31, #40, #52, #61, #63, #64, #70, #78, #79, #91 and Unsampled Resident A). Observation and interview with the Acting Director of Nursing (DON) on 02/05/18 at 6:40 PM, revealed had been working on the second floor unit of the facility as the only licensed nurse since approximately 3:45 PM. Per interview she was in the process of performing Accuchecks (procedure to determine Blood Glucose levels) for the diabetic residents which were ordered to be performed at 4:00 PM and 5: 00 PM. Interview on 02/06/18, 02/07/18, and 02/08/18 with Licensed Practical Nurse (LPN) #7, LPN #8, and the Acting DON revealed LPN #7 and LPN #8 arrived on the second floor unit at approximately 6:45 PM on 02/05/18, to assist the Acting DON with administering medications, performing treatments and completing staff nurse duties. The nurses revealed the Sliding Scale Insulin medication which was ordered to be administered at 4:00 PM and 5:00 PM based on the results of the Accuchecks were not administered until between 7:00 PM and 8:00 PM on 02/05/18. Furthermore, the nurses revealed they performed 8:00 PM and 9:00 PM Accuchecks; administered Sliding Scale Insulin coverage; and administered routine long acting Insulin between 9:00 PM and 11:30 PM on 02/05/18. However, the Electronic Medication Administration Record [REDACTED]. This affected Residents 1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A. (Refer to F-580, F-725 and F-760) Furthermore, interview with the Acting DON, revealed the Unit Managers for both units who were responsible for ensuring the skin management protocol was followed, left shortly after the previous DON left in January 2018, as did several other nurses. Interview further revealed due to the building being short staffed the staff nurses were unable to complete skin and wound assessments and documentation weekly as per facility protocol. Record review revealed there was no documented evidence these assessments were consistent, complete and accurately documented. Additionally, staff signed the Treatment Administration Record (TAR) to indicate the skin assessments were complete on several dates in which there was no documentation of a skin assessment. This affected Residents #1, #9, #27, #52, #70, and #91. (Refer to F-725, and F-686) The facility's failure to have an effective system in place to ensure medical records were complete, and accurately documented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 02/08/18, and determined to exist on 02/05/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/15/18 with the facility alleging removal of the Immediate Jeopardy on 02/14/18. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/14/18, prior to exit on 02/16/18, with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Guidelines for Maintaining Health Information and Medical Records Systems, dated July 2015, revealed a medical record must be maintained for every resident in a long term care facility. Facilities must have formalized systems in place to maintain records that are organized systematically and readily accessible. 1. Review of the facility Medication Administration Policy, undated, revealed medications are administered in accordance with written orders of the prescriber and if necessary the nurse calls the prescriber for clarification. The individual who administers the medication dose, records the administration on the resident's Medication Administration Record [REDACTED]. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled and an explanatory note is entered on the reverse of the record. There was no clarification in the policy to state the procedure for documentation when a medication was given other than the scheduled time on the Electronic Medication Administration Record [REDACTED] Interview with LPN #8, on 02/06/18 at 3:15 PM, and with LPN #7, on 02/08/17 at 12:27 PM, revealed they arrived at the facility on the second floor unit at approximately 6:45 PM. The nurses revealed they received a list of Accucheck results which had been obtained by the Acting DON upon arrival, and started administering Insulin in accordance with the Accuchecks. Both nurses revealed they administered Insulin that was due at 4:00 PM and 5:00 PM between 7:00 PM and 7:30 PM. Further interview with the Acting DON on 02/07/18 at 4:00 PM revealed she held off on the administration of the 9:00 PM Accuchecks and Insulin until 10:00 to 11:30 PM due to giving the 4:00 PM and 5:00 PM Insulin's late. Record review of the EMAR Detailed Report, revealed fourteen (14) sampled residents and one (1) unsampled resident (Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78 #79, and Unsampled Resident A) did not receive their scheduled Insulin or Sliding Scale (S/S) Insulin as ordered the evening of 02/05/18, due to the medication being administered two (2) to four (4) hours late. Further review of the EMAR Detailed Report, revealed Residents #13, #31, #40, #61, #64, #78, and Unsampled Resident A received both SS Insulin and scheduled Insulin at the same time the evening of 02/05/18. Also, record review of the EMAR Detailed Report, revealed Resident #4 did not receive his/her SS Insulin as indicated for a blood glucose result of 235; Residents #19 and #20 did not receive their scheduled Insulin; and Residents #13, #31, #40, #61, #64, #78 and Unsampled Resident A received SS Insulin and scheduled insulin at the same time. Continued interview with the Acting DON, on 02/07/18 at 4:00 PM, revealed the Electronic Medication Administration Record [REDACTED]. However, she stated she should have documented the actual times the Accuchecks were performed and the Insulin's were given in the Nurse's Notes to ensure there was an actual timeline for other staff and the Physician to review in case there was an episode of hypo/[MEDICAL CONDITION] for the residents due to the late Insulin administration that evening. Per interview, clinical records should be accurate and complete and she did not ensure resident records were accurate and complete for the residents in which she was assigned on 02/05/18. Interview with LPN #8, on 02/06/18 at 3:15 PM, revealed review of the EMAR revealed the Insulin's were administered at the scheduled times on the evening of 02/05/18. However, she re-iterated the Insulin's were given late that evening. Per interview, she should have documented the times the Insulin's were actually given that evening in the Nurse's Notes to ensure the clinical records were complete and accurate. Interview with LPN #7 on 02/08/17 at 12:27 PM, revealed on the evening of 02/05/18, the Insulins were not given at the specific times according to meals and were given hours late; however, the EMAR revealed the Insulin was given according to the scheduled times. She stated she should have ensured the actual times of Insulin administration was documented in the Nurse's Notes to ensure the clinical records were complete and accurate. Interview on 02/08/18 at 3:00 PM, with the Attending Physician/Medical Director for Residents #1, #4, #13, #14, #19, #20, #22, #31, #40, #61, #63, #64, #78, #79, and Unsampled Resident A, revealed Accuchecks were to be performed and Insulin was to be administered at the correct times as per physician's orders [REDACTED]. He further stated if the EMAR did not indicate the times the Insulin was actually administered, the Nurse's should have documented the exact times the Accuchecks and the Insulin's were administered in the Nurse's Notes. Per interview, it was important for the clinical record to be accurate and complete. Interview with the Administrator on 02/08/18 at 7:10 PM, revealed it was his expectation that the clinical record be accurate and complete and if Insulin's were not given timely as per physician's orders [REDACTED]. have documented the exact times the Accuchecks and Insulin's were administered in the Nurse's Notes. 2. Review of the facility's Skin System Policy and Procedure, undated, revealed a skin assessment would be completed on admission/re-admission, with any fall, and weekly thereafter. Staging and measuring will be done by the assigned nurse to maintain continuity in documentation of progression of wound healing. However, review of the clinical record revealed the weekly skin assessments and/or wound assessments for Residents #1, #9, #27, #52, #70 and #91 were not consistently documented per the residents' care plan and facility's policy and procedures. Review of the Treatment Administration Records (TAR) for Residents #1, #52, #70, and #91 revealed documentation of skin assessments being completed; however, there was no documented evidence these assessments were completed as documented. Review of Resident #1's Skin Inspection Report, for December 2017 through February 2018, revealed there was no documented evidence of a skin assessment from 12/23/17 until 01/06/18, fourteen (14) days later. However, review of the December 2017 TAR revealed the intervention for a skin assessment was signed to indicate it was completed on 12/30/17. Continued review of the Skin Inspection Report revealed no documented evidence of a skin assessment from 01/20/18 until 02/03/18, fourteen (14) days later. Review of Resident #9's Wound Assessment Report revealed no Wound Assessment from 12/20/17 until 01/03/18, fourteen (14) days later. In addition, there were no further Skin Assessments noted from 01/03/18 until 01/17/18, fourteen (14) days later. Review of Resident #27's Wound Assessment Reports dated 11/04/17, 11/11/17, 11/18/17, 12/02/17 (fourteen (14) days later), and 12/09/17, revealed Resident #27 had a Stage II Pressure Ulcer to the Right Inner Thigh which was unchanged. However, there were no measurements noted for the Wound Assessments completed from 11/04/17 through 12/09/17. Also, there were no documented measurements of the resident's Pressure Ulcer to the Right Inner thigh on the Wound Assessment Reports or in the Nurse's Notes from 11/01/17 until 12/23/17, fifty-two (52) days later. The next wound report was not completed until 01/27/18, seventeen (17) days later. Review of Resident #70's Skin Inspection Report revealed no documented evidence of Skin Assessments completed from 11/11/17 until ten (10) days later, on 11/21/17. Further review revealed no documented evidence of Skin Assessments or Wound Assessments with measurements from 12/23/17 until 01/06/18, fourteen (14) days later. Additional review revealed there was no documented evidence of a Skin Assessment or Wound Assessment from 01/06/18 until 01/20/18, fourteen (14) days later. Further review revealed there was no documented evidence of a Skin Assessment or Wound Assessment from 01/20/18 until 02/03/18, fourteen (14) days later; although the TAR was initialed on 01/27/18 to indicate the skin assessment was completed. Review of Resident #91's Skin Inspection Report revealed no documented evidence of a Skin Assessment from 11/24/17 until 12/21/17, twenty-seven (27) days later, although the TAR was signed indicating a Skin Assessment was completed on 11/30/17, 12/07/17 and 12/14/17. Subsequently there was no documented evidence of a Wound Assessment from 12/21/17 until 01/11/18, twenty-one (21) days later, although the TAR was signed on 12/28/17 and 01/04/18 to indicate a skin assessment was completed. Subsequently there was no documented evidence of a Skin Assessment after the IDT Note on 01/18/18, until 02/03/18, which was seventeen (17) days later, although the TAR revealed it was signed on 01/25/18 to indicate a Skin Assessment/Wound Assessment had been completed. Review of Resident #52's Skin Inspection Report revealed no documented evidence of a skin assessment from 11/17/17 until 12/14/17, twenty-seven (27) days later. However, review of the TAR dated 11/24/17, 12/01/17 and 12/08/17, revealed skin assessments were initialed as completed. Further review revealed no documented evidence of a skin assessment from 12/29/17 until 01/12/18, fourteen (14) days later. However, the TAR was signed on 01/06/18 indicating the skin assessment was completed. Further review revealed there was no documented evidence of a skin assessment from 01/12/18 until 01/25/18, thirteen (13) days. However, the TAR dated 01/19/18, revealed it was signed indicating a skin assessment was completed on that date. Interview on 02/13/18 at 4:00 PM, with LPN #6, revealed she had worked at the facility five (5) years and worked the evening shift. She further revealed over the last month or even longer there had been a staffing shortage and she had to stay at the facility through the early morning hours to get treatments done. Per interview, she thought she completed the skin assessments when she signed the TAR; however, probably did not document them due to time constraints. Interview on 02/13/18 at 4:13 PM, with Registered Nurse (RN) #4, revealed she had worked at the facility for five (5) years and she had recognized a staffing shortage since November 2017. She stated sometimes documentation of skin assessments was not completed as a result of not having enough time. Interview with the Acting DON, on 02/07/18 at 4:00 PM, revealed the Unit Managers who were responsible for ensuring skin/wound assessments were completed resigned shortly afterward as did other nurses over the past months. She stated she was aware there were discrepancies in measurements and descriptions of wounds. She was also aware there were discrepancies related to the TAR being signed indicating the skin assessment/wound assessment was complete, but there was no documentation of the skin/wound assessment. Per interview, skin assessments/wound assessments were not completed weekly due to the staffing shortage. Further interview revealed clinical records related to weekly wound/skin assessments should be accurate and complete. Interview with the Administrator on 02/08/18 at 7:10 PM and on 02/16/18 at 4:00 PM, revealed the clinical record related to skin management needed to be accurate and complete, and he felt the lack of monitoring and documentation stemmed from the staffing issue. The facility provided an acceptable credible Allegation of Compliance on (A(NAME)) 02/16/18, which alleged removal of the IJ effective 02/14/18. Review of the A(NAME) revealed the facility implemented the following: 1. On 02/08/18 the facility added additional staffing on the 3:00 to 11:00 PM shift to include one Licensed Practical Nurse (LPN) who clocked in at 6:30 PM and one LPN who clocked in at 6:45 PM. 2. On 02/09/18, a licensed nurse completed Medication Error Reports for each of the fifteen (15) residents (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33) identified in the deficient practice of insulin administration. 3. On 02/09/18, a licensed nurse verified no new orders or adverse outcomes were noted as a result of the medication errors for any of the identified fifteen residents, (Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33). 4. On 02/06/18, the facility entered into a contract with a nursing staffing agency to supplement any staffing needs. 5. On 02/08/18, the Human Resource Manager/Staffing Coordinator validated that all open positions were posted for recruitment. Further interview revealed, the facility expanded the recruitment area for licensed nurses. 6. On 02/11/18, the Regional Quality Manager performed an audit of residents. Thirty-nine total residents were identified who received blood glucose monitoring and subsequent insulin orders. The audit validated blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. 7. On 02/09/18, the Administrator and Regional Director of Operations created and adopted a new Emergency Staffing Procedure to address actions to be taken during emergencies or where additional staffing is optional. 8. On 02/09/18, the Administrator and the Regional Director of Operations reviewed and updated the staffing component of the facility self-assessment. 9. On 02/09/18, re-education was provided by the Regional Quality Manager to the Acting Director of Nursing (DON) in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. On 02/09/18, re-education was provided by the Regional Director of Operations to the Administrator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. On 02/10/18, re-education was provided by the Regional Quality Manager to a licensed Staff Educator in regards to the newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 12. The Acting DON and/or the licensed Staff Educator and Regional Quality Manager provided education to licensed nurses. The education included notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Approximately 93% of the current facility licensed nursing staff completed education by 02/13/18. Those remaining will have completed education prior to assuming duties upon returning to work. 13. Agency nursing binder implemented with orientation reference steps and training information and copies to be given to any agency nurse. Any agency nurse will be required to complete education by Director of Nursing or Assistant Director of Nursing prior to assuming duties and will sign for received education. 14. Acting DON, Staff Educator and/or Regional Quality Manager provided validation of educational understanding by the licensed nursing staff with return verbal exchange. 15. Audits were to be done by the Acting DON, Nurse Manager, and/or the Regional Quality Manager daily beginning 02/09/18, for blood sugar test completion, physician follow up if indicated, physician orders [REDACTED]. 16. Quality Assurance (QA) Meetings were held on 02/09/18 to discuss the IJ allegation and develop an action plan. The Attendees included the Administrator, Regional Quality Manager, Acting DON, Social Services (2), Business Director, Human Resources/Staffing Coordinator, and the Regional Director of Operations. The Administrator corresponded with the Medical Director via phone on this date to review the IJ citing and planned for the development of the immediate action to be initiated. QA meetings were to be held at least weekly until substantial compliance was achieved and monthly thereafter. A member of the Regional Team will be in attendance in addition to the facility team for the weekly QA. The Team was to include at a minimum the Administrator, Acting DON, Social Services, State Registered Nursing Assistant and the Charge Nurse. 17. On 2/09/18, a Governing Body Meeting was held to officially document in the minutes the appointment of a replacement Administrator and outline the Administrative duties. The Administrator had received an official letter of appointment on 01/30/18. The Administrator, the Acting DON and the Regional Director of Operations were in attendance. The Medical Director was contacted by the Administrator on 02/09/18 and reviewed the Governing Body Meeting Minutes were reviewed with him. The State Survey Agency validated the implementation of the facility's A(NAME) as follows: 1. Reviewed facility staffing sheets for 02/05/18. LPN #7 clocked in at 6:30 PM and LPN #8 clocked in at 6:45 PM on 02/05/18. Interview with Administrator on 02/16/18 revealed he had verified LPN # 7 had clocked in at 6:30 PM and LPN #8 had clocked in at 6:45 PM on 02/05/18, per the Acting DON and time sheets. Interview with the Acting DON, during a post survey interview, on 02/22/18 at 10:10 AM, revealed on 02/05/18, she had been the only nurse on the second floor until LPN #7 and LPN #8 clocked in around 6:30 PM. Further interview revealed, the shift started at 3:00 PM. 2. Review of the Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, Resident #33, identified with the deficient practice sliding scale insulin administered outside the time frame on 02/05/18. These reports were completed by the Acting DON. Interview with the Acting DON, during a post survey interview on 02/22/18 at 10:10 AM, revealed she had completed the Medication error reports on 02/09/18. 3. Review of Medication Error Reports, dated 02/09/18, for Resident #6, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32, and Resident #33, revealed they were signed by the Acting DON. Further review revealed, the Acting DON notified the physician and documented there were no new orders or adverse outcomes related to the insulin administration errors made on 02/05/18. Post Survey Interview with the Acting DON, on 02/22/18 at 10:10 AM, revealed she notified physician and there were no adverse effects or orders from physician related to Medication Error Reports on 02/09/18. 4. Review of the facility's contract with the nurse staffing agency, dated 02/06/18, revealed the contract was signed by the Administrator. Further review revealed, the contact was to provide supplemental staffing and staffing placement options. Interview with the Administrator, on 02/16/18 at 1:00 PM, revealed he did sign the staffing agreement with the nursing staffing agency on 02/06/18. 5. Review of the Human Resource/Staffing Coordinator statement, dated 02/08/18, reported marketing strategies were reviewed and placed in surrounding areas for nurse recruitment purposes. Interview with the Human Resources/Staffing Coordinator, on 02/16/18 at 2:00 PM, validated marketing strategies were used in an attempt to recruit staff and expand recruitment areas on 02/08/18. 6. Review of the audit, dated 02/11/18, revealed thirty-nine (39) residents were identified to receive finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and physician's orders [REDACTED]. Interview with Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she audited all residents in the facility. Continued interview revealed, she identified thirty-nine (39) residents that received finger glucose monitoring and subsequent blood sugar testing. Further interview revealed she audited areas to included: residents receiving finger blood glucose monitoring and subsequent blood sugar testing with auditing of blood sugar testing completion, physician follow up if indicated and orders being followed with any discrepancies addressed. 7. Review of the Emergency staffing Procedure reveals, the procedure was dated effective 02/10/18. Continued review of the document revealed, during emergencies, scheduled staffing interruption, or other temporary situations, a supervisor may require an employee to work different workdays, additional shift(s), different shift(s), or extended shift(s) without advanced notice. 8. Review of the staffing component of the facility self-assessment, dated 02/09/18, revealed the Administrator and the Regional Director of Operations reviewed and updated the staffing component previously dated 11/28/17. Further review revealed, the document was reviewed by the Governing body, Acting DON, Medical Director and Maintenance Director on 02/09/18. Interview with Administrator, on 2/16/18 at 11:00 AM, revealed the staffing component was updated on 02/09/18. Interview with Medical Director, on 02/16/18 at 4:20 PM, revealed he was updated on the facility self-assessment updates in the Governing Body Meeting on 02/09/18. 9. Review of the facility Education sign in sheets, dated 02/09/18, revealed the Acting DON was re-educated on newly adopted policy, Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Further review revealed, the education was provided by the Regional Quality Manager. Post Survey Interview with the Acting DON, on 02/22/16 at 10:10 AM, revealed she had been re-educated by the Regional Quality Manager on the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 10. Review of Education sign in sheets, dated 02/09/18, revealed the Administrator was re-educated by the Regional Director of Operations. Continued review revealed the education consisted of: the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Interview with the Administrator, on 02/16/18 at 1:15 PM, revealed he had received training from the Regional Director of Operations regarding the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. 11. Review of the Education sign in sheets revealed, the Regional Quality Manager provided education to the licensed Staff Educator, on 02/10/18, in regards to the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Interview with the Regional Quality Manager, on 02/16/18 at 2:30 PM, indicated she had provided the education to the Staff Educator to include the verbal return of information and her signature of understanding. 12. Review of the facility Education Sign in sheets, revealed the Acting DON, the licensed Staff Educator and the Regional Quality Manager provided re-education to the licensed staff nurses in regards to the Emergency Staffing Procedure, following the plan of care as it relates to insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside of physician ordered parameters and medication errors. Review of the Education Staffing Rosters and sign in sheets revealed, approximately 93% of the facility's licensed nursing staff had received re-education by 02/13/18 with education provided to others prior to working a shift. Interview, on 02/16/18 with Licensed Practical Nurse (LPN) #3, LPN #10, LPN #11, LPN #12 and Registered Nurse (RN) #7 revealed, education was provided to them on 2/13/18. Interview with LPN# 10 and RN #6, on 02/16/18, revealed they had received education on the above topics on 02/14/18, prior to the start of their shift. Interview with the Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she reviewed the staffing rosters and compared them to the Education sign on sheets for completeness by 02/13/18. Continued interview revealed any staff that had not received the education by 02/13/18 was educated as they returned to work and prior to beginning their shift. 13. Review of the Agency Binder revealed, orientation reference steps and training Information was included in the binder. Interview with the Regional Quality Manager, on 02/16/18 at 2:30 PM, revealed she had compiled the Agency Binder to be a tool for Agency or outside facility employees in orientation and to be a reference tool for training information. 14. Review of the Education Sign in sheets indicated LPN #3, LPN #10, LPN #11, LPN #12, RN #7, LPN#10 and RN #6 had received the re-education regarding insulin, accurate and complete documentation in the medical record as it relates to insulin, accurate and complete documentation as it relates to medications, notification of the physician as related to late administration of insulin, blood glucose results outside o (TRUNCATED)

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to have an effective system in place to ensure the facility's protocol was implemented related to pressure ulcers to ensure a resident at risk for pressure ulcers or a resident with pressure ulcers, received the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for six (6) of fifty-two (52) sampled residents (Residents #1, #9, #27, #52, #70 and #91). Interview and record review revealed the previous Director of Nursing's (DON) last day at the facility was 01/05/18, and the Assistant DON was placed in the Acting DON position. However, the Acting DON was not able to fulfill the duties of the Acting DON due to being assigned to the medication cart and having to complete staff nurse duties. Also, interview revealed the Staff Development Nurse left the faciity on [DATE], the Unit Managers for the first and second floor left shortly afterward, and several staff nurses resigned since the resignation of the previous DON on 01/05/18. Interview further revealed the building was short staffed and the nurses were unable to complete skin and wound documentation and treatments as per protocol. Review of the facility's Skin System Policy and Procedure, revealed a skin assessment would be completed on admission/re-admission, with any fall and weekly thereafter. However, record review revealed there was no documented evidence of consistent monitoring of the progress of the resident's wounds. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure. (Refer to F-659 and F-725) The findings include: Review of the facility's Skin System Policy and Procedure, undated, revealed residents who enter the facility without a pressure sore would not develop a pressure sore unless the individual's clinical condition demonstrates it was unavoidable; and a resident having a pressure sore would receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. A skin assessment would be completed on admission/re-admission, with any fall, and weekly thereafter. The skin committee will meet at least weekly to review the care of residents with pressure ulcers, complex wounds and skin compromise; to include resident's nutritional status and response to healing. Staging and measuring will be done by the assigned nurse to maintain continuity in documentation of progression of wound healing. Further review of the Policy, revealed the assigned Nurse Manager would provide oversight of the resident's skin/wound care in collaboration with the nurse, and physician, and report changes to the Skin Committee on a weekly basis. 1. Review of Resident #70's medical record revealed the facility admitted the resident on 04/08/16 and readmitted the resident on 06/30/17. The resident's [DIAGNOSES REDACTED]. Review of Resident #70's Comprehensive Care Plan with an initial onset date of 04/21/16, revealed the resident was at risk for impaired skin integrity as evidenced by impaired mobility, debility, cognitive loss, incontinence, and a History of a Stage II Pressure Ulcer of the Right Heel. The goal stated the resident's skin would remain intact with no pressure ulcers. There were several interventions including: use draw sheet for bed mobility; promote adequate nutrition; incontinence care as needed; notify Physician as needed; pressure reduction cushion to wheelchair; mutipodus boots to bilateral lower extremities to be worn while in bed; Weekly Skin Checks; and Weekly Wound Monitoring. Review of the Annual Minimum Data Set (MDS) Assessment, dated 01/02/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of six (6) out of fifteen (15) indicating the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as requiring extensive assist of one (1) person for bed mobility, as activity only occurred once or twice for transfers with one (1) person assist, as requiring total assist of one (1) person for toileting, and as always incontinent of bowel and bladder. Continued review revealed the facility assessed the resident to be at risk for pressure ulcers, but as having no pressure ulcers. (Refer to F-641) Review of the Braden Risk Assessment Report, dated 01/10/18, revealed the facility assessed the resident as being at moderate risk for pressure sores related to the following: sensory perception was slightly limited; skin was often moist; chair fast and could not bear weight or had to be assisted into chair or wheelchair; very limited mobility and was unable to make frequent or significant changes in position independently; nutrition was probably inadequate; and the resident had the potential problem of friction and shear. A Risk score of thirteen (13) was noted. Review of the Skin Inspection Report dated 11/11/17, revealed the resident's skin was intact. The Treatment Administration Record (TAR) was signed as N on 11/18/17, indicating the Skin Assessment was not completed the next week on that date. There was no further documented evidence of Skin Assessments completed from 11/11/17 until ten (10) days later, on 11/21/17, when per review of the Wound Healing Progress Report, the resident was assessed to have an unstageable Pressure Ulcer measuring 2.20 centimeters (cm) length x 3.0 depth cm x 0 cm width with Eschar and Slough to the Right Heel. Per the Report, the Physician was notified on 11/21/17. Review of the physician's orders [REDACTED]. A revision to the Comprehensive Care Plan, dated 11/21/17, revealed the resident had impaired skin integrity as evidenced by an unstageable Right Heel Pressure Ulcer. Further review revealed Wound Assessments were completed 11/25/17, 12/2/17, 12/9/17, 12/16/17, and 12/23/17. However, there was no documented evidence of Skin Assessments or Wound Assessments with measurements from 12/23/17 until 01/06/18 (fourteen (14) days) when the resident's Right Heel Ulcer was assessed as measuring 0.80 cm length x 0.30 cm width x 0.10 depth and described as unstageable, due to having Eschar/Slough. Interview was attempted on 02/18/18 at 2:41 PM, with the previous DON who signed as N, meaning not administered for the skin assessment on the Treatment Administration Record (TAR) for 12/30/17. However, the phone call was disconnected and although the State Survey Representative called directly back and left a message, there was no return phone call. Further review revealed there was no documented evidence of a Skin Assessment or Wound Assessment from 01/06/18 until 01/20/18, fourteen (14) days later, when the resident's Right Heel Ulcer was assessed as measuring 0.30 cm length x 0.10 cm width x 0.10 cm depth and described as unstageable due to Eschar/Slough. The TAR dated 01/13/18, was initialed to indicate the Skin Assessment was done on that date; however, there was no Skin Assessment/Wound Assessment noted in the record for that date. Continued review revealed there was no documented evidence of a Skin Assessment or Wound Assessment from 01/20/18 until 02/03/18, fourteen (14) days later. However, the TAR was initialed on 01/27/18 to indicate the skin assessment was completed. On 02/03/18, a Wound Assessment completed by Licensed Practical Nurse (LPN) #3, revealed the resident's Right Heel Pressure Ulcer measured 0.40 cm length x 0.10 cm width x 0.10 cm depth and was described as unstageable due to Slough/Eschar. Further review of the Wound Assessment completed by LPN #3, on 02/03/18, revealed the resident had a new Stage II Pressure Ulcer to the Right Buttock which measured 1.50 cm length x 0.50 cm width x 0.10 cm depth and had 100 % (percent) granulation with surrounding skin macerated. Per the Assessment, the Physician was notified. Review of the physician's orders [REDACTED]. A further revision of the Comprehensive Care Plan, dated 02/03/18, revealed the resident had a Stage II Pressure Ulcer to the Right buttock. The goal stated the resident's Right Heel and Right Buttock would be free of signs and symptoms of infection. Observation of a skin assessment for Resident #70, performed by LPN #3, on 02/06/18 at 1:45 PM, revealed the resident's Right Buttock and the Right Heel Pressure Ulcers were healed. Interview was conducted on 02/06/18 at 2:00 PM, with LPN #3, who documented most of the Skin Assessments for Resident #70 for the months of November 2017 through February 2018, and identified the resident's right buttocks pressure ulcer on 02/03/18. She stated the nurses and State Registered Nurse Aides (SRNA) had been challenged recently as far as staffing. She further stated patient care sometimes trumped skin assessments so some skin assessments may have been missed by the other nurses. She further stated she did manage to get skin assessments done on the days she worked, but sometimes had to put it off until the next day if she ran out of time. Continue interview revealed on her hall she ensured the turning and repositioning was done every two (2) hours, but would have to assist the SRNA's with positioning the residents to ensure this was done due to lack of staff. Per interview, last week on Thursday, sister facility nurses started coming in to help due to the staffing shortage. She stated, It's been rough and scary, referring to the staffing shortage. 2. Review of Resident #27's medical record revealed the facility readmitted the resident on 08/16/17 with [DIAGNOSES REDACTED]. Review of the Wound Assessment Report, dated 11/01/17, revealed the resident had a Stage II Pressure Ulcer to the Right Inner Thigh measuring 2.20 cm length x 1.40 cm width x 0.0 cm depth which was described as 100% [MEDICATION NAME] tissue. Review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan with an onset date of 11/01/17, revealed the resident had impaired skin integrity as evidenced by a Stage II to the Right thigh related to impaired mobility, pain, incontinence, and cognitive loss. The goal stated the stage II would be free of signs and symptoms of infection. There were several interventions including: use draw sheet for bed mobility to prevent friction and shearing; incontinence care as needed; pressure reduction cushion to wheelchair turn and reposition every two (2) hours; air mattress; and weekly skin checks. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (3) indicating severe cognitive impairment. Further review of the MDS revealed the facility assessed the resident as at risk of Pressure Ulcers and as having no Pressure Ulcers. (Refer to F-641) Review of the Braden Scale Assessment Report, dated 11/29/17, revealed the facility assessed the resident as being at mild risk for Pressure Ulcers related to the following: Slightly limited sensory perception; skin rarely moist; chair fast and cannot bear weight and/or must be assisted into chair or wheelchair; very limited mobility; adequate nutrition; and potential for friction and shear. A Risk Score of sixteen (16) was noted. Review of the next Wound Assessment Reports dated 11/04/17, 11/11/17, 11/18/17, 12/02/17 (fourteen (14) days later), and 12/09/17, revealed the resident had a Stage II Pressure Ulcer to the Right Inner Thigh which was unchanged. However, there were no measurements noted for the Wound Assessments from 11/04/17 through 12/09/17. There were no documented measurements of the resident's Pressure Ulcer to the Right Inner thigh on the Wound Assessment Reports or the Nurse's Notes from 11/01/17 until 12/23/17, fifty-two (52) days later, when the Wound Assessment Report dated 12/23/17, revealed the resident had a Stage II Pressure Ulcer to the Right Inner Thigh measuring 1.30 cm length x 0.40 cm width with 75% granulation tissue and 25% slough. The next Wound Assessment Report dated 01/09/18, seventeen (17) days later, revealed the resident's Stage II Pressure Ulcer to the Right Thigh was measured at 3.0 cm length x 3.60 cm width x 0.10 depth and described as 80% granulation and 20% slough. Another Wound Assessment Report, dated 01/10/18, revealed the resident's Stage II Pressure Ulcer measured 3.0 cm x 3.30 cm x 0.10 cm depth. The next Wound Assessment Report dated 01/27/18, seventeen (17) days later, revealed the resident's Stage II Pressure Ulcer to the Right Thigh measured 2.0 cm length x 2.0 cm width x .50 cm depth with 95% [MEDICATION NAME] tissue and 5% granulation. The next Wound Assessment was completed on 02/03/18, and revealed the resident had a Stage II to the right rear thigh which measured 0.50 cm length x 0.60 cm width x 0.20 cm depth and was described as 70% [MEDICATION NAME] tissue, 30% granulation tissue. Observation of a skin assessment on 02/06/18 at 12:00 PM, revealed the resident's right posterior thigh had a Pressure Ulcer measuring 0.6 cm length x 0.4 cm width and was described as the wound bed having a whitish hard scab. LPN #3 who performed the skin assessment revealed she did not want to stage the wound and would have a consult done by the Wound Nurse who came from the local clinic to see wounds in the facility as requested. 3. Review of Resident #91's medical record revealed the facility admitted the resident on 07/10/10 and readmitted the resident on 06/17/15 with [DIAGNOSES REDACTED]. Review of the Braden Risk Assessment Report, dated 11/08/17, revealed the facility assessed the resident as high risk for Pressure Ulcers related to very limited sensory perception; very moist skin; chair fast; very limited mobility; probably inadequate nutrition; and the potential for friction and shear. A Risk Score of twelve (12) was noted. Review of the Comprehensive Care Plan, dated 12/21/17, revealed Resident #91 had impaired skin integrity as evidenced by an unstageable to coccyx related to decreased mobility, incontinence and cognitive loss. The goal stated the unstageable to coccyx would be free of signs and symptoms of infection and show signs of healing. There were several interventions including: promote nutrition and hygiene; provide assist with repositioning while in bed; air mattress to bed; incontinence care; anti-thrust cushion to broda chair; weekly skin checks; and weekly wound monitoring. Review of the Significant Change MDS assessment dated [DATE], revealed the facility assessed the resident as having both short and long term memory loss. Further review of the MDS Assessment, revealed the facility assessed the resident as requiring extensive assist of two (2) for bed mobility, transfers, and toileting and as always incontinent of bowel and bladder. Additional review of the MDS revealed the facility assessed the resident as being at risk for pressure ulcers, but having no pressure ulcers. (Refer to F-641) However, review of the Care Area Assessment Summary, for the Significant Change MDS, dated , 01/10/18, revealed the resident triggered for Pressure Ulcers, and review of the CAT Worksheet related to this Summary, revealed the resident had a treatment to the coccyx wound with no skin assessment after the assessment period. Further review revealed the cause of the Pressure Ulcer was Debility due to Dementia. Review of the Skin Inspection Report starting November 2017, revealed Skin Assessments were completed 11/02/17, 11/09/17, 11/17/17, and 11/24/17 and the resident's skin was intact. However, there was no documented evidence of a Skin Assessment from 11/24/17 until 12/21/17, twenty-seven (27) days later, even though the TAR was signed indicating a Skin Assessment was completed on 11/30/17, 12/07/17 and 12/14/17. On 12/21/17, a Stage II Pressure Ulcer was identified to the Sacrum measuring 1.0 length cm x 0.50 width cm x 0 depth. A physician's orders [REDACTED]. There was no documented evidence of a Wound Assessment from 12/21/17 until 01/11/18, twenty-one (21) days later, even though the TAR was signed on 12/28/17 and 01/04/18 to indicate a skin assessment was completed. On 01/11/18, the resident's Sacrum wound was described as Stage II Pressure Ulcer to the sacrum measuring 2.0 cm length x 1.50 cm width x 0 depth indicating the wound was larger in size. The next Wound Assessment was completed on 01/17/18, which described the resident's Sacrum wound as Unstageable due to suspected deep tissue injury and the wound was measured at 4.50 cm length x 4.0 cm width indicting the wound was larger and deeper. physician's orders [REDACTED]. Review of the Interdisciplinary Progress (IDT) Note, dated 01/18/18 at 12:2 PM, revealed the resident had an unstageable wound to the coccyx with 100% slough and measuring 4.0 cm x 4.5 cm with scant drainage and undermining from 1 to 4 o'clock. Further review revealed there was an air mattress in place and the resident was currently on multivitamin (MVI) with mineral, diet puree, ice cream all meals and house supplement TID (three times a day). Per the Note, given overall condition end of life/palliative care despite treatment modalities, wound may not show signs of improvement. There was no documented evidence of a Skin Assessment after the IDT Note on 01/18/18, until 02/03/18, seventeen (17) days later, although the TAR revealed it was signed on 01/25/18 to indicate a Skin Assessment/Wound Assessment had been completed. Review of the Wound assessment dated [DATE], revealed the resident's Sacrum Wound had deteriorated and was a Stage II measuring 5.0 cm length x 5.0 cm width x 0.50 cm depth with serosanguinous drainage, 30% [MEDICATION NAME] tissue, 70% granulation, with tunneling at 11 o'clock, and the Physician was notified. Review of physician's orders [REDACTED]. Observation of a Skin Assessment for Resident #91, on 02/06/18 at 11:05 AM, completed by LPN #3, revealed the Sacrum Wound was described as a Stage III and measured 3.8 cm length x 3.1 cm width x 0.4 cm depth with a beefy red wound bed. Interview was conducted on 02/13/18 at 4:00 PM, with LPN #6, who signed Resident #91's TAR indicating the Skin Assessment had been completed on 11/30/17, 12/07/17, 01/04/18, and 01/25/18; although there was no documented evidence of Skin Assessments/Wound Assessments completed on these dates. She stated she had worked at the facility five (5) years and worked the evening shift. She further stated over the last month or even longer there had been a staffing shortage and she had to stay at the facility through the early morning hours to get treatments done. She stated she thought she completed the skin assessments for Resident #91 when she signed the TAR; however, probably did not document them due to time constraints. LPN #6 stated it was important to document the skin assessments in order to monitor if the pressure ulcers were healing or deteriorating and to ensure treatment orders were obtained as needed. 4. Review of Resident #9's medical record revealed the facility admitted the resident on 02/08/16 and readmitted the resident on 07/30/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/08/17, revealed the facility assessed the resident as having a BIMS score of eleven (11) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) persons for bed mobility, transfers, and toilet use; as not rated for urinary incontinence; and as always incontinent of bowel. Additional review revealed the facility assessed the resident as being at risk for pressure ulcers and having no pressure ulcers. Review of the Braden Risk Assessment Report, dated 11/15/17, revealed the facility assessed the resident as at mild risk for Pressure Ulcers related to: slightly limited sensory perception; very moist skin; walks occasionally; slightly limited mobility; adequate nutrition; and potential for friction and shear. The Risk Score was note to be a fifteen (15). Review of the Skin Inspection Report, revealed the resident's skin was intact on 11/29/17. However, review of the Wound Assessment Report revealed a Pressure Ulcer was identified on 12/01/17, as Stage II to the Left Buttock measuring 0.50 cm length x 0.50 cm width. Review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan dated 12/01/17, revealed the resident had impaired skin integrity as evidenced by a Stage II to the left buttock related to impaired mobility, incontinence, general aging and disease process. The goal stated the Stage II would be free of infection and the resident would have no further skin breakdown. The interventions included: Use draw sheet for bed mobility; promote adequate nutrition; notify physician of changes as needed; and weekly skin checks. Wound Assessments were completed on 12/06/17, 12/13/17, and 12/20/17. However, the next Wound Assessment was not completed until 01/03/18, fourteen (14) days later The Wound Assessment Report dated 01/03/18, revealed the resident had a Stage II Pressure Ulcer to the Left Buttock that was unchanged; however, there were no measurements or description of the wound on this Report. Also, there were no further Skin Assessments noted from 01/03/18 until 01/17/18, fourteen (14) days later when the Skin Inspection Report stated skin intact. The previous DON had signed N on 01/10/18 indicating the Skin Assessment had not been completed. Review of the IDT Progress Note, dated 01/18/18 at 12:40 PM, revealed the resident's skin continued to be monitored, and skin evaluated 01/17/18 with no skin areas noted. Observation of a Skin Assessment on 02/15/18 at 11:30 AM, performed by LPN #10, a nurse from the sister facility, revealed the resident had no Pressure Ulcers. 5. Review of Resident #52's medical record revealed the facility admitted the resident on 12/06/12, and readmitted the resident on 04/14/17 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan with an onset date of 05/20/16, revealed the resident was at risk for impaired skin integrity as evidenced by impaired mobility/balance, incontinence, cognitive loss and a history of Pressure Ulcers. The goal stated the resident's skin would remain intact. There were several interventions including turn and reposition every two (2) hours and as needed; promote adequate nutrition; report changes in skin integrity promptly and notify Physician as needed; and weekly skin checks. Review of the Quarterly MDS Assessment, dated 12/17/17, revealed the facility assessed Resident #52 as having a BIMS score of twelve (12) out of fifteen (15) indicating the resident had moderate cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) for bed mobility, as activity did not occur for transfer, as requiring extensive assist of two (2) for toilet use, and as always incontinent of bowel and bladder. Additional review revealed the facility assessed the resident as being at risk for pressure ulcers, and having no pressure ulcers. Review of the Braden Risk Assessment Report, dated 12/28/17, revealed the facility assessed the resident as being at high risk for pressure ulcers related to constantly moist; bedfast; very limited mobility; and potential problem of friction and shear. The Braden Scale Score was noted as a twelve (12). Review of the Skin Inspection Report, revealed skin assessments were documented 11/03/17, 11/10/17, and 11/17/17 with skin intact. However, further review revealed there was no documented evidence of a skin assessment from 11/17/17 until 12/14/17, twenty-seven (27) days. On 12/14/17, it was documented the resident's skin was intact. However, review of the TAR dated 11/24/17, 12/01/17 and 12/08/17, revealed skin assessments were completed. The skin assessments for the dates of 11/24/17 and 12/08/17 were initialed as completed by LPN #6; however, there was no documented evidence of skin assessments on those dates. Further review revealed there were skin assessments at least weekly on 12/22/17, 12/26/17, 12/29/17 with documentation the resident's skin was intact. However, there was no documented evidence of a skin assessment from 12/29/17 until 01/12/18, fourteen (14) days. On 01/12/18, it was documented the resident had Right Buttock excoriation. However, the TAR was signed on 01/06/18 by LPN #6, indicating the skin assessment was completed. Continued interview on 02/13/18 at 4:00 PM, with LPN #6, revealed due to being rushed and short staffed, she must have forgotten to document the resident's skin assessments for 11/24/17, 12/08/17, and 01/06/18. Additional review revealed there was no documented evidence of a skin assessment from 01/12/18 until 01/25/18, thirteen (13) days. However, the TAR dated 01/19/18, revealed it was signed indicating the nurse had completed a skin assessment on that date. On 01/25/18, the Wound Assessment Report, revealed the resident was identified to have a Stage II Pressure Ulcer to the coccyx measuring 1.20 cm length x 0.30 cm width x 0.10 cm depth with macerated edges, and [MEDICATION NAME] tissue 50% and slough 50 %. Per the Report the Physician was notified on 1/25/18. Review of physician's orders [REDACTED]. Further review of the Comprehensive Care Plan, revealed a revision dated 01/25/18, which stated the resident had a Stage II Pressure Ulcer to the coccyx with a goal stating the area would be free of infection. The next Wound Assessment Report, dated 02/03/18, nine (9) days after the last Wound Assessment, revealed the resident's wound had deteriorated and the Ulcer to the Buttocks was unstageable due to slough/eschar and measured 4.0 cm length x 4.50 cm width x 0.2 cm depth, with purulent drainage and granulation tissue 50% and slough 50%. Review of physician's orders [REDACTED]. Observation of a skin assessment for Resident #52 on 02/06/18 at 12:00 Noon, performed by LPN #3, revealed the coccyx wound measured 5.0 cm length x 3.2 cm width x 0.2 cm depth. 6. Review of Resident #1's medical record revealed the facility admitted the resident on 01/30/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS Score of four (4) out of fifteen (15) indicating the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as requiring extensive assist of one (1) staff for bed mobility, transfers, and toileting; and as urinary incontinence not rated, occasionally incontinent of bowel, and as having no pressure ulcers. Review of the Braden Risk Assessment Report, dated 11/07/17, revealed Resident #1 was assessed to be at minimal risk for Pressure Ulcers due to no impairment of sensory perception; rarely had moist skin; walked occasionally; slightly limited mobility; adequate nutrition; and potential problem of friction and shear. Review of the Comprehensive Care Plan, dated 12/15/17, revealed the resident was at risk for impaired skin integrity related to decreased mobility due to Memory Loss, and History of [MEDICAL CONDITION]. The goal stated the resident's skin would remain intact as evidenced by no Pressure Ulcers. There were several interventions including: use draw sheet for bed mobility; incontinence care as needed; turn and reposition every two (2) hours and as needed; notify physician of changes as needed; and weekly skin checks. Review of the Skin Inspection Report, for December 2017 through February 2018, revealed there was no skin assessment from 12/23/17 until 01/06/18, fourteen (14) days. On 01/06/18, the resident's skin was intact per the Report. Additionally, review of the Report revealed there was no skin assessment from 01/20/18 until 02/03/18, fourteen (14) days. On 02/03/18 the resident's skin was intact per the Report. However, review of the December 2017 TAR, revealed the intervention for a skin assessment was signed indicating it was completed on 12/30/17. Also, the January 2018 TAR, revealed on 01/27/18, there was an N on the TAR, indicating the skin assessment was not performed by the previous DON. Interview on 01/31/18 at 9:10 AM, with Registered Nurse (RN) #2, revealed staffing had not been adequate and nurses who had been employed at the facility were leaving because they were stressed and felt like their nursing license was on the line. Per interview, there were more pressure sores at this time due to staffing. Interview on 02/13/18 at 1:43 PM with LPN #4, revealed she had worked at the facility for nine (9) years and the facility had been short staffed for months. We kill ourselves but there is only so much time. Per interview, she made sure the residents were turned and repositioned and incontinence care was done by helping the aides herself, and by completing rounds. However, she stated the turning and repositioning and incontinence care may not be as often as every two (2) hours due to a shortage of nurses and State Registered Nurse Assistants (SRNA). Per interview, she ensured her skin assessments were performed. Interview on 02/13/18 at 4:13 PM, with RN #4, revealed she had worked at the facility for five years and there had been a staffing shortage since November 2017. When asked what care was not provided as a result of short staffing, she stated whatever you don't have time for. Per interview, she made sure Accuchecks were performed and medications were passed and treatments were the last thing on her plate. She stated sometimes some of the treatments such as powders or creams were not completed as a result of being short staffed; however, she tried to get the pressure ulcer treatments completed. Interview with the Acting DON, on 02/07/18 at 4:00 PM, revealed she had worked at the facility for nine (9) years and stepped into the role as Acting DON on 01/05/18, on the same day the previous DON and the Staff Development nurse left. Per interview, the Unit Managers also resigned shortly afterward as did other nurses over the past months. She stated she had worked in the staff nurse role passing medications, and performing treatments all but about three (3) days since 01/05/18. Per interview, she was also working a lot of double shifts due to the staffing shortage. She stated she was aware skin assessments and wound assessments were not be (TRUNCATED)

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately notify the Physician when pain medications were unavailable to administer as ordered for five (5) of twenty-six (26) sampled residents (Residents #3, #11, #23, #24, and #26). Resident #11 had a physician's orders [REDACTED]. The resident's supply of [MEDICATION NAME] ran out after the resident received a dose on 09/10/16 at 9:30 PM. Even though the resident requested the [MEDICATION NAME], he/she did not receive the next dose until 09/12/16 at 8:00 AM, 34.5 hours later. There was no documented evidence the Physician was notified the resident was in pain, and had run out of pain medication. Resident #23 had a physician's orders [REDACTED]. The resident's supply of [MEDICATION NAME] ran out after the resident received a dose on 05/07/16 at 12:30 AM. There was no documented evidence the resident received the scheduled nightly dose on 05/08/16, or any PRN dose until 05/09/16 at 10:45 AM, 34.25 hours later. There was no documented evidence the Physician was notified the resident was in pain and was out of pain medication. The facility admitted Resident #3 on 09/11/16 at approximately 3:30 PM, with two (2) written prescriptions from the hospital. The prescriptions were for [MEDICATION NAME] ([MEDICATION NAME]) Liquid (narcotic pain medication) to be administered every four (4) hours PRN for pain, and [MEDICATION NAME] Liquid (anti-anxiety medication) to be administered every four (4) hours PRN for agitation. The Physician was notified at 8:00 PM, and verified the new orders. The nurse faxed the prescriptions to the pharmacy at 8:42 PM. In the meantime, the Hospice nurse had been called by the family and arrived at the facility at 8:30 PM. The resident was assessed to be in pain. Since there was a four (4) hour pharmacy delivery time for STAT medications, and no medication was available from the emergency narcotic box, the Hospice nurse and the family made the decision to transfer the resident back to the inpatient Hospice facility for pain control. There was no documented evidence the Physician was notified of changes in the resident's pain status, problems procuring pain control medications in a timely manner, or the resident's transfer back to the hospital. Resident #24 had a physician's orders [REDACTED]. Review of the resident's narcotic sign-out sheet revealed staff documented the resident received a dose on 09/22/16 at 1:50 AM, and not again until 09/22/16 at 1:00 PM, more than eleven (11) hours later. There was no documented evidence the Physician was notified the resident was in pain, and the need for the pain medication. The resident stated, It was really bad. I went almost twelve (12) hours with no pain med. I felt nauseated, dizzy, and sweaty. Resident #26 had a physician's orders [REDACTED]. Interview and record review revealed Resident #26 received the medication on 09/12/16 at 4:00 PM, and not again until 09/13/16 at 4:00 PM, a period of twelve (12) hours, with five (5) missed doses. Although Resident #26 complained of pain and requested a pain pill several times, there was no documented evidence the Physician was notified the resident's pain was uncontrolled, and no pain medication was available. (Refer to F-309) The findings include: Review of the facility's document titled, Pain Management Process, revised 10/15, revealed the Physician would be notified when pain levels were outside normal levels for the individual resident. Interview with the Director of Nursing (DON), on 09/24/16 at 1:50 PM, revealed the facility did not have a policy related to the specific time frame for Physician notification of a change in condition. She stated her expectation was for the Physician to be notified immediately for direction if a resident's pain medication was not available. 1. Review of the clinical record revealed Resident #11 was admitted by the facility on 03/23/15, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/09/16, revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident had no cognitive impairment. Continued review of the MDS revealed the resident was assessed to have frequent pain that affected his/her sleep and day to day activities. Further review of the MDS revealed the resident was assessed to have a pain rating of nine (9) on a scale of zero (0) to ten (10), with ten (10) being the worst pain the resident could imagine. Review of the current active physician's orders [REDACTED].#11 was to receive [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 10/325 milligrams (mg) every six (6) hours as needed for pain. Review of Resident #11's Medication Administration Record (MAR), dated September 2016, revealed on 9/10/16 the resident was administered [MEDICATION NAME] 10/325 mg at 9:30 PM. Continued Review of the MAR revealed Resident #11 did not receive [MEDICATION NAME] again until 09/12/16 at 8:00 AM, 34.5 hours later. Review of Resident #11's Controlled Drug Record (CDR) for the [MEDICATION NAME], revealed on 09/10/16 at 9:30 PM, the resident's last dose of [MEDICATION NAME] pain medication was signed out. Continued review revealed on 09/12/16 at an undocumented time, the facility received a new supply of thirty (30) [MEDICATION NAME] tablets for Resident #11 from the pharmacy. Further review of the CDR revealed, on 09/12/16 at 8:00 AM, the first dose of [MEDICATION NAME] was signed out from the new supply. Interview with Resident #11, on 09/23/16 at 9:20 AM, revealed the resident was in pain and requested [MEDICATION NAME] on 09/11/16 at 3:30 AM and was told by the nurse the resident was out of pain medication, but it had been ordered and should arrive any time. Resident #11 stated he/she did ask for, and received, [MEDICATION NAME] (a non-narcotic anti-[MEDICAL CONDITION] medication), but it did not help the pain at all. Continued interview revealed if the resident had been asked by the nurse, he/she would have rated the pain at an eight (8), with ten (10) being the most severe pain. Additionally, Resident #11 reported she asked the nurse about the pain medication sometime on the morning of 09/11/16, and was told the Physician needed to write a prescription; however, staff hadn't been able to reach him. Further interview revealed around noon on 09/11/16, Resident #11's pain had increased to a nine (9) or ten (10), and the resident experienced irritability caused by the pain. The resident reported having to stay in bed all day on 09/11/16, and was not being able to go on a scheduled activities outing due to being in pain, having nausea, and having a headache. Further interview revealed Resident #11 thought he/she was experiencing withdrawal from the pain medication due to cramping of his/her back and legs. Resident #11 further reported having hot and cold flashes on the 3:00 PM to 11:00 PM shift on 09/11/16. Additionally, Resident #11 stated he/she cried during the day on 09/11/16 due to the pain, and not being able to go on the scheduled outing with activities, and this being his/her son's birthday. Resident #11 did not feel he/she received the pain medication timely, and stated his/her needs were not met. Review of the Nurses Notes for 09/10/16 through 09/12/16 revealed no documented evidence the Physician was notified the resident was out of pain medication and was having pain that interfered with the resident's activities. Interview with Licensed Practical Nurse (LPN) #6, on 09/23/16 at 3:45 PM, revealed on 09/11/16 during the 7:00 AM to 3:00 PM shift, she was informed by the pharmacy a new written prescription for Resident #11 was needed from the Physician. She stated she spoke to the Physician at approximately 10:30 AM and was told he had already sent a prescription to the Pharmacy, but would fax another one. Subsequent interview with LPN #6, on 09/24/16 at 1:30 PM, revealed Resident #11 was in tears without his/her pain medication. LPN #6 stated the Physician should always be notified immediately when a resident was out of a medication and it could not be received quickly, especially if it was a pain medication. Interview with LPN #10, on 09/23/16 at 9:23 AM, revealed during the shift report on 09/11/16 at 3:00 PM, it was reported Resident #11 had been requesting pain medication. The 7:00 AM to 3:00 PM nurse further reported the resident was out of pain medication and the Physician was aware. Continued interview with LPN #10 revealed Resident #11 requested pain medication early into the 3:00 PM to 11:00 PM shift, and rated his/her pain at a 7 or 8 on a scale of 10. LPN #10 further stated since the resident was requesting pain medication she notified the physician on 09/11/16 at approximately 5:00 PM, and was informed he would not be able to fax a prescription to the pharmacy until around midnight. Further interview revealed Resident #11 did not receive his/her medication in a timely manner and the resident was threatening to leave the facility and go to the hospital for pain control. Interview with the Unit 2 Manager, on 09/22/16 at 10:20 AM, revealed the 7:00 AM to 3:00 PM shift nurse faxed a medication reorder sheet for Resident #11's pain medication on 09/10/16. She stated the facility contacted the physician at approximately 2:00 AM on 09/12/16 for him to write a prescription and fax it to the pharmacy. The Unit 2 Manager acknowledged Resident #11 received his/her last dose of pain medication on 09/10/16 at 9:30 PM and did not receive pain medication again until 09/12/16 at 8:00 AM due to the facility not having the medication on hand. She further stated it was her expectation the floor nurses were aware when a resident's pain medication needed to be reordered. Additionally, she revealed her expectation that the Physician be notified immediately when there was a problem getting a resident's pain medication. Interview with Resident #11's Physician, on 09/23/16 at 4:55 PM, revealed although he knew the resident needed a new prescription for refills, he was not made aware Resident #11 was without pain medication from 09/10/16 until 09/12/16. Continued interview revealed his expectation was for his residents to receive their medications timely, as ordered, and he would be notified of any changes in condition as soon as possible. 2. Review of the clinical record revealed Resident #23 was admitted by the facility on 01/05/11, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/20/16, revealed the facility assessed Resident #23 to have a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed the resident was assessed to have frequent pain, with a rating of three (3) on a scale of ten (10). Review of the Physicians Orders for May 2016 revealed Resident #23 was to receive two (2) [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 tablets, each bedtime at midnight, for chronic pain. Continued review of the Physicians Orders revealed the resident was also to receive [MEDICATION NAME] every six (6) hours PRN for chronic pain. Review of the MAR for May 2016 revealed Resident #23 received the scheduled dose of [MEDICATION NAME] on 05/07/16 at 12:00 AM. Although it was not documented on the MAR, review of the CDR revealed Resident #23 did not receive another dose of [MEDICATION NAME] until 05/09/16 at 10:45 AM, 58.25 hours later, after thirty (30) tablets were received from the pharmacy on the same date. Review of Resident #23's Nurse's notes between 05/07/16 and 05/09/16 revealed no documented evidence the Physician was notified the resident did not have pain medication available, and missed the scheduled dose of [MEDICATION NAME] on 05/08/16 at midnight. 3. Review of the clinical record for Resident #3 revealed the resident was initially admitted by the facility on 08/01/07, and readmitted on [DATE] from an inpatient Hospice Unit, with [DIAGNOSES REDACTED]. Per review of inpatient Hospice unit notes, Resident #3 was noted to have severe pain, rated ten (10) on a scale of ten (10), especially when repositioned or moved around. Further review of the Hospice notes revealed the resident was transferred to the facility from the inpatient Hospice Unit on 09/11/16 at 3:30 PM. Continued review of the clinical record revealed Resident #3 arrived at the facility on 09/11/16 with two (2) written prescriptions, for [MEDICATION NAME] 100 to 200 mg every four (4) hours as needed for pain, and [MEDICATION NAME] 1 mg every four (4) hours as needed for agitation. Review of the Quarterly MDS Assessment, dated 08/30/16 during the resident's previous admission, revealed the facility assessed Resident #3 to have a BIMS score of 10, which indicated the resident was moderately cognitively impaired. Review of the Nurse's Notes, dated 09/11/16 at 10:59 PM by the admitting nurse, Registered Nurse (RN) #4, revealed Resident #3 arrived at the facility at 4:00 PM. Continued review revealed a verbal order was obtained from the Physician, and [MEDICATION NAME] pain medication was ordered and administered on 09/11/16 at 8:00 PM. Interview with Resident #3, on 09/23/16 at 9:30 AM, revealed the resident recalled the evening and night of 09/11/16. The resident stated he/she was tired, rated his/her pain level a nine (9), and said it made him/her feel like crap because he/she had to go back to the hospital. The resident stated, They should have been able to take care of me here. They could have done the same thing the hospital did. Interview with RN #4, on 09/22/16 at 10:36 AM, revealed she began working on the admission assessment for Resident #3 upon arrival, but was only able to complete a skin assessment before having to stop and pass medications, between 5:00 PM and 6:30 PM. She stated she returned to complete the assessment, then notified the Physician for verification of the admitting orders. She further stated she did not remember what time she called the Physician, but he confirmed the orders for [MEDICATION NAME] and [MEDICATION NAME], and directed the nurse to administer [MEDICATION NAME] to the resident. Review of the Hospice notes, dated 09/11/16 at 8:33 PM, revealed the Hospice nurse arrived at the facility and proceeded to Resident #3's room. The resident asked if the Hospice nurse was the one that would take his/her pain away. At 8:45 PM, the Hospice nurse documented RN #4 had just spoken with the resident's Physician. Interview with Resident #3's Physician, on 09/23/16 at 4:55 PM, revealed he received only one call from RN #4, late in the evening on 09/11/16, regarding Resident #3's admission and new prescriptions, and was notified the resident was transferring back to the inpatient Hospice unit for pain control. Interview with the Director of Nursing (DON), on 09/22/16 at 8:15 AM, revealed the facility had to have written prescriptions for narcotic medications because the pharmacy would not accept verbal orders. She stated Resident #3 arrived at the facility with written prescriptions but the initial assessment had to be completed by the nurse, orders reviewed and the Physician called to verify the orders. Further interview with the DON, on 09/24/16 at 1:50 PM, revealed her expectation was for the Physician to be notified immediately if a resident was in pain and did not have pain medication available. 4. Review of Resident #24's medical record revealed the facility admitted the resident on 02/15/16, and readmitted the resident on 09/10/16, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 07/22/16, revealed the facility assessed Resident #24 to have a BIMS score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Further review of the MDS revealed Resident #24 frequently had pain which made it hard to sleep and limited the resident's day-to-day activities. At the time of the assessment, Resident #24 rated his/her pain a nine (9) on a scale of zero (0) to ten (10). Review of the physician's orders [REDACTED]. Interview with Resident #24, on 09/24/16 at 8:40 AM, revealed he/she takes [MEDICATION NAME] ([MEDICATION NAME]) every 4 hours, or the pain is not controlled. The resident stated two (2) days ago the facility ran out of pain medicine. Resident #24 further stated he/she was given [MEDICATION NAME] around 9:30 PM on 09/21/16, and was told by the nurse he only had one (1) dose left. The nurse told the resident the medication had been ordered, but had not been delivered. The resident stated he/she requested, and received, the last pain pill available at 1:50 AM on 09/22/16. Continued interview revealed Resident #24 did not receive another pain pill until 1:00 PM on 09/22/16, and the pain was really bad. The resident stated he/she felt nauseated, dizzy and sweaty, and his/her blood pressure kept going up and down. Review of the Nurses Notes for Resident #24 revealed no documented evidence the Physician was notified of the resident being out of pain medication and having complaints of pain. Review of Resident #24's CDR, dated 08/08/16 through 09/24/16, revealed the resident averaged taking the prescribed narcotic pain medication, [MEDICATION NAME]/APAP ([MEDICATION NAME]) 10/325 mg, one (1) tablet every four (4) hours daily. Further review of the CDR revealed Resident #24 received the last available dose on 09/22/16 at 1:50 AM. Continued review revealed the next dose was signed out for administration to the resident on 09/22/16 at 1:00 PM after a refill was received from the pharmacy. Resident #24 went without pain medication for 11 hours and 10 minutes. 5. Review of Resident #26's medical record revealed the facility admitted the resident on 11/12/15, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/07/16, revealed the facility assessed the resident as having a BIMS score of fourteen (14) of fifteen (15), which indicated no cognitive impairment. Interview with Resident #26, on 09/24/16 at 11:00 AM, revealed the resident ran out of pain medication earlier in the month. The resident stated he/she received a pain pill about 4:00 PM, and had to wait until late the next day for the pharmacy to deliver more pain medication. Resident #26 reported a pain level of at least eight (8) on a scale of ten (10) by the time the refill was available. Review of the physician's orders [REDACTED]. Continued review of the Physician order [REDACTED]. Review of the CDR revealed the last [MEDICATION NAME] was signed out on 09/12/16 at 4:00 PM, and the next dose was signed out at 4:00 PM on 09/13/16 after a delivery from the pharmacy, confirming Resident #26 did not receive his/her scheduled pain medication for twenty-four (24) hours. Review of the Nurses Notes, dated 09/13/16 at 3:41 AM, revealed a call was placed to the pharmacy related to Resident #26 being out of his/her scheduled [MEDICATION NAME]. The pharmacy related a new prescription was required and they would fax the Physician for it. Further review revealed no documentation of the Physician being notified by the nurse when the resident ran out of pain medication which was to be administered every four (4) hours around the clock. Interview with LPN #7, on 09/24/16 at 1:45 PM, revealed she was the nurse on duty the day Resident #26 was out of pain medication. She stated the resident was upset, and did ask for a pain pill several times that day. LPN #7 further stated she did not notify the Physician because she knew the medication had already been ordered. Continued interview revealed the medication was delivered on 09/13/16, and the resident received a dose at approximately 4:00 PM. Interview with the Physician, on 09/23/16 at 4:55 PM, revealed he expects the residents to receive their pain medications timely and as ordered. He stated he should be notified as soon as possible of changes in a residents condition. Continued interview revealed he always tells the nurses when he is in the facility to let him know early when a prescription is needed and not wait until the medication is out. He further stated he tells the pharmacy the same thing when they contact him. Additionally, the Physician stated he always faxes a prescription as soon as he is notified if he is in the office or at home, but it may take a little longer if he is driving. Interview with the DON, on 09/24/16 at 2:00 PM, revealed the Physician should be notified immediately if a resident experiences a change in condition. The DON stated she expected the residents' medications to be available. If they were not, she expected the Physician to be notified by the nurse. She further stated the nurse should ask for a different medication, a substitute, or a change in schedule until the medication is available. Interview with the facility Administrator, on 09/24/16 at 3:37 PM, revealed it was his expectation for staff to notify the Physician as soon as possible when a resident was out of pain medication. Continued interview revealed it was important the Physician be notified so he was made aware of the resident's condition and could make changes as needed.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure services were provided in accordance with each resident's written Plan of Care. There was no documented evidence the resident's care plans were implemented for six (6) of twenty six (26) sampled residents (Residents #10, #11, #17, #23, #24 and #26). Substandard Quality of Care with actual harm was identified related to the facility's systemic failure to assess, monitor, and control residents' pain. (Refer to F-157, F-309, and F-425) Interview and record review revealed Residents #11, #23, #24, and #26's Comprehensive Care Plan was not implemented related to interventions the facility had in place including consistently assessing, and documenting effectiveness of pain medication. Observation and interview revealed Resident #10's Comprehensive Care Plan was not implemented related to interventions the facility had in place including consistently using plastic utensils for this resident. Resident #17 had a physician's orders [REDACTED]. These treatments were not observed to be on the resident on 09/21/16 and 09/22/16. The findings include: Interview, on 09/23/16 at 4:30 PM, with the Director of Nursing (DON) revealed the facility did not have a policy regarding following comprehensive care plans. Continued interview revealed the facility followed the RAI guidelines for care plan procedures. Review of the facility form titled, Careplan Procedures, dated 2013, revealed it was the practice of Preferred Care Partners and their affiliates to initiate, complete, and revise resident care plans in accordance with all Federal and State regulations and the RAI guidance. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 03/23/15, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/09/16, revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review of the MDS revealed the resident was assessed to have frequent pain that had affected his/her sleep and day to day activities. Further review of the MDS revealed the resident was assessed to have a pain rating of a nine (9) on a scale of zero (0) to ten (10) with 10 being the worst pain the resident could have imagined. Review of Resident #11's Comprehensive Care Plan, revealed the facility identified on 04/03/16 the problem of the resident experiencing alteration in comfort as evidenced by (AEB) pain at a 5 - 8 on a 0 - 10 scale related to history (HX) of cervical fracture and [MEDICAL CONDITION] and dental discomfort related to natural missing teeth, with a goal stating the resident would voice relief from pain interventions within ½ hr to 45 min from administration with the resident reporting an acceptable level of pain. The care plan interventions revealed, pain assessment was to be completed per facility policy, monitor for and document location of pain and document the pain scale before and after interventions, monitor effectiveness of pain medication, monitor for signs and symptoms of verbal, non-verbal pain or distress every 4 hrs and as needed (PRN). Interventions also included monitor for sign and symptoms of pain with rest or movement, and update family and MD of changes as needed. Review of Resident #11's Facility Physician Orders, dated September 2016 revealed, the resident was ordered on [DATE] and continued, [MEDICATION NAME] tablet ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 mg every six (6) hours as needed for pain. Continued review of the Physician order [REDACTED]. Interview, on 09/23/16 at 9:20 AM, with Resident #11 revealed during the weekend of 09/10/16 he/she suffered in pain for almost two (2) days. Continued interview revealed he/she was in pain and requested [MEDICATION NAME] pain medication on 09/11/16 at 3:30 AM and was told by the nurse he/she did not have any pain medication and they had put an order in for it and it should be there anytime. Resident #11 stated he/she did ask for [MEDICATION NAME] at that time; however it did not help the pain at all. Continued interview revealed during this time if he/she would have been asked by nursing to rate his/her pain, the rating would have been an eight (8) out of ten (10) with ten (10) being the most severe pain. Resident #11 further stated nursing never asked him/her to rate his/her pain. Additionally Resident #11 revealed he/she asked nursing again sometime on the morning of 09/11/16 and was told the Physician needed to write a prescription; however, they hadn't been able to get hold of him. Continued interview with Resident #11 revealed that around noon on 09/11/16, his/her pain had increased to a nine (9) or ten (10) and he/she was experiencing irritability caused by the pain. Resident #11 stated he/she stayed in bed all day on 09/11/16 and was not able to go on a scheduled outing with activities due to being in pain, having nausea, and having a headache. Continued interview with Resident #11 revealed he/she thought he/she was experiencing withdrawals due to cramping of his/her back and legs. Resident #11 stated on the afternoon of 09/11/16, staff from activities came to his/her room to see if he/she was going on the outing to a festival, where he/she told the activities staff he/she couldn't go due to being in so much pain. Continued interview with Resident #11 revealed during the 3:00 PM shift his/her pain had increased to a ten (10) or above and a State Registered Nursing Assistant (SRNA) had to get him/her a cold washcloth to place on his/her head due to him/her having hot and cold flashes. Additionally Resident #11 stated he/she cried during the day on 09/11/16 due to the pain he/she was experiencing and not being able to go on the scheduled outing with activities. Continued interview with Resident #11 revealed he/she did not feel the nurses asked or care about the pain and would have liked to have gotten pain medication timely after requesting it. Review of Resident #11's Controlled Drug Record for [MEDICATION NAME], undated, revealed on 09/10/16 at 9:30 PM, the residents last dose of [MEDICATION NAME] pain medication was signed out. Review of the residents Controlled Drug Record for [MEDICATION NAME], dated 09/12/16 revealed thirty (30) [MEDICATION NAME] Tablets was received by the facility. Continued review of Resident #11's Controlled Drug Record, dated, 09/12/16 revealed the first dose of [MEDICATION NAME] signed out was on 09/12/16 at 8:00 AM. The resident did not receive [MEDICATION NAME] from 09/10/16 at 9:30 PM until 09/12/16 at 8:00 AM. This was a time span of thirty-four and a half (34 ½) hours the resident went without the pain medication and there was no evidence the care plan was followed. Interview, on 09/24/16 at 9:22 AM, with SRNA #11 revealed Resident #11 was in bed all day because he/she was hurting and did not have any pain medication available. Continued interview with SRNA #11 revealed Resident #11 was scheduled to go to a festival off grounds that day; however, he/she was not able to go because he/she was in pain and did not have any pain medication available. Interview, on 09/23/16 at 10:45 AM, with SRNA #13 revealed on 09/11/16 during the 3:00 PM to 11:00 PM shift she answered Resident #11's call light where she discovered the resident in bed crying. Continued interview with SRNA #13 revealed she asked Resident #11 why he/she was still in bed and why he/she was crying. Further interview revealed Resident #11 replied to SRNA #13 and stated he/she was in so much pain he/she couldn't get out of bed. Continued interview revealed SRNA #13 got Resident #11 a cold wet wash cloth per the residents request to apply to his/her face because the resident stated he/she was hot. Interview, on 09/23/16 at 3:45 PM, with Licensed Practical Nurse (LPN) #6 revealed on 09/11/16 during the 7:00 AM to 3:00 PM shift, Resident #11 requested his/her [MEDICATION NAME] pain medication; however, she told the resident his/her medication still hadn't come in. Continued interview revealed LPN #6 administered the medication [MEDICATION NAME] to Resident #11. LPN #6 further stated Resident #11 was in tears and she could see how the pain was affecting him/her, so she rated his/her pain a 10, but acknowledged she did not document the pain assessment, as per the care plan intervention. Continued interview with LPN #6 revealed Resident #11 did not receive his/her medication in a timely manner as ordered and per the care plan. Interview, on 09/23/16 at 9:23 AM, with LPN #10 revealed during shift report from the prior shift, it was reported to her, Resident #11 had been requesting pain medication; however, he/she was out of it. Continued interview with LPN #10 revealed Resident #11 requested pain medication early into the 3:00 PM to 11:00 PM shift. LPN #10 further stated Resident #11's pain level was a 7 or 8 the best she could remember, however she stated she did not document the pain assessment or implement care plan interventions as per the care plan. Continued interview with LPN #10 revealed Resident #11 did not receive his/her medication in a timely manner and the resident was threatening to leave the facility and go to the hospital due to pain. 2. Review of Resident #23's medical record revealed the facility admitted the resident on 01/05/11, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/20/16, revealed the facility assessed Resident #23 to have a BIMS score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review of the MDS revealed the resident was assessed to have frequent pain. Further review of the MDS revealed the resident was assessed to have a pain rating of a three (3) on a scale of zero (0) to ten (10) with 10 being the worst pain the resident could have imagined. Review of Resident #23's Comprehensive Care Plan, revealed on 03/30/16 the facility identified the problem of being at risk for alteration in comfort related to a HX of chronic pain and routine pain management. The goal stated the resident would receive routine pain management that would remain effective through the next review with minimal complaints breakthrough pain. The interventions included: Pain assessment per protocol; Identify location and rate of pain prior to and after any interventions; Routine pain medications as ordered; Attempt and document effectiveness of non-pharmacological interventions as appropriate; Report unrelieved or increase in breakthrough pain to MD; Give PRN medication as ordered for complaints of or signs and symptoms of pain; Document intervention severity and effectiveness of medication; and Monitor for verbal and non-verbal signs and symptoms of pain every 4 hours PRN (as needed). Review of the Physician Orders, dated May 2016 for Resident #23 revealed, the resident was ordered on [DATE] and continued, routine [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 tablet by mouth at bedtime, at 12 midnight for chronic pain. Continued review of the Physician order [REDACTED]. Further review of the Physician order [REDACTED].#23 as a clarification order for [MEDICATION NAME]-APAP 5/325 by mouth ever six (6) hours PRN for chronic Pain. Review of Resident #23's Controlled Drug Record, dated 04/09/16 revealed the resident's last does of routine and PRN [MEDICATION NAME] 5-325 was signed out on 05/07/16 at 12:30 AM. Review of Resident #23's Controlled Drug Record dated 05/09/16 revealed thirty (30) [MEDICATION NAME] 5-325 tablets for routine and PRN use was received by the facility. Continued review of the residents Controlled Drug Record dated 05/09/16 revealed the first dose of [MEDICATION NAME] 5-325 was signed out on 05/09/16 at 10:45 AM. The resident did not receive [MEDICATION NAME] from 05/07/16 at 12:30 AM until 05/09/16 at 10:45 AM, when thirty (30) [MEDICATION NAME] Tablets were delivered from the pharmacy to the facility. This was a time span of fifty-eight (58) hours and fifteen (15) minutes the resident went without pain medication. There was no documented evidence the care plan was implemented related to assessing and monitoring for pain and the administration of pain medication. Review of Resident #23's MAR revealed Pain Assessments for PRN medication was not being completed per facility Pain Management Process Policy and the residents comprehensive care plan. Interview, on 09/23/16 at 3:45 PM, with LPN #6 revealed nursing staff was to complete pre and post pain assessments on residents to see if the pain was being controlled. Further interview revealed it was important for staff to follow residents care plans for continuity of care. LPN #6 stated if a resident's care plan was not followed, their condition could have worsened causing possible harm. 3. Review of Resident #24's medical record revealed the facility admitted the resident on 02/15/16, and readmitted the resident on 09/10/16, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, Section C0500, dated 07/22/16, revealed a BIMS score of fifteen (15) of fifteen (15), which indicated Resident #24 was cognitively intact and interviewable. Further review of the MDS, Section J0300 through J0600, revealed Resident #24 frequently had pain, which made it hard to sleep, limited day-to-day activities and rated his/her pain a nine (9) on a scale of 0-10. Review of Resident #24's Comprehensive Care Plan, dated 05/04/16 revealed the resident experienced alteration in level of comfort as evidenced by back pain frequently reported/observed at seven (7), on a scale of zero to ten (0-10). The resident's pain was related to history of chronic pain, with increased risks secondary to [MEDICAL CONDITION] Joint Disease. The goal stated the resident would voice relief from pain interventions within one half (1/2) hour to forty-five (45) minutes from administration of pain medication, pain would not interfere with daily routine and pain would be reported at acceptable level to resident. The interventions included: pain assessment per protocol; identify location and document rate of pain prior to and after any interventions; medications as ordered and monitor effectiveness; report unrelieved or unacceptable levels of pain to MD as needed; monitor signs and symptoms of verbal, or non-verbal, pain or distress every four (4) hours. However, the care plan was not implemented related to interventions the facility had in place including consistently assessing, and documenting effectiveness of pain medication. Review of the physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Code Y = Yes, or N = No. If No, provide the pain rating. If the resident was non-interviewable, the Wong-Baker Pain Scale, (a pictorial of facial expressions), was to be utilized to determine the resident's pain level. Review of the MAR and nurses notes for Resident #24, revealed no documented evidence care plan was followed for assessing, monitoring, administering pain medication or evidence of follow-up pain assessments after medications were administered. Interview with Resident #24, on 09/24/16 at 8:40 AM, revealed he/she took [MEDICATION NAME] every 4 hours, and if he/she didn't, the pain was not controlled. The resident stated, Two (2) days ago they ran out of my pain medicine. The resident continued, It was really bad. I went almost twelve (12) hours with no pain medication. I felt nauseated, dizzy, sweaty and my blood pressure kept going up and down. The nurse checked my vital signs, and she said they were okay. But, I didn't feel okay. I've been on pain medicine for years. My body needs it. I feel sick when I don't get it. Further interview with Resident #24, on 09/21/16 at 8:40 PM, revealed he/she had ran out of medications three to four (3-4) times since he/she had been at the facility. The resident further revealed the nurses did not always ask him/her to rate the pain level on a scale zero-ten (0-10), before they gave him/her the medication. The resident also stated the nurses did not follow-up afterward to see if the medication had relieved his/her pain, revealing the care plan was not followed. Review of Resident #24's individual Narcotic Sign-Out Sheet dated 08/08/16 through 09/24/16, revealed there was a time span of eleven (11) hours and ten (10) minutes the resident went without pain medication between doses. Further review of Resident #24's Medication Administration Record (MAR), from 08/11/16-09/23/16, revealed the staff documented the resident's Pain Program was effective for sixty-three (63) out of one-hundred-thirty-five (135) shifts. This review of the MAR revealed there were seventy-two (72) shifts the staff did not document effectiveness according to the Pain Program Policy and as per the care plan. Interview with LPN #5, on 09/23/16 at 11:15 AM, revealed residents' quality of life was affected if they were in pain. Further interview with LPN #5, on 09/23/16 at 11:25 AM, revealed it is every nurse's responsibility to make sure residents didn't run out of their medications. She said the plan of care was not followed for Resident #24. Interview with RN #2, on 09/23/16 at 3:05 PM, revealed the facility's policy was for nurses to do a pre and post pain assessment and document it on the MAR as per the care plan. She further revealed it was important to do pre and post pain assessments to make sure the pain was controlled. She stated if a resident's pain was not controlled, or if they were going without their medicine due to not being in stock, it could potentially cause heart problems, depressive symptoms, increased pain and the care plan would not be followed. 4. Review of Resident #26 medical record revealed the facility admitted the resident on 11/12/15, with [DIAGNOSES REDACTED]. Review of the quarterly MDS Assessment, dated 08/07/16, revealed the facility assessed the resident as having a BIMS score of fourteen (14) of fifteen (15) which indicated no cognitive impairment. Further review of section J (Pain) revealed the facility sassed the resident to have pain present which recurred frequently and limited the ability to perform day to day activities in the last five (5) days. The assessment indicated the resident rated their pain at a severity level of seven (7) on a scale of one (1) to ten (10). Review of the Physician Orders, dated September, 2016 for Resident #26 revealed, the resident was ordered on [DATE] and continued, routine [MEDICATION NAME] ([MEDICATION NAME] HCL/[MEDICATION NAME]) 7.5-325 tablet by mouth every 4 hours scheduled. Continued review of the Physician order [REDACTED]. Review of Resident #26's Comprehensive Care Plan, revealed the facility identified on 06/12/15 the problem of the resident experiences alteration in level of comfort related to HX of chronic pain related to [MEDICAL CONDITION], pain in left shoulder related to [MEDICAL CONDITION]. The goal stated the resident will voice relief from pain interventions within 1/2 hr to 45 min from administration. The interventions included: Pain assessment per protocol, identify and document location and rate of pain prior to and after any interventions, routine pain medications as ordered, attempt and document effectiveness of non-pharmacological interventions as appropriate, report unrelieved or unacceptable levels of pain to MD as needed, Give PRN medication with complaints and as ordered and monitor effectiveness of PRN medication. Monitor for verbal and non-verbal signs and symptoms of pain every 4 hours PRN. Review of the Controlled Drug Record revealed the last [MEDICATION NAME] was signed out on 09/12/16 at 4:00 PM, and the new record revealed the first (1st) [MEDICATION NAME] was signed out on 09/13/16 at 4:00 PM, revealing the resident was out of [MEDICATION NAME] for at least twenty four (24) hours. Continued review of the record revealed no documented evidence the care plan was implemented related assessing the resident's pain, monitoring the resident's pain and administering pain medications as ordered. Interview with Resident #26, on 09/24/16 at 11:00 AM, revealed that the resident was out of pain medication one time. He/she stated that they had received a pain pill about 4:00 PM, he/she didn't remember the date but it was this month, and then had to wait until the pharmacy brought the pain medication late the next day. He/she further stated the pain level was at least an eight (8) of ten (10) on a scale of zero (0) to ten (10) with ten (10) being the worst pain he/she had ever had, when he/she received the pain medication after pharmacy brought it the following day. The resident said he/she normally took the pain medication every four (4) hours or so, because of his/her aching back and [MEDICAL CONDITION]. Interview further revealed the resident was in pain through out the night and into the next day. Resident #26 stated the nurse was aware of the pain because he/she had asked for the medication through the night and even went to the nurse's station the next day to ask for pain medication at which time the nurse told the resident she was waiting the Physician to write the prescription. Interview with LPN #7 on 09/24/16 at 1:45 PM, revealed she was the nurse on duty the day the resident was out of pain medication. She further stated the resident was upset and did ask for pain medication several times that day, even though there was no documented evidence of assessment and monitoring related to the pain. LPN #7 continued that the resident's pain medication came in and that she did give the resident a dose about 4:00 PM and the best she remembered the resident stated his/her pain level was an eight (8) of ten (10), but she did not document the pain assessment. LPN #7 stated the care plan was not followed when the pain medication was not available and pain assessments were not documented per the plan of care. Interview, on 09/23/16 at 9:00 AM, with the Unit 2 Manager revealed residents should receive their pain medication as ordered. She continued that if pain medication was not available and/or pain assessments were not documented then the care plan had not been followed. Interview, on 09/24/16 at 1:50 PM, with the Director of Nursing (DON) revealed the facility had a problem with the Pharmacy and getting residents medications. Continued interview revealed it was her expectation residents would receive their pain medication in a timely manner. The DON acknowledged if a resident was in pain and other interventions did not help, then there would be a potential for a negative outcome. The DON further stated, it was her expectation nursing would complete and document pre and post pain assessments so they would know if the pain program was effective or not and ensure the residents' care plans were followed. She continued that nurses could document the pain assessments on the MAR or in the nurse's notes. She further stated that if pain medication was not available and/or pain assessments were not documented then the care plan had not been followed. Interview, on 09/24/16 at 3:37 PM, with the facility Administrator revealed his expectation was residents would not be out of medications ordered by the physician and if a resident was, then he would expect staff to notify the physician. The Administrator further stated I'm not clinical, but my expectation is that staff would completed a pre and post pain assessments, so effectiveness could be measured. He further stated that he expected staff to follow the residents' care plan. 5. Review of Resident #10's medical record revealed the facility admitted the resident on 03/24/16, with [DIAGNOSES REDACTED]. Review of Resident #10's quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of three (3) of fifteen (15) which indicates severe cognition impairment. Observation of the evening meal, on 09/20/16, revealed LPN #6 delivered Resident #10's tray to his/her room at 6:10 PM. The tray card stated Plastic utensils all meals; however, the resident's tray had metal utensils. LPN #6 set the tray up for the resident and left the room. Review of the Physician orders [REDACTED]. Review of the Comprehensive Care Plan for Resident #10 revealed the facility had revised the residents Self Care Deficit care plan interventions on 07/20/16, use plastic utensils at all meals. The care plan did not address why plastic utensils were to be used. Interview with LPN #6 on 09/20/16 at 6:20 PM, revealed she didn't usually pass trays, but the SRNA was busy so she had started passing the trays and did serve Resident #10 his/her tray. She continued to say she did not look at the tray card related to the resident requiring plastic utensils. LPN #6 stated she did not notice if the utensils were metal or plastic. She further stated it was not due to a danger for the resident but that he/she keeps all the silverware, thinks he/she is going to have a yard sale. She further stated the care plan was not followed for Resident #10. Interview with the DON, on 09/24/16 at 1:50 PM, revealed that staff should read the tray card and assure the resident's tray matches. She further stated the care plan should have a problem/reason for the intervention and stated the care plan was not followed for plastic utensils at all meals. Interview with the Administrator on 09/24/16 at 3:35 PM, revealed that he expected staff to follow the residents care plan and if there was questions to address it with the nurse or Physician. 6. Record review revealed Resident #17 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #17's Quarterly MDS Assessment, dated 09/01/16, revealed the resident had a BIMS score of eleven (11) of fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of the physician's orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of the resident's Comprehensive Care Plan, dated 05/20/16 and reviewed 07/14/16, revealed the Problem: At Risk for Impaired Skin Integrity and History of Stage II and Stage I (pressure ulcer) to left heel. Goal stated: Skin will remain intact as evidenced by no pressure ulcers and minimal irritation and bruising. Interventions included: Encourage to wear Geri sleeves to bilateral upper extremities, skin check every shift, monitor feet and elbows/protect as needed, and resident to wear gel heel protector boot at all times for skin integrity, remove every shift and check skin. Review of the Aide Care Plan revealed interventions which included: gel heel protector boot to left foot at all times, with sock under boot, remove every shift for skin check. Seven (7) pillows in bed, one (1) behind head, two (2) under left arm, two (2) under right arm, one (1) under each leg. Incontinent of urine and bowel; check & change resident every two hours. Review of Resident #17's Treatment Administration Record (TAR), dated 09/01/16-09/23/16 3:00 PM, revealed the nurses had initialed that the heel protectors were in place all shifts on 09/21/16 and 09/22/16 and the Geri sleeves were on during all three shifts on 09/21/16 and on the 7-3 PM and 3-11 PM shift on 09/22/16. Observation of Resident #17, on 09/21/16 at 3:30 PM, revealed the resident was lying supine in bed in a private room located on Hall 2-South. The resident was dressed in a short-sleeved top, pull-up pants and the resident was partially covered by a bed sheet. The resident wore no shoes and both feet were elevated on pillows. The left foot was turned out to the side. There were multiple pillows under the resident's head, arms and legs. The resident did not have any Geri sleeves on either arm and no heel protector boots on the feet. Observation of Resident #17, on 09/21/16 at 5:30 PM and again on 09/22/16 at 9:00 AM, revealed the resident was in bed, lying on his/her back, There were no Geri sleeves on the resident's arms or heel protectors on the resident's feet. Interview with SRNA #7, on 09/22/16 at 9:30 AM revealed the Aide was assigned to Resident #17's care. SRNA #7 accompanied this surveyor to the resident's room. When SRNA #7 was asked if he/she had an Aide Care Plan for the resident, he/she stated, I left it in the supervisor's office. Observation of Resident #17 on 09/22/16 at 9:30 AM revealed the resident was in bed, awake, alert and receptive to visit. Interviewed the resident, with SRNA #7 present, and the resident stated he/she didn't mind wearing the sleeves on his/her arms and nobody asked if he/she wanted to take them off. The resident further stated it doesn't matter to me if the boot is on or off. When the resident was asked if it was okay for the Aide to put them on, the resident said, Yes. Interview with SRNA #7 revealed he/she was aware the Aide Care Plan, stated for the resident to wear the Geri sleeves, and the left heel protector boot, at all times except for skin assessments. SRNA #7 stated he/she knew, but sometimes the Geri sleeves were removed to be laundered. He/she further stated, Sometimes I leave the boot off to give the resident a break. Continued interview with SRNA #7 revealed she could not make the decision to take the Geri sleeves or boot off except for skin assessments. Interview with SRNA #2, on 09/23/16 at 3:45 PM, revealed Geri sleeves and heel protector boot orders are printed on Aide Care Plans. If they're ordered to be on at all times, except for skin assessments and bathing, it meant they must be on all the time. Continued interview revealed if

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to provide the necessary care and services to obtain or maintain the highest practical and highest well-being for five (5) of twenty six (26) sampled Residents. (Residents #3, #11, #23, #24 and #26). The facility failed ensure they were addressing residents' pain and failed to ensure pain medication was available for residents as ordered. The facility failed to implement policies regarding assessing and documenting the residents' pain presence and also failed to assess the effectiveness of PRN (as needed) medications on the Medication Administration Record (MAR). The facility failed to ensure narcotic medication refills were re-ordered as per the facility's process, in a timely manner to ensure residents did not experience pain, without pain medications on hand. The facility process was for the nurse giving the dose with a refill sticker next to it, to re-order the medication at that time. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure to assess, monitor, and control residents' pain. Resident #11 had a physician's orders [REDACTED]. The facility allowed the resident to suffer from pain for thirty-four and a half (34 ½) hours without the pain medication. Resident #11 did not receive the next dose of [MEDICATION NAME] until 09/12/16 at 8:00 AM, even though the resident requested the [MEDICATION NAME]. Resident #23 had physician's orders [REDACTED]. The resident did not receive the next routine nor PRN (as needed) dose of [MEDICATION NAME] until 05/09/16 at 10:45 AM when at that time he/she was in distress from being without the pain medication for fifty-eight (58) hours and fifteen (15) minutes. Resident #3 had resided at the facility since 08/01/07. After hospitalized from [DATE]-09/11/16, the resident was re-admitted to the facility on [DATE], under Hospice care. The resident was in the facility for six and one-half (6.5) hours and expressed the need for pain medication. The resident was without an effective pain management plan. Subsequently, the resident was transferred back to inpatient Hospice for pain management control on 09/11/16. Resident #24 had a physician's orders [REDACTED]. Review of the resident's medication records revealed the resident usually requested, and received, five to seven (5-7) doses per day to manage pain symptoms. Due to the medication not being re-ordered timely, the resident did not have the medication available for eleven (11) hours and ten (10) minutes from 09/22/16 at 1:50 AM until 09/22/16 at 1:00 PM. The resident revealed during that period he/she experienced symptoms of nausea, sweating, dizziness, changes in blood pressure and uncontrolled pain. Resident #26 had a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. The resident stated that they had received a pain pill about 4:00 PM, didn't remember the date but it was this month, and then had to wait until the pharmacy brought his/her pain medication late the next day. Review of the Controlled Drug Record revealed the last [MEDICATION NAME] was signed out on 09/12/16 at 4:00 PM, and the new record revealed the first (1st) [MEDICATION NAME] was signed out on 09/13/16 at 4:00 PM, revealing the resident was out of [MEDICATION NAME] for at least twenty four (24) hours. The findings include: Review of the facility's policy titled, Pain Management Process, with a revision date of October 2015, revealed the facility recognized that each resident had the right to treatment and services to maintain their quality of life. Continued review revealed the facility's goal was to ensure all residents receive appropriate pain relief measures to assure that the resident's pain did not affect their ability to function within their designated goals for functional ability. Further review of the Pain Management Process Policy, Section titled Process, indicated upon admission and re-admission the facility would complete a pain assessment/evaluation, complete pain interviews or reviews based on Minimum Data Set (MDS) Resident Assessment Instrument (RAI) guidelines. If pain triggered the facility would complete a comprehensive pain assessment/evaluation. The resident's care plan would be generated from the data collected from the pain assessment. The Physician would be notified when pain levels were outside normal levels for each individual resident. Documentation of pain intensity would be recorded using appropriate facility forms. Upon follow-up, if the intervention was ineffective, the process should be repeated until the resident indicated adequate relief. Review of the facility's policy titled Controlled Substance Medication Orders, from the Pharmacy Policy and Procedure Manual dated 2007, Section 2.2 page 3, revealed each controlled substance medication order was to be documented in the resident's medical record with the date, time, and signature of the person receiving the prescription. The medication order was to be recorded on the physician order [REDACTED]. Review of the facility's policy titled Medication Ordering and Receiving From Pharmacy Provider dated September 2010, revealed all new medication orders are transmitted to pharmacy. If utilizing a cycle fill or anniversary fill system, all routinely used dosage forms are provided by automatic dispensing and no reorder is required of these medications. For remaining routine and PRN orders, repeat medications (refills for a new supply) are ordered by writing the medication name and prescription number, or applying the peel off bar coded label from the prescription label on the re-order sheet and faxing or otherwise transmitting the order to pharmacy. Re-order routine medications by the re-order date on the label to assure an adequate supply is on hand. For new medications, if the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 03/23/15, and readmitted the resident on 06/29/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/09/16, revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review of the MDS revealed the resident was assessed to have frequent pain that had affected his/her sleep and day to day activities. Further review of the MDS revealed the resident was assessed to have a pain rating of a nine (9) on a scale of zero (0) to ten (10) with 10 being the worst pain the resident could have imagined. Review of Resident #11's Comprehensive Care Plan, revealed the facility identified on 04/03/16 the problem of the resident experiencing alteration in comfort AEB pain at a 5 - 8 on a 0 - 10 scale to back related to a history (HX) of cervical fracture and [MEDICAL CONDITION] with increased risks secondary to general aging process and dental discomfort related to natural missing teeth, with a goal stating the resident will voice relief from pain interventions with ½ hr to 45 minutes from administration and that the residents pain would be reported at an acceptable level. The interventions revealed pain assessment to be completed per facility policy, monitor for and document location and pain scale before and after interventions, monitor effectiveness of pain medication, monitor for signs and symptoms of verbal, non-verbal pain or distress every four (4) hours and PRN and monitor for signs and symptoms of pain with rest or movement, and update family and Physician of changes as needed. Review of the Physician Orders, dated September 2016 for Resident #11, revealed on 06/29/16, the resident was ordered [MEDICATION NAME] tablet ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 milligram (MG) every six (6) hours as needed for pain. Continued review of the Physician order [REDACTED]. Review of Resident #11's Controlled Drug Record for [MEDICATION NAME], revealed on 09/10/16 at 9:30 PM, the residents last dose of [MEDICATION NAME] pain medication was signed out. Review of the residents Controlled Drug Record for [MEDICATION NAME], dated 09/12/16 revealed thirty (30) [MEDICATION NAME] Tablets was received by the facility. Continued review of Resident #11's Controlled Drug Record, dated 09/12/16 revealed the first dose of [MEDICATION NAME] signed out was on 09/12/16 at 8:00 AM. The resident did not receive [MEDICATION NAME] from 09/10/16 at 9:30 PM until 09/12/16 at 8:00 AM. This was a time span of thirty-four (34) hours and thirty (30) minutes the resident went without the pain medication. Review of Resident #11's Medication Administration Record (MAR), dated September 2016 revealed on 9/10/16 the resident was administered [MEDICATION NAME] 10-325 MG tablet at 9:30 PM. Continued review of the MAR revealed Resident #11 was not administered [MEDICATION NAME] again until 09/12/16 at 8:00 AM. Further review of Resident #11's September MAR revealed no documented evidence Pain Assessments were completed during that time frame as per ordered. Interview, on 09/23/16 at 9:20 AM, with Resident #11 revealed he/she was in pain and requested [MEDICATION NAME] pain medication on 09/11/16 at 3:30 AM and was told by the nurse he/she did not have any pain medication and they had put an order in for it and it should be there anytime. Resident #11 stated he/she did ask for [MEDICATION NAME] at this time; however, it did not help the pain at all. Continued interview revealed during this time if he/she would have been asked by nursing, he/she would have rate his/her pain eight (8) out of ten (10) with ten (10) being the most severe pain. Additionally Resident #11 revealed she asked nursing again sometime on morning of 09/11/16 and was told the Physician needed to write a prescription; however, they hadn't been able to get hold of him. Continued interview with Resident #11 revealed that around noon on 09/11/16, his/her pain had increased to a nine (9) or ten (10) and he/she was experiencing irritability caused by the pain. Resident #11 stated he/she stayed in bed all day on 09/11/16 and was not able to go on a scheduled outing with activities, which the resident reported he/she was looking so forward to, due to being in extreme pain, having nausea, and having a headache. Continued interview with Resident #11 revealed he/she thought he/she was experiencing withdrawals due to cramping of his/her back and legs. Resident #11 stated on the afternoon of 09/11/16, staff from activities came to his/her room to see if he/she was going on the outing and he/she told the activities staff he/she couldn't go due to being in so much pain. Continued interview with Resident #11 revealed during the 3:00 PM shift his/her pain had increased to a ten (10) or above and a State Registered Nursing Assistant (SRNA) had to get him/her a cold washcloth to place on his/her head due to him/her having hot and cold flashes. Additionally Resident #11 stated he/she cried during the day on 09/11/16 due to the pain he/she was experiencing and not being able to go on the scheduled outing with activities. Continued interview with Resident #11 revealed he/she did not feel like he/she got their pain medication timely after requesting it. Interview, on 09/24/16 at 9:22 AM, with SRNA #11, who was assigned to Resident #11, revealed the resident was in bed all day on 09/11/16 because he/she was hurting and did not have any pain medication available. Continued interview with SRNA #11 revealed Resident #11 was scheduled to go to a festival off grounds that day; however, he/she was not able to go because he/she was in pain and did not have any pain medication available. Interview, on 09/23/16 at 10:45 AM, with SRNA #13, who cared for Resident #11 during that time frame revealed on 09/11/16 during the 3:00 PM to 11:00 PM shift she answered Resident #11's call light where she discovered the resident in bed crying. Continued interview with SRNA #13 revealed she asked Resident #11 why he/she was still in bed and why he/she was crying. Further interview revealed Resident #11 replied to SRNA #13 he/she was in so much pain he/she couldn't get out of bed. Continued interview revealed SRNA #13 got Resident #11 a cold wet wash cloth per the residents request to apply to his/her face because the resident stated he/she was hot. Interview, on 09/23/16 at 9:50 AM, with the Activity Assistant revealed Resident #11 was very disappointed about not being able to go to the festival on 09/11/16 due to not having his/her pain medication. Continued interview revealed Resident #11 was visibly uncomfortable and disgusted. The Activity Assistant further stated she did not confirm with nursing about Resident #11 being out of pain medication because he/she would have gone on the trip if he/she could have. Interview, on 09/22/16 at 9:50 AM, with the Activity Director revealed Resident #11 was scheduled to attend an outing off grounds on 09/11/16. Continued interview with the Activity Director revealed on 09/11/16, she went to Resident #11 to remind him/her to be ready to leave for the activity at 1:00 PM; however, the resident told her that he/she couldn't go due to being in pain and not having any pain medication in stock. Interview, on 09/23/16 at 3:45 PM, with Licensed Practical Nurse (LPN) #6 revealed on 09/11/16 during the 7:00 AM to 3:00 PM shift, Resident #11 requested his/her [MEDICATION NAME] pain medication; however, she told the resident his/her medication still hadn't come in but she would call the pharmacy and see where it was. Continued interview with LPN #6 revealed she called the pharmacy on 09/11/16 at approximately 9:30 AM and was told they needed a prescription from the Physician. LPN #6 further stated she then called the residents Physician and left a voicemail for him and he returned her call at approximately 10:30 AM and stated he had already faxed the prescription but would refax it since the pharmacy had not received it. Continued interview revealed LPN #6 administered the medication [MEDICATION NAME] to Resident #11. LPN #6 further stated Resident #11 was in tears and she could see how the pain was affecting him/her, so she had rated his/her pain a 10, but acknowledged she did not document the pain assessment and stated nursing staff were to complete pre and post pain assessments to see if the pain was being controlled. Continued interview revealed Resident #11 did not get his/her pain medication timely. Interview, on 09/23/16 at 9:23 AM, with LPN #10 revealed during shift report from the prior shift, it was reported to her, Resident #11 had been requesting pain medication; however, the resident was out of it and the Physician was aware. Continued interview with LPN #10 revealed Resident #11 requested his/her pain medication early into the 3:00 PM to 11:00 PM shift. LPN #10 further stated Resident #11's pain level was a 7 or 8 the best she could remember; however, she stated she did not document the pain assessment. Continued interview with LPN #10 revealed since the resident was requesting pain medication she notified the Physician on 09/11/16 at approximately 5:00 PM, who informed her he would not be able to fax a prescription to the pharmacy until around midnight. LPN #10 further stated she contacted the pharmacy to get permission to access medication from the Emergency Box (EBox); however, she was denied and was told the facility could only access the EBox for new admissions. Continued interview with LPN #10 revealed Resident #11 did not receive his/her medication in a timely manner and the resident was threatening to leave the facility and go to the hospital for pain. Interview, on 09/22/16 at 9:35 AM, with LPN #5 revealed when residents at the facility go without their pain medications, nine (9) times out of ten (10) it is because the pharmacy is waiting on a hard copy of the prescription. Continued interview revealed if nurses failed to re-order medication when triggered by the refill sticker, it did not allow enough time for a hard copy to be obtained from the Physician, in order to prevent the resident from running out of pain medication. Interview, on 09/22/16 at 10:20 AM, with the Unit 2 Manager revealed if a resident was out of their pain medication, usually it was because the pharmacy was waiting on a prescription from the physician. Continued interview, on 09/22/16 at 3:15 PM with the Unit 2 Manager revealed Resident #11's pain medication should have been ordered by the floor nurse three (3) days prior to the last dose given on 09/10/16. Unit 2 Manager further stated the system breakdown of Resident #11 not receiving his/her pain medication started with the facility nurses not reordering the medication timely before the resident was down to the last doses on 09/10/16 and the pharmacy not notifying the Physician for a prescription after the fax for reorder was received by the pharmacy. Continued interview with the Unit 2 Manager revealed the 7:00 AM to 3:00 PM shift nurse faxed a medication reorder sheet for Resident #11's pain medication on 09/10/16 when the resident was probably down to two (2) does left. Unit 2 Manager further stated the facility contacted the Physician at approximately 2:00 AM on 09/12/16 to get him to write a prescription and fax it to the pharmacy. Unit 2 Manager acknowledged Resident #11 received his/her last dose of pain medication on 09/10/16 and did not receive pain medication again until 09/12/16 due to the facility not having the medication on hand. Continued interview revealed it was her expectation the floor nurses were aware when a resident's pain medication needed to be reordered. Unit 2 Manager further stated it was important for pain medication to be ordered timely so residents were not in pain. Interview, on 09/23/16 at 4:55 PM, with the residents Physician, also the facility Medical Director revealed he was not made aware that Resident #11 was without pain medication from 09/10/16 until 09/12/16. Continued interview revealed Resident #11's pain should have been controlled and the resident should not have been in pain for that long. The Medical Director further stated he had spoken to staff before about notifying him ahead of time and not waiting until the last minute. Continued interview, with the Medical Director revealed the facility staff was not pulling the re-order sticker that the pharmacy put on the medication in a timely manner. The Medical Director revealed his expectation was his residents would have received their medication timely and as ordered. Further interview with the Medical Director, on 10/20/16 at 1:50 PM, revealed he had talked with the Pharmacy about six months ago at which time they implemented the refill sticker system so that they would be notified three to four days before the last does in order to give the Pharmacy time to contact the Physician if a new perscription was needed. Review, of the Pharmacy shipping manifest signed by the facility staff revealed the facility received Resident #11's [MEDICATION NAME] on 09/12/16. 2. Review of Resident #23's medical record revealed the facility admitted the resident on 01/05/11, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/20/16, revealed the facility assessed Resident #23 to have a BIMS score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review of the MDS revealed the resident was assessed to have frequent pain. Further review of the MDS revealed the resident was assessed to have a pain rating of a three (3) on a scale of zero (0) to ten (10) with 10 being the worst pain the resident could have imagined. Review of Resident #23's Comprehensive Care Plan, revealed the facility identified on 03/30/16 the problem of, the resident was at risk for alteration in comfort related to a HX of chronic pain and routine pain management. The goal stated the resident would receive routine pain management that would remain effective thru the next review as evidenced by (AEB) minimal complaint of (C/O) of breakthrough pain. The interventions included: Pain assessment per protocol, identify location and rate of pain prior to and after any interventions, routine pain medications as ordered, attempt and document effectiveness of non-pharmacological interventions as appropriate, report unrelieved or increase in break through pain to Medical Doctor (MD), give PRN medication as ordered for complaints or signs/symptoms of pain, document intervention severity and effectiveness of medication, and monitor for verbal and non-verbal signs and symptoms of pain every 4 hrs and PRN. Review of the Physician Orders, dated May 2016 for Resident #23 revealed, the resident was ordered on [DATE] and continued, routine [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5-325 tablet by mouth at bedtime at 12 midnight for chronic pain. Continued review of the Physician order [REDACTED]. Further review of the Physician order [REDACTED].#23 as a clarification order for [MEDICATION NAME]-APAP 5/325 by mouth ever six (6) hours PRN for chronic Pain. Review of Resident #23's Controlled Drug Record, dated 04/09/16 revealed the resident's last does of routine and PRN [MEDICATION NAME] 5-325 was signed out on 05/07/16 at 12:30 AM. Review of Resident #23's Controlled Drug Record dated 05/09/16 revealed thirty (30) [MEDICATION NAME] 5-325 tablets for routine and PRN use was received by the facility. Continued review of the residents Controlled Drug Record dated 05/09/16 revealed the first dose of [MEDICATION NAME] 5-325 was signed out on 05/09/16 at 10:45 AM. The resident did not receive [MEDICATION NAME] from 05/07/16 at 12:30 AM until 05/09/16 at 10:45 AM, when thirty (30) [MEDICATION NAME] tablets were delivered from the pharmacy to the facility. This was a time span of fifty-eight (58) hours and fifteen (15) minutes the resident went without the pain medication. Review of Resident #23's MAR, dated May 2016 revealed on 05/07/16 during the 12:00 AM medication pass, was the last time the resident was administered his/her routine [MEDICATION NAME] 5-325 until 05/16/16, when the resident returned from a hospital stay. Continued review of the MAR revealed on 05/05/16 at 5:20 PM, was the last time the resident was administered his/her PRN [MEDICATION NAME] 5-325 until 05/16/16, when the resident returned from a hospital stay. Further review of the MAR revealed Pain Assessments for PRN medication were not being completed per facility Pain Management Process Policy. Review of LPN #5's Nurse's Notes, dated 05/09/16 at 3:46 PM, revealed Resident #23 was complaining of chest pain and an order was obtained from the Physician to send the resident to the emergency room . Continued review revealed 911 was called and the resident left the facility at 12:00 PM. Interview, on 09/23/16 at 3:45 PM, with LPN #6 revealed on 05/09/16, Resident #23 was exhibiting signs and symptoms of withdrawal due to him/her going without pain medication for so long. Continued interview revealed the resident did not have any pain medication due it not being available. Interview, on 09/24/16 at 10:25 AM, with LPN #5 revealed she was not Resident #23's assigned nurse on 05/09/16. LPN #5 stated the resident came up to her and told her he/she was experiencing chest pain. LPN #5 further stated if the resident was out of pain medication, then that could be the reason he was experiencing chest pain. 3. Review of Resident #3's medical record revealed the revealed the facility admitted the resident on 08/01/07, with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 10, which indicated the resident's cognition was moderately impaired. The MDS also documented one (1) Stage 4 Pressure Ulcer and Pain Intensity Scale Rated at seven (7) out of ten (10). Review of the previous Significant Change MDS, dated [DATE], documented the resident rated pain eight (8) out of ten (10). Continued review of the medical record, Hospice notes, revealed the resident was initially evaluated by inpatient Hospice on 09/11/16 at 1:30 PM. The resident was noted to have severe pain, rated at a ten (10), especially with movement and repositioning. Further review of the Hospice notes revealed documentation the resident was transferred to the facility on [DATE] at 3:30 PM. Review of Resident #3's medical record revealed two (2) prescriptions on admission 09/11/16. The prescriptions were for [MEDICATION NAME] Liquid 20 milligrams per milliliter, give 5-10 milligrams every four (4) hours as needed for pain and [MEDICATION NAME] Liquid 1 milligram orally every four (4) hours as needed for agitation. Continued review of the medical records revealed there was no documentation on 09/11/16 of a pain assessment per the facility's policy and no written Physician's telephone orders and there was no evidence of assessment and care planning sufficient to meet the needs of the newly admitted resident. Review the nurse's note by Registered Nurse (RN) #4, dated 09/11/16 at 10:59 PM, revealed Resident #3 was readmitted to the facility and a call was placed to the Medical Doctor (MD) to verify orders. The nurse documented the resident arrived via stretcher at 4:00 PM. RN #4 also documented a skin assessment was done, wound measurements were noted, and the Medical Doctor (MD) was contacted to verify orders. Continued review of the nurse's note revealed a verbal order for Narco pain medication was received from the Physician and administered to Resident #3 on 09/11/16 at 8:00 PM. The note indicated the resident refused the medication initially, stating it would not help, but then agreed to take it. Interview with SRNA #1, on 09/20/16 at 4:30 PM, regarding the resident and skin conditions, revealed she worked the Sunday night the resident was re-admitted on [DATE]. She stated, He/she was in a lot of pain, more than in the past. The nurses were doing care to the open places on the buttocks, and the resident was very verbal about how much it was hurting. The nurse's note also documented the Hospice nurse contacted his supervisor and they decided, with the family, the resident would be sent to in-house Hospice. The note concluded the resident was out of the facility at 10:03 PM. There was no documentation of completion of the admission to the facility on [DATE]. Review of the inpatient Hospice note, dated 09/11/16 at 10:30 PM, revealed the resident was admitted for symptom management due to the nursing home staff being unable to obtain the resident's medications for pain and anxiety. Review of the Hospice nurse's note, dated 09/11/16 at 10:29 PM, revealed documentation the resident was assessed as being in pain at a level of six (6) of ten (10) on a scale of zero to ten (0-10). Record record review revealed Resident #3 was readmitted to the facility on Tuesday, 09/13/16, and was still under Hospice care. The resident's pain medication orders included [MEDICATION NAME] Patch 12 microgram per hour, apply topically every three (3) days, [MEDICATION NAME] 20 milligrams per milliliter Oral Syringe, 5 milligrams by mouth every two (2) hours as needed for mild pain or dyspnea (difficulty breathing); 10 milligrams by mouth every two (2) hours as needed for moderate pain or dyspnea; 20 milligrams by mouth every two (2) hours as needed for severe pain or dyspnea. [MEDICATION NAME] ([MEDICATION NAME]) two (2) milligrams per milliliter Oral Concentrate, 0.5 milliliters by mouth every three (3) hours as needed for restlessness or anxiety. Hospice records documented the resident had received the [MEDICATION NAME] Patch on 09/12/16, prior to leaving inpatient Hospice, and the patch was due to be changed on 09/15/16. Observation of Resident #3 on 09/20/16 at 2:00 PM, revealed the resident was lying on his/her back on an air mattress with alternating pressure settings. The head of the bed was elevated forty-five (45) degrees. The resident had severe contractures of the left arm and both legs. The resident complained, My tailbone hurts bad. When encouraged to change positions, the resident said, I like laying just the way I am. When asked about his/her left arm (contracted with hand to chest), the resident stated, This is where I keep it, like this. The resident's left leg was bent to the left, contracted, and positioned out from under the sheet. A quarter-sized cut-like abrasion that was scabbed, and without drainage, was on the resident's left knee. The resident said, It hurts to move it, so I let it stay there. On 09/20/16 at 6:15 PM, interview was conducted with Resident #3's brother/Power of Attorney and sister-in-law, who visited in the resident's room. Interview revealed on the evening of 09/11/16, the resident was in severe pain. The sister-in-law stated it was after she called Hospice, at 7:30 PM, the Hospice nurse came to the facility and ultimately the resident was readmitted to inpatient Hospice for medications for pain control. Continued observation of Resident #3 on 09/20/16, from 6:30-7:00 PM, revealed LPN #2 explained the wound care procedure to the resident and the resident agreed to treatment. Observed Resident #3 moaned and complained it hurts every time the resident was touched, or a lower extremity was moved. LPN #2 provided care to wounds on resident's right stump, left ankle and left toes. Resident #3 moaned out in pain and said, Stop, after the ankle and toe dressings were done. The resident adamantly refused to be turned so the nurse could provide wound care to the buttocks. Interview with LPN #2 on 09/20/16 at 7:00 PM, revealed the resident periodically developed cysts on the buttocks which would rupture and drain. LPN #2 further revealed the right stump Stage IV ulcer previously had bone visible, and was now much improved. The status of the resident's buttock wounds were not assessed due to resident's refusal. Interview with the Direc

Based on interview, record review, review of the facility's policies, and review of the facility's Administrator Position Description, it was determined the facility's Administration failed to ensure there was an effective system in place to ensure its resources, including policies and procedures related to acquiring, receiving, dispensing, and administering medications, were used effectively and efficiently to attain or maintain the highest practical physical, mental, and psychological well-being for the residents. The facility's Administration failed to have an effective system to ensure resident's pain medication was ordered/re-ordered and received from pharmacy in a timely manner to be available for administration in order for residents to obtain and maintain an acceptable level of pain control. In addition, the Administrator failed to ensure pain assessments were being completed and documented in order to assess effectiveness of pain medications. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure. This failure effected Resident #11, #3, #23, #24, #26. (Refer to F-309) The findings include: Review of the facility's Administrator Position Description, undated, revealed the purpose of the position was to direct the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care could be provided to residents at all times. Further review revealed essential functions of this position included the responsibility of facility management and compliance management. In addition, the essential functions included ensuring excellent care for the resident was maintained by overseeing and monitoring the delivery of patient care services. Review of the facility's policy titled, Pain Management Process, with a revision date of October 2015, revealed the facility recognized that each resident had the right to treatment and services to maintain their quality of life. Continued review revealed the facility's goal was to ensure all residents received appropriate pain relief measures to assure that the resident's pain did not affect their ability to function within their designated goals for functional ability. Review of the facility's policy titled Medication Ordering and Receiving From Pharmacy Provider dated September 2010, revealed all new medication orders are transmitted to pharmacy. If utilizing a cycle fill or anniversary fill system, all routinely used dosage forms are provided by automatic dispensing and no reorder is required of these medications. For remaining routine and PRN orders, repeat medications (refills for a new supply) are ordered by writing the medication name and prescription number, or applying the peel off bar coded label from the prescription label on the re-order sheet and faxing or otherwise transmitting the order to pharmacy. Re-order routine medications by the re-order date on the label to assure an adequate supply is on hand. For new medications, if the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Resident #11 had a physician's orders [REDACTED]. Resident #11 did not receive the next dose of [MEDICATION NAME] until 09/12/16 at 8:00 AM, even though the resident requested the [MEDICATION NAME]. The facility allowed the resident to suffer from pain for thirty-four and a half (34 ½) hours without the pain medication. Resident #23 had physician's orders [REDACTED]. The resident did not receive the next routine nor PRN (as needed) dose of [MEDICATION NAME] until 05/09/16 at 10:45 AM, when at that time he/she was in distress from being without the pain medication for fifty-eight (58) hours and fifteen (15) minutes. Resident #24 had physician's orders [REDACTED]. The resident did not receive requested pain medicine again until 09/22/16 at 2:00 PM. The resident's pain medication was not available for eleven (11) hours and fifty minutes (50) minutes, from 09/22/16 at 1:50 AM until 09/22/16 at 2:00 PM. During that time, the resident experienced symptoms of nausea, sweating, dizziness, changes in blood pressure and uncontrolled pain. Resident #26 had a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the Controlled Drug Record revealed the last [MEDICATION NAME] was signed out on 09/12/16 at 4:00 PM, and the new record revealed the first (1st) [MEDICATION NAME] was signed out on 09/13/16 at 4:00 PM, revealing the resident was out of [MEDICATION NAME] for at least twenty four (24) hours. The resident stated he/she was in pain through out the night and the next day rating the pain at an eight (8) out of ten (10) on a scale of zero (0) to ten (10). Resident #3 arrived at the facility for admission on 09/11/16 at 4:00 PM with a written prescription for [MEDICATION NAME] Liquid 20 milligrams per milliliter, give 5-10 milligrams every four (4) hours as needed for pain. The Physician was not notified for order verification until 09/11/16 at 8:00 PM, and it was not expected the medications would be received from the Pharmacy for four (4) hours. The resident was transferred back to the inpatient Hospice unit for pain management. Interview, on 09/24/16 at 1:50 PM, with the Director of Nursing (DON) revealed it was her expectation residents would receive their pain medication in a timely manner. Continued interview revealed the facility had a problem with the Pharmacy and getting residents' medications. The DON stated if a resident was in pain and other interventions did not help, then there was a potential for a negative outcome. Further interview revealed the nurses had brought to her attention about re-order issues, and she gave those concerns to the Unit Managers, and they were to handle them. She stated, narcotics should be re-ordered when the narcotic sheet triggers them for re-order to ensure the resident doesn't run out of pain medicine. She further stated, it was every nurse's responsibility to send in the refill request in time to get the re-ordered medication; however, she was not tracking to ensure this was being done. Post Survey interview, on 10/20/16 at 3:00 PM, with the DON, revealed she was aware there was a problem related to pain assessments not being documented but didn't know the degree of the problem. She also said it was her expectation, for a new admission, that getting the physician's orders [REDACTED]. Interview, on 09/23/16 at 4:55 PM, with the facility Medical Director, revealed he had spoken to staff before about notifying him when residents' needed a prescription and not waiting until the last minute. Continued interview with the Medical Director, revealed the facility staff was not pulling the re-order sticker that the pharmacy puts on the medication in a timely manner. The Medical Director revealed his expectation was that his residents receive their medication including pain medication timely and as ordered. He stated, That's why I prescribe medications for anxiety and pain. I have talked with the nurses and told them they need to have prescriptions ready. The pharmacy and the nurses need to let me know the prescription was due in time to get it refilled timely. Further interview with the Physician revealed he had asked the Pharmacy Consultant to tell him when he needed to write new prescriptions. Interview with the Director of Pharmacy Services, on 09/23/16 2:30 PM, revealed there was a process in place to remind the nurses to re-order medications. Further interview revealed the facility needed to re-order three to four (3-4) days ahead to ensure medications did not run out. Per interview, the pharmacy faxed the reminder to the Physician advising if a new prescription was due. Interview, on 09/24/16 at 3:37 PM, with the facility Administrator, revealed it was his expectation residents would not run out of Physician ordered medications and if a resident ran out of medication, he would expect staff to notify the Physician. He further stated he was aware of the incident with Resident #3 being transferred back the the Hospice Unit because the facility could not control the resident's pain. The Administrator further stated it was his expectation that staff complete pre and post pain assessments. He stated, I'm not clinical, but I know it should be done. It is important to measure effectiveness. Further interview, revealed he was aware the facility was having difficulties with the Pharmacy and knew the problems had to do with residents not receiving their medication as ordered. He further stated he had requested a conference with the Pharmacy Director, but to date this conference had not been scheduled. Post Survey interview with the Administrator, on 10/20/16 at 2:53 PM, revealed the facility becomes responsible for a resident upon arrival to the facility.

Based on record review, interview, review of the facility's policies and review of the American Nurses Association's (ANA) Principles for Nursing Documentation, it was determined the facility failed to maintain clinical records that were complete and accurately documented in accordance with acceptable professional standards and practices, for five (5) of twenty-six (26) sampled residents (Residents #3, #11, #23, #24, and #26). The facility failed to ensure all doses of medications administered were documented on the Medication Administration Record (MAR). In addition the facility failed to ensure pain assessments were completed and documented according to Physician's orders and the facility's policy. The findings include: Review of the facility's policy titled, Pain Management Process, revised October 2015, revealed the facility recognized each resident had the right to treatment and services to maintain their quality of life. Continued review revealed the facility's goal was to ensure all residents received appropriate pain relief measures to assure pain did not affect their ability to function within their designated goals for functional ability. Further review revealed the facility's process included necessary evaluation, intervention, and re-evaluation as standard care practice for licensed nurses. In addition, the process included the completion of a pain assessment/evaluation upon admission or re-admission to the facility, and pain intensity would be recorded using appropriate facility forms. Furthermore, if an intervention was ineffective, the process should be repeated until the resident indicated adequate relief or functional goals were met. Review of the facility policy titled Administering Medications, undated, revealed the following: the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next one. Review of the ANA's Principles of Documentation, dated 2010, revealed clear and accurate documentation is an essential element of safe, quality nursing practice. Continued review revealed documentation of nurses' work is critical for effective communication among nurse and between disciplines. Furthermore, documentation is how the provider creates a record of services for use by payors, government agencies, and other entities. In addition, the ANA defined high quality documentation to include the following characteristics: accessible; accurate; clear, concise and complete; legible; and timely. Post-survey interview with the Director of Nursing (DON), on 10/20/16 at 2:53 PM, revealed it was her expectation that all medications administered were documented on the Medication Administration Record (MAR). Interview with the Unit Manager second floor, on 09/23/16 at 3:50 PM, regarding Pain Assessment and documentation according to the facility's Pain Management Process Policy and Pain Program, revealed the nurses were supposed to document the pain rating pre and post medication, and also document effectiveness. The Comprehensive Pain Assessment Admission Data Set goes into the computer. The nurses were supposed to document pain level, pain medication administered, and the effectiveness. The nurses have been in-serviced on this process. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 03/23/15, and readmitted the resident on 06/29/16, with [DIAGNOSES REDACTED]. Review of the active Physician Orders for Resident #11, dated September 2016, revealed the resident was to receive [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 10/325 milligram (mg) every six (6) hours as needed (PRN) for pain. Continued review of the Physician Orders revealed the resident was to have a Pain Assessment completed PRN to identify pain characteristics including location, a rating of the pain, any non-pharmacological interventions applied, and a post-intervention rating. Further review of the medical record, including the Controlled Drug Record (CDR) and the MAR, revealed Resident #11 did not receive [MEDICATION NAME] between 09/10/16 at 9:30 PM and 09/12/16 at 8:00 AM due to the medication being unavailable to the resident. Review of the Nurses Notes for Resident #11 from 09/10/16 through 09/12/16 revealed no documented evidence the Physician was notified the resident was out of pain medication, and had ongoing pain that prevented the resident from participating in routine and special activities. Interview with Licensed Practical Nurse (LPN) #6, on 09/23/16 at 3:45 PM, revealed on 09/11/16 during the 7:00 AM to 3:00 PM shift, Resident #11 requested his/her [MEDICATION NAME] pain medication; however, the facility did not have the resident's pain medication available and were waiting for a delivery from the pharmacy. LPN #6 stated Resident #11 was in tears; she could see how the pain was affecting the resident, so she rated it as ten (10) on a scale of one (1) to ten (10). LPN #6 acknowledged she did not document the pain assessment. She further stated nursing staff were to complete and document pain assessments to ensure the residents' pain was controlled. Interview with LPN #10, on 09/23/16 at 10:15 AM, revealed Resident #11 requested pain medication early into the 3:00 PM to 11:00 PM shift on 09/11/16; however the medication was still not available. LPN #10 stated the resident's pain level was a seven (7) or eight (8) to the best of her recollection; however, she acknowledged she did not document Resident #11's pain assessment but should have done so. 2. Review of the medical record revealed Resident #23 was admitted by the facility on 01/05/11, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the CDR and the MAR for the month of May 2016 revealed on ten (10) occasions [MEDICATION NAME] 5/325 was signed out for Resident #23 on the CDR, but was not documented on the MAR. Furthermore, pain assessments associated with those doses were not documented according to the facility's Pain Management Process. 3. Review of the medical record revealed Resident #3 was admitted by the facility on 08/01/07 with [DIAGNOSES REDACTED]. Continued review of the medical record revealed no documented evidence a pain assessment was completed upon admission according to the facility's policy, even though Resident #3 was known to have a history of pain, was accustomed to receiving frequent PRN pain medications, and the resident arrived for re-admission with two written Physician prescriptions for narcotic medications to treat the resident's pain and agitation. Furthermore, there was no documented evidence of assessment and care planning sufficient to meet the needs of Resident #3 upon re-admission. After approximately six (6) hours, Resident #3 was transferred back out of the facility to a Hospice unit, for pain control. Resident #3 returned to the facility on [DATE]. Review of the CDR revealed twenty-four (24) doses of [MEDICATION NAME] were signed out for Resident #3 from 09/13/16 to 09/20/16. Review of the MAR for the same period revealed only fifteen (15) of the doses were documented as having been administered to the resident. Continued review of the MAR revealed only one (1) pain assessment was documented to have been performed during the same time period. 4. Review of the medical record for Resident #24 revealed the resident was admitted on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #24 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of the Comprehensive Care Plan, dated 05/04/16, revealed Resident #24 was assessed for the problem of pain. Interventions included documentation of the location of the resident's pain, and an intensity rating prior to and after any interventions. Interview with Resident #24, on 09/24/16 at 8:40 AM, revealed he/she takes [MEDICATION NAME] ([MEDICATION NAME]) every 4 hours, or the pain is not controlled. The resident continued to say two (2) days ago the facility ran out of pain medicine. Resident #24 further stated he/she was given [MEDICATION NAME] around 9:30 PM on 09/21/16, and was told by the nurse he/she only had one (1) dose left. Resident #24 stated he/she requested, and received, the last pain pill available at 1:50 AM on 09/22/16. Continued interview revealed Resident #24 did not receive another pain pill until 1:00 PM on 09/22/16, and the pain was really bad. The resident stated he/she felt nauseated, dizzy and sweaty, and it even effected his/her blood pressure. Review of the Nurses Notes for Resident #24 revealed no documented evidence the Physician was notified of the resident being out of pain medication and having complaints of pain. Continued review revealed no documented evidence of pain assessments during the time the resident had no pain medication available. Review of the CDR and the MAR for Resident #24 revealed between 09/01/16 and 09/24/16 the resident received 124 doses of narcotic pain medication that were signed out on the CDR but only 97 doses were documented on the MAR. Further review revealed pre and post pain assessments were only documented 27 times. 5. Review of the medical record revealed Resident #26 was admitted by the facility on 11/12/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS Assessment, dated 08/07/16, revealed the facility assessed the resident as having a BIMS score of fourteen (14) of fifteen (15) which indicated Resident #26 was cognitively intact. Further review of the medical record revealed although Resident #26 was to receive [MEDICATION NAME] 7.5/325 mg every four (4) hours, the narcotic pain medication was not available to the resident for a twenty-four (24) hour period between 4:00 PM on 09/12/16 and 4:00 PM on 09/13/16. There was no documented evidence the Physician was notified the resident did not have pain medication available and missed five (5) doses. In addition, no pain assessment was documented to indicate how the resident managed without the pain medication during the same twenty-four (24) hour period. Review of the MAR for September 2016 revealed on seven (7) occasions Resident #26 was given a narcotic pain medication, but no pain assessment was completed and documented. Interview with LPN #7, on 09/24/16 at 1:45 PM, revealed facility policy directed nursing to document a pain assessment before and after pain medication was administered. She acknowledged she did not always do this, but was aware she should. Interview with Registered Nurse (RN) #1, on 09/23/16 at 3:00 PM, revealed she was not aware there was a routine way to document pain levels. She stated she usually documented in the nurses notes. However, she stated she probably did not document a pain assessment before and after every pain medication administered. Interview with RN #2, on 09/23/16 at 3:05 PM, revealed the facility's policy was for nurses to do a pre- and post-pain assessment and document it on the MAR. She stated these assessments were important to complete to make sure the resident's pain was controlled. Continued interview revealed she knew this was not always completed and documented. Continued interview revealed if a resident's pain was uncontrolled but not identified by staff, the resident could suffer other potentially serious conditions like heart problems or depression. Interview with the Director of Nursing (DON), on 09/24/16 at 1:50 PM, revealed she expected the nurses to document pain assessments before and after administering pain medication in order to determine if the medication was effective or not. Post Survey interview with the DON, on 10/20/16 at 3:00 PM, revealed she reviewed the Nurses Notes for all residents daily, Monday through Friday, and noticed not all residents were receiving pre and post pain assessments when receiving narcotic pain medication. She said she did compare the narcotic sign out sheets with the record to ensure this was being completed. She further stated the Unit Mangers were to look at the MARs, that she did not look at them. She continued to say she expected any medication administered to be documented/initialed on the MAR. Post Survey interview with the Administrator, on 10/20/16 at 2:53 PM, revealed he expected nurses to complete pre and post pain assessments, as per the facility's policy, each time a pain medication was given. He stated he felt the Unit Managers should be monitoring this. He continue to say he expected residents' records to be complete and accurate.

Based on observation, interview, record review, review of the facility's policies, review of the Lippincott Manual of Nursing Practice, review of the Rapid Assessment Instrument Guidance (RAI), and review of the American Nurses Association's Nursing:Scope and Standards of Practice, Second Edition it was determined the facility failed to assure services provided met professional standards for quality of care for one (1) of twenty-six (26) sampled residents (Resident #3). Resident #3 was readmitted to the facility at approximately 3:30 PM on 09/11/16, and was transferred back to in-patient Hospice at 10:00 PM, for pain control management and medications. There was no documented evidence of a comprehensive assessment and care planning for six and a half (61/2) hours, sufficient to meet the needs of the newly admitted resident. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure to assess, monitor, and control residents' pain. Responsible for residents upon admission (Refer to F-157, F-309, and F-425) The findings include: Interview with the Director of Nursing (DON), on 09/23/16 at 4:30 PM, revealed the facility nurses followed the Lippincott Manual of Nursing Practice, Ninth Edith, as reference to professional standards of quality. Continued interview with the DON revealed the facility did not have a policy regarding Initial Care Plans. Further interview revealed the facility followed the Minimum Data Set (MDS)/Resident Assessment Instrument Guidelines (RAI) for care plan procedures. Review of the American Nurses Association's Nursing:Scope and Standards of Practice, Second Edition revealed the Registered Nurse (RN) would develop an individualized plan of care with stratagies which included the alleviation of suffering. Review of the Lippincott Manual of Nursing Practice revealed professional nursing standards were minimum levels of acceptable performance for which its practitioners were accountable. Continued review revealed patients were at risk for adverse outcomes when nurses failed to assess properly, failed to notify the physician of changes and obtain orders for care, failed to adhere to policy or procedures, and failed to document information in the medical record. Review of the facility form titled, Care Plan Procedures, dated 2013, revealed it was the practice of Preferred Care Partners, and their affiliates to initiate, complete, and revise resident care plans in accordance with all Federal and State regulations and the RAI guidance. Review of the RAI Guidance procedures revealed Care plan development begins the day of admission. Each resident will have Care Plans initiated at time of admission, either through a set of standardized paper care plans or in the MDS software program. There was no distinction between a preliminary care plan and the comprehensive. Review of Resident #3's medical record revealed the resident was initially admitted to the facility on [DATE]. The resident had a history of [REDACTED]. The resident had a history of [REDACTED]. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 10, which indicated the resident's cognition was moderately impaired. The MDS also documented one (1) Stage 4 Pressure Ulcer and Pain Intensity Scale Rated at seven (07) out of ten (10). Review of the previous Significant Change MDS, dated [DATE], documented the resident rated pain eight (8) out of ten (10). The MDS Assessment had not been completed yet for the most recent admission. Continued review of the medical record, Hospice notes, revealed the resident was initially evaluated by inpatient Hospice on Sunday, 09/11/16 at 1:30 PM. The resident was noted to have severe pain, rated at a ten (10), especially when repositioned or moved around a lot. Further review of the Hospice notes revealed documentation the resident was transferred to the facility on [DATE] at 3:30 PM. Review of Resident #3's medical record revealed two (2) prescriptions on admission 09/11/16. The prescriptions were for [MEDICATION NAME] Liquid 20 milligrams per milliliter, give 5-10 milligrams every four (4) hours as needed for pain and [MEDICATION NAME] Liquid 1 milligram orally every four (4) hours as needed for agitation. Review of the medical record revealed a single entry nurse's note, dated 09/11/16 at 10:59 PM, by the admitting nurse, Registered Nurse (RN) #4. The nurse documented the resident arrived via stretcher at 4:00 PM. The nurse also documented a skin assessment was done, wound measurements were noted, and the MD (Medical Doctor) was contacted to verify orders. The nurse's note documented a verbal order was obtained from the physician, and [MEDICATION NAME] pain medication was administered on 09/11/16 at 8:00 PM. The nurse documented the resident refused the medication initially, but was encouraged to take it and agreed. The nurses note also documented the Hospice nurse contacted his supervisor and they decided, with the family, the resident would be sent to in-house Hospice. The note concluded the resident was out of the facility at 10:03 PM. There was no documentation of completion of the nursing admission process to included initial care planning related to the resident's pain nor procurement of the residents medications. Interview with DON about resident is aa resident upon entery to the facility On 09/20/16 at 6:15 PM, interview was conducted with Resident #3's brother/Power of Attorney and sister-in-law, who visited in the resident's room. Interview revealed on the evening of 09/11/16, the resident was in severe pain. The sister-in-law stated it was after she called Hospice, at 7:30 PM, the Hospice nurse came to the facility and ultimately the resident was readmitted to inpatient Hospice for medications for pain control. Continued review of the medical record revealed there was no documentation by RN #4, on 09/11/16, of a pain assessment per the facility's policy and no written physician's telephone orders. Further review of the medical record revealed there was no evidence of assessment and care planning sufficient to meet the needs of the newly admitted resident and there was no Interim Care Plan developed related to pain or anxiety. Review of the inpatient Hospice hospital note, dated 09/11/16 at 10:30 PM, revealed the resident was admitted for symptom management due to the nursing home staff being unable to obtain the resident's medications for pain and anxiety. Review of the Hospice nurse's note, dated 09/11/16 at 10:29 PM, revealed documentation the resident was assessed as being in pain at a level of six (6). Interview with Resident #3, on 09/23/16 at 9:30 AM, revealed the resident did recall coming to the facility after having been in the hospital in September this year. The resident recalled the evening and night of 09/11/16 and stated he/she was tired and in pain, which the resident described as a nine (9) on a scale of zero-ten (0-10). Interview with Registered Nurse (RN) #4, on 09/22/16 at 10:36 AM, revealed she was scheduled as weekend supervisor, and was also assigned to work the first floor. She further revealed another nurse called in, so she had to cover two (2) halls on the first floor and pass medications. RN #4 stated she went to help a new nurse with the admission of Resident #3 and after she completed the skin assessment, she had to return to the first floor to pass medications, which she did from 5:00 to 6:30 PM. Interview with the Director of Nursing (DON), on 09/22/16 at 8:15 AM, revealed Resident #3 came in with written prescriptions for pain so an Initial Care Plan should have been developed related to pain and anxiety, but the initial assessment had to be completed by the nurse. She stated, the initial assessment and planning of care had to be done first. Continued interview with the DON, at xxx on 10/20/16, revealed Continued interview with the DON, on 09/24/16 at 2:30 PM, regarding the admission of Resident #3 on 09/11/16, the DON stated he/she was only there six and one-half (6-1/2) hours, that's why there was no admission paperwork completed to include an assessment and the development of an initial care plan. Further interview revealed the admission process should be completed the same whether it was a week-end or a week-day admission.

Based on interview, record review, review of the Police report, review of the facility's investigation, and review of the facility's policies, it was determined the facility failed to have an effective system to provide supervision and monitoring to prevent accidents and to maintain a safe environment for one (1) of seven (7) sampled residents (Resident #1). The facility failed to have a system in place to ensure staff was aware of Resident #1's location and failed to ensure door alarm equipment was functioning properly to alert staff of Resident #1 accessing the exit doors. On [DATE], at approximately 11:22 AM, Resident #1 was last seen in the facility by Certified Nursing Assistant (CNA) #10. CNA #10 observed Resident #1 to be at the end of the West hall when she went into another resident's room to provide care. CNA #10 completed the other resident's care and without hearing any emergency door alarms, exited the room approximately seven (7) minutes later without seeing Resident #1 in the hall. Interview with CNA #10 who was assigned to the resident on [DATE] from 7:00 AM until 3:00 PM and CNA #11 who was assigned to the resident on [DATE] from 3:00 PM until 11:00 PM, revealed they did not check on the resident or provide care because they were told by Registered Nurse (RN) #2, the resident was out of the facility with family. Interview with staff also revealed the facility's door alarm system had malfunctioned on [DATE] and at approximately 2:30 PM it was identified a breaker had tripped and was reset by maintenance at that time. However, staff failed to check the facility's doors to ensure all door alarms were engaged. Resident #1 was identified as missing between 8:00 PM and 8:15 PM and was found at approximately 9:46 PM, deceased on the second floor West wing emergency exit stairs landing, nine (9) steps down from the exit door. Interview revealed it was determined the alarm on the West wing door was disengaged by the alarm malfunction that occurred earlier on [DATE]. In addition, observation on [DATE], revealed an unattended medication cart located outside of Room 130, with a Symbicort Inhaler medication in an open box, lying on the top of the medication cart, accessible to Unsampled Resident A, residents, unauthorized staff, and/or visitors. The facility's failure to have an effective system to provide supervision and monitoring to prevent accidents and to maintain a safe environment has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An Acceptable Credible Allegation of Compliance (AOC) was received on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. On [DATE], the State Survey Agency verified the Immediate Jeopardy was removed on [DATE], as alleged, with remaining non-compliance at 42 CFR 483.25 Quality of Care, F-323 at a Scope and Severity (S/S) of a D while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes to maintain an environment as free of hazards as possible and to ensure adequate supervision to prevent accidents. The findings include: 1. Review of the facility's five (5) day Final Report submitted to the State Survey Agency, dated [DATE], revealed Resident #1 was noted to be missing on [DATE], when the Charge Nurse contacted his/her family and was told the resident was not with them. The facility immediately began a missing person search per the facility's policy. Per the facility's Final Report, the family, Director of Nursing (DON), Administrator, other staff and Police were notified. A search was conducted both outside and inside the facility with Resident #1 found deceased by facility staff at approximately 9:40 PM in the West hall stairwell. Continued review, revealed Resident #1 was seen on the facility's surveillance video on [DATE] at 11:21 AM, alone and was self-propelling his/her electric wheel chair down the West hall with no other residents or staff in the hall. Further review of the facility's five (5) day Final Report revealed the facility's investigation indicates a suicide. Review of the Preliminary Police Report, dated [DATE], revealed the Police Department was dispatched for a report of a missing handicapped adult male around 8:30 PM. Continued review revealed staff reported they had searched the facility several times. Per the Report, police on the scene requested assistance from the Fire Department for the search. A Police Officer and the DON began to watch the security video and was able to identify the resident on surveillance footage at 10:40 AM, 10:43 AM and last at 11:22 AM. Per the Report, Resident #1 was found at 9:46 PM on a middle landing between two (2) flights of steps. It was noted on the Report, Resident #1 had been there for a while. Per the Report, Resident #1 was found lying face up with his/her motorized wheelchair on his/her chest. Resident #1 was noted to be cold, stiff, purple in color, and had no pulse. Interview with the Coroner, on [DATE] at 3:49 PM, revealed the Coroner's office did respond to the facility on [DATE]. Further interview revealed Resident #1 was found deceased lying in a stairwell. The Coroner revealed Resident #1's body was sent for an autopsy and final results of the autopsy would not be completed for six (6) to eight (8) weeks. Continued interview revealed, per his observation only, Resident #1 did not die from the fall itself because there was a pooling of blood and had he/she died instantly there would have been an oozing of blood; however, the autopsy was not complete at the time of the interview. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Chronic Pai[DIAGNOSES REDACTED], Peroneal Muscle Atrophy, Anxiety State, Depression, Peripheral Vascular Disease, and Acute Respiratory Failure with Hypercarbia with Hypercapnia (abnormally elevated carbon dioxide levels in the blood). Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact. Further review revealed the facility assessed the resident as having no evidence of an acute change in mental status from the resident's baseline, and no mood distress or behaviors. Per the MDS, the facility assessed the resident to require extensive assistance in Activities of Daily Living (ADL's), to have functional limitation of range of motion (ROM) and impairment to both right and left upper and lower extremities, and to require the use of a wheel chair for mobility. Review of Resident #1's Comprehensive Care Plan, initiated [DATE], revealed the resident was at risk for injury/falls as evidenced by impaired mobility, Muscle Dystrophy and use of mechanical wheel chair with seatbelt and mechanical lift. Interview with CNA #10, on [DATE] at 6:38 PM, revealed she was the CNA responsible for Resident #1's care on [DATE] from 7:00 AM to 3:00 PM. She stated on [DATE] around 10:30 AM, she assisted Resident #1 out of bed and with getting dressed. CNA #10 served Resident #1 cereal and soda (per resident preference) in his/her room and filled his/her oxygen tank. CNA #10 further stated Resident #1's mood had not changed from his/her baseline and she detected no increased depression or reason for concern. CNA #10 revealed she had observed Resident #1 around 11:20 AM sitting in his/her electronic wheel chair in the second floor West hall when she went into another resident's room to provide care. CNA #10 further revealed she spent approximately seven (7) minutes providing care to another resident and upon exiting the resident's room, she did not observe Resident #1 in the hall. Further interview with CNA #10, revealed when Resident #1's lunch was served; she did not see the resident and reported this to Registered Nurse (RN) #2. CNA #10 stated RN #2 advised her Resident #1 was out of the facility with family. Additionally, CNA #10 revealed she advised CNA #11, in her resident report at the 3:00 PM shift change, Resident #1 was out of the facility with family. Interview with CNA #11, on [DATE] at 6:06 PM, revealed she was the CNA responsible for Resident #1 on [DATE], on the 3:00 PM to 11:00 PM shift. Further interview, revealed during shift report on [DATE] at 3:00 PM, Resident #1 was not in his/her room. She stated RN #2 advised her Resident #1 was out of the facility with family. Per interview, CNA #11 spoke with RN #2 around 5:30 PM, when the resident's meal tray was delivered, and again RN #2 advised her Resident #1 was out of the facility with family and would not be back for dinner. CNA #11, stated she entered Resident #1's room around 8:00 PM or 8:15 PM, to pull back the covers on his/her bed, when she discovered the resident's cell phone. CNA #11 revealed she went back to RN #2 and asked her if she was sure Resident #1 was with family because he/she never goes anywhere without his/her cell phone. CNA #11 stated staff called Resident #1's mother and son and was advised he/she was not with family and the staff immediately began to search for the resident. The State Survey Agency made several attempts to contact RN #2; however, RN #2 did not answer calls or return calls for an interview. On [DATE] at 6:59 PM, two (2) attempts to contact RN #2 were made utilizing a cell phone with a connection made; however, there was an immediate disconnection. A third (3rd) attempt to contact RN #2 was made on [DATE] at 7:01 PM with the connection made, one ring, and then a disconnection. A fourth (4th) attempt was made on [DATE] at 8:44 PM; however, the call was disconnected. A fifth (5th) attempt to contact RN #2 on [DATE] at 7:48 AM was made and the call was completed; however, was then immediately disconnected. The facility attempted to text and call RN #2, for the State Survey Agency without success. Additionally, the Police Department had scheduled an appointment with RN #2 for her to present to the Police Department on [DATE] for an interview. However, per interview with the Law Enforcement Officer #1, RN #2 did not show up. Interview with Resident #1's father, on [DATE] at 11:38 AM, revealed staff called the family on [DATE] at 8:11 PM, and questioned them to determine if Resident #1 was out of the facility with them. Per interview, staff informed the family, they did not know where Resident #1 was. Resident #1's father reported he and his wife lived about two (2) minutes from the facility and they immediately drove to the facility. Further interview revealed upon arrival to the facility, the Administrator and Police had not been notified. Per interview, Resident #1's mother directed staff to call the Police and she (Resident #1's mother), using the resident's cell phone, called the Administrator. Resident #1's father reported during the search, the video surveillance was accessed to determine where Resident #1 was last observed. He reported the video documented Resident #1 to be in the West wing near the emergency exit doors around 11:22 AM. Continued interview revealed after viewing the video, staff checked the emergency exit doors and found him/her. Resident #1's father reported, he went to the door, looked down and saw him/her at the foot of the steps with the electric wheel chair on top of him/her and the oxygen tank still strapped to his/her body. Interview with the Administrator, on [DATE] at 3:50 PM, revealed Resident #1 was identified by the facility as missing on [DATE] around 8:15 PM. Per interview, the facility's surveillance video, revealed Resident #1 was last seen on the facility video on [DATE] around 11:21 AM. Continued interview with the Administrator, revealed per his interviews with staff and review of the video, the door alarms did not alarm to alert staff the exit door had been accessed. Continued interview with the Administrator on [DATE] at 7:05 PM, revealed per the ongoing investigation, there was a lengthy delay in the facility identifying the resident to be missing (last seen on video at 11:22 AM and identified as missing around 8:15 PM). Per the investigation, Registered Nurse (RN) #2, who was responsible for Resident #1's care, had informed CNA #10 and CNA #11, the resident was out of the facility with family. Interview with the DON, on [DATE] at 5:20 PM, revealed she was not on call on [DATE]; however, she did receive notification around 8:27 PM informing her of the missing resident. Per the DON, she responded to the facility immediately arriving around 9:00 PM. Further interview revealed staff, Police and the Fire Department were at the facility upon her arrival with a search in progress. Continued interview with the DON on [DATE] at 6:10 PM, revealed, per her investigation, RN #2 advised CNA #10 and CNA #11 that Resident #1 was out of the facility with family. The DON stated, the nurse was responsible for her resident and if he/she had left the facility, the resident should have been signed out on the Log. Per interview, the DON reported the nurse failed by not knowing where her residents were, by telling other staff the resident was out with family (when he/she was not) and by not following the sign out policy. Continued interview revealed the facility's Resident Sign In/Out Log had not been consistently adhered to and was an unreliable tool to assist staff in confirming a resident's location. Continued interview, on [DATE] at 6:38 PM with CNA #10, revealed she did not refer to the Resident Sign out/in Log because the Log was not consistently adhered to and RN #2 told her the resident was out of the facility with family. CNA #10 further stated staff as a whole did not follow the facility's policy related to signing residents out and in the facility and checking the Sign out/in Log. Review of the facility's policy, titled, Signing Residents Out, 2001 MED-PASS, Inc. revised [DATE], revealed all residents leaving the premises must be signed out. Further review of the facility's policy, revealed a sign-out register was located at each nurses' station and registers must indicate the resident's expected time of return. If staff was to observe a resident leaving the premises, and had doubts about the resident being properly signed out, staff should notify their supervisor at once. Continued review, revealed the Nurse Supervisor/Charge Nurse was responsible for notifying the Dietary Manager when the resident would be away from the facility during meal hours and when the resident returned. Per the Policy, residents must be signed in upon return to the facility. Continued interview with CNA #10, on [DATE] at 6:38 PM, revealed she heard no door alarms during her shift. Per interview, the alarms were loud and she would have heard them had the doors alarmed. Continued interview with CNA #11, on [DATE] at 6:06 PM, revealed after Resident #1 was found deceased , and while she and other staff were at the Police Department, she was told by other staff, the doors had been unlocked and malfunctioning earlier in the day and the Administrator was aware. Interview with the Administrator, on [DATE] at 3:50 PM, revealed he had been called to the facility earlier on [DATE], for a mulch fire. The Administrator stated he entered the facility through the front doors and they were not operating normally, and he did not have to use a code to access entrance. Further interview revealed he exited the facility through a back door without entering a code and the door did not alarm. Continued interview revealed he verbally told the Maintenance Director the doors had opened without the use of the code. Further interview revealed he should have checked all the doors, or directed someone to check the doors. However, all the doors were not checked to ensure the alarms were functioning. Review of the facility's policy, titled, Elopement Protocol effective [DATE], revealed the facility would ensure any monitoring devices were operational and maintained. Further review revealed the Maintenance Director/designee, under the supervision of the Administrator, would check each door alarm periodically. Per the policy, if a problem was noted with the door alarm, the facility would post a staff member at the exit until the door alarm was functional. Interview with RN #3, on [DATE] at 3:35 PM, revealed on [DATE] around 2:30 PM, she identified the alarmed door on the first floor in the Library area to be malfunctioning. RN #3 revealed she was able to push the door open without utilizing a code and the door did not alarm. Continued interview revealed she immediately notified the Maintenance Director of the malfunction. Further interview revealed she did not know how long the door had been malfunctioning or if any other doors were affected. Per interview, RN #3 did not notify staff to check the location of the residents, and did not have a staff member stay at the door until Maintenance checked the door and was not advised to do so; however, in hindsight, she stated she should have per the facility's policy. Review of the Maintenance Director's calendar, listing work requested and completed, revealed on [DATE], RN #3 called him to the facility for no door alarm working found 2nd floor #35 breaker off. Continued review of the calendar, revealed he advised RN #3, the alarms were back in place. Further review revealed he checked the smoke doors and magnet door with her and they were OK. Interview with the Maintenance Director, on [DATE] at 2:30 PM, revealed RN #3 called him to the facility on [DATE] around 2:30 PM, due to the doors in the Library malfunctioning. Further interview, revealed upon arrival to the facility, he checked the electrical circuit panel and identified breaker #35 to be tripped. Per interview, he re-set the breaker and checked the Library door, found the door functioning, and left the facility. Continued interview, revealed he did not complete an alarm check of all doors; however, upon finding the system malfunctioning, all the doors should have been checked. Interview, on [DATE], at 3:50 PM, with the Administrator, revealed the Maintenance Director would have specific information regarding the alarmed doors. Interview, on [DATE], at 12:52 PM with the Maintenance Director, revealed the facility did not have a policy to periodically check or service the alarmed doors and he was unaware of a contract with an outside company for monitoring, service or maintenance of the alarmed doors. However, review of the facility's policy titled, Elopement Protocol effective [DATE], revealed the Maintenance Director/designee, under the supervision of the Administrator, would check each door alarm periodically. Observation, on [DATE] at 12:49 PM, revealed the electrical circuit breaker #35 was intentionally tripped by the Maintenance Director and witnessed by the Administrator, Law Enforcement Officer #1 and the State Survey Agency. Observation of the second floor West wing exit doors, which Resident #1 exited through on [DATE], revealed during the time the electrical breaker was tripped, with no electrical power to the alarm system, there was no power to the doors and the alarm did not work. Continued observation revealed the doors opened without the alarm sounding. Further observation, revealed the Administrator leaned against the door and the door opened without the use of the handle and still, no alarm sounded. Continued observation revealed the Maintenance Director removed the alarm panel to expose a nine (9) volt battery connected to the panel. Interview with the Maintenance Director, during the demonstration of the door alarm and battery backup, on [DATE] at 12:49 PM, revealed he had been employed at the facility since [DATE] and was not aware the system had a battery backup function and had not checked or changed the batteries. Further interview revealed he identified the alarm system had a battery backup function on [DATE] at 3:00 AM, during his investigation of the alarm system. He further stated he took an alarm panel apart and found the re-chargeable battery. Continued interview, revealed he did not have documented records or have knowledge of when the batteries were last checked or replaced and had purchased six (6) rechargeable batteries (all that were available locally) just prior to the State Survey Agency's arrival; however, had not installed the new batteries, and was going to order the remainder needed. Interview with the Administrator, during the demonstration of the door alarm and battery backup, on [DATE] at 12:49 PM, revealed he had been employed at the facility since [DATE] and was not aware the system had a battery backup function and was not aware of when the batteries had last been checked or replaced. Further interview revealed he was made aware the system had a battery backup function on [DATE] at 3:00 AM, during the facility's investigation of the system. The Administrator stated he should have been aware in order to ensure the system was serviced and maintained. Continued interview with the Administrator on [DATE] at 2:15 PM, revealed he was not aware the alarm system was malfunctioning on [DATE], because the alarm monitoring company had not called him. However, there was no documented evidence provided of a contract with an alarm monitoring company. Interview with the alarm system Contractor, on [DATE] at 10:44 AM, revealed he did not have a Service Contract with the facility to service and maintain the alarm system. Continued interview, revealed his company did provide Service Contracts to provide service and maintenance to the alarm system; however, the facility declined to enter into a contract. Further interview revealed the facility's alarm system did have a battery backup function and if the battery backup was not tested and serviced per the manufacturer's recommendations, the system's battery backup function may malfunction and not work. The Contractor revealed, should an electrical circuit breaker trip, the battery backup system, when functioning appropriately, would take over and the alarms would have the same sound as on electric power. Review of an Email and Attachments received post survey from the Contractor, on [DATE], revealed the alarm system Manufacturer recommended annual service and for the battery backup to be replaced yearly. Continued interview with the Administrator, on [DATE] at 6:50 PM, revealed he felt this incident involving Resident #1 was an opportunistic suicide. However, further interview on [DATE] at 11:38 AM, with Resident #1's father, revealed Resident #1 was very fearful of tipping over in the wheel chair and stated he/she would never attempt suicide down the stairs, that was a fear. Resident #1's father reported during the colder months, the resident would generally stay in the facility and family would visit there; however, during warmer days, family would sign the resident out of the facility, generally on Sunday, for visits. Resident #1's father revealed the resident had shown no increased signs or symptoms of depression, stating a friend and Resident #1 had a very good visit just days prior and Resident #1 was looking forward to an upcoming visit with his/her six (6) year old granddaughter. Continued interview revealed, he felt Resident #1's hand (with decreased mobility and only able to use two fingers) got caught in the joy stick (power controller) of the wheel chair and was unable to stop the wheel chair from accessing through the unsecured door. Per interview with the Regional Director of Operations, on [DATE] at 7:30 PM, his expectation was for staff to follow the facility's policies and be knowledgeable of the facility's security systems. 2. Review of the facility's policy titled, Storage of Medication dated [DATE], revealed medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review of the policy, revealed medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. Review of Unsampled Resident A's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Unsampled Resident A's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9), indicating the resident had moderate cognitive impairment. Observation, on [DATE] at 9:39 AM, revealed a Symbicort Inhaler (bronchodilator medication to treat Asthma and Chronic Obstructive Pulmonary Disease) medication in an open box, lying on top of an unattended medication cart, with Unsampled Resident A, within reach of the medication cart. Continued observation, revealed the medication cart was unattended for five (5) minutes until Licensed Practical Nurse (LPN) #4 walked up to the medication cart at 9:44 AM. Interview, on [DATE] at 9:44 AM, with LPN #4, revealed the medication cart should not have been left unattended with a resident's medication unsecured. Interview, on [DATE] at 9:50 AM, with the Unit Manager revealed the medication should never had been left on top of the unattended medication cart because residents would have access to a medication which was not prescribed to them. Interview, on [DATE] at 9:55 AM, with the Director of Nursing (DON) revealed the medication should not have been left on top of the medication cart unattended, and staff were to follow facility policy related to storage of medications. Interview, [DATE] at 8:35 PM, with the facility Administrator, revealed it was unacceptable for staff to leave medications on top of unattended medication carts and it was his expectation that facility policies were followed. The facility provided an acceptable Credible Allegation of Compliance (AOC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. Resident #1 no longer resides at the facility. 2. On [DATE], all residents residing in the facility (107 residents) were assessed by the Unit Managers for elopement risk with one (1) resident identified through this process, to be a risk for wandering. 3. On [DATE], residents utilizing an electric wheel chair were assessed by a Physical Therapist or Occupational Therapist, using a Power Operated Vehicle Assessment form. No residents were deemed unsafe. 4. On [DATE], the door protection system was checked by the licensed contractor for Secure Care. 5. On [DATE], the Missing Resident procedure was reviewed and updated by members of the QAPI committee and the Regional Quality Manager. 6. On [DATE] the Resident sign in/out procedure was reviewed by members of the QAPI committee and Regional Quality Manager. 7. On [DATE], the facility QAPI committee changed the review of the door system log, which validate function of doors and delayed egress alarms, from weekly to once daily. This review will be conducted seven (7) days per week by the Maintenance staff and documented on the Magnetic Lock and Delay Egress Alarm Check Long form daily. 8. On [DATE], the Regional Quality Manager provided an educational review of the Resident Signout/procedure for the Staff Development Coordinator, DON and Administrator. 9. On [DATE], the Regional Quality Manager educated the Administrator regarding Missing Resident Process and procedure. 10. On [DATE], education related to the new Missing Resident procedure was provided to the Staff Development Coordinator, DON and Administrator by the Regional Director of Operations. 11. On [DATE], a licensed electrical contractor evaluated the electrical panel. 12. On [DATE], [DATE] and [DATE], the Maintenance Director replaced the re-chargeable back up batteries for the twenty (20) alarm panels. 13. Education was provided by the Staff Development Coordinator to all licensed nurses on [DATE], [DATE] and [DATE] to include resident head counts in shift report to shift report, to confirm whereabouts via search and sign in/sign out log if all residents were not accounted for. 14. On [DATE], [DATE] and [DATE], the Staff Development Coordinator completed face to face class education on the Missing Resident procedure for all facility licensed and unlicensed staff. 15. Education was provided from [DATE] to [DATE], to nursing staff on the facility's procedure regarding residents signing out or being signed out when leaving the facility and signing back in upon return. 16. On [DATE], the Administrator and/or DON and/or Maintenance Director began random Missing Resident Drills with on duty facility staff on all three (3) shifts for three (3) days, then to continue randomly twice weekly for seven (7) days, then weekly for four (4) weeks, then monthly thereafter. The Administrator was reporting the results of the Missing Resident drills to the Regional Quality Manager and Regional Director of Operations daily. 17. On [DATE], a licensed contractor for Secure Care presented a review of the facility's door alarm procedure to include the delayed egress system, battery back-up system, servicing, maintenance of the system and how to check the delayed egress and wander system, for the Administrator and Maintenance Director. 18. On [DATE], the Regional Director of Operations educated Maintenance staff and department heads regarding the delay egress system, battery backup, servicing and maintenance of the system and how to check the delayed egress and wander system. The Administrator to audit the Magnetic Lock and Delayed Egress Alarm Check Log form weekly and reporting the results to the QAPI committee with any discrepancy noted in the audit to be corrected at that time with immediate check of the doors and with re-education to the person conducting the door system review. 19. On [DATE], a letter was sent to the residents' families and/or responsible parties as a reminder of the sign out/in procedure 20. On [DATE], the Quality Assurance Performance Improvement (QAPI) committee reorganized the Missing Resident checklist form with the procedure remaining the same. 21. All newly hired licensed staff after [DATE] will be educated on the shift to shift report during general orientation by the Staff Development Coordinator. 22. On [DATE], the Regional Quality Manager conducted an in-service for the Administrator regarding F-490 and F-323 as it related to a safe resident environment, the Immediate Jeopardies, the Allegation of Compliance, corrective action and auditing related to all areas and his responsibility in each. 23. The door keypad batteries will be changed by the Maintenance staff every six (6) months and record in TELs (maintenance tracking system) when completed. 24. The QAPI Committee met [DATE] and [DATE] with plans to meet again on [DATE] to continue review of audits. 25. The Administrator will oversee and monitor the results of the Missing Resident drills and audits, audits of the Resident sign out/in logs, the door alarm audits, and audit for keypad battery changes, education provided to staff by the Staff Development Coordinator

Based on interview, record review, and review of the facility's policies, it was determined the facility's Administration failed to provide oversight and ensure there was an effective system to implement policies and procedures to ensure the environment was as hazard free as possible. The facility's Administration was aware the secured alarming doors had malfunctioned and did not take action to ensure the facility adhered to established policies. (Refer to F323) On [DATE], at approximately 11:22 AM, Resident #1 was last seen in the facility by Certified Nursing Assistant (CNA) #10 when she observed Resident #1 to be in his/her motorized wheel chair, at the end of the West hall as she entered another resident's room. CNA #10 completed the other resident's care and without hearing any emergency door alarms, exited the room approximately seven (7) minutes later without seeing Resident #1 in the hall. Interview with staff revealed the facility's door alarm system had malfunctioned on [DATE] and at approximately 2:30 PM and it was identified a breaker had tripped and was reset by maintenance at that time. However, staff failed to check the facility's doors to ensure all door alarms were engaged. Resident #1 was identified as missing between 8:00 PM and 8:15 PM and was found at approximately 9:46 PM, deceased on the second floor West wing emergency exit stairs landing, nine (9) steps down from the exit door. Interview revealed it was determined the alarm on the West wing door was disengaged by the alarm malfunction that occurred earlier on [DATE]. The facility Administration's failure to have an effective system in place to ensure policy/procedures were implemented to ensure each resident was free from accident hazards has caused or is likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An Acceptable Credible Allegation of Compliance (AOC) was received on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. On [DATE], the State Survey Agency verified the Immediate Jeopardy was removed on [DATE], as alleged, with the remaining non-compliance at 42 CFR 483.75 Administration, F-490 at a Scope and Severity (S/S) of a D while the facility develops and implements the Plan of Correction (POC) and, the facility's Quality Assurance monitors the effectiveness of the systemic changes to maintain an environment as free of hazards as possible. The findings include: Review of the facility's Administrator Position Description, undated, revealed the purpose of the position was to direct the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care could be provided residents at all times. Further review revealed essential functions of this position included the responsibility of facility management and compliance management. In addition, the essential functions included ensuring excellent care for the resident was maintained by overseeing and monitoring the delivery of patient care services. Review of the facility's policy, titled, Elopement Protocol with an effective date of [DATE], revealed the Maintenance Director/designee, under the supervision of the Administrator, would check each door alarm periodically. Per the facility's policy, if a problem was noted with the door alarm, the facility would post a staff member at the exit until the door alarm was functional. Per interview with the Administrator on [DATE] at 3:50 PM, he verbally notified the Maintenance Director on [DATE] when he entered the front doors, without use of a code and exited the back door without use of a code and without the alarm sounding. The Administrator stated he should have checked all doors or directed someone to check the doors. However, per the facility's policy if a problem was noted with the door alarm a staff member would be posted at the exit until the alarm was functional and interview revealed this was not done. Interview, on [DATE], at 12:52 PM, with the Maintenance Director, revealed the facility did not have a policy related to periodically checking the alarmed doors. However, review of the facility's policy titled, Elopement Protocol revealed the Maintenance Director/designee, under the supervision of the Administrator, would check each door alarm periodically. Continued interview with the Administrator on [DATE], at 12:49 PM, revealed the facility's alarm door system did not operate as functionally designed and it was his expectations for staff to follow the facility's policies. The facility provided an acceptable Credible Allegation of Compliance (AOC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. Resident #1 no longer resides at the facility. 2. On [DATE], all residents residing in the facility (107 residents) were assessed by the Unit Managers for elopement risk with one (1) resident identified through this process, to be a risk for wandering. 3. On [DATE], residents utilizing an electric wheel chair were assessed by a Physical Therapist or Occupational Therapist, using a Power Operated Vehicle Assessment form. No residents were deemed unsafe. 4. On [DATE], the door protection system was checked by the licensed contractor for Secure Care. 5. On [DATE], the Missing Resident procedure was reviewed and updated by members of the QAPI committee and the Regional Quality Manager. 6. On [DATE] the Resident sign in/out procedure was reviewed by members of the QAPI committee and Regional Quality Manager. 7. On [DATE], the facility QAPI committee changed the review of the door system log, which validate function of doors and delayed egress alarms, from weekly to once daily. This review will be conducted seven (7) days per week by the Maintenance staff and documented on the Magnetic Lock and Delay Egress Alarm Check Long form daily. 8. On [DATE], the Regional Quality Manager provided an educational review of the Resident Signout/procedure for the Staff Development Coordinator, DON and Administrator. 9. On [DATE], the Regional Quality Manager educated the Administrator regarding Missing Resident Process and procedure. 10. On [DATE], education related to the new Missing Resident procedure was provided to the Staff Development Coordinator, DON and Administrator by the Regional Director of Operations. 11. On [DATE], a licensed electrical contractor evaluated the electrical panel. 12. On [DATE], [DATE] and [DATE], the Maintenance Director replaced the re-chargeable back up batteries for the twenty (20) alarm panels. 13. Education was provided by the Staff Development Coordinator to all licensed nurses on [DATE], [DATE] and [DATE] to include resident head counts in shift report to shift report, to confirm whereabouts via search and sign in/sign out log if all residents were not accounted for. 14. On [DATE], [DATE] and [DATE], the Staff Development Coordinator completed face to face class education on the Missing Resident procedure for all facility licensed and unlicensed staff. 15. Education was provided from [DATE] to [DATE], to nursing staff on the facility's procedure regarding residents signing out or being signed out when leaving the facility and signing back in upon return. 16. On [DATE], the Administrator and/or DON and/or Maintenance Director began random Missing Resident Drills with on duty facility staff on all three (3) shifts for three (3) days, then to continue randomly twice weekly for seven (7) days, then weekly for four (4) weeks, then monthly thereafter. The Administrator was reporting the results of the Missing Resident drills to the Regional Quality Manager and Regional Director of Operations daily. 17. On [DATE], a licensed contractor for Secure Care presented a review of the facility's door alarm procedure to include the delayed egress system, battery back-up system, servicing, maintenance of the system and how to check the delayed egress and wander system, for the Administrator and Maintenance Director. 18. On [DATE], the Regional Director of Operations educated Maintenance staff and department heads regarding the delay egress system, battery backup, servicing and maintenance of the system and how to check the delayed egress and wander system. The Administrator to audit the Magnetic Lock and Delayed Egress Alarm Check Log form weekly and reporting the results to the QAPI committee with any discrepancy noted in the audit to be corrected at that time with immediate check of the doors and with re-education to the person conducting the door system review. 19. On [DATE], a letter was sent to the residents' families and/or responsible parties as a reminder of the sign out/in procedure 20. On [DATE], the Quality Assurance Performance Improvement (QAPI) committee reorganized the Missing Resident checklist form with the procedure remaining the same. 21. All newly hired licensed staff after [DATE] will be educated on the shift to shift report during general orientation by the Staff Development Coordinator. 22. On [DATE], the Regional Quality Manager conducted an in-service for the Administrator regarding F-490 and F-323 as it related to a safe resident environment, the Immediate Jeopardies, the Allegation of Compliance, corrective action and auditing related to all areas and his responsibility in each. 23. The door keypad batteries will be changed by the Maintenance staff every six (6) months and record in TELs (maintenance tracking system) when completed. 24. The QAPI Committee met [DATE] and [DATE] with plans to meet again on [DATE] to continue review of audits. 25. The Administrator will oversee and monitor the results of the Missing Resident drills and audits, audits of the Resident sign out/in logs, the door alarm audits, and audit for keypad battery changes, education provided to staff by the Staff Development Coordinator and competencies from all audits. Any discrepancy will be corrected by the Administrator requiring further education of staff by the Staff Development Coordinator as indicated. A report of the discrepancies will be submitted by the Administrator to the QAPI Committee and reviewed by the Regional Director of Operations and/or Regional Quality Manager. 26. The Regional Director of Operations or Regional Quality Manager will conduct weekly reviews of the Missing Resident drill audits, the resident sign out/in log and the Magnetic Lock and Delayed Egress Alarm Check Log audits to confirm that the audit function is being performed and reported to the QAPI Committee as needed with follow-up being directed by the Administrator if appropriate until the IJ is verified removed. Thereafter, the monthly QAPI minutes will be reviewed by the Regional Director of Operations or Regional Quality Manager during facility visits to validate that audit function is continuing to be performed and is being reported to QAPI with follow up being directed by the Administrator. 27. Results of the audits, education and drills will be discussed at QAPI Committee meetings, twice monthly, for two (2) months and monthly thereafter for six (6) months. Any corrective action needed will be performed by the DON and/or Maintenance Director and follow-up will be reported at the next QAPI Committee meeting. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Resident # 1 was found deceased in the stairwell at the facility on [DATE] at 9:46 PM. 2. Record review revealed one-hundred and seven (107) residents were assessed. Further review revealed physician's orders [REDACTED]. 3. Review of the Physical Therapist or Occupational Therapist assessments revealed four (4) residents in electric wheel chairs were assessed. 4. Review of the contractors work statement and interview with the Owner of the contract business on [DATE] at 10:45 AM, revealed the Owner validated the door protection system was working properly while on electrical current. 5. Review of the QAPI sign in sheet for [DATE], Missing Resident procedure check list, and interviews on [DATE] with the Staff Development Coordinator at 5:14 PM, the DON at 6:15 PM, the Administrator at 6:50 PM and the Regional Director of Operations at 7:30 PM confirmed the meeting and agenda. 6. Review of the QAPI sign in sheet and agenda for [DATE], revealed the resident sign in/out procedure was reviewed by members of the QAPI committee and the Regional Quality Manager. 7. Review of the log verified the checks were completed on a daily bases for all twenty (20) doors by the Maintenance Staff. 8. Review of the educational sign in sheets, and interviews on [DATE] at 5:14 PM with the Staff Development Coordinator, at 6:15 PM with the DON, and at 6:50 PM with the Administrator, verified they received the education related to the Resident Sign out /procedure. 9. Review of the sign in sheet related to the Missing Resident process and procedure education, and interview with the Administrator on [DATE] at 6:50 PM validated he received the education. 10. Review of the education sign in sheet, and interviews on [DATE] with the Staff Development Coordinator at 5:14 PM, the DON at 6:15 PM, and the Administrator at 6:50 PM validated education related to the new Missing Resident Procedure was provided by the Regional Director of Operations. 11. Review of the licensed Electrical Contractors service documentation, and interview with the Electrical Contractor, on [DATE] at 5:00 PM, revealed he had serviced the electrical panel and was unable to confirm or deny the panel had malfunctioned. Per interview, he took the breaker out of service and re-wired the panel to feed the load of the one (1) breaker into two (2) spare breakers. 12. Interview with the Administrator and Maintenance Director on [DATE] at 12:29 PM, revealed the Maintenance Director had purchased six (6) re-chargeable batteries (all available at the local store) and would order the additional batteries. Observation on [DATE] revealed maintenance changing the rechargeable battery on the alarm panels. 13. Review of education sign-in sheets and interview on [DATE], with Licensed Practical Nurse (LPN) #5 at 9:20 AM, Certified Nursing Assistant (CNA) #1 at 11:05 AM, LPN #3 at 11:35 AM, Registered Nurse (RN) #1 at 11:50 AM, CNA #13 at 12:00 PM, CNA #10 at 2:00 PM, LPN #1 at 2:25 PM, CNA #7 at 4:55 PM, CNA #8 at 5:07 PM, CNA #6 at 5:20 PM, CNA #9 at 5:35 PM, Unit Manager (UM) #2 at 5:45 PM, CNA #4 at 6:35 PM, RN #4 at 6:55 PM, RN #5 at 7:10 PM and LPN #6 at 7:40 PM, revealed they had all received education related to resident head counts in shift to shift report, to confirm whereabouts via search and sign in/sign out log if all residents were not accounted for. 14. Review of the sign in sheet for education provided on [DATE], [DATE] and [DATE] related to the Missing Resident procedure, and interview on [DATE] with Licensed Practical Nurse (LPN) #5 at 9:20 AM, Certified Nursing Assistant (CNA) #1 at 11:05 AM, Central Supply Staff #14 at 11:25 AM, LPN #3 at 11:35 AM, Registered Nurse (RN) #1 at 11:50 AM, CNA #13 at 12:00 PM, CNA #10 at 2:00 PM, LPN #1 at 2:25 PM, Assistant Environmental Supervisor #1 at 2:57 PM, House Keeping Staff #13 at 2:45 PM, CNA #7 at 4:55 PM, CNA #8 at 5:07 PM, CNA #6 at 5:20 PM, CNA #9 at 5:35 PM, Unit Manager (UM) #2 at 5:45 PM, CNA #4 at 6:35 PM, RN #4 at 6:55 PM, RN #5 at 7:10 PM, and LPN #6 at 7:40 PM, revealed they had all received education on the Missing Resident procedure. 15. Review of the sign in sheet for the sign in and sign out education, and interview, on [DATE] with Licensed Practical Nurse (LPN) #5 at 9:20 AM, Certified Nursing Assistant (CNA) #1 at 11:05 AM, LPN #3 at 11:35 AM, Registered Nurse (RN) #1 at 11:50 AM, CNA #13 at 12:00 PM, CNA #10 at 2:00 PM, LPN #1 at 2:25 PM, CNA #7 at 4:55 PM, CNA #8 at 5:07 PM, CNA #6 at 5:20 PM, CNA #9 at 5:35 PM, Unit Manager (UM) #2 at 5:45 PM, CNA #4 at 6:35 PM, RN #4 at 6:55 PM, RN #5 at 7:10 PM, and LPN #6 at 7:40 PM, confirmed they had received the education related to residents signing out or being signed out when leaving the facility and signing back in upon return. 16. Review of the Missing Resident drill sheets validated the first three (3) drills. Interview on [DATE] with Licensed Practical Nurse (LPN) #5 at 9:20 AM, Certified Nursing Assistant (CNA) #1 at 11:05 AM, Central Supply Staff #14 at 11:25 AM, LPN #3 at 11:35 AM, Registered Nurse (RN) #1 at 11:50 AM, CNA #13 at 12:00 PM, CNA #10 at 2:00 PM, LPN #1 at 2:25 PM, Assistant Environmental Supervisor #1 at 2:57 PM, House Keeping Staff #13 at 2:45 PM, CNA #7 at 4:55 PM, CNA #8 at 5:07 PM, CNA #6 at 5:20 PM, CNA #9 at 5:35 PM, Unit Manager (UM) #2 at 5:45 PM, CNA #4 at 6:35 PM, RN #4 at 6:55 PM, RN #5 at 7:10 PM, and LPN #6 at 7:40 PM, revealed they had been involved with the Missing Resident drills. Review of the results of the Missing Resident drills, revealed the drills were validated by signature of Regional office. Interviews on [DATE] with Regional Director of Operations at 7:30 PM, and Regional Quality Manager at 7:50 PM, verified they had reviewed the results of the Missing Resident drills. 17. Review of the licensed contractor's service visit documentation, dated [DATE], and interview with the Owner of the contractor company, on [DATE] at 10:46 AM, validated a review of the system. 18. Review of the educational sign in sheet for [DATE], and interview on [DATE] with the Staff Development Coordinator at 5:14, the DON at 6:15 PM and the Administrator at 6:50 PM, validated the education was provided by the Regional Director of Operations. Record review revealed audits were completed by the Administrator to date. 19. Record review revealed the letters to the residents' families and responsible parties of the reminder of procedure to sign in/out the resident was sent on [DATE]. 20. Review of the Missing Person Checklist form revealed the checklist had been revised to a one (1) sheet (front and back) check sheet with each area to search listed and a space to enter the staff that was assigned to search that area. The check sheet was listed in the order the areas were to be searched. 21. Review of the New Hire Orientation packet, and interview with the Staffing Development Coordinator on [DATE] at 5:14 PM validated education of newly hired licensed staff. 22. Review of the in-service education, dated [DATE], and interview with the Administrator on [DATE] at 6:50 PM, validated he received the education. 23. Interview with the Maintenance Director on [DATE] at 4:07 PM, revealed the manufacturer recommended the batteries be replaced every year; however, the facility scheduled battery replacement for the door alarms every six (6) months in the TELs system. 24. Review of the QAPI sign in sheets and agenda, validated the committee met on [DATE] and [DATE]. 25. Interview on [DATE] at 6:50 PM, with the Administrator verified his plans and his process to audit, review and report to QAPI. Further interview revealed his Regional Director of Operations and Region Quality Manager would be conducting weekly reviews during their facility visits. 26. Interview on [DATE] at 6:50 PM, with the Administrator, at 7:30 PM, with the Regional Director of Operations, and at 7:50 PM, with the Regional Quality Manager, validated the Regional Director of Operations and the Regional Quality Manager would conduct weekly reviews of the Missing Resident drill audits, the resident sign out/in log and the Magnetic Lock and Delayed Egress Alarm Check log audits to confirm the audit function was being performed and reported to the QAPI Committee as needed with follow up being directed by the Administrator. 27. Interview on [DATE] at 6:50 PM, with the Administrator, revealed the committee would meet the second and fourth Wednesday of the month. The agenda for the upcoming meetings had not been developed as it would be based on the incident, audits and facility needs.

Based on interview, record review, review of the Resident Assessment Instrument (RAI) User Manual Version 3.0 and the facility's Incident Reports, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of four (4) sampled residents (Resident #2). Resident #2's Comprehensive Care Plan included an intervention for the resident to be transferred with extensive assist of two (2) staff. However, on 03/18/15, State tested Nursing Assistant (STNA) #1 assisted Resident #2 with transferring from a sitting position to a standing position without assistance after the resident's shower. After transferring Resident #2 to stand, STNA #1 asked the resident to hold onto a grab bar while she obtained a brief and lotion. STNA #1 turned away from Resident #2, leaving the resident standing unassisted holding onto the grab bar. While Resident #2 was standing at the grab bar unsupervised the resident fell hitting his/her back on the bathroom sink counter, and his/her wrist on the trash can, and landed in a sitting position on the floor. Resident #2 was transferred to the hospital emergency room (ER) where the resident was diagnosed with [REDACTED]. (Refer to F323) The findings include: A policy related to Comprehensive Care Plans was requested several times; however, none was received. On 03/27/15 at 10:00 AM, interview with the Director of Nursing (DON) revealed the facility did not have a written policy regarding care plans. Per the DON, the facility utilized the RAI process for residents' Comprehensive Care Plans. Review of the RAI User Manual Version 3.0, May 2011, revealed the Interdisciplinary Team (IDT) was to develop the Comprehensive Care Plan based on the results of the comprehensive assessment. Review revealed the IDT and resident and/or resident's representative determined the areas requiring care plan interventions for development, revision or continuance of the individualized care plan. Per the User Manual, a fall referred to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an external force. Further review revealed the care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. However, further review revealed the RAI process did not address the implementation of residents' Comprehensive Care Plans. Further interview, on 03/31/15 at 4:50 PM, with the DON revealed nurses and STNAs received education in orientation and as needed throughout the year related to care plans to include ensuring they followed residents' care plans. Record review revealed the facility admitted Resident #2 on 03/20/14, with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#2 was to be transferred with the assistance of two (2) for safety. Review of Resident #2's Comprehensive Care Plan dated 10/02/14, revealed the facility had care planned Resident #2 for potential risk for falls and related injuries related to a history of falls, impaired mobility, cognitive loss and a history of an ORIF to the left hip. Continued review of the risk for falls care plan revealed interventions which included two (2) person assist with transfers. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 as being severely cognitively impaired, and to require extensive physical assistance of two (2) staff for transfers. Review of the Falls Risk Data Set information, dated 01/29/15 at 3:24 PM, revealed the facility assessed Resident #2 to be a high falls risk related to need of maximum assist of two (2) staff for transfers, severe cognitive impairment, incontinence, poor vision, use of wheelchair and walker, mobility and medications which could increase the risk for falls. Interventions included on the Falls Risk Data Set revealed to transfer Resident #2 with a two (2) person assist, sensor alarms to the resident's bed, wheelchair and floor, and Dycem (a non-slip material used to provide stabilization) above the wheelchair cushion. Review of the Incident Report dated 03/18/15, timed 5:01 PM, completed by Registered Nurse (RN) #2, revealed RN #2 heard a commotion in Resident #2's bathroom and responded. Per the Incident Report, when RN #2 entered Resident #2's bathroom she observed the resident sitting on the floor. RN #2 noted Resident #2 was assessed and observed to have a five (5) centimeter (cm) laceration to the right middle back area, an eight (8) cm abrasion to the left hip are and the resident's left wrist bone was malformed. Continued review revealed the immediate action included vital sign, range of motion (ROM) and pain level assessment, a neurocheck. Review of the Incident Report revealed Resident #2's left wrist was splinted and the resident assisted to bed. Further review revealed the Physician was notified on 03/18/15 at 5:12 PM and Resident #2's family notified on 03/18/15 at 5:15 PM of the incident. Review revealed Resident #2 was going to be transported to the hospital ER per squad 911. Review of STNA #1's written statement dated 03/18/15, which was attached to the Incident Report, revealed STNA #1 noted having given Resident #2 a shower at 5:00 PM, and after assisting the resident into a gown and nonskid socks, she had prompted and asked the resident to stand up and hold onto the bar with both hands. STNA #1 documented Resident #2 stood up, held onto the bar, and then she (STNA #1) asked the resident to stand still and he/she stated okay, okay, okay. Per the written statement, STNA #1 turned around to get a brief and a bottle of lotion and when she turned back toward Resident #2 she saw the resident falling and hitting his/her back on the sink and then falling to the floor in a sitting position. Continued review of the Incident Report revealed the immediate Post-Incident Action noted staff was educated on gathering supplies and having those supplies at hand so staff did not have to take her eyes off of or assistance off of the resident. Further review revealed on the Resident Incident Follow-up, dated 03/19/15, the root cause of the fall was noted to be staff error. Review of an untitled document, dated 03/19/15, revealed it was documentation of an interview conducted with STNA #1 after written statement provided related to incident on 03/18/15, signed by STNA #1. Review of the document revealed STNA #1 was asked if she had had her STNA care plan for Resident #2 on 03/18/15 at the time of the fall. Review revealed STNA #1 reported she could not recall, but stated she had read it (STNA care plan) earlier. Continued review revealed when STNA #1 was asked if she had the care plan memorized to know how to provide care for each of her residents, she stated no. Per the document, when asked how many staff were to transfer Resident #2, STNA #1 revealed she transferred the resident as a one (1) assist everyday. The document noted STNA #1 said she transferred Resident #2 as a one (1) assist related to a discussion she had with another unidentified STNA a few months ago. According to the document, STNA #1 revealed the other STNA told her she walked Resident #2 to the bathroom and helped the resident onto the toilet without assistance from other staff. Further review revealed STNA #1 didn't think Resident #2 needed a two (2) person assist for transfers. The document revealed it was noted STNA #1 reported to the Charge Nurse in January she felt Resident #2 could be a one (1) person transfer. Review of the document revealed even though nothing was changed on Resident #2's care plan, STNA #1 continued to transfer the resident by herself. In addition, review of the document revealed STNA #1 reported lack of help as the reason she had not requested assistance with transferring Resident #2 on 03/18/15 prior to the fall. Review revealed when asked what she meant by that, STNA #1 stated it depended on who her hall partner was, because sometimes they're hard to find. Further review revealed STNA #1 stated she had not asked for assistance from other staff on 03/18/15. Interview, on 03/26/15 at 3:50 PM by phone, with STNA #1 revealed on 03/18/15 she had been assigned to provide care for Resident #2, and was routinely assigned to the resident. She stated on 03/18/15 at approximately 5:00 PM, she had given Resident #2 a shower, and then needed to obtain a brief and lotion for the resident. STNA #1 stated, so she had Resident #2 stand, hold onto a grab bar with both hands and then told the resident not to move. Per interview, she turned away from Resident #2 for a few seconds to get the brief and lotion, and when she turned back around the resident was falling. STNA #1 revealed even though she knew Resident #2 was a two (2) person assist for transfers she didn't think standing the resident up to put a brief on was a transfer. However, STNA #1 stated after the incident she was was told when having residents stand from a seated position it was a transfer. Per STNA #1, she was made aware she should have followed the care plan and had assistance in transferring Resident #2 into a standing position, and not had the resident standing unassisted while she got supplies. STNA #1 stated STNAs had care plans for each resident which included the amount of assistance their assigned residents required. Further interview revealed she should have transferred Resident #2 with a two (2) person assist as the care plan stated. Interview, on 03/26/15 at 3:40 PM, with RN #2, revealed she was the nurse assigned to Resident #2's care on 03/18/15 on the evening shift. RN #2 stated she heard a commotion coming from Resident #2's room and ran into the room where she found Resident #2 sitting on the bathroom floor, with STNA #1 also present in the bathroom. Further interview revealed after reviewing Resident #2's care plan she discovered the resident was a two (2) person assist with transfers. RN #2 stated she then realized STNA #1 had not followed Resident #2's care plan; however, the STNA should have ensured she had assistance when transferring the resident, as per the care plan. Interview, on 03/29/15 at 3:44 PM, with Licensed Practical Nurse (LPN) #2 revealed she was the House Supervisor on the evening of 03/18/15 at the time of Resident #2's fall. Continued interview revealed STNA #1 reported having just given Resident #2 a shower, helped the resident stand and told him/her to hold onto the bar. She revealed the STNAs had a care plan to follow for the amount of assistance required for transfers, and other activities of daily living (ADLs). LPN #2 stated STNAs were supposed to follow residents' care plans. Interview, on 04/01/15 at 5:00 PM, with STNA #6 by phone, revealed Resident #2 required a two (2) person assist with transfers; however, STNA #1 had not asked her for assistance after the resident's shower. Continued interview revealed she was no longer employed at the facility, but when she had worked there the STNAs were supposed to follow the STNA care plans for residents' care needs and the amount of assistance they required for transfers and other care. Interview on 03/26/15 at 9:10 AM with STNA #2, and at 12:00 PM with STNA #4, revealed STNAs had care plans they were to refer to regarding the care and assistance residents required. Interview, on 04/01/15 at 11:35 AM, with STNA #7 revealed she had cared for Resident #2 in the past and knew the resident required a two (2) person assist for transfers which was on the STNA care plan. Per interview, STNAs were supposed to follow the care plan to know the assistance required. According to STNA #7, education on care plans was provided during orientation and on the computer periodically. STNA #7 stated STNAs were to carry the residents' care plan on their person at all times. Continued interview the STNA care plans were updated daily by the Unit Managers (UM) for any necessary changes. Per STNA #7, STNAs could not make changes to a resident's STNA care plan, but could tell the nurse if they felt a change was needed. She stated however, a STNA should never change anything about a resident's care unless it had been changed on the care plan. Interview, on 04/01/15 at 12:20 PM, with LPN #4 revealed the care plans for residents should always be followed. Per interview, if a resident's Comprehensive Care Plan and STNA Care Plan had an intervention to transfer with a two (2) person assist, then the intervention should be followed when the resident was being transferred. Interview, on 04/01/15 at 9:30 AM, with RN #4 revealed the nursing staff were educated on hire and periodically throughout the year on care plans. Continued interview revealed STNAs could not make a determination on changes in a resident's transfer assistance, should ensure they follow the care plan exactly as it said unless it was changed by the Interdisciplinary Team (IDT). Interview, on 04/01/15 at 12:23 PM, with the Unit II Manager, and at 12:26 PM with the Unit I Manager, revealed staff should always follow the residents' Comprehensive Care Plans, Immediate Care Plans, and STNA Care plans when caring for residents. Further interview revealed if a resident was care planned to be transferred with assist of two (2) persons, then staff should not transfer the resident with less than two (2) people. The Unit I Manager revealed if a STNA felt a resident's assistance needs with transfers required changing they should report this to a nurse who would then discuss it in the facility's morning triage meeting and the IDT meeting. Per interview, the therapy department would have to evaluate the resident and make a decision regarding the transfer assistance; however, the amount of assistance a resident required with transfers would not change until the care plan was updated with the change. Interview on 04/01/15 at 11:44 AM with the MDS Nurse and at 11:54 AM with the MDS Coordinator, revealed they were responsible for developing, updating, and revising Comprehensive Care Plans and the nurses had responsibility for Immediate Care Plans for an acute need. Per interview, if a resident was care planned with an intervention for two (2) person assist with transfers, then staff should follow the care plan when transferring the resident. Interview, on 04/01/15 at 9:58 AM, with the DON, revealed all facility nurses were educated during orientation and as needed on residents' Comprehensive Care Plans, Immediate Care Plans, and STNA care plans. Per interview, STNAs were educated during orientation and as needed on STNA care plans which included ensuring they followed the care plan. A copy of the STNA education material titled, CNA POC was provided by the DON. The education material stated STNA care plans must be followed, and stated STNAs could not make decisions to use less assistance for care than the care plan stated was required. Continued interview with the DON on 04/01/15 at 12:50 PM, revealed she was present in the facility on 03/18/15 when Resident #2 experienced the fall. The DON revealed STNA #1 stated she had stood Resident #2 up to a grab bar by herself, then turned her back to get a brief leaving the resident unassisted at the bar. She stated she educated STNA #1 regarding not leaving a resident unassisted to get supplies, and to make sure she had her supplies ready prior to the shower. Per the DON, during the facility's investigation of the fall, it was discovered Resident #2's care plan had an intervention for a two (2) person assist with transfers; however, STNA #1 had transferred the resident to a standing position by herself. She stated STNA #1 was educated and then suspended on 03/19/15 after it was discovered STNA #1 had not followed the care plan and transferred the resident by herself. The DON stated her expectation was for the staff to follow residents' care plans to the letter and if a resident required a two (2) person assist for transfers she expected that to be done. Interview, on 04/01/15 1:56 PM, with the Applicant Administrator revealed he would have expected staff to follow the interventions listed on Resident #2's care plan. However, he stated the staff member involved in Resident #2's case had not transferred the resident with the required two (2) person assist to maintain his/her safety, as per the care plan.

Based on interview, record review and review of the facility's Incident Reports and policy, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #2) received adequate supervision to prevent a fall during a transfer. Resident #2 had a Comprehensive Care Plan which directed the resident to be transferred with extensive assist of two (2) staff. However, on 03/18/15, State tested Nursing Assistant (STNA) #1 assisted Resident #2 with a shower and after completing the shower, transferred the resident from a sitting to a standing position without requesting assistance from other staff, as per the care plan. After STNA #1 transferred Resident #2 from a sitting to a standing position, STNA #1 asked Resident #2 to stand unassisted and hold a grab bar in the bathroom while she (STNA #1) obtained a brief and lotion for him/her. STNA #1 turned away gathering the supplies, and left Resident #2 standing alone and unassisted. While the STNA was turned away, Resident #2 fell to the floor, hitting his/her back on the bathroom sink, and wrist on the trash can during the fall. As a result of the fall, Resident #2 was transferred to the hospital emergency room (ER) on 03/18/15, and diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled, Woodcrest Nursing and Rehabilitation Incident and Accident Program, dated 02/10/13, revealed it was the facility's standard to ensure each resident received adequate supervision and assistive devices to prevent accidents. Per the Policy, adequate supervision was defined as the type and frequency of supervision based on the individual resident's assessed needs. Continued review revealed implementation of the Policy included each resident would be assessed upon admission, readmission, and quarterly for risk of falls and based on assessment findings reasonable and immediate prevention strategies would be taken to reduce the risk of falls for that individual resident. Review of the clinical record revealed the facility admitted Resident #2 on 03/20/14 with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan, with an onset date of 10/02/14, for the potential for falls related to a history of falls, impaired mobility and ORIF of his/her left hip. Continued review revealed the interventions included to transfer the resident with assist of two (2) staff. Review of Resident #2's Annual Minimum Data Set (MDS) assessment dated [DATE], and the Quarterly MDS Assessment, dated 01/16/15, revealed the facility assessed the resident as unable to be interviewed for a Brief Interview for Mental Status (BIMS) score as the resident was rarely/never understood. Continued review revealed the facility assessed Resident #2 as severely cognitively impaired for daily decision making, and to require extensive assistance of two (2) person physical assist for transfers, dressing and toilet use. Per the MDS Assessment, a transfer was defined as how a resident moved between surfaces including to or from a bed, chair, wheelchair, or a standing position. Further review of the MDS Assessment revealed the facility assessed Resident #2 to not be steady and only able to stabilize with staff's assistance with surface-to-surface transfers and when moving from a seated to standing position. Review of Resident #2's most recent Falls Risk Data Set assessment tool, dated 01/29/15 at 3:24 PM, revealed a score of thirteen (13) which indicated the resident was a high falls risk. Continued review revealed Resident #2's score was based on the following: severe cognitive impairment; maximum assist of two (2) for transfers; poor vision; daily incontinence; mobility in his/her chair; use of a wheelchair and walker; and a prescribed medication which could increase the risk for falls. Further review of the Falls Risk Data Set revealed the comment section noted interventions which included transferring the resident with a two (2) person assist, Dycem (a non-slip stabilizing material) above the wheelchair cushion, and sensor alarms to the bed, wheelchair, and floor. Review of the physician's orders [REDACTED].#2 was to be transferred with the assistance of two (2) for safety. Review of the Incident Report dated 03/18/15 at 5:01 PM, completed by Registered Nurse (RN) #2, revealed the RN documented hearing a commotion in Resident #2's bathroom and when she entered the bathroom she noted she observed the resident on the floor. Continued review of the Incident Report revealed RN #2 noted she assessed Resident #2 who had a right middle back five (5) centimeter (cm) laceration, a left hip abrasion measuring eight (8) cm , and his/her left wrist bones malformed. Per the Incident Report, under the immediate actions taken section revealed RN #2 noted vital signs were assessed, a neurocheck was performed, pain level and range of motion (ROM) assessed, a splint was applied to the resident's left wrist, and staff assisted Resident #2 to bed where alarms were noted to have been on. Further review revealed the Attending Physician was notified of the incident on 5:12 PM and Resident #2's family notified at 5:15 PM on 03/18/15. In addition, RN #2 noted Resident #2 was to be transported to the hospital ER per Emergency Medical Services (EMS) per 911. Further review of the Incident Report revealed the 24 Hour Follow-up information noted Resident #2 remained hospitalized with fracture of distal ulna and radius (wrist fracture). Review of STNA #1's written statements attached to the 03/18/15 Incident Report revealed STNA #1, documented she had given Resident #2's scheduled shower at 5:00 PM. Per the written statement STNA #1 noted after completing Resident #2's shower she dried the resident and assisted him/her into a gown and slip resistant socks while the resident was seated. STNA #1's written statement revealed she prompted and asked Resident #2 to stand up and hold onto a bar with both hands which he/she did. STNA #1 documented asking Resident #2 to stand still, don't move, and the resident responded saying, okay, okay, okay. According to STNA #1's written statement, she turned around to get a brief and a bottle of lotion leaving the resident standing unassisted at the bar. Per the written statement, when STNA #1 turned back toward Resident #2 she witnessed Resident #2 falling and hitting his/her back on the sink counter and then falling to the floor in a sitting position. STNA #1's written statement further revealed STNA #1 attempted to reach to help Resident #2 during the fall; however, the resident was already sitting on the floor. Continued review of STNA #1's written statement revealed Resident #2 had also hit his/her arm on the trash can, and had yelled, oh my goodness, goodness my arm, my arm it hurts you see. In addition, review of the written statement revealed the nurses came immediately to assess Resident #2 and to check the residents vitals. Further review of STNA #1's written statement revealed no documented evidence of other staff being in the bathroom to assist her with transferring Resident #2, as per the care plan. Additional review of the 03/18/15 Incident Report revealed on 03/19/15 it was determined the root cause of Resident #2's fall was staff error. Continued review revealed on the Resident Incident Follow-up, dated 03/19/15 revealed the root cause of the fall was noted to be staff error. Review of the facility's interview document with STNA #1 obtained after her written statement provided related to incident on 03/18/15, signed and dated on 03/19/15 by STNA #1, revealed STNA #1 couldn't remember if she had her STNA care plan with her on 03/18/15 when she assisted Resident #2. Per the document, STNA #1 stated she had read it (STNA care plan) earlier in the shift on 03/18/15, prior to Resident #2's shower. Review of the interview document revealed when STNA #1 was asked how many staff were required to transfer Resident #2 she revealed she transferred Resident #2 as a one (1) person assist everyday. According to the interview document STNA #1 stated she was told by another unidentified STNA she ambulated Resident #2 to the bathroom by herself, had Resident #2 hold the bar, and transferred Resident #2 to the toilet by herself with no assistance. Per the interview document, STNA #1 stated that was why she thought she could do a one (1) person assist for Resident #2. Continued review revealed STNA #1 stated she did not follow Resident #2's care plan because she didn't think Resident #2 needed a two (2) person assist for transfers. Review revealed it was documented STNA #1 had reported to the Charge Nurse in January that perhaps the resident could be a one (1) person transfer; however, even though nothing was changed regarding the resident's transfers, STNA #1 continued to transfer Resident #2 by herself. Further review of the written interview document revealed STNA #1 stated lack of help as the reason she performed one (1) person assists with Resident #2. Interview with STNA #1, on 03/26/15 at 3:50 PM by phone, revealed she was assigned to Resident #2 on the evening shift of 03/18/15, and was assigned to Resident #2's care routinely. Per interview, she had given Resident #2 a shower on the evening of 03/18/15 at approximately 5:00 PM, after drying the resident, putting a gown and nonskid socks on him/her, she had needed to get a brief and lotion. STNA #1 revealed she had Resident #2 stand up and hold on to a bar in the bathroom with both hands and had told the resident not to move while she retrieved the brief and lotion. STNA #1 stated when she turned back around Resident #2 was falling and was almost to the floor at that time. She revealed she tried to stop Resident #2's fall, but could not get to the resident in time and the resident landed on the floor on his/her bottom in a sitting up position. According to STNA #1, Resident #2 also had hit his/her back on the sink when falling. She reported she immediately pulled the call light in the bathroom and another STNA responded who told her to alert the nurses of the fall, and the nurses came in right away. STNA #1 revealed RN #2 and Licensed Practical Nurse (LPN) #2 assessed Resident #2, and immediately thought the resident's wrist might have been fractured. Per STNA #1, the nurses splinted the resident's wrist to immobilize it with a piece of cardboard and tape. Further interview revealed the Director of Nursing (DON) came in and asked STNA #1 what had happened, and when STNA #1 told her what had happened the DON inserviced her on having the supplies together before showering residents. STNA #1 further revealed Resident #2 was a two (2) person assist for transfers but she didn't think standing Resident #2 up to get the brief on was a transfer. She stated after the incident she was made aware when having residents stand from a seated position it was considered a transfer and she should have followed the care plan and had assistance in transferring Resident #2 into a standing position. The STNA reported she was told she should not have had Resident #2 stand unassisted while she turned away to get supplies. Per STNA #1, she and another STNA transferred Resident #2 back to the bed with a gait belt after the resident was assessed by the nurses. Continued interview revealed the STNAs had care plans for each resident they were given at the beginning of every shift which included assistance required for transfers for each resident. According to STNA #1, Resident #2's STNA care plan indicated the resident was to have assistance of two (2) staff for transfers, and she should have ensured the care plan was followed. She stated she completed her shift on 03/18/15, and worked on 03/19/15 until approximately 10:30 PM, when she was notified by a supervisor the DON wanted to speak with her. Per the STNA, after talking with the DON on the night of 03/19/15, she was suspended until the investigation of the incident was completed. She revealed the DON told her the facility was going to report the incident of Resident #2's fall on 03/18/15 to the State Agency. STNA #1 reported she decided to quit her job at the facility on the following Monday, 03/23/15 due to being upset about the incident which caused injury to a resident. Interview with RN #2, on 03/26/15 at 3:40 PM, revealed she was the nurse assigned to Resident #2 on the evening shift of 03/18/15 when the resident experienced the fall after a shower. Per interview, she was standing at the medication cart and heard a commotion coming from Resident #2's room and ran into the bathroom where she found Resident #2 sitting on his/her buttocks with his/her hands on the floor. RN #2 revealed STNA #1 was also in Resident #2's bathroom as she had just finished giving Resident #2 a shower. Continued interview revealed she assessed Resident #2 immediately while he/she was sitting on the floor and observed Resident #2's left wrist was not in alignment. She reported she instructed STNA #6 to go and notify LPN #2, who was the Charge Nurse that night, to come and assist her. Per RN #2, the DON had been notified and came to Resident #2's room, where the DON and LPN #2 splinted the resident's left wrist with a piece of cardboard and an ace wrap to immobilize the wrist. She reported Resident #2 was repeating over and over, I broke my arm. Further interview revealed LPN #2 called the Physician and received a telephone order for a portable x-ray of the resident's left wrist, left arm, left hand, and left hip. RN #2 reported she called Resident #2's daughter to notify her of the incident and of the physician's orders [REDACTED]. She stated however, the resident's daughter wanted Resident #2 to be sent to the hospital ER where she would meet him/her. Per RN #2, 911 was called and Resident #2 was sent to the ER. RN #2 revealed the DON asked STNA #1 what had happened and the STNA reported the resident was standing and holding the bar in the bathroom and she took her eyes off of him/her for a second to get a brief and the resident fell . According to RN #2, the DON educated STNA #1 immediately on having supplies ready before showering a resident. Further interview revealed it was only after Resident #2 had been transported to the ER, and she was reviewing the resident's care plan that she discovered Resident #2 was supposed to have been a two (2) person assist for transfers. Interview with STNA #6 by phone, on 04/01/15 at 5:00 PM, revealed she was working on the same hall as STNA #1 on the evening of 03/18/15 when Resident #2 experienced the fall. She revealed she responded to Resident #2's call light at approximately the same time as RN #2, which she thought was after 5:00 PM. STNA #6 stated when entering the bathroom she saw Resident #2 on the bathroom floor with STNA #1 also there. Per interview, RN #2 immediately started to assess Resident #2 for injury after STNA #1 explained to RN #2 about the resident's fall. STNA #6 reported Resident #2's wrist appeared fractured from the fall. She stated Resident #2 required a two (2) person assist for transfers; however, STNA #1 had not asked her for assistance to transfer Resident #2 after the shower. Continued interview revealed she notified LPN #2 of RN #2's request for assistance with assessing Resident #2, and obtained the vital sign machine to take to the nurses in Resident #2's room. STNA #6 revealed LPN #2 and the DON splinted the resident's wrist, finished assessing the resident for other injuries and then she and STNA #1 transferred Resident #2 back to bed. Further interview revealed the nurses notified the Physician and Resident #2's family and the resident was transferred to the hospital shortly thereafter. Interview with LPN #2, on 03/29/15 at 3:44 PM, revealed she was working as the House Supervisor on the evening of 03/18/15 when Resident #2 fell . LPN #2 revealed STNA #6 notified her of Resident #2's fall and told her she needed to go to the resident's room. Per interview, when she got to Resident #2's room at approximately 5:30 PM she though, the resident was sitting on the bathroom floor. LPN #2 stated she and RN #2 assessed Resident #2, and she didn't recall the resident complaining of pain at the time, but his/her left wrist appeared to be fractured. Continued interview revealed she learned STNA #1 had just finished giving Resident #2 a shower and the STNA #1 told her she had stood the resident up to the bar in the bathroom and told her to hold on to the bar and then turned around to grab supplies. LPN #2 reported she clarified with STNA #1 her statement of turning around to grab supplies, and STNA #1 stated yes. Per LPN #2, STNA #1 told her she did Resident #2's shower the same way all the time. LPN #2 revealed she went to find something to splint Resident #2's left arm, and asked another nurse to start making copies from the medical record to send with Resident #2 to the hospital. Further interview revealed she and the DON splinted the Resident #2's arm and she and RN #2 finished assessing the resident for injuries. LPN #2 stated she called the Physician and received a telephone order for mobile x-rays; however, when RN #2 notified Resident #2's daughter of the incident she wanted the resident sent to the hospital ER. According to LPN #2, Resident #2 was transported to the hospital ER per 911. LPN #2 revealed she couldn't remember if the DON talked with STNA #1 about the incident while in the resident's room because she was focused on assessing Resident #2 for injuries. Interview with Resident #2's daughter, on 03/25/15 at 9:05 AM, revealed the facility notified her after the resident's fall on 03/18/15 of a staff member having the resident stand and hold a bar while the staff member turned around to get supplies. She reported Resident #2 could only ambulate with a two (2) person assist. Per interview, a facility staff member explained the Physician had been notified and ordered a portable x-ray of Resident #2's wrist, hip, and femur. Resident #2's daughter stated the staff member told her she believed Resident #2's wrist was broken, so she requested Resident #2 be sent to the ER. Further interview revealed Resident #2's wrist was fractured and her left hip was bruised. Resident #2's daughter stated the resident was admitted to a different facility after discharge from the hospital. Interview with the Director of Rehabilitation Services, on 03/27/15 at 11:30 AM, revealed Resident #2 was on therapy services when he/she was initially admitted on [DATE], after having an ORIF procedure done for a Left Hip Fracture prior to admission to the facility. Further interview revealed Resident #2 had never been able to stand without assistance since admission to the facility due to the resident being a falls risk and his/her cognitive deficits. Interview with the DON, on 04/01/15 at 12:50 PM, revealed the DON was in the facility on the evening of 03/18/15, when Resident #2 experienced the fall. She revealed the unit nurses sent an STNA to notify her of Resident #2's fall. The DON revealed she went to Resident #2's bathroom where the nurses were assessing the resident and reported the nurses could tell Resident #2's wrist had been fractured during the fall. The DON reported she assisted with splinting Resident #2's wrist, then questioned STNA #1 about what happened to cause the fall. Per interview, STNA #1 told her she had stood Resident #2 up to a grab bar by herself after the resident's shower, left the resident standing unassisted to turn around to get a brief. The DON revealed she discussed with STNA #1 to never turn her back on the residents during care, and always to have her supplies ready prior to showering residents. Per the DON, during the investigation it was discovered Resident #2 was a two (2) person assist for transfers, and STNA #1 had transferred Resident #2 into a standing position by herself without assistance as per the care plan. She stated STNA #1 was educated on following the STNA care plan, and suspended on 03/19/15 after it was discovered STNA #1 had transferred Resident #2 by herself. The DON stated her expectation was for the staff to follow residents' care plans to the letter, and if a resident required a two (2) person assist for transfers she expected staff to transfer the resident with a two (2) person assist. Further interview revealed she expected the staff to ensure each resident received adequate supervision to prevent accidents, as per the facility's policy. Interview with the Applicant Administrator, on 04/01/15 1:56 PM, revealed in the case involving Resident #2, the staff member, STNA #1, did not transfer the resident with the required two (2) person assist to maintain his/her safety, as per the care plan.

Based on interview, record review, review of the facility's Fax/Incident Reports and policies, it was determined the facility failed to have an effective system to ensure residents remained free from abuse for two (2) of ten (10) sampled residents (Residents #2 and #3). Review of the initial Fax/Incident Report dated 04/27/14, revealed Resident #3 told staff he/she was afraid of Resident #1 who had "touched" him/her on the leg under his/her "dress" twice. Continued review of the Fax/Incident Report revealed Resident #1 was to be "under close watch", and the Director of Nursing (DON) and Administrator had been notified. However, there was no documented evidence the facility implemented interventions on 04/27/14 to protect other residents from potential abuse. Review of Resident #1's Comprehensive Care Plan revealed on 04/28/14 an intervention was added for the resident to be on every fifteen (15) minute checks. However, record review revealed no documented evidence the intervention was implemented on 04/28/14. Continued record review revealed from 04/28/14 through 05/10/14, documentation of the every fifteen (15) minute checks was incomplete and/or undated. Interviews with Certified Nursing Assistants (CNAs) revealed they were not informed of Resident #1 being sexually abusive to Resident #3. Interviews with nurses and CNAs revealed they were not aware Resident #1 had been placed on every fifteen (15) minute checks on 04/28/14. As a result of the facility's failure to monitor Resident #1, other residents were not protected from potential abuse. On 05/10/14, the resident was observed by a staff person to be "groping" another resident, Resident #2, between the legs. Resident #1 was placed on one to one (1:1) supervision and transferred to another facility for further evaluation. The facility's failure to have an effective system in place to ensure residents remained free from abuse was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 05/28/14 and was determined to exist on 04/27/14. The facility was notified of the Immediate Jeopardy on 05/28/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 06/05/14, with the facility alleging removal of the Immediate Jeopardy on 06/04/14. The Immediate Jeopardy was verified to be removed on 06/04/14 as alleged with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-223 at a S/S of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program monitors to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "Abuse Resident to Resident", effective October 2012, revealed all residents had the right to be free from any mental or physical mistreatment. Immediate action was to be taken in any occurrence of a resident to resident altercation with immediate interventions taken to prevent reoccurrence. Continued review of the policy revealed measures included monitoring of residents at the nurses station, one on one (1:1) therapy/activity, and discharge to the hospital for medical evaluation if necessary. Review of the facility's Fax/Incident Report dated 04/27/14 which was faxed to the State Survey Agency revealed Resident #3 told a nurse Resident #1 had "touched" him/her on the leg under his/her "dress" two (2) times and he/she was afraid of Resident #1. Further review of the Report revealed Resident #3 was placed "under close watch" and preventative measures were taken to keep Resident #1 under watch by staff during the investigation. Review of the final five (5) day investigation results Fax/Incident Report dated 05/01/14, for the 04/27/14 incident, revealed "follow-up" with Resident #3 revealed the resident did not recall the incident and had "shown no catastrophic reaction" after the incident. Further review of the final five (5) day Fax/Incident Report revealed Resident #1 denied the incident, was seen by the Psychiatrist, and the facility was to continue to monitor "the situation". Review of the Nurse's Note dated 04/27/14 at 2:21 PM, documented as a "late entry" Note for 9:15 AM that morning, revealed a resident reported Resident #1 had made inappropriate advances at him/her. Continued review of the Note revealed the resident stated Resident #1 had reached up his/her "dress" and attempted to touch him/her. The resident reported this had happened yesterday (04/26/14) and also on a previous day. Review of Licensed Practical Nurse (LPN) #3's written statement, included in the facility's investigation, revealed on 04/27/14 at 9:20 AM, Registered Nurse (RN) #2 informed her Resident #3 told her Resident #1 "tried to touch" him/her on the leg. LPN #3 documented she notified the Director of Nursing (DON) who informed her to interview Resident #3 which she did. LPN #3 noted Resident #3 told her "the big" man/woman had "touched" him/her two (2) times, "putting" a "hand under" his/her gown and reached "more than halfway above" his/her knees on the inner thigh. Further review of the LPN #3's written statement revealed Resident #3 told her he/she was "afraid" of Resident #1 and the "last time" Resident #1 had "touched" him/her was on 04/26/14. Interview, on 05/27/14 at 10:00 AM, with RN #2 revealed she had worked on 04/27/14, and Resident #3 had told her Resident #1 touched him/her. RN #2 stated she told the House Supervisor what Resident #3 reported to her. Interview with LPN #3 on 05/27/14 at 12:30 PM, revealed she was the House Supervisor on 04/27/14. LPN #3 stated she was informed of the incident involving Residents #1 and #3 on 04/27/14. She indicated she called the DON who told her to start the investigation by collecting interviews and to notify the Physician. LPN #3 stated she called the Physician who gave an order to send Resident #1 to the local hospital's Behavioral Unit; however, the Behavioral Unit was full and could not accept the resident. Continued interview revealed she did not ensure the Certified Nursing Assistant (CNA) Worksheets were updated for the CNAs to watch Resident #1 for sexual behavior towards other residents. Interview with CNA #2, on 5/23/14 at 2:50 PM, revealed Resident #3 told her on 04/27/14 that Resident #1 had touched his/her legs and pointed at Resident #1. CNA #2 asked Resident #3 if he/she was okay and the resident replied "no". According to CNA #2, Resident #3 told her Resident #1 put his/her hand up his/her dress, but he/she stopped Resident #1. CNA #1 said she told the Charge Nurse, Registered Nurse (RN) #2, immediately. The CNA stated there was no documentation on the CNA worksheets about Resident #1 having sexual behaviors and the CNAs were only told to "keep an eye on" Resident #1. Interview with CNA #1 on 05/23/14 at 2:30 PM, with CNA #3 on 05/29/14 at 7:15 PM, and with CNA #4 on 05/29/14 at 7:15 PM, revealed nurses had not informed them of Resident #1's sexually abusive behavior toward Resident #3. They stated other CNAs had told them to "watch out for" and "keep an eye on" Resident #1. Interview with CNA #5, on 05/29/14 at 7:00 PM, revealed one (1) time Charge Nurse #12 told her to keep an "eye on" Resident #1 because he/she had tried to put his/her "hand up" Resident #3's "dress". Interview, on 05/23/14 at 3:30 PM, with Registered Nurse (RN) #1, Second Shift House Supervisor, revealed she was told when she worked as the House Supervisor that Resident #1 was "following a lady around"; however, she did not remember the resident's name. RN #1 revealed she was unaware that Resident #1 had sexual behaviors towards other residents. Interview with the Director of Nursing (DON) on 5/22/14 at 3:00 PM, revealed Resident #1 had experienced increased behavior disturbances prior to 04/27/14. The DON stated she was uncertain if she had told the House Supervisor (HS), LPN #3 to start fifteen (15) minute checks on Resident #1 on 04/27/14, after the HS called her at home to report the incident involving Resident #3. She stated she was uncertain when Resident #1 was put on the fifteen (15) minute checks. Review of the medical record revealed Resident #3 was admitted by the facility on 01/17/14, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, 03/17/14, revealed the facility assessed Resident #3 to have A Brief Mental Status (BIMS) score of three (3) which indicated the resident was severely cognitively impaired. Review of Resident #1's medical record revealed the facility admitted the resident on 04/16/13, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #1 to have a BIMS score of nine (9) which indicated the resident was moderately cognitively impaired. Review of Resident #1's Comprehensive Care Plan revealed an intervention was added on 04/28/14 for the resident to be on every fifteen (15) minute checks. However, review of the facility's documentation of the fifteen (15) minute checks for Resident #1, for the period of 04/28/14 through 05/10/14, revealed some of the check sheets were undated and there was inconsistent documentation of the checks. Additionally, review of the fifteen (15) minute check sheets revealed no documented evidence the checks were completed on several days between the dates of 04/28/14 and 05/10/14. Continued review of the Nurse's Note dated 05/10/14 at 2:46 PM, revealed it was a "late entry" Note and at 1:20 PM a staff member reported Resident #1 inappropriately touching another resident, Resident #2. Review of the facility's Fax/Incident Report dated 05/10/14, which was sent to the State Survey Agency, revealed on 05/10/14 at 1:30 PM a staff member observed Resident #1 with his/her hand between Resident #2's legs while both were sitting in the hallway. Interview, on 05/23/14 at 10:15 AM, with the Housekeeping Manager (HM) revealed he witnessed Resident #1 rubbing Resident #2's "crotch" area on 05/10/14. He stated both residents were sitting in their wheelchairs in the hallway and Resident #2's eyes were closed. The HM reported Resident #2 opened his/her eyes when he asked Resident #1 what he/she was doing. Interview, on 05/24/14 at 4:30 PM, with RN #2 revealed on 05/10/14 the HM reported to her Resident #1 was "groping" Resident #2 in the "vagina area". Per interview, she thought Resident #1 might have been placed on fifteen (15) minutes checks a couple of days before the incident on 05/10/14 with Resident #2, but she was not sure. Further review of Resident #1's record revealed a Nurse's Notes for 05/10/14 at 2:46 PM, (late entry for 1:20 PM) which noted "a staff member assigned for one to one monitoring" of the resident and the Power of Attorney (POA) and Physician were notified. Review of the Nurse's Note for 05/10/14 at 6:05 PM revealed the Physician had called with a new order received to send Resident #1 out to the emergency room (ER) for evaluation and treatment. Telephone interview with Resident #1's Psychiatrist on 05/23/14 at 4:35 PM, revealed he did not send the resident out of the facility for the incident on 04/27/14, because the resident's niece did not want him/her sent out of the facility. The Psychiatrist stated it was "not surprising" Resident #1 would "behave sexually inappropriate". According to the Psychiatrist, Resident #1 had a problem with "impulse control" given his/her history. He stated Resident #1 "cannot be fixed". Continued interview revealed he was aware Resident #1 had exhibited verbal and "sexually inappropriate behavior" at the facility in the past towards staff and residents. However, he was "unsure" if Resident #1 had ever been physically sexual towards another resident. However, interview with Resident #1's niece and Power of Attorney (POA), revealed the facility did not "approach" her about sending the resident out of the facility on 04/27/14 after the incident. She stated she had never personally spoken to the Psychiatrist. Interview with the DON on 5/29/14 at 7:25 PM revealed interventions should have been put in place to protect Resident #2 and Resident #3, and to observe how they were coping after the incidents involving Resident #1. The DON stated it was her responsibility to ensure all staff was informed of incidents of abuse. However, staff interviews revealed this was not done. Interview with the Administrator on 05/29/14 at 7:30 PM, revealed he was aware Resident #1's behaviors had exacerbated and was looking for placement for the resident elsewhere. The facility provided an acceptable credible AOC on 06/05/14 that alleged removal of the IJ effective 06/04/14. Review of the AOC revealed the facility implemented the following: 1. The Administrator, DON, ADON and SDN were educated on 05/30/14 by the Regional Director of Operations for Preferred Care Partners, Management Group on Accidents and Supervision on residents must be free from abuse and neglect in order to ensure residents' were protected. 2. The Quality Assurance (QA) Committee reviewed all educational materials and developed a data collection tool on 05/30/14 to validate assessments and Care Plans were being utilized per policy protocol. The tool includes a monitor for aggressive resident behaviors. If aggressive behavior occurs, interventions implemented will be reviewed for effectiveness and a determination if additional interventions are needed will be made. The tool was implemented on 05/30/14 and is ongoing. 3. Resident #3 had a weekly skin assessment completed on 05/03/14, and Resident #2 had a weekly skin assessments completed on 05/16/14. All residents were assessed for the potential to be an abuser, assessments were completed by 06/03/14. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Staff Development Nurse (SDN), and/or the Registered Nurse (RN) Supervisor completed the assessments. Information obtained was used to develop and implement appropriate interventions, and the Care Plans were updated initially by the DON, ADON or the SDN, and will be updated thereafter by RN Unit Managers and Charge Nurses. 4. For any resident to resident allegations, the aggressor is to be removed from the situation and placed on continuous observation until otherwise notified by the DON and/or the Administrator. CNAs will be notified of the continuous observation order via the CNA Care Plan and "Accunurse" (the CNA computer documentation system). Nurses and CNAs were educated on the process by the DON, ADON or SDN, with the education completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. The facility does not use agency staff. 5. The Administrator and the DON educated the ADON, SDN, RN Unit Managers, Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist tool, with the education completed by 06/03/14. The Administrator and the DON will monitor use of the checklist for every abuse investigation. The facility's general orientation for new hires was revised to include the education. 6. Licensed nursing staff were educated on performing assessments, interventions and updating the Care Plan, implementation and use of the Care Plan, the components of accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. The education was provided by the DON, ADON and SDN, and completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 7. All facility staff were educated on identifying and reporting abuse, with a focus on resident to resident sexual aggression, and on resident rights. The education was provided by the DON, ADON and SDN, and was completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 8. The Administrator or the DON will notify the Office of Inspector General, Adult Protective Services, the Ombudsman, and local law enforcement of all sexually aggressive behaviors as required by law and within specified time limits. 9. Educational records will be maintained and will include signatures of attendance, signatures of the education received, and copies of tests designed to determine the effectiveness of the education initiated on 05/30/14 and completed by 06/03/14. 10. The Administrator is charged to administer the facility in a safe and efficient manner to assure the safety of the residents at all times. The Administrator, in conjunction with the DON, ADON and SDN, will assure education is provided and resident care and treatment is delivered in accordance with the Care Plan. Continued evaluation, assessment and Care Plan updates will be used to ensure all residents are safe from harm. 11. Monitoring and utilizing the (QA) Committee data collection tool developed on 05/30/14, is done by the DON, ADON, SDN, RN Unit Managers and RN Supervisors. QA meetings to review the collected data will be held five (5) days per week, and as needed, for thirty (30) days, then weekly for thirty (30) days, then monthly or as needed thereafter. Any identified concerns will be corrected immediately. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the education sign-in sheets revealed the Administrator, DON, ADON and SDN were educated by the Regional Director of Operations on 05/30/14, prior to the administrative team conducting education of all facility staff. Continued review revealed topics covered included supervision of incidents/accidents; abuse reporting; conducting investigations, and reviewing residents who are at risk or cognitively impaired. Interview with the Administrator, on 06/06/14 at 1:30 PM, revealed the Regional Director of Operations performed the education for the DON, ADON, SDN and himself on 05/30/14. The Administrator stated the education was to ensure all residents were free from abuse and the facility was administered in a manner to assist residents to achieve their highest physical, mental and psychosocial well-being. 2. Review of the data collection tool developed by the QA Committee revealed it included, but was not limited to, validation of assessments completed, use of Care Plans, and a monitor of resident behaviors. In addition, in the case of aggressive behaviors, the tool allowed for a review of current interventions for effectiveness and a determination of the need for additional interventions. Interview with the DON and the Administrator, on 06/05/14 at 4:45 PM, revealed the tool was developed and implemented on 05/30/14, and was being used as outlined in the AOC ongoing. 3. Review of Resident #3's record revealed a weekly skin assessment was completed on 05/03/14, with no documented evidence of physical injury. Review of Resident #2's record revealed a weekly skin assessment was completed on 05/16/14, with no documented evidence of physical injury. Review of the facility's implementation documentation binder for the AOC revealed all residents were assessed, care plans were reviewed and updated for residents with identified behaviors, as alleged by the DON, ADON, SDN and RN Supervisor. Interview with the DON, on 06/05/14 at 2:20 PM, revealed she reviewed Resident #3's weekly skin assessment dated [DATE], and Resident #2's weekly skin assessment dated [DATE] and confirmed the residents had no physical injuries documented on those dates. The DON stated all residents in the facility were assessed, and those with behaviors were monitored for the potential to be an abuser, care planned for the behaviors, and any behaviors were documented every shift. In addition, all new admissions were assessed for any history of behaviors and care planned accordingly. 4. Review of the facility's implementation documentation binder for the AOC revealed staff signatures of nurses and CNAs who received the education on residents on continuous supervision, updating and following residents' care plans, use of the Abuse Allegation Checklist and completed post-tests successfully. Continued review revealed all education was provided on or prior to 06/03/14 as alleged. Review of the Abuse Allegation Checklist form utilized by the facility revealed it included removing the aggressor resident and placing the resident on continuous observation. Review of the QA Data Collection tool revealed monitoring included whether staff used the Abuse Allegation Checklist after each incident. Review of the ongoing investigation file for the only resident to resident incident after implementation of the AOC revealed the Abuse Allegation Checklist was used, the aggressor resident was removed from the situation, and 1:1 supervision was initiated and thoroughly documented on. Review of the CNA Worksheet/Care Plan for the resident aggressor revealed it was updated to reflect the increased supervision. Interviews 06/05/14 with CNA #6 at 2:45 PM; CNA #7 at 3:40 PM; and CNA #8 at 3:45 PM, revealed the CNAs education on residents on continuous supervision would be in the "Accunurse" computer system and on the CNA Worksheet/Care Plan. The CNAs reported receiving education related to providing the one on one (1:1) supervision and ensuring they documented the continuous supervision. Interviews 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and, LPN #9 at 3:35 PM, revealed the nurses were educated on use of the Abuse Allegation Checklist, and updating and ensuring the CNAs and they followed residents' care plans. 5. Review of the facility's implementation documentation binder for the AOC revealed education sign-in sheets and post-tests for the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors who attended the education provided by the Administrator and DON. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they educated the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist, on or before 06/03/14. The Administrator and DON stated they were monitoring for use of the Checklist with every abuse investigation. They reported the education had been added to the facility's general orientation for new hires. Interview with RN Supervisor #1, on 06/05/14 at 3:15 PM, revealed she had received the education provided, took a post-test and was knowledgeable about when and how to use the Abuse Investigation Checklist. 6. Review of the facility's implementation documentation binder for the AOC revealed licensed nursing staff received mandatory education related to performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. Review of the Sign-in sheets reflected the nurses' attendance, and their completion of the post-tests which cross-matched with the signatures. Continued review revealed all education was received on or prior to 06/03/14 by the DON, ADON and SDN. Interviews on 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and LPN #9 at 3:35 PM, revealed the nurses confirmed receiving the education on performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents and had taken the post-test afterwards. Interview with the DON on 06/06/14 at 4:45 PM, revealed the education had been provided prior to 06/03/14 as per the AOC for all licensed nursing staff. The DON stated the education had been added to the facility's general orientation for new hires. 7. Review of the facility's implementation documentation binder for the AOC revealed all facility staff had received education on abuse which included identifying and reporting abuse, resident to resident sexual aggression and Resident Rights. Continued review of the binder revealed a master list of employees, education sign-in sheets and post-tests which were cross-referenced to confirm the education. Interview with the SDN on 06/05/14 at 4:30 PM, revealed she had participated in providing education for all facility staff related to abuse and Resident Rights. She stated each Department Head had a list of all staff who still needed to receive the education prior to returning to work and ensured the education was provided before the employee was allowed to work. Interview with the DON, on 06/06/14 at 4:45 PM, revealed the facility ensured all facility staff received the mandatory education on abuse and Resident Rights, as per the AOC, by maintaining a master list of all staff and checking off names as they received the education. She stated a list of all staff on vacation or other leave included their return to work date, and no staff were allowed to be on duty prior to the education being completed. Interviews on 06/05/14 with: Dietary Personnel #1 at 2:00 PM, Dietary Personnel #2 at 2:05 PM; Maintenance Assistant #1 at 2:15 PM; Social Services (SS) Assistant #1 at 2:18 PM; Laundry Personnel #1 at 2:20 PM; Occupational Therapist (OT) #1 at 2:23 PM; LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; CNA #6 at 2:45 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; LPN #9 at 3:35 PM; CNA #7 at 3:40 PM; and, CNA #8 at 3:45 PM revealed they all had attended the mandatory inservices related to abuse and Resident Rights. Those interviewed were able to explain their responsibilities if abuse were observed, reported or suspected. All interviewees were cross-checked to the education sign-in sheets and post-tests. 8. Review of the facility's implementation documentation binder for the AOC revealed an ongoing investigation of a resident to resident altercation, which was not sexual in nature. Review of the investigation documentation revealed all required notifications were made timely in accordance with facility policy and federal and state regulations. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they would ensure notification of the State Survey Agency, Adult Protective Services, the Ombudsman and local law enforcement of all sexually aggressive behaviors as indicated in the AOC. However, they reported no incidents of sexually aggressive behaviors had occurred since the alleged date of compliance, 06/04/14. 9. Review of the facility's implementation documentation binder for the AOC revealed education records included sign-in sheets for all education provided. Continued review revealed staff members were checked off from a master list of all employees in order for the facility to ensure every staff member received the education prior to returning to work. In addition, copies of completed post-tests were available for review and were cross-checked with the sign-in sheets. A review of educational offering agendas revealed all topics included in the AOC were provided. Further review revealed all education was completed prior to or on 06/03/14 as alleged. Interview with the Administrator and the DON on 06/05/14 at 4:45 PM, revealed all the education was mandatory with records being maintained. Interview with the SDN, on 06/05/14 at 4:30 PM, revealed she tracked employee attendance via the sign-in sheets and the master list. She stated she tried to make the inservices interesting to maintain the learners' attention, and utilized post-tests to verify effectiveness of the education. 10. Interview with the Administrator and the DON on 06/06/14 at 1:30 PM, revealed the Administrator was responsible for the overall administration of the facility. He stated his goal was to ensure every resident was safe and staff were knowledgeable regarding providing care according to the written Care Plan. He further stated he had been closely involved with the DON throughout the development and implementation of the AOC, including the monitoring of data collected as part of the QA process. The Administrator stated he and the DON ensured the education was provided. He indicated the facility would continue to evaluate, assess and update residents' Care Plans to ensure all residents were safe from harm. Both the Administrator and the DON stated every action outlined in the AOC had been conducted as alleged. 11. Review of the facility's implementation documentation binder for the AOC revealed residents' behaviors were documented by staff every shift. Continued review revealed QA team members reviewed the collected data daily Monday through Friday. Interview with the DON revealed she reviewed all documented behaviors daily Monday through Friday to ensure the Care Plans were revised to include new interventions as indicated by the exhibited behavior. She stated the data is collected by her, the ADON, SDN, RN Unit Managers and RN Supervisors, with all behaviors reviewed by her.

Based on interview, record review, and review of the facility's Fax/Incident Reports, investigation, and policies, it was determined the facility failed to have an effective system in place to ensure allegations of resident to resident sexual abuse were investigated thoroughly, and to ensure residents were protected from further abuse. The facility's failure affected two (2) of ten (10) sampled residents (Residents #2 and #3). On 04/27/14, Resident #3 reported being touched on the inner thigh under his/her clothes by Resident #1. Resident #3 reported the incident occurred on 04/26/14. The facility initiated their investigation of the incident immediately; however, their actions did not include a physical assessment of Resident #3 for possible injury. Although cognitively intact residents on the unit were interviewed by the facility, non-interviewable residents were not assessed for signs of possible abuse. In addition, the facility revised Resident #1's plan of care to implemented visual checks of the resident every fifteen (15) minutes; however, review of documentation and interviews with staff revealed the checks were not conducted consistently. As a result of the facility's failure to monitor Resident #1, other residents were not protected from potential abuse. On 05/10/14, a staff member observed Resident #1 to have his/her hand between Resident #2's legs. Resident #1 was placed on 1:1 supervision at that time, until transferred to the hospital for further evaluation. The resident was discharged from the facility prior to initiation of the survey, and was not available for observation or interview. (Refer to F-223) The facility's failure to have an effective system in place to ensure allegations of resident to resident sexual abuse were investigated thoroughly, and to ensure residents were protected from further abuse,was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 05/28/14 and was determined to exist on 04/27/14. The facility was notified of the Immediate Jeopardy on 05/28/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 06/05/14, with the facility alleging removal of the Immediate Jeopardy on 06/04/14. The Immediate Jeopardy was verified to be removed on 06/04/14 as alleged with remaining non-compliance at 42 CFR 483.13 Resident Behavior and Facility Practice, F-225 at a S/S of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program monitors to ensure residents are free from abuse. The findings include: Review of the facility's policy, titled "Abuse Resident to Resident" (effective October 2012), revealed all residents had the right to be free from any mental or physical mistreatment. In response to a resident to resident altercation, the facility was to take immediate action to prevent a reoccurrence of the behavior. Continued review of the policy revealed measures included, but were not limited to, monitoring of residents at the nurses station, one on one (1:1) therapy/activity, and discharge to the hospital for a medical evaluation if necessary. Further review of the policy revealed it did not address specific measures to ensure a thorough investigation was conducted, e.g. conducting physical assessments of victim residents or other vulnerable non-interviewable residents. Review of the facility's Fax/Incident Report, dated 04/27/14 and faxed to the State Survey Agency, revealed Resident #3 told a nurse Resident #1 had "touched" him/her on the leg under his/her "dress" two (2) times and he/she was afraid of Resident #1. Further review of the Report revealed preventive measures were taken to keep Resident #1 under watch by staff during the investigation. Review of Licensed Practical Nurse (LPN) #3's written statement, included in the facility's investigation, revealed on 04/27/14 at 9:20 AM, she was informed by Registered Nurse (RN) #2 of an allegation by Resident #3 that Resident #1 "tried to touch" him/her on the leg. LPN #3 documented she notified the Director of Nursing (DON), who informed her to interview Resident #3, which she did. Continued review revealed LPN #3 noted Resident #3 told her "the big" man/woman "touched" him/her two (2) times, by putting his/her hand under Resident #3's clothes, and reached "more than halfway above" his/her knees on the inner thigh. In addition, Resident #3 reported he/she was afraid of Resident #1, and the "last time" Resident #1 touched him/her was on 04/26/14. Further review of the facility's investigation of the incident reported on 04/27/14, revealed no documented evidence cognitively-impaired residents, i.e. those resident with a BIMS score of less than eight (8), were questioned or physically assessed for signs of possible abuse by the alleged perpetrator, Resident #1. Continued review revealed Resident #3 was not assessed for any evidence of sexual assault or other injury after reporting the incident on 04/27/14. Interview with LPN #3 on 05/25/14 at 4:55 PM, revealed she was the House Supervisor on 04/27/14. LPN #3 stated a head to toe physical assessment was not completed on Resident #3 after she learned of the reported incident. Interview with Registered Nurse (RN) #2 on 05/27/14 at 10:00 AM, revealed she was the Charge Nurse on 04/27/14 when Resident #3 reported the incident. She stated she did not perform a head to toe skin assessment on Resident #3 after his/her report because the resident appeared to be okay. Review of Resident #1's Comprehensive Care Plan revealed an intervention was added on 04/28/14 for Resident #1 to be checked by staff every fifteen (15) minutes. However, interviews with Certified Nursing Assistant (CNA) #1 on 05/23/14 at 2:30 PM; CNA #2 on 05/23/14 at 2:50 PM; CNA #3 on 05/29/14 at 4:45 PM; and with CNA #4 on 05/29/14 at 7:15 PM, revealed they were unaware Resident #1 was placed on every fifteen (15) minute checks. In addition, interviews with LPN #2, on 05/29/14 at 4:00 PM; RN #2, on 05/27/14 at 10:00 AM; and, with LPN #3 on 05/25/14 at 4:55 PM, all revealed they were not aware Resident #1 had been placed on 15 minute checks. Review of the facility's documentation of the fifteen (15) minute checks for Resident #1, for the period of 04/28/14 through 05/10/14, revealed some of the check sheets were undated and there was inconsistent documentation of the checks. Interview with the Director of Nursing (DON) on 5/22/14 at 3:00 PM, revealed she was uncertain if she had told the House Supervisor (HS), LPN #3 to start fifteen (15) minute checks on Resident #1 on 04/27/14, after the HS called her at home to report the incident involving Resident #3. She also stated she was uncertain when Resident #1 was put on the fifteen (15) minute checks. The DON indicated she did not know why the records for the fifteen (15) checks were so inconsistent and not dated. She commented there were periods of time when there was no documentation of the checks. The DON stated "if it was not documented it was not done". Review of the facility's Fax/Incident Report dated 05/10/14, which was sent to the State Survey Agency revealed on 05/10/14 at 1:30 PM a staff member observed Resident #1 with his/her hand between Resident #2's legs while both were sitting in the hallway. Interview, on 05/24/14 at 4:30 PM, with RN #2 revealed on 05/10/14 the Housekeeping Manager (HM) reported to her Resident #1 was "groping" Resident #2 in the "vagina area". Continued interview with RN #2 on 05/27/14 at 10:00 AM, revealed she was the Charge Nurse on 05/10/14 when Resident #1 was observed by the staff member with his/her hand between Resident #2's legs. She stated she did not perform a head to toe skin assessment on Resident #2. She further stated the resident seemed to be okay. Further interview with the DON, on 05/29/14 at 5:35 PM, revealed the nurses on the units were responsible for ensuring the fifteen (15) minute checks were done. She stated the direction for the checks should have been passed from shift to shift during report. Continued interview revealed she could not understand how any of the nurses could not have known about the checks. Subsequent interview with the DON, on 5/29/14 at 7:25 PM, revealed interventions should have been put in place to protect Resident #2 and Resident #3, and to observe how they were coping after the incidents involving Resident #1. The DON revealed head to toe physical assessments were not done on Resident #2 and Resident #3 immediately after the incidents; however, she stated they should have been. Interview with the Administrator on 05/29/14 at 7:30 PM, revealed he knew the fifteen (15) minute checks were implemented, but was unaware the checks were not being done consistently. Continued interview with the Administrator revealed everything had been done to protect the residents. The facility provided an acceptable credible AOC on 06/05/14 that alleged removal of the IJ effective 06/04/14. Review of the AOC revealed the facility implemented the following: 1. The Administrator, DON, ADON and SDN were educated on 05/30/14 by the Regional Director of Operations for Preferred Care Partners, Management Group on Accidents and Supervision on residents must be free from abuse and neglect in order to ensure residents' were protected. 2. The Quality Assurance (QA) Committee reviewed all educational materials and developed a data collection tool on 05/30/14 to validate assessments and Care Plans were being utilized per policy protocol. The tool includes a monitor for aggressive resident behaviors. If aggressive behavior occurs, interventions implemented will be reviewed for effectiveness and a determination if additional interventions are needed will be made. The tool was implemented on 05/30/14 and is ongoing. 3. Resident #3 had a weekly skin assessment completed on 05/03/14, and Resident #2 had a weekly skin assessments completed on 05/16/14. All residents were assessed for the potential to be an abuser, assessments were completed by 06/03/14. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Staff Development Nurse (SDN), and/or the Registered Nurse (RN) Supervisor completed the assessments. Information obtained was used to develop and implement appropriate interventions, and the Care Plans were updated initially by the DON, ADON or the SDN, and will be updated thereafter by RN Unit Managers and Charge Nurses. 4. For any resident to resident allegations, the aggressor is to be removed from the situation and placed on continuous observation until otherwise notified by the DON and/or the Administrator. CNAs will be notified of the continuous observation order via the CNA Care Plan and "Accunurse" (the CNA computer documentation system). Nurses and CNAs were educated on the process by the DON, ADON or SDN, with the education completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. The facility does not use agency staff. 5. The Administrator and the DON educated the ADON, SDN, RN Unit Managers, Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist tool, with the education completed by 06/03/14. The Administrator and the DON will monitor use of the checklist for every abuse investigation. The facility's general orientation for new hires was revised to include the education. 6. Licensed nursing staff were educated on performing assessments, interventions and updating the Care Plan, implementation and use of the Care Plan, the components of accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. The education was provided by the DON, ADON and SDN, and completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 7. All facility staff were educated on identifying and reporting abuse, with a focus on resident to resident sexual aggression, and on resident rights. The education was provided by the DON, ADON and SDN, and was completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 8. The Administrator or the DON will notify the Office of Inspector General, Adult Protective Services, the Ombudsman, and local law enforcement of all sexually aggressive behaviors as required by law and within specified time limits. 9. Educational records will be maintained and will include signatures of attendance, signatures of the education received, and copies of tests designed to determine the effectiveness of the education initiated on 05/30/14 and completed by 06/03/14. 10. The Administrator is charged to administer the facility in a safe and efficient manner to assure the safety of the residents at all times. The Administrator, in conjunction with the DON, ADON and SDN, will assure education is provided and resident care and treatment is delivered in accordance with the Care Plan. Continued evaluation, assessment and Care Plan updates will be used to ensure all residents are safe from harm. 11. Monitoring and utilizing the (QA) Committee data collection tool developed on 05/30/14, is done by the DON, ADON, SDN, RN Unit Managers and RN Supervisors. QA meetings to review the collected data will be held five (5) days per week, and as needed, for thirty (30) days, then weekly for thirty (30) days, then monthly or as needed thereafter. Any identified concerns will be corrected immediately. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the education sign-in sheets revealed the Administrator, DON, ADON and SDN were educated by the Regional Director of Operations on 05/30/14, prior to the administrative team conducting education of all facility staff. Continued review revealed topics covered included supervision of incidents/accidents; abuse reporting; conducting investigations, and reviewing residents who are at risk or cognitively impaired. Interview with the Administrator, on 06/06/14 at 1:30 PM, revealed the Regional Director of Operations performed the education for the DON, ADON, SDN and himself on 05/30/14. The Administrator stated the education was to ensure all residents were free from abuse and the facility was administered in a manner to assist residents to achieve their highest physical, mental and psychosocial well-being. 2. Review of the data collection tool developed by the QA Committee revealed it included, but was not limited to, validation of assessments completed, use of Care Plans, and a monitor of resident behaviors. In addition, in the case of aggressive behaviors, the tool allowed for a review of current interventions for effectiveness and a determination of the need for additional interventions. Interview with the DON and the Administrator, on 06/05/14 at 4:45 PM, revealed the tool was developed and implemented on 05/30/14, and was being used as outlined in the AOC ongoing. 3. Review of Resident #3's record revealed a weekly skin assessment was completed on 05/03/14, with no documented evidence of physical injury. Review of Resident #2's record revealed a weekly skin assessment was completed on 05/16/14, with no documented evidence of physical injury. Review of the facility's implementation documentation binder for the AOC revealed all residents were assessed, care plans were reviewed and updated for residents with identified behaviors, as alleged by the DON, ADON, SDN and RN Supervisor. Interview with the DON, on 06/05/14 at 2:20 PM, revealed she reviewed Resident #3's weekly skin assessment dated [DATE], and Resident #2's weekly skin assessment dated [DATE] and confirmed the residents had no physical injuries documented on those dates. The DON stated all residents in the facility were assessed, and those with behaviors were monitored for the potential to be an abuser, care planned for the behaviors, and any behaviors were documented every shift. In addition, all new admissions were assessed for any history of behaviors and care planned accordingly. 4. Review of the facility's implementation documentation binder for the AOC revealed staff signatures of nurses and CNAs who received the education on residents on continuous supervision, updating and following residents' care plans, use of the Abuse Allegation Checklist and completed post-tests successfully. Continued review revealed all education was provided on or prior to 06/03/14 as alleged. Review of the Abuse Allegation Checklist form utilized by the facility revealed it included removing the aggressor resident and placing the resident on continuous observation. Review of the QA Data Collection tool revealed monitoring included whether staff used the Abuse Allegation Checklist after each incident. Review of the ongoing investigation file for the only resident to resident incident after implementation of the AOC revealed the Abuse Allegation Checklist was used, the aggressor resident was removed from the situation, and 1:1 supervision was initiated and thoroughly documented on. Review of the CNA Worksheet/Care Plan for the resident aggressor revealed it was updated to reflect the increased supervision. Interviews 06/05/14 with CNA #6 at 2:45 PM; CNA #7 at 3:40 PM; and CNA #8 at 3:45 PM, revealed the CNAs education on residents on continuous supervision would be in the "Accunurse" computer system and on the CNA Worksheet/Care Plan. The CNAs reported receiving education related to providing the one on one (1:1) supervision and ensuring they documented the continuous supervision. Interviews 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and, LPN #9 at 3:35 PM, revealed the nurses were educated on use of the Abuse Allegation Checklist, and updating and ensuring the CNAs and they followed residents' care plans. 5. Review of the facility's implementation documentation binder for the AOC revealed education sign-in sheets and post-tests for the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors who attended the education provided by the Administrator and DON. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they educated the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist, on or before 06/03/14. The Administrator and DON stated they were monitoring for use of the Checklist with every abuse investigation. They reported the education had been added to the facility's general orientation for new hires. Interview with RN Supervisor #1, on 06/05/14 at 3:15 PM, revealed she had received the education provided, took a post-test and was knowledgeable about when and how to use the Abuse Investigation Checklist. 6. Review of the facility's implementation documentation binder for the AOC revealed licensed nursing staff received mandatory education related to performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. Review of the Sign-in sheets reflected the nurses' attendance, and their completion of the post-tests which cross-matched with the signatures. Continued review revealed all education was received on or prior to 06/03/14 by the DON, ADON and SDN. Interviews on 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and LPN #9 at 3:35 PM, revealed the nurses confirmed receiving the education on performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents and had taken the post-test afterwards. Interview with the DON on 06/06/14 at 4:45 PM, revealed the education had been provided prior to 06/03/14 as per the AOC for all licensed nursing staff. The DON stated the education had been added to the facility's general orientation for new hires. 7. Review of the facility's implementation documentation binder for the AOC revealed all facility staff had received education on abuse which included identifying and reporting abuse, resident to resident sexual aggression and Resident Rights. Continued review of the binder revealed a master list of employees, education sign-in sheets and post-tests which were cross-referenced to confirm the education. Interview with the SDN on 06/05/14 at 4:30 PM, revealed she had participated in providing education for all facility staff related to abuse and Resident Rights. She stated each Department Head had a list of all staff who still needed to receive the education prior to returning to work and ensured the education was provided before the employee was allowed to work. Interview with the DON, on 06/06/14 at 4:45 PM, revealed the facility ensured all facility staff received the mandatory education on abuse and Resident Rights, as per the AOC, by maintaining a master list of all staff and checking off names as they received the education. She stated a list of all staff on vacation or other leave included their return to work date, and no staff were allowed to be on duty prior to the education being completed. Interviews on 06/05/14 with: Dietary Personnel #1 at 2:00 PM, Dietary Personnel #2 at 2:05 PM; Maintenance Assistant #1 at 2:15 PM; Social Services (SS) Assistant #1 at 2:18 PM; Laundry Personnel #1 at 2:20 PM; Occupational Therapist (OT) #1 at 2:23 PM; LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; CNA #6 at 2:45 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; LPN #9 at 3:35 PM; CNA #7 at 3:40 PM; and, CNA #8 at 3:45 PM revealed they all had attended the mandatory inservices related to abuse and Resident Rights. Those interviewed were able to explain their responsibilities if abuse were observed, reported or suspected. All interviewees were cross-checked to the education sign-in sheets and post-tests. 8. Review of the facility's implementation documentation binder for the AOC revealed an ongoing investigation of a resident to resident altercation, which was not sexual in nature. Review of the investigation documentation revealed all required notifications were made timely in accordance with facility policy and federal and state regulations. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they would ensure notification of the State Survey Agency, Adult Protective Services, the Ombudsman and local law enforcement of all sexually aggressive behaviors as indicated in the AOC. However, they reported no incidents of sexually aggressive behaviors had occurred since the alleged date of compliance, 06/04/14. 9. Review of the facility's implementation documentation binder for the AOC revealed education records included sign-in sheets for all education provided. Continued review revealed staff members were checked off from a master list of all employees in order for the facility to ensure every staff member received the education prior to returning to work. In addition, copies of completed post-tests were available for review and were cross-checked with the sign-in sheets. A review of educational offering agendas revealed all topics included in the AOC were provided. Further review revealed all education was completed prior to or on 06/03/14 as alleged. Interview with the Administrator and the DON on 06/05/14 at 4:45 PM, revealed all the education was mandatory with records being maintained. Interview with the SDN, on 06/05/14 at 4:30 PM, revealed she tracked employee attendance via the sign-in sheets and the master list. She stated she tried to make the inservices interesting to maintain the learners' attention, and utilized post-tests to verify effectiveness of the education. 10. Interview with the Administrator and the DON on 06/06/14 at 1:30 PM, revealed the Administrator was responsible for the overall administration of the facility. He stated his goal was to ensure every resident was safe and staff were knowledgeable regarding providing care according to the written Care Plan. He further stated he had been closely involved with the DON throughout the development and implementation of the AOC, including the monitoring of data collected as part of the QA process. The Administrator stated he and the DON ensured the education was provided. He indicated the facility would continue to evaluate, assess and update residents' Care Plans to ensure all residents were safe from harm. Both the Administrator and the DON stated every action outlined in the AOC had been conducted as alleged. 11. Review of the facility's implementation documentation binder for the AOC revealed residents' behaviors were documented by staff every shift. Continued review revealed QA team members reviewed the collected data daily Monday through Friday. Interview with the DON revealed she reviewed all documented behaviors daily Monday through Friday to ensure the Care Plans were revised to include new interventions as indicated by the exhibited behavior. She stated the data is collected by her, the ADON, SDN, RN Unit Managers and RN Supervisors, with all behaviors reviewed by her.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure the facility's policy and procedures related to abuse were implemented. In addition, the facility's policy failed to provide guidance to conduct a thorough investigation. This failure affected two (2) of ten (10) sampled residents (Resident #3 and #2). On 04/27/14, Resident #3 reported being touched on the inner thigh under his/her clothes by Resident #1. Resident #3 reported the incident occurred on 04/26/14. The facility initiated their investigation of the incident immediately; however, their actions did not include a physical assessment of Resident #3 for possible injury. Although cognitively intact residents on the unit were interviewed by the facility, non-interviewable residents were not assessed for signs of possible abuse. In addition, the facility revised Resident #1's plan of care to implemented visual checks of the resident every fifteen (15) minutes; however, review of documentation and interviews with staff revealed the checks were not conducted consistently. As a result of the facility's failure to monitor Resident #1, other residents were not protected from potential abuse. On 05/10/14, a staff member observed Resident #1 to have his/her hand between Resident #2's legs. Resident #1 was placed on 1:1 supervision at that time, until transferred to the hospital for further evaluation. The resident was discharged from the facility prior to initiation of the survey, and was not available for observation or interview. (Refer to F-223, F-225 and F-282) The facility's failure to have an effective system in place to ensure implementation of Abuse Policies to prevent abuse was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 05/28/14 and determined to exist on 04/27/14. The facility was notified of the Immediate Jeopardy on 05/28/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 06/05/14 with the facility alleging removal of the IJ on 06/04/14. The IJ was verified to be removed on 06/04/14 as alleged, prior to exit from the facility on 06/06/14, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-226 with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor the Abuse Policies for implementation to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "Abuse: Resident to Resident", effective October 2012, revealed immediate action was to be taken in incidents of resident to resident altercations to prevent reoccurrence of altercations. Monitoring of residents at the nurse's station, 1:1 therapy/activity and discharge to the hospital for medical evaluation were some measures staff could use to keep aggressive residents separated. Further review of the policy revealed an investigation was to be completed and documentation was to include interventions placed to prevent reoccurrence's. Further review of the policy revealed it did not address specific measures to ensure a thorough investigation was conducted, e.g. conducting physical assessments of victim residents or other vulnerable non-interviewable residents. Review of the facility's Incident Report Form dated 04/27/14, revealed the facility reported Resident #1 touched Resident #3 on the thigh under his/her clothes on 04/26/14. Continued review revealed Resident #3 expressed he/she was afraid of Resident #1. Review of the facility's investigation of the incident reported on 04/27/14, revealed no documented evidence cognitively-impaired residents, i.e. those resident with a BIMS score of less than eight (8), were interviewed or assessed for signs of possible abuse by the alleged perpetrator, Resident #1. Continued review revealed Resident #3 was not assessed for injury on 04/27/14 after the incident was reported. Interview with LPN #3 on 05/25/14 at 4:55 PM, who was the House Supervisor on 04/27/14, and on 05/27/14 at 10:00 AM with Registered Nurse (RN ) #2, who was the Charge Nurse, revealed neither nurse conducted a head to toe physical assessment on Resident #3 to determine if the resident had sustained any injury. RN #2 stated the resident appeared to be okay. Review of the facility's five (5) Day Follow-up Report dated 05/01/14, for the 04/27/14 incident, revealed Resident #1 was to remain "under close watch by staff during the investigation". However, review of the medical record for Resident #1 revealed no documented evidence Resident #1 remained under close watch of staff as indicated in the investigation; was monitored at the nurse's station; or provided 1:1 therapy/activity as indicated per facility policy. Review of Resident #1's Comprehensive Care Plan revealed on 04/28/14, an intervention for Resident #1 to be monitored every fifteen (15) minute checks was added. However, review of the documentation of the fifteen (15) minute checks for Resident #1 between 04/28/14 and 05/10/14, revealed some checks with no dates and inconsistent documentation. Further review of the fifteen (15) minute check documentation revealed no checks were documented on several days during that time frame. Interview on 04/27/14 at 10:00 AM, with RN #2, revealed she did not think Resident #1 was put on every fifteen (15) minute checks after the incident. RN #2 stated staff kept "an eye on" Resident #1; however, indicated she did not implement special monitoring of the resident on 04/27/14 per the facility's policy. Interviews with Certified Nursing Assistant (CNA) #2 on 05/23/14 at 2:50 PM; with CNA #3 on 05/29/14 at 4:45 PM; and, with CNA #4 on 05/29/14 at 7:15 PM revealed they had been told by other CNAs to "keep an eye on" Resident #1; however, they were not aware of when Resident #1 was placed on every fifteen (15) minute checks. Review of the facility's Incident Report Form dated 05/10/14, revealed Resident #1 was observed with his/her hand between Resident #2's legs by a staff person. Interview, on 05/24/14 at 4:30 PM, with RN #2 revealed on 05/10/14 the staff reported to her Resident #1 was "groping" Resident #2 in the "vagina area". Per interview, RN #2 did not assess Resident #2 for injury because the resident appeared to be okay. Interview with the Director of Nursing (DON) on 5/22/14 at 3:00 PM, revealed she did not know why the fifteen (15) minute check documentation was undated, inconsistent or why there was no documentation of the checks for several days. Additional interview with the DON, on 05/29/14 at 5:35 PM, revealed the Abuse Policy was not followed as a result of not ensuring the documenting of the fifteen minutes checks, which was an intervention placed to prevent reoccurrence's. In addition, the DON revealed head to toe physical assessments on Resident #2 and Resident #3 should have been completed immediately after the incidents; however, staff failed to do so. The facility provided an acceptable credible AOC on 06/05/14 that alleged removal of the IJ effective 06/04/14. Review of the AOC revealed the facility implemented the following: 1. The Administrator, DON, ADON and SDN were educated on 05/30/14 by the Regional Director of Operations for Preferred Care Partners, Management Group on Accidents and Supervision on residents must be free from abuse and neglect in order to ensure residents' were protected. 2. The Quality Assurance (QA) Committee reviewed all educational materials and developed a data collection tool on 05/30/14 to validate assessments and Care Plans were being utilized per policy protocol. The tool includes a monitor for aggressive resident behaviors. If aggressive behavior occurs, interventions implemented will be reviewed for effectiveness and a determination if additional interventions are needed will be made. The tool was implemented on 05/30/14 and is ongoing. 3. Resident #3 had a weekly skin assessment completed on 05/03/14, and Resident #2 had a weekly skin assessments completed on 05/16/14. All residents were assessed for the potential to be an abuser, assessments were completed by 06/03/14. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Staff Development Nurse (SDN), and/or the Registered Nurse (RN) Supervisor completed the assessments. Information obtained was used to develop and implement appropriate interventions, and the Care Plans were updated initially by the DON, ADON or the SDN, and will be updated thereafter by RN Unit Managers and Charge Nurses. 4. For any resident to resident allegations, the aggressor is to be removed from the situation and placed on continuous observation until otherwise notified by the DON and/or the Administrator. CNAs will be notified of the continuous observation order via the CNA Care Plan and "Accunurse" (the CNA computer documentation system). Nurses and CNAs were educated on the process by the DON, ADON or SDN, with the education completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. The facility does not use agency staff. 5. The Administrator and the DON educated the ADON, SDN, RN Unit Managers, Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist tool, with the education completed by 06/03/14. The Administrator and the DON will monitor use of the checklist for every abuse investigation. The facility's general orientation for new hires was revised to include the education. 6. Licensed nursing staff were educated on performing assessments, interventions and updating the Care Plan, implementation and use of the Care Plan, the components of accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. The education was provided by the DON, ADON and SDN, and completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 7. All facility staff were educated on identifying and reporting abuse, with a focus on resident to resident sexual aggression, and on resident rights. The education was provided by the DON, ADON and SDN, and was completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 8. The Administrator or the DON will notify the Office of Inspector General, Adult Protective Services, the Ombudsman, and local law enforcement of all sexually aggressive behaviors as required by law and within specified time limits. 9. Educational records will be maintained and will include signatures of attendance, signatures of the education received, and copies of tests designed to determine the effectiveness of the education initiated on 05/30/14 and completed by 06/03/14. 10. The Administrator is charged to administer the facility in a safe and efficient manner to assure the safety of the residents at all times. The Administrator, in conjunction with the DON, ADON and SDN, will assure education is provided and resident care and treatment is delivered in accordance with the Care Plan. Continued evaluation, assessment and Care Plan updates will be used to ensure all residents are safe from harm. 11. Monitoring and utilizing the (QA) Committee data collection tool developed on 05/30/14, is done by the DON, ADON, SDN, RN Unit Managers and RN Supervisors. QA meetings to review the collected data will be held five (5) days per week, and as needed, for thirty (30) days, then weekly for thirty (30) days, then monthly or as needed thereafter. Any identified concerns will be corrected immediately. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the education sign-in sheets revealed the Administrator, DON, ADON and SDN were educated by the Regional Director of Operations on 05/30/14, prior to the administrative team conducting education of all facility staff. Continued review revealed topics covered included supervision of incidents/accidents; abuse reporting; conducting investigations, and reviewing residents who are at risk or cognitively impaired. Interview with the Administrator, on 06/06/14 at 1:30 PM, revealed the Regional Director of Operations performed the education for the DON, ADON, SDN and himself on 05/30/14. The Administrator stated the education was to ensure all residents were free from abuse and the facility was administered in a manner to assist residents to achieve their highest physical, mental and psychosocial well-being. 2. Review of the data collection tool developed by the QA Committee revealed it included, but was not limited to, validation of assessments completed, use of Care Plans, and a monitor of resident behaviors. In addition, in the case of aggressive behaviors, the tool allowed for a review of current interventions for effectiveness and a determination of the need for additional interventions. Interview with the DON and the Administrator, on 06/05/14 at 4:45 PM, revealed the tool was developed and implemented on 05/30/14, and was being used as outlined in the AOC ongoing. 3. Review of Resident #3's record revealed a weekly skin assessment was completed on 05/03/14, with no documented evidence of physical injury. Review of Resident #2's record revealed a weekly skin assessment was completed on 05/16/14, with no documented evidence of physical injury. Review of the facility's implementation documentation binder for the AOC revealed all residents were assessed, care plans were reviewed and updated for residents with identified behaviors, as alleged by the DON, ADON, SDN and RN Supervisor. Interview with the DON, on 06/05/14 at 2:20 PM, revealed she reviewed Resident #3's weekly skin assessment dated [DATE], and Resident #2's weekly skin assessment dated [DATE] and confirmed the residents had no physical injuries documented on those dates. The DON stated all residents in the facility were assessed, and those with behaviors were monitored for the potential to be an abuser, care planned for the behaviors, and any behaviors were documented every shift. In addition, all new admissions were assessed for any history of behaviors and care planned accordingly. 4. Review of the facility's implementation documentation binder for the AOC revealed staff signatures of nurses and CNAs who received the education on residents on continuous supervision, updating and following residents' care plans, use of the Abuse Allegation Checklist and completed post-tests successfully. Continued review revealed all education was provided on or prior to 06/03/14 as alleged. Review of the Abuse Allegation Checklist form utilized by the facility revealed it included removing the aggressor resident and placing the resident on continuous observation. Review of the QA Data Collection tool revealed monitoring included whether staff used the Abuse Allegation Checklist after each incident. Review of the ongoing investigation file for the only resident to resident incident after implementation of the AOC revealed the Abuse Allegation Checklist was used, the aggressor resident was removed from the situation, and 1:1 supervision was initiated and thoroughly documented on. Review of the CNA Worksheet/Care Plan for the resident aggressor revealed it was updated to reflect the increased supervision. Interviews 06/05/14 with CNA #6 at 2:45 PM; CNA #7 at 3:40 PM; and CNA #8 at 3:45 PM, revealed the CNAs education on residents on continuous supervision would be in the "Accunurse" computer system and on the CNA Worksheet/Care Plan. The CNAs reported receiving education related to providing the one on one (1:1) supervision and ensuring they documented the continuous supervision. Interviews 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and, LPN #9 at 3:35 PM, revealed the nurses were educated on use of the Abuse Allegation Checklist, and updating and ensuring the CNAs and they followed residents' care plans. 5. Review of the facility's implementation documentation binder for the AOC revealed education sign-in sheets and post-tests for the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors who attended the education provided by the Administrator and DON. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they educated the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist, on or before 06/03/14. The Administrator and DON stated they were monitoring for use of the Checklist with every abuse investigation. They reported the education had been added to the facility's general orientation for new hires. Interview with RN Supervisor #1, on 06/05/14 at 3:15 PM, revealed she had received the education provided, took a post-test and was knowledgeable about when and how to use the Abuse Investigation Checklist. 6. Review of the facility's implementation documentation binder for the AOC revealed licensed nursing staff received mandatory education related to performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. Review of the Sign-in sheets reflected the nurses' attendance, and their completion of the post-tests which cross-matched with the signatures. Continued review revealed all education was received on or prior to 06/03/14 by the DON, ADON and SDN. Interviews on 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and LPN #9 at 3:35 PM, revealed the nurses confirmed receiving the education on performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents and had taken the post-test afterwards. Interview with the DON on 06/06/14 at 4:45 PM, revealed the education had been provided prior to 06/03/14 as per the AOC for all licensed nursing staff. The DON stated the education had been added to the facility's general orientation for new hires. 7. Review of the facility's implementation documentation binder for the AOC revealed all facility staff had received education on abuse which included identifying and reporting abuse, resident to resident sexual aggression and Resident Rights. Continued review of the binder revealed a master list of employees, education sign-in sheets and post-tests which were cross-referenced to confirm the education. Interview with the SDN on 06/05/14 at 4:30 PM, revealed she had participated in providing education for all facility staff related to abuse and Resident Rights. She stated each Department Head had a list of all staff who still needed to receive the education prior to returning to work and ensured the education was provided before the employee was allowed to work. Interview with the DON, on 06/06/14 at 4:45 PM, revealed the facility ensured all facility staff received the mandatory education on abuse and Resident Rights, as per the AOC, by maintaining a master list of all staff and checking off names as they received the education. She stated a list of all staff on vacation or other leave included their return to work date, and no staff were allowed to be on duty prior to the education being completed. Interviews on 06/05/14 with: Dietary Personnel #1 at 2:00 PM, Dietary Personnel #2 at 2:05 PM; Maintenance Assistant #1 at 2:15 PM; Social Services (SS) Assistant #1 at 2:18 PM; Laundry Personnel #1 at 2:20 PM; Occupational Therapist (OT) #1 at 2:23 PM; LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; CNA #6 at 2:45 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; LPN #9 at 3:35 PM; CNA #7 at 3:40 PM; and, CNA #8 at 3:45 PM revealed they all had attended the mandatory inservices related to abuse and Resident Rights. Those interviewed were able to explain their responsibilities if abuse were observed, reported or suspected. All interviewees were cross-checked to the education sign-in sheets and post-tests. 8. Review of the facility's implementation documentation binder for the AOC revealed an ongoing investigation of a resident to resident altercation, which was not sexual in nature. Review of the investigation documentation revealed all required notifications were made timely in accordance with facility policy and federal and state regulations. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they would ensure notification of the State Survey Agency, Adult Protective Services, the Ombudsman and local law enforcement of all sexually aggressive behaviors as indicated in the AOC. However, they reported no incidents of sexually aggressive behaviors had occurred since the alleged date of compliance, 06/04/14. 9. Review of the facility's implementation documentation binder for the AOC revealed education records included sign-in sheets for all education provided. Continued review revealed staff members were checked off from a master list of all employees in order for the facility to ensure every staff member received the education prior to returning to work. In addition, copies of completed post-tests were available for review and were cross-checked with the sign-in sheets. A review of educational offering agendas revealed all topics included in the AOC were provided. Further review revealed all education was completed prior to or on 06/03/14 as alleged. Interview with the Administrator and the DON on 06/05/14 at 4:45 PM, revealed all the education was mandatory with records being maintained. Interview with the SDN, on 06/05/14 at 4:30 PM, revealed she tracked employee attendance via the sign-in sheets and the master list. She stated she tried to make the inservices interesting to maintain the learners' attention, and utilized post-tests to verify effectiveness of the education. 10. Interview with the Administrator and the DON on 06/06/14 at 1:30 PM, revealed the Administrator was responsible for the overall administration of the facility. He stated his goal was to ensure every resident was safe and staff were knowledgeable regarding providing care according to the written Care Plan. He further stated he had been closely involved with the DON throughout the development and implementation of the AOC, including the monitoring of data collected as part of the QA process. The Administrator stated he and the DON ensured the education was provided. He indicated the facility would continue to evaluate, assess and update residents' Care Plans to ensure all residents were safe from harm. Both the Administrator and the DON stated every action outlined in the AOC had been conducted as alleged. 11. Review of the facility's implementation documentation binder for the AOC revealed residents' behaviors were documented by staff every shift. Continued review revealed QA team members reviewed the collected data daily Monday through Friday. Interview with the DON revealed she reviewed all documented behaviors daily Monday through Friday to ensure the Care Plans were revised to include new interventions as indicated by the exhibited behavior. She stated the data is collected by her, the ADON, SDN, RN Unit Managers and RN Supervisors, with all behaviors reviewed by her.

Based on record review, interview and review of the facility's policies, it was determined the facility failed to have an effective system to ensure the implementation of care plan interventions by facility staff for one (1) of ten (10) sampled residents (Resident #1). On 04/27/14, Resident #3 reported to staff Resident #1 had "touched" him/her under his/her clothes, which the resident indicated had happened on 04/26/14 and on another day. Resident #3 told staff he/she was afraid of Resident #1. Review of Resident #1's Comprehensive Care Plan revealed an intervention dated 04/28/14 for the resident to be checked on every fifteen (15) minutes. However, record review revealed no documented evidence the intervention was implemented on that date. Additionally, review of the fifteen (15) minute check sheets revealed undated sheets and incomplete documentation of the checks through 05/10/14, with no documented evidence of the checks on several days. As a result of the facility's failure to implement Resident #1's care plan intervention for 15 minute checks, other residents were not protected from potential abuse. On 05/10/14, a staff person observed Resident #1 "groping" Resident #2 between his/her legs. Resident #1 was then placed on one on one (1:1) supervision, the Physician was notified, and an order was received to send the resident to the emergency room (ER) for evaluation and treatment. Resident #1 was discharged and was not a resident of the facility during the survey. (Refer to F-223) The facility's failure to have an effective system in place to ensure implementation of care plan interventions was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 05/28/14, and was determined to exist on 04/27/14. The facility was notified of the Immediate Jeopardy on 5/28/14. The facility provide an acceptable credible Allegation of Compliance (AOC) on 06/05/14, with the facility alleging removal of the Immediate Jeopardy on 06/04/14. The State Agency validated, the Immediate Jeopardy was removed on 06/04/14 as alleged with remaining non-compliance at 42 CFR 483.20 Resident Assessment, F-282 at a Scope and Severity of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program monitors to ensure residents' care plans are implemented. The findings include: Review of the facility's policy titled, "Care Plans-Comprehensive", revised October 2010, revealed an individualized comprehensive care plan which included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs was to be developed for each resident. Further review of the policy revealed each resident's care plan was designed to identify the professional services that were responsible for each element of care. Review of the facility's policy titled, "Abuse Resident to Resident", dated October 2012, revealed immediate action was to be taken in any occurrence of a resident to resident altercation with immediate interventions taken to prevent reoccurrence of the altercation. Review of Resident #1's medical record revealed the facility admitted the resident on 06/14/13, with [DIAGNOSES REDACTED]. Review of the 03/16/14, Quarterly Minimum Data Set (MDS) Assessment for Resident #1 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), which indicated he/she was moderately cognitively impaired. Review of Resident #1's Comprehensive Care Plan initiated on 09/25/13, revealed a behavior care plan for threatening staff verbally, physically throwing items at other residents, threatening to shoot another resident and expressing agitation towards another resident. Interventions included: removing the resident from "common areas during times of unacceptable behavior"; one on one (1:1) as needed; giving emotional support; explaining his/her behaviors were unacceptable; and reapproaching at a later time. Review of Resident #1's Comprehensive Care Plan, with a revision date of 01/08/14, revealed a problem onset of wandering, going into others rooms. Continued review of the wander risk care plan revealed a goal for the resident not to go into other resident rooms without permission by next review on 06/15/14 and interventions including provide cueing as to where his/her room is as needed, redirect resident out of others rooms as needed, monitor for changes in cognitive status and rule out medical concerns. Continued record review for Resident #1 revealed a "late entry" Nurse's Note, dated 04/27/14 at 2:21 PM, for an incident which occurred at 9:15 AM that morning. Review of the "late entry" Note revealed a resident reported Resident #1 made inappropriate advances at him/her. Continued review of the "late entry" Note revealed the other resident told staff Resident #1 had attempted to touch him/her under his/her clothes yesterday and on another day. Review of the facility's initial Incident Report dated 04/27/14, revealed it noted Resident #3 reported to a nurse Resident #1 had "touched" him/her on the leg under his/her clothes two (2) times, and he/she was "afraid" of Resident #1. Further review of the Incident Report revealed measures were implemented to keep Resident #1 under watch by staff during the investigation. Continued review of the "Immediate Need Plan of Care", which was part of Resident #1's Comprehensive Care Plan, revealed it was revised on 04/28/14, with measures which included interventions to change Resident #1's [MEDICATION NAME] (an antipsychotic medication) to fifty (50) milligram (mg) PRN (as necessary) and for fifteen (15) minute checks. Interview with Certified Nursing Assistant (CNA) #1 on 5/23/14 at 2:30 PM, revealed she was assigned Resident #1's care frequently, and had been told by the nurses at times to keep an "eye on" the resident. She stated she had worked on 04/27/14 and Resident #3 told her about Resident #1 touching his/her legs. However, CNA #1 indicated she had not seen fifteen (15) minutes check sheets for the resident and thought the nurses were completing those. Interview with CNA #2 on 05/23/14 at 2:50 PM, with CNA #3 on 05/29/14 at 4:45 PM and with CNA #4 on 05/29/14 at 7:15 PM revealed they indicated they were not aware Resident #1 had been put on fifteen (15) minute checks. They reported they had been told to watch Resident #1 and "keep an eye on" the resident by other CNAs. Interview with CNA #5 on 05/29/14 at 7:00 PM revealed she had been told by the Charge Nurse once to keep an "eye on" Resident #1 after an incident involving Resident #3. CNA #5 indicated she was aware Resident #1 was on fifteen (15) minute checks; however, was uncertain when the checks started, and the nurses were supposed to do the checks. However, interview with LPN #2 on 05/29/14 at 4:00 PM, revealed she was not aware an intervention to perform fifteen (15) minutes checks was on Resident #1's Comprehensive Care Plan, and did not know fifteen (15) minute checks were to be completed on Resident #1. Interview with Registered Nurse (RN) #1 on 05/23/14 at 3:30 PM revealed she was unaware Resident #1 had sexual behaviors towards other residents and was unaware the resident was care planned for fifteen (15) minute checks. RN #1 commented she "just thought" Resident #1 had behaviors; however, not sexual behaviors towards other residents. She stated she "usually" just looked at residents' care plans for "lifts and transfers". Interview, on 05/27/14 at 10:00 AM with RN #2, Charge Nurse on the unit on which Resident #1 resided, revealed she was unaware Resident #1 was care planned for fifteen (15) minute checks after the 04/27/14 incident. She stated she was uncertain if the fifteen (15) minute checks were on Resident #1's care plan. Review of the facility's fifteen (15) minute check sheets for Resident #1 revealed some of the check sheets were undated and the documentation of the fifteen (15) minute checks was inconsistent, with no documented evidence of the checks for several days from 04/28/14 through 05/10/14. Further review of Resident #1's record revealed a Nurse's Note dated 05/10/14 at 2:46 PM, which was noted to be a "late entry" for 1:20 PM that same afternoon. Review of the Note revealed a staff member had observed Resident #1 "touching" other resident "inappropriately". Further review of the Note revealed a staff member was assigned for one on one (1:1) monitoring of Resident #1. Review of the facility's initial Incident Report dated 05/10/14, revealed Resident #1 and Resident #2 were sitting in the hallway in their wheelchairs at 1:30 PM, when a staff member observed Resident #1 with his/her hand between Resident #2's legs while the residents were sitting in the hallway in their wheelchairs. Continued interview, on 05/27/14 at 10:AM, with RN #2, Charge Nurse on the unit on which Resident #1 resided, revealed she thought the fifteen (15) minutes checks were started a day or two before the 05/10/14 incident involving Resident #2; however could not recall why the resident was placed on the checks. Interview with the Director of Nursing (DON) on 5/29/14 at 7:25 PM, revealed her responsibilities included ensuring staff was aware of interventions to protect residents from abuse. She indicated the facility needed to have a more effective system for informing staff of resident to resident abuse. The DON stated her expectations were for staff to follow residents' care plan interventions, and protect residents from potential abuse. However, the facility failed to ensure per the facility's policy, immediate action/interventions were implemented to prevent reoccurrence of the altercation. The facility provided an acceptable credible AOC on 06/05/14 that alleged removal of the IJ effective 06/04/14. Review of the AOC revealed the facility implemented the following: 1. The Administrator, DON, ADON and SDN were educated on 05/30/14 by the Regional Director of Operations for Preferred Care Partners, Management Group on Accidents and Supervision on residents must be free from abuse and neglect in order to ensure residents' were protected. 2. The Quality Assurance (QA) Committee reviewed all educational materials and developed a data collection tool on 05/30/14 to validate assessments and Care Plans were being utilized per policy protocol. The tool includes a monitor for aggressive resident behaviors. If aggressive behavior occurs, interventions implemented will be reviewed for effectiveness and a determination if additional interventions are needed will be made. The tool was implemented on 05/30/14 and is ongoing. 3. Resident #3 had a weekly skin assessment completed on 05/03/14, and Resident #2 had a weekly skin assessments completed on 05/16/14. All residents were assessed for the potential to be an abuser, assessments were completed by 06/03/14. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Staff Development Nurse (SDN), and/or the Registered Nurse (RN) Supervisor completed the assessments. Information obtained was used to develop and implement appropriate interventions, and the Care Plans were updated initially by the DON, ADON or the SDN, and will be updated thereafter by RN Unit Managers and Charge Nurses. 4. For any resident to resident allegations, the aggressor is to be removed from the situation and placed on continuous observation until otherwise notified by the DON and/or the Administrator. CNAs will be notified of the continuous observation order via the CNA Care Plan and "Accunurse" (the CNA computer documentation system). Nurses and CNAs were educated on the process by the DON, ADON or SDN, with the education completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. The facility does not use agency staff. 5. The Administrator and the DON educated the ADON, SDN, RN Unit Managers, Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist tool, with the education completed by 06/03/14. The Administrator and the DON will monitor use of the checklist for every abuse investigation. The facility's general orientation for new hires was revised to include the education. 6. Licensed nursing staff were educated on performing assessments, interventions and updating the Care Plan, implementation and use of the Care Plan, the components of accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. The education was provided by the DON, ADON and SDN, and completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 7. All facility staff were educated on identifying and reporting abuse, with a focus on resident to resident sexual aggression, and on resident rights. The education was provided by the DON, ADON and SDN, and was completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 8. The Administrator or the DON will notify the Office of Inspector General, Adult Protective Services, the Ombudsman, and local law enforcement of all sexually aggressive behaviors as required by law and within specified time limits. 9. Educational records will be maintained and will include signatures of attendance, signatures of the education received, and copies of tests designed to determine the effectiveness of the education initiated on 05/30/14 and completed by 06/03/14. 10. The Administrator is charged to administer the facility in a safe and efficient manner to assure the safety of the residents at all times. The Administrator, in conjunction with the DON, ADON and SDN, will assure education is provided and resident care and treatment is delivered in accordance with the Care Plan. Continued evaluation, assessment and Care Plan updates will be used to ensure all residents are safe from harm. 11. Monitoring and utilizing the (QA) Committee data collection tool developed on 05/30/14, is done by the DON, ADON, SDN, RN Unit Managers and RN Supervisors. QA meetings to review the collected data will be held five (5) days per week, and as needed, for thirty (30) days, then weekly for thirty (30) days, then monthly or as needed thereafter. Any identified concerns will be corrected immediately. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the education sign-in sheets revealed the Administrator, DON, ADON and SDN were educated by the Regional Director of Operations on 05/30/14, prior to the administrative team conducting education of all facility staff. Continued review revealed topics covered included supervision of incidents/accidents; abuse reporting; conducting investigations, and reviewing residents who are at risk or cognitively impaired. Interview with the Administrator, on 06/06/14 at 1:30 PM, revealed the Regional Director of Operations performed the education for the DON, ADON, SDN and himself on 05/30/14. The Administrator stated the education was to ensure all residents were free from abuse and the facility was administered in a manner to assist residents to achieve their highest physical, mental and psychosocial well-being. 2. Review of the data collection tool developed by the QA Committee revealed it included, but was not limited to, validation of assessments completed, use of Care Plans, and a monitor of resident behaviors. In addition, in the case of aggressive behaviors, the tool allowed for a review of current interventions for effectiveness and a determination of the need for additional interventions. Interview with the DON and the Administrator, on 06/05/14 at 4:45 PM, revealed the tool was developed and implemented on 05/30/14, and was being used as outlined in the AOC ongoing. 3. Review of Resident #3's record revealed a weekly skin assessment was completed on 05/03/14, with no documented evidence of physical injury. Review of Resident #2's record revealed a weekly skin assessment was completed on 05/16/14, with no documented evidence of physical injury. Review of the facility's implementation documentation binder for the AOC revealed all residents were assessed, care plans were reviewed and updated for residents with identified behaviors, as alleged by the DON, ADON, SDN and RN Supervisor. Interview with the DON, on 06/05/14 at 2:20 PM, revealed she reviewed Resident #3's weekly skin assessment dated [DATE], and Resident #2's weekly skin assessment dated [DATE] and confirmed the residents had no physical injuries documented on those dates. The DON stated all residents in the facility were assessed, and those with behaviors were monitored for the potential to be an abuser, care planned for the behaviors, and any behaviors were documented every shift. In addition, all new admissions were assessed for any history of behaviors and care planned accordingly. 4. Review of the facility's implementation documentation binder for the AOC revealed staff signatures of nurses and CNAs who received the education on residents on continuous supervision, updating and following residents' care plans, use of the Abuse Allegation Checklist and completed post-tests successfully. Continued review revealed all education was provided on or prior to 06/03/14 as alleged. Review of the Abuse Allegation Checklist form utilized by the facility revealed it included removing the aggressor resident and placing the resident on continuous observation. Review of the QA Data Collection tool revealed monitoring included whether staff used the Abuse Allegation Checklist after each incident. Review of the ongoing investigation file for the only resident to resident incident after implementation of the AOC revealed the Abuse Allegation Checklist was used, the aggressor resident was removed from the situation, and 1:1 supervision was initiated and thoroughly documented on. Review of the CNA Worksheet/Care Plan for the resident aggressor revealed it was updated to reflect the increased supervision. Interviews 06/05/14 with CNA #6 at 2:45 PM; CNA #7 at 3:40 PM; and CNA #8 at 3:45 PM, revealed the CNAs education on residents on continuous supervision would be in the "Accunurse" computer system and on the CNA Worksheet/Care Plan. The CNAs reported receiving education related to providing the one on one (1:1) supervision and ensuring they documented the continuous supervision. Interviews 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and, LPN #9 at 3:35 PM, revealed the nurses were educated on use of the Abuse Allegation Checklist, and updating and ensuring the CNAs and they followed residents' care plans. 5. Review of the facility's implementation documentation binder for the AOC revealed education sign-in sheets and post-tests for the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors who attended the education provided by the Administrator and DON. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they educated the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist, on or before 06/03/14. The Administrator and DON stated they were monitoring for use of the Checklist with every abuse investigation. They reported the education had been added to the facility's general orientation for new hires. Interview with RN Supervisor #1, on 06/05/14 at 3:15 PM, revealed she had received the education provided, took a post-test and was knowledgeable about when and how to use the Abuse Investigation Checklist. 6. Review of the facility's implementation documentation binder for the AOC revealed licensed nursing staff received mandatory education related to performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. Review of the Sign-in sheets reflected the nurses' attendance, and their completion of the post-tests which cross-matched with the signatures. Continued review revealed all education was received on or prior to 06/03/14 by the DON, ADON and SDN. Interviews on 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and LPN #9 at 3:35 PM, revealed the nurses confirmed receiving the education on performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents and had taken the post-test afterwards. Interview with the DON on 06/06/14 at 4:45 PM, revealed the education had been provided prior to 06/03/14 as per the AOC for all licensed nursing staff. The DON stated the education had been added to the facility's general orientation for new hires. 7. Review of the facility's implementation documentation binder for the AOC revealed all facility staff had received education on abuse which included identifying and reporting abuse, resident to resident sexual aggression and Resident Rights. Continued review of the binder revealed a master list of employees, education sign-in sheets and post-tests which were cross-referenced to confirm the education. Interview with the SDN on 06/05/14 at 4:30 PM, revealed she had participated in providing education for all facility staff related to abuse and Resident Rights. She stated each Department Head had a list of all staff who still needed to receive the education prior to returning to work and ensured the education was provided before the employee was allowed to work. Interview with the DON, on 06/06/14 at 4:45 PM, revealed the facility ensured all facility staff received the mandatory education on abuse and Resident Rights, as per the AOC, by maintaining a master list of all staff and checking off names as they received the education. She stated a list of all staff on vacation or other leave included their return to work date, and no staff were allowed to be on duty prior to the education being completed. Interviews on 06/05/14 with: Dietary Personnel #1 at 2:00 PM, Dietary Personnel #2 at 2:05 PM; Maintenance Assistant #1 at 2:15 PM; Social Services (SS) Assistant #1 at 2:18 PM; Laundry Personnel #1 at 2:20 PM; Occupational Therapist (OT) #1 at 2:23 PM; LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; CNA #6 at 2:45 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; LPN #9 at 3:35 PM; CNA #7 at 3:40 PM; and, CNA #8 at 3:45 PM revealed they all had attended the mandatory inservices related to abuse and Resident Rights. Those interviewed were able to explain their responsibilities if abuse were observed, reported or suspected. All interviewees were cross-checked to the education sign-in sheets and post-tests. 8. Review of the facility's implementation documentation binder for the AOC revealed an ongoing investigation of a resident to resident altercation, which was not sexual in nature. Review of the investigation documentation revealed all required notifications were made timely in accordance with facility policy and federal and state regulations. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they would ensure notification of the State Survey Agency, Adult Protective Services, the Ombudsman and local law enforcement of all sexually aggressive behaviors as indicated in the AOC. However, they reported no incidents of sexually aggressive behaviors had occurred since the alleged date of compliance, 06/04/14. 9. Review of the facility's implementation documentation binder for the AOC revealed education records included sign-in sheets for all education provided. Continued review revealed staff members were checked off from a master list of all employees in order for the facility to ensure every staff member received the education prior to returning to work. In addition, copies of completed post-tests were available for review and were cross-checked with the sign-in sheets. A review of educational offering agendas revealed all topics included in the AOC were provided. Further review revealed all education was completed prior to or on 06/03/14 as alleged. Interview with the Administrator and the DON on 06/05/14 at 4:45 PM, revealed all the education was mandatory with records being maintained. Interview with the SDN, on 06/05/14 at 4:30 PM, revealed she tracked employee attendance via the sign-in sheets and the master list. She stated she tried to make the inservices interesting to maintain the learners' attention, and utilized post-tests to verify effectiveness of the education. 10. Interview with the Administrator and the DON on 06/06/14 at 1:30 PM, revealed the Administrator was responsible for the overall administration of the facility. He stated his goal was to ensure every resident was safe and staff were knowledgeable regarding providing care according to the written Care Plan. He further stated he had been closely involved with the DON throughout the development and implementation of the AOC, including the monitoring of data collected as part of the QA process. The Administrator stated he and the DON ensured the education was provided. He indicated the facility would continue to evaluate, assess and update residents' Care Plans to ensure all residents were safe from harm. Both the Administrator and the DON stated every action outlined in the AOC had been conducted as alleged. 11. Review of the facility's implementation documentation binder for the AOC revealed residents' behaviors were documented by staff every shift. Continued review revealed QA team members reviewed the collected data daily Monday through Friday. Interview with the DON revealed she reviewed all documented behaviors daily Monday through Friday to ensure the Care Plans were revised to include new interventions as indicated by the exhibited behavior. She stated the data is collected by her, the ADON, SDN, RN Unit Managers and RN Supervisors, with all behaviors reviewed by her.

Based on interview, record review and review of the facility's policy, incident report, and investigation it was determined the facility's Administration failed to have an effective system in place to ensure policy and procedures were implemented to ensure each resident was free from abuse and to ensure care plan interventions related to supervision were implemented to prevent reoccurrence of potential abuse. The facility's failure affected two (2) of ten (10) sampled residents (Residents #2 and #3). On 04/27/14, Resident #3 reported being touched on the inner thigh under his/her clothes by Resident #1. Resident #3 reported the incident occurred on 04/26/14. The facility initiated their investigation of the incident immediately; however, their actions did not include a physical assessment of Resident #3 for possible injury. Although cognitively intact residents on the unit were interviewed by the facility, non-interviewable residents were not assessed for signs of possible abuse. In addition, the facility revised Resident #1's plan of care to implemented visual checks of the resident every fifteen (15) minutes; however, review of documentation and interviews with staff revealed the checks were not conducted consistently. As a result of the facility's failure to monitor Resident #1, other residents were not protected from potential abuse. On 05/10/14, a staff member observed Resident #1 to have his/her hand between Resident #2's legs. Resident #1 was placed on 1:1 supervision at that time, until transferred to the hospital for further evaluation. The resident was discharged from the facility prior to initiation of the survey, and was not available for observation or interview. (Refer to F-223, F-225, F-226, F-282 and F-520.) The facility Administration's failure to have an effective system in place to ensure policy and procedures were implemented to ensure each resident was free from abuse and to ensure care plan interventions related to supervision were implemented to prevent reoccurrence of potential abuse, was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 05/28/14 and determined to exist on 04/27/14. The facility was notified of the Immediate Jeopardy on 05/28/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 06/05/14 with the facility alleging removal of the IJ on 06/04/14. The IJ was verified to be removed on 06/04/14 as alleged, prior to exit from the facility on 06/06/14, with remaining non-compliance at 42 CFR 483.75, F-490 Administration with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance program continues to monitor to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "Abuse Resident to Resident", effective October 2012, revealed all residents had the right to be free from any mental or physical mistreatment. Immediate action was to be taken in any occurrence of a resident to resident altercation with immediate interventions taken to prevent reoccurrence. Continued review of the policy revealed measures included monitoring of residents at the nurses station, and one on one (1:1) therapy/activity and discharge to the hospital for medical evaluation if necessary. Review of the facility's policy titled, "Care Plans-Comprehensive", revised October 2010, revealed an individualized comprehensive care plan which included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs was to be developed for each resident. Further review of the policy revealed each resident's care plan was designed to identify the professional services that were responsible for each element of care. No policy related to Administration was provided. Review of the facility's Incident Report form dated 04/27/14, revealed the facility reported Resident #1 "touched" Resident #3 on the leg under his/her clothes on 04/26/14. Continued review revealed Resident #3 expressed fear of Resident #1 after the incident. Review of the facility's investigation of the incident reported on 04/27/14, revealed no documented evidence non-interviewable residents, those with a Brief Interview for Mental Status (BIMS) score of less than 8, were questioned or physically assessed for signs of possible abuse by Resident #1, the alleged perpetrator. Continued review revealed Resident #3 was not assessed for any evidence of sexual assault or other injury after the incident on 04/27/14. Record review revealed the facility revised Resident #1's care plan to include fifteen (15) minute checks after the 04/27/14 incident. However, there was no documented evidence the fifteen (15) minute checks were consistently completed. In addition, staff interviews revealed this intervention was not communicated to all staff and there was confusion as to who was responsible to conduct the checks. On 05/10/14, Resident #1 was observed to "grope" another resident (Resident #2). Record review revealed Resident #2 was not assessed for injury. Interview with the Director of Nursing (DON) and the Administrator on 05/29/14 at 5:35 PM, revealed after the 04/26/14 incident she instructed the staff to place Resident #1 on fifteen (15) minute checks. The DON acknowledged the checks were not done and/or had been inconsistently documented and the care plan not implemented per the facility's policy. The Administrator stated he was informed of the incident on 04/27/14 by the DON. He stated the DON kept him informed as the investigation proceeded. Continued interview with the DON and the Administrator revealed they felt they had done everything they could to ensure all residents were protected. The DON stated she believed the fifteen (15) minute checks provided adequate supervision and monitoring of Resident #1 because no staff reported the resident to be engaged in any inappropriate behaviors prior to 05/10/14, when Resident #1 was observed to have his/her hand between Resident #2's legs. However, there was no evidence the 15 minutes checks were consistently conducted, and interviews with staff revealed some were not aware Resident #1 was on 15 minutes checks. The Administrator further stated the facility went "above and beyond" by continuing the fifteen (15) minutes checks past the typical seventy-two (72) hour period when increased monitoring was indicated, despite the fact of the lack of, and inconsistent, documentation of the checks during the period between 04/28/14 and 05/10/14. Subsequent interview with the DON, on 05/29/14 at 7:25 PM, revealed head to toe skin assessments should have been completed on Residents #2 and #3 after the incidents were reported. She stated additional interventions should have been put in place to protect Resident #3 after the facility became aware, on 04/27/14, of the resident's allegation regarding Resident #1, and Residents #2 and #3 should have been monitored to determine how they were coping after the incidents. The DON indicated her responsibilities included ensuring facility staff were notified of incidents involving abuse and knew how to implement policies and procedures. The DON indicated the facility needed to create a more effective system of communicating incidents of resident to resident abuse to staff. The facility provided an acceptable credible AOC on 06/05/14 that alleged removal of the IJ effective 06/04/14. Review of the AOC revealed the facility implemented the following: 1. The Administrator, DON, ADON and SDN were educated on 05/30/14 by the Regional Director of Operations for Preferred Care Partners, Management Group on Accidents and Supervision on residents must be free from abuse and neglect in order to ensure residents' were protected. 2. The Quality Assurance (QA) Committee reviewed all educational materials and developed a data collection tool on 05/30/14 to validate assessments and Care Plans were being utilized per policy protocol. The tool includes a monitor for aggressive resident behaviors. If aggressive behavior occurs, interventions implemented will be reviewed for effectiveness and a determination if additional interventions are needed will be made. The tool was implemented on 05/30/14 and is ongoing. 3. Resident #3 had a weekly skin assessment completed on 05/03/14, and Resident #2 had a weekly skin assessments completed on 05/16/14. All residents were assessed for the potential to be an abuser, assessments were completed by 06/03/14. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Staff Development Nurse (SDN), and/or the Registered Nurse (RN) Supervisor completed the assessments. Information obtained was used to develop and implement appropriate interventions, and the Care Plans were updated initially by the DON, ADON or the SDN, and will be updated thereafter by RN Unit Managers and Charge Nurses. 4. For any resident to resident allegations, the aggressor is to be removed from the situation and placed on continuous observation until otherwise notified by the DON and/or the Administrator. CNAs will be notified of the continuous observation order via the CNA Care Plan and "Accunurse" (the CNA computer documentation system). Nurses and CNAs were educated on the process by the DON, ADON or SDN, with the education completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. The facility does not use agency staff. 5. The Administrator and the DON educated the ADON, SDN, RN Unit Managers, Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist tool, with the education completed by 06/03/14. The Administrator and the DON will monitor use of the checklist for every abuse investigation. The facility's general orientation for new hires was revised to include the education. 6. Licensed nursing staff were educated on performing assessments, interventions and updating the Care Plan, implementation and use of the Care Plan, the components of accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. The education was provided by the DON, ADON and SDN, and completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 7. All facility staff were educated on identifying and reporting abuse, with a focus on resident to resident sexual aggression, and on resident rights. The education was provided by the DON, ADON and SDN, and was completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 8. The Administrator or the DON will notify the Office of Inspector General, Adult Protective Services, the Ombudsman, and local law enforcement of all sexually aggressive behaviors as required by law and within specified time limits. 9. Educational records will be maintained and will include signatures of attendance, signatures of the education received, and copies of tests designed to determine the effectiveness of the education initiated on 05/30/14 and completed by 06/03/14. 10. The Administrator is charged to administer the facility in a safe and efficient manner to assure the safety of the residents at all times. The Administrator, in conjunction with the DON, ADON and SDN, will assure education is provided and resident care and treatment is delivered in accordance with the Care Plan. Continued evaluation, assessment and Care Plan updates will be used to ensure all residents are safe from harm. 11. Monitoring and utilizing the (QA) Committee data collection tool developed on 05/30/14, is done by the DON, ADON, SDN, RN Unit Managers and RN Supervisors. QA meetings to review the collected data will be held five (5) days per week, and as needed, for thirty (30) days, then weekly for thirty (30) days, then monthly or as needed thereafter. Any identified concerns will be corrected immediately. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the education sign-in sheets revealed the Administrator, DON, ADON and SDN were educated by the Regional Director of Operations on 05/30/14, prior to the administrative team conducting education of all facility staff. Continued review revealed topics covered included supervision of incidents/accidents; abuse reporting; conducting investigations, and reviewing residents who are at risk or cognitively impaired. Interview with the Administrator, on 06/06/14 at 1:30 PM, revealed the Regional Director of Operations performed the education for the DON, ADON, SDN and himself on 05/30/14. The Administrator stated the education was to ensure all residents were free from abuse and the facility was administered in a manner to assist residents to achieve their highest physical, mental and psychosocial well-being. 2. Review of the data collection tool developed by the QA Committee revealed it included, but was not limited to, validation of assessments completed, use of Care Plans, and a monitor of resident behaviors. In addition, in the case of aggressive behaviors, the tool allowed for a review of current interventions for effectiveness and a determination of the need for additional interventions. Interview with the DON and the Administrator, on 06/05/14 at 4:45 PM, revealed the tool was developed and implemented on 05/30/14, and was being used as outlined in the AOC ongoing. 3. Review of Resident #3's record revealed a weekly skin assessment was completed on 05/03/14, with no documented evidence of physical injury. Review of Resident #2's record revealed a weekly skin assessment was completed on 05/16/14, with no documented evidence of physical injury. Review of the facility's implementation documentation binder for the AOC revealed all residents were assessed, care plans were reviewed and updated for residents with identified behaviors, as alleged by the DON, ADON, SDN and RN Supervisor. Interview with the DON, on 06/05/14 at 2:20 PM, revealed she reviewed Resident #3's weekly skin assessment dated [DATE], and Resident #2's weekly skin assessment dated [DATE] and confirmed the residents had no physical injuries documented on those dates. The DON stated all residents in the facility were assessed, and those with behaviors were monitored for the potential to be an abuser, care planned for the behaviors, and any behaviors were documented every shift. In addition, all new admissions were assessed for any history of behaviors and care planned accordingly. 4. Review of the facility's implementation documentation binder for the AOC revealed staff signatures of nurses and CNAs who received the education on residents on continuous supervision, updating and following residents' care plans, use of the Abuse Allegation Checklist and completed post-tests successfully. Continued review revealed all education was provided on or prior to 06/03/14 as alleged. Review of the Abuse Allegation Checklist form utilized by the facility revealed it included removing the aggressor resident and placing the resident on continuous observation. Review of the QA Data Collection tool revealed monitoring included whether staff used the Abuse Allegation Checklist after each incident. Review of the ongoing investigation file for the only resident to resident incident after implementation of the AOC revealed the Abuse Allegation Checklist was used, the aggressor resident was removed from the situation, and 1:1 supervision was initiated and thoroughly documented on. Review of the CNA Worksheet/Care Plan for the resident aggressor revealed it was updated to reflect the increased supervision. Interviews 06/05/14 with CNA #6 at 2:45 PM; CNA #7 at 3:40 PM; and CNA #8 at 3:45 PM, revealed the CNAs education on residents on continuous supervision would be in the "Accunurse" computer system and on the CNA Worksheet/Care Plan. The CNAs reported receiving education related to providing the one on one (1:1) supervision and ensuring they documented the continuous supervision. Interviews 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and, LPN #9 at 3:35 PM, revealed the nurses were educated on use of the Abuse Allegation Checklist, and updating and ensuring the CNAs and they followed residents' care plans. 5. Review of the facility's implementation documentation binder for the AOC revealed education sign-in sheets and post-tests for the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors who attended the education provided by the Administrator and DON. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they educated the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist, on or before 06/03/14. The Administrator and DON stated they were monitoring for use of the Checklist with every abuse investigation. They reported the education had been added to the facility's general orientation for new hires. Interview with RN Supervisor #1, on 06/05/14 at 3:15 PM, revealed she had received the education provided, took a post-test and was knowledgeable about when and how to use the Abuse Investigation Checklist. 6. Review of the facility's implementation documentation binder for the AOC revealed licensed nursing staff received mandatory education related to performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. Review of the Sign-in sheets reflected the nurses' attendance, and their completion of the post-tests which cross-matched with the signatures. Continued review revealed all education was received on or prior to 06/03/14 by the DON, ADON and SDN. Interviews on 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and LPN #9 at 3:35 PM, revealed the nurses confirmed receiving the education on performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents and had taken the post-test afterwards. Interview with the DON on 06/06/14 at 4:45 PM, revealed the education had been provided prior to 06/03/14 as per the AOC for all licensed nursing staff. The DON stated the education had been added to the facility's general orientation for new hires. 7. Review of the facility's implementation documentation binder for the AOC revealed all facility staff had received education on abuse which included identifying and reporting abuse, resident to resident sexual aggression and Resident Rights. Continued review of the binder revealed a master list of employees, education sign-in sheets and post-tests which were cross-referenced to confirm the education. Interview with the SDN on 06/05/14 at 4:30 PM, revealed she had participated in providing education for all facility staff related to abuse and Resident Rights. She stated each Department Head had a list of all staff who still needed to receive the education prior to returning to work and ensured the education was provided before the employee was allowed to work. Interview with the DON, on 06/06/14 at 4:45 PM, revealed the facility ensured all facility staff received the mandatory education on abuse and Resident Rights, as per the AOC, by maintaining a master list of all staff and checking off names as they received the education. She stated a list of all staff on vacation or other leave included their return to work date, and no staff were allowed to be on duty prior to the education being completed. Interviews on 06/05/14 with: Dietary Personnel #1 at 2:00 PM, Dietary Personnel #2 at 2:05 PM; Maintenance Assistant #1 at 2:15 PM; Social Services (SS) Assistant #1 at 2:18 PM; Laundry Personnel #1 at 2:20 PM; Occupational Therapist (OT) #1 at 2:23 PM; LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; CNA #6 at 2:45 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; LPN #9 at 3:35 PM; CNA #7 at 3:40 PM; and, CNA #8 at 3:45 PM revealed they all had attended the mandatory inservices related to abuse and Resident Rights. Those interviewed were able to explain their responsibilities if abuse were observed, reported or suspected. All interviewees were cross-checked to the education sign-in sheets and post-tests. 8. Review of the facility's implementation documentation binder for the AOC revealed an ongoing investigation of a resident to resident altercation, which was not sexual in nature. Review of the investigation documentation revealed all required notifications were made timely in accordance with facility policy and federal and state regulations. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they would ensure notification of the State Survey Agency, Adult Protective Services, the Ombudsman and local law enforcement of all sexually aggressive behaviors as indicated in the AOC. However, they reported no incidents of sexually aggressive behaviors had occurred since the alleged date of compliance, 06/04/14. 9. Review of the facility's implementation documentation binder for the AOC revealed education records included sign-in sheets for all education provided. Continued review revealed staff members were checked off from a master list of all employees in order for the facility to ensure every staff member received the education prior to returning to work. In addition, copies of completed post-tests were available for review and were cross-checked with the sign-in sheets. A review of educational offering agendas revealed all topics included in the AOC were provided. Further review revealed all education was completed prior to or on 06/03/14 as alleged. Interview with the Administrator and the DON on 06/05/14 at 4:45 PM, revealed all the education was mandatory with records being maintained. Interview with the SDN, on 06/05/14 at 4:30 PM, revealed she tracked employee attendance via the sign-in sheets and the master list. She stated she tried to make the inservices interesting to maintain the learners' attention, and utilized post-tests to verify effectiveness of the education. 10. Interview with the Administrator and the DON on 06/06/14 at 1:30 PM, revealed the Administrator was responsible for the overall administration of the facility. He stated his goal was to ensure every resident was safe and staff were knowledgeable regarding providing care according to the written Care Plan. He further stated he had been closely involved with the DON throughout the development and implementation of the AOC, including the monitoring of data collected as part of the QA process. The Administrator stated he and the DON ensured the education was provided. He indicated the facility would continue to evaluate, assess and update residents' Care Plans to ensure all residents were safe from harm. Both the Administrator and the DON stated every action outlined in the AOC had been conducted as alleged. 11. Review of the facility's implementation documentation binder for the AOC revealed residents' behaviors were documented by staff every shift. Continued review revealed QA team members reviewed the collected data daily Monday through Friday. Interview with the DON revealed she reviewed all documented behaviors daily Monday through Friday to ensure the Care Plans were revised to include new interventions as indicated by the exhibited behavior. She stated the data is collected by her, the ADON, SDN, RN Unit Managers and RN Supervisors, with all behaviors reviewed by her.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to identify a Quality Assurance (QA) concern, and develop and implement an appropriate plan of action, when an allegation of resident to resident sexual abuse was made. The failure affected two (2) of ten (10) sampled residents (Residents #2 and #3). On 04/27/14, Resident #3 reported to staff he/she was touched on the inner thigh under his/her clothes by Resident #1. Resident #3 further reported the incident occurred on 04/26/14. The facility had a weekly Interdisciplinary Team (IDT) meeting on 04/28/14, during which the incident was reviewed. Staff was directed to perform every fifteen (15) minute checks on Resident #1; however, no monitoring system was put in place to ensure the checks were completed as directed. In addition, review of the fifteen (15) minute check sheets revealed no documented evidence the checks were performed consistently every fifteen (15) minutes, or documented to include the date the checks were performed. As a result of the facility's failure to monitor Resident #1, other residents were not protected from potential abuse. On 05/10/14, a staff member observed Resident #1 to have his/her hand between Resident #2's legs. Resident #1 was placed on 1:1 supervision at that time, until transferred to the hospital for further evaluation. The resident was discharged from the facility prior to initiation of the survey, and was not available for observation or interview. (Refer to F-223, F-225, F-226, F-282 and F-490) The failure of the facility's QA program to identify and develop an appropriate plan of action after an allegation of abuse, to prevent a reoccurrence of potential abuse, was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 05/28/14 and determined to exist on 04/27/14. The facility was notified of the Immediate Jeopardy on 05/28/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 06/05/14, with the facility alleging removal of the IJ on 06/04/14. The IJ was verified to be removed on 06/04/14 as alleged, prior to exit from the facility on 06/06/14, with remaining non-compliance at 42 CFR 483.75 Administration, F-520 with a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance program monitors to ensure residents are free from abuse. The findings include: Review of the facility's policy, titled "QA Committee Meeting Process" (dated 08/2008), revealed the facility's QA Committee met weekly as an IDT to discuss resident information and make recommendations. Continued review of the policy revealed five (5) areas, including incidents and accidents, were to be reviewed at each meeting. Review of the facility's Incident Report form, dated 04/27/14, revealed the facility reported Resident #1 "touched" Resident #3 on the leg under his/her clothes on 04/26/14. Continued review revealed Resident #3 expressed fear of Resident #1 after the incident. Review of Resident #1's Care Plan revealed it was revised to include every fifteen (15) minute checks after the 04/27/14 incident. However, the facility could not provide documented evidence the fifteen (15) minute checks were consistently performed. Review of the check sheets that were present in the medical record revealed the checks that were documented did not always include the date the action took place. In addition, staff interviews revealed all were not aware the intervention for fifteen (15) minute checks had been implemented, and there was confusion as to who was responsible for conducting the checks. On 05/10/14, Resident #1 was observed by a staff member to "grope" another resident (Resident #2). At that time, Resident #1 was placed on 1:1 observation until transferred out to the hospital for further evaluation. A post-survey telephone interview with the Administrator and the Director of Nursing (DON), conducted on 06/30/14 at 10:35 AM, revealed the facility conducted an IDT meeting weekly, as part of the overall QA program. Attendees included Clinical Managers and the Administrator. Continued interview revealed the incident reported by Resident #3 on 04/27/14 was discussed by the IDT at the weekly meeting on 04/28/14. The DON stated she could not be sure whether she directed staff to perform every fifteen (15) minute checks of Resident #1 on 04/27/14 when the incident was reported, or on 04/28/14 as a result of the IDT meeting. She further stated, in either case the frequent checks were determined by the IDT to be the appropriate plan of action in response to the incident involving Residents #3 and #1. However, continued interview with the Administrator and the DON, on 06/30/14 at 10:35 AM, revealed no formal QA action plan or monitoring was initiated after the 04/27/14 allegation of abuse involving Resident #1. The facility did not perform any monitoring to ensure the fifteen (15) minute checks were completed. The DON and the Administrator were unaware the checks were not performed and/or documented consistently. In addition, the Administrator and the DON did not know some nursing staff were unaware of a directive for the fifteen (15) minute checks. The facility provided an acceptable credible AOC on 06/05/14 that alleged removal of the IJ effective 06/04/14. Review of the AOC revealed the facility implemented the following: 1. The Administrator, DON, ADON and SDN were educated on 05/30/14 by the Regional Director of Operations for Preferred Care Partners, Management Group on Accidents and Supervision on residents must be free from abuse and neglect in order to ensure residents were protected. 2. The Quality Assurance (QA) Committee reviewed all educational materials and developed a data collection tool on 05/30/14 to validate assessments and Care Plans were being utilized per policy protocol. The tool includes a monitor for aggressive resident behaviors. If aggressive behavior occurs, interventions implemented will be reviewed for effectiveness and a determination if additional interventions are needed will be made. The tool was implemented on 05/30/14 and is ongoing. 3. Resident #3 had a weekly skin assessment completed on 05/03/14, and Resident #2 had a weekly skin assessments completed on 05/16/14. All residents were assessed for the potential to be an abuser, assessments were completed by 06/03/14. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Staff Development Nurse (SDN), and/or the Registered Nurse (RN) Supervisor completed the assessments. Information obtained was used to develop and implement appropriate interventions, and the Care Plans were updated initially by the DON, ADON or the SDN, and will be updated thereafter by RN Unit Managers and Charge Nurses. 4. For any resident to resident allegations, the aggressor is to be removed from the situation and placed on continuous observation until otherwise notified by the DON and/or the Administrator. CNAs will be notified of the continuous observation order via the CNA Care Plan and "Accunurse" (the CNA computer documentation system). Nurses and CNAs were educated on the process by the DON, ADON or SDN, with the education completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. The facility does not use agency staff. 5. The Administrator and the DON educated the ADON, SDN, RN Unit Managers, Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist tool, with the education completed by 06/03/14. The Administrator and the DON will monitor use of the checklist for every abuse investigation. The facility's general orientation for new hires was revised to include the education. 6. Licensed nursing staff were educated on performing assessments, interventions and updating the Care Plan, implementation and use of the Care Plan, the components of accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. The education was provided by the DON, ADON and SDN, and completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 7. All facility staff were educated on identifying and reporting abuse, with a focus on resident to resident sexual aggression, and on resident rights. The education was provided by the DON, ADON and SDN, and was completed by 06/03/14. The facility's general orientation for new hires was revised to include the education. 8. The Administrator or the DON will notify the Office of Inspector General, Adult Protective Services, the Ombudsman, and local law enforcement of all sexually aggressive behaviors as required by law and within specified time limits. 9. Educational records will be maintained and will include signatures of attendance, signatures of the education received, and copies of tests designed to determine the effectiveness of the education initiated on 05/30/14 and completed by 06/03/14. 10. The Administrator is charged to administer the facility in a safe and efficient manner to assure the safety of the residents at all times. The Administrator, in conjunction with the DON, ADON and SDN, will assure education is provided and resident care and treatment is delivered in accordance with the Care Plan. Continued evaluation, assessment and Care Plan updates will be used to ensure all residents are safe from harm. 11. Monitoring and utilizing the (QA) Committee data collection tool developed on 05/30/14, is done by the DON, ADON, SDN, RN Unit Managers and RN Supervisors. QA meetings to review the collected data will be held five (5) days per week, and as needed, for thirty (30) days, then weekly for thirty (30) days, then monthly or as needed thereafter. Any identified concerns will be corrected immediately. The State Agency validated the implementation of the facility's AOC as follows: 1. Review of the education sign-in sheets revealed the Administrator, DON, ADON and SDN were educated by the Regional Director of Operations on 05/30/14, prior to the administrative team conducting education of all facility staff. Continued review revealed topics covered included supervision of incidents/accidents; abuse reporting; conducting investigations, and reviewing residents who are at risk or cognitively impaired. Interview with the Administrator, on 06/06/14 at 1:30 PM, revealed the Regional Director of Operations performed the education for the DON, ADON, SDN and himself on 05/30/14. The Administrator stated the education was to ensure all residents were free from abuse and the facility was administered in a manner to assist residents to achieve their highest physical, mental and psychosocial well-being. 2. Review of the data collection tool developed by the QA Committee revealed it included, but was not limited to, validation of assessments completed, use of Care Plans, and a monitor of resident behaviors. In addition, in the case of aggressive behaviors, the tool allowed for a review of current interventions for effectiveness and a determination of the need for additional interventions. Interview with the DON and the Administrator, on 06/05/14 at 4:45 PM, revealed the tool was developed and implemented on 05/30/14, and was being used as outlined in the AOC ongoing. 3. Review of Resident #3's record revealed a weekly skin assessment was completed on 05/03/14, with no documented evidence of physical injury. Review of Resident #2's record revealed a weekly skin assessment was completed on 05/16/14, with no documented evidence of physical injury. Review of the facility's implementation documentation binder for the AOC revealed all residents were assessed, care plans were reviewed and updated for residents with identified behaviors, as alleged by the DON, ADON, SDN and RN Supervisor. Interview with the DON, on 06/05/14 at 2:20 PM, revealed she reviewed Resident #3's weekly skin assessment dated [DATE], and Resident #2's weekly skin assessment dated [DATE] and confirmed the residents had no physical injuries documented on those dates. The DON stated all residents in the facility were assessed, and those with behaviors were monitored for the potential to be an abuser, care planned for the behaviors, and any behaviors were documented every shift. In addition, all new admissions were assessed for any history of behaviors and care planned accordingly. 4. Review of the facility's implementation documentation binder for the AOC revealed staff signatures of nurses and CNAs who received the education on residents on continuous supervision, updating and following residents' care plans, use of the Abuse Allegation Checklist and completed post-tests successfully. Continued review revealed all education was provided on or prior to 06/03/14 as alleged. Review of the Abuse Allegation Checklist form utilized by the facility revealed it included removing the aggressor resident and placing the resident on continuous observation. Review of the QA Data Collection tool revealed monitoring included whether staff used the Abuse Allegation Checklist after each incident. Review of the ongoing investigation file for the only resident to resident incident after implementation of the AOC revealed the Abuse Allegation Checklist was used, the aggressor resident was removed from the situation, and 1:1 supervision was initiated and thoroughly documented on. Review of the CNA Worksheet/Care Plan for the resident aggressor revealed it was updated to reflect the increased supervision. Interviews 06/05/14 with CNA #6 at 2:45 PM; CNA #7 at 3:40 PM; and CNA #8 at 3:45 PM, revealed the CNAs education on residents on continuous supervision would be in the "Accunurse" computer system and on the CNA Worksheet/Care Plan. The CNAs reported receiving education related to providing the one on one (1:1) supervision and ensuring they documented the continuous supervision. Interviews 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and, LPN #9 at 3:35 PM, revealed the nurses were educated on use of the Abuse Allegation Checklist, and updating and ensuring the CNAs and they followed residents' care plans. 5. Review of the facility's implementation documentation binder for the AOC revealed education sign-in sheets and post-tests for the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors who attended the education provided by the Administrator and DON. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they educated the ADON, SDN, RN Unit Managers, RN Shift Supervisors and Weekend Supervisors on the use of the Abuse Investigation Checklist, on or before 06/03/14. The Administrator and DON stated they were monitoring for use of the Checklist with every abuse investigation. They reported the education had been added to the facility's general orientation for new hires. Interview with RN Supervisor #1, on 06/05/14 at 3:15 PM, revealed she had received the education provided, took a post-test and was knowledgeable about when and how to use the Abuse Investigation Checklist. 6. Review of the facility's implementation documentation binder for the AOC revealed licensed nursing staff received mandatory education related to performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents. Review of the Sign-in sheets reflected the nurses' attendance, and their completion of the post-tests which cross-matched with the signatures. Continued review revealed all education was received on or prior to 06/03/14 by the DON, ADON and SDN. Interviews on 06/05/14 with LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; and LPN #9 at 3:35 PM, revealed the nurses confirmed receiving the education on performing assessments, interventions and updating the Care Plan, implementation of the Care Plan, accurate and thorough shift reporting, and identification, documentation and investigation of incidents and accidents and had taken the post-test afterwards. Interview with the DON on 06/06/14 at 4:45 PM, revealed the education had been provided prior to 06/03/14 as per the AOC for all licensed nursing staff. The DON stated the education had been added to the facility's general orientation for new hires. 7. Review of the facility's implementation documentation binder for the AOC revealed all facility staff had received education on abuse which included identifying and reporting abuse, resident to resident sexual aggression and Resident Rights. Continued review of the binder revealed a master list of employees, education sign-in sheets and post-tests which were cross-referenced to confirm the education. Interview with the SDN on 06/05/14 at 4:30 PM, revealed she had participated in providing education for all facility staff related to abuse and Resident Rights. She stated each Department Head had a list of all staff who still needed to receive the education prior to returning to work and ensured the education was provided before the employee was allowed to work. Interview with the DON, on 06/06/14 at 4:45 PM, revealed the facility ensured all facility staff received the mandatory education on abuse and Resident Rights, as per the AOC, by maintaining a master list of all staff and checking off names as they received the education. She stated a list of all staff on vacation or other leave included their return to work date, and no staff were allowed to be on duty prior to the education being completed. Interviews on 06/05/14 with: Dietary Personnel #1 at 2:00 PM, Dietary Personnel #2 at 2:05 PM; Maintenance Assistant #1 at 2:15 PM; Social Services (SS) Assistant #1 at 2:18 PM; Laundry Personnel #1 at 2:20 PM; Occupational Therapist (OT) #1 at 2:23 PM; LPN #4 at 2:30 PM; LPN #5 at 2:35 PM; CNA #6 at 2:45 PM; RN Supervisor #1 at 3:15 PM; LPN #7 at 3:20 PM; LPN #8 at 3:25 PM; LPN #6 at 3:30 PM; LPN #9 at 3:35 PM; CNA #7 at 3:40 PM; and, CNA #8 at 3:45 PM revealed they all had attended the mandatory inservices related to abuse and Resident Rights. Those interviewed were able to explain their responsibilities if abuse were observed, reported or suspected. All interviewees were cross-checked to the education sign-in sheets and post-tests. 8. Review of the facility's implementation documentation binder for the AOC revealed an ongoing investigation of a resident to resident altercation, which was not sexual in nature. Review of the investigation documentation revealed all required notifications were made timely in accordance with facility policy and federal and state regulations. Interview with the Administrator and the DON, on 06/06/14 at 1:30 PM, revealed they would ensure notification of the State Survey Agency, Adult Protective Services, the Ombudsman and local law enforcement of all sexually aggressive behaviors as indicated in the AOC. However, they reported no incidents of sexually aggressive behaviors had occurred since the alleged date of compliance, 06/04/14. 9. Review of the facility's implementation documentation binder for the AOC revealed education records included sign-in sheets for all education provided. Continued review revealed staff members were checked off from a master list of all employees in order for the facility to ensure every staff member received the education prior to returning to work. In addition, copies of completed post-tests were available for review and were cross-checked with the sign-in sheets. A review of educational offering agendas revealed all topics included in the AOC were provided. Further review revealed all education was completed prior to or on 06/03/14 as alleged. Interview with the Administrator and the DON on 06/05/14 at 4:45 PM, revealed all the education was mandatory with records being maintained. Interview with the SDN, on 06/05/14 at 4:30 PM, revealed she tracked employee attendance via the sign-in sheets and the master list. She stated she tried to make the inservices interesting to maintain the learners' attention, and utilized post-tests to verify effectiveness of the education. 10. Interview with the Administrator and the DON on 06/06/14 at 1:30 PM, revealed the Administrator was responsible for the overall administration of the facility. He stated his goal was to ensure every resident was safe and staff were knowledgeable regarding providing care according to the written Care Plan. He further stated he had been closely involved with the DON throughout the development and implementation of the AOC, including the monitoring of data collected as part of the QA process. The Administrator stated he and the DON ensured the education was provided. He indicated the facility would continue to evaluate, assess and update residents' Care Plans to ensure all residents were safe from harm. Both the Administrator and the DON stated every action outlined in the AOC had been conducted as alleged. 11. Review of the facility's implementation documentation binder for the AOC revealed residents' behaviors were documented by staff every shift. Continued review revealed QA team members reviewed the collected data daily Monday through Friday. Interview with the DON revealed she reviewed all documented behaviors daily Monday through Friday to ensure the Care Plans were revised to include new interventions as indicated by the exhibited behavior. She stated the data is collected by her, the ADON, SDN, RN Unit Managers and RN Supervisors, with all behaviors reviewed by her.