Every finding on record at Wurtland Nursing and Rehabilitation

Based on interviews, record review, and review of the facility's documents and policy, the facility failed to ensure the physician was notified of a change in condition when the resident began showing signs of fluid overload. Resident (R) 117 experienced a significant weight gain of 17 pounds in 13 days, from [DATE] to [DATE], while a resident at the facility. The facility's failure to recognize and notify the physician of the resident's condition change beginning on [DATE] resulted in a delay in intervention and treatment for the resident. The resident was admitted to the hospital on [DATE] with diagnoses of fluid overload and myocardial infarction and expired at the hospital on [DATE], approximately eight hours and forty-five minutes after his arrival at the hospital. The deficient practice affected 1 of 35 residents reviewed for physician notification.Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the area of 42 CFR 483.10, Resident Rights, F580 at a Scope and Severity (S/S) of a J. The facility's Administrator was notified of the IJ on [DATE].The facility provided an acceptable IJ Removal Plan on [DATE] alleging removal of the IJ on [DATE]. The State Survey Agency's survey team validated the facility's corrective action to remove the IJ prior to exit with remaining non-compliance remaining at a S/S of a D.Refer to F684 and F656The findings include: Review of the facility's policy titled, Weight Monitoring, dated [DATE], revealed staff was to weigh residents as ordered. Further review revealed staff was to notify the physician of a weight gain or loss of three pounds within one week.Closed record review of R117's admission Record revealed the facility admitted R117 on [DATE] with diagnoses including pneumonia, nontraumatic subdural hemorrhage, and primary hypertension.Review of R117's admission Note, revealed the resident weighed 252.8 pounds on [DATE].Review of R117's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of eight out of 15, indicating the resident was moderately cognitively impaired. Further review revealed the resident had diagnoses of atrial fibrillation and hypertension. Review of R117's Care Plan, dated [DATE], revealed interventions for nurses to weigh the resident as ordered and notify the physician of significant weight changes. Further review of the care plan revealed staff was to document abnormal findings and notify the physician.Review of the Physician's Orders for R117, dated [DATE], revealed an order for weekly weights.Review of R117's weights on the facility's document Weight Summary revealed the Director of Nursing (DON) entered the resident's weight of 259 pounds on [DATE], a gain of 6.2 pounds in four days, from admission. Further review revealed LPN1 entered the resident's weight of 267 pounds on [DATE], for a gain of 14.2 pounds in nine days, from admission. However, there was no documentation to support the provider was notified related to the 14.2-pound gain. Review of the Skilled Care Nursing Documentation, the assessment dated [DATE], revealed Licensed Practical Nurse (LPN) 1 documented R117 as having shortness of breath and/or labored breathing with exercise and while lying flat, but there was no documentation to support the physician was notified related to the resident's abnormal findings of having shortness of breath and/or labored breathing, as per the resident's care plan. Review of R117's weights on the facility's document Weight Summary revealed on [DATE], LPN4 documented the resident's weight of 270 pounds, 13 days from admission, for a gain of 17.2 pounds since admission. Review of R117's Health Status Note, found in the electronic medical record (EMR), dated [DATE], revealed LPN4 notified the APRN of her assessment findings and obtained orders for a chest x-ray (related to fluid retention), labs, and intramuscular furosemide (a potent diuretic used to treat fluid retention).Review of R117's Progress Notes-View All, from [DATE] through [DATE], revealed no evidence the facility staff identified R117's weight gain as a symptom of a significant change in condition. Further review revealed no evidence that the facility staff notified the physician of a weight gain of three pounds or more after the weights were taken on [DATE], with a 6.2-pound weight gain in four days, and on [DATE] with a 14.2-pound weight gain in nine days.Review of R117's Health Status Note, dated [DATE] at 2:43 PM and written by LPN4, revealed the resident had +3 to +4 pitting edema (swelling caused by too much fluid trapped in the body's tissue) in all four extremities, as well as shortness of breath. Further review revealed the facility sent R117 to the hospital for an evaluation at the request of the resident's family member, FM1.In an interview on [DATE] at 10:00 AM, R117's family member (FM) 1 stated he visited the resident every day and noticed the resident's legs, feet, and scrotum were increasingly swollen throughout R117's stay at the facility. He further stated he expressed his concerns to staff every day, but they told him the edema was not a problem. FM1 stated he told the staff he wanted to take R117 home early in his stay because he felt staff ignored his worries about R117's edema. FM1 stated he communicated his concerns about R117's edema to LPN4 on the morning of [DATE]. Review of R117's hospital records revealed the hospital admitted R117 on [DATE] with diagnoses of acute congestive heart failure (CHF) exacerbation, fluid overload, atrial fibrillation, and myocardial infarction. Further review revealed R117 expired at the hospital at 12:25 AM on [DATE].In an interview on [DATE] at 1:42 PM, LPN1, who charted R117's weight on [DATE] stated if she noticed a significant change in a resident's weight, she would re-weigh the resident to check for accuracy, assess the resident for swelling or respiratory distress, and notify the physician. LPN1 further stated she could not recall if she notified the Advanced Practice Registered Nurse (APRN) about R117 gaining weight. She stated her practice was to always document when she notified the APRN or physician about a resident's condition. In an interview on [DATE] at 1:18 PM, the APRN stated any time a resident experienced a rapid weight gain, it was important for staff to notify the APRN or physician. He stated that a lot of things could cause weight gain, so if a resident gained weight, his practice was to order a re-weigh of the resident and instruct staff to complete an assessment of the resident to check for fluid overload. In further interview, the APRN stated staff did not notify him of any of R117's repeated weight gains until [DATE]. In an interview on [DATE] at 5:27 PM, the Medical Director, who was also R117's primary physician, stated his expectation was for staff to notify him or the APRN of significant changes in the resident's condition, including weight changes. In continued interview, the Medical Director stated he relied heavily on nurses to follow the policies and act appropriately on assessment findings. In an interview on [DATE] at 5:49 PM, the Director of Nursing (DON) stated her expectations were for staff to ensure accurate weights and to re-weigh the residents if there was a discrepancy. Further, she stated staff should notify the physician. The DON stated she could not find evidence that would suggest the facility's staff identified R117's weight gain as a symptom of a significant change in condition or notified the APRN of R117's weight gain. In an additional interview on [DATE] at 12:42 PM, with the DON, she stated she did not recall identifying R117's weight gain on [DATE] as a significant increase from his admission weight after she entered the increased weight in the electronic health record. She further stated she did not recall notifying the APRN of R117's weight gain.In an interview on [DATE] at 9:30 AM, the Administrator stated he was not clinical, but he expected staff to follow policies and notify the APRN or physician when appropriate. The Administrator further stated he could not find evidence the facility had notified the APRN or physician of R117's weight change, stating, If we missed a weight, that's on us. The facility provided an acceptable IJ Removal Plan on [DATE] alleging removal of the IJ on [DATE] which the State Survey Agency survey team validated prior to exit on [DATE]. The IJ Removal Plan is as follows verbatim: Address what corrective action will be accomplished for those residents found to have been affected by the deficient practice.1. Resident number 117 was discharged on [DATE].Address how the facility will identify other residents having the potential to be affected by the same deficient practice.2. All current residents were re-weighed and reassessed for change of condition on 3.7.26 by Director of Nursing Services, Assistant Director of Nursing Services and Unit Manager with weights being reviewed for the last 6 months. All significant changes in weight resulted in nursing assessment per Director of Nursing Services, Assistant Director of Nursing services, or Unit manager with notification of physician or nurse practitioner for orders as needed. All residents were reassessed and reweighed on 3.7.26. All residents were reassessed by Director of Nursing Services, Assistant Director of Nursing Services, Unit Manager with any changes of condition reported to the Nurse Practitioner and orders given on 3.7.26.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.3. Director of Nursing Services educated by the Regional Nurse Consultant on [DATE] to review weight reports timely related to weekly Nutritional At Risk (NAR) meeting. Beginning on 3.7.26 all nurses educated by Infection Preventionist/Staff Development, Director of Nursing Services or Assistant Director of Nursing Services regarding policy on notifying the physician or nurse practitioner of all changes of conditions including weight changes with no nurse working before receiving the education, 13 of 23 currently completed. Post test given to all nurses regarding the education with expected 100% pass rate. If 100% pass rate is not achieved, re-education was given. DNS, ADNS, IPSO or unit manager will provide education until all 23 of 23 nurses completed.Education will be added to all new hire orientation for nurses. No outside nursing agencies utilized at this time.Indicate how the facility plans to monitor its performance to ensure that solutions are sustained.4. On 3/7 /26 an ADHOC Quality Assurance Performance Improvement (QAPI) meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and the Medical Director. This meeting reviewed the alleged deficiency, audit tools and education for all care team members regarding notification of changes.The QAPI (Quality Assurance Performance Improvement) Committee consists of the Medical Director, Executive Director, Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, Human Resources Director, Business Office Manager, Therapy Manager, Social Services Director, Activities Director, and MOS Nurse.Beginning 3.8.26 Director of Nursing Services, Assistant Director of Nursing or Unit Manager will audit to ensure that all changes in condition including weight changes resulted in physician or nurse practitioner notification. Results of audit will be forwarded to the QAPI Committee for review, presented by the Director of Nursing.An Ad Hoc QAPI was completed on [DATE] with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant and Medical Director. This meeting reviewed the audit tools, plan and education audits regarding notification of change in conditions.5. Completion Date [DATE]

Based on observation, interview, record review, and review of the facility's documents and policies, the facility failed to develop and implement a comprehensive care plan to ensure the care plan met each of the resident's medical, nursing, mental and psychosocial needs identified on his/her comprehensive assessment for 1 of 35 residents reviewed for comprehensive care plans, Resident (R) 117.R117 gained 17 pounds in 13 days while a resident at the facility from [DATE] through [DATE], a significant weight gain with exhibited signs of edema. The resident was sent to the hospital on [DATE] and admitted with diagnoses of fluid overload and myocardial infarction (heart attack). The resident expired at the hospital on [DATE], approximately eight hours and forty-five minutes after his arrival at the hospital. The facility's failure to implement interventions from his care plan and notify the physician beginning on [DATE] resulted in a delay in intervention and treatment for the resident. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the area of 42 CFR 483.21, Comprehensive Resident Centered Care Plan, F656 at a Scope and Severity (S/S) of a J. The facility's Administrator was notified of the IJ on [DATE].The facility provided an acceptable IJ Removal Plan on [DATE] alleging removal of the IJ on [DATE]. The State Survey Agency survey team validated the facility's corrective action to remove the IJ prior to exit with remaining non-compliance remaining at a S/S of a D.See F684The findings include:Review of the facility's policy titled, Comprehensive Care Plans, dated [DATE], revealed the facility was to develop and implement a resident-specific comprehensive care plan.Review of the facility's policy titled, Weight Monitoring, dated [DATE], revealed staff was to weigh residents as ordered. Further review revealed staff was to notify the physician of a weight gain or loss of three pounds within one week.Review of R117's admission Record revealed the facility admitted R117 on [DATE] with diagnoses including pneumonia, nontraumatic subdural hemorrhage, and primary hypertension.Review of R117's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the resident had diagnoses of atrial fibrillation and hypertension. Further review revealed the facility documented the resident had an intravenous (IV) access to receive antibiotics, however, failed to fully develop the resident's care plan which included goals and interventions for the IV. Review of R117's Care Plan, dated [DATE], revealed an intervention for nurses to weigh the resident as ordered and notify the physician of significant weight changes. Further review of the care plan revealed the facility updated the care plan on [DATE] to include the resident was at risk for cardiac dysfunction due to arrythmias and coronary artery disease. Per review of the care plan, an intervention was developed for staff to observe R117 for signs and symptoms of cardiac dysfunction such as shortness of breath, cough, abnormal lung sounds, change in mental status, activity intolerance, decreased urine output, edema, dizziness, and weakness. Continued review revealed staff was to document abnormal findings and notify the physician. Additional review of the care plan revealed no resident specific interventions developed in R117's care plan to address his needs related to potential complications from continuously infusing intravenous (IV) fluids. Review of the Physician's Orders for R117, dated [DATE], revealed an order for weekly weights.Review of R117's weights on the facility's document Weight Summary revealed the Director of Nursing (DON) entered the resident's weight of 259 pounds on [DATE], a gain of 6.2 pounds in four days, from the admission weight obtained on [DATE]. Further review revealed LPN1 entered the resident's weight of 267 pounds on [DATE], for a gain of 14.2 pounds in 9 days, from admission. There was no documented evidence, however, to support the facility implemented the resident's care plan and notified the physician of the significant weight changes between [DATE] to [DATE]. Review of R117's weights on the facility's document Weight Summary revealed on [DATE], LPN4 documented the resident's weight of 270 pounds, 13 days from admission, for a gain of 17.2 pounds since admission. Review of the hospital documentation All Progress Notes revealed hospital nurses documented R117 arrived on the inpatient unit on [DATE] at 9:44 PM. Further review revealed nurses noted R117's duress alarm activated in R117's room, and they entered to find R117 unresponsive, in pulseless electrical activity (PEA) with agonal breathing. Continued review revealed the nurses activated the Code Blue at 11:59 PM on [DATE]. Further review revealed the physician determined R117 expired at 12:25 AM on [DATE].In an interview on [DATE] at 10:00 AM, R117's family member (FM) 1 stated he visited the resident every day and noticed the resident's legs, feet, and scrotum swelling increasing throughout R117's stay at the facility. FM1 stated he told the staff he wanted to take R117 home early in his stay because he felt staff ignored his worries about the R117's edema (swelling caused by too much fluid trapped in the body's tissues. It can be life-threatening if not treated quickly). In further interview, he stated the facility convinced him to give them a chance to show him they could care for R117. FM1 stated he told the staff on [DATE] that he wanted R117 sent to the hospital due to his concerns with the resident's edema. According to FM1, it was not until he made the request that the facility staff finally arranged to send R117 to the hospital. In an interview on [DATE] at 1:42 PM, Licensed Practical Nurse (LPN) 1 stated she did not remember R117's care plan specifically, but standard interventions for monitoring weight changes included notifying the physician about changes in the resident's weight. LPN1 stated she did not recall notifying R117's physician about the weight gain, nor was she able to find evidence of the physician notification after reviewing R117's chart. Further, she stated she did not remember assessing R117 specifically, but she would listen to resident lung sounds as part of her assessment. She stated she did not always directly assess the resident for edema. However, review of the resident's care plan revealed staff would observe the resident for signs and symptoms of cardiac dysfunction, which included assessing the resident for edema. This was a failure to follow the resident's care plan. In an interview on [DATE] at 11:06 AM, LPN3 stated she did not remember R117's care plan specifically, but she would expect a cardiac care plan to include weighing the resident as ordered and notifying the physician of any changes. She further stated following the care plan was important to take care of each resident in ways that met their needs.In an interview on [DATE] at 6:17 PM, LPN7 stated care plans were the means for communicating to everyone what kind of care each resident needed. LPN7 stated the orders for R117's 24-hour IV antibiotic infusion were something nurses at the facility had never seen before, but they received no guidance on any kind of special precautions or monitoring for the IV. In an interview on [DATE] at 12:34 PM, the Minimum Data Set Coordinator (MDSC) stated she did not recall R117 specifically and had not participated in any interdisciplinary team meetings or root cause analyses related to his care. She further stated general interventions for a resident with cardiac problems would be for staff to follow medication orders, obtain weights and vital signs as ordered, and monitor for signs of fluid overload. She further stated she would also expect an intervention about notifying the physician with any change in condition, including weights.In an interview on [DATE] at 10:11 AM, the Unit Manager (UM) stated it was important for staff to implement care planned interventions to ensure residents received the care they needed. She further stated she conducted spot checks on resident care plans to ensure care planned interventions were implemented. The UM stated she did not know what caused staff to fail to implement the interventions in R117's care plan.In an interview on [DATE] at 1:18 PM, the Advanced Practice Registered Nurse (APRN) stated that any time a resident experienced a rapid weight gain, it was important for staff to notify the APRN or physician. He stated a lot of things could cause weight gain, so if a resident gained weight, his practice was to order a re-weight and focused assessment on the resident to check for fluid overload. Per interview, the APRN stated staff did not notify him of changes in assessment findings, including the weight gain, until [DATE]. In an interview on [DATE] at 5:49 PM, the Director of Nursing (DON) stated she expected staff to follow care plans, including R117's interventions to notify the physician of significant weight changes and edema.In an interview with the Administrator on [DATE] at 1:30 PM, he stated he expected staff to follow the residents' care plans to ensure the residents' care needs and identified interventions were implemented.The facility provided an acceptable IJ Removal Plan on [DATE] alleging removal of the IJ on [DATE] which the State Survey Agency survey team validated prior to exit on [DATE]. The IJ Removal Plan is as follows verbatim: Address what corrective action will be accomplished for those residents found to have been affected by the deficient practice.1. Resident number 117 was discharged on [DATE].Address how the facility will identify other residents having the potential to be affected by the same deficient practice.2. All current residents have the potential to be affected. All residents were reassessed and reweighed on 3.7.26. All were reassessed by Director of Nursing Services, Assistant Director of Nursing Services, Unit Manager with any changes of condition reported to the Nurse Practitioner and orders given on 3.7.26.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.3. All care plans were reviewed for residents with congestive heart failure, use of diuretics, and orders for daily or weekly weights by Regional Resident Assessment Specialist on 3/7 /26 to ensure accuracy.Beginning on 3.7.26 all nurses were re-educated by Infection Preventionist/Staff Development, Director of Nursing Services or Assistant Director of Nursing Services regarding care plan policy specifically, implementation and notification to physician with changes of condition. with no nurse working before receiving the education, 13 of 23 currently completed. Post test given to all nurses regarding the education with expected 100% pass rate. If 100% pass rate not achieved, re-education was given. DNS, ADNS, IPSO or unit manager will provide education until all 23 of 23 nurses completed.Education will be added to all new hire orientation for nurses. No outside nursing agencies utilized at this time. Indicate how the facility plans to monitor its performance to ensure that solutions are sustained.4. On 3/7 /26 an ADHOC Quality Assurance Performance Improvement (QAPI) meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and the Medical Director. This meeting reviewed the alleged deficiency, audit tools, plan and education for all care team members regarding notification of changes.The QAPI (Quality Assurance Performance Improvement) Committee consists of the Medical Director, Executive Director, Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, Human Resources Director, Business Office Manager, Therapy Manager, Social Services Director, Activities Director, and MDS Nurse.Beginning 3.8.26 Director of Nursing Services, Assistant Director of Nursing or Unit Manager will audit to ensure that all weight changes resulted in physician or nurse practitioner notification per the care plan. Results of audit will be forwarded to the QAPI Committee for review, presented by the director of nursing.An Ad Hoc QAPI was completed on [DATE] with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant and Medical Director. This meeting reviewed the audit tools, plan and education audits regarding implementation of care plans related to notification of changes.5. Completion Date [DATE]

Based on interview, record review, and review of the facility's policies, the facility failed to recognize a change in a resident's condition, to ensure the resident received quality of care based on the facility's identified care and treatment needs for the resident and failed to ensure professional standards of practice for the resident's care were provided that would meet the resident's physical, mental, and psychosocial needs for 1 of 35 sampled residents reviewed for quality of care concerns, Resident (R) 117.R117 gained 17 pounds in 13 days, a significant weight gain with exhibited signs of edema, while a resident at the facility from [DATE] through [DATE]. The facility's failure to recognize the weight gain as a sign of a change in condition beginning on [DATE] resulted in a delay in intervention and treatment for the resident. The resident was sent to the hospital on [DATE] and admitted with diagnoses of fluid overload and myocardial infarction (heart attack). The resident expired at the hospital on [DATE], approximately eight hours and forty-five minutes after his arrival at the hospital. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the area of 42 CFR 483.25, Quality of Care, F684 at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F684. The facility's Administrator was notified of the IJ on [DATE]. The facility provided an acceptable IJ Removal Plan on [DATE] alleging removal of the IJ on [DATE]. The State Survey Agency survey team validated the facility's corrective action to remove the IJ prior to exit with remaining non-compliance at a S/S of a D.The findings include:Review of the facility's policy titled, Change in Condition, dated [DATE], revealed the facility's staff was to notify the nurse practitioner and/or physician for changes in condition including abnormal weights, the need to alter medications or treatment, and significant changes in the resident's mental status.Review of the facility's policy titled, Weight Monitoring, dated [DATE], revealed the facility's staff was to weigh residents as ordered. Further review revealed the facility's staff was to re-weigh the resident for a weight change of three pounds or greater in one day or five pounds in one week. Continued review revealed the facility's staff was to notify the physician, the resident, and the resident's representative of the weight change.Review of the hospital record documents, Physician Discharge Summary, and Discharge Papers, dated [DATE], revealed R117 was discharged from the hospital to the facility for short term rehabilitation following a serious illness with sepsis and a spinal abscess, weighing 257 pounds. Further review revealed the hospital diagnosed the resident with atrial fibrillation, coronary artery disease, and pneumonia. Per the Physician Discharge Summary, R117 had stable shortness of breath and coarse breath sounds at discharge from the hospital.Review of R117's admission Record revealed the facility admitted R117 on [DATE] with diagnoses including pneumonia, nontraumatic subdural hemorrhage, and primary hypertension.Review of R117's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the resident had diagnoses of atrial fibrillation and hypertension. Further review revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of eight of 15, indicating the resident was moderately cognitively impaired. Continued review revealed the facility documented the resident had an intravenous (IV) access and did not receive diuretics in the lookback period. Additional review revealed R117 planned to return home after discharge. Per the admission MDS, the facility assessed R117 as having shortness of breath when lying flat.Review of R117's Care Plan, dated [DATE], revealed interventions for nurses to weigh the resident as ordered and notify the physician of significant weight changes. Further review of the Care Plan revealed the facility updated the care plan on [DATE] to include identifying the resident as at risk for cardiac dysfunction with interventions of staff to observe R117 for signs and symptoms of cardiac dysfunction such as shortness of breath, cough, abnormal lung sounds, change in mental status, activity intolerance, decreased urine output, edema, dizziness, and weakness. Continued review revealed staff was to document abnormal findings and notify the physician.Review of the Physician's Orders for R117, dated [DATE], revealed orders for intravenous (IV) nafcillin 0.5 grams per hour (an antibiotic) to infuse at 47 milliliters per hour continuously. Further review revealed orders for weekly weights, oxygen via nasal cannula at 2 liters per minute (L/min), and BiPAP (a device which maintained positive airway pressure) to be worn at night at 30 percent oxygen. Review of the admission Progress Note, dated [DATE], revealed the note stated R117's admission weight was 252.8 pounds.Review of the facility's document Health Status Note, dated [DATE] and written by Licensed Practical Nurse (LPN) 5, stated Family Member (FM) 1 notified her that R117's right hand was swollen. Further review revealed LPN5 documented R117 had swelling, increased confusion from the resident's baseline, and complained of shortness of breath. Per the documentation, LPN5 notified the Advanced Practice Registered Nurse (APRN), who gave orders to continue to monitor the resident. Review of R117's weights on the facility's document Weight Summary revealed the Director of Nursing (DON) entered the resident's weight of 259 pounds on [DATE], a gain of 6.2 pounds in four days, from admission. Further review revealed LPN1 entered the resident's weight of 267 pounds on [DATE], for a gain of 14.2 pounds in 9 days, from admission. Review of the facility's document Skilled Care Nursing Documentation, the assessment dated [DATE], revealed the nurse documented R117 as having shortness of breath and/or labored breathing with exercise and while lying flat. Per the nursing assessment, R117 required supplemental oxygen and maintaining the head of the bed in an elevated position. Further review revealed the nurse documented R117 had edema in both his lower extremities. Review of the Skilled Care Nursing Documentation, the assessment dated [DATE], revealed LPN1 documented R117 as having shortness of breath and/or labored breathing with exercise and while lying flat. Per the nursing assessment, R117 required supplemental oxygen and maintaining the head of the bed in an elevated position.Review of R117's Progress Notes-View All, from [DATE] through [DATE], revealed none of the notes documented the resident had edema or shortness of breath. Further review revealed there was no evidence the facility's staff recognized the resident's weight gain as a significant change in status. Continued record review revealed no evidence the facility staff re-weighed the resident and notified the physician of the significant weight gain after any of the weights taken on [DATE] or [DATE], per the facility policy and resident's care plan. Review of R117's weights on the facility's document Weight Summary revealed on [DATE], LPN4 documented the resident's weight of 270 pounds, 13 days from admission, for a gain of 17.2 pounds since admission.Review of R117's Health Status Note, dated [DATE] and written by LPN4, revealed the resident had +3 to +4 pitting edema in all four extremities, as well as shortness of breath. In an interview on [DATE] at 10:00 AM, R117's family member (FM) 1 stated he visited the resident every day and noticed the resident's legs, feet, and scrotum were increasingly swollen throughout R117's stay at the facility. He further stated he expressed his concerns to staff every day, but they told him the edema was not a problem. FM1 stated he told the staff he wanted to take R117 home early in his stay because he felt staff ignored his worries about R117's edema, but the facility convinced him to give them a chance to show they could care for R117. Per interview, when FM1 expressed his concerns about R117's edema to LPN4 on the morning of [DATE], FM1 stated the LPN4 informed him the APRN wanted to treat the resident in the facility with diuretics (water pills that assisted with removing excess fluid from the body). FM1 stated the APRN initially did not agree to send R117 to the hospital. However, he stated, in the afternoon of [DATE], FM1 repeated his insistence that the facility send R117 to the hospital for evaluation and treatment. FM1 stated after his second request for a hospital transfer, the APRN finally agreed to send R117 to the hospital.In an interview on [DATE] at 1:42 PM, LPN1, who charted R117's weight on [DATE], stated if she noticed a change in a resident's weight, she would re-weigh the resident to check for accuracy, assess the resident for swelling or respiratory distress, and notify the physician for a change of so many pounds [not specific], depending on what was going on with the resident, including diagnoses and overall presentation. LPN1 stated she could not recall if R117 had a weight gain, but if she had noticed one, her practice was to always document when she notified a provider. Per interview, when asked what she did in response to the weight gain on [DATE], LPN1 stated she did not recall, but if she notified the physician, she would have charted it. She further stated she did not recall re-weighing R117. In an interview on [DATE] at 9:24 AM, LPN5 stated she recalled FM1 telling her he was concerned about R117's swelling. She further stated she did recall seeing some swelling, but the resident seemed okay to her overall. Per interview, LPN5 knew it was important to watch R117 for signs of fluid overload, such as shortness of breath, because he was on continuous intravenous medication. LPN5 stated she notified the APRN about the swelling, on [DATE], in R117's arm, but the APRN's only order was to continue to monitor the resident without details on what findings would be significant to a potential change in condition. In an interview on [DATE] at 4:52 PM, Licensed Practical Nurse (LPN) 4 stated she assessed R117 in the mid-morning of [DATE] after FM1 expressed concerns to her about R117's swelling. She stated FM1 was frustrated because his concerns had not been addressed. She stated R117 had +3 to +4 pitting edema in all extremities, and his scrotum was also extremely swollen. LPN4 stated she had last seen the resident while assisting with drawing labs on [DATE], and he did not have the level of swelling she saw on [DATE]. Review of the Emergency Medical Services (EMS) Run Sheet, dated [DATE] starting at 3:14 PM, revealed the EMS team assessed the resident as being in acute respiratory distress with increased respiratory effort, crackles/wheezing/diminished for breath sounds, wet cough, and pitting edema in all four extremities. Further review revealed vital signs were unremarkable, and the resident was confused, but he did have some confusion at baseline. Further review revealed EMS continued supplemental oxygen, elevated the head of the bed, and then transferred care to the hospital at 3:40 PM.Review of R117's hospital document, Visit Information, dated [DATE] revealed R117 arrived at the Emergency Department (ED) at 3:36 PM, with a primary diagnosis of fluid overload, followed by acute systolic heart failure, atrial fibrillation, and myocardial infarction. Continued review revealed the hospital weighed R117 at 270 pounds with blood pressures mildly elevated (as high as 156/92) and oxygen saturations that fell as low as 89 percent but were mostly in the mid-90s on supplemental oxygen. Per review of the document, R117's respirations trended higher through his stay in the ED, up to 26 breaths per minute. Additional review revealed the hospital admitted R117 to a medical surgical floor under Advanced Illness Management at 9:39 PM with a full code status. Review of the ED Provider Note, dated [DATE], revealed the ED physician assessed R117 as having edema in his bilateral lower extremities and crackles heard with breath sounds, and R117 complained of shortness of breath. Review of R117's lab values while at the hospital on [DATE] revealed the following levels: baseline troponin (measured heart muscle damage) 381 (very high), 1-hour troponin 364, and 3-hour troponin 405. Further review revealed the following values: ProBNP (measured the severity of heart failure) at 10,234 (very high), blood gas pH 7.4, pCO 252, and HCO3 29.6. These lab values were consistent with respiratory distress, cardiac distress, and myocardial infarction.Review of the hospital's Order Report, dated [DATE] at 4:33 PM, revealed the hospital performed a chest X-ray on [DATE]. Further review revealed the X-ray showed cardiomegaly (enlarged heart) with pulmonary vascular congestion (fluid overload in the lungs), bilateral pleural effusions (pockets of fluid in the lungs), and atelectasis (collapsed lung tissue) of the bilateral lower lobes.Review of the Hospital Medicine Admission note on [DATE], revealed Hospital Physician 1 noted R117 reported becoming more short of breath over the last few days, noticed increased swelling in feet and legs. Physician 3 noted R117 to have marked [fluid] overload with CHF [congestive heart failure] exacerbation. Further review revealed the hospital administered Lasix (to remove fluid, a diuretic) 40 milligrams (mg) IV push, followed by a Lasix drip of 10 mg/hour. Continued review revealed R117's mental status remained alert with some confusion, as had been noted to be his baseline.Review of the hospital documentation All Progress Notes revealed hospital nurses documented R117 arrived on the inpatient unit on [DATE] at 9:44 PM. Further review revealed nurses noted R117's duress alarm activated in R117's room, and they entered to find R117 unresponsive, in pulseless electrical activity (PEA) with agonal breathing. Continued review revealed the nurses activated the Code Blue at 11:59 PM on [DATE].Review of the document Clinical Note, by Hospital Physician 2, revealed the physician charted R117 was in PEA, received multiple rounds of cardiopulmonary resuscitation (CPR), as well as code drugs such as epinephrine and bicarbonate, and two rounds of electrical shock for cardiac arrythmias, but R117 was unable to achieve return of spontaneous circulation (ROSC). Further review revealed the physician determined R117 expired at 12:25 AM on [DATE].Review of the hospital's All Progress Notes, dated [DATE] to [DATE], revealed the hospital coded R117 from 11:59 PM on [DATE] until 12:26 AM on [DATE], when the physician pronounced R117 deceased .In an interview on [DATE] at 1:18 PM, the Advanced Practice Registered Nurse (APRN) stated any time a resident experienced a rapid weight gain, it was important for staff to notify the APRN or physician. He stated a lot of things could cause weight gain, so if a resident gained weight, his practice was to order a re-weigh and focused assessment on the resident to check for fluid overload. In further interview, the APRN stated he would also physically assess a resident with a possible change in condition. Per interview, the APRN stated staff did not notify him of changes in assessment findings, including the weight gain, until [DATE]. In an interview on [DATE] at 5:27 PM, the Medical Director, who was also R117's primary physician, stated he relied heavily on nurses to follow the policies and act appropriately on assessment findings. The Medical Director stated the facility treated residents with acute illnesses and changes in condition wherever possible but would send them to the hospital if they were in distress. In an interview on [DATE] at 5:49 PM, the Director of Nursing (DON) stated her expectations were for staff to ensure accurate weights, re-weigh if there was a discrepancy, and notify the physician. She further stated she could find no evidence staff identified R117's weight gain as a sign of a potential change in condition, nor could she find evidence staff had notified the APRN after [DATE]. The DON stated she recalled staff mentioning to her that R117's hands were swollen, but she did not believe any intervention had been implemented to address the swelling. In an additional interview on [DATE] at 12:42 PM, the DON stated she did not recall identifying R117's weight gain as a significant increase from his admission weight after she entered it in the electronic health record. She further stated she failed to assess R117 after entering his weight on [DATE], even though that was a six-pound weight gain in less than a week, which would be clinically significant per the facility's policy. The DON stated she did not recall notifying the APRN of R117's weight gain.In an interview on [DATE] at 9:30 AM, the Administrator stated he was not clinical, but he expected staff to follow policies and work with the APRN on necessary interventions to treat residents' symptoms such as weight gain and confusion. The Administrator further stated, If we missed a weight, that's on us. The facility provided an acceptable IJ Removal Plan on [DATE] alleging removal of the IJ on [DATE] which the State Survey Agency survey team validated prior to exit on [DATE]. The IJ Removal Plan is as follows verbatim: Address what corrective action will be accomplished for those residents found to have been affected by the deficient practice.1. Resident number 117 was discharged on [DATE].Address how the facility will identify other residents having the potential to be affected by the same deficient practice.2. All current residents were re-weighed and reassessed for change of condition on 3.7.26 by Director of Nursing Services, Assistant Director of Nursing Services and Unit Manager with weights being reviewed for the last 6 months. All significant changes in weight resulted in nursing assessment per Director of Nursing Services, Assistant Director of Nursing services, or Unit manager with notification of physician or nurse practitioner for orders as needed. All residents were reassessed and reweighed on 3.7.26. All residents were reassessed by Director of Nursing Services, Assistant Di.[NAME] of Nursing Services, Unit Manager with any changes of condition reported to the Nurse Practitioner and orders given on 3.7.26.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.3. Beginning on 3.7.26 all nurses re-educated by Infection Preventionist/Staff Development, Director of Nursing Services or Assistant Director of Nursing Services regarding the policy of notifying the physician or nurse practitioner of all significant weight changes, and the policy of changes in condition with no nurse working before receiving the education, 13 of 23 completed. Post test given to all nurses regarding the education with expected 100% pass rate. If 100% pass rate is not achieved, re-education was given. Director Of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development or unit manager will provide education until all 23 of 23 nurses completed.Education will be added to all new hire orientation for nurses and certified medication technicians. No outside nursing agencies utilized at this time.Indicate how the facility plans to monitor its performance to ensure that solutions are sustained. 4. On 3/7 /26 an ADHOC Quality Assurance Performance Improvement (QAPI) meeting was held with the Executive Director, Director of Nursing, Assistant Director of Nursing Regional Nurse Consultant, and the Medical Director. This meeting reviewed the alleged deficiency, audit tools, plan and education for all care team members regarding notification of changes.The QAPI (Quality Assurance Performance Improvement) Committee consists of the Medical Director, Executive Director, Director of Nursing, Assistant Director of Nursing, Infection Preventionist/Staff Development, Human Resources Director, Business Office Manager, Therapy Manager, Social Services Director, Activities Director, and MOS Nurse.Beginning 3.8.26 Director of Nursing Services, Assistant Director of Nursing or Unit Manager will audit to ensure that all weight changes and head to toe resident assessments resulted in physician or nurse practitioner notification, if warranted. Results of audit will be forwarded to the QAPI Committee for review, presented by the Director of Nursing.An Ad Hoc QAPI was completed on [DATE] with the Executive Director, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant and Medical Director. This meeting reviewed the audit tools, plans and education regarding notification of change in conditions.5. Completion Date [DATE]

Based on observation, interview, record review, review of the facility's incident report, and review of the facility's documents and policy, the facility's staff failed to follow a menu for a resident on a puree diet for 1 of 11 sampled residents, Resident (R) 76.Review of the facility's Incident Report, revealed R76 was provided the wrong texture of diet on 01/08/2026, which caused the resident to choke. Actual harm was identified with the highest scope and severity (S/S) of a G.The facility provided an acceptable Removal Plan alleging the removal of the G on 01/28/2026, prior to the State Survey Agency (SSA) initial entrance to the facility on [DATE]. The SSA validated removal of the G and determined the G to be past noncompliance.The findings include:Review of the facility's policy titled, Meal Supervision and Assistance, dated 12/12/2023, revealed the facility was to prepare residents for a well-balanced meal in a calm environment, location of his/her choice and with adequate supervision and assistance to prevent accidents, provide adequate nutrition and assure an enjoyable event. The policy specifically addressed tray service as, Check the tray before serving it to the resident to be sure that it is the correct diet ordered, and the food consistency is appropriate to the resident's ability to chew and swallow. Record review of R76's Face Sheet found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 01/07/2026 with diagnoses to include anorexia nervosa, anxiety disorder, and dysphagia. Review of R76's significant change Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/24/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 10 out of 15, which indicated the resident had moderate impaired cognition and noticeable challenges with memory and orientation but was not severely impaired. Continued review revealed R76 required assistance with mobility, toileting, transfers, and ambulation. It stated she was 75 percent independent with eating. Review of R76's Discharge Placement packet, from the acute care hospital, dated 12/29/2025, revealed the resident's paperwork was drafted several days prior to the actual discharge date of 01/07/2026. Further review revealed she was on a puree diet upon discharge. Review of R76's Orders Summary Report, revealed a puree diet was ordered on 01/07/2026 at 4:16 PM. Review of R76's Care Plan, revealed interventions, on 01/07/2026, was to follow diet as ordered. Review of the Incident Report #2696 for Obstructed Airway, dated 01/08/2026 at 8:06 PM, revealed Licensed Practical Nurse (LPN) 10 was walking in to start the shift after clocking in, and R76's roommate was screaming for me to stop and help because the resident was choking. Per the report, R76 could not speak, held her throat, and began to turn cyanotic. The note stated R76 could not give a description at the time of the incident. However, after the incident, the resident stated she was attempting to take a bite of the chicken, and it got stuck in my airway. The Incident Report #2696 also detailed the immediate actions taken as followed, Nurse immediately went into resident's room and performed Heimlich maneuver. After two quick inward-upward thrusts this nurse was able to clear airway. After clearing airway this nurse checked for any remaining pieces of food in mouth. Offered resident to go to ER for evaluation. Incident Report #2696 documented R76 received a regular tray and not a puree tray, and the tray ticket was correct but a regular texture tray was served. Also, it stated R76 was not taken to the hospital.Continued review of R76's Care Plan, revealed dysphagia was added as a focus on 01/09/2026, the day after the choking event. The interventions added were all medication to be crushed in applesauce; regular, puree texture, thin consistency diet as ordered; instruct the resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly; and observe for signs of dysphagia.During an interview with R76 on 03/04/2026 at 11:55 AM, she stated she remembered choking and now ate smoothed out food. Observation at the time revealed R76 received a puree diet for the lunch meal.Observation on 03/04/2026 at 5:10 PM revealed R76 received a puree diet for the dinner meal.During an interview with Dietary Services (DS) 1, a Dietary Services Manager, on 03/03/2026 at 10:25 AM, she stated her department had experienced a nearly complete overhaul since January 2026, and she had trained and mentored new employees. She stated, upon the resident's admission, the diet, preferences, allergies, and sensitivities were added to the meal suite dietary software. She stated it was important for residents to be served the correct diet order so they could swallow it and not be allergic to anything. She stated there were no current dietary employees who were working at the facility during January 2026. During an interview with Dietary Services (DS) 2, a Dietary Services Manager, on 03/03/2026 at 10:55 AM, she stated it was important for residents to get the right tray due to their needs and according to their medical orders. During an interview with Speech Therapist (ST) 1 on 03/05/2026 at 10:55 AM, she stated she had been an employee of the facility since August 2025. She stated newly admitted residents who had mechanically altered diets and those with a dysphagia diagnosis were typically referred to her. She stated R76 had a Modified Barium Swallow on 12/30/2025, and the puree diet was clinically indicated. During an interview with LPN5 on 03/06/2026 at 9:30 AM, she stated staff training for both nursing and dietary staff began immediately after the choking event, which happened on 01/08/2026. During an interview with Infection Preventionist/Staff Development Coordinator (IP/SDC) 1 on 03/06/2026 at 3:30 PM, she stated she provided safe mealtime training as part of the New Employee Orientation, which covered diet textures, different diet orders, and adaptive equipment. During an interview with Nurse Practitioner (NP) 1 on 03/05/2026 at 5:15 PM, he stated he learned of the choking incident and how R76 received the wrong tray. NP1 stated it was his expectation for staff to have full communication and the correct information to best serve the residents. He stated delivering the correct diet texture/order was important to prevent choking, aspiration, and aspiration pneumonia. During an interview with Administrator 1 on 03/06/2026 at 9:20 AM, he stated he heard about the choking event and immediately began drafting an action plan to prevent any future events. He stated he focused on tightening up the kitchen staff and changing the culture. He stated the expectation was for the kitchen staff to be sharp and understand the importance of the diet orders being adhered to. Administrator 1 stated dietary education was implemented, which included auditing the tray service, monitoring mealtimes, and post testing. Administrator 1 stated he expected the kitchen staff to get it right every single time, and residents could choke if an incorrect tray was served.The facility submitted the following action plan to the State Survey Agency (SSA) Surveyor verbatim, who validated on 03/09/2026 the facility had taken the following actions:1. Identification of Resident's Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional resident adverse outcomes. (Completion date 1/9/26)NP assessed resident on 1/9/26 and completed documentation and will follow up with resident and complete documentation.Xray completed of resident chest/neck for assessment of injury. Beginning on 1/9/26 a facility-wide audit was conducted by the dietary manager and DNS [Director of Nursing Services] to ensure that all diet orders are correct. Beginning on 1/9/26 an audit of the meal trays was conducted by the dietary manager to ensure that all meal trays and diet orders were correct before going to all residents. Beginning on 1/9/26 the dietary manager completed education with all dietary personnel along with post test. Beginning on 1/9/26 an in house education was initiated by IPSO for all nursing staff to ensure the accuracy of meals to residents.2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion date: 1/9/26) Beginning on 1/9/26 a facility-wide audit was conducted by the dietary manager and DNS to ensure that all diet orders are correct. Beginning on 1/9/26 an audit of the meal trays was conducted by the dietary manager to ensure that all meal trays and diet orders were correct before going to all residents. Beginning on 1/9/26 a new system of calling out tray items will be completed in order for more accuracy of trays. (Dietary staff are to initial meal cards for accuracy) Beginning on 1/9/26 the dietary manager completed education with all dietary personnel along with post test. Beginning on 1/9/26 an in house education was initiated by IPSO for all nursing staff to ensure the accuracy of meals to residents. Daily audits: Beginning on 1/9/26 the dietary manager will complete daily audits x4 weeks, then bi weekly audits for 4 weeks, then monthly audits x 3 months. Posttest Monitoring: Dietary manager will complete one random post test per week x4 weeks, then biweekly for 4 weeks them monthly for 3 months. QAPI Oversight: AD Hoc QAPI (Quality Assurance and Performance Improvement) meeting held on 1/9/26 to review plan, audits and education. Monthly Reporting: Beginning on 1/27/26 audit results will be presented at the monthly QAPI (Quality Assurance Performance Improvement) committee meetings. The QAPI (Quality Assurance Performance Improvement) committee includes, Executive Director, Medical Director, Director of Nursing Services, Assistant Director of Nursing Services, Social Services Director, Minimum Data Set Nurse, Infection Control Nurse, Staff Development, Business Office Manager, Medical Records, Activities Director, Housekeeping Supervisor, Maintenance Director, Dietary Manager and the Director of Rehab.

Based on observation, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to 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 for 2 of 28 sampled residents, Resident (R) 13 and R84. The findings include:Review of the facility's policy titled, Decontaminating and Labeling Equipment, revised 02/2018, revealed reusable resident care equipment would be decontaminated and/or sterilized between residents. Review of the CDC's Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed reusable medical equipment (e.g., blood glucose meters and other point-of-care devices such as blood pressure cuffs, oximeter probes, surgical instruments, and endoscopes should be cleaned and reprocessed (disinfected or sterilized) prior to use on another patient or when soiled. Additional review revealed aseptic technique should be followed when preparing and administering medications.Review of the facility's policy titled, Infection Prevention & Control Program (IPCP), dated 10/01/2025, revealed the facility would provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Further review revealed all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with current procedures governing the cleaning and sterilization of soiled or contaminated equipment. 1. Observation on 03/04/2026 at 8:17 AM revealed Kentucky Medication Aide (KMA) 1 removed a blood pressure cuff from the vitals cart, applied the cuff directly to R13's uncovered left arm, and obtained the resident's blood pressure. KMA1 then removed the blood pressure cuff, failed to disinfect it, and placed the cuff back into the vitals cart. Additional observation on 03/04/2026 at 8:34 AM revealed KMA1 removed the blood pressure cuff used on R13 from the vitals cart and placed the uncleaned cuff on R84's left arm over his shirt. KMA1 then obtained R84's blood pressure, removed the blood pressure cuff, placed the cuff back on the vitals cart, and again failed to disinfect the cuff.During an interview with KMA1 on 03/04/2026 at 4:19 PM, she stated earlier today when the State Survey Agency (SSA) Surveyor observed her during medication administration, she failed to clean the blood pressure cuff between residents' use. KMA1 stated the facility's policy required all multiuse equipment to be cleaned between residents' use. She further stated she normally cleaned the BP cuff between residents, but she was just nervous this morning. During an interview with State Registered Nurse Aide (SRNA) 5 on 03/06/2026 at 9:44 AM, she stated she cleaned shared equipment between use on residents to help prevent the spread of infection. During a follow up interview with KMA1 on 03/06/2026 at 9:56 AM, she stated she received infection prevention and control program (IPCP) education, and it was important to follow facility guidelines related to IPCP to help prevent the spread of infection. KMA1 stated she should have disinfected the blood pressure cuff before it was used on either resident. During an interview with KMA2 on 03/06/2026 at 10:10 AM, she stated she disinfected shared equipment including blood pressure cuffs before being used on residents. She further stated it was important to help prevent the spread of infection.During an interview with SRNA7 on 03/06/2026 at 10:19 AM, she stated she was newly employed and received IPCP training when she was hired. She further stated her training included cleaning shared equipment between residents. SRNA7 stated it was important to follow IPCP policies to help prevent the spread of infection and diseases. During an interview with Licensed Practical Nurse (LPN) 1 on 03/06/2026 at 10:35 AM, she stated, Basically anything considered community property should be disinfected before use on another resident. LPN1 further stated it was important that shared equipment was properly disinfected between use to help prevent the spread of infection. During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 03/06/2026 at 4:04 PM, she stated multiuse equipment should be disinfected between each resident use to prevent cross contamination. During an interview with the Director of Nursing (DON) on 03/07/2026 at 10:21 AM, she stated multiuse equipment should be cleaned between use on residents. She further stated it was important that shared equipment was properly disinfected to prevent the spread of infection.Review of the facility's policy titled, Medication Administration, dated 01/02/2024, revealed medications were administered as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Review of the facility's policy titled, Infection Prevention & Control Program (IPCP), dated 10/01/2025 revealed, all care team members shall adhere to safe injection and medication administration practices, as described in relevant policies. 2. Observation on 03/04/2026 at 8:28 AM, during medication administration, revealed KMA1 dropped a pill into a medicine cup that already contained a dispensed medication. Continued observation revealed KMA1 reached into the medicine cup with an ungloved hand, removed the dropped pill and then administered the other medication.During a continued interview with KMA1 on 03/06/2026 at 9:56 AM, she stated she should have donned gloves before she removed the pill from the medicine cup. She further stated she should have destroyed both medications and repulled them before they were administered to prevent cross contamination.During a continued interview with LPN1 on 03/06/2026 at 10:35 AM, she stated medications should not be handled with an ungloved hand because of infection control concerns. LPN1 further stated if a pill was touched with an ungloved hand, it should be wasted and repulled prior to administration. During a continued interview with the IP/SDC on 03/06/2026 at 4:04 PM, she stated it was her expectation that staff followed facility IPCP policies during medication administration to prevent contamination. During a continued interview with the DON on 03/07/2026 at 10:21 AM, she stated medications should not be touched with an ungloved hand because of the risk of cross contamination.During an interview with the Administrator on 03/07/2026 at 10:31 AM, he stated it was his expectation that all staff followed the facility's IPCP policies and procedures to help prevent the spread of diseases and infections.

Based on review of the facility's documents contained in the facility provided binder and interview, the facility failed to ensure results of their surveys, certifications and complaints, made during the three preceding years, and any related plans of correction, were available for any individual to review upon request, which would potentially affect all 111 current residents in the facility.The findings include:Review of the facility's policy titled, Resident Rights, revised 12/12/2023, revealed the resident had a right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.Review of the facility provided binder with survey results revealed it did not have the results of surveys, certifications and complaints, and any related plans of correction, since 2001 available for any individual to review upon request. Those survey results missing from the binder for the preceding three years were for a Recertification and Abbreviated Survey, with an exit date of 02/11/2025; the first Revisit Survey for the previous survey, with an exit date of 04/02/2025; and a second Revisit Survey for the previous survey, with an exit date of 04/29/2025. Also missing was the related Life Safety Code Survey, with an exit date of 01/29/2025 and its Revisit Survey, with an exit date of 03/20/2025.During Resident Council on 03/03/2026 at 2:30 PM, Resident (R) 17 stated that she had looked for the location of the survey book but did not ask about the location because she found the information online. During an interview with the Administrator on 03/03/2026 at 3:30 PM, he stated he knew the survey book was incomplete and lacked the most current documents. He stated he understood the requirement to have the binder current and up to date so the survey results were available to anyone who would like to view the binder.

Based on interview, record review, and review of the facility's documents and policy, the facility failed to provide a required transfer form to the resident's representatives for 2 of 2 residents reviewed for hospitalizations, Resident (R) 36 and R117. The findings include:Review of the facility's policy titled Transfer and Discharge, dated 12/12/2023, revealed the facility was to provide residents and their representatives with a written notice for the specific reason for the transfer, including for emergency transfers to an acute care hospital.1. Review of R36's admission Record revealed the facility admitted the resident on 05/21/2024 with diagnoses including unspecified intellectual disabilities, type 2 diabetes, and epilepsy.Review of R36's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/10/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of zero of 15, indicating severe cognitive impairment.Review of the facility's document MD/NP/PA Progress Note, dated 02/17/2026 at 1:59 PM, revealed the Advance Practice Registered Nurse (APRN) wrote that R36 was to be transferred to the hospital related to a concern identified on a Computed Tomography (CT) scan.Review of the facility's document for R36 Notice of Transfer or Discharge/Notice of Bed Hold, dated 02/17/2026, revealed the section at the bottom of the document for date mailed to responsible party was blank. In an interview on 03/06/2026 at 8:47 AM, Family Member (FM) 4, R36's resident representative, stated she had never received paperwork in the mail from the facility related to a hospital transfer. She further stated she sometimes found out R36 was in the hospital if the hospital called with a question about R36's care needs and not from the facility.2. Review of R117's admission Record revealed the facility admitted R117 on 12/29/2025 with diagnoses including pneumonia, nontraumatic subdural hemorrhage, and primary hypertension.Review of R117's admission MDS, with an ARD of 01/05/2026, revealed the facility assessed the resident to have a BIMS score of 8 out of 15, indicating the resident was moderately cognitively impaired.Review of the facility's document Health Status Note, dated 01/11/2026 at 2:43 PM, revealed Licensed Practical Nurse (LPN) 4 wrote the facility sent R117 to the hospital for evaluation per the request of the resident's family member, FM1.Review of the facility's document for R117 Notice of Transfer or Discharge/Notice of Bed Hold, dated 01/11/2026, revealed the section at the bottom of the document for date mailed to responsible party was blank.In an interview on 03/07/2026 at 10:00 AM, FM1, R117's resident representative, stated he never received any paperwork from the facility about R117's transfer to the hospital.In an interview on 03/09/2026 at 2:00 PM, the Medical Records Nurse stated she took the transfer forms after the nurses filled them out and scanned them into the medical record before turning them over to the Social Services Director (SSD) to be mailed to the resident's representative.In an interview on 03/09/2026 at 1:52 PM, the SSD stated she had been the SSD since 07/2025, but she had not been responsible for mailing the transfer forms until a few weeks prior to the survey. She further stated she did not know who had been mailing the transfer notices prior to her taking over that task, but she thought it was the Medical Records Nurse. The SSD stated she would look for documentation that the facility had mailed the forms. However, the facility did not provide such evidence.In an interview on 03/09/2026 at 1:20 PM, the Administrator stated his expectations were for either the Medical Records Nurse or the SSD to mail the form [Notice of Transfer or Discharge/Notice of Bed Hold] to the resident's representative, especially if the resident was cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and/or implement a comprehensive person-centered care plan to meet the needs of five (Resident (R) 80, R27, R52, R36, and R124) of 32 sampled residents The facility failed to develop specific, effective interventions for staff to follow and /or ensure that approaches were implemented to meet each resident's needs. The findings include: Review of the facility policy, Comprehensive Care Plan, dated 11/01/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Further review revealed the comprehensive care plan was to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. During interview on 01/26/2025 at 3:04 PM with R80, she stated her head was itching, and it was driving her crazy. R80 stated she had a history of plaque psoriasis (a skin condition in which skin cells build up and form itchy, dry patches) on her scalp that caused her head to bleed and scab and she did not know what the solution was. R80 further stated she had told the nurse, and a shampoo was ordered; however, her head continued to itch. Observation of R80's head revealed an approximate one-inch lesion in the hairline near the forehead on the right with skin and blood on the pillowcase and sheet under her head. (Refer to F684). a. Review of R80's Comprehensive Care Plan (CCP) for risk of skin breakdown revealed on 12/13/2024, an intervention for medicated shampoo as ordered was documented. Further review of the CCP revealed that the CCP did not address specific instructions for the use of the medicated shampoo. Review of R80 ' s Medication Administration Record (MAR) dated 12/2025 revealed the order for Ketoconazole Shampoo 2%, apply to scalp topically one time a day every Wednesday and Sunday for dry scalp had a start date of 12/15/2024 was administered. However, review of R80 ' s Progress Note dated 01/28/2025 at 3:37 PM (after surveyor initiation of the concern) revealed R80 had reported her head was still really itchy and her scalp is full of scabs, Review of the facility provided package leaflet for Nizoral (ketoconazole) 2% shampoo, revised in 01/2024, under the section labeled how to apply revealed the hair was to be wet thoroughly, apply a small amount of shampoo to the scalp and massage into a lather, leave the lather on the scalp for three to five minutes and rinse thoroughly. During an interview on 01/31/2025 at 5:07 PM with R80, she stated the State Registered Nurse Aides (SRNAs), not the nurses, applied her shampoo and rinsed it out, but they never left it in for three to five minutes. Interviews on 01/30/2025 at 10:42 AM with SRNA12 and SRNA13, as well as with SRNA11 on 01/31/2025 at 5:10 PM, revealed they were unaware of the instructions for use, and used medicated shampoo like it was regular shampoo, rather than leaving it on for three - five minutes. b. Review of R80 ' s Comprehensive Care Plan (CCP) for Risk of Skin Breakdown initiated on 10/11/2023 and revised on 10/20/2023, revealed R80 was at risk for skin breakdown related to incontinent episodes and decreased mobility. Although the intervention for medicated shampoo as ordered was initiated on 12/13/2024, review of the CCP revealed it was not until 01/28/2025 that a care plan with goals and interventions specific to her scalp was developed. 2. Review of R27's Admission Record revealed the facility admitted the resident on 05/23/2023 with diagnoses including mild cognitive impairment, osteoarthritis, and depression. Review of R27's Comprehensive Care Plan (CCP), dated 12/10/2024 revealed the facility identified R27 had a pressure ulcer on her left buttock and listed interventions including assisting the resident with bed mobility to turn and reposition routinely, as well as providing incontinence care as needed. (Refer to F686). Review of R27's Bedside Kardex Report, dated 02/01/2025 revealed the interventions to check routinely for incontinence and provide care as needed. Further review revealed the Kardex listed R27 as requiring assistance with repositioning in bed. Observation on 02/01/2025 at 9:50 AM revealed SRNA5 and SRNA 18 changed R27's draw sheet, which was soiled with urine. Further observation revealed neither SRNA offered to assist R27 with repositioning. Interview with SRNA5 at this time revealed since she started her shift at 6:00 AM, she had not changed R27's briefs or repositioned the resident. She further stated SRNAs could access the resident's Kardex, which was generated from the care plan, to know what specific needs each resident had. In continued interview, SRNA5 stated it was important to provide care as described on the care plan. In an additional interview on 02/01/2025 at 8:04 PM, SRNA5 stated the facility was short staffed and the SRNAs did not typically get the support they needed to take care of the residents according to their care plans. In an interview on 02/01/2025 at 3:18 PM, the Assistant Director for Nursing Services (ADNS) stated all staff needed to follow care planned interventions for pressure ulcer prevention and treatment. Per interview, the ADNS stated she conducted audits, but was unable to verify if any of those audits covered turning and repositioning. interview on 02/01/2025 at 5:06 PM, the Director of Nursing Services (DNS) revealed that, depending on the number of SRNAs assigned to a hallway, it would be difficult for them to get to each resident room to perform incontinence care and turning and repositioning as outlined in the resident's care plan to treat and prevent pressure ulcers. Per interview, the DNS stated there was not a process in place to communicate when the resident was last turned so that different team members could contribute to ensuring adequate repositioning. 3. Review of R52's Admission Record revealed the facility admitted the resident on 06/10/2024 with diagnoses including early onset Alzheimer's Disease, depression, and osteoarthritis. a. Review of R52's Comprehensive Care Plan (CCP) dated 06/11/2024 revealed the facility identified the resident as needing assistance with activities of daily living (ADLs), including toileting and personal hygiene. Review of R52's Bedside Kardex Report, dated 02/01/2025 revealed facility staff were to provide toileting to R52 frequently, as well as checking for incontinence routinely and as needed. In an interview on 01/27/2025 at 9:47 AM, Family Member (F)52 stated she asked for R52's care plan to include the intervention that she needed to be checked for incontinence and offered toileting more often than every two hours because R52 can still use a commode at times. In interview on 01/30/2025 at 9:42 AM, SRNA3 stated aides were supposed to change incontinent resident's briefs at least every two hours. She further stated if staff knew the resident had a history of soaking through briefs, they needed to check them more frequently than every two hours. In continued interview, SRNA3 stated she had seen R52 urinate through a brief but knew that the resident could use the toilet if staff assisted her in time. In an interview on 02/01/2025 at 9:50 AM, SRNA 5 stated staff should follow the Kardex, which was generated from the care plan, to know what care needs each resident had. Observation on 02/01/2025 at 11:04 AM revealed SRNA5 changed R52's brief, which was soaked with urine. Further observation revealed the resident also had a small amount of stool. Per observation, when SRNA5 cleaned R52's stool, the skin in the gluteal fold was reddened, with the appearance of previously broken-down skin in the area where the buttocks meet. In an interview on 02/01/2025 at 11:07 AM, SRNA5 stated this was the first round of incontinence care she had provided to her residents, and she had not had time to get to everyone. (Refer to F677.) In an interview on 02/01/2025 at 5:06 PM, the Director of Nursing Services (DNS) stated she attended care plan meetings with F52 and had observed the interventions related to R52's dining needs, but she could not verify incontinence care had been provided according to the care plan for R52. The DNS further stated not following the care plan related to incontinence care needs could lead the resident to feel embarrassed and like they did not have their dignity. b. Further review of R52's Comprehensive Care Plan (CCP) dated 06/11/2024 revealed the facility identified the resident had her own teeth in poor condition and listed interventions including providing mouth care or encouraging the resident to perform oral care twice daily and as needed. Observation on 01/29/2025 at 10:17 AM revealed State Registered Nurse Aide (SRNA) 9 assisted R52 with ADL care, including getting dressed. Further observation revealed SRNA9 told the resident she was finished with helping her get ready and the resident could go to activities. Continued observation revealed SRNA9 failed to remind or assist R52 with performing oral care before leaving her room. (Refer to F677.) In an interview on 01/29/2025 at 10:44 AM, SRNA9 stated she forgot to assist R52 with oral care because she had been busy taking care of a large number of residents that morning. She further stated she had not seen a toothbrush in R52's room and that someone might have thrown it away. In an interview on 02/01/2025 at 5:06 PM, the Director of Nursing Services (DNS) stated she attended care plan meetings with F52 and had observed the interventions related to R52's dining needs, but she could not verify R52 received oral care according to the care plan. The DNS further stated a resident not receiving care planned oral care interventions could result in the resident getting an infection and having oral pain. 4. Review of R36's Admission Record found in the resident's electronic health record (EHR) revealed the facility admitted the resident on 12/31/2020 with diagnoses to include Alzheimer's disease, dementia, and presence of artificial eye. Review of R36's CCP, undated, revealed the facility identified R36 as having impaired visual function due to an artificial left eye on 11/24/2015. Care plan interventions initiated included to perform artificial eye care as ordered. However, the care plan did not include specific details of how to clean the artificial eye, including whether or not the eye was to be removed. Although the CCP stated to perform artificial eye care as ordered, review of physician's orders revealed that there were no orders for eye care until 01/27/2025, after the initiation of the survey. During an observation on 01/27/2025 at 3:46 PM, R36 was seated in her wheelchair in the day room, positioned in front of the nurse's station. Two nurses were seated in the nurse's station. Observation of R36's eye revealed green, pus-filled drainage was weeping from the resident's left eye. The eyelid and lashes were coated with a thick, crusty material, causing the eye to be matted shut. (Refer to F684.) During an interview with the Nurse Practitioner (NP) on 01/29/2025 at 7:30 AM, he stated that [R36's] eye should absolutely come out for proper cleaning. During an interview with Licensed Practical Nurse (LPN) 1 on 01/27/2025 at 4:55 PM, she stated that prior to a new order (which was received after the initiation of the survey, staff just knows to clean it [the eye]. Interviews with SRNA3 on 01/30/2024 at 9:40 AM, SRNA13 on 01/30/2024 at 10:41 AM, and SRNA11 on 01/30/2024 at 10:48 AM, revealed each cleaned the resident's eye with warm water and soap and were unaware that R36 had a prosthetic left eye that needed to be removed for cleaning. 5. Review of R124's medical record revealed the facility admitted the resident on 01/16/2025 with diagnoses including sepsis related to septic knees and intravenous (IV) antibiotic therapy. Review of R124's care plan, initiated on 01/17/2025, revealed an intervention for the left arm midline dressing to be changed as ordered. Review of R124's physician orders revealed an order dated 01/19/2025 with instructions for the resident's midline dressing to be changed once a week and as needed. Review of R124's Medication Administration Record (MAR)/Treatment Administration Record (TAR) for the month of January 2025 revealed the dressing was not changed between admission on 01/16/2025 and 01/30/2025 (Refer to F684). Observation on 01/28/2025 at 10:16 AM revealed R124 with a left upper arm (LUA) midline covered with an intact transparent adhesive dressing dated 01/16/2025. An additional observation made at 2:14 PM revealed the dressing was dated 01/16/2025. Observation of R124's LUA midline dressing on 01/29/2025 at 4:47 PM also revealed the transparent adhesive dressing with a date of 01/16/2025. In an interview with R124 on 01/28/2025 at 10:16AM, she stated staff flushed her midline before and after she received antibiotics, but the dressing had not been changed since she was admitted to the facility. In an interview with LPN3 on 01/30/2025 at 4:54 PM, she stated care plans were in place so residents received the care they needed and should be followed. In an interview with LPN4 on 01/31/2025 at 11:37 AM, she stated a resident's care plan included dressing changes and the ordered frequency of those changes. In an interview with the Assistant Director of Nursing Services (ADNS) on 02/01/2025 at 4:11 PM, she stated it was her expectation nursing changed midline dressings as ordered and per a resident's care plan. She further stated it was important a resident's care plan was followed because that was how his/her care needs were met. In an interview with Minimum Data Set (MDS) Coordinator 1 on 02/01/2025 at 4:59 PM, she stated care plans were in place, so staff knew the appropriate care needed for each individual resident. In an interview on 02/01/2025 at 3:18 PM, the ADNS stated she expected staff to implement care planned interventions to ensure residents received the care they needed. In an interview with the DNS on 02/01/2025 at 5:58 PM, she stated it was her expectation staff followed care plan interventions. She further stated it was important to follow a resident's care plan because it served as a guideline for care team members and the facility's goal was that each resident received quality care. In interview on 02/01/2025 at 6:28 PM, the DNS added that not following the care plan could lead the resident not getting the care they needed, and it was important for staff to follow the care plans to ensure the residents received good care. 44001 49267 46651 49050

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide necessary services to maintain good personal and oral hygiene for six (Resident (R)362, R27, R90, R52, R79, and R22) of 14 sampled residents investigated for activities of daily living care, The facility failed to provide timely incontinence care for R362, R27, R90, R52, and R79, with residents expressing feelings of embarrassment and humiliation due to the facility's failure to provide incontinence care as needed to meet the needs of the residents. Interviews with the residents and their family members revealed they complained the residents often waited a long time (approximately 4 hours) before staff could change the residents resulting in the residents urinating in their beds and lying in urine for long periods. Additionally, the facility failed to provide daily oral care as needed for R52 and R22, who had plaque build-up as noted by the dentist. The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), dated 01/02/2024 revealed care and services will be provided for the following ADLs, including bathing, dressing, grooming, and oral care; transfer and ambulation; and toileting. Per policy review, a resident who is unable to carry out ADLs will receive the necessary services to maintain good grooming, and personal and oral hygiene. Review of the facility policy titled, [Name of Facility] Nursing & Rehabilitation, Position Summary-State Registered Nurse Aide (SRNA), dated 02/2020, revealed the SRNA essential responsibilities (not comprehensive) include; To perform or assist the resident with completing ADLs; Respond to residents call lights to provide maximum comfort, safety, and privacy. 1. Review of the Face Sheet found in R362's EMR revealed the facility admitted the resident on 01/14/2025, with diagnoses including unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, chronic combined systolic (congestive) and diastolic (congestive) heart failure, and type II diabetes mellitus with other specified complications. Review of R362's Annual MDS Assessment, with ARD of 01/23/2025, revealed the facility assessed the resident to have a BIMS score of 15/15, indicating no cognitive impairment. Per review, the facility assessed R362 to require substantial/ maximal assistance for toileting hygiene and lower body dressing. Further review revealed R362 required partial moderate assistance for shower/bathe self and personal hygiene. Review of the CCP dated 01/15/2025 for R362, revealed the facility identified a problem for the resident relating to risk for incontinence of bowel and bladder. Per review the goal dated 01/15/2025 and revised on 01/31/2025, for the resident to be assisted with routine toileting as needed, check routinely for incontinence, and provide incontinence care as needed. Further review revealed additional focus on ADLs with staff providing substantial assistance for toileting, with fluctuations in need, and provide additional assistance as needed. The Care plan instructed staff to assist as needed for toileting. During interview on 01/26/2025 at 1:58 PM with R362, she stated, On 01/24/2025 I had to wait over four hours from 6:00 PM till after 10:00 PM to be changed. It is humiliating and nasty. She added, I have a leg brace on my right leg, and it became soiled because I was not changed. The staff had to clean the brace because it got dirty. 2. Review of R27's Admission Record revealed the facility admitted the resident on 05/23/2023 with diagnoses including mild cognitive impairment, osteoarthritis, and depression. Review of R27's physician's orders revealed they included furosemide (a diuretic) 20 milligrams by mouth twice daily. Review of R27's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/2025 revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13/15, indicating the resident was cognitively intact. Further review revealed R27 required partial to moderate assistance with turning side to side in the bed and with bed to chair transfers. Continued review revealed R27 was always incontinent of bowel and bladder. Additional review revealed the facility also assessed R27 as having one Stage III pressure ulcer that was not present on admission. Review of R27's Comprehensive Care Plan (CCP), dated 12/10/2024 revealed the facility identified R27 had a pressure ulcer on her left buttock and listed interventions including providing incontinence care as needed. In an interview on 01/27/2025 at 5:13 PM, R27 stated she knew staff were trying their best, but the facility was often short staffed, and she had to wait long periods of time to get incontinence care. R27 further stated she would often soak through her briefs onto her sheets after receiving her water pill. Per interview, R27 reported having to lay in a wet bed for over two hours at least once per week while waiting for staff to change her, which made her feel embarrassed. In continued interview, R27 stated she developed problems with her skin in the past few months, including a pressure ulcer (Refer to F686). Observation on 02/01/2025 at 9:50 AM revealed State Registered Nurse Aide (SRNA) 5 changing R27's draw sheet, which was soiled with urine. In an interview at that time, SRNA5 stated she had not changed R27's briefs since she started her shift at 6:00 AM. In an additional interview on 02/01/2025 at 8:27 PM, SRNA5 stated she had asked another aide around 8:00 AM that day to check on the residents she had not yet changed, including R27, and the other aide told her everyone was fine. She further stated that even if the other aide had checked on the residents between 8:00 AM and 8:30 AM, that would still have left over 2.5 hours since the residents had been checked for incontinence. In an interview on 01/30/2025, SRNA10 stated R27 skin breakdown had worsened due to being left wet for long periods of time several days per week. In further interview, SRNA10 stated when the facility was short staffed, residents do not get the care necessary to be well groomed, including incontinence care. Per interview, SRNA10 felt bad when he knew residents were receiving poor care. 3. Record review revealed the facility admitted R90 on 02/14/2024 with diagnoses of unspecified dementia, incontinence, muscle weakness, depression, and adult failure to thrive. Review of R90's MDS Annual Assessment, with an ARD of 01/27/2025, revealed a BIMS score of 14/15, indicating intact cognition. Per the MDS, the resident was always incontinent and required substantial/maximum assistance with toileting. Review of R90's CCP, initiated on 02/15 2024, revealed R90 required assistance with activities of daily living which included personal hygiene and provision of good peri care after each incontinent episode. During an interview with R90 on 01/26/2025 at 4:40 PM she stated she had been sitting in a wet bed for a couple hours and had her call light on twice. R90 stated she had been told by an SRNA they had a new admission and were busy, but she would come back with help, but she had not returned. R90 also stated she was unable to get out of bed on her own. Observation during this interview revealed the resident was wearing a brief which appeared heavy with urine. During an interview on 01/30/2025 at 9:41 AM with SRNA3, she stated on one occasion, she answered R90's call light and found her to be soaked in urine, requiring a complete bed bath and brief change. R90 had also stated she had her call light on for a while, but no one had answered it. SRNA3 stated R90 was not her assigned resident but R90 told her she was expecting her daughter for a visit and was anxious her daughter would arrive and find her soiled and that would embarrass her, so SRNA3 stated she bathed and changed her. 4. Review of R52's Admission Record revealed the facility admitted the resident on 06/10/2024 with diagnoses including early onset Alzheimer's Disease, depression, and osteoarthritis. Review of R52's Quarterly MDS, with an ARD of 12/30/2024, revealed the facility assessed the resident with a BIMS score of 3/15, indicating severe cognitive impairment. Further review revealed R52 required substantial/maximal assistance for toileting hygiene. Continued review revealed R52 required moderate assistance with transfers from sitting to standing and from the bed to the wheelchair. Review of R52's Comprehensive Care Plan (CCP) dated 06/11/2024 revealed the facility identified the resident as needing assistance with Activities of Daily Living (ADLs), including toileting and personal hygiene. Additionally, the facility assessed R52 as always incontinent of bladder and frequently incontinent of stool. a. Review of a facility document titled, Report of Concern, dated 11/02/2024, revealed a family member (F52) filed the grievance when she found R52 sitting in briefs and clothes soiled with urine and noted urine dripping into the floor beneath R52's wheelchair. Further review revealed the Executive Director (ED) marked the grievance as confirmed and noted the care team member was terminated on 11/04/2024. Review of a photograph provided by F52 on 01/30/2025 and takenn on 01/14/2025 revealed the resident was in maroon athletic shorts that were wet from the top of her buttocks to her knees. In an interview on 01/27/2025 at 9:47 AM, F52 stated she came in to visit R52 in the afternoon on 01/14/2025, 01/15/2025, and 01/16/2025 and found the resident's briefs saturated and her pants wet with urine to the knees. Per interview, F52 believed the facility was short staffed those days. In further interview, F52 stated on 11/02/2024, she came in to find R52's briefs, clothing, and wheelchair saturated with urine and urine puddled in the floor beneath R52's wheelchair. F52 continued to state she asked an aide, whose name she could not recall, to clean R52 up. F52 stated the staff member told her she could not help until she had picked up dinner trays. When the staff member did come back to clean the resident, F52 reported she was rude and slammed the door, which F52 reported to the administrator. In an interview on 01/29/2025 at 3:40 PM, SRNA9 stated that when there was insufficient staff. she did not have time to do ADL care. SRNA9 stated she remembered occasions when she had come in to start her shift and found R52 in a urine-soaked brief and urine-soaked sheets. Additionally, SRNA9 stated F52 had come to her in the past and told her R52 needed her brief changed, but SRNA9 was feeding another resident at the time and was unable to assist her. SRNA9 continued to state that if a resident was known to urinate heavily, staff needed to check on the resident more frequently than every two hours, but that was often not possible when there were only three aides on the hallway. b. Observation on 02/01/2025 at 11:04 AM revealed SRNA5 changed R52's brief, which was soaked with urine. Further observation revealed the resident had a small amount of stool. Per observation, when SRNA5 cleaned R52's stool, the skin in the gluteal fold was reddened, with the appearance of previously broken-down skin in the area where the buttocks meet. In an additional observation of R52's skin with the Director of Nursing Services at 8:27 PM, the skin in R52's gluteal fold was [NAME] than the surrounding skin. In an interview on 02/01/2025 at 11:07 AM, SRNA5 stated this was the first round of incontinence care she had provided to her residents as she had 12 rooms in her assignment, one of which had four residents in it. Per interview, this meant she was responsible for 24 residents, and she had not had time to get to everyone. In an additional interview on 02/01/2025 at 8:27 PM, SRNA5 stated she had asked another aide around 8:00 AM that day to check on the residents she had not yet changed, including R52, and the other aide told her everyone was fine. She further stated if the other aide had checked on the residents between 8:00 AM and 8:30 AM, that would still have left over 2.5 hours since the residents had been checked for incontinence. In interview on 01/30/2025 at 9:42 AM, SRNA3 stated aides were supposed to change incontinent resident's briefs at least every two hours. She further stated if staff knew the resident had a history of soaking through briefs, they needed to check them more frequently than every two hours. In continued interview, SRNA3 stated she had seen R52 urinate through a brief but knew that the resident could use the toilet if staff assisted her in time. Per interview, SRNA3 stated it was often not possible to assist R52 before she urinated in her briefs due to short staffing. In an interview on 01/30/2025 at 3:32 PM, SRNA10 stated he worked primarily on the back hall, where R52 lived, and getting residents' briefs changed timely was a challenge due to staffing. He further stated it was often three or three and a half hours between checks because of the time it took to clean each resident and address their needs. He continued to state residents who could speak up for themselves had told him they were upset at being left wet and their skin would hurt if they were left soiled. Per interview, SRNA 10 stated the nurses on the floor would come to tell aides that call lights were ringing rather than answer the light themselves. In continued interview, SRNA10 stated a resident in their right mind would cry at the lack of care in the facility. In an interview on 02/01/2025 at 3:18 PM, the Assistant Director of Nursing Service (ADNS) stated she was aware F52 had concerns about R52 not getting timely incontinence care. Per interview, the facility identified that the SRNA caring for R52 that day had not been completing care rounds on residents and was terminated. In further interview, the ADNS stated, after F52 filed grievances, the ADNS personally rounded on R52 during the day and had not seen the resident visibly wet with urine. 5. Review of the Face Sheet found in R79's electronic medical record (EMR) revealed the facility admitted the resident on 12/24/2024, with diagnoses including chronic obstructive pulmonary disease (COPD) unspecified (primary), muscle weakness (generalized), and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. Review of R79's Annual MDS Assessment, with an ARD of 01/02/2025, revealed the facility assessed the resident to have a BIMS score of 15/15, indicating no cognitive impairment. Per review, the facility assessed R79 to be dependent on staff for toileting hygiene and shower/bathing. Review of the facility's Comprehensive Care Plan (CCP) developed for R79 revealed the resident was care planned for requiring assistance with self-care and mobility tasks to include assist with ADL tasks as needed. Per the CCP, R79 was dependent on staff for toileting, and needed assistance with incontinence care. Further review of the CCP, dated 12/26/2024 for R79, revealed the facility identified a problem for the resident relating to episodes of incontinence of bowel and bladder. Per review, the goal dated 12/24/2024 and revised on 01/30/2025, for the resident to be assisted with routine toileting and as needed, check routinely for incontinence, and provide incontinence care as needed. Review revealed additional interventions encouraging the resident to sit on the toilet to evacuate bowels if possible. Interview on 01/26/2025 at 1:53 PM with R79 she stated the staff does not have time to change me. She stated, It feels nasty to lay in bed and being dirty. R79 expressed frustration with having to wait for a long time. She stated, I had a stroke and am not able to move in bed very well. During interview on 01/29/2025 at 2:35 PM with SRNA 10, he stated he did not have enough time to change all of his residents. In an interview on 02/01/2025 at 5:06 PM, the Director of Nursing Services (DNS) stated a reasonable person would be embarrassed and would feel like they did not have their dignity if their family members visited and saw them soaked in urine. She stated if there were only three aides per hall, they might not be able to get to all residents for incontinence within two hours. She further stated nurses should change and reposition a resident if they were in the room and find the resident dirty. She stated she hoped a nurse would not leave a resident dirty but did not audit or observe for this practice. In an interview on 02/01/2025 at 6:28 PM, the Executive Director (ED1) stated she was not aware of residents not getting their briefs changed for 3.5 hours or longer. She further stated the team members, including SRNAs would ask for help if their assignment was too heavy to be able to meet resident needs and management would pitch in. In continued interview, ED1 stated she could not provide an estimate for how long it would take for an aide to complete a routine rounding visit with one resident, including incontinence care, and therefore could not provide an estimate for how many residents an aide could have in an assignment before they could no longer provide incontinence care and repositioning every two hours. Review of the facility's policy titled, Oral Care, dated 01/02/2024 revealed it was the practice of the facility to provide oral care to prevent plaque-associated diseases. 6. Review of R52's Quarterly MDS, with an ARD of 12/30/2024, revealed the facility assessed as totally dependent on staff for oral care. Review of R52's CCP. dated 06/11/2024 revealed the facility identified the resident as needing assistance with ADLs, including personal hygiene. Further review revealed the facility identified R52 had her own teeth in poor condition and listed interventions including providing mouth care or encouraging the resident to perform oral care twice daily and as needed. Review of the facility document Summary Report for [R52], dated 01/15/2025, revealed the dentist examined R52 on that date and noted a bridge of calculus [hardened plaque on teeth] on the front of the resident's lower teeth. Further review revealed the dentist noted heavy plaque and heavy calculus on the resident's teeth and recommended daily assistance from staff for oral hygiene. Observation on 01/29/2025 at 10:17 AM revealed SRNA 9 assisted R52 with ADL care, including getting dressed. Further observation revealed SRNA9 told the resident she was finished with helping her get ready and the resident could go to activities. Continued observation revealed SRNA9 failed to remind or assist R52 with performing oral care before leaving her room. In an interview on 01/29/2025 at 10:44 AM, SRNA9 stated she forgot to assist R52 with oral care because she had been busy taking care of a large number of residents that morning. She further stated she had not seen a toothbrush in R52's room and that someone might have thrown it away. In an interview on 02/01/2025 at 3:18 PM the Assistant Director of Nursing Services (ADNS) stated she was aware F52 complained about R52 not getting oral care and the ADNS rounded on R52 to assist with this. Per interview, the only indicator the ADNS used to determine if R52 had oral care was to see if she was still in bed. The ADNS stated if she found the resident still in bed after breakfast, she would perform oral care, however, she had not done this recently. After review of the findings from R52's dental notes from 01/15/2025 which indicated the presence of calculus and recommendation for the resident to receive assistance with oral hygiene twice daily, the ADNS stated the presence of calculus indicated R52 had not received sufficient oral hygiene. In an interview on 02/01/2025 at 5:06 PM, the Director of Nursing Services (DNS) stated the presence of calculus would indicate R52 had not received adequate oral care, which could result in pain and infection. In an interview on 02/01/2025 at 6:28 PM, the Executive Director (ED) stated she expected staff to assist residents with oral care. She stated her process for ensuring proper dental care as recommended by the dentist that visited the facility was to review the dentist's notes. Per interview, she had not reviewed the dentist's note for the visit with R52 on 01/15/2025. After being told the note described heavy buildup of plaque, the ED stated that could indicate the resident had not received adequate oral care or that she had a disease, and she was not aware of a disease R52 might have that would explain the plaque. 7. Review of R22's Admission Record revealed the facility admitted the resident on 11/13/2013 with diagnoses to include cerebral palsy and dysphagia. Review of R22's Quarterly MDS, with an ARD of 01/10/2025 revealed the resident had both short- and long-term memory problems. Continued review of the MDS revealed R22 was dependent (helper does all of the effort) on staff for all oral hygiene. Review of R22's CCP, revealed the facility identified R22 as having no natural teeth or dentures on 03/13/2019, and on a revised date of 12/11/2019. Interventions initiated on 12/11/2019 included the coordination of arrangements for dental care and to provide mouth care or encourage resident to perform oral care twice daily and as needed. Review of R22's Dental Patient Summary Note, dated 02/13/2024, found in the resident's EMR, revealed the provider recommended assistance from staff for daily hygiene. Review of R22's Dental Patient Summary Note, dated 05/23/2024, found in the resident's EMR, revealed that R22 presented for a routine oral examination. The exam revealed that R22 had partial dentition and required assistance with daily tooth brushing. According to the provider's notes, oral hygiene instructions were provided, which included brushing any existing teeth, the tongue, and oral tissues. The instructions also stated the importance of rinsing or swabbing the mouth daily to reduce bacteria. Observation of R22, on 01/27/2025 at 9:01 AM, revealed the resident had partial dentition and food in the mouth. The resident's tongue showed a white coating, and their breath had a foul odor. During an interview with SRNA3 on 01/30/2025 at 9:40 AM, she stated that aides assist residents with brushing their teeth and taking care of their gums. SRNA3 explained that R22 does not have any teeth, so she used an oral foam swab to provide oral care for R22. She stated further that R22 keeps food in her mouth and has bad breath. During an interview with SRNA12 on 01/30/2025 at 10:42 AM, she stated she tried to provide oral care as frequently as possible, even when they were short-staffed. SRNA13 stated further that R22 does not have teeth, and she used an oral foam swab for the resident's oral care. During an interview with SRNA13 on 01/30/2025 at 10:42 AM, she stated she performed oral care as several times a day and after meals. SRNA13 stated that R22 does not have teeth, and she used oral foam swab for the resident's oral care. During an interview with SRNA11 on 01/30/2025 at 11:46 AM, she stated that R22 does not have teeth, and she used an oral foam swab to perform oral care on residents without teeth. Review of the resident's Dental Patient Summary Note, dated 05/23/2024, however, revealed the resident had partial dentition and required assistance with daily tooth brushing. Further, interview with SRNA2 on 01/30/2025 at 2:33 PM confirmed that R22 had some teeth. SRNA2 stated the resident would allow staff to brush her teeth and it was important to provide R22's oral care because she kept food in her mouth. In an interview on 02/01/2025 at 5:06 PM, the DNS stated that aides should perform oral care as ordered and as needed, and nursing staff should assess the residents for any changes in oral health. The DNS added that oral care was important to prevent tooth decay and preserve the residents' teeth. During an interview with ED1 on 02/01/2025 at 9:30 AM, she stated that R22 had partial dentation and was unaware of the staff's confusion regarding R22's teeth. ED1 stated it was important for residents to receive proper oral care, including brushing their teeth. She stated that the nurses assess oral care during their evaluations; however, she had not reviewed the specific notes related to R22. The ED stated further that that heavy plaque could indicate inadequate oral care or potential health issues. 46651 44001 49050

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three residents (Resident (R)124, R80, and R36) reviewed for quality of care. Facility staff failed to ensure medicated shampoo was applied correctly for R80, who had ongoing itching from a scalp condition. In addition, staff failed to provide appropriate services when providing care to R36's prosthetic eye. Staff failed to ensure a dressing was changed according to physician orders for R124. The findings include: 1. Review of the facility policy titled, Wound Care Policy, effective date 05/30/2024 under the section labeled, Promotion of Treatment and Healing of Skin Integrity Impairment, revealed the facility would have a system in place to identify impaired skin integrity development early to prevent further damage and treat the condition as soon as it was identified. Review of the facility policy titled, Medication Administration, approved 12/12/2023, revealed medications were to be administered by licensed nurses, or other staff legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the same policy under the section titled, Procedure, item 14, instructed to administer the medication as ordered in accordance with manufacturer specifications. During observation and interview on 01/26/2025 at 3:04 PM with R80, she stated her head was itching. The resident added that it was driving her crazy. R80 stated she had a history of plaque psoriasis on her scalp that caused her head to bleed and scab and she did not know what the solution was. R80 further stated she had told the nurse, and she was now being treated with a shampoo; however, the treatment was not helping. R80 added that she had not seen the doctor or the nurse practitioner in more than a month, and no one had looked at her scalp. Observation of R80's head at this time revealed an approximately one inch sized lesion in hairline near the forehead on the right with skin and blood on the pillowcase and sheet under her head. Review of the Face Sheet revealed the facility admitted R80 on 05/07/2024 with diagnoses including anxiety. Review of R80's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 11/04/2024, revealed the resident was cognitively intact, based on a Brief Interview for Mental Status (BIMS) score of 15/15. Per the MDS, the resident required substantial/maximum assistance for showering/bathing and personal hygiene. Review of R80's Progress note, dated 12/10/2024 at 1:31 PM by the Nurse Practitioner (NP) revealed R80 was seen for a routine evaluation, had complaints of significant psoriasis ( a skin condition in which skin cells build up and form itchy, dry patches) to her scalp and was documented as stating she had special shampoo ordered recently, and she was awaiting its arrival so that she may begin using it once again. R80 was also documented as having described quite a bit of itching and flaking. The assessment and plan was documented as Psoriasis to her scalp, shampoo was on order and recheck as per routine. Review of R80's Skin Evaluation dated 12/12/2024 and signed as completed by Licensed Practical Nurse (LPN) 1 revealed after completing the head-to-toe skin assessment, no new areas had been noted. Also, on 12/12/2024 at 12:02 PM, new orders were received and noted for ketoconazole shampoo to scalp with showers. R80 was made aware of the new orders, which were received two days after the resident's initial complaints. Review of Skin Evaluations for R80 dated 12/19/2024, 12/26/2024, 01/02/2025, 01/09/2025, 01/16/2025, and 01/23/2025 revealed no documentation of the condition of R80's scalp or any evidence of evaluation addressing the effectiveness of the ordered medicated shampoo. Further review of R80's progress notes through 01/28/2025 confirmed the resident's interview that after she was seen by the NP on 12/10/2024 (when the scalp condition was identified), she had not been seen again. Further review of the Progress notes revealed no further mention of the scalp condition until 01/28/2025 (after surveyor intervention) when a nurses note dated 01/28/2025 revealed that R80 complained of continued itching and scabs to her scalp. Review of R80's Medication Administration Record (MAR) dated 12/2025 revealed the order for Ketoconazole Shampoo 2%, apply to scalp topically one time a day every Wednesday and Sunday for dry scalp, with the start date of 12/15/2024. The documented start date was five days after R80's initial complaints and the shampoo had been documented as applied on 12/15/2024, 12/18/2024, 12/22/2024, 12/25/2024, 12/29/2024, 01/01/2025, 01/05/2025, 01/08/2025, 01/12/2025, 01/15/2025, 01/19/2025, 01/22/2025, and 01/26/2025. Although review of the MAR revealed that the medicated shampoo was being applied on the ordered schedule, interviews with the resident and staff revealed that it was not being applied for the length of time specified in the manufacturer's instructions. Review of the facility provided package leaflet for Nizoral (ketoconazole) 2% shampoo, revised in 01/2024, under the section labeled how to apply revealed the hair was to be wet thoroughly, apply a small amount of shampoo to the scalp and massage into a lather, leave the lather on the scalp for three to five minutes and rinse thoroughly. Further review of the leaflet revealed the shampoo was to be used every three to four days for two to four weeks. During an interview on 01/31/2025 at 5:07 PM with R80, she stated the State Registered Nurse Aides (SRNAs), not the nurses, applied her shampoo and rinsed it out, but they never left it in for three to five minutes. R80 stated SRNA11 had washed her hair today. During an interview on 01/31/2025 at 5:10 PM with SRNA11, she confirmed she had washed R80's hair and stated she did not know to leave the shampoo on for three to five minutes. She stated the Infection Preventionist Staff Development Nurse (IPSD) had given her the shampoo for R80 and sometimes nurses would give her a shampoo or a cream for a resident and ask her to come back and tell them what the resident's skin looked like. During an interview on 01/30/2025 at 10:42 AM with SRNA12 and SRNA13, they also stated that at times, different nurses would hand them the shampoo for R80 for her scalp with no direction on how to use it, The SRNAs stated they used the medicated shampoo like it was regular shampoo, rather than leaving it on for three - five minutes. During an interview on 02/01/2025 at 1:30 PM with the IPSD, she stated it was the job of the nurses to apply medicated creams and shampoos and they should not be handed to the aides for use. Interview on 01/30/2025 at 7:32 PM with LPN1 revealed she was not sure when the scalp condition for R80 began but she knew R80 had a shampoo ordered that was usually applied during her shower. LPN1 stated she had not applied the shampoo and was not sure how long to leave it in but was sure it was to be rinsed out. She further stated she did not chart the scalp condition as a new skin condition on R80's 12/12/2024 skin assessment because it was not new; however, if the previous skin evaluation dated 12/05/2024 had been marked no new areas and the scalp condition was determined to be present on 12/10/2024, then the scalp condition should have been documented on the 12/12/2024 skin evaluation as a new area. LPN1 indicated she was not sure why she marked no new areas on R80's skin evaluation. During an interview with the Director of Nursing Services (DNS) on 01/28/2025 at 3:36 PM she stated she was not aware until that morning (after surveyor initiation of investigation into this care area) that R80 was in continued discomfort and the NP needed to be contacted to ask about increasing the frequency of treatment to her scalp or review the medications for it. During interview on 01/29/2025 at 7:31AM with the Nurse Practitioner (NP), he stated R80 first complained of her scalp itching a little over a month ago and he had ordered Ketoconazole 2% Shampoo to be applied twice a week. He stated during rounds he determined R80 had run out of the shampoo and was waiting for it to be replaced. He further stated after two weeks with no improvement to R80's scalp, he ordered the frequency of the shampoo to be increased to three to four times a week, but could not remember the date, and then determined there was no record of that order so the application frequency of the shampoo had not been increased. Further interview with the NP revealed that, after the survey was initiated, he re-wrote the order for Ketoconazole 2% Shampoo to be applied more frequently, and the resident was started on Terbinafine 250 milligram (mg) tablet (an oral antifungal) once a day for 14 days The NP stated his expectation was all orders for residents be carried out as ordered and the shampoo would be used per manufacturer instructions. The NP continued that he was not sure which staff applied it or if the order was being carried out per protocol, but since the shampoo was considered a medication, it would be a nursing duty. He stated his expectation was the shampoo be applied, left on for three - five minutes then rinsed out, and that he would be made aware of any resident refusals of medication, acute changes in resident condition and anything that affected resident care. During an additional interview on 02/01/2025 at 4:56 PM with the DDNS, she stated the nurses should not be handing an aide a medicated shampoo or topical treatment to be applied to a resident. Instead, the nurses should be applying medications to assess its effectiveness or if a change was needed. The DNS stated it was her expectation the nurses would administer and apply all medications and assess for effectiveness as ordered and as needed. 2. Review of R36's Admission Record revealed the facility admitted the resident on 12/31/2020 with diagnoses to include Alzheimer's disease, dementia, and presence of an artificial eye. Per the Admission Record, the resident had a legal Resident Representative (RR). Review of R36's Quarterly MDS, with an ARD of 12/30/2024, revealed the resident had long and short-term memory issues. Review of the MDS revealed the resident did not exhibit any rejection of care. Further review of R36's MDS revealed the resident was dependent (helper does all the work) with activities of daily living (ADLs) including personal hygiene. Review of R36's undated Comprehensive Care Plan (CCP), revealed the facility identified R36 as having impaired visual function due to an artificial left eye on 11/24/2015. Care plan interventions in place as of 01/26/2025 included: 1. arrange consultation with eye care practitioner as required; 2. perform artificial eye care as ordered; and 3. observe for signs of acute eye problems. Further review of the CCP revealed that it did not include specific instructions on the need to remove the artificial eye when performing eye care. Although the CCP stated to perform artificial eye care as ordered, review of physician's orders revealed that there were no orders for eye care until 01/27/2025, after the initiation of the survey. Further review of 01/2025 physician orders revealed that the resident was not being treated for any eye infection. Review of R36's EMR revealed no evidence through Progress Notes that the resident had any type of eye infection as of 01/26/2025. During an observation on 01/27/2025 at 3:46 PM, R36 was seated in her wheelchair in the day room, positioned in front of the nurse's station where two nurses were seated. Observation of R36's face revealed green, pus-filled drainage was weeping from the resident's left eye. The eyelid and lashes were coated with a thick, crusty material, causing the eye to be matted shut. An attempt was made to interview R36 on 01/27/2025 at 3:46 PM, however, the resident did not respond to questions. Although review of R36's EMR revealed no evidence that the resident had drainage, weeping, or signs of eye infection, interviews with staff revealed that this was an ongoing problem for the resident. During an interview with the Social Service Director (SSD) on 01/27/2025 at 3:47 PM, she stated R36 always had an eye infection. She did not know if the resident was being treated for an infection. Interview with Licensed Practical Nurse (LPN) 1 on 01/27/2025 at 4:55 PM revealed she was R36's nurse. She also stated that she was aware of issues with R36's eye. She stated she was unsure how long R36's eye had been draining, but she stated that it continuously discharged green, purulent drainage, often causing the eyelids to stick together. LPN1 was unaware if R36 had been seen by a specialist for this condition. During an interview with SRNA3 on 01/30/2024 at 9:40 AM, she stated she wiped R36's eye with warm water and soap from the dispenser using a washcloth. However, she added, the eye continued to weep and drain. SRNA3 stated further that R36's left eyelids remained crusted together. During an interview with SRNA13 on 01/30/2024 at 10:41 AM, she stated R36's eye constantly drained and teared. She stated that even after it was cleansed with warm water using a washcloth, the eye continued to weep thick green drainage. During an interview with SRNA11 on 01/30/2024 at 10:48 AM, she stated that R36's eye persistently drained thick green discharge even after it was cleansed with soap and warm water. During an interview with the NP on 01/29/2025 at 7:30 AM, he stated that R36 had received treatments in the past for infections. He stated R36 was referred to an Optometrist over the summer; however, R36's guardian refused care. He emphasized that his expectation was to follow the protocol to ensure the safety and well-being of the resident. During an interview with the NP on 01/29/2025 at 7:30 AM, he stated the treatment protocol for R36's eye care was to keep it clean. He stated that [R36's] eye should absolutely come out for proper cleaning but added that it was his understanding that it had never been removed while in the facility. The NP stated that R36 seldom exhibits behavioral issues and he emphasized that his expectation was for staff to follow the protocol to ensure the safety and well-being of the resident. The NP revealed that after surveyor intervention, he gave new orders for eye care. Review of R36's new Physician Orders, revealed nursing staff received verbal orders on 01/27/2025 to cleanse the (artificial) left eye with baby shampoo, pat dry, every shift as needed, and every shift as a preventative. Interview with LPN 1 on 01/27/2025 at 4:55 PM, revealed she was R36's nurse. She stated that R36 was care planned for having an artificial left eye; however, she was unsure of what the interventions were for R36 related to her prosthesis. LPN1 stated R36's eye was cleansed using soap and water. The LPN stated to her knowledge, the staff had never removed the eye prosthesis for cleaning purposes. She indicated R36 was non-compliant with care and would probably not allow staff to remove the prothesis. LPN1 stated that the resident's care plan should be followed to ensure she received person-centered care. During an interview with SRNA3 on 01/30/2024 at 9:40 AM, she stated she wiped R36's eye with warm water and soap from the dispenser using a washcloth. SRNA3 was unaware that R36 had a prosthetic left eye that needed to be removed for cleaning. During an interview with SRNA13 on 01/30/2024 at 10:41 AM, she stated R36's eye was cleansed with warm water using a washcloth, but the eye continued to weep thick green drainage. Further interview revealed SRNA13 was unaware R36 had a prosthetic left eye that needed to be removed for care. During an interview with SRNA11 on 01/30/2024 at 10:48 AM, she stated that R36's eye persistently drained thick green discharge even after it was cleansed with soap and warm water. SRNA11 was also unaware that R36 had a prosthetic left eye that needed to be removed for cleaning. During an interview with the Assistant Director of Nursing Services (ADNS) on 02/01/2025 at 3:18 PM, she stated all staff need to follow each residents' care planned interventions. She stated she was unsure of why R36 did not have a treatment to address her eye drainage, or when she last saw an ophthalmologist. She stated further the nurses should do the baby shampoo treatment, not the SRNAs. The ADNS stated it was her expectation the nurses would administer and apply all treatments as ordered and assess for effectiveness. During an interview with the DNS on 02/01/2025 at 4:56 PM, she stated nurses should not have allowed SRNAs to apply treatments; instead, nurses should perform the treatments as ordered. She stated it was important for nurses to assess the effectiveness of the treatments and determine if changes were needed. The DNS stated it was her expectation that nurses would follow the orders as written, administer and apply all medications, and assess their effectiveness as instructed and as necessary. 3. Review of R124's medical record revealed the facility admitted the resident on 01/16/2025 with diagnoses including rehab following myocardial infarction (MI) with life vest, sepsis related to septic knees, and intravenous (IV) antibiotic therapy. Review of R124's admission MDS, with an ARD of 01/16/2025, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. Further review revealed R124 admitted to the facility with IV access. Review of R124's care plan, initiated on 01/17/2025, revealed the resident had a midline IV access to her left arm, with an intervention for the midline dressing to be changed as ordered. Review of R124's physician orders revealed an order dated 01/19/2025 with instructions for the resident's midline dressing to be changed once a week and as needed. Review of R124's Medication Administration Record/Treatment Administration Record (MAR/TAR) for the month of 01/2025 revealed the entry on 01/23/2025 for R124's weekly dressing change was marked as not completed. Review of R124's progress notes dated 01/16/2025-01/30/2025 revealed that although nursing staff assessed the midline site for edema and redness, there was no evidence the dressing was changed per R124's physician orders and plan of care prior to the line being pulled on 01/30/2025. Observation on 01/28/2025 at 10:16 AM revealed R124 with a left upper arm (LUA) midline, covered with an intact transparent adhesive dressing dated 01/16/2025. An additional observation made at 2:14 PM revealed the dressing was dated 01/16/2025. Observation or R124's LUA midline dressing on 01/29/2025 at 4:47 PM revealed the transparent adhesive dressing was dated 01/16/2025. In an interview with R124 on 01/28/2025 at 10:16AM, she stated she received IV antibiotics for a knee infection through her midline. She further stated staff flushed the line before and after she received antibiotics, but the dressing had not been changed since she was admitted to the facility. In an interview with the NP on 01/29/2025 at 7:45 AM, he stated he expected nursing and/or other appropriate staff to carry out orders that were written. In an interview with LPN3 on 01/29/2025 at 3:45 PM, she confirmed R124 was admitted with a midline to her LUA and received antibiotics for an infection. LPN3 further stated she flushed the line daily, but the Registered Nurses (RNs) performed dressing changes. LPN3 stated she was not aware the dressing had not been changed as ordered. In an additional interview with LPN3 on 01/30/2025 at 4:54 PM, she stated care plans were in place so residents received the care they needed and should be followed. In an interview with LPN4 on 01/31/2025 at 11:37 AM, she stated the RNs at the facility changed midline dressings, but if she personally identified an outdated dressing, she reported it to an RN. She further stated a resident's care plan included dressing changes as well as the ordered frequency of those changes, and that information was documented on the MAR/TAR. Further interview revealed that LPN4 had not identified that the resident's dressing was outdated. In an interview with Registered Nurse (RN) 2 on 01/31/2025 at 4:10 PM, he stated he had not changed R124's midline dressing and was not aware the dressing was outdated. In an interview with the ADNS on 02/01/2025 at 4:11 PM, she stated it was her expectation that nursing changed midline dressings as ordered and per a resident's care plan. She further stated it was important a resident's care plan was followed because that was how his/her care needs were met. The ADNS stated midline dressing changes were an RN responsibility because LPNs at the facility were not trained for those dressing changes. When asked why R124's dressing had not been changed since she was admitted , the ADNS stated that would need to be investigated further because dressing changes were reviewed in morning meetings and also flagged on the TAR when due to be changed. However, no further information about the failure to change the dressing as ordered was provided prior to exit. In an interview with the DNS on 02/01/2025 at 5:58 PM, she stated it was her expectation staff followed care plan interventions and physician orders. She further stated if R124's orders specified the dressing should be changed weekly, she expected that nursing followed the order. The DNS stated it was important to maintain midlines for residents on IV antibiotics to prevent infection. She further stated it was the facility's goal that residents received quality care. 46651 49267

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for two (Resident (R) 27 and R10) of six sampled residents reviewed for pressure ulcers. R27 and R10, who were dependent on staff for pressure prevention interventions including prompt incontinence care and turning/repositioning, each developed facility-acquired pressure ulcers. The findings include: Review of the facility's policy, Wound Care Policy, dated 05/20/2024 revealed the facility was to ensure residents who did not have skin integrity impairments did not develop a new condition involving the skin. Further review revealed the facility was to implement interventions to address the resident's risks for skin breakdown to maintain skin integrity. 1) Review of R27's Admission Record revealed the facility admitted the resident on 05/23/2023 with diagnoses including mild cognitive impairment, osteoarthritis, and depression. Review of R27's Comprehensive Care Plan (CCP), dated 05/24/2023 revealed the facility identified the resident as at risk for skin breakdown and pressure ulcers. Further review revealed the facility listed interventions including assisting with routine incontinence care and as needed, assisting with bed mobility to turn and reposition routinely, and to provide preventative skin care as indicated. Review of R27's current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13/15, indicating the resident was cognitively intact. Further review revealed R27 required partial to moderate assistance with turning side to side in the bed and with bed to chair transfers. Per the MDS, the resident did not refuse care. Continued review revealed R27 was always incontinent of bowel and bladder. Additional review of the MDS revealed that at the time of this assessment, R27 had one Stage III pressure ulcer that was not present on admission. Review of the resident's pressure ulcer history revealed the following: Review of a Wound Assessment Report, dated 11/19/2024 revealed R27 had developed partial thickness moisture associated skin damage (MASD) to the right buttock. Review of the next weekly Wound Assessment report, dated 11/26/2024, revealed that the area was considered a new area of skin breakdown that was noted to be improving, with no date listed for when the wound was acquired. Review of a Wound Assessment Report, dated 12/03/2024, revealed R27 had partial thickness MASD to the right buttock that was noted to be worsening, with no date listed for when the wound was acquired. Further review revealed the wound care nurse practitioner listed wound treatment instructions to cleanse with soap and water, apply collagen particles, and apply barrier cream, while leaving the wound open to air. Review of the facility's Wound Assessment Report, dated 12/10/2024 revealed R27 had a deep tissue injury (DTI) to the left buttock measuring 1 cm (centimeter) by 2 cm. Further review revealed the right buttock MASD progressed to a facility-acquired Stage III pressure ulcer which was noted to be worsening since the previous assessment. At this time, the orders for wound care were changed. Review of R27's Comprehensive Care Plan (CCP), dated 12/10/2024 revealed the facility updated the CCP to show that R27 had a pressure ulcer on her left buttock and listed interventions including assisting the resident with bed mobility to turn and reposition routinely, as well as providing incontinence care as needed. Review of an IDT [Interdisciplinary Team] Risk Review, dated 12/11/2024, revealed the facility assessed R27 as having a Stage III pressure ulcer to the right buttock and a DTI to the left buttock. Further review revealed the facility listed supplements and diet orders for R27, as well as the placement of a low air loss mattress for wound healing. Continued review revealed the facility did not identify a root cause of the wound. Further review of the document revealed it failed to address the need for timely incontinence care or turning and repositioning needs in the IDT note. Review of the facility's document, Assessing Unavoidable Pressure Ulcers, signed 12/10/2024 revealed the facility assessed R27 as having chronic renal, liver, or heart disease, history of stroke, hip fracture, a history of pressure ulcers, decreased mobility, incontinence, and use of psychotropic medications. Continued review revealed the form did not indicate a root cause of R27's wound. The form did show that the resident needed incontinence care and marked that it was being provided. Additional review revealed the Director of Nursing Services (DNS), and Medical Director signed the form on 12/10/2024. Further review of a Wound Assessment Report, dated 12/17/2024 revealed that, after completing the Risk Review and Assessing Unavoidable Pressure Ulcer documents, R27's DTI to the left buttock had progressed to a Stage III pressure ulcer with slough in the wound. In an interview on 01/27/2025 at 5:13 PM, R27 stated she knew staff were trying their best, but the facility was often short staffed, and she had to wait long periods of time to get incontinence care. R27 stated urine would often soak through her briefs onto her sheets after receiving her water pill. Per interview, R27 reported having to lay in a wet bed for over two hours at least once per week while waiting for staff to change her, which made her feel embarrassed. In continued interview, R27 stated she developed problems with her skin in the past few months, including a pressure ulcer. Observation on 01/31/2025 at 10:40 AM revealed Licensed Practical Nurse (LPN) 4 changed R27's brief and wound dressing. R27's wound was covered in pink granulation tissue, with a small area in the middle that was raw in appearance. Additional observation revealed LPN4 asked R27 if she wanted to be repositioned, R27 responded I'm fine. While still in the room, R27 was interviewed related to why she did not want to be repositioned. R27 responded she would turn if staff wanted her to do so; however, LPN4 failed to reposition the resident or remind the resident why it was important to reposition. In an interview on 01/31/2025 at 10:50 AM, LPN4 stated she educated residents about the need to reposition to prevent pressure ulcers, but they often would reposition themselves right back to how they were comfortable. She stated no matter how much she explained the need to reposition residents, the families would often remove positioning devices if they believed they did not look comfortable. LPN4 stated that because R27 stated she was fine, she did not reposition her. In an interview on 01/30/2025, SRNA10 stated the belied that R27's skin breakdown had worsened due to being left wet for long periods of time several days per week. SRNA10 stated when the facility was short staffed, residents did not get the care necessary to prevent pressure ulcers, including incontinence care and repositioning. SRNA10 stated he felt bad when he knew residents were receiving poor care. In an interview on 02/01/2025 at 9:50 AM SRNA5 stated she had not come in to provide any care to R27 since her shift began at 6:00 AM. She stated the care she provided to residents was to meet their basic needs, including being kept clean. Observation on 02/01/2025 at 9:50 AM revealed SRNA5 and SRNA 18 failed to offer to reposition R27 off her back after changing her soiled draw sheet. In an interview on 02/01/2025 at 1:29 PM, the Staff Development Coordinator (SDC) stated she was part of the Interdisciplinary Team (IDT) that evaluated R27's facility acquired Stage III pressure ulcer. She stated the IDT performed root cause analyses on each wound and ensured interventions, including appropriate cushions, air mattresses, and supplements were in place for the resident. The SDC stated each resident with a pressure wound should be on a turning and repositioning schedule, which was not based on specific times. She stated that repositioning schedule meant the aide needed to keep track of the last time the resident was turned and turn them two hours after that. The SDC did not recall the root cause the team identified for R27's wound. In an interview on 02/01/2025 at 3:18 PM, the Assistant Director of Nursing Services (ADNS) stated she was part of the IDT that looked at different risk factors for a resident developing a pressure wound, including their diagnoses, medications, diets, and treatments. She stated the IDT filled out an Assessing Unavoidable Pressure Ulcer form, which was a tool to assess if a wound was unavoidable. Per interview, the ADNS believed having the tool filled out on a resident did not necessarily indicate the wound was unavoidable because all the interventions would need to be implemented in order for it to be unavoidable. In an interview on 02/01/2025 at 5:06 PM, the Director of Nursing Services (DNS) stated the SRNAs at the facility had a lot of responsibilities. She stated if there were only three SNRAs assigned to resident groups on the hall, it would likely be difficult for them to reposition every resident who needed it every two hours, as required to prevent and heal pressure ulcers. The DNS stated the Assessing Unavoidable Pressure Ulcers document was a tool to help the facility implement necessary interventions. Per interview, the DNS stated her signature on the document did not represent her attestation that all interventions had been effectively implemented. In an interview on 02/01/2025 at 6:28 PM, the Executive Director (ED) stated she would have to review the documentation for R27 to recall the root cause of the resident's pressure ulcer. The ED further stated she had not been made aware of concerns related to barriers in implementing R27's care plan. She continued to state that she had no concerns about the wound being acquired in house because the facility determined the wound was healed as of 02/01/2025. 2. Review of R10's Admission Record revealed the facility initially admitted the resident on 04/17/2015, with the most recent admission on 08/23/2018. R10's diagnoses included multiple sclerosis (MS), vascular dementia, diabetes melllitus (DM) and neuromuscular dysfunction of bladder. Review of R10's most recent MDS assessment, a quarterly assessment with an ARD of 11/21/2024, revealed Section A Brief Interview for Mental Status (BIMS) score of 11/15. Per the MDS, the resident had no wounds. Continued review revealed R10 was always incontinent of bowel and had a suprapubic catheter in place for voiding. Review of R10's Care Plan, dated 04/30/2015 and most recently revised on 11/04/2024 revealed the facility identified R10 was at risk for pressure ulcers, excoriation, MASD, and vascular and diabetic wounds related to MS, DM, decreased mobility and incontinence. Review of interventions for wound risk included to check routinely for incontinence and provide incontinent care as needed/notify nurse of redness or irritation, incontinence care as needed, reposition R10 every 2-3 hours and as needed, assist with toileting as needed, pressure reduction mattress on bed, all initiated on 02/06/2020. Review of the facility's document Wound Assessment Report, dated 12/31/2024, revealed R10 had a new facility-acquired pressure wound identified to the right hip, described as a Deep Tissue Injury (DTI). Further review revealed the measurements were 5 centimeter (cm) in length by 2.5 cm in width. The physician was notified and ordered a treatment of calcium alginate and bordered foam. Review of the facility's document IDT Risk Review, dated 01/03/2025, revealed the facility assessed R10 as having a DTI to the right hip. Further review revealed the facility listed the supplements and diet orders for R10, as well as the placement of a low air loss mattress for wound healing, and the care plan was updated. Review of a Wound Assessment Report, dated 01/07/2025, revealed the right hip pressure wound was 2 cm in length by 1.5 cm in width and Stage II, with treatment unchanged. Review of the IDT Risk Review, dated 01/08/2025, revealed the resident continued to have a Stage II pressure wound. Review of a Wound Assessment Report, dated 01/15/2025, revealed the right hip pressure wound was 2 cm in length by 1 cm in width, 0.10 in depth, and a Stage II Review of a Skin Condition Evaluation, dated 01/16/2025, revealed the right hip pressure wound remained 2 cm by 1 cm by 0.10 cm and was confirmed as in house acquired. Review of a Skin Condition Evaluation, dated 01/22/2025, revealed the right hip wound was now 3 cm in length, 2.5 cm in depth, 0.10 cm in depth and unstageable. Review of the facility's IDT Risk Review, dated 01/23/2025, revealed the facility assessed R10's wound as unstageable. During interview with SRNA3 on 01/30/2025 at 9:59 AM, she stated they were supposed to do rounds every two hours. However, when they were responsible for 22 residents, they just had to do the best they could. In further interview, she stated she sometimes walks into rooms of residents who were reported as having been changed but found they had been soiled for an extended period. She stated it was possible to tell by the wetness or soil on the bed and the longer the residents sat wet, the darker the yellow urine ring was on the bed. During interview with SRNA2 on 01/30/2025 at 2:33 PM, she stated she has started the day finding residents soiled for an extended while. During interview with SRNA11 on 01/30/2025 at 11:46 AM, she stated it was the aides' responsibility for oral care, hair combing, as well as toileting or incontinence care. The SRNA stated it was hard to get everything done. She stated the aides were expected to report skin or other changes to the nurse but felt it did not always happen. She stated she could tell because if she had been off for a few days and someone cared for her residents who had a bruise or a wound, she could tell that nothing had been done. The SRNA stated that a lot of the residents would get upset when they did not get what they needed, such as getting changed timely. During interview with SRNA 10 on 01/30/2025 at 3:30 PM, he stated he would like to say residents were changed every two hours like they were supposed to be; however, some have to wait three or three and-a-half hours. In further interview, he stated residents would say they were upset, that they have been laying in urine or feces for a long time and We have some with skin breakdown. He stated, it is hard to take care of 15 residents, never mind 30 residents, adding that the care given was inadequate due to not having enough staff. SRNA10 stated when the facility was short staffed, residents did not get the care necessary to prevent pressure ulcers, including incontinence care and repositioning. Interview on 01/29/2025 at 11:05 AM with LPN3 revealed the facility had recently terminated their contract with the (previously used) wound care service and the facility nurses were now responsible for wound care. She stated it was difficult to manage the wounds in addition to other duties. In an interview on 02/01/2025 at 5:06 PM, the DNS stated the SRNAs had a lot of responsibilities. She further stated if there were only three SNRAs assigned to resident groups on the hall, it would likely be difficult for them to reposition every resident who needed it every two hours, as required to prevent and heal pressure ulcers. The DNS stated she hoped nurses were changing resident's briefs if they were in the resident's room doing a treatment, but she had not audited for the practice. The DNS further stated she could not verify that the timely incontinence care and repositioning was being provided. 44396 49267

Based on observation, interview, record review, review of facility staffing documentation and review of the facility's Payroll Based Journal (PBJ) [NAME] report, the facility failed to have an effective system in place to ensure sufficient, qualified, nursing staff with the appropriate competencies and skill sets was present in sufficient numbers to provide nursing and related services to residents. The facility failed to provide nursing services to meet the assessed needs of the residents according to each resident's care plan and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being. A lack of sufficient, competent staff has the potential to affect the total census of 109 residents. The findings include: 1. Based on observation, interview, and record review, dependent residents R25, R52, R90, F79, R36, and R22 failed to receive needed assistance with Activities of Daily Living (ADL) in the areas of incontinence care and dental care. (Refer to F677 for specific findings.) 2. Based on observation, interview, and record review, R124, R80, and R36 failed to receive care as needed. Staff incorrectly applied medicated treatments, failed to properly clean a resident's prosthetic eye, and failed to change a dressing as ordered. (Refer to F684 for specific findings.) 3. Based on observation, interview, and record review, R27 and R10 developed facility-acquired pressure ulcers after staff failed to provide pressure prevention approaches including incontinence care and turning/repositioning. (Refer to F686 for specific findings.) 4. Based on observation, interview, and record review, R1 and R125, who each had a catheter, failed to receive care in a manner to prevent and/or timely treat urinary tract infections. (Refer to F690 for specific findings.) 5. Based on interview and record review, R62 was hospitalized for dehydration and hypernatremia after failing to receive all ordered nutrition and fluids through a feeding tube, (Refer to F693 for specific findings.) 6. Based on interview and record review, R119 failed to receive pain medication as ordered after nursing staff failed to order it in a timely manner. (Refer to F697 for specific findings.) Review of the facility policy titled, Staffing, effective 10/01/2024, revealed the purpose was to provide sufficient care team members with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The census, acuity and diagnoses of the resident population would be considered based on the facility assessment. Further review of the facility policy revealed the company would supply services by sufficient numbers of each of the following care team member types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: licensed nurses and other nursing personnel, including but not limited to State Registered Nurse Aides (SRNAs). Review of the facility document titled, Facility Assessment Tool (FAT) dated 11/2023-12/2024 revealed the purpose was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The assessment was used to make decisions about direct care staff needs as well as the facility's capability to provide services to the residents in the facility and was focused on ensuring each resident was provided care that allowed the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Continued review of the document, dated 11/2023-12/2024, revealed the intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Additional review of the FAT, Page 3, revealed the facility average daily census was 109 and Page 18 revealed the facility had assessed the need for 12-18 nurse SRNAs per day, four to ten on the day shift and four to eight on the night shift, as well as, the need for four to seven nurses per day, two to five on the day shift and two to four on the night shift. Per the FAT, the facility estimated caring for an average of 35 residents who were dependent of staff for toileting needs with an additional 61 residents requiring assistance of one or two staff members for toileting. Additionally, the facility estimated all residents required some form of assistance with eating, eight of which were totally dependent and an additional three who required substantial/maximal assist. The general facility process section of the FAT outlined to ensure the facility had sufficient staff to meet the needs of the residents at any given time was documented as refer to the Centers for Medicare and Medicaid (CMS) Minimum Staffing Rule. Review of the facility's PBJ [NAME] report for the fourth quarter of the Fiscal Year 2024 (July 1 - September 30) revealed the facility had a One Star Staffing Rating and submitted weekend staffing data was excessively low. Initial review of the Detailed Hours Report (DHR) which documented actual hours staff were punched in for work for hours worked on weekend shifts for 09/07/2024, 09/08/2024, 09/15/2024, 09/21/2024, 10/05/2024, and 10/06/2024, 10/20/2024 revealed: 7. On 09/07/2024, five SRNAs worked from 6:00 AM-6:00 PM and an additional one SRNA worked from 8:00 AM to 2:00 PM, indicating from 6:00 AM to 8:00 AM and from 2:00 PM to 6:00 PM each SRNA was responsible for the care of 22 residents and from 8:00 AM to 2:00 PM each SRNA was responsible for the care of 18 residents. On 09/08/2024, six SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 18 residents. On 09/15/2024 four SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 27 residents. On 09/21/2024 six SRNAs worked from 6:00 AM-6:00 PM indicating each SRNA was responsible for the care of 18 residents. On 10/05/2024 six SRNAs worked from 6:00 AM-6:00 indicating each SRNA was responsible for the care of 18 residents. On 10/06/2024 five SRNAs worked from 6:00 AM-6:00 indicating each SRNA was responsible for the care of 22 residents. On 10/20/2024 four SRNAs worked from 6:00 AM-6:00 PM each SRNA was responsible for the care of 27 residents. Review of the DHR dated 10/14/2024 revealed one nurse was working from 6:00 PM to 12:00 AM and was responsible for the care of all the facility's residents. Review of the facility DHR dated 01/21/2025 revealed five SRNAs were working from 6:00 PM-6:00 AM requiring each SRNA to be responsible for the care of 22 residents. Review of the DHR dated 01/24/2025 revealed four SRNAs worked from 6:00 PM-6:00 AM and one SRNA worked from 6:00 PM to 12:00 AM, requiring each SRNA to be responsible for the care of 21 residents from 6:00 PM to 12:00 AM and 27 residents from 12:00AM to 6:00 AM. Review of the DHR dated 01/25/2025 revealed three SRNAs worked from 6:00 PM-9:00 PM, requiring each SRNA to be responsible for the care of 37 residents until an additional two SRNAs arrived at 9:00 PM, totaling five SRNAs who worked from 9:00 PM-6:00 AM requiring each SRNA to be responsible for the care of 22 residents. Review of the facility document titled Daily Staffing (DS) sheet dated 01/26/2025 revealed the facility scheduled a total of four SRNAs from 6:00 PM-6:00 AM, requiring each SRNA to be responsible for the care of 27 residents. Review of the DS dated 01/28/2025 revealed six SRNAs worked from 6:00 PM-6:00 AM, requiring each SRNA to be responsible for the care of 18 residents. Review of the DS dated 01/29/2025 revealed three SRNAs worked from 1:00 AM-6:00 AM, requiring each SRNA to be responsible for the care of 36 residents. Review of the DS dated 02/01/2025 revealed six SRNAs worked from 6:00 AM-6:00 PM, requiring each SRNA to be responsible for the care of 18 residents. Review of the facility document titled, Engagement Survey Results, dated 11/2024 revealed documented comments from staff citied the chronic frustrations with the need for more SRNAs 17 times. One comment stated, We need more SRNAs, the workload is horrible and to get everyone changed you sometimes have to miss showers. Review of the facility document Detailed Hours, dated 07/23/2024 revealed a total of seven SRNAs working from 6:00 AM until 2:00 PM and six SRNAs working from 2:00PM until 6:00 PM. Further review revealed a total of five SRNAs working 6:00 PM until 6:00 AM. Review of the staffing sheet for 07/23/2024 revealed a facility census of 115. 8. a. Review of a Report of Concern, dated 07/02/2024, Family Member (F) 52 reported a concern of R52's call light not being answered timely. The Executive Director (ED) marked the grievance as confirmed and wrote that nurses were educated about call light wait times. In an interview on 01/27/2025 at 9:47 AM, F52 stated she reported to the facility that there had been multiple times the family had waited with R52 for over 20 minutes after pressing the call light. She further stated when they had been waiting, they would go down to the nurse's desk to find nurses sitting there. Per interview, F52 stated the ED took notes of the concerns and said she would talk to staff. F52 continued to state administration told her they would put it in R52's Care Plan that she needed to be toileted more frequently than every two hours. F52 added that R52 had a doctor's appointment on 07/24/2024 and was supposed to receive a shower on the evening of 07/23/2024 and wear the clean clothes F52 put out on R52's wheelchair. Per interview, when F52 met R52 at the doctor's office, R52 was still wearing the clothes she was wearing during the day on 07/23/2024, not the clean ones. R52's hair was dirty and unbrushed. She stated she filed a grievance with the ED, who told her the aide had not given the shower but had charted that she had by mistake. In further interview, F52 stated the ED told her if she did not like the care provided to R52, she could take R52 home. Review of the facility time punch document, Detailed Hours, dated 11/02/2024 revealed a total of six SRNAs working from 6:00 AM until 6:00 PM. Further review revealed a total of four SRNAs working from 6:00 PM until 6:00 AM. Review of the facility staffing sheet for 11/02/2024 revealed the census was 115. b. Review of a Report of Concern, dated 11/02/2024, revealed F52 filed a grievance when she found R52 sitting in briefs and clothes soiled with urine and noted urine dripping into the floor beneath R52's wheelchair. Further review revealed the ED marked the grievance as confirmed and noted the care team member was terminated on 11/04/2024. In an interview on 01/27/2025 at 9:47 AM, F52 stated on 11/02/2024, she came in to find R52's briefs, clothing, and wheelchair saturated with urine and urine puddled in the floor beneath R52's wheelchair. F52 asked an aide, whose name she could not recall, to clean R52 up. F52 stated the staff member told her she could not help until she had picked up dinner trays. In an interview on 02/01/2025 at 6:28 PM, the Executive Director (ED) stated she recalled F1's grievance related to R52 being left wet on 11/02/2024. She further stated that in investigating the grievance, she confirmed R52 had been wet with urine and the SRNA who responded was rude to F52. c. Review of the facility time punch document, Detailed Hours, dated 11/22/2024 revealed a total of five SRNAs working 6:00 PM until 6:00 AM. Review of the facility staffing sheet dated 11/22/2024 revealed the facility census was 109. In an interview on 01/27/2025 at 9:47 AM, F52 stated that on 11/22/2024, she waited one hour and three minutes for staff to answer R52's call light when the resident needed assistance with toileting/incontinence care. Per interview, F52 timed the wait on her phone and took a video. d. Review of the facility time punch document Detailed Hours, dated 12/04/2024 revealed six SRNAs working from 6:00 AM until 6:00 PM, with two additional SRNAs working 10:00 AM until 4:00 PM, and one SRNA working 6:00 AM until 4:00PM. Further review revealed four SRNAs working 6:00 PM until 6:00 AM. Review of the facility staffing sheet dated 12/04/2024 revealed the facility census was 103. In an interview on 01/27/2025 at 9:47 AM, F52 stated that on the evening of 12/04/2024, she waited a prolonged period of time for staff to answer R52's call light when the resident needed assistance with toileting and incontinence care. e. Review of the facility time punch document, Detailed Hours, dated 01/14/2025, revealed six nurse aides working 6:00 AM until 6:00 PM, one SRNA working 12:30 PM until 5:00 PM, one SRNA working 10:00 AM until 6:00 PM, and the wound care SRNA working 9:00 AM until 5:00 PM. Review of the facility staffing sheet dated 01/14/2025 revealed the census was 108. In an interview on 01/27/2025 at 9:47 AM, F1 stated she came in the afternoon of 01/14/2025 to find R52 in a soaked brief and clothes wet with urine. f. Review of the facility time punch document Detailed Hours, dated 01/15/2025, there were six SRNA working 6:00 AM until 6:00 PM, with two additional SRNAs working partial shifts. Further review revealed five SRNAs working from 6:00 PM until 1:00 AM, and 4 SRNAs working from 11:00 PM until 7:00 AM. Review of the facility staffing sheet for 01/15/2025 revealed the facility census was 109. In an interview on 01/27/2025 at 9:47 AM, F52 stated she came in the afternoon of 01/15/2025 to find R52 in a soaked brief and clothes wet with urine. 9. a. Observation on 01/29/2025 at 4:42 PM revealed three call lights, both visual and audible, were alerting on the back hall. A male resident was overheard stating, Can someone help me, I am a mess. Licensed Practical Nurse (LPN) 2 stated, You will need to wait, buddy. b. Observation, on 01/29/2025 at 4:45 PM, during dining service, revealed the call light for room [ROOM NUMBER], both visual and audible, was alerting on the front hall. LPN6 was observed sitting at the nurse's station with the call light board behind him alarming and illuminated and he did not get up to assist with answering the call light. c. Observation on 01/29/2025 at 4:46 PM during dining service, revealed a call light for room [ROOM NUMBER], both visual and audible, was alerting on the front hall. The Activities Director (AD) walked past the room and did not address the call light. d. Observation on 01/31/2025 at 10:53 AM revealed two call lights illuminated and audible on the South Hall. LPN1 and LPN2 were observed sitting at the nurse's station with the call light board behind nurses' station illuminated and audible. Neither LPN1 nor LPN2 got up to answer the call lights. e. Observation on 01/31/2025 at 4:45 PM of one SRNA in the dining room sorting meal tickets while six meal trays were waiting in the pass through ready to be given to the residents and four call lights on the North Hall were illuminated and audible. f. Observation on 01/31/2025 at 7:50 AM revealed the call light for room [ROOM NUMBER] was lit above the resident's door. Further observation revealed the call light board at the nurse's station displayed a light indicating room [ROOM NUMBER]'s call light was on, as well as making an intermittent beep to alert staff to the call light. Continued observation revealed LPN1 and LPN2 sitting at the nurse's desk, in view of the control board, where the beeping could be heard, Neither LPN looked over at the control board to see which light was on, nor did they get up to look in the hallway. Per observation, the call light for room [ROOM NUMBER] sounded for four minutes without any response from the LPNs. In an interview on 01/31/2025 at 8:00 AM, LPN1 and LPN2 stated it was everyone's responsibility to answer call lights. When asked about the call light that had sounded for several minutes prior to the interview, the LPNs asked the survey team if the sound went off at the nurse's station. When the survey team confirmed that the sound went off, the LPNs failed to provide any response to why they had not acknowledged the call lights. g. Observation on 02/01/2025 at 10:08 AM revealed the call light for room [ROOM NUMBER] was on. No SRNAs were seen in the hallway. Qualified Medication Aide (QMA)8 was present, preparing medicine. The Maintenance Director walked past room [ROOM NUMBER] without turning his head. Observations at 10:12 and 10:13 AM revealed the Social Services Director (SSD) also walked by room [ROOM NUMBER] while the call light was on, without turning her head to look in the resident's room. Observation at 10:17 AM revealed the call light was still going off (nine minutes after first observed) when ED2 entered the room, asked the resident what he needed and stated he would go get the nurse. The call light remained lit until 10:19 AM when LPN4 entered, asked the resident if he wanted a breathing treatment, and began to administer it, then walked away while it was going in. 10. a. During an interview on 01/26/2025 at 4:40 PM with R90, she stated she had been sitting in a wet bed for a couple hours, had put her call light on twice and was told by the SRNAs they had a new admission and were busy. Observation during this interview revealed the resident's brief appeared heavy with urine. Review of the DHR, dated 01/26/2025, revealed six SRNAs worked from 6:00 AM-6:00 PM and one SRNA worked from 8:00 AM to 5:00 PM. During the time that R90 was left sitting in the wet bed, each SRNA was responsible for the care of 18 residents from 8:00 AM to 5:00 PM and 22 residents from 6:00AM to 8:00 AM and from 5:00 PM to 6:00 PM. b. During an interview on 01/26/2025 at 1:58PM with R362, she stated on 01/24/2025 at 6:00 PM during shift change, she requested help having her brief changed. She stated it took staff until after 10:00 PM for them to come and change her brief. R362 stated having to lay in her waste made her feel humiliated/nasty. She stated it took staff so long to come in and change her that some of her body fluid had leaked on her right leg splint where she had broken her leg back in December. R362 also indicated on her cell phone where she had tried to call the facility for help, and no one would answer the phone. c. During an interview on 01/26/2025 at 2:03 PM, R79 stated she also had to wait at least four (4) hours on 01/24/2025 for staff to come in and change her. R79 stated she felt nasty having to lay in bed waiting for help to change her. She stated she had a stroke and needed assistance in cleaning herself. She stated one staff member came in her room and turned off the call light and disappeared without providing assistance. During an interview on 01/28/2025 at 9:06 AM with SRNA4, she stated when there were four SRNA's on the back (North) hall, they had between 12-15 residents apiece. When there were only three SRNAs, they had approximately 20 residents apiece. She stated the back hall had many residents who were overweight and were a higher level of care and she needed SRNA3, who was in training, to help out. During an interview on 01/29/2025 at 10:27 AM with SRNA7, she stated staffing had been an issue at the facility for a while. SRNA7 stated that although she could not remember the exact date, there was one night there were three SRNAs for the entire building. SRNA7 further stated it was hard to get staff to come to work, as well as, retain new staff due to the heavy workload. During an interview on 01/30/2025 at 9:41 AM with SRNA3, she stated she had been at the facility about a month, worked day shift and was typically assigned 16-18 residents. However, one Saturday, the facility was short staffed, and she had 22 residents to care for which she felt was not safe. She stated she often felt like she was drowning and even though residents with behaviors required more care, 22 residents felt like a lot to care for anywhere. SRNA3 stated she tried to answer all the lights and had been told it was the SRNAs job to answer them. SRNA3 stated the Certified Medication Technicians (CMTs) would help when they could, but the nurses did not get up to answer call lights. She further stated residents have complained to her about long waits for their call light to be answered and there had been mealtimes when there was only one SRNA in the dining room when there should be two. During mealtimes, there were four - five residents that needed total assist with eating, and she has had to sit all those residents at the same table and feed two residents at a time. After the meal and upon her return to her assigned hall, SRNA3 stated she would often see several call lights on and no staff visible. SRNA3 stated on this day she had 14 residents and felt like she was rushing around. Further, on 01/30/2025 at 9:41 AM, SRNA3 stated she was supposed to complete check and change rounds every two hours; however, it was easy to fall behind when caring for a resident that urinated more frequently or in larger amounts. SRNA3 stated on her first round before breakfast, she had walked into a resident's room after a night shift SRNA had told her the resident had been changed. However, she found the resident's bed was soaked and it looked like he had been a mess for hours which she could tell because the longer they sit, the darker the yellow ring (urine-soakage) was. SRNA3 stated it was hard to complete every two-hour rounds on every resident and complete four showers. She stated sometimes she did not take a lunch or would have to leave a resident soiled longer while she finished another resident's shower. Ideally, SRNA3 stated she would like to be able to get to every resident before they soiled themselves so she could assist them to the bathroom if possible. She stated she had to prioritize care based on which residents were the heaviest care need and there were some residents that did not get the attention they deserved, and she felt bad about that. SRNA3 stated sometimes residents ask her to sit and talk with them, adding, she does not have time to do it. During an interview on 01/30/2025 at 9:41 AM with SRNA12, she stated she had been at the facility since January 2024. SRNA13, who was present, stated she had been at the facility since July 2024 and neither SRNA had been issued a name tag. Both SRNAs agreed that in an average day, they cared for 15-20 residents and were responsible for meals, baths/showers and changing briefs/clothes/beds as needed, assisting with transportation to activities/smoke breaks, and individual resident care requests. SRNA12 and SRNA13 stated they would lose their bonus if they did not take a lunch, so they would punch out for lunch but then worked through to keep their bonus. SRNA12 and SRNA13 stated many SRNAs have left because of the workload and the nurses did not help out. They further stated they worked short last week, there were only three SRNAs on each hall (18 residents per SRNA) and sometimes they were only staffed for two SRNAs on each hall (27 residents per SRNA). Furnter, SRNA12 and SRNA13 stated, on 01/30/2025 at 9:41 AM, there was usually one SRNA in the dining room who was responsible for sorting the meal tickets, passing the trays, and feeding the assisted diners and there had been times they would have to sit all the assisted diners at the same table and feed one while the others watched and had to wait, which was painful for staff to watch. SRNA12 and SRNA13 stated the facility was short staffed five to seven days a week and especially on the weekend. They stated with three SRNAs on each hall, they would have to split showers and get done as much as they could. They added there was never any time to sit with residents and just talk with them, even with four SRNAs on each hall. SRNA13 stated that most of the nurses were not supportive of the SRNAs and their work but would add tasks like applying a medicated cream or shampoo. They stated Nurses did not come into the room to pause a tube feeding so the SRNA could check and change a resident, they would tell the SRNA to pause the feed and restart it when care was completed. During an interview on 01/30/2025 at 11:47 AM with SRNA11, she stated it was hard to get all her responsibilities of oral care, hair combing, toileting, and feeding done and a lot of times they were short staffed. She stated she usually had to also complete three showers in a day and with four SRNAs on each hall, it was still a struggle. SRNA11 stated on this day she had 14 residents and felt like maybe she could complete a check and change every two hours on most of them. She stated her charting recorded the task was done for the resident but not how many times in the shift it was done. SRNA11 stated when they had enough staff, they could complete more showers, do nail care, and help out with work for the next shift. When they worked short, SRNA11 stated sometimes residents did not get their shower and she hoped to be able to pick up that shower the next day. SRNA11 stated that when she alerted management she was unable to complete her work, she was told, We are short and can only do what we can. In continued interview, on 01/30/2025 at 11:47 AM, SRNA11 stated the nurses would get up from the nurses' station to pass a medication or to do wound care but did not do general rounds on the residents. She stated the nurses have asked the SRNAs to put on a medicated cream or shampoo and asked her to come back and tell them what the skin looked like. SRNA11 stated the SRNAs would help each other but some were too busy with their own work and the nurses did not help. She remembered one time she entered a droplet precaution room without full personal protective equipment (PPE), only a mask, because she was so far behind, she did not take the time to put on the additional PPE. She further stated it was hard to find anyone to help due to the short staffing. She stated call lights seemed to come on one right after the other and she tried to glance in on the residents that cannot use the call light. Additionally, SRNA11 stated she had no time to just visit with the residents and felt like since staff were all the family the residents had, not being able to spend more time with them could make the residents emotionally depressed. During an interview on 01/30/2025 at 2:32 PM with SRNA2, she stated she had worked at the facility for three years. She stated staff had been hired and it seemed like she had trained many, but no one would stay. SRNA2 stated she had gotten used to working short and sometimes resident showers did not get done, but she tried to at least get them dressed and wiped off. She stated everyone deserved their shower and she tried to make it up the next day. SRNA2 stated the residents did complain about their call lights not being answered and stated residents would say, I've been waiting so long, but the SRNA came in and shut the light off and left, or said, The aide said they were going to get you and then didn't come back. During an interview on 01/30/2025 at 3:25 PM with SRNA10, he stated he had been an SRNA for thirteen years and started at the facility in 10/2024. He stated he did not know who the Director of Nursing Services (DNS) was until the state survey team entered the building, as he had never seen her. He added he did not know who the Assistant Director of Nursing Services (ADNS) was until two months after he started. SRNA10 stated typical staffing on the weekends was two SRNAs on each hall (27 residents to each SRNA) and sometimes there was a float SRNA available. He stated there were a lot of call offs on the weekends and there had been times the SRNAs were responsible for 30-35 residents each, which he felt was unsafe. SRNA10 stated management did not pitch in if short on the weekends, and he had not really seen management at all until State Surveyors showed up, then Everyone came out of the woods or something to help. He stated he believed it was everyone's responsibility to answer a call light, but the nurses did not answer a call light or change a resident. In fact, they would walk farther to try and find an SRNA instead of answering a light or changing a resident themselves. SRNA 10 stated when he was responsible for 30-35 residents, he could not get them changed every two hours, they would have to wait, and some would end up sitting for three to three and a half hours. State Registered Nurse Aide (SRNA)10 stated, on 01/30/2025 at 3:25 PM, that residents complained and told him it was ridiculous they had been laying in their urine and feces and they were upset. He stated some would end up with skin breakdown and it hurt them. Additionally, SRNA 10 stated he rarely saw nurses just round on and talk to the residents and he rarely saw management walking in the halls, they mostly stayed in their offices and the ADON only came out of her office when there was something wrong. He stated he charted at the end of the shift but knew a lot of SRNAs did all their charting in the morning which he felt was wrong because you should not chart what you had not done. He stated it got so crazy it felt like there was not enough time to get everything done and if charting was not done, staff would lose their bonus for the week. SRNA10 stated it was hard enough to care for 15 residents, let alone 35 residents and he went home feeling bad because he felt like he had given poor care and the residents had not been cared for how they should be. Finally, SRNA 10 stated he has had to use at mechanical lift alone and risk resident injury due to not enough staff to help. In an interview on 02/01/2025 at 11:07 AM, SRNA5 stated at the time of interview, she was finishing the first round of incontinence care for the residents in her assignment. Per interview, she stated she was responsible for 25 residents. In continued interview, SRNA5 stated management did not help with incontinence care, and she had rarely seen a member of management on the floor during a weekend. SRNA5 stated when she was responsible for that many residents, she did not have time to perform oral care or showers, and those tasks would only be completed if there was a float aide working. In an additional interview on 02/01/2025 at 8:04 PM, SRNA5 stated that when the facility was short staffed, the SRNAs did not typically get the support they needed to care for the residents according to their care plans. During an interview on 01/29/2025 at 7:31 AM with the Nurse Practitioner (NP) he stated he had worked at the facility for one year. The NP stated the SRNAs were great, but based on resident condition, he felt they needed more education on the importance of hygiene, position changes, and that relationship to skin breakdown. The NP also stated staffing was an uphill battle across the board and although it was improving, there was still a high turnover. During an interview on 01/29/2025 at 4:22 PM with the Scheduler (SCH) she stated she had been at the facility for thirteen years and had been the scheduler since 2020. SCH stated staffing was census based and the facility was considered full at 100 residents. SCH stated her staffing goal for each of the two halls was one to two licensed nurses on each hall, one Certified Medication Technician (CMT) on each hall and four nurse SRNAs on each hall for the day shift. On night shift, her goal was to have one licensed nurse on each hall, one CMT on each hall, and four SRNAs on each hall. SCH stated she was available 24 hours a day, seven days a week to work the schedule to find coverage for call offs. She stated there was never a time where no one was available to help, and all the staff pitched in, and all staff were responsible for answering call lights. She also stated the company had their own staff float pool as a resource and the facility did not use agency staff. SCH stated during the time of the low staffing indication on the PBJ [NAME] report, nothing unusual was going on but it was warm outside and that may have accounted for increased call offs. SCH stated she felt like there was enough staff to provide for resident needs. During an interview on 02/01/2025 at 1:30 PM with the Infection Preventionist/Staff Developmen [TRUNCATED]

Based on interview, record review, and facility policy review, the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for eight of 13 sampled residents reviewed for advanced directives. (Resident (R) 93, R124, R17, R102, R5, R76. R12, and R36). The findings include: Review of the facility's undated policy, titled, Advance Directives, revealed that prior to or upon admission, the Social Services Director (SSD) or Designee will provide written information to the resident concerning his/her right to make decisions about medical care including the right to accept or refuse medical treatment, and the right to formulate advance directives. Further review revealed the SSD or Designee will inquire about the existence of any advance directives and, should the resident indicate that they issued advance directives about their care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive should be included in the resident's medical record. Review of a Skilled Nursing Facility Admission Agreement revealed that, under the section titled, Treatment Decision Making and Surrogate Decision Makers/Right to Make Treatment Decisions and Make Advance Directives, the resident had the right to make informed treatment decisions for him/herself including the right to refuse treatment and to exercise those rights through a surrogate decision maker (Guardian, Patient Advocate, or other legally appropriate representative) when the resident was not competent to do so him/herself, in accordance with applicable law. Additional review revealed a competent resident also had the right to make an advance directive to appoint a surrogate decision maker and to provide information about what kind of treatment was desired in the future in the event the resident became unable to make his/her own treatment decisions. Final review revealed information about how to make an advance directive and the facility's policies regarding implementation of the residents right to make an advance directive was attached and incorporated into the agreement as Exhibit N. Review of a sample resident admission packet revealed that under Section 10, titled Exhibits, it stated, By signing this Agreement, the Resident acknowledges that he/she has received a copy of all of the following Exhibits to the Agreement, each of which is incorporated into and made part of this Agreement. Exhibit N of the agreement outlined information about Advance Directives and included documents to be completed which were labeled as N-11, N-12, and N-13. Review of Exhibit N revealed that this section of forms included spaces with the instructions to check box and initial line if you desire the option below for various living will directives, including marking whether they desired life-saving treatment. 1. Review of R93's Face Sheet revealed the facility admitted the resident on 12/24/2024 with diagnoses including infection and inflammatory reaction due to indwelling urethral catheter, type 2 diabetes, and muscle weakness. Review of R93's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. In an interview with R93 on 01/28/2025 at 4:15 PM, he stated he did not have an advance directive in place and was not asked by facility staff at admission if he wished to formulate an advance directive. Review of R93's, Skilled Nursing Facility Admission Agreement, dated 12/24/2024, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner he understood. 2. Review of R124's record revealed the facility admitted the resident on 01/16/2025 with diagnoses including rehab following myocardial infarction (MI) with life vest, sepsis related to septic knees, and intravenous (IV) antibiotic therapy. Review of R124's admission MDS, with an ARD of 01/16/2025, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. In an interview with R124 on 01/28/2025 at 10:16 AM, she stated she had an existing advance directive; however, facility staff had not requested a copy, and she was not asked about advance directives on admission. Although R124, who was cognitively intact, stated she had an existing advance directive completed prior to admission, review of R124's Resident Documents revealed no evidence the resident had an existing advance directive in her electronic medical record (EMR). Review of R124's Skilled Nursing Facility Admission Agreement, dated 01/16/2025, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner she understood, or that the facility requested a copy of the advance directive she had previously formulated. 3. Review of R17's Face Sheet revealed the facility admitted the resident on 09/14/2024 with diagnoses including acute and chronic respiratory failure with hypoxia, alcoholic cirrhosis of the liver with ascites, and congestive heart failure (CHF). Review of R17's quarterly MDS, with an ARD of 12/19/2024, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. Review of R17's Admission Agreement, dated 09/14/2024, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident in a manner he understood. 4. Review of R102's Face Sheet revealed the facility admitted the resident on 10/15/2024 with diagnoses including dementia, major depressive disorder, and muscle weakness. Per the Face Sheet, the resident's daughter was her Responsible Party (RP). Review of R102's quarterly MDS, with an ARD of 01/15/2025, revealed the resident had a BIMS score of 3/15, indicating the resident was severely cognitively impaired. Review of R102's Skilled Nursing Facility Admission Agreement, dated 10/15/2024 revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident and/or their RP in a manner they understood. 5. Review of R5's Face Sheet revealed the facility admitted the resident on 07/13/2023 with diagnoses including end stage renal disease (ESRD), type 2 diabetes, and CHF. Review of R5's quarterly MDS, with an ARD of 12/25/2024, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. Review of R5's, Skilled Nursing Facility Admission Agreement, dated 07/13/2023, revealed an incomplete Living Will Packet in the section titled, Exhibit N - Information About Advance Directives. The only information filled in on the form was the resident's name and birthdate. Further review revealed no documented evidence the facility explained the opportunity to formulate or decline an advance directive to R5 in a manner she understood. 6. The facility admitted R76 on 07/18/2022 with diagnoses of quadriplegia, heart failure diabetes mellitus, and malnutrition. Review of R76's Skilled Nursing Facility Admission Agreement revealed R76 had signed and printed her name under the statement that read, By signing below, the parties have executed this Agreement, intending to be bound by its terms. The resident party(ies) certify by their signatures that they have read and understand this Agreement, and that they received a copy of this Agreement, and the other documents referred to or attached to this Agreement, including but not limited to all Exhibits. However, the form was undated and there was no indication when it was completed. Although R76 signed that they received a copy of all exhibits, review of the documents revealed that all required exhibits were not completed. Review of Page 10 of R76's Exhibit N of the Skilled Nursing Facility Admission Agreement, titled, Information about Advance Directives revealed that the sections which should have been filled out and signed by R76 were blank. 7. The facility admitted R12 on 04/30/2024 with diagnoses of Parkinson's disease, schizophrenia, seizures, depression, and diabetes mellitus. Review of R12's Skilled Nursing Facility Admission Agreement revealed R12 had signed and printed her name, indicating that she had received a copy of all documents referred to or attached to this Agreement, including but not limited to all Exhibits. However, review of R12's Skilled Nursing Facility Admission Agreement revealed Exhibit N, titled Information about Advance Directives, was not completed. Review of R12's Skilled Nursing Facility Admission Agreement under the section titled, Kentucky Living Will Directive and Healthcare Surrogate Designation exhibits N-11, N-12 and N-13 revealed R12's name and date of birth had been filled in at the top but the check boxes for the sections labeled, Health Care Surrogate Designation and Living Will Directive were blank and the document was unsigned. No declination to formulate an Advance Directive was documented. 8. Review of R36's Admission Record found in the resident's EMR revealed the facility admitted the resident on 12/31/2020 with diagnoses to included Alzheimer's disease, dementia, and chronic obstructive pulmonary disease. Per the Face Sheet, the resident had an RP. Review of R36 's Quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/30/2024 revealed the resident was assessed by the facility as having long and short-term memory problems. Review of R36's Resident Documents, revealed there was no Skilled Nursing Facility Admission Agreement, found in the resident's medical record. Further review revealed no documented evidence the opportunity to formulate or decline an advance directive was explained to the resident and/or RP in a manner which she understood. Further record review revealed R36 had Authorization to Treat and Code Status, documents, dated 11/05/2015 and 11/20/2021, which indicated that she had a Do Not Resuscitate (DNR) code status. However, review of 36's, Resident Documents, revealed no evidence the resident had an existing Advance Directive/Living documented in her EHR. During an interview with the Social Services Director (SSD) on 01/31/2025 at 10:58 AM, she stated she acted as the Admission's Coordinator, and reviewed all admission documentation with the residents and/or their representatives. She stated this process included discussions about Advance Directives. Additionally, she stated that as part of the admission packet, all residents and/or their representatives were given the opportunity to complete an Advanced Directive/Living Will. The SSD stated all information regarding advance directives was documented in each resident's chart. Furthermore, she stated if a resident has an advance directive prior to admission, a copy was obtained and uploaded to the resident's EHR. When asked about the failure to complete the forms/have evidence that the information was actually provided to each resident, the SSD stated it was acceptable to include the blank forms in the record because she had discussed the information verbally with the residents. Interview with the Director of Nursing Services (DNS) on 02/01/2025 at 7:15 PM, revealed the SSD was to discuss advance directives with residents and/or their representatives at admission. She further stated it was important the entire advance directive process was explained to residents in a manner they easily understood. Further interview with the DNS revealed she was unaware that there was no evidence that the process had actually been completed as required, with each resident afforded the opportunity to formulate, decline, or provide a copy of an advance directive which had previously been formulated. During an interview with the Executive Director (ED1) on 01/28/2025 at 9:00 AM, she stated that residents or their legal representatives sign paperwork in the admission packet, acknowledging receipt of all its components. At this time, the survey team requested evidence that the information in Section N regarding advance directives was actually provided to the residents and all required forms were completed. The ED stated all the residents had signed the Acknowledgement of Receipt of documents, and That was enough. ED1 stated that the signed page was all the facility obtained and they could not provide any other evidence to show that the above-listed residents received the information about Advance Directives and were given the opportunity to formulate or decline formulation of an advance directive. Additional interview with ED1, on 02/01/2025 at 6:28 PM, revealed the Admissions Coordinator reviews admission documentation, including Advanced Directives and Living Wills, at the time of admission. In addition, she stated the facility provides opportunities for residents to discuss and review advance directives on a quarterly basis, and as needed. ED1 stated it was her expectation that all residents have the chance to engage in discussions about their advance directives and it was important to ensure their wishes were honored. 46651 44001

Based on interview, record review, and facility policy review, the facility failed to notify the resident and/or the resident's representative(s) in writing of the specific reasons for transfer to another facility for five (Residents (R) 6, R61, R62, R12, and R84) of seven residents reviewed for hospitalization. The findings include: Review of the facility's policy Transfer and Discharge, dated 12/12/2023, revealed the facility was to provide residents and their representatives with a written notice for the specific reason for the transfer, including for emergency transfers to an acute care hospital. 1. Review of R6's admission Record revealed the facility admitted the resident on 03/22/2019 with diagnoses including early onset Alzheimer's disease, Crohn's disease (a disease of the intestines), and ulcerative colitis (a disease of the intestines). Review of R6's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. Review of the Progress Note, dated 08/18/2024, revealed R6 had bloody stools and was sent to the hospital for evaluation. Review of the facility's document, Notice of Transfer or discharge: Notice of Bed Hold Days, dated 08/18/2024, revealed the facility documented R6 was transferred for eval. Further review revealed the document failed to include the specific reason which necessitated the transfer. In an interview on 01/26/2025 at 2:59 PM, R6 stated she recalled needing to go to the hospital in the last few months but did not recall the facility giving her paperwork related to her transfer to the hospital. 2. Review of R61's admission Record revealed the facility admitted the resident on 12/15/2022 with diagnoses including schizoaffective disorder, morbid obesity, and unspecified disorders of the skin. Review of the Progress Note, dated 11/03/2024 revealed R61 was coughing up blood on that date and was sent to the hospital for evaluation. Review of the facility's document Notice of Transfer or discharge: Notice of Bed Hold Days, dated 11/03/2024 revealed the facility documented R61 was transferred for eval. Further review revealed the notice failed to include the specific reason condition which necessitated the transfer. 3. Review of R62's admission Record revealed the facility admitted the resident on 04/14/2022 with diagnoses including Dravet syndrome (severe epilepsy) seizure disorder, and obstructive uropathy. Review of R62's Quarterly MDS, with an ARD of 12/26/2024, revealed the resident had severe cognitive impairment and a legal guardian who participated in the resident's overall assessments and goal setting and all decision making. Review of a Progress Note, dated 10/12/2024, revealed R62 had excessive vomiting and bowel obstruction and was sent to the local hospital for evaluation. Review of the Notice of Transfer or discharge: Notice of Bed Hold Days, dated 10/09/2024, revealed the facility documented R62 was transferred for eval. Further review did not provide additional details about the specific reason that led to the transfer. 4. Record review revealed the facility admitted R12 on 04/18/2024 with diagnoses of Parkinson's Disease, schizophrenia, seizures, depression, and diabetes mellitus. Review of R12's MDS Assessment records from 06/12/2024-12/23/2024 revealed R12 was transferred to the hospital on [DATE] and 08/22/2024. Review of R12's Progress Note dated 08/08/2024 at 6:00 PM revealed R12 was admitted to the hospital with diagnosis of hepatic encephalopathy. Review of R12's Progress Note dated 08/22/2024 at 4:24 PM revealed R12's blood ammonia level was elevated; the Nurse Practitioner was notified, and orders were to send the resident to the hospital. Review of R12's EMR revealed no evidence that notice of the resident's transfer, which included the specific reason for the transfer, was provided to the resident for either of the two hospitalizations. 5. Review of R84's admission Record, revealed the facility admitted the resident on 01/11/2024 with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and gastrointestinal hemorrhage. Review of R84's, Progress Note, dated 01/24/2025 revealed the resident reported to staff she had breathing difficulties and continuous oxygen at 4 Liters (L). Further review of the progress note revealed the resident had an elevated pulse rate of 158 beats per minute (BPM). The Nurse Practitioner (NP) was present, and instructed staff to call 911, and R84 was transferred to a hospital via Emergency Medical Services (EMS). Review of the facility's document Notice of Transfer or discharge: Notice of Bed Hold Days, dated 01/24/2025, revealed the facility documented R84 was transferred for eval. Further review revealed the transfer notice failed to detail the specific reason which necessitated the transfer. During an interview with the Medical Records Nurse (MRN) on 01/29/2025 at 1:37 PM, she stated that the resident/representative gets a copy of the Bed Hold notice referenced above. The MRN provided no further evidence that the resident/representative was provided the specific reason, in writing, for the transfer, as opposed to the generic term eval which was used on the above-referenced forms. During an interview with the Executive Director (ED1) on 01/30/2025 at 9:32 AM, she stated that the resident and family were informed verbally of the specific reason that a transfer was necessary. However, she confirmed that the written notice that the resident/representative received did not include the specific reason for the transfer to the hospital.

Based on observations, interview, record review, and review of the manufacturer's instructions, the facility failed to store medications at the correct temperature. Insulin was stored below the recommended temperature range of 36 degrees Fahrenheit (F) and 46 degrees F in two of four medication refrigerators. The findings include: Review of the manufacturer's instructions, revised 02/2023, for NovoLog, (insulin aspart)100 units per milliliter (u/ml), revealed unused NovoLog Pens were to be stored in the refrigerator at 36 degrees F - 46 degrees F. Further review revealed instructions to not freeze NovoLog nor use NovoLog if it had been frozen. Review of the manufacturer's instructions for Fiasp, (insulin aspart) 100 u/ml, revealed it should not be frozen, nor used if having been frozen. Further review revealed instruction to store unused insulin in a refrigerator between 36 degrees F and 46 degrees F. Review of the manufacturer's instructions for Tresiba (insulin degludec injection) 100 u/ml FlexTouch pen, copyrighted and revised 07/2022, revealed guidance to store unused pens in the refrigerator at 36 degrees F to 46 degrees F and to not freeze the pens nor use them if having been frozen. Review of the package insert for Lantus (insulin glargine) 100 u/ml, dated 2023, revealed unused Lantus should be stored in a refrigerator between 36 degrees F and 46 degrees F. Further review revealed instruction not to freeze Lantus and to discard if frozen. Review of Basaglar, (insulin glargine) 100 u/ml, instructions for use, revised 08/2022, revealed instruction to not freeze Basaglar and to not use it if it had been frozen. Further review revealed instruction to store the pens in the refrigerator between 2 degrees Celsius (C) and 8 degrees C (35.6 F and 46.4 F.) Review of the manufacturer's instructions for Admelog insulin, dated 11/2019, revealed instruction to keep new pens in the refrigerator between 36 degrees F and 46 degrees F. Further review revealed Admelog should not be frozen or used if it had been frozen. 1. Observation in the Front Hall Medication Room on 01/29/2025 at 3:10 PM revealed Refrigerator 1's thermometer registered 26 degrees F. Further observation revealed thick frost in the small freezer section in the top of the refrigerator. Observation of the temperature logbooks revealed instructions that the accepted range was 36 degrees F - 46 degrees F. The inventory in the refrigerator included the following insulin pens: Lantus 100 u/m - three pens Insulin Glargine 300 u/ml - two pens Insulin Deglu[DATE] u/ml - two pens Basaglar 100 u/ml - three pens Novolog 100 u/ml - five pens. 2. Observation in the Back Medication Room on 01/29/2025 at 3:40 PM revealed Refrigerator 3's thermometer registered 30 degrees F. The inventory in Refrigerator 3 included: Admelog insulin 100 u/ml- four pens Fiasp insulin 100 u/ml - one vial Fiasp insulin 100/u/ml three pens Tresiba insulin 100 u/ml - seven pens Basaglar insulin 100 u/ml - three pens Lantus insulin 100 u/ml - eight pens. During an interview with the Assistant Director of Nursing (ADON) on 01/29/2025 at 3:10 PM, she stated the outcome of medications stored at 26 degrees F was that they would freeze and thus be ineffective. Additional interview with the ADON, on 01/29/2025 at 5:05 PM, revealed the Maintenance Director needed to adjust or repair the two refrigerators and defrost Refrigerator 1. The ADON added that the medications in both refrigerators needed to be returned back to the pharmacy. Interview with the Executive Director (ED1) on 02/01/2025 at 6:28 PM revealed the nurses were responsible for monitoring the medication refrigerator temperatures. She indicated the temperatures were to be monitored on both shifts. In further interview, she stated if staff observed temperatures out of range, the nurses were responsible to take action to correct the temperature and to contact the pharmacy about whether medications should be discarded and reordered. A Medication Storage policy was requested in writing on 01/29/2025 at 6:04 PM and by email on 02/11/2025 at 10:59 AM. However, none was received prior to exit.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of manufacturer's directions for use (DFU), and review of the facility's policies, the facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices to help prevent the development and transmission of communicable diseases and infections. Additionally, the facility failed to ensure that food items used during medication administration were properly dated when opened and kept on ice during use, for 5 of 5 medication carts observed, 3 medication carts on the Back Hall and 2 medication carts on the Front Hall. 1. Observation of room [ROOM NUMBER], a droplet precaution room, on 03/31/2025 revealed a CDC Droplet Precaution sign on the door. However, the facility did not ensure that a personal protective equipment (PPE) cart was available outside the room for staff to use to provide PPE before entering. 2. Observation of room [ROOM NUMBER], a droplet precaution room, on 04/01/2025 revealed staff failed to ensure the door to the room was closed according to CDC guidelines related to transmission-based precautions (TBP). 3. The facility failed to ensure staff cleaned and sanitized shared equipment according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's DFU. a. Observation of the Front Hall on 04/01/2025 revealed Licensed Practical Nurse (LPN) 9 failed to properly clean and sanitize a glucometer (a blood sugar monitoring device) after use according to the EPA registered disinfectant manufacturer's DFU. Additionally, LPN9 failed to perform hand hygiene after removing her gloves. b. Observation of the Back Hall on 04/01/2025 revealed LPN11 failed to properly clean and sanitize bandage scissors at the point of care and walked through the hall and entered the nurses' station holding the contaminated bandage scissors with bare hands. Additionally, LPN11 failed to properly clean and sanitize the bandage scissors according to the EPA registered disinfectant manufacturer's DFU. 4. Observation of the Back Hall on 04/01/2025 revealed LPN8 failed to properly bag and transport contaminated cups away from her person when she disposed of them. 5. Observations made on 03/31/2025 and 04/01/2025 of the Front and Back Halls, revealed the facility did not ensure that food items used during medication administration were properly dated when opened and kept on ice during use of medication carts. Multiple observations revealed opened pudding and applesauce containers that were neither dated nor stored on ice during or after medication administration. The findings include: Review of the CDC's Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately after glove removal. Additionally, the guidelines stated facilities should ensure proper selection and use of PPE based on the nature of the resident interaction and potential for exposure to infectious materials. Review of the CDC's Guidelines, provided by the facility, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 01/02/2024, 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. Continued review revealed all reusable resident care equipment would be cleaned and disinfected in accordance with current facility procedures. Review of the facility's policy titled, Standard Precautions, revised 03/05/2025, revealed the charge nurse was responsible to check PPE supply carts twice per shift and replenish as needed. Review of the facility's policy titled, Glucometer Disinfection, undated, revealed the facility would ensure glucometers would be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use, using an EPA registered disinfectant. According to the policy, nursing staff would remove and discard their gloves and perform hand hygiene before leaving the room. Nursing staff would then reapply gloves and take two disinfectant wipes from the container. Per the policy, the first wipe was used to clean and remove any heavily soiled blood or other contaminants from the surface of the glucometer. The policy stated, after cleaning, the second wipe was used to thoroughly disinfect the glucometer, following the manufacturer's instructions. Review of the cleaning and disinfecting DFU for the Evencare ProView Meter, undated, revealed the meter should be clean and disinfected between each resident use. Per the directions, perform hand hygiene and put on gloves; clean the glucose meter, including the front, back, and sides; use a second wipe and follow the disinfectant's instructions for the dwell time (time a surface must remain visibly wet after the application of a disinfectant) listed on the disinfecting wipes DFU. Review of the cleaning and disinfecting DFU for the Super Sani-Cloth Germicidal Wipes container, undated, revealed for cleaning, to use one or more wipes as necessary to thoroughly clean the surface. Then, the DFU stated to use a second wipe to thoroughly wet all surfaces to be treated. According to the DFU, all surfaces must remain visibly wet for a two-minute dwell time to assure complete disinfection of all pathogens and let air dry. 1. Observation, upon initial entrance to the facility, of the Front Hall on 03/31/2025 at 1:35 PM, revealed room [ROOM NUMBER] was designated as a TBP room. The entrance door to the room had a CDC Droplet Precaution sign on it. However, observation revealed there was no PPE cart available outside the room for staff to put on before entering. Further observation revealed there was no PPE cart near room [ROOM NUMBER] or anywhere in the hallway. During an interview with Qualified Medication Aide (QMA) 7 on 03/31/2025 at 1:40 PM, she stated PPE carts should be located outside any TBP room or nearby, allowing staff easy access to the necessary PPE to care for residents. She stated she was unaware the room lacked a PPE cart. She further stated having PPE readily available was important not only for the protection of staff, but also to help prevent the spread of infection. During an interview with LPN1 on 03/31/2025 at 1:50 PM, she stated PPE supply carts should be positioned outside any TBP room or in close proximity, ensuring staff had easy access to the necessary equipment to care for residents. She stated she was not aware room [ROOM NUMBER] did not have a PPE cart. LPN1 stated the Infection Preventionist/Staff Development Coordinator (IP/SDC) ensured carts were available and stocked. LPN1 stated having PPE available was important to protect staff and prevent the spread of infection within the facility. During an interview with the IP/SDC on 04/01/2025 at 10:50 AM, she stated the residents in room [ROOM NUMBER] were COVID-19 positive. She stated she did not know why there was not a PPE cart outside the room and, There is one there now. She stated everyone was responsible for ensuring there were PPE supply carts available and stocked. 2. Observation of the Front Hall on 04/01/2025 at 8:54 AM revealed room [ROOM NUMBER] was designated as a TBP room. However, the entrance door to the room was open, and a CDC Droplet Precaution sign was displayed on the door which indicated the door should remain closed. During an interview with LPN1 on 04/01/2025 at 8:55 AM, she stated room [ROOM NUMBER] had been designated as a droplet precaution room because the two residents in the room were diagnosed with COVID-19. LPN1 stated she was unsure why the door had been left open. She stated, according to CDC guidelines, the door must remain shut to prevent the spread of infection. During continued interview with the IP/SDC on 04/01/2025 at 10:50 AM, she stated the door should remain closed at all times according to signage on the door and CDC guidelines because infection could be transmitted through respiratory droplets produced by a patient [resident] who was coughing or sneezing. During an interview with the Assistant Director of Nursing Services (ADNS) on 04/02/2025 at 4:10 PM, the ADNS stated that doors to droplet precaution rooms should remain closed to prevent droplets produced from coughing or sneezing from spreading into the hall. During an interview with the Director of Nursing Services (DNS) on 04/02/2025 at 6:40 PM, she stated doors to droplet precaution rooms should remain closed to prevent infection spreading. During an interview with Executive Director 2 on 04/01/2025 at 8:58 AM, he stated the door should remain closed in accordance with CDC guidelines. During additional interview with Executive Director 2 on 04/01/2025 at 4:37 PM, he stated, upon inspection, room [ROOM NUMBER]'s door latch was not functioning properly, preventing the door from closing securely. He stated he had requested for maintenance to repair the door, and it was now functioning properly. 3.a. Observation of the Front Hall on 04/01/2025 at 4:10 PM revealed LPN9 exited room [ROOM NUMBER] holding a glucometer with gloved hands. She disposed of the lancet, placed the glucometer on top of the medication cart, and removed her gloves. She did not perform hand hygiene before opening the container of Super Sani-Cloth Germicidal Wipes. She then wiped down the glucometer with one germicidal wipe for 21 seconds and placed it on a barrier sheet. She did not keep the glucometer wet for the required two-minute dwell (time that a device is placed in a specific area). Additionally, LPN9 did not sanitize the top of the medication cart. During an interview with LPN9 on 04/01/2025 at 4:14 PM, she stated she performed hand hygiene after removing her gloves and put on gloves to clean the glucometer. She stated she cleaned the glucometer with a disinfection wipe and placed it on the barrier sheet to dry. She stated each medication cart had a second glucometer to alternate while one was drying. She stated the dwell was the time the glucometer must dry between uses. During additional interview with the IP/SDC on 04/02/2025 at 12:00 PM, she could not explain the steps for cleaning and disinfecting the glucometer. She stated items should be cleaned for one minute and left to air dry. She stated once cleaned and disinfected, the glucometer could be placed on the medication cart because the cart is clean. The IP/SDC did not mention the use of barriers to prevent cross-contamination of disinfected shared equipment. She stated nursing staff was educated to use the two glucometers on the medication carts: one to use and one to dry. She stated everyone should perform hand hygiene before and after resident care to prevent the spread of infection. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated nurses had been educated on how to clean shared glucometers. She stated each treatment cart was equipped with two glucometers to use alternately. She stated nurses should use two wipes to clean and disinfect the glucometer and then wrap it to keep it wet for the allotted dwell time. She stated dwell times varied depending on the product used. She stated the glucometer should be allowed to air dry. The ADNS stated staff should not place glucometers on a bare surface, but a barrier should be used when the glucometer was set down. 3.b. Observation of the Back Hall on 04/01/2025 at 6:50 PM revealed LPN11 walked down the entire hall and approached the nurses' station while holding contaminated bandage scissors wrapped loosely in a glove. She requested disinfecting wipes from another staff member. LPN11 used her contaminated hand to take the wipes, removed the lid, and reached inside the container for a wipe without first performing hand hygiene. LPN11 cleaned the bandage scissors for 33 seconds using one Super Sani-Cloth Germicidal Wipe and then closed the blades while still wet. She did not allow the scissors to remain wet for the required two-minute dwell time, nor did she ensure that all surfaces were air-dried. During an interview with LPN11 on 04/01/2025 at 6:53 PM, she stated she used scissors to cut a resident's cushion. She stated she discovered there were no wipes available in the Front Hall, which prompted her to walk from the Front Hall to the Back Hall in search of disinfecting wipes. LPN11 stated she should have placed the bandage scissors in a container for transport, rather than carrying them with a contaminated glove. She stated she should have gathered her supplies in advance to bring to the point of care. Additionally, LPN11 stated she should have performed hand hygiene and put on gloves to prevent contamination before opening the container of wipes and cleaning the bandage scissors. LPN11 stated she had received IPCP training on multiple occasions since her hire. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated it was her expectation that nursing staff cleaned and disinfected shared equipment according to CDC guidelines and that all nurses followed the facility's policy related to cleaning and disinfecting shared equipment. She stated it was important to prevent the spread of infection. During continued interview with the DNS on 04/02/2025 at 6:40 PM, she stated it was her expectation that nursing staff used the designated disinfectant on any shared items before and after use. She stated, This means that when a nurse picks up a piece of equipment, it should be clean and ready for them to use. She stated any equipment used on one resident should be thoroughly cleaned before it was used on another resident. 4. Observation of the Back Hall on 04/01/2025 at 6:25 PM revealed LPN8 took two large stacks of small plastic drink cups off of the medication cart and transported the cups away, holding them against her scrub top. During an interview with LPN8 on 04/01/2025 at 6:27 PM, she stated she had observed a resident approach the medication cart, touch multiple cups, and take some. She stated she was removing the cups because they were contaminated. She further stated to prevent cross-contamination, she should have used a trash bag to dispose of the cups and not transported them against her person. LPN8 stated she had received multiple training modules related to IPCP during her employment at the facility. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, she stated while transporting any items, especially items for residents' use or contaminated items, staff should ensure the items were held away from their person to prevent cross-contamination. 5.a. Observation of the Back Hall on 03/31/2025 at 1:35 PM, revealed three of three medication carts observed each had one opened applesauce container that was not dated and was not being stored on ice to keep it chilled. 5.b. Observation of the Front Hall on 03/31/2025 at 1:45 PM revealed two of two medication carts observed each had opened, undated pudding that was not stored on ice to keep it chilled. During additional interview with QMA7 on 03/31/2025 at 1:48 PM, she stated she was in the middle of medication administration and had just opened the pudding but had not yet dated the container. She stated typically, at the end of each medication administration, there was usually no pudding or applesauce left, and any remaining portions were discarded. She also stated she was getting ice to keep the pudding and applesauce cold when she was approached by the State Survey Agency (SSA) Surveyor for an interview. QMA7 stated food used for medication administration should be dated when opened and placed on ice for the remainder of medication administration. She stated unused food should be discarded at the end of administration. She stated she received IPCP education. QMA7 stated properly storing residents' food was important to control infection and prevent foodborne illnesses. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, the IP/SDC stated food used for medication administration should be dated when opened and placed on ice for the remainder of the administration. She stated unused food should be discarded. She stated staff members were educated on how to prevent foodborne illnesses. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated food used for medication administration should be dated when opened and placed on ice for the remainder of the administration. She stated nurses should discard unused food at the end of each administration and should replace them with fresh food items. She stated staff members were educated on the prevention of foodborne illness. During additional interview with the DNS on 03/31/2025 at 1:35 PM, she stated food used for medication administration should be dated when opened and placed on ice for the remainder of medication administration. She stated unused food should be discarded at the end of the administration. She stated clinical staff licensed to administer medications were educated on this. She stated it was important to prevent foodborne illness. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, she stated it was her expectation that all staff adhered to infection control policies and procedures. She stated all facility staff had received infection control training, which she provided and reviewed many times throughout the year. She stated it was important to follow CDC guidelines to prevent the spread of infection and cross-contamination. During continued interview with the DNS on 04/02/2025 at 6:40 PM, she stated adhering to infection control guidelines was important to prevent the spread of infection and disease to both residents and staff. During additional interview with Executive Director 2 on 04/02/2025 at 4:00 PM, he stated it was his expectation that all staff followed facility polices related to infection control to help prevent the spread of infection and diseases. During an interview with the Medical Director on 04/02/2025 at 4:53 PM, he stated it was his expectation that all staff followed facility polices related to infection control to help prevent the spread of infection and diseases.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of manufacturer's directions for use (DFU), and review of the facility's policies, the facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices to help prevent the development and transmission of communicable diseases and infections. Additionally, the facility failed to ensure that food items used during medication administration were properly dated when opened and kept on ice during use, for 5 of 5 medication carts observed, 3 medication carts on the Back Hall and 2 medication carts on the Front Hall. 1. Observation of room [ROOM NUMBER], a droplet precaution room, on 03/31/2025 revealed a CDC Droplet Precaution sign on the door. However, the facility did not ensure that a personal protective equipment (PPE) cart was available outside the room for staff to use to provide PPE before entering. 2. Observation of room [ROOM NUMBER], a droplet precaution room, on 04/01/2025 revealed staff failed to ensure the door to the room was closed according to CDC guidelines related to transmission-based precautions (TBP). 3. The facility failed to ensure staff cleaned and sanitized shared equipment according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's DFU. a. Observation of the Front Hall on 04/01/2025 revealed Licensed Practical Nurse (LPN) 9 failed to properly clean and sanitize a glucometer (a blood sugar monitoring device) after use according to the EPA registered disinfectant manufacturer's DFU. Additionally, LPN9 failed to perform hand hygiene after removing her gloves. b. Observation of the Back Hall on 04/01/2025 revealed LPN11 failed to properly clean and sanitize bandage scissors at the point of care and walked through the hall and entered the nurses' station holding the contaminated bandage scissors with bare hands. Additionally, LPN11 failed to properly clean and sanitize the bandage scissors according to the EPA registered disinfectant manufacturer's DFU. 4. Observation of the Back Hall on 04/01/2025 revealed LPN8 failed to properly bag and transport contaminated cups away from her person when she disposed of them. 5. Observations made on 03/31/2025 and 04/01/2025 of the Front and Back Halls, revealed the facility did not ensure that food items used during medication administration were properly dated when opened and kept on ice during use of medication carts. Multiple observations revealed opened pudding and applesauce containers that were neither dated nor stored on ice during or after medication administration. The findings include: Review of the CDC's Guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately after glove removal. Additionally, the guidelines stated facilities should ensure proper selection and use of PPE based on the nature of the resident interaction and potential for exposure to infectious materials. Review of the CDC's Guidelines, provided by the facility, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. Further review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment. Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 01/02/2024, 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. Continued review revealed all reusable resident care equipment would be cleaned and disinfected in accordance with current facility procedures. Review of the facility's policy titled, Standard Precautions, revised 03/05/2025, revealed the charge nurse was responsible to check PPE supply carts twice per shift and replenish as needed. Review of the facility's policy titled, Glucometer Disinfection, undated, revealed the facility would ensure glucometers would be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use, using an EPA registered disinfectant. According to the policy, nursing staff would remove and discard their gloves and perform hand hygiene before leaving the room. Nursing staff would then reapply gloves and take two disinfectant wipes from the container. Per the policy, the first wipe was used to clean and remove any heavily soiled blood or other contaminants from the surface of the glucometer. The policy stated, after cleaning, the second wipe was used to thoroughly disinfect the glucometer, following the manufacturer's instructions. Review of the cleaning and disinfecting DFU for the Evencare ProView Meter, undated, revealed the meter should be clean and disinfected between each resident use. Per the directions, perform hand hygiene and put on gloves; clean the glucose meter, including the front, back, and sides; use a second wipe and follow the disinfectant's instructions for the dwell time (time a surface must remain visibly wet after the application of a disinfectant) listed on the disinfecting wipes DFU. Review of the cleaning and disinfecting DFU for the Super Sani-Cloth Germicidal Wipes container, undated, revealed for cleaning, to use one or more wipes as necessary to thoroughly clean the surface. Then, the DFU stated to use a second wipe to thoroughly wet all surfaces to be treated. According to the DFU, all surfaces must remain visibly wet for a two-minute dwell time to assure complete disinfection of all pathogens and let air dry. 1. Observation, upon initial entrance to the facility, of the Front Hall on 03/31/2025 at 1:35 PM, revealed room [ROOM NUMBER] was designated as a TBP room. The entrance door to the room had a CDC Droplet Precaution sign on it. However, observation revealed there was no PPE cart available outside the room for staff to put on before entering. Further observation revealed there was no PPE cart near room [ROOM NUMBER] or anywhere in the hallway. During an interview with Qualified Medication Aide (QMA) 7 on 03/31/2025 at 1:40 PM, she stated PPE carts should be located outside any TBP room or nearby, allowing staff easy access to the necessary PPE to care for residents. She stated she was unaware the room lacked a PPE cart. She further stated having PPE readily available was important not only for the protection of staff, but also to help prevent the spread of infection. During an interview with LPN1 on 03/31/2025 at 1:50 PM, she stated PPE supply carts should be positioned outside any TBP room or in close proximity, ensuring staff had easy access to the necessary equipment to care for residents. She stated she was not aware room [ROOM NUMBER] did not have a PPE cart. LPN1 stated the Infection Preventionist/Staff Development Coordinator (IP/SDC) ensured carts were available and stocked. LPN1 stated having PPE available was important to protect staff and prevent the spread of infection within the facility. During an interview with the IP/SDC on 04/01/2025 at 10:50 AM, she stated the residents in room [ROOM NUMBER] were COVID-19 positive. She stated she did not know why there was not a PPE cart outside the room and, There is one there now. She stated everyone was responsible for ensuring there were PPE supply carts available and stocked. 2. Observation of the Front Hall on 04/01/2025 at 8:54 AM revealed room [ROOM NUMBER] was designated as a TBP room. However, the entrance door to the room was open, and a CDC Droplet Precaution sign was displayed on the door which indicated the door should remain closed. During an interview with LPN1 on 04/01/2025 at 8:55 AM, she stated room [ROOM NUMBER] had been designated as a droplet precaution room because the two residents in the room were diagnosed with COVID-19. LPN1 stated she was unsure why the door had been left open. She stated, according to CDC guidelines, the door must remain shut to prevent the spread of infection. During continued interview with the IP/SDC on 04/01/2025 at 10:50 AM, she stated the door should remain closed at all times according to signage on the door and CDC guidelines because infection could be transmitted through respiratory droplets produced by a patient [resident] who was coughing or sneezing. During an interview with the Assistant Director of Nursing Services (ADNS) on 04/02/2025 at 4:10 PM, the ADNS stated that doors to droplet precaution rooms should remain closed to prevent droplets produced from coughing or sneezing from spreading into the hall. During an interview with the Director of Nursing Services (DNS) on 04/02/2025 at 6:40 PM, she stated doors to droplet precaution rooms should remain closed to prevent infection spreading. During an interview with Executive Director 2 on 04/01/2025 at 8:58 AM, he stated the door should remain closed in accordance with CDC guidelines. During additional interview with Executive Director 2 on 04/01/2025 at 4:37 PM, he stated, upon inspection, room [ROOM NUMBER]'s door latch was not functioning properly, preventing the door from closing securely. He stated he had requested for maintenance to repair the door, and it was now functioning properly. 3.a. Observation of the Front Hall on 04/01/2025 at 4:10 PM revealed LPN9 exited room [ROOM NUMBER] holding a glucometer with gloved hands. She disposed of the lancet, placed the glucometer on top of the medication cart, and removed her gloves. She did not perform hand hygiene before opening the container of Super Sani-Cloth Germicidal Wipes. She then wiped down the glucometer with one germicidal wipe for 21 seconds and placed it on a barrier sheet. She did not keep the glucometer wet for the required two-minute dwell (time that a device is placed in a specific area). Additionally, LPN9 did not sanitize the top of the medication cart. During an interview with LPN9 on 04/01/2025 at 4:14 PM, she stated she performed hand hygiene after removing her gloves and put on gloves to clean the glucometer. She stated she cleaned the glucometer with a disinfection wipe and placed it on the barrier sheet to dry. She stated each medication cart had a second glucometer to alternate while one was drying. She stated the dwell was the time the glucometer must dry between uses. During additional interview with the IP/SDC on 04/02/2025 at 12:00 PM, she could not explain the steps for cleaning and disinfecting the glucometer. She stated items should be cleaned for one minute and left to air dry. She stated once cleaned and disinfected, the glucometer could be placed on the medication cart because the cart is clean. The IP/SDC did not mention the use of barriers to prevent cross-contamination of disinfected shared equipment. She stated nursing staff was educated to use the two glucometers on the medication carts: one to use and one to dry. She stated everyone should perform hand hygiene before and after resident care to prevent the spread of infection. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated nurses had been educated on how to clean shared glucometers. She stated each treatment cart was equipped with two glucometers to use alternately. She stated nurses should use two wipes to clean and disinfect the glucometer and then wrap it to keep it wet for the allotted dwell time. She stated dwell times varied depending on the product used. She stated the glucometer should be allowed to air dry. The ADNS stated staff should not place glucometers on a bare surface, but a barrier should be used when the glucometer was set down. 3.b. Observation of the Back Hall on 04/01/2025 at 6:50 PM revealed LPN11 walked down the entire hall and approached the nurses' station while holding contaminated bandage scissors wrapped loosely in a glove. She requested disinfecting wipes from another staff member. LPN11 used her contaminated hand to take the wipes, removed the lid, and reached inside the container for a wipe without first performing hand hygiene. LPN11 cleaned the bandage scissors for 33 seconds using one Super Sani-Cloth Germicidal Wipe and then closed the blades while still wet. She did not allow the scissors to remain wet for the required two-minute dwell time, nor did she ensure that all surfaces were air-dried. During an interview with LPN11 on 04/01/2025 at 6:53 PM, she stated she used scissors to cut a resident's cushion. She stated she discovered there were no wipes available in the Front Hall, which prompted her to walk from the Front Hall to the Back Hall in search of disinfecting wipes. LPN11 stated she should have placed the bandage scissors in a container for transport, rather than carrying them with a contaminated glove. She stated she should have gathered her supplies in advance to bring to the point of care. Additionally, LPN11 stated she should have performed hand hygiene and put on gloves to prevent contamination before opening the container of wipes and cleaning the bandage scissors. LPN11 stated she had received IPCP training on multiple occasions since her hire. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated it was her expectation that nursing staff cleaned and disinfected shared equipment according to CDC guidelines and that all nurses followed the facility's policy related to cleaning and disinfecting shared equipment. She stated it was important to prevent the spread of infection. During continued interview with the DNS on 04/02/2025 at 6:40 PM, she stated it was her expectation that nursing staff used the designated disinfectant on any shared items before and after use. She stated, This means that when a nurse picks up a piece of equipment, it should be clean and ready for them to use. She stated any equipment used on one resident should be thoroughly cleaned before it was used on another resident. 4. Observation of the Back Hall on 04/01/2025 at 6:25 PM revealed LPN8 took two large stacks of small plastic drink cups off of the medication cart and transported the cups away, holding them against her scrub top. During an interview with LPN8 on 04/01/2025 at 6:27 PM, she stated she had observed a resident approach the medication cart, touch multiple cups, and take some. She stated she was removing the cups because they were contaminated. She further stated to prevent cross-contamination, she should have used a trash bag to dispose of the cups and not transported them against her person. LPN8 stated she had received multiple training modules related to IPCP during her employment at the facility. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, she stated while transporting any items, especially items for residents' use or contaminated items, staff should ensure the items were held away from their person to prevent cross-contamination. 5.a. Observation of the Back Hall on 03/31/2025 at 1:35 PM, revealed three of three medication carts observed each had one opened applesauce container that was not dated and was not being stored on ice to keep it chilled. 5.b. Observation of the Front Hall on 03/31/2025 at 1:45 PM revealed two of two medication carts observed each had opened, undated pudding that was not stored on ice to keep it chilled. During additional interview with QMA7 on 03/31/2025 at 1:48 PM, she stated she was in the middle of medication administration and had just opened the pudding but had not yet dated the container. She stated typically, at the end of each medication administration, there was usually no pudding or applesauce left, and any remaining portions were discarded. She also stated she was getting ice to keep the pudding and applesauce cold when she was approached by the State Survey Agency (SSA) Surveyor for an interview. QMA7 stated food used for medication administration should be dated when opened and placed on ice for the remainder of medication administration. She stated unused food should be discarded at the end of administration. She stated she received IPCP education. QMA7 stated properly storing residents' food was important to control infection and prevent foodborne illnesses. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, the IP/SDC stated food used for medication administration should be dated when opened and placed on ice for the remainder of the administration. She stated unused food should be discarded. She stated staff members were educated on how to prevent foodborne illnesses. During continued interview with the ADNS on 04/02/2025 at 4:10 PM, she stated food used for medication administration should be dated when opened and placed on ice for the remainder of the administration. She stated nurses should discard unused food at the end of each administration and should replace them with fresh food items. She stated staff members were educated on the prevention of foodborne illness. During additional interview with the DNS on 03/31/2025 at 1:35 PM, she stated food used for medication administration should be dated when opened and placed on ice for the remainder of medication administration. She stated unused food should be discarded at the end of the administration. She stated clinical staff licensed to administer medications were educated on this. She stated it was important to prevent foodborne illness. During continued interview with the IP/SDC on 04/02/2025 at 12:00 PM, she stated it was her expectation that all staff adhered to infection control policies and procedures. She stated all facility staff had received infection control training, which she provided and reviewed many times throughout the year. She stated it was important to follow CDC guidelines to prevent the spread of infection and cross-contamination. During continued interview with the DNS on 04/02/2025 at 6:40 PM, she stated adhering to infection control guidelines was important to prevent the spread of infection and disease to both residents and staff. During additional interview with Executive Director 2 on 04/02/2025 at 4:00 PM, he stated it was his expectation that all staff followed facility polices related to infection control to help prevent the spread of infection and diseases. During an interview with the Medical Director on 04/02/2025 at 4:53 PM, he stated it was his expectation that all staff followed facility polices related to infection control to help prevent the spread of infection and diseases.

Based on observation, interview, and record review, the facility failed to provide a reasonable accommodation of resident needs related to call lights for three (Resident (R) 21, R27, and R91) of six residents reviewed for environmental concerns. Call lights were out of reach and not accessible to residents, two of whom were verbally calling out for assistance. The findings include: Although requested, no policy regarding call lights was provided prior to exit from the facility. 1. Review of R21's Admission Record found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 04/04/2023 with diagnoses including debility, coronary artery disease, and dementia. Review of R21's Admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/11/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3/15, indicating the resident was severely cognitively impaired. Further review of a quarterly MDS, with an ARD of 12/09/2024, revealed a BIMS was not completed due to the resident rarely being understood. Per the MDS, R21 was dependent (helper does all the effort) on staff for all activities of daily living (ADLs) and required substantial/maximal assist (helper does more than half the effort) for mobility performance. Review of R21's undated Comprehensive Care Plan (CCP) revealed the facility assessed R21 as at risk for falls. An intervention initiated on 04/29/2024 to prevent falls was to keep the resident's call light and frequently used personal items within reach. a. During an observation of R21's room on 01/26/2025 at 3:15 PM, R21 was lying in bed, with the head of the bed elevated slightly. R21 had a nightstand next to the bed above, and to the left, of R21's position in bed. An adaptive call light (wide-based touchpad with a cord which plugged into the call light switch) was sitting on top of the resident's nightstand. The adaptive call light was near the wall and behind the resident's supplies, out of the resident's reach. An interview was attempted with the resident; however, R21 was non-interviewable due to severe cognitive impairment. During an interview with Licensed Practical Nurse (LPN) 1 on 01/26/2025 at 3:20 PM, the nurse was notified that R21's adaptive call light was not within reach of the resident. LPN1 stated that all call lights should be within reach of the resident to ensure the resident's safety. Further observation on 01/26/2025 from 3:20 PM until 3:40 PM revealed that neither LPN1 nor any other staff entered R21's room to place the call light within the resident's reach. b. On 01/26/2025 at 5:08 PM, observation again revealed that R21's adaptive call light was on top of the resident's nightstand, out of the resident's reach. During an interview with State Registered Nurse Aide (SRNA) 3, on 01/26/2025 at 5:10 PM, she stated that R21's adaptive call light should be kept within reach of the resident. SRNA3 was uncertain as to why the adaptive call light was not within the resident's reach. She stated that keeping the call light within reach was important for the resident's safety and to prevent accidents. 2. Review of R27's Admission Record revealed the facility admitted the resident on 05/23/2023 with diagnoses including mild cognitive impairment and osteoarthritis. Review of R27's Quarterly MDS, with an ARD of 01/22/2025 revealed the facility assessed the resident with a BIMS score of 13/15, indicating the resident was cognitively intact. Further review revealed R27 required partial to moderate assistance with most activities, including turning side to side in the bed and with bed to chair transfers. Review of R27's Care Plan, dated 05/24/2023, revealed the facility assessed the resident as at risk for falls and included the intervention of keeping the resident's call light in reach. Observation on 01/29/2025 at 5:09 PM revealed R27 in bed with her legs swung over the side of the bed, attempting to get up. Further observation revealed the resident's call light was tangled in her bed frame, out of the resident's reach. In continuous observation until 5:21 PM, R27 intermittently yelled for help, but there was no staff member in the hallway to hear her when she called out. Interview on 01/29/2025 at 5:21 PM with R27 revealed she could not find her call light. R27 stated she had screamed and cussed for help, but it didn't do any good. 3. Review of R91's Admission Record revealed the facility admitted the resident on 01/18/2024 with diagnoses including unspecified dementia, mild intellectual disabilities, and abnormal posture. Review of R91's care plan, revised 02/08/2024, revealed the resident was at risk for falls. Approaches to prevent accidents included keep call light and frequently used personal items within reach. Observation on 01/26/2025 at 1:13 PM revealed the resident calling for help, stating he needed to be pulled up in bed. Further observation revealed R91's call light was sitting on a nightstand by the window, out of the resident's reach. During an interview with the Director of Nursing Services (DNS) on 02/03/2025 at 5:06 PM, she stated that staff were trained to keep call lights within reach of residents. The DNS stated it was her expectation that call lights were accessible to residents for their safety and well-being. She stated further that knowing that someone would return was crucial for the resident's sense of security. During an interview with the Executive Director (ED 1) on 02/03/2025 at 6:28 PM, she stated it was her expectation that call lights were within the resident's reach at all times to ensure the resident's safety. 46710

Based on interview, record review, and facility policy review, the facility failed to develop a baseline care plan within 48 hours that included the minimum instructions needed to provide effective and person-centered care that met professional standards of quality care for one of 32 sampled residents (Resident (R) 93). The facility admitted R93 with pressure ulcers present; however, neither the identification nor treatment of R93's pressure ulcers were addressed on his baseline care plan. The findings include: Review of the facility's policy titled, Baseline Care Plan, revised 05/16/2024 revealed the baseline care plan will be developed within 48 hours of a resident's/patient's admission and will include the minimum healthcare information necessary to properly care for a resident/patient including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy and social services, and PASARR (Pre-Admission Screening and Resident Review) process recommendation, if applicable. Further review revealed the admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident/patient and resident/patient representative, if applicable. Additional review of the policy revealed interventions shall be initiated that address the resident's/patient's current needs including any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk; any identified needs for supervision, behavioral interventions, and assistance with activities of daily living; and any special needs such as for intravenous (IV) therapy, dialysis, or wound care. Review of the facility's policy titled, Wound Care, dated 05/30/2024 revealed it was the policy of the facility that those residents with impaired skin integrity were recognized by the care teams and residents of the facility have their skin assessed at admission/readmission. Review of R93's, Face Sheet revealed the facility admitted the resident on 12/24/2024 with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, type 2 diabetes, and muscle weakness. Review of R93's, Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating the resident was cognitively intact. Review of R93's baseline care plan, Section 1N Nursing Services: Fall risk/interventions, wound, and medical needs such as cardiac, diabetes, and respiratory dated 12/26/2024 revealed the resident's pressure wounds were not addressed. In an interview with R93 on 01/26/2025 at 3:46 PM, he stated his pressure ulcers were present when he was admitted to the facility, and he developed them several months ago. In an interview with State Registered Nurse Aide (SRNA) 10 on 01/30/2025 at 3:29 PM, he stated R93 had pressure wounds present on admission. In an interview with Licensed Practical Nurse (LPN) 3 on 01/30/2025 at 4:54 PM, she stated R93 had pressure wounds, but they were present on admission. In an interview with the Assistant Director of Nursing (ADON) on 02/01/2025 at 4:11 PM, she stated the MDS nurse developed baseline care plans, and all baseline care plans were discussed daily in their morning meeting. In an interview with the MDS Nurse on 02/012025 at 4:59 PM, she stated nursing evaluated new admissions for information included on the baseline care plan. The MDS Nurse stated information was retrieved through interview and assessment. She further stated every care area was assessed, and if a resident was admitted with a pressure ulcer that should be included on the baseline care plan. She stated it was important that the baseline care plans were accurate, so staff ensured the best quality of care was provided and residents' needs were met. In an interview on 02/01/2025 at 7:15 PM with the Director of Nursing Services (DNS), she stated the purpose of a baseline care plan was it provided a basic outline of a resident's required care. She further stated a pressure ulcer present on admission was a care area included on their baseline care plan. The DNS stated it was important the baseline care plan was accurate, so residents received proper care based on their needs.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to provide care and treatment to prevent and/or treat urinary tract infections (UTI) in accordance with accepted standards of practice for two (Resident (R) 1 and R125) of seven sampled residents who had an indwelling urinary catheter. R1 and R125's catheter collection bags were not secured and were, instead, on the floor. In addition, the facility failed to take immediate action when R1 presented with indicators of a urinary tract infection. The findings include: Review of the facility's policy titled, Indwelling Catheter. revised 01/02/2024, revealed the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Additionally, the policy stated that care practices included recognition and assessment for complications and their causes and maintaining a record of any catheter related problems. Review of the Centers for Disease Control and Prevention [CDC] and Health Research and Educational Trust [HRET] Presentation, dated 2015, revealed catheter care essentials included use of a catheter securement device to anchor the catheter. Further review revealed catheter care included keeping the collection bag off the floor. Review of the CDC's Guideline for Prevention of Catheter Associated Urinary Tract Infections [CAUTI], dated 2009, revealed proper techniques for catheter maintenance included to maintain unobstructed urine flow and to keep the catheter and tube free from kinking. Further review revealed the collecting bag should always be kept below the level of the bladder and should not rest on the floor. 1. Review of R1's Admission Record, found in the electronic medical record (EMR), revealed the facility admitted the resident on 07/14/2022 with diagnoses including end-stage renal disease, and uropathy (blockage in the urinary tract). Review of Physician Orders, dated 12/26/2024, revealed the resident had a urinary Foley catheter with tubing and drainage bag. Review of R1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Further review of the MDS revealed the resident had an indwelling catheter. Observation in R1's room, on 01/28/2025 at 10:10 AM, revealed R1 was in bed. The resident's catheter collection bag was not secured to the bed and was observed lying flat on the floor. Continued observation revealed the catheter tubing was not anchored in any way. Upon examining the catheter tubing, it was noted to have streaks of white sediment. The urine collection bag contained approximately 250 milliliters (ml) of dark amber urine, which also had sediment present. During observation and interview with R1 on 01/28/2025 at 10:15 AM, R1 reported experiencing pain in her lower abdomen, which she believed was consistent with a UTI. She stated that she recently had been treated for a UTI but had experienced bladder spasms and pain with urination overnight. R1 stated that she informed the evening staff about her pain and communicated it to the nursing aide presently on duty. However, according to R1, staff had not addressed her concerns, and no nurse had come to assess her this morning. Review of R1's EMR revealed there was no documentation of R1's complaint of bladder spasms overnight, or the morning of 01/28/2025. In response to the resident's concerns, the State Survey Agency Surveyor informed Licensed Practical Nurse (LPN) 1, on 01/28/2025 at 10:40 AM, that R1 had complained of pain with urination and bladder spasms. LPN1 stated she would assess the resident immediately. Review of a Progress Note, dated 01/28/2025 at 3:18 PM, revealed new orders were received to obtain a urinalysis (UA) and culture and sensitivity (C&S) due to frequent urination and pain with urination. An additional Progress Note, dated 01/28/2025 at 5:02 PM, revealed that when R1's catheter was changed, per her request, the urine collection bag contained 300 milliliters (ml) of straw-colored urine with moderate sediment noted. Review of a Progress Note, dated 01/28/2025 at 8:13 PM, revealed a UA sample was obtained via the catheter tubing and sent to lab for testing. Review of the Progress Note, dated 01/29/2025 at 8:14 AM, revealed new orders for ceftriaxone injection (an antibiotic which kills bacteria) to be administered intramuscularly (in the muscle) for five days due to a UTI. During an interview with State Registered Nurse Aide (SRNA) 19 on 01/28/2024 at 10:24 AM, she stated R1 had an indwelling catheter, and the catheter collection bag always dark urine with sediment in it. SRNA19 confirmed she was aware of R1's dark urine and complaints of bladder spasms earlier in the shift. She stated she told one of the nurses but could not recall which nurse she told. During an interview with LPN1 on 01/28/2024 at 10:40 AM, she stated that R1 had just finished antibiotic therapy on 01/26/2025 to treat a UTI. The nurse stated she was not aware if the resident had been assessed for the antibiotic's effectiveness. She stated that despite rounding on the resident, she was unaware R1 was not feeling well. LPN1 stated that no one brought R1's concerns to her attention. Further interview revealed the catheter bags should not touch the floor due to the risk of causing an infection. During an interview with the Nurse Practitioner (NP) on 01/29/2025 at 7:30 AM, he stated R1 was recently treated for a UTI. The NP stated that he was not aware that the resident's UTI symptoms continued until he was notified yesterday, after the SSA intervention. The NP added that R1 had a history of recurring UTI's, and dysuria (discomfort, pain, or burning during urination). The NP stated that the nurses communicated changes in condition (CIC) by calling the provider. The NP stated that he would like the nurses to increase nursing documentation, as the providers reviewed all notes. He stated that while nurses chart by exception, this was inadequate, and that any changes in patients' (residents') conditions should be documented in the nursing notes. 2. Review of R125's Admission Record revealed the facility admitted the resident on 01/27/2025 with diagnoses including adult failure to thrive and UTI. Review of R125's Baseline Care Plan, dated 01/27/2025, revealed a focus, initiated 01/27/2025, that the resident was at risk for infection/complications related to a suprapubic catheter in place due to obstructive uropathy. Interventions, dated 01/27/2024, included: suprapubic catheter care every shift and observe for symptoms of urinary tract infection. Further review revealed a focus area, initiated 01/27/2025, that R125 had a UTI. During an observation of R125 on 02/01/2025 at 4:50 PM, revealed the resident was in his wheelchair, resting with his eyes closed. R125's suprapubic catheter collection bag was not secured to the wheelchair and was observed lying flat on the floor near the back wheel. During an interview with SRNA12 on 01/30/2025 at 10:42 AM, she stated she was trained on catheter care, which included ensuring the tubing was not kinked, keeping the tubing below the bladder, and anchoring it to the bed or wheelchair. During an interview with SRNA13 on 01/30/2025 at 10:42 AM, she stated catheter care included ensuring the tubing was not kinked or looped and to keep the tubing below the bladder to prevent back up. She stated that the catheter collection bag should be anchored to the bed or wheelchair and never placed directly on the floor as it could put the resident at risk for infection. During an interview with the Infection Preventionist and Staff Development Nurse (IP/SD) on 02/01/2025 at 1:29 PM, she stated that the facility recently focused on catheter care and hygiene, observing aides as they practiced their skills to ensure competency and to provide guidance if necessary. She stated that catheter maintenance involved ensuring an unobstructed urine flow and keeping the catheter and tube free from kinks. The IP/SD stated the collecting bag should always be below the bladder level and not rest on the floor, explaining that this was important to prevent the risk of healthcare acquired infections (HAI), including UTIs. During an interview with the Assistant Director of Nursing (ADNS) on 02/01/2025 at 4:50 PM, she stated catheter bags should be anchored to the bed frame or wheelchair and never rest on the floor. The ADNS stated this was important to prevent UTIs. During an interview with the Executive Director (ED) on 02/01/2025 at 6:28 PM, she stated it was her expectation that staff follow facility policies and CDC guidelines to ensure the safety and well-being of the residents and to prevent the spread of infection.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to have an effective system to ensure services were provided to residents in accordance with each resident's written plan of care for seven (7) (Residents: #2, #3, #14, #15, #16, #18, and #19) of twenty-five (25) sampled residents and five (5) unsampled residents (Unsampled Residents: B, C, D, E, and F) of seventeen (17) unsampled residents. The facility failed to ensure care plan interventions for lighters to be kept at the nurses station were implemented for eleven (11) of fifteen (15) smoking residents at the facility. The facility also failed to ensure two (2) residents, who were assessed and care planned for supervision while smoking, were supervised as per their care plans. In addition, one (1) of twenty-five (25) sampled residents (Resident #3) had a care plan for daily restorative nursing, dated 05/30/14; however, review of documentation revealed no documented evidence the care plan was being followed until 06/05/14 when identified by the surveyor. The facility's failure to ensure an effective system was in place to ensure residents' care plans were implemented in regards to a safe and secure environment was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 06/06/14 and was determined to exist on 06/03/14. The facility was notified of the Immediate Jeopardy on 06/06/14. An acceptable credible Allegation of Compliance (AOC) was received on 06/13/14 alleging removal of the Immediate Jeopardy on 06/10/14. The Immediate Jeopardy was verified to be removed on 06/10/14 as alleged, prior to exiting the facility on 06/19/14, with remaining non-compliance at 42 CFR 483.20 Resident Assessment F-282 at a Scope and Severity (S/S) of a "E" while the facility develops and implements the Plan of Correction (POC) and, the facility's Quality Assurance monitors the effectiveness of systemic changes to ensure residents' care plans are implemented. The findings include: Review of the facility's policy: "Comprehensive Plan of Care", effective date 08/01/12, revealed the purpose of the policy was to provide an individualized plan of care for each resident by means of a written document. The policy stated all staff personnel who provided care were to be knowledgeable of the resident's plan of care. Further review of the policy revealed it was the responsibility of each interdisciplinary team member involved in the resident's care to provide input into the implementation of the resident's plan of care. Interview, on 06/06/14 at 11:53 AM, with the Administrator revealed staff was supposed to follow the resident's plan of care. 1. Record review of Resident #14's medical record revealed the facility admitted Resident #14 on 11/02/13 with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) Assessment, dated 11/14/13, revealed the resident was assessed, by the facility, with a Brief Interview of Mental Status (BIMS) score of fifteen (15) of fifteen (15) indicating the resident's cognition was intact and the resident was interviewable. Review of the most recent Safe Smoking Evaluation, dated 05/08/14, revealed the resident was determined, by the evaluation, to need supervision by staff at all times when smoking. Review of the resident's comprehensive plan of care revealed the resident had been care planned for the potential of injury related to smoking, dated 04/25/11, with interventions which included: the resident's lighter was to be kept at the nurse's station and maintain the level of supervision determined by the smoking assessment. Review of the Front Hall Smokers list, kept by the facility at the nurse's station, dated 05/29/14, revealed Resident #14 was listed as an independent smoking resident. However, the facility assessed the resident to require supervision when smoking on 05/08/14. Observation of Resident #14 in his/her room, on 06/05/14 at 2:20 PM, revealed the resident had cigarettes and a lighter in his/her possession. Interview at that time with the resident revealed he/she had cigarettes and a lighter which were kept on the overbed table and he/she went outside to smoke. Observation of Resident #14, on 06/05/14 at 2:40 PM, revealed the resident was in the outside designated smoking area (for unsupervised residents) and was smoking unsupervised. Interview with State Registered Nursing Assistant (SRNA) #11, on 06/05/14 at 10:16 AM, revealed she thought unsupervised residents were allowed to keep lighters, but supervised residents could not. The SRNA stated Resident #14's had a lighter in his/her room and she did not know the resident required supervision while smoking. Interview with Licensed Practical Nurse (LPN) #7, on 06/05/14 at 3:54 PM, and LPN #6, on 06/05/14 at 4:20 PM, revealed they were aware Resident #14 had a lighter in his/her possession. 2. Record review of Resident #19's medical record revealed the facility admitted the resident on 06/13/11 with [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed a BIMS score of twelve (12), which indicated he/she was assessed as moderately cognitively impaired and was interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was to be supervised at all times while smoking. Review of Resident #19's Comprehensive Care Plan for Potential for Injury related to smoking, dated 07/08/13, revealed the resident's lighter was to be kept at the nurse's station and staff were to maintain the appropriate level of supervision as determined by the smoking assessment. Review of the POS [REDACTED]. Observation, on 06/03/14 at 5:20 PM, revealed Resident #19 was in the dining room with a lighter on the table. Observations on 06/05/14 revealed: at 9:15 AM staff was exiting the resident's room and a cigarette case with a lighter was observed on the overbed table; at 2:30 PM and 4:35 PM the resident was observed smoking outside with no supervision. Interview, on 06/05/14 at 6:55 PM, with MDS Coordinator #1 revealed based on Resident #19's Safe Smoking Evaluation, dated 06/02/14, the resident was supposed to be supervised by staff. Interviews on 06/05/14 with SRNA #13 at 4:20 PM, and SRNA #14 at 4:45 PM, revealed there was a list at the nurse station which identified which smokers were supposed to be supervised when smoking and supervised smokers were supposed to have their lighters kept at the nurse's station; however, both identified Resident #19 as one of the residents who had a lighter in his/her room and stated they did not always supervise the resident while smoking. 3. Record review of Resident #2's medical record revealed the facility admitted Resident #2 initially on 04/25/11 and readmitted the resident on 04/20/14 ,with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS), dated [DATE] revealed the facility assessed Resident #2 with a BIMS score of twelve (12) out of fifteen (15) indicating the resident was cognitively intact and interviewable. Review of the "Safe Smoking Evaluation", dated 06/02/14, revealed the resident was determined to be able to smoke independently. Review of the resident's comprehensive plan of care revealed the resident had been care planned for the potential for injury related to smoking, dated 04/25/11, and had an intervention the resident's lighter was to be kept at the nurse's station. Interview, on 06/05/14 at 2:35 PM, with Resident #2, revealed he/she kept cigarettes and a lighter and staff wasn't checking his/her room for smoking materials/ignition sources. 4. Record review of Resident #15's medical record revealed the facility admitted the resident on 04/10/14 with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS, dated [DATE], revealed the resident was assessed with [REDACTED]. Review of the Safe Smoking Evaluation, dated 06/02/14, revealed the resident was able to smoke independently. Review of the resident's comprehensive plan of care revealed the resident had been care planned for the potential for injury related to smoking, dated 04/29/14, and included the intervention the resident's lighter was to be kept at the nurse's station. Observation and interview with Resident #15, on 06/05/14 at 3:15 PM, revealed the resident was in his/her room and had cigarettes and a lighter on the overbed table. Interview with the resident at that time revealed he/she was a smoker and kept his/her cigarettes and lighter on the table. Interview, on 06/05/14 at 4:45 PM, with SRNA #14 revealed she was aware Resident #15 had a lighter in his/her possession even though it was against the facility's policy. Further interview with LPN #7, on 06/05/14 at 3:54 PM, and LPN #6, on 06/05/14 at 4:20 PM, revealed they were aware Resident #15 had a lighter in his/her possession. They further stated they were aware of the care plan intervention to keep lighters at the nursing station. 5. Record review of Resident #16's medical record revealed the facility admitted the resident initially on 06/22/09 and readmitted by the facility on 11/16/10 with [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score was (15), which indicated the facility had assessed the resident as cognitively intact and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was assessed to smoke independently. Review of the resident's comprehensive plan of care revealed the resident had been care planned for the potential of injury related to smoking, dated 07/01/09, and included the intervention the resident's lighter was to be kept at the nurse's station. Observation, on 06/05/14 at 8:40 AM, revealed Resident #16 was outside smoking and had a lighter in his/her possession. Interview with Resident #16, on 06/05/14 at 2:30 PM, revealed the resident kept the cigarettes and lighter all day in his/her pocket. 6. Record review revealed the facility admitted Resident #18 initially on 08/17/12 and readmitted the resident on 12/04/13 with [DIAGNOSES REDACTED]. Further review of the Quarterly MDS, dated [DATE], revealed the BIMS score was fifteen (15), which indicated the facility assessed the resident as cognitively intact and interviewable. Review of Resident #18's most current Safe Smoking Evaluation, dated 06/02/14, revealed he/she was assessed as being able to smoke unsupervised. Review of the Comprehensive Care Plan Potential for Injury related to smoking, dated 07/08/13, revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Resident #18, on 06/05/14 at 10:00 AM and at 10:08 AM, revealed the resident had cigarettes and lighter in his/her possession. Interview with the resident revealed he/she smoked independently and got his/her cigarettes and lighter from a friend. Interview with SRNA #12, on 06/05/14 at 10:16 AM, and with SRNA #13, on 06/05/14 at 4:20 PM, revealed they both were aware Resident #18 had a lighter in his/her possession and neither were aware the care plan interventions to keep lights at the nursing station. Interview with LPN #6, on 06/05/14 at 4:20 PM, revealed unsupervised residents were allowed to have lighters and Resident #18 had a lighter. However, she further stated she was aware of the intervention on the care plan to keep lighters at the nursing station and the care plan should have been followed. 7. Record review of Unsampled Resident B's medical record revealed the facility initially admitted the resident initially on 10/26/10 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident B's most recent BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was evaluated as being able to smoke independently. Review of the Comprehensive Care Plan for Potential for Injury related to smoking, dated 08/05/12, revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Unsampled Resident B, on 06/05/14 at 3:20, revealed the resident had a lighter in his/her possession. The resident stated his/her lighter was kept in his/her pocket and on the overbed table (in room) at night. 8. Record review of Unsampled Resident C's medical record revealed the facility initially admitted Unsampled Resident C on 03/13/14 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident C's most recent BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the evaluation was complete and the resident was evaluated as being able to smoke independently. Review of the Comprehensive Care Plan Potential for Injury related to smoking, dated 03/21/14, revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Unsampled Resident C, on 06/05/14 at 3:00 PM, revealed the resident was in his/her room and had a cigarette case with a lighter. Interview with Unsampled Resident C revealed he/she kept the lighter in his/her possession at all times. 9. Record review of Unsampled Resident D's medical record revealed the facility admitted the resident initially on 10/12/11 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident D's most recent BIMS as twelve (12), which indicated the facility assessed the resident as moderately cognitively impaired and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the evaluation was complete and the resident was evaluated as able to smoke independently. Review of the Comprehensive Care Plan revealed the resident was care planned as a smoker with a history of being non-compliant with the smoking rules, dated 05/15/12, and included an intervention the resident's lighter was to be kept at the nurse's station Observation and interview of Unsampled Resident D, on 06/05/14 at 2:30 PM, revealed the resident was smoking outside and had a lighter. Interview with Unsampled Resident D revealed he/she kept the lighter in his/her pocket. 10. Record review of Unsampled Resident E's medical record revealed the facility admitted Unsampled Resident E on 01/22/13 with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident E's BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the evaluation was complete and the resident was evaluated as able to smoke independently. Review of the Comprehensive Care Plan: potential for injury related to smoking, dated 02/06/13, revealed the resident's lighter was to be kept at the nurse's station. Interview with Unsampled Resident E, on 06/05/14 at 2:30 PM, revealed he/she kept a lighter in his/her possession. Interview, on 06/05/14 at 3:54 PM, with LPN #7 revealed she was aware Unsampled Resident E had a lighter but did not realize there was a care plan intervention to keep the lighters at the nursing station. Interview, on 06/05/14 at 4:49 PM, with Registered Nurse/Supervisor #1 revealed the resident had a lighter in his/her possession but was not aware of the care plan intervention to keep the lighters at the nursing station. 11. Record review of Unsampled Resident F's medical record revealed the facility initially admitted Unsampled Resident F on 01/10/13 and readmitted the resident on 03/07/14 with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident F's most recent BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the evaluation was complete and the resident was evaluated as able to smoke independently. Review of the Comprehensive Care Plan for Potential for Injury related to smoking, dated 03/20/14, revealed the resident's lighter was to be kept at the nurse's station. Observation of and interview with Unsampled Resident F, on 06/05/14 at 2:20 PM, revealed the resident had a lighter in his/her cigarette package. Interview with Unsampled Resident F revealed the resident kept the lighter in a purse on the back of his/her wheelchair. Interview, on 06/06/14 at 3:05 PM, with SRNA #16 revealed staff was supposed to follow the resident's care plan, but the aide care plans had no documentation lighters were supposed to be kept at the nurse's station and thought unsupervised residents were allowed to have lighters. Interviews on 06/06/14, with LPN #8 at 2:45 PM, and LPN #1 at 4:07 PM, revealed the comprehensive care plans should be followed and if the resident's care plan included the intervention to store lighters at the nurse station they were not following the care plan if the residents had lighters. Interview, on 06/06/14 at 10:53 AM and at 3:10 PM, with MDS Coordinator #1 revealed if the smoking care plans included an intervention lighters were to be kept at the nurse station they were not following the care plan if the resident had a lighter. Further interview revealed she was unsure why this intervention was included on the care plans because the residents got lighters from family and other residents and they weren't able to ensure lighters were kept from residents. Interview with the DON, on 06/06/14 at 3:00 PM and on 06/19/14 at 11:53 PM, regarding residents evaluated as needing smoking supervision (Residents #14 and #19), revealed it was her expectation staff was aware of the resident's plan of care, the related interventions when they provided care and supervised residents. Further interview revealed staff should have followed the residents' smoking care plan. Interview, on 06/06/14 at 11:20 AM, with the Administrator revealed if the residents' care plan included storing lighters at the the nurse's station staff was to follow the care plan or if they were unable to follow the intervention the care plan should have been revised. 12. Review of the facility's policy: "Restorative Nursing", effective date 08/01/12, revealed the licensed restorative nurse will develop the resident's rehabilitation/restorative plan of care to be carried out by the rehabilitation/restorative nursing assistant. Review of Resident #3's medical record revealed the resident was admitted by the facility on 11/13/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident's BIMS score of three (3), which indicated severe cognitive impairment. Review of the physician's orders [REDACTED]. Record review of Resident #3's Nursing Rehab/Restorative Plan of Care, dated 05/30/14, revealed the resident had stiffness of upper and lower extremities and Restorative Nursing interventions included providing Passive Range of Motion (PROM) to both upper/lower extremities and the application of warm/hot packs to all joints of upper and lower extremities once daily times ten (10) minutes. Review of documentation, on 06/05/14 at 11:15 AM, revealed no documented evidence the resident had received any Restorative Nursing per the plan of care. Interview with SRNA #18, on 06/04/14 at 11:41 AM, and SRNA #19 on 06/05/14 at 9:54 AM, revealed they provided care for Resident #3 and both reported the resident was getting therapy at the time. However, interview with Physical Therapy Assistant (PTA) #1, on 06/05/14 at 10:52 AM and 11:15 AM, revealed Resident #3 was discharged from therapy and nursing was given the restorative program recommended by therapy. The PTA stated the Restorative Nurse was responsible for initiating the care plan which was put into the Restorative Nursing Notebook at the nurses station. After review of Resident #3's care plan, the PTA revealed there was no documentation the care plan interventions were done by staff. Interview with the facility's Restorative Nurse, on 06/06/14 at 10:58 AM, revealed Resident #3 was supposed to get restorative nursing once the order was written. The Restorative Nurse stated she wrote the care plan on 05/30/14 and put it in the Restorative Book which staff was supposed to check daily. She stated the aides performed the assignments (care plan interventions), initialed in the book when completed, and the floor nurses were supposed to make sure it was being done. After review of the Restorative Nurse book, she stated based on documentation Resident #3's restorative nursing program (care plan) was not started until 06/05/14. Interview, on 06/06/14 at 11:23 AM, with SRNA #21 revealed the resident had been getting therapy and was supposed to get restorative nursing for range of motion. She stated the resident got restorative on 06/05/14, but didn't know why there was no restorative initiated earlier when the care plan was dated 05/30/14. Interview, on 06/06/14 at 10:21 AM, with LPN #7, who cared for Resident #3 06/03/14 through 06/06/14, revealed the Restorative Nurse wrote the nursing care plan, put the plan into the restorative book, and nursing was to follow. The LPN stated nurses and aides were supposed to check the restorative book and expected restorative to be started after the 05/30/14 order. Further interview with LPN #7 revealed she did not know why restorative was not started until 06/05/14. Interview, on 06/06/14 at 3:10 PM, with MDS Coordinator #1 revealed the Restorative Care Plan, dated 05/30/14, was part of the resident's comprehensive care plan. She stated if the care plan had restorative interventions that were to be performed daily, they were not following the care plan. Interview, on 06/06/14 at 4:39 PM, with the DON revealed she expected staff to follow care plans. The DON stated the restorative care plan, dated 05/30/14, was written by the Restorative Nurse and was part of the comprehensive care plan. She stated there was a breakdown in both the aides and nurses checking the restorative log daily. The nurses were supposed to make sure it was being done. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 06/13/14 that alleged removal of the Immediate Jeopardy (IJ) effective 06/10/14. Review of the AOC revealed the facility implemented the following: 1) On 06/06/14 care plans for the sixteen (16) resident smokers (one of which was out of the facility at the time) were reviewed by the two (2) MDS Coordinators and the Regional MDS Specialist to ensure the plan of care related to smoking accurately reflected the resident needs to smoke safely. Each resident will have supervised/unsupervised noted on the care plan. The resident care plans were to be reviewed and updated, as needed, per Resident Assessment Instrument requirements, i.e. Annually, Quarterly, and with Significant Change or when there was a change in the resident's smoking status. 2) Beginning on 06/06/14 and completed on 06/09/14 the Staff Development Coordinator, DON, ADON, RN Supervisor, Housekeeping Supervisor, and Dietary Supervisor provided education to all staff (3 PRN staff were not available but were to be educated before working) regarding the importance of implementing the plan of care related to safety during smoking for each resident. 3) The smoking roster was to be updated by the DON/ADON, MDS Coordinator/RN Supervisor or charge nurse as necessary to include any changes in a smoking resident's care plan needs. The roster will be reviewed daily, by the DON/ADON, until successful abatement of the jeopardy occurred. Thereafter, the roster will be reviewed at least three (3) times a week for at least four (4) weeks for accuracy by the DON/ADON or in their absence the charge nurse or RN supervisor. After those four (4) weeks the Focus Team will determine how often the roster reviews were to be done based on results of reviews. At a minimum reviews were to be conduced weekly and when a resident was admitted that chooses to smoke. 4) The Administer/DON/RN Supervisor will monitor implementation of the plan of care for residents who smoke via daily rounds starting 06/06/14. 5) Beginning on 06/07/14 the Administrator/DON/ADON/Staff Development Coordinator and RN Supervisors would conduct ten (10) quizzes per day to ensure employees were competent in the facility's smoking protocols and were aware of the individualized interventions for each resident identified as a smoker with the facility. Incorrect answers were to be corrected with 1:1 verbal education at the time. The quizzes would be daily until abatement of the jeopardy. The focus team, based on quiz findings, would determine the frequency of future quizzes but at a minimum would continue three (3) times a week for at least four (4) weeks. 6) The results of all logs/quizzes were to be reviewed daily by the Administrator. DON, ADON, Staff Development Coordinator, and or RN Supervisor to identify any concerns and then enable the Administrative Team to focus on additional educational needs. The Regional Vice President or the Regional Director of Clinical Operations would also review the information at least two (2) times per week until the jeopardy was abated. 7) The results of all quizzes would be reviewed weekly during the FOCUS Meeting (a sub-committee of the QAPI meeting) in order to identify areas that need additional monitoring for continued compliance. The results would also be reviewed at the monthly QAPI meeting. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Review of the care plans, of the sixteen (16) smokers revealed the care plans had been revised, dated 06/08/14, and included the smokers current safe/unsafe smoking designation per the assessment in compliance with AOC. Interview, on 06/19/14 at 10:26 AM, with the DON revealed the MDS's were updated with changes by the MDS Coordinators. Care plans were to be initiated based on assessment and any changes were to be done as needed and reviewed at proper intervals per AOC. 2) Review of educational inservice information, the staff roster and inservice sign-in sheets revealed staff had been educated concerning the facility's smoking policy and implementation of the care plans. Interviews with LPN #2 on 06/17/14 at 4:35 PM; LPN #10 on 06/17/14 at 3:30 PM; LPN #1 on 06/17/14 at 4:27 PM; LPN #5 on 06/17/14 at 9:30 AM; LPN # 9 on 06/17/14; LPN #7 on 06/17/14 at 9:32 AM; LPN #3 on 06/17/14 at 8:45 PM; RN/MDS Coordinator #1 on 06/17/14 at 11:46 AM; RN/MDS Coordinator #2 on 06/17/14 at 11:46 AM; SRNA #9 on 06/17/14 at 2:05 PM; SRNA #27 on 06/17/14 at 4:17 PM; SRNA #6 on 06/17/14 at 3:05 PM; SRNA #16 on 06/17/14 at 2:50 PM, SRNA #17 on 06/17/14 at 4:45 PM; SRNA #3 on 06/17/14 at 9:20 AM; SRNA #23 on 06/17/14 at 11:05 AM; SRNA #22 on 06/17/14 at 8:36 AM; SRNA #21 on 06/17/14 at 9:23 AM; SRNA # 12 on 06/17/14 at 9:43 AM; SRNA #11 on 06/17/14 at 9:51 AM; SRNA #24 on 06/17/14 at 8:50 AM; SRNA # 26 on 06/17 at 3:16 PM; SRNA #25 on 06/17/14 at 9:45 AM; Certified Medical Technician #1 on 06/17/14 at 9:50 AM; Physical Therapy Assistant #1 on 06/17/14 at 8:50 AM; Physical Therapy Assistant #3 on 06/17/14 at 11:05 AM; Occupational Therapy Assistant #1 on 06/17/14 at 2:59 PM; Activity Director on 06/17/14 at 10:56 AM; Activity Assistant on 06/17/14 at 1:25 PM; Dietary Aide #5 on 06/17/14 at 1:10 PM; Dietary Aide #4 on 06/17/14 at 1:05 PM; Dietary Aide #2 on 06/17/14 at 9:25 AM; Cook #1 06/17/14 at 9:15 AM; Laundry Aide #1 on 06/17/14 at 9:10 AM; Housekeeping #1 on 06/17/14 at 8:35 AM; Housekeeping #2 on 06/17/14 at 9:30 AM; and Maintenance Staff #1 06/17/14 at 9:35 AM all revealed they had been inserviced on safe smoking care plans/practices, smoking rosters per AOC. Staff reported they had been quizzed by Administrative staff per AOC to ensure competency. 3) Reviewed updated 06/06/14 smoking roster with DON signature dated 06/06/14. Observation revealed Smoking Roster was updated daily and included list of residents who smoke, who were unsupervised/independent smokers, and supervised smokers and any special interventions. Review of the roster revealed one resident was to wear a smoking apron. Observations of residents, on 06/17/14 at 8:32 AM, 8:41 AM, 10:55 AM, 4:31 PM, 4:52 PM; and on 06/18/14 at 10:31 AM, 12:36 PM, 3:35 PM and 4:38 PM, revealed residents were smoking at the unsupervised/supervised designated smoke areas per care plans and one supervised resident wore smoking apron per the care plan. 4) Observation of staff monitoring smoking areas via rounds, on 06/17/14 at 8:32 AM, 8:41 AM, 10:55 AM, 4:31 PM and 4:52 PM; and on 06/18/14 at 3:35 PM and 4:38 PM. Interview, on 06/19/14 at 1:20 PM, with the Clinical Regional Director and the Administrator revealed they have been making rounds and checking smoking areas daily or, when not in facility, called each day and spoke to staff and managers to ensure they were making daily rounds to observe for compliance with smoking policy. 5) Interview with the DON, on 06/19/14 at 12:06 PM, revealed Administrative staff had been conducting quizzes, starting on 06/07/14, on smoking protocols/ interventions being implemented daily per the AOC and they were reviewed daily in morning meeting to collect data related to accuracy of responses and any additional education needs. Interviews with LPN #1 on 06/17/14 at 4:27 PM; LPN #5 on 06/17/14 at 9:30 AM; LPN # 9 on 06/17/14; LPN #7 on 06/17/14 at 9:32 AM; LPN #3 on 06/17/14 at 8:45 PM; RN/MDS Coordinator #1 on 06/17/14 at 11:46 AM; RN/MDS Coordinator #2 on 06/17/14 at 11:46 AM; SRNA #9 on 06/17/14 at 2:05 PM; SRNA #27 on 06/17/14 at 4:17 PM; SRNA #6 on 06/17/14 at 3:05 PM; SRNA #16 on 06/17/14 at 2:50 PM, SRNA #17 on 06/17/14 at 4:45 PM; SRNA #3 on 06/17/14 at 9:20 AM; SRNA #23 on 06/17/14 at 11:05 AM; and, SRNA #22 on 06/17/14 at 8:36 AM revealed they had been quizzed regarding smoking protocols. Review of quiz documentation revealed quizzes were initiated on 06/07/14 and ten (10) or more quizzes were conducted by administration with staff per day as per AOC. 6) Interview with the Administrator and Regional Director of Clinical Operations, on 06/19/14 at 1:20 PM revealed the Administrator reviewed data daily and when not at the facility called in to get information. The Regional Director of Clinical Operations revealed she had been at the facility most days and reviewed education and quizzes looking for concerns, abnormal or incorrect answers. 7) Interview with the Administrator, on 06/19/14 at 1:30 PM, revealed one FOCUS team meeting had been conducted on 06/12/14 and quiz results were discussed and more questions were added to address more areas, but no concerns had been identified. Review of Focus Meeting Minutes documentation, dated 06/12/14, revealed they discussed AOC, quizzes were revi

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 maintain an environment that was free from accident hazards and failed to provide supervision and monitoring for residents who smoked, for seven (7) of twenty-five (25) sampled residents (Residents #2, #10, #14, #15, #16, #18, and #19) and six (6) of seventeen (17) unsampled residents (Unsampled Residents A, B, C, D, E, and F). The facility failed to implement smoking policy procedures to ensure: residents had no fire igniting materials (matches/lighters) at any time; rooms of smokers were routinely inspected for smoking materials; and staff supervised the smoking of each resident the facility assessed to be a "supervised smoker". The facility identified a total of fifteen (15) residents who smoked. Interviews revealed staff did not routinely search smokers' rooms for ignition sources and were aware some residents had lighters. Observation, interview, and record review revealed twelve (12) residents who smoked had lighters in their possession, including two (2) residents assessed as needing supervision, and six (6) of the residents with lighters also had oxygen in their rooms. In addition, two (2) smokers assessed by the facility to require supervision while smoking were observed to be smoking unsupervised. Furthermore, observation revealed the facility failed to ensure the toilet base bolts in all thirty-eight (38) resident bathrooms and three (3) shower rooms had bolt covers which placed residents at risk for injury. The facility's failure to ensure residents assessed for supervision with smoking were supervised and monitored, residents did not possess ignition materials, and resident rooms were routinely inspected for the presence of ignition materials, including those residents with oxygen, as per the facility's policy resulted in the failure to protect residents from the risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified 06/06/14 and was determined to exist on 06/03/14. The facility was notified of the Immediate Jeopardy on 06/06/14. An acceptable credible Allegation of Compliance (AOC) was received on 06/14/14, alleging removal of the Immediate Jeopardy on 06/10/14. The Immediate Jeopardy was verified to be removed on 06/10/14 as alleged, prior to exiting the facility on 06/19/14, with remaining non-compliance at 42 CFR 483.25 Quality of Care, F-323 at a Scope and Severity (S/S) of "E" while the facility develops and implements the Plan of Correction (POC), and the facility's Quality Assurance program monitors the effectiveness of systemic changes to maintain an environment as free of hazards as possible and ensures adequate supervision to prevent accidents. The findings include: Review of the facility's policy, titled "Smoking Policy" (effective date 07/01/08), revealed the purpose of the policy was to maximize the facility's ability to provide a safe environment for all residents. The policy procedures revealed a "Safe Smoking Assessment" was to be completed upon admission, quarterly, annually, and with any change of condition, to determine if a resident required supervision when smoking. Further review of the "Smoking Policy" revealed no fire igniting materials (matches/lighters) were to be in any resident's possession at any time and supervised smokers were to smoke only with a staff person present. Review of the policy's "essential points" revealed the rooms of smokers were to be inspected routinely for smoking materials and when oxygen was initiated. Continued review revealed all such materials were to be removed from resident rooms when noted on routine inspection. Interview with the Administrator, on 06/06/14 at 11:20 AM, revealed the facility had a smoking policy which included an assessment of residents, performed by nursing staff, to evaluate for safe or unsafe smoking habits. The Administrator stated, based on the assessments, smokers were determined to require supervision while smoking, or to be able to safely smoke unsupervised. Further interview revealed, per the policy, residents were not to keep lighters or matches in their possession. Review of the facility's lists of Front Hall Smokers and Back Hall Smokers, updated 05/29/14, revealed thirteen (13) residents were determined to be Independent/Safe Smokers, and two (2) residents were identified as Supervised Smokers (Residents #14 and #19). Further review of the list revealed residents' lighters were to be kept at the Nurse's Station. However, observation and interview revealed smoking materials were not being kept at the Nurse's Station. 1. Review of Resident #14's medical record revealed the facility admitted the resident on 11/02/13 with [DIAGNOSES REDACTED]. Review of the resident's initial Minimum Data Set (MDS) Assessment revealed a Brief Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact and was interviewable. Further record review revealed a Physician Order, dated 11/02/13, for oxygen at four (4) liters per minute via nasal cannula. Review of the most recent Safe Smoking Evaluation, dated 05/08/14, revealed the resident was evaluated by the facility to require supervision by staff at all times when smoking. Review of the resident's comprehensive plan of care revealed interventions to keep the resident's lighter at the nurse's station and to maintain the level of supervision determined by the smoking assessment. However, review of the Front Hall Smokers list at the nurse's station, dated 05/29/14, revealed Resident #14 was listed as an independent smoker. Observation and interview with Resident #14 in his/her room, on 06/05/14 at 2:20 PM, revealed the resident had an oxygen concentrator set at four (4) liters per minute and was wearing a nasal cannula. Further observation revealed the resident had cigarettes and a lighter in his/her possession. The resident stated he/she needed oxygen due to shortness of breath. Continued interview revealed the resident kept the cigarettes and lighter on the overbed table, and the resident went outside to smoke in the designated unsupervised smoking area. Subsequent observation of Resident #14, on 06/05/14 at 2:40 PM, revealed the resident was at the designated outside smoking area, smoking without supervision, but was not using oxygen. Interview with State Registered Nursing Assistant (SRNA) #11, on 06/05/14 at 10:16 AM, revealed she thought unsupervised residents were allowed to keep lighters, but supervised residents could not. The SRNA stated she had seen lighters in resident rooms and knew Resident #14 had a lighter in his/her room and she did not know the resident required supervision while smoking. 2. Review of Resident #19's medical record revealed the facility admitted the resident on 06/13/11 with [DIAGNOSES REDACTED]. Continued review revealed Resident #19 was legally blind. Review of the MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS score of twelve (12), which indicated the resident was moderately cognitively impaired and interviewable. Review of the most recent Safe Smoking Evaluation, dated 06/02/14, revealed Resident #19 was assessed to lack the fine motor skills necessary to securely hold cigarettes, and therefore required supervision at all times when smoking. Review of the resident's comprehensive care plan revealed the resident's lighter was to be kept at the nurse's station and staff were to maintain the appropriate level of supervision as determined by the smoking assessment. Review of the facility's Front Hall Smokers list revealed Resident #19 was listed as a supervised smoker. However, observation, on 06/03/14 at 5:20 PM, revealed Resident #19 was seated in the dining room and had cigarettes and a lighter on the table. Subsequent observations, on 06/05/14, revealed the following: at 9:15 AM staff was observed exiting the resident's room and a cigarette case with a lighter was lying on the overbed table; at 2:30 PM the resident was observed smoking outside with no supervision and was holding a cigarette case and a lighter; and at 4:35 PM the resident was observed smoking outside with no supervision. Interview with MDS Coordinator #1, on 06/05/14 at 6:55 PM, revealed based on Resident #19's Safe Smoking Evaluation dated 06/02/14, the resident was supposed to be supervised by staff when smoking. 3. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Significant Change MDS Assessment, dated 05/16/14, revealed the facility assessed Resident #2 to score a fifteen (15) on the BIMS, which indicated the resident was cognitively intact and was interviewable. Review of the "Safe Smoking Evaluation", dated 06/02/14, revealed the resident was determined to be able to smoke independently. Review of the resident's comprehensive plan of care revealed an intervention the resident's lighter was to be kept at the nurse's station. Observation of Resident #2's room, on 06/03/14 at approximately 1:20 PM, revealed an oxygen concentrator was present on the roommate's side of the room. Interview with Resident #2, on 06/05/14 at 2:35 PM, revealed the resident kept cigarettes and a lighter with him/her, and staff did not check the room for smoking materials or ignition sources. 4. Review of Resident #10's medical record revealed the facility admitted Resident #10 initially on 06/11/09, and readmitted the resident on 09/05/12, with [DIAGNOSES REDACTED]. Review of the resident's most current MDS Assessment revealed a BIMS score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was determined to be able to smoke independently. Observation of Resident #10's room, and interview with the resident, on 06/05/14 at 2:11 PM, revealed no cigarettes or lighters were visible. Continued observation revealed the presence of an oxygen concentrator for Resident #10's roommate, Unsampled Resident B. Resident #10 stated he/she currently had no cigarettes or a lighter. However, record review of a Nurse's Progress Note, dated 06/09/14, revealed Resident #10 was found to have a lighter in his/her possession. 5. Review of Resident #15's medical record revealed the facility admitted Resident #15 on 04/10/14 with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS revealed a BIMS score of fourteen (14), which indicated the resident was cognitively intact and was interviewable. Review of the Safe Smoking Evaluation, dated 06/02/14, revealed Resident #15 was able to smoke independently. Review of the resident's comprehensive plan of care revealed the resident's lighter was to be kept at the nurse's station. However, interview with Resident #15, and observation of his/her room, on 06/05/14 at 3:15 PM, revealed the resident had cigarettes and a lighter on the overbed table. Interview with the resident revealed he/she was a smoker and kept his/her cigarettes and lighter on the table. 6. Review of Resident #16's medical record revealed the facility admitted the resident initially on 06/22/09, and readmitted the resident on 11/16/10, with [DIAGNOSES REDACTED]. Review of the facility's list of interviewable residents revealed Resident #16 had a BIMS score of fifteen (15), which indicated the resident was cognitively intact and was interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed Resident #16 was able to smoke independently. Review of the resident's comprehensive plan of care revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Resident #16, on 06/05/14 at 2:30 PM, revealed the resident kept cigarettes and a lighter in a pocket in his/her possession during the day, but had staff lock them up in the Activities Department at night. 7. Review of Resident #18's medical record revealed the facility admitted the resident initially on 08/17/12, and readmitted the resident on 12/04/13, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed a BIMS score of fifteen (15), which indicated the facility assessed the resident to be cognitively intact and interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was assessed to be able to smoke independently. Review of the comprehensive care plan revealed the resident's lighter was to be kept at the nurse's station. However, observations of Resident #18, and interview with the resident in his/her room, on 06/05/14 at 10:00 AM and at 10:08 AM, revealed the resident had cigarettes and a lighter in his/her possession. Interview with the resident revealed he/she smoked independently and obtained his/her cigarettes and lighter from a friend. Resident #18 also reported he/she had a lock box, but kept the cigarettes and lighter on the window ledge or overbed table. In addition, the resident stated he/she had cigarettes and lighters missing in the past and had reported it to facility staff, but could not remember which staff. 8. Review of Unsampled Resident A's medical record revealed the resident was admitted to the facility on [DATE], and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's list of interviewable residents revealed Unsampled Resident A had a BIMS score of fifteen (15), indicating the resident had no cognitive impairment and was interviewable. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was evaluated as being able to smoke independently. Observation of ,and interview with Unsampled Resident A, on 06/05/14 at 3:15 PM, revealed the resident had a pad lock attached to the night stand drawer. Interview with the resident revealed he/she had a lighter and kept it locked up in the night stand. 9. Review of the medical record for Unsampled Resident B revealed the facility initially admitted the resident on 10/26/10, and readmitted the resident on 08/05/12 with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident B as interviewable with a BIMS score of fifteen (15). Review of the Physician order [REDACTED]. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed he/she was determined by the facility as able to smoke independently. Review of the comprehensive care plan revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Resident Unsampled B, on 06/05/14 at 3:20 PM, revealed the resident was on oxygen, had a lighter in his/her possession, and did not have a locked drawer. The resident stated he/she kept the lighter and cigarettes in a pocket or on the overbed table. 10. Review of the medical record for Unsampled Resident C revealed the resident was initially admitted by the facility on 03/13/14, and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident C as interviewable with a BIMS score of fifteen (15). Review of the Physician order [REDACTED]. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed Resident C was assessed to smoke independently. Review of the comprehensive care plan revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Unsampled Resident C, on 06/05/14 at 3:00 PM, revealed the resident was in his/her room with an oxygen concentrator near the resident, although it was not in use. Further observation revealed the resident had a cigarette case and a lighter. Interview with Resident C revealed he/she used oxygen at times. Resident C stated he/she kept a lighter in possession at all times, but turned the cigarettes over for safekeeping at the nurse's station because of a concern they would be stolen. 11. Review of Unsampled Resident D's medical record revealed the facility initially admitted the resident on 10/12/11, and readmitted the resident on 08/13/12 with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident D as interviewable with a BIMS score of twelve (12). Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was assessed to be able to smoke independently. However, review of a prior Safe Smoking Evaluation, dated 03/12/14, revealed the resident had safe technique but smoked in areas not designated as smoking areas, for example in his/her room or common areas, and therefore was a supervised smoker. Review of the resident's comprehensive care plan revealed the resident had a history of [REDACTED]. Observation of, and interview with Unsampled Resident D, on 06/05/14 at 2:30 PM, revealed the resident was smoking outside in the designated unsupervised smoking area and had a lighter. Interview with Resident D revealed he/she kept the lighter in his/her pocket. Subsequent observation of Unsampled Resident D's room, on 06/05/14 at 3:00 PM, revealed an oxygen concentrator was in the room, but was not in use. Interview with the Registered Nurse Supervisor (RNS), on 06/05/14 at 4:49 PM, revealed Resident D had a history of [REDACTED]. 12. Review of the medical record revealed the facility admitted Unsampled Resident E on 01/22/13 with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident E as interviewable with a BIMS score of fifteen (15). Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was evaluated as able to smoke independently. Review of the comprehensive care plan revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Resident E, on 06/05/14 at 2:30 PM, revealed the resident had a night stand with a pad lock on one drawer. Interview with the resident revealed he/she kept a lighter in a pants pocket during the day and locked the lighter in the night stand drawer at night. 13. Review of the medical record revealed the facility initially admitted Unsampled Resident F on 01/10/13, and readmitted the resident on 03/07/14, with [DIAGNOSES REDACTED]. The facility listed Unsampled Resident F as interviewable with a BIMS score of fifteen (15). Review of the resident's Physician order [REDACTED]. Review of the resident's most recent Safe Smoking Evaluation, dated 06/02/14, revealed the resident was evaluated as able to smoke independently. Review of the comprehensive care plan revealed the resident's lighter was to be kept at the nurse's station. Observation and interview with Resident F, on 06/05/14 at 2:20 PM, revealed two oxygen concentrators were present in the resident's room. Continued observation revealed Resident F was carrying a lighter inside his/her cigarette package. Interview with the resident revealed the resident kept the lighter in a bag on the back of his/her wheelchair, and used oxygen. Interview with staff revealed the facility's smoking policy and procedures were not being followed related to ensuring no fire igniting materials (matches/lighters) were in any resident's possession at any time; ensuring supervised smokers were to smoke only with a staff person present; and, ensuring rooms of smokers were inspected routinely for smoking materials. Interview with SRNA #12, on 06/05/14 at 10:24 AM, revealed she thought unsupervised residents could keep lighters, but supervised smokers could not. Interview with SRNA #8, on 06/05/14 at 4:00 PM, revealed facility staff did not perform room checks for lighters. She stated she was aware of two former residents who tried to smoke in their rooms. Interview with SRNA #15, on 06/05/14 at 4:18 PM, revealed she worked at the facility on an as needed basis and was unsure about the facility's smoking procedures. The SRNA stated she did not feel lighters should be kept in resident rooms, especially when there was oxygen present. Interview with SRNA #16, on 06/05/14 at 4:50 PM, revealed unsupervised residents were allowed to keep lighters in their rooms and were responsible for securing their lighters from other residents. The SRNA stated she felt it was the resident's right, if unsupervised, to keep cigarettes and lighters in their room. Interviews with SRNAs #4 and #14, on 06/05/14 at 4:20 PM and 4:45 PM respectively, revealed supervised residents' cigarettes and lighters were kept at the nurse's station, but unsupervised residents kept their own lighters and were supposed to store them securely where other residents did not have access. However, the SRNAs revealed Resident #19, who was listed as a supervised smoker, had a lighter in his/her room. Both SRNAs felt it was not safe to make the residents responsible to secure the lighters from other residents and it was not safe to have lighters around oxygen. Interviews on 06/05/14 with Licensed Practical Nurse (LPN) #7, at 3:54 PM and 5:45 PM, and LPN #6 at 4:20 PM and 5:34 PM, revealed the aides checked to see if supervised residents had lighters in their rooms, and they were aware some unsupervised residents kept their own lighters. The LPNs acknowledge staff was not checking to see if the lighters were stored securely by the residents. Further interview with the LPNs revealed residents who kept lighters in a room where oxygen was present posed a safety risk. LPN #7 stated it was a safety risk if the resident's lighter was not stored securely and they had a cognitively impaired roommate. In addition, she stated it was a safety issue if lighters were not stored securely in resident rooms because there were residents in the facility who wandered into the wrong rooms at times. Interview with LPN #3, on 06/05/14 at 4:37 PM, revealed resident lighters were supposed to be kept at the the nurses station and not in resident rooms. However, the LPN stated room checks for lighters were not done due to privacy, unless there was a specific reason, for example if a resident was found to be smoking in their room. Interview with LPN #2, on 06/06/14 at 3:15 PM, revealed residents were reminded to return their lighters to the nurse's station. Continued interview revealed LPN #2 was aware of one resident who went to the store and brought lighters back to the facility and provided them to other residents. Interview with LPN #8, on 06/06/14 at 2:45 PM, revealed some smoking residents had lighters in their possession. The LPN revealed Resident #15 and Unsampled Resident E were allowed to leave the facility, and sometimes purchased lighters and passed them out to the other residents. Interview with LPN #1, on 06/06/14 at 2:48 PM and 4:03 PM, revealed the facility had a smoking policy, but it was not enforced. The LPN stated resident lighters were supposed to be kept at the nurse's station, but residents carried their own lighters. The LPN also revealed they had two (2) residents, Resident #15 and Unsampled Resident E, who went out and of the facility, bought lighters and sometimes passed them out to other residents. She stated it was unsafe and was a safety issue for all the residents. Interview with the RNS, on 06/05/14 at 4:49 PM, revealed supervised smokers were supposed to be monitored by staff and unsupervised residents were allowed to have their own lighters. The RNS further stated the residents were supposed to store the lighters in drawers, but she did not know if staff were supposed to check to see if the lighters were secured. Further interview with the RNS revealed it was a safety issue if the lighters were not secured because they had residents who roamed from room to room and it was possible lighters may be taken by a resident who was not safe to possess one. In addition, the RNS stated it was not safe to have lighters in rooms with oxygen because of the fire risk. Interview with the Activities Director, on 06/06/14 at 4:23 PM, revealed she was aware residents had lighters and there was one resident who brought lighters and passed them out to other residents. She stated it was not safe and was a potential hazard. Interview with the DON, on 06/06/14 at 3:00 PM and on 06/19/14 at 11:53 AM, regarding residents evaluated as needing smoking supervision (Residents #14 and #19), revealed staff were responsible to know which residents required supervision while smoking, and those residents should not have been smoking without supervision, as it was a potential hazard. The DON stated she did not think incident reports were completed when smoking infractions occurred, such as when residents smoked in non-designated locations, but should have been reported per policy. In addition, the DON revealed because staff did not report unsecured ignition sources and smoking infractions as safety issues, no related interventions had been implemented. Interview with the Administrator, on 06/06/14 at 11:20 AM, revealed the facility had a smoking policy which included an evaluation of residents to determine if they were safe to smoke unsupervised, and lighters and matches were supposed to be kept at the nurse's station. However, the Administrator acknowledged she was aware some residents had lighters. She stated the facility's policy noted residents could keep "smoking materials" if approved by the interdisciplinary team. The Administrator interpreted that to include lighters. She stated it was not safe for Resident #19, evaluated as needing supervision while smoking, to have a lighter. Continued interview revealed the facility tried to ensure lighters stored in resident rooms were secured by providing lock boxes to some, but not all, unsupervised smokers and staff were to ensure their lighters were secured when they made rounds. The Administrator further revealed oxygen was a hazard around smoking, but only one resident had a portable oxygen tank and staff were supposed to monitor him/her. Further interview revealed the facility's processes failed because lighters could be hidden, staff were not inspecting resident rooms specifically to find lighters, and they had not scheduled staff to supervise the resident smoking areas. The Administrator stated she was not aware any residents had reported lighters missing or stolen, but expected to be notified of such occurrences. Further interview revealed she did not know of any facility that was able to state with 100% certainty their residents did not have lighters, but she felt the facility could improve its process related to smoking supervision and the securement of lighting materials. Interview with the Medical Director (MD), on 06/19/14 at 1:18 PM, revealed he never saw residents with lighters or matches and the subject was never identified as a safety issue. He acknowledged it could pose a risk if some residents obtained lighters or matches. The MD stated he was unaware of any episodes of a resident smoking in their room or passing lighters to other residents. The MD further stated any type of spark around oxygen was a fire hazard. 14. Interview with the Administrator, on 6/19/14 10:12 AM, revealed the facility did not have a policy related to environmental safety. The Administrator stated it was her expectation for staff to notify their supervisor whenever they identified any environmental safety hazard. Observation during the initial facility tour, beginning 06/03/14 at 12:45 PM, revealed no bolt covers over screws used to anchor the toilets to the floor were observed. Observations during a subsequent extensive tour of the facility including all bathrooms, beginning on 06/05/14 at 9:30 AM, revealed no bolt covers were present on toilets throughout the facility. Interview with the Maintenance Director, on 06/04/14 2:30 PM, revealed he received a work order from the staff when something needed to be repaired or replaced. He stated he did not normally check the bathrooms, unless a work order was completed and turned in to him. He further stated he utilized a monthly checklist for upkeep of the facility. Continued interview revealed it could be dangerous for a residents if they hit their foot on an exposed screw. The Maintenance Director stated he planned to revise his monthly checklist to include monitoring the bathrooms and toilets for environmental concerns. Interview with the Administrator, on 06/04/14 at 2:40 PM, revealed the Maintenance Department was responsible for checking all areas; however, she relied on staff to fill out work orders when hazards were identified. Further interview with the Administrator revealed she did not think the toilet bolts were a problem for residents since they were on the back of the commode. Observation with the Administrator, on 06/05/14 at 10:00 AM, revealed the exposed toilet screws in room E-8 were on the side of the commode, not on the back. The Administrator acknowledged the screws were a hazard to the residents and caused a potential for harm if left uncovered. She stated the monthly maintenance checklist should have included checking the bathrooms for hazards. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 06/13/14 that alleged removal of the Immediate Jeopardy (IJ) effective 06/10/14. Review of the AOC revealed the facility implemented the following: 1) On 06/06/14, a search of resident rooms and general facility areas for ignition sources was completed by the Administrator, Assistant Director of Nursing (ADON), MDS Specialists, Social Services Directors, Staff Development Coordinator, Health Information Management Coordinator, Director of Dietary, Business Office Manager, Director of Housekeeping, Maintenance Supervisor, and Activities Director. All igniting materials found were removed from the resident rooms or persons on 06/06/14, were labeled with the resident's name and/or room number and were secured. 2) On 06/06/14, as igniting materials were identified in resident rooms, the staff member who found the materials provided one to one (1:1) education to the resident involved related to facility policy which prohibited residents from possessing ignition sources. In addition, the Administrator and the Social Services Director conducted group meetings with all smokers related to enforcement of the facility's smoking policy. Furthermore, Special Resident Council Meetings were held for all residents to discuss the smoking policy. 3) On 06/06/14, the DON reviewed the smoking assessments (Safe Smoking Evaluations) for the sixteen (16) residents who smoked (this number included one (1) resident who was out of the facility), and ten (10) evaluations were updated by the DON. 4) On 06/08/14, the DON e

Based on observation, interview and review of the facility's policies, it was determined the facility's Administration failed provide oversight to ensure there was an effective system to ensure policies and procedures were implemented to ensure residents were free from accident hazards, to provide supervision/monitoring to each resident to prevent avoidable accidents, and to ensure services were provided in accordance with each resident's written plan of care. The facility's Administration was aware residents in the facility were keeping lighters in their possession which was not the facility's policy. Observation, interview, and record review revealed twelve (12) of the fifteen (15) residents who smoked had lighters in their possession, including two (2) assessed by the facility as needing supervision when smoking. Six (6) of the twelve (12) residents who kept lighters had either oxygen or a roommate on oxygen. In addition, observation and record review revealed two (2) smokers assessed by the facility as needing supervision were smoking unsupervised. Further, eleven (11) of twelve (12) residents with lighters in their possession were care planned to have his/her lighter kept at the nurse's station and two (2) residents didn't have the appropriate level of staff supervision, based on the smoking assessment, as care planned. (Refer to F-282 and F-323) 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, to provide supervision/monitoring to each resident to prevent avoidable accidents, and to ensure services were provided in accordance with each resident's written plan of care was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 06/06/14 and was determined to exist on 06/03/14. The facility was notified of the Immediate Jeopardy on 06/06/14. An acceptable Credible Allegation of Compliance (AOC) was received on 06/14/14 alleging removal of the Immediate Jeopardy on 06/10/14. The Immediate Jeopardy was verified to be removed on 06/10/14 as alleged, prior to exiting the facility on 06/19/14, with remaining non-compliance at 42 CFR 483.75 F-490 Administration with a Scope and Severity (S/S) of a "E" while the facility develops and implements the Plan of Correction (POC) and, the facility's Quality Assurance monitors the effectiveness of systemic changes to maintain an environment as free of hazards as possible and, to ensure adequate supervision to prevent accidents. The findings include: Review of the facility's policy: "Smoking Policy", effective date 07/01/08, revealed the purpose of the policy was to maximize the facility's ability to provide a safe environment for all residents. The policy procedures revealed a "Safe Smoking Assessment" was completed upon admission, quarterly, and with any change of condition to determine if a resident required supervision when smoking. Further review of policy procedures revealed no fire igniting materials (matches/lighters) were to be in any resident's possession at any time and supervised smokers were to only smoke with staff present. Review of the policy's essential points revealed the rooms of smokers were to be inspected routinely for smoking materials and when oxygen was initiated and all such materials were to be removed from the room. Review of the facility's policy: "Comprehensive Plan of Care", effective date 08/01/12, revealed the purpose of the policy was to provide an individualized plan of care for each resident by means of a written document. The policy stated all staff personnel who provided care were knowledgeable of the resident's plan of care. Further review of the policy revealed it was the responsibility of each interdisciplinary team member involved in the resident's care to provide input into the implementation of the resident's plan of care. Observation, interview, and record review revealed the following smokers: Sampled Residents: #2, #10, #14, #16, #18, and #19 and Unsampled Residents: A, B, C, D, E, F all had lighters in their possession. Two (2) residents: Resident #14 and Resident #19 were assessed by the facility to be supervised when smoking and were observed smoking without supervision. Observation, interview, and record review revealed Sampled Residents: #2, #14, #15, #16, #18, and #19 and Unsampled Residents: B, C, D, E and F had care plan interventions to keep lighters at the nurses station not followed by facility staff. In addition, two (2) residents: Resident #14 and #19 did not have the appropriate level of staff supervision, based on the smoking assessment, as care planned. Interview with facility staff revealed they were aware residents were keeping lighters in their possession and most were not aware of the facility's policy and procedures related to smoking materials. Interview with the Director of Nursing (DON), on 06/06/14 at 3:00 PM and on 06/19/14 at 11:53 PM, regarding residents evaluated as needing smoking supervision (Residents #14 and #19), revealed staff was responsible to know which residents needed smoking supervision and they should have been supervised while smoking, it was a potential hazard. The DON stated because staff did not report unsecured ignition sources and smoking infractions as safety issues, no related interventions were implemented. The DON revealed it was her expectation staff was aware of the resident's plan of care and related interventions when they provided care, and supervised residents. The DON further revealed staff should have followed the residents' smoking care plan. Interview, on 06/06/14 at 11:20 AM, with the Administrator revealed the facility had a smoking policy which included evaluating residents to determine safe/unsafe smokers and lighters/matches were supposed to be kept at the nurse's station. However, the Administrator revealed she was aware some residents had lighters, but indicated she didn't interpret the policy to mean "all" residents were not allowed to keep lighters because the policy noted residents, if approved by the interdisciplinary team, were able to keep smoking materials. However, she stated it wasn't safe for Residents #19 and #14 (supposed to be supervised when smoking) to have a lighter. Further interview revealed the facility's processes failed because lighters could be hidden, staff was not inspecting resident rooms specifically to find lighters as per the policy, and they had not scheduled staff to check resident smoking areas. The Administrator revealed if residents' care plans included storing lighters at the nurse's station, staff was to follow the care plan. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 06/14/14 which alleged removal of the Immediate Jeopardy (IJ) effective 06/10/14. Review of the AOC revealed the facility had implemented the following: 1) On 06/06/14 the Administrator reviewed the Smoking Policy for the facility and determined no revisions were needed. 2) On 06/06/14 the Regional Vice President and the Regional Director of Clinical Operations educated the Administrator on Administrative duties and on the Smoking Policy with special focus on the key elements of the policy. 3) The Administrator initiated, implemented and continues to review, on a daily basis, the implementation of the AOC for F-282 and F-323 to abate the jeopardy. This included reviewing and utilizing the daily resident room checks and smoking area monitoring log. It included daily review of nursing supervisor reports, daily physical rounds in the facility, daily review of the 24 hour nursing communication sheet, and daily review of incident reports. The State Survey Agency validated the implementation of the facility's AOC as follows: 1) Interview with the Administrator, on 06/19/14 at 12:20 PM revealed she, along with the Regional Vice President and the Regional Director of Clinical Operations reviewed the Smoking Policy on 06/06/14 2) Interview with the Regional Director of Clinical Operations, on 06/19/14 at 1:30 PM, revealed she along with the Regional Vice President educated the Administrator on the key elements of the Smoking Policy including prohibiting residents from having lighters in their possession, the need for 100% enforcement of the policy, and ensuring residents assessed as requiring supervision were supervised. Interview with the Administrator 06/19/14 at 1:20 PM revealed she had been educated regarding duties and responsibility by the Regional Vice President on 06/06/14 after the survey team had left. 3) Further interview, on 06/19/14 at 1:20 PM, with the Regional Director of Clinical Operations and the Administrator revealed they have been making rounds/monitoring, checking smoking areas, and gathering/reviewing data collected such as audits, reports, rounds, nursing communication sheets, incident reports, quizzes and logs, related to the AOC to ensure implementation and compliance seven days a week. Further interview revealed when not in facility, the Administrator called each day and spoke to staff and managers.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to have an effective system to ensure residents were free from abuse. The facility failed to ensure staff reported allegations of abuse immediately and failed to ensure residents were protected from further abuse by allowing the alleged perpetrator to continue to provide resident care. On 10/04/12, three (3) eyewitnesses (State Registered Nursing Assistants #3, #4, and #6) observed State Registered Nursing Assistant (SRNA) #2 cursing at five (5) separate residents (Residents #2, #3, #4, #5, and #6) and being physically abusive to two (2) of the five (5) residents (Residents #2 and #3) from approximately 7:30 AM until after the evening meal on 10/04/12. SRNA #4 witnessed SRNA #2 curse at Resident #5 and observed her to jerk on the resident. SRNA #6 witnessed SRNA #2 curse at Resident #2 and observed her to open handedly slap the resident on the shoulder leaving a red mark. SRNA #3 witnessed SRNA #2 curse at Residents #3, #4, and #6, and observed SRNA #2 smack Resident #3's hand "a few times". However the three (3)eyewitnesses failed to notify a Supervisor of the abusive incidents immediately as per facility policy. This allowed SRNA #2 to continue providing care to other residents on 10/04/12 until her shift ended at 9:59 PM, which was approximately fourteen and a half (14 1/2) hours after the first alleged abusive incident. The facility's failure to ensure residents were free from abuse placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 10/19/12 and was determined to exist on 10/04/12. The facility was notified of the Immediate Jeopardy on 10/19/12. Substandard Quality of Care (SQC) was identified at 42 CFR 483.13, Resident Behavior and Facility Practice. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/23/12 with the facility alleging removal of the Immediate Jeopardy on 10/21/12. The State Survey Agency verified removal of Immediate Jeopardy as alleged in the acceptable AoC on 10/21/12 prior to exiting the facility on 10/26/12. However, non-compliance continued to exist at 42 CFR 483.13 Resident Behavior and Facility Practice, with a S/S of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure residents remain free from abuse. The findings include: Review of the facility's policy titled, "Abuse, Neglect, and Exploitation", dated 07/01/09 revealed when abuse, mistreatment, exploitation, or neglect was suspected, the person who suspected abuse would immediately notify the Supervisor. The Supervisor would notify the Administrator or Director of Nursing (DON), who would complete an incident report immediately and initiate an investigation. Review of the written statement obtained by the DON on 10/05/12, from SRNA #10 revealed three (3) aides had come to her about SRNA #2 being abusive. She documented SRNA #4 reported to her that SRNA #2 had jerked on Resident #5 and the resident had told her (SRNA #2) to stop jerking him/her. SRNA #2 "cussed" him/her and yelled at him/her for not helping them. SRNA #10 documented SRNA #2 called Resident #5 a "[***] ing dumbass". Continued review of the statement revealed SRNA #3 had told her that while working the evening shift on 10/04/12, SRNA #2 had cursed at Resident #4 and was too rough with the resident. Then when they (SRNA #3 and SRNA #2) went to Resident #6's room SRNA #2 was screaming and cursing at the resident so loudly that SRNA #7/Certified Medication Technician (CMT) came in and told her to stop. SRNA #10 documented SRNA #3 told her that when Resident #3 was being combative, SRNA #2 had "smacked" Resident #3 on the arm and "cussed and yelled" at him/her. Further review of the written statement revealed SRNA #10 documented at 11:30 PM on 10/04/12, SRNA #6 had telephoned her and told her SRNA #2 had been abusive and he wanted to know what to do about it. SRNA #10 documented SRNA #6 and SRNA #2 had been caring for Resident #2 when he/she became combative. SRNA #10 documented SRNA #2 cursed at Resident #2 and "smacked" him/her "so hard it left a red mark...". SRNA #10 documented she had informed all three (3) of the SRNAs who had witnessed the abusive incidents to "come forward" and tell. 1. Review of Resident #5's medical record revealed the facility readmitted the resident on 09/20/12 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #5 to have Brief Interview of Mental Status (BIMS) score of nine (9) out of fifteen (15), which indicated the resident was moderately impaired with daily decision making. Further review of the MDS revealed the facility assessed the resident as requiring extensive assistance with his/her Activities of Daily Living (ADLs). Review of the written statement obtained by the DON on 10/05/12 during the abuse investigation, SRNA #4 revealed on 10/04/12 at approximately 7:30 AM, she observed SRNA #2 jerking Resident #5's brief up, and heard Resident #5 tell SRNA #2 to stop jerking him/her around. SRNA #4 heard SRNA #2 raise her voice and state to Resident #5 that he/she had to "[***] ing help you dumbass". SRNA #4 continued to observe SRNA #2 jerking on Resident #5. Resident #5 told SRNA #2 she was being rough. When SRNA #2 and SRNA #4 assisted Resident #5 into the wheelchair, SRNA #2 was screaming, "[***] ing help, (Resident #5) goddamn". SRNA #4 placed Resident #5's hat on the resident's head and SRNA #2 jerked it off his/her head and "slung it across the room". SRNA #2 told the resident he/she needed to start helping or they were going to have broken backs and end up in bed like him/her; and they weren't going to get him/her out of bed anymore. SRNA #2 stated to the resident, "...this is [***] ing ridiculous" and left the room. Interview, on 10/17/12 at 11:20 AM, with SRNA #4 revealed she confirmed the incidents of abuse in her written statement. She stated she did not report the abusive incident to the nurses as there was a "bunch of people" at the nurse's station and she didn't want to say anything in front of everybody. SRNA #4 stated she usually worked the 10:00 PM to 6:00 AM shift; however, on 10/04/12 had stayed over to help out on day shift for a while. The SRNA stated she told SRNA #10 about the abusive incident when she got off work the morning of 10/04/12. She stated SRNA #10 informed her she needed to report the abuse. According to the SRNA, she was going to call the DON about the abusive incidents; however, did not have her telephone number. SRNA #4 stated when she went to work at 10:00 PM on 10/04/12, she reported the abusive incidents to Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #1. The SRNA stated when she told LPN #3, the LPN informed her she should report the abusive incident to RN #1. SRNA #4 stated she informed RN #1 and he informed her she should report the abuse as soon as possible to the DON, however did not give her a number to do so. She stated she and SRNA #10 reported the abuse at approximately 9:30 AM on 10/05/12 to the Assistant Director of Nursing (ADON). In an additional interview, on 10/17/12 at 6:47 PM, SRNA #4 stated Resident #5 "got really quiet" when SRNA #2 started cursing and jerking at him/her. SRNA #4 stated this was "not like" Resident #5, as he/she usually was talking and "cutting up" with staff. The SRNA stated she thought Resident #5 "felt bad" after SRNA #2 told him/her that he/she was hurting the SRNA's backs. Interview, on 10/18/12 at 2:51 PM, with LPN #3 revealed she worked the 10:00 PM to 6:00 AM shift on 10/04/12. The LPN stated on her shift on 10/04/12, SRNA #4 had reported SRNA #2 had been rough and cursed at a resident earlier that day. She stated she believed what SRNA #4 reported was that SRNA #2 had told a resident to "sit his ass down in the [***] ing wheelchair". LPN #3 stated she immediately told SRNA #4 she had to report the abuse to RN #1 as he was their RN Supervisor. She stated she told SRNA #4 to tell RN #1 "everything she needed to about it" (abusive incident), then RN #1 would decide if he needed to call the DON. Interview, on 10/17/12, with RN #1 revealed he worked the 10:00 PM to 6:00 AM shift. The RN stated SRNA #4 did report the abusive incidents, she had witnessed earlier in the day on 10/04/12, to him. He stated SRNA #4 told him that SRNA #2 had used profanity towards a resident and she was concerned. He stated he referred her to the DON as he didn't want it to be "gossip" and she wasn't making an official report to him. The RN stated even though SRNA #4 reported the abuse to him, he felt it would be better for her (SRNA #4) to report it as she was the person who had observed it. RN #1 stated he thought the time frame for reporting abuse was twenty-four (24) hours. Interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed on the morning of 10/04/12 she had picked SRNA #4 up from work after she had stayed over to help out day shift. SRNA #10 stated SRNA #4 was "upset" when she picked her up and told SRNA #10 she didn't know what to do. The SRNA stated SRNA #4 told her that she had witnessed SRNA #2 "jerking" Resident #5 up, and cursing and screaming at him/her. She stated SRNA #4 told her she felt like she needed to talk to the DON or the ADON as she thought she was supposed to report "anything" to them. According to SRNA #10, she told SRNA #4 she needed to report the abuse, however she stated she had always been told they had twenty-four (24) hours to report it if it wasn't something that was "going to be harm". SRNA #10 stated she and SRNA #4 were together all day on 10/04/12 until 4:30 PM, and to her knowledge SRNA #4 had called the DON or ADON on 10/04/12 to report the alleged abuse. SRNA #10 stated she had told SRNA #4 that she would go with SRNA #4 to tell the DON/ADON on 10/05/12. She stated she "honestly" thought SRNA #4 had twenty-four (24) hours to report the abuse. 2. Review of Resident #2's medical record revealed the facility readmitted the resident on 01/27/12 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #2 to have short term and long term memory problems and was moderately impaired with daily decision making. Further review of the MDS revealed the facility assessed the resident as requiring extensive assistance with his/her Activities of Daily Living (ADLs). Review of the written statement obtained by the DON on 10/05/12, for SRNA #6, revealed at approximately 10:45 AM on 10/04/12, he observed and heard SRNA #2 tell Resident #2 "God xxx xx" and open handedly slapped the resident on the upper left shoulder. SRNA #6 indicated he stopped assisting SRNA #2 as he was speechless. Interview, on 10/16/12 at 7:20 PM, with SRNA #6 revealed somewhere between 10:00 AM and 12:00 PM, while he and SRNA #2 were assisting Resident #2 with dressing after his/her bath, Resident #2 started "fighting". He stated SRNA #2 said "god damn it" to the resident and then open handedly slapped Resident #2 on his/her left shoulder. According to SRNA #6, the area where SRNA #2 slapped Resident #2 "immediately" started turning red. The SRNA stated he had never witnessed anything like that and didn't know what to do. He stated he "thought if she did this in front of me then what would she do in a room by herself". When asked what the facility policy was on reporting, SRNA #6 indicated he did not remember "the exact timing on reporting". He stated he did tell SRNA #10 that night about the abuse he witnessed. Further interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed at approximately 11:30 PM on 10/04/12, SRNA #6 had telephoned her and reported he had witnessed SRNA #2 being verbally and physically abusive to Resident #2 earlier that day. SRNA #10 stated SRNA #6 informed her that SRNA #2 had jerked on Resident #2 and he/she had started "swatting" at her and SRNA #2 had open handedly slapped the resident. She stated SRNA #6 felt that he needed to report the abuse, however didn't know what to do. SRNA #10 stated she told SRNA #6 he had to report the abuse and she would go with him to report it the next morning. 3. Review of Resident #4's medical record revealed the facility readmitted the resident on 10/10/09 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #4 to have a BIMS score of eleven (11) out of fifteen (15), which indicated the resident was moderately impaired with daily decision making. Further review of the MDS revealed the facility assessed the resident as requiring limited to extensive assistance with his/her Activities of Daily Living (ADLs). Review of the written statement obtained by the DON on 10/05/12, for SRNA #3 revealed after dinner on 10/04/12, SRNA #3 heard SRNA #2 being verbally abusive to Resident #4, stating "come on (Resident #4), this is the same[***] different day, hush", and was "being excessively rough". The resident was "screaming" telling her to stop being so rough, however SRNA #2 continued. Interview, on 10/12/12 at 4:45 PM, with SRNA #3 revealed on 10/04/12 after dinner she was assisting Resident #4's roommate while SRNA #2 was assisting Resident #4. She stated she heard Resident #4 tell SRNA #2 she was hurting him/her, and pulling on him/her too hard. SRNA #3 stated she asked SRNA #2 if she needed help and SRNA #2 stated "no" she could do the resident herself. SRNA #3 stated she heard SRNA #2 tell Resident #4, "come on (Resident #4), it's the same[***]just a different day". Continued interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed her daughter, SRNA #3 had come home on 10/04/12 at approximately 10:20 PM and told her that she had worked with SRNA #2 that day. She stated SRNA #3 told her SRNA #2 cursed and screamed Resident #4, and the resident had told SRNA #3 that she was hurting him/her. Interview, on 10/18/12 at 3:20 PM, with Unsampled Resident A, Resident #4's roommate, revealed he/she had observed SRNA #2 being "mean" to Resident #4. He/She stated SRNA #2 "yells" at Resident #4 and was "rough with him/her". 4. Review of Resident #6's medical record revealed the facility readmitted the resident on 06/18/09 with [DIAGNOSES REDACTED]. Review of the Annual MDS, dated [DATE], revealed the facility assessed Resident #6 to have short term and long term memory problems and was moderately impaired with daily decision making. Further review of the MDS revealed the facility assessed the resident as requiring extensive assistance with his/her Activities of Daily Living (ADLs). Continued review of SRNA #3's written statement, obtained on 10/05/12 by the DON, revealed SRNA #3 and SRNA #2 left Resident #4's room and went to Resident #6's room to assist him/her to bed. SRNA #3 heard SRNA #2 scream at Resident #6 and observed SRNA #2 "roughly" tug on his/her shirt, calling him/her an "old son of a [***] " and telling the resident she was going to "knock" him/her "the [***] out". SRNA #3 intervened and assisted SRNA #2 who kept screaming and cussing. SRNA #7, who was also a Certified Medication Tech (CMT), came in the room and heard SRNA #2 screaming and made the comment she needed to quiet down and SRNA #2 left the room. The SRNA #7/CMT stated to SRNA #3 that SRNA #2 must have been mad at her husband or something; that she was in a bad mood. Interview, on 10/12/12 at 4:45 PM, with SRNA #3 revealed on 10/04/12, SRNA #2 told Resident #6 she was "going to knock him/her the [***] out" and called the resident an old "son of a [***] ". She stated SRNA #2 had been "rough" with Resident #6 before and after cursing at the resident. Interview, on 10/16/12 at 7:04 PM, with SRNA #7/CMT revealed on 10/04/12 at "probably past 8:00 PM" SRNA #2 was in Resident #6's room cussing "but not at the resident". He stated SRNA #2 went out into the hallway still cussing and he stated he told her she needed to go take a break. He stated he did not report this to anyone because SRNA #2 was not cussing directly at a resident. Continued interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed SRNA #3 told her while they, SRNA #3 and SRNA #2, were in Resident #6's room, she had heard SRNA #2 tell the resident she, SRNA #2, was going to "knock him the [***] out". According to SRNA #10, SRNA #3 stated to her that she had observed SRNA #2 jerk Resident #6's clothes off. SRNA #10 stated SRNA #3 informed her that the CMT had heard SRNA #2 as she was being so loud and came into the room and told SRNA #2 she needed to go take a break. She stated SRNA #3 told her that SRNA #2 threw her hands up and stated "[***] it I can't deal with this old son of a [***] ". 5. Review of Resident #3's medical record revealed the facility readmitted the resident on 10/12/02 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #3 to have short term and long term memory problems and was severely impaired with daily decision making. Further review of the MDS revealed the facility assessed the resident as requiring extensive assistance to total dependence with his/her Activities of Daily Living (ADLs). Further review of the written statement, obtained by the DON on 10/05/12 for SRNA #3, revealed as she was assisting SRNA #2 with Resident #3, the resident became combative as they were changing him/her and started smacking SRNA #2 on the arms. SRNA #3 observed SRNA #2 smack Resident #3's hands "a few times". SRNA #3 informed SRNA #2 she didn't have to smack Resident #3; to just have the resident hold onto the side rail. SRNA #3 asked Resident #3 to hold onto the side rail which the resident did and Resident #3 was no longer combative. SRNA #2 continued to be rough and used profanity towards Resident #3. SRNA #3 documented she knew she needed to report the abusive incidents she had witnessed SRNA #2 perform. Review of the written statement revealed SRNA #3 informed her mother (SRNA #10) of the abuse and she advised SRNA #3 to go to the DON. However, SRNA #3 documented on 10/05/12 she had to go to class and her mother (SRNA #10) reported the abuse to the DON for her. Interview, on 10/12/12 at 4:30 PM, with SRNA #3 revealed on 10/04/12 SRNA #2 was being "rough" with Resident #3. She stated Resident #3 exhibited "behavior problems" at times and was also resistant to care. SRNA #3 stated Resident #3 "smacked" SRNA #2 on the hands and SRNA #2 "smacked" the resident back on the hand. Additional interview, on 10/18/12 at 9:00 PM, with SRNA #3 revealed Resident #3 would cooperate with care if he/she was approached calmly. She stated when the resident hit SRNA #2, SRNA #2 hit Resident #3 back. SRNA #3 stated she informed SRNA #2 to stop, she didn't have to do him/her that way. She stated she, SRNA #3 calmed the resident down and then he/she was cooperative with care. SRNA #3 stated she thought she had twenty-four (24) hours to report the abuse because of a poster she had seen in the breakroom. She stated she did not report the abuse to the DON as she wasn't in the facility at the time, and she didn't have a telephone number at which to phone her, (DON). Continued interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed SRNA #3 and SRNA #2 went to Resident #3's room and the resident started hitting at SRNA #2. She stated SRNA #3 told her SRNA #2 yelled at the resident and took Resident #3's hand and "open handed slapped it several times". SRNA #10 stated SRNA #3 did not tell anyone, and when asked why, she said that SRNA #2 and the nurse were friends. She stated SRNA #3 felt she needed to report the abuse to the DON or ADON, but there was no way to do so as she didn't have their telephone numbers. Further interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed at approximately 9:30 AM on 10/05/12, the ADON was notified of the abusive incidents by SRNA #2 that were witnessed by SRNA's #3, #4, and #6. She stated the ADON asked all involved to write out their statements, which they did. SRNA #10 stated the DON told them they should have reported the abuse sooner, however SRNA #10 stated they were still within the twenty-four (24) hour time frame at that time. Review of the written statement obtained on 10/05/12 by the DON from SRNA #2 revealed SRNA #2 denied being verbally or physically abusive to the five (5) residents involved. Interview, on 10/14/12 at 12:20 PM, with SRNA #2 revealed she denied being physically or verbally abusive towards any resident. Review of the facility's time keeping records revealed on 10/04/12, SRNA #2 clocked in for work at 5:59 AM and clocked out at 9:59 PM. Interview, on 10/15/12 at 10:20 AM, with the DON revealed the posting in the staff break room indicated there was twenty-four (24) hours in which to report abuse. However, she stated she had made it clear that any sign of abuse was to be reported immediately to the Nurse in charge or the Supervisor. The DON stated she did not know why the posting was in the break room. She stated she could see where staff misunderstood the posting; however, that was not what they were taught. Additional interview, on 10/19/12 at 6:58 PM, with the DON revealed the nurses (LPNs and RNs) were the Supervisors for SRNAs. She indicated in her interviews with staff they didn't always feel comfortable reporting to the nurse, so she had posted her phone number, the Assistant Director of Nursing's (ADON) phone number, and the Administrator's phone number in the break room. The DON stated she was first made aware of the abusive incident allegations on 10/05/12 at approximately 9:30 AM to 10:00 AM. Per interview, she had identified a pattern with residents involved in the abusive incidents, and that most of residents could not voice concerns or issues. She stated she immediately had the nurses perform skin assessments on the residents and immediately suspended SRNA #2. She stated she did not know where the posting related to twenty-four (24) hour reporting had come from. Interview, on 10/19/12 at 7:27 PM, with the Administrator revealed the posting which indicated a time of twenty-four (24) hours to report abuse had come from "Corporate", and it's use was to walk staff through how to report abuse themselves. He stated the facility's expectation was for abuse to be reported "as soon as practicable, immediately as defined by the federal regulations" and staff should not wait twenty-four (24) hours. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/23/12 that alleged removal of the Immediate Jeopardy (IJ) on 10/21/12, based on the following: 1. All residents in the facility underwent skin assessments, starting 10/05/12, by Licensed Nurses. 2. All interviewable residents were interviewed regarding if they had experienced any form of mistreatment in the facility by the DON, ADON, Staff Development Nurse and Social Services Director. Responsible parties were notified of the abuse allegations starting on 10/05/12. 3. All facility staff received education on the facility Abuse Protocols on 10/19/12 and 10/20/12, by the DON, ADON and Staff Development Nurse. The education was all inclusive of the facility's abuse policies, with special emphasis on reporting immediately any suspected abuse. Immediately was clarified (as soon as you see it or suspect it and resident safety had been secured). 4. Additional education was provided to the Administrator, by the Continuous Quality director for Kentucky, related to the Resident Advocacy Protocols which included the correct abuse policy. 5. During staff interviews, conducted by the DON and ADON, it was identified that the Elder Abuse federally required posting in the employee break room stated that immediate reporting was required but identified the time frame as two (2) to twenty-four (24) hours. The posting was removed from the employee break room and placed in an alternate area, by the time clock on 10/19/12. This posting was identified as a possible root cause of timely reporting. All staff was educated on 10/19/12 and 10/20/12, by the DON, ADON and Staff Development Nurse, on the clear expectation of immediate reporting and immediate was clarified (as soon as you see it or suspect it and resident safety had been secured). New hires would be provided the education by the Staff development Nurse during orientation. 6. The Activities Director, Administrator and Social Services Director held a Resident Council Meeting on 10/22/12 to determine if residents felt safe. The Administrator, Social Services Director, or Activity Director will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe and that residents are permitted and encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family members or visitors. Any concerns will be forwarded to the Administrator or DON. 7. Results of the Resident Council Meetings will be discussed weekly in the facility Focus Interdisciplinary Team (IDT) meetings. The IDT meets every Thursday and is a sub-committee of the facility's Continuous Quality Improvement (CQI) Committee. Results of the IDT meetings will be forwarded to the CQI meeting the second Wednesday of every month. 8. The Administrator, DON, ADON, or Staff Development Coordinator will conduct a total of fifteen (15) staff interviews per week for eight (8) weeks regarding the abuse policy. The interviews are to be conducted on all shifts and in all departments. 9. Additional education was provided to the Administrator and DON regarding their duties and responsibilities for effective administering of the facility's Abuse Policies on 10/19/12 by the Continuous Quality Director for Kentucky. 10. Cell phone numbers of the Administrator, DON, and ADON were posted at each nurse's station on 10/06/12 and at the time clock on 10/07/12. On 10/26/12, the State Agency verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AoC, effective 10/21/12, based on the following: Interview, on 10/26/12 at 3:15 PM, with the DON revealed all facility residents had received a skin assessment after the abuse allegations were made. Record review of four (4) resident's records (Residents #9, #10, #11, and #12) revealed skin assessments had been performed. Interview, on 10/26/12 at 3:15 PM, with the Director of Nursing (DON) revealed all interviewable residents in the facility had been interviewed on 10/20/12 related to how staff treated them, if they felt safe, and if they felt comfortable reporting issues. Interview, on 10/25/12 at 2:40 PM with Resident #8, at 2:45 PM, with Unsampled Resident A at 2:55 PM, and with Resident #7 at 3:08 PM, revealed they had been interviewed by facility staff recently related to how they were treated, if they felt safe, and if they were comfortable reporting issues. Interview, on 10/18/12 at 11:25 AM, with an unsampled resident, and on 10/19/12 at varying times with eight (8) unsampled residents revealed no complaints of abuse or mistreatment by facility staff. Interview, on 10/18/12 at 6:25 PM, with Resident #6's responsible party revealed she had been informed of the abuse allegations. Interview, on 10/18/12 at 6:40 PM, with Resident #4's responsible party revealed she had been informed of the abuse allegations. Interview, on 10/18/12 at 6:58 PM, with Resident #3's responsible party revealed she had been informed of the abuse allegations. Review of the inservice records, dated 10/19/12 and 10/20/12 revealed all levels of facility staff, including Dietary, Housekeeping, and Laundry staff, received additional education on the facility's abuse policies with "immediate" being clarified. Interview, on 10/25/12 at 4:33 PM with Housekeeper #1; at 4:33 PM with SRNA #1; at 4:50 PM with LPN #6; at 4:56 PM with LPN #2; at 6:14 PM with SRNA #12, who all worked the 2:00 PM to 10:00 PM shift; and at 6:22 PM with SRNA #10 (who worked the 10:00 PM to 6:00 AM shift), revealed they had all received additional education on abuse which included clarification of "immediate". Interview, on 10/26/12 at 9:10 AM with Housekeeper #3; at 9:20 AM with LPN #5; at 9:20 AM with Housekeeper 2; at 9:27 AM with Dietary Aide #1; at 9:30 AM with Housekeeper #4; at 9:34 AM with Dietary Aide #2; at 9:40 AM with LPN #7; at 9:45 AM with Housekeeper #5; at 9:52 AM with SRNA #13; at 10:00 AM with Laundry Personnel #1; at 10:05 AM with Cook #1; at 10:10 AM with SRNA #14; at 10:25 AM with SRNA #15; at 10:50 AM with SRNA #16; at 11:03 AM with Valet #1; at 11:08 AM with SRNA #17 (who usually worked the 2:00 PM to 10:00 PM shift); at 11:10 AM with SRNA #23; at 11:20 AM with SRNA #18; at 11:25 AM with SRNA #19 and #24; at 11:33 AM with SRNA #20; at 11:35 AM with SRNA #22; at 11:45 AM with SRNA #21; at 12:55 PM with RN #1 (who worked the 10:00 PM to 6:00 AM shift); and at 2:20 PM with SRNA #25 (who worked the 10:00 PM to 6:00 AM shift), revealed they had all received additional education on abuse which included clarification of "immediate". Observation, on 10/26/12 at 2:15 PM, of the area surrounding the time clock revealed the federally required posting related to Elder Abuse was present. Additionally, the Administrator's, DON's, and ADON's phone numbers were also present in this area. Interview, on 10/26/12 at 3:55 PM, with the Administrator revealed he had received education related to the correct abuse policy, and on administering the facility as per the AoC. The Administrator stated a Resident Council Meeting had been held that week, and would be held every week for four (4) weeks as per the AoC. He stated results of the Resident Council Meetings would be discussed weekly in the facility Focus Interdisciplinary Team (IDT) meetings. Results of the IDT meetings would be forwarded to the CQI meeting the second Wednesday of every month. In addition, he stated staff interviews were being conducted to ensure staff were knowledgeable of the Abuse policy. The Administrator stated a total of fifteen (15) staff interviews per week for eight (8) weeks regarding the abuse policy would be conducted. Review of the Staff Abuse Questionnaire forms dated, 10/24/12, revealed the Administrator had conducted seven (7) staff interviews. Review of the Staff Abuse Questionnaire forms, dated 10/25/12, revealed the Administrator had conducted two (2) staff interviews. Interview, on 10/26/12 at 3:15 PM, with the Director of Nursing (DON) revealed she had been re-educated on the facility abuse policy and the administering of the facility by the Continuous Quality Improvement Director for Kentucky. She stated the Abuse policy given to the surveyors previously had been the incorrect one. She stated education was provided for all facility staff; and some staff interviews related to the education had been performed already that week. According to the DON, the staff interviews were to take place for eight (8) weeks, and if staff did not answer correctly they would receive a one on one education to ensure they were knowledgeable. In addition, she stated a Resident Council Meeting had been held earlier in the week, and if there were nursing issues she or the Assistant Director of Nursing (ADON) would be notified so they could decide what needed to be done. Interview, on 10/26/12 at 4:20 PM, with the Continuous Quality Improvement Director for Kentucky revealed she had re-educated the Administrator and DON on the correct facility Abuse policy. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

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 policy and procedures were implemented to protect residents from abuse for five (5) of twelve (12) sampled residents (Residents #2, #3, #4, #5, and #6). Three (3) different State Registered Nursing Assistants (SRNAs) witnessed SRNA #2 be physically and verbally abusive to five (5) residents on 10/04/12 starting at approximately 7:30 AM and continuing until after the evening meal. Two licensed staff, Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #1 were also aware of the alleged abuse. However, the staff failed to notify a Supervisor of the witnessed abuse immediately as per facility policy. This failure allowed SRNA #2 to continue providing care to other residents until her shift ended at 9:59 PM on 10/04/12. The alleged abuse was not reported to Administrative staff until approximately 9:30 AM on 10/05/12. (Refer to F-223) The facility's failure to implement policy and procedures to protect residents from abuse placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 10/19/12 and was determined to exist on 10/04/12. The facility was notified of the Immediate Jeopardy on 10/19/12. Substandard Quality of Care (SQC) was identified at 42 CFR 483.13, Resident Behavior and Facility Practice. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/23/12 with the facility alleging removal of the Immediate Jeopardy on 10/21/12. The State Survey Agency verified removal of Immediate Jeopardy as alleged in the acceptable AoC on 10/21/12 prior to exiting the facility on 10/26/12. However, non-compliance continued to exist at 42 CFR 483.13 Resident Behavior and Facility Practice, with a scope and severity of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure policy and procedures were implemented to protect residents from abuse. The findings include: Review of the facility's policy titled, "Abuse, Neglect, and Exploitation", dated 07/01/09 revealed when abuse, mistreatment, exploitation, or neglect is suspected, the person who suspects abuse will immediately notify the Supervisor. The Supervisor was to notify the Administrator or Director of Nursing (DON), who would complete an incident report immediately and initiate an investigation. Interview, on 10/17/12 at 11:20 AM, with SRNA #4 and review of her written statement revealed on 10/04/12 at approximately 7:30 AM, she observed SRNA #2 jerking Resident #5's brief up and heard SRNA #2 raise her voice and tell Resident #5 to "[***] ing help you dumbass". SRNA #2 continue to jerk on Resident #5 and the resident told SRNA #2 she was being rough. When SRNA #2 assisted Resident #5 into his/her wheelchair, SRNA #2 screamed, "[***] ing help, (Resident #5) goddamn". SRNA #4 placed Resident #5's hat on his/her head and SRNA #2 jerked it off his/her head and "slung it across the room". SRNA #2 stated to the resident, "...this is [***] ing ridiculous" and left the room. Per interview, SRNA #4 did not immediately report the abuse. She reported the witnessed abuse to LPN #3 and RN #1 when she returned to work on 10/04/12 at 10:00 PM. However, SRNA #4 failed to immediately report the alleged abuse immediately to a Supervisor as per the facility policy. Interview, on 10/17/12, with RN #1 revealed he worked the 10:00 PM to 6:00 AM shift. The RN stated SRNA #4 did report the abusive incidents, she had witnessed earlier in the day on 10/04/12, to him. However, SRNA #4 was not making an official report to him, so he referred her to the DON. The RN stated even though SRNA #4 reported the abuse to him, he felt it would be better for her (SRNA #4) to report it as she was the person who had observed it. RN #1 stated he thought the time frame for reporting abuse was twenty-four (24) hours. According to the RN, he had had no extensive teaching on the facility's abuse policy since being hired in November, 2011. There was no documented evidence RN #1 notified the Administrator or DON as per facility policy so an incident report could be completed and an investigation initiated. Interview, on 10/16/12 at 7:20 PM, with SRNA #6 revealed somewhere between 10:00 AM and 12:00 PM on 10/04/12, during Resident #2's bath, the resident started "fighting". SRNA #6 stated SRNA #2 said "god damn it" to the resident and then open handedly slapped Resident #2 on his/her left shoulder. According to SRNA #6, the area where SRNA #2 slapped Resident #2 "immediately" started turning red. SRNA #6 stated he didn't know what to do as he had never witnessed anything like that. The SRNA stated he "thought if she did this in front of me then what would she do in a room by herself". Per interview, SRNA #6 indicated he did not remember "the exact timing on reporting". He stated he did tell SRNA #10 that night about the abuse he witnessed. However, there was no documented evidence SRNA #6 immediately notified a Supervisor as per facility policy after witnessing the abuse by SRNA #2. Interview, on 10/12/12 at 4:30 PM, with SRNA #3 revealed on 10/04/12 SRNA #2 was being "rough" with Resident #3. She stated Resident #3 exhibited "behavior problems" at times and was also resistant to care. SRNA #3 stated Resident #3 "smacked" SRNA #2 on the hands and SRNA #2 "smacked" the resident back on the hand. In an interview, on 10/12/12 at 4:45 PM, with SRNA #3 she stated on 10/04/12 she was assisting Resident #4's roommate and SRNA #2 was assisting Resident #4 she heard Resident #4 tell SRNA #2 she was hurting him/her, and pulling on him/her too hard. SRNA #3 stated she asked SRNA #2 if she needed help and SRNA #2 stated "no" she could do the resident herself. SRNA #3 stated she heard SRNA #2 tell Resident #4, "come on (Resident #4), it's the same[***]just a different day". Continued interview with SRNA #3 revealed on 10/04/12, SRNA #2 told Resident #6 she was "going to knock" him/her "the [***] out" and called the resident an old "son of a [***] ". She stated SRNA #2 had been "rough" with Resident #6 before and cursed at the resident. Additional interview, on 10/18/12 at 9:00 PM, with SRNA #3 revealed she thought she had twenty-four (24) hours to report the abuse because of a poster she had seen in the breakroom. She stated she did not report the abuse to the DON as she wasn't in the facility at the time, and she didn't have a telephone number at which to phone her, (DON). There was no documented evidence SRNA #3 immediately notified a Supervisor of the abusive incidents she witnessed SRNA #2 do on 10/04/12 after the evening meal. Interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed on the morning of 10/04/12 SRNA #4 was "upset" and told SRNA #10 she had witnessed SRNA #2 "jerking" Resident #5 up, and cursing and screaming at him/her. According to SRNA #10, she told SRNA #4 she needed to report the abuse, however she stated she had always been told they had twenty-four (24) hours to report it if it wasn't something that was "going to be harm". She stated she "honestly" thought SRNA #4 had twenty-four (24) hours to report the abuse. Continued interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed on 10/04/12 at approximately 10:20 PM, SRNA #3 told her SRNA #2 cursed and screamed at Resident #4; jerked Resident #6's clothes off; and, yelled at Resident #3 and took the resident's hand and "open handed slapped it several times". She stated SRNA #3 felt she needed to report the abuse to the DON or ADON, but there was no way to do so as she didn't have their telephone numbers. Further interview, on 10/18/12 at 7:47 AM, with SRNA #10 revealed at approximately 11:30 PM on 10/04/12, SRNA #6 telephoned her and reported he had witnessed SRNA #2 being verbally and physically abusive to Resident #2 earlier that day. She stated SRNA #6 felt that he needed to report the abuse, however didn't know what to do. SRNA #10 stated she told SRNA #6 he had to report the abuse and she would go with him to report it the next morning. SRNA #10 stated at approximately 9:30 AM on 10/05/12, the Assistant Director of Nursing (ADON) was notified of the abusive incidents by SRNA #2 that were witnessed by SRNA's #3, #4, and #6. She stated the ADON asked all involved to write out their statements, which they did. SRNA #10 stated the DON told them they should have reported the abuse sooner, however SRNA #10 stated they were still within the twenty-four (24) hour time frame at that time. Review of the facility's final "Resident Abuse & Neglect Investigation Report Form", completed by the Director of Nursing (DON) revealed the incident date as 10/04/12, and the date the incident was reported as 10/05/12. Review revealed SRNA #10 reported the incidents and there were three (3) witnesses listed to the incidents (State Registered Nursing Assistants #3, #4, and #6). Under the summary of the witness interviews it was documented all three (3) witnesses reported witnessing Stated Registered Nursing Assistant (SRNA) #2 curse at residents, and SRNA #3 and #6 reported witnessing SRNA #2 "open handedly smacking" two residents. Under the summary of investigator's findings section of the Form the DON documented "Residents unable to confirm or deny events. Assessments revealed-no marks, bruises, pain or evidence that physical abuse occurred. All events witnessed by one other staff member only." The DON documented under the "did the findings indicate that abuse occurred", "no". She documented "unable to substantiate due to lack of evidence". Further review of the Form revealed the DON signed and dated the Form on 10/08/12. Interview, on 10/19/12 at 6:58 PM, with the DON revealed LPNs and sometimes RNs were the direct Supervisor for SRNAs. The DON stated she did not know where the posting related to twenty-four (24) hour reporting had come from. The DON stated she was first made aware of the abusive incident allegations on 10/05/12 at approximately 9:30 AM to 10:00 AM. She stated she immediately had the nurses perform skin assessments on the residents and immediately suspended SRNA #2. Per interview, she had unsubstantiated the abuse allegations on her final investigation report, because there was no evidence of abuse, no mark on the residents SRNA#2 had allegedly struck, and no resident could say they were verbally abused. However, she had identified a pattern with the residents involved, stating "most of them can't voice concerns or issues". Further interview, on 10/26/12 at 3:15 PM, with the DON revealed she was unaware SRNA #4 had reported the abuse she had witnessed to RN #1 on the 10:00 PM to 6:00 AM on 10/04/12, until 10/24/12 when the State Survey Agency reported their findings to the facility. Interview, on 10/19/12 at 7:27 PM, with the Administrator revealed the posting which indicated a time of twenty-four (24) hours to report abuse had come from "Corporate", and it's use was to walk staff through how to report abuse themselves. Per interview, the Administrator stated staff should report as soon as practicable, "the sooner the better". He stated the DON or ADON usually took the lead in investigations and he had only briefly reviewed the final investigation report of the alleged abuse due to being out of town. He further stated three (3) eyewitnesses to abuse would be enough evidence to substantiate the allegation. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/23/12 that alleged removal of the Immediate Jeopardy (IJ) on 10/21/12, based on the following: 1. All residents in the facility underwent skin assessments, starting 10/05/12, by Licensed Nurses. 2. All interviewable residents were interviewed regarding if they had experienced any form of mistreatment in the facility by the DON, ADON, Staff Development Nurse and Social Services Director. Responsible parties were notified of the abuse allegations starting on 10/05/12. 3. All facility staff received education on the facility Abuse Protocols on 10/19/12 and 10/20/12, by the DON, ADON and Staff Development Nurse. The education was all inclusive of the facility's abuse policies, with special emphasis on reporting immediately any suspected abuse. Immediately was clarified (as soon as you see it or suspect it and resident safety had been secured). 4. Additional education was provided to the Administrator, by the Continuous Quality director for Kentucky, related to the Resident Advocacy Protocols which included the correct abuse policy. 5. During staff interviews, conducted by the DON and ADON, it was identified that the Elder Abuse federally required posting in the employee break room stated that immediate reporting was required but identified the time frame as two (2) to twenty-four (24) hours. The posting was removed from the employee break room and placed in an alternate area, by the time clock on 10/19/12. This posting was identified as a possible root cause of timely reporting. All staff was educated on 10/19/12 and 10/20/12, by the DON, ADON and Staff Development Nurse, on the clear expectation of immediate reporting and immediate was clarified (as soon as you see it or suspect it and resident safety had been secured). New hires would be provided the education by the Staff development Nurse during orientation. 6. The Activities Director, Administrator and Social Services Director held a Resident Council Meeting on 10/22/12 to determine if residents felt safe. The Administrator, Social Services Director, or Activity Director will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe and that residents are permitted and encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family members or visitors. Any concerns will be forwarded to the Administrator or DON. 7. Results of the Resident Council Meetings will be discussed weekly in the facility Focus Interdisciplinary Team (IDT) meetings. The IDT meets every Thursday and is a sub-committee of the facility's Continuous Quality Improvement (CQI) Committee. Results of the IDT meetings will be forwarded to the CQI meeting the second Wednesday of every month. 8. The Administrator, DON, ADON, or Staff Development Coordinator will conduct a total of fifteen (15) staff interviews per week for eight (8) weeks regarding the abuse policy. The interviews are to be conducted on all shifts and in all departments. 9. Additional education was provided to the Administrator and DON regarding their duties and responsibilities for effective administering of the facility's Abuse Policies on 10/19/12 by the Continuous Quality Director for Kentucky. 10. Cell phone numbers of the Administrator, DON, and ADON were posted at each nurse's station on 10/06/12 and at the time clock on 10/07/12. On 10/26/12, the State Agency verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AoC, effective 10/21/12, based on the following: Interview, on 10/26/12 at 3:15 PM, with the DON revealed all facility residents had received a skin assessment after the abuse allegations were made. Record review of four (4) resident's records (Residents #9, #10, #11, and #12) revealed skin assessments had been performed. Interview, on 10/26/12 at 3:15 PM, with the Director of Nursing (DON) revealed all interviewable residents in the facility had been interviewed on 10/20/12 related to how staff treated them, if they felt safe, and if they felt comfortable reporting issues. Interview, on 10/25/12 at 2:40 PM with Resident #8, at 2:45 PM, with Unsampled Resident A at 2:55 PM, and with Resident #7 at 3:08 PM, revealed they had been interviewed by facility staff recently related to how they were treated, if they felt safe, and if they were comfortable reporting issues. Interview, on 10/18/12 at 11:25 AM, with an unsampled resident, and on 10/19/12 at varying times with eight (8) unsampled residents revealed no complaints of abuse or mistreatment by facility staff. Interview, on 10/18/12 at 6:25 PM, with Resident #6's responsible party revealed she had been informed of the abuse allegations. Interview, on 10/18/12 at 6:40 PM, with Resident #4's responsible party revealed she had been informed of the abuse allegations. Interview, on 10/18/12 at 6:58 PM, with Resident #3's responsible party revealed she had been informed of the abuse allegations. Review of the inservice records, dated 10/19/12 and 10/20/12 revealed all levels of facility staff, including Dietary, Housekeeping, and Laundry staff, received additional education on the facility's abuse policies with "immediate" being clarified. Interview, on 10/25/12 at 4:33 PM with Housekeeper #1; at 4:33 PM with SRNA #1; at 4:50 PM with LPN #6; at 4:56 PM with LPN #2; at 6:14 PM with SRNA #12, who all worked the 2:00 PM to 10:00 PM shift; and at 6:22 PM with SRNA #10 (who worked the 10:00 PM to 6:00 AM shift), revealed they had all received additional education on abuse which included clarification of "immediate". Interview, on 10/26/12 at 9:10 AM with Housekeeper #3; at 9:20 AM with LPN #5; at 9:20 AM with Housekeeper 2; at 9:27 AM with Dietary Aide #1; at 9:30 AM with Housekeeper #4; at 9:34 AM with Dietary Aide #2; at 9:40 AM with LPN #7; at 9:45 AM with Housekeeper #5; at 9:52 AM with SRNA #13; at 10:00 AM with Laundry Personnel #1; at 10:05 AM with Cook #1; at 10:10 AM with SRNA #14; at 10:25 AM with SRNA #15; at 10:50 AM with SRNA #16; at 11:03 AM with Valet #1; at 11:08 AM with SRNA #17 (who usually worked the 2:00 PM to 10:00 PM shift); at 11:10 AM with SRNA #23; at 11:20 AM with SRNA #18; at 11:25 AM with SRNA #19 and #24; at 11:33 AM with SRNA #20; at 11:35 AM with SRNA #22; at 11:45 AM with SRNA #21; at 12:55 PM with RN #1 (who worked the 10:00 PM to 6:00 AM shift); and at 2:20 PM with SRNA #25 (who worked the 10:00 PM to 6:00 AM shift), revealed they had all received additional education on abuse which included clarification of "immediate". Observation, on 10/26/12 at 2:15 PM, of the area surrounding the time clock revealed the federally required posting related to Elder Abuse was present. Additionally, the Administrator's, DON's, and ADON's phone numbers were also present in this area. Interview, on 10/26/12 at 3:55 PM, with the Administrator revealed he had received education related to the correct abuse policy, and on administering the facility as per the AoC. The Administrator stated a Resident Council Meeting had been held that week, and would be held every week for four (4) weeks as per the AoC. He stated results of the Resident Council Meetings would be discussed weekly in the facility Focus Interdisciplinary Team (IDT) meetings. Results of the IDT meetings would be forwarded to the CQI meeting the second Wednesday of every month. In addition, he stated staff interviews were being conducted to ensure staff were knowledgeable of the Abuse policy. The Administrator stated a total of fifteen (15) staff interviews per week for eight (8) weeks regarding the abuse policy would be conducted. Review of the Staff Abuse Questionnaire forms dated, 10/24/12, revealed the Administrator had conducted seven (7) staff interviews. Review of the Staff Abuse Questionnaire forms, dated 10/25/12, revealed the Administrator had conducted two (2) staff interviews. Interview, on 10/26/12 at 3:15 PM, with the Director of Nursing (DON) revealed she had been re-educated on the facility abuse policy and the administering of the facility by the Continuous Quality Improvement Director for Kentucky. She stated the Abuse policy given to the surveyors previously had been the incorrect one. She stated education was provided for all facility staff; and some staff interviews related to the education had been performed already that week. According to the DON, the staff interviews were to take place for eight (8) weeks, and if staff did not answer correctly they would receive a one on one education to ensure they were knowledgeable. In addition, she stated a Resident Council Meeting had been held earlier in the week, and if there were nursing issues she or the Assistant Director of Nursing (ADON) would be notified so they could decide what needed to be done. Interview, on 10/26/12 at 4:20 PM, with the Continuous Quality Improvement Director for Kentucky revealed she had re-educated the Administrator and DON on the correct facility Abuse policy. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

Based on interview, record review, and facility policy review, it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility's Administration failed to have an effective system to ensure policy and procedures were implemented to protect residents from abuse; failed to ensure staff was knowledgeable of the facility's policy and procedures related to abuse; and, failed to ensure information made available to staff regarding abuse was accurate. On 10/04/12 three staff witnessed State Registered Nursing Assistant (SRNA) #2 verbally and/or physically abuse five residents (Residents #2, #3, #4, #5, and #6). Staff failed to report the abuse immediately and the alleged perpetrator continued to provide resident care for approximately fourteen and a half hours after the first alleged abusive incident was witnessed. (Refer to F-223 and F-226) The facility's failure to be administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 10/19/12 and was determined to exist on 10/04/12. The facility was notified of the Immediate Jeopardy on 10/19/12. Substandard Quality of Care (SQC) was identified at 42 CFR 483.13, Resident Behavior and Facility Practice. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/23/12 with the facility alleging removal of the Immediate Jeopardy on 10/21/12. The State Survey Agency verified the removal of Immediate Jeopardy as alleged in the acceptable AoC on 10/21/12 prior to exiting the facility on 10/26/12. However, non-compliance continued to exist at 42 CFR 483.13 Resident Behavior and Facility Practice, with a scope and severity of a "D", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure residents remain free from abuse. The findings include: Review of the facility's policy "Abuse, Neglect, and Exploitation", dated 07/01/09 revealed when abuse, mistreatment, exploitation, or neglect is suspected, the person who suspects abuse will immediately notify the Supervisor. On 10/04/12, from approximately 7:30 AM to after the evening meal, three (3) eyewitnesses, SRNAs #3, #4, and #6 observed SRNA #2 cursing at five (5) residents (Residents #2, #3, #4, #5, and #6) and being physically abusive to two (2) of these residents (Residents #2 and #3). SRNA #2 was observed by SRNA #4 to jerk on Resident #5 and to curse at the resident. SRNA #2 was observed by SRNA #6 to open handedly slap Resident #2 on the shoulder leaving a red mark and to curse at the resident. SRNA #2 was observed by SRNA #3 to smack Resident #3's hand "a few times" and to curse at Residents' #3, #4, and #6. However, SRNA #3, #4, and #6 failed to immediately notify a Supervisor of the abusive incidents as per the facility policy. Interviews with staff revealed they were under the impression they had 24 hours to report an abuse allegation. This allowed SRNA #2 to continue providing care to other residents until her shift ended at 9:59 PM on 10/04/12. Review of the facility's final "Resident Abuse & Neglect Investigation Report Form", completed by the Director of Nursing (DON) revealed "Residents unable to confirm or deny events. Assessments revealed-no marks, bruises, pain or evidence that physical abuse occurred. All events witnessed by one other staff member only." Per the investigation, the DON was unable to substantiate the abuse occurred due to lack of evidence. Interview, on 10/19/12 at 6:58 PM, with the DON revealed she had unsubstantiated the abuse allegations on her final investigation report, because there was no evidence the abuse had occurred. Per the DON, there was no mark on the residents SRNA#2 had struck, and no resident could say they were verbally abused. However, the DON stated the residents who were allegedly abused were not able to "voice concerns or issues". The DON stated she was unaware SRNA #4 had reported the abuse she had witnessed to RN #1 until 10/24/12 when the State Survey Agency reported their findings to the facility. She stated she was very disturbed when she learned of this information and RN #1 had been terminated. Interview, on 10/15/12 at 10:20 AM, with the DON revealed there was a posting in the staff break room that indicated there was twenty-four (24) hours in which to report abuse. However, she stated she had made it clear that any sign of abuse was to be reported immediately to the Nurse in charge or the Supervisor. The DON stated she did not know why the posting was in the break room. She stated she could see where staff misunderstood the posting, however that was not what they were taught. Interview, on 10/19/12 at 7:27 PM, with the Administrator revealed the posting which indicated a time of twenty-four (24) hours to report abuse had come from "Corporate", and it's use was to walk staff through how to report abuse themselves. He stated staff was told to report as soon as it (abuse) occurs and there was never anytime the facility would want them to delay reporting it. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/23/12 that alleged removal of the Immediate Jeopardy (IJ) on 10/21/12, based on the following: 1. All residents in the facility underwent skin assessments, starting 10/05/12, by Licensed Nurses. 2. All interviewable residents were interviewed regarding if they had experienced any form of mistreatment in the facility by the DON, ADON, Staff Development Nurse and Social Services Director. Responsible parties were notified of the abuse allegations starting on 10/05/12. 3. All facility staff received education on the facility Abuse Protocols on 10/19/12 and 10/20/12, by the DON, ADON and Staff Development Nurse. The education was all inclusive of the facility's abuse policies, with special emphasis on reporting immediately any suspected abuse. Immediately was clarified (as soon as you see it or suspect it and resident safety had been secured). 4. Additional education was provided to the Administrator, by the Continuous Quality director for Kentucky, related to the Resident Advocacy Protocols which included the correct abuse policy. 5. During staff interviews, conducted by the DON and ADON, it was identified that the Elder Abuse federally required posting in the employee break room stated that immediate reporting was required but identified the time frame as two (2) to twenty-four (24) hours. The posting was removed from the employee break room and placed in an alternate area, by the time clock on 10/19/12. This posting was identified as a possible root cause of timely reporting. All staff was educated on 10/19/12 and 10/20/12, by the DON, ADON and Staff Development Nurse, on the clear expectation of immediate reporting and immediate was clarified (as soon as you see it or suspect it and resident safety had been secured). New hires would be provided the education by the Staff development Nurse during orientation. 6. The Activities Director, Administrator and Social Services Director held a Resident Council Meeting on 10/22/12 to determine if residents felt safe. The Administrator, Social Services Director, or Activity Director will conduct Resident Council Meetings on a weekly basis for four (4) weeks to determine that residents feel safe and that residents are permitted and encouraged to express and report any concerns regarding behaviors displayed by staff, residents, family members or visitors. Any concerns will be forwarded to the Administrator or DON. 7. Results of the Resident Council Meetings will be discussed weekly in the facility Focus Interdisciplinary Team (IDT) meetings. The IDT meets every Thursday and is a sub-committee of the facility's Continuous Quality Improvement (CQI) Committee. Results of the IDT meetings will be forwarded to the CQI meeting the second Wednesday of every month. 8. The Administrator, DON, ADON, or Staff Development Coordinator will conduct a total of fifteen (15) staff interviews per week for eight (8) weeks regarding the abuse policy. The interviews are to be conducted on all shifts and in all departments. 9. Additional education was provided to the Administrator and DON regarding their duties and responsibilities for effective administering of the facility's Abuse Policies on 10/19/12 by the Continuous Quality Director for Kentucky. 10. Cell phone numbers of the Administrator, DON, and ADON were posted at each nurse's station on 10/06/12 and at the time clock on 10/07/12. On 10/26/12, the State Agency verified the immediacy of the IJ was removed and the facility implemented corrective actions as alleged in the AoC, effective 10/21/12, based on the following: Interview, on 10/26/12 at 3:15 PM, with the DON revealed all facility residents had received a skin assessment after the abuse allegations were made. Record review of four (4) resident's records (Residents #9, #10, #11, and #12) revealed skin assessments had been performed. Interview, on 10/26/12 at 3:15 PM, with the Director of Nursing (DON) revealed all interviewable residents in the facility had been interviewed on 10/20/12 related to how staff treated them, if they felt safe, and if they felt comfortable reporting issues. Interview, on 10/25/12 at 2:40 PM with Resident #8, at 2:45 PM, with Unsampled Resident A at 2:55 PM, and with Resident #7 at 3:08 PM, revealed they had been interviewed by facility staff recently related to how they were treated, if they felt safe, and if they were comfortable reporting issues. Interview, on 10/18/12 at 11:25 AM, with an unsampled resident, and on 10/19/12 at varying times with eight (8) unsampled residents revealed no complaints of abuse or mistreatment by facility staff. Interview, on 10/18/12 at 6:25 PM, with Resident #6's responsible party revealed she had been informed of the abuse allegations. Interview, on 10/18/12 at 6:40 PM, with Resident #4's responsible party revealed she had been informed of the abuse allegations. Interview, on 10/18/12 at 6:58 PM, with Resident #3's responsible party revealed she had been informed of the abuse allegations. Review of the inservice records, dated 10/19/12 and 10/20/12 revealed all levels of facility staff, including Dietary, Housekeeping, and Laundry staff, received additional education on the facility's abuse policies with "immediate" being clarified. Interview, on 10/25/12 at 4:33 PM with Housekeeper #1; at 4:33 PM with SRNA #1; at 4:50 PM with LPN #6; at 4:56 PM with LPN #2; at 6:14 PM with SRNA #12, who all worked the 2:00 PM to 10:00 PM shift; and at 6:22 PM with SRNA #10 (who worked the 10:00 PM to 6:00 AM shift), revealed they had all received additional education on abuse which included clarification of "immediate". Interview, on 10/26/12 at 9:10 AM with Housekeeper #3; at 9:20 AM with LPN #5; at 9:20 AM with Housekeeper 2; at 9:27 AM with Dietary Aide #1; at 9:30 AM with Housekeeper #4; at 9:34 AM with Dietary Aide #2; at 9:40 AM with LPN #7; at 9:45 AM with Housekeeper #5; at 9:52 AM with SRNA #13; at 10:00 AM with Laundry Personnel #1; at 10:05 AM with Cook #1; at 10:10 AM with SRNA #14; at 10:25 AM with SRNA #15; at 10:50 AM with SRNA #16; at 11:03 AM with Valet #1; at 11:08 AM with SRNA #17 (who usually worked the 2:00 PM to 10:00 PM shift); at 11:10 AM with SRNA #23; at 11:20 AM with SRNA #18; at 11:25 AM with SRNA #19 and #24; at 11:33 AM with SRNA #20; at 11:35 AM with SRNA #22; at 11:45 AM with SRNA #21; at 12:55 PM with RN #1 (who worked the 10:00 PM to 6:00 AM shift); and at 2:20 PM with SRNA #25 (who worked the 10:00 PM to 6:00 AM shift), revealed they had all received additional education on abuse which included clarification of "immediate". Observation, on 10/26/12 at 2:15 PM, of the area surrounding the time clock revealed the federally required posting related to Elder Abuse was present. Additionally, the Administrator's, DON's, and ADON's phone numbers were also present in this area. Interview, on 10/26/12 at 3:55 PM, with the Administrator revealed he had received education related to the correct abuse policy, and on administering the facility as per the AoC. The Administrator stated a Resident Council Meeting had been held that week, and would be held every week for four (4) weeks as per the AoC. He stated results of the Resident Council Meetings would be discussed weekly in the facility Focus Interdisciplinary Team (IDT) meetings. Results of the IDT meetings would be forwarded to the CQI meeting the second Wednesday of every month. In addition, he stated staff interviews were being conducted to ensure staff were knowledgeable of the Abuse policy. The Administrator stated a total of fifteen (15) staff interviews per week for eight (8) weeks regarding the abuse policy would be conducted. Review of the Staff Abuse Questionnaire forms dated, 10/24/12, revealed the Administrator had conducted seven (7) staff interviews. Review of the Staff Abuse Questionnaire forms, dated 10/25/12, revealed the Administrator had conducted two (2) staff interviews. Interview, on 10/26/12 at 3:15 PM, with the Director of Nursing (DON) revealed she had been re-educated on the facility abuse policy and the administering of the facility by the Continuous Quality Improvement Director for Kentucky. She stated the Abuse policy given to the surveyors previously had been the incorrect one. She stated education was provided for all facility staff; and some staff interviews related to the education had been performed already that week. According to the DON, the staff interviews were to take place for eight (8) weeks, and if staff did not answer correctly they would receive a one on one education to ensure they were knowledgeable. In addition, she stated a Resident Council Meeting had been held earlier in the week, and if there were nursing issues she or the Assistant Director of Nursing (ADON) would be notified so they could decide what needed to be done. Interview, on 10/26/12 at 4:20 PM, with the Continuous Quality Improvement Director for Kentucky revealed she had re-educated the Administrator and DON on the correct facility Abuse policy. The facility remained out of compliance at a lower Scope and Severity of a "D", an isolated deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).