Every finding on record at Andalusia Manor

Based on observations, interviews, the facility's document Associate In-Service Record, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, the facility failed to ensure food stored in the walk-in cooler was completely covered, sealed, labeled properly, and outdated food was discarded on [DATE] during the initial kitchen observation. This had the potential to affect 82 of 82 residents receiving food from the kitchen. Findings include: A facility in-service record dated [DATE], documented: . Topic: Labeling, Dating, and Expired Foods Procedures Refresh For Already Refrigerated Foods: All Refrigerated Food, assumed as Ready To Eat, must contain the following: Item Description ., In On Date ., Opened On Date ., and Use By Date . Once Deli Meats are opened, they have a 7 (seven) day life span. The day it was opened is counted as Day 1. Food Storage and Retention Guide . Ready-to-Eat/Prepared Foods- Food in a form that is edible without additional preparation to achieve food safety. (Example: leftovers, deli salads, cut produce) Up to 7 (seven) days Day 1 is the day of preparation . The 2022 U.S. FDA Food Code included the following: ,d+[DATE].11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (2) Where it is not exposed to splash, dust, or other contamination . On [DATE] at 1:31 PM, during the initial kitchen tour an observation was made of food stored in the walk-in cooler to include: a small aluminum pan of cranberry sauce partially covered with foil had no label, half an unsealed bag of broccoli had no label, and a round aluminum pan covered in foil was labeled, tuna fish, and was dated [DATE]. An interview was conducted with the Dietary Manager (DM) on [DATE] at 1:51 PM. The DM admitted that the cranberry sauce and broccoli was not sealed properly and was not labeled. The DM stated open items should be stored and labeled with the item description, date, and completely sealed. The DM stated, the concern of food not being labeled and covered was anything could have gotten in the food and be harmful to the residents. The DM admitted the tuna fish observed in the walk- in cooler dated [DATE] should have been discarded seven (7) days from date on label. The DM stated the concern of outdated tuna fish being stored in the walk-in cooler was it could have been served to residents and they could have become sick.

Based on observations, interview, resident record review, and review of a facility policy titled Oxygen Therapy, the facility failed to ensure Resident Identifier (RI) #33, one of one resident sampled for Respiratory Care, received oxygen (O2) at two liters per minute (2 l/m) as ordered by physician, on 01/02/2024 and 01/03/2024, two of three days of the survey. Findings include: An undated facility policy titled Oxygen Therapy documented: Policy: Oxygen is administered to residents who need it, . Oxygen is only administered with a Physician's order. RI #33 was admitted to the facility 02/13/2023 and readmitted on [DATE] and had diagnoses to include: Chronic Obstructive Pulmonary Disease. RI #33's Physician Order List documented an as needed order dated 03/26/2023 for RI #33 to receive oxygen at two liters per minute. On 01/02/2024 at 5:36 PM RI #33 was observed receiving O2 at three liters per minute. On 01/03/2024 at 9:38 AM RI #33 was observed receiving O2 at three liters per minute per nasal cannula. On 01/03/2024 at 1:56 PM RI #33 was observed receiving O2 at three liters per minute per nasal cannula. On 01/03/2024 at 1:59 PM Registered Nurse (RN) #9 was asked about RI #33 receiving oxygen. RN #9 said, RI #33 used O2 as needed and she thought it should be at 2 l/m. RN #9 said, RI #33's O2 was set at three liters per minute. RN #9 reviewed RI #33's physician orders and said, it should be at two l/m. RN #9 said, the concern for O2 not administered at the ordered liters per minute was the doctor's orders were not being followed.

Based on observation, interview, and a review of a facility policy titled,Manual Warewashing, the facility failed to ensure 10 metal pans were not wet and stacked on a shelf, ready for use. This was observed on 10/16/19, and had the potential to affect 132 of 132 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, Manual Warewashing with a revised date of 9/2017, revealed: . Procedures . 3. All serviceware and cookware will be air dried prior to storage . On 10/16/19 at 5:10 PM, the surveyor observed 10 pans stacked on a shelf wet with water. The surveyor, along with Employee Identifier (EI) #4, Certified Dietary Manager (CDM), observed the wetness of the pans. EI #4 began to remove the pans that were wet. A total of 10 pans were removed from the shelf. EI #3, Dietary Manager, was asked if the pans that were wet were supposed to be clean. EI #3 replied, yes. On 10/17/19 at 1:50 PM, an interview was conducted with EI #3. EI #3 was asked if the metal pans were ready for use. EI #3 replied, yes. EI #3 was asked, what was the potential for harm in storing wet metal pans in a manner that prevented air-drying (stacked on a shelf). EI #3 replied, bacteria control for residents.

Based on observations, interviews, record review and a review of a facility policy titled, OXYGEN THERAPY AEROSOL TREATMENT, the facility failed to ensure Resident Identifier (RI) #220's breathing treatment mask was stored in a Ziploc bag and the mask and the tubing was dated. This affected RI #220, one of two residents sampled with respiratory treatments. Findings Include: A review of a facility policy titled, OXYGEN THERAPY AEROSOL TREATMENT with no date, revealed: .7. Store nebulizer sets in plastic bag change weekly and as needed. 8. Change oxygen and nebulizer sets and bags weekly. Date when changed. RI #220 was admitted to the facility on [DATE] and re-admitted [DATE], with [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. On 10/15/19 at 3:29 PM, RI #220 was resting in bed watching TV. A nebulizer machine was on the nightstand table beside the bed. A breathing treatment mask was attached to the side of the machine. The treatment mask was not in a bag. There were no dates on the mask or the tubing. On 10/16/19 at 8:25 AM, an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). EI #2 was asked, who was the nurse for RI #220. EI #2 stated, she was. EI #2 was asked, if RI #220 received breathing treatments. EI #2 replied, yes. EI #2 was asked, what was the order. EI #2 replied, Atrovent inhaled every six hours while awake. EI #2 was asked how often were the treatment masks changed. EI #2 replied, once a week. EI #2 was asked where should the treatment mask be placed between treatments. EI #2 replied, in the plastic bag. EI #2 was asked who was responsible for replacing the mask to the proper place. EI #2 replied, any nurse who gave the breathing treatment. EI #2 was asked, what was the potential harm in the mask not being stored properly. EI #2 replied, infection control. On 10/17/19 at 1:23 PM, an interview was conducted with EI #1, Registered Nurse (RN), Infection Control Specialist. EI #1 was asked, how often were the treatment masks changed. EI #1 replied, they were changed at least weekly and on an as needed basis. EI #1 was asked where should the treatment mask be placed between treatments. EI #1 replied, they should be in the plastic bag or discarded, if for once only treatments. EI #1 was asked how often were the Ziploc bags changed. EI #1 replied, they were changed when tubing and masks were replaced on a weekly basis. EI #1 was asked who was responsible for replacing the mask to the proper place. EI #1 replied, once the treatment was done, the nurse should place the treatment mask back into the Ziploc bag. EI #1 was asked what was the potential harm in the mask not being cared for properly. EI #1 replied, infection.

Based on observations, interviews and review of facility policies titled, Food Preparation, Service Line Checklist and Manual Warewashing, the facility failed to ensure: 1. staff washed hands before putting on a new pair of gloves; 2. the temperatures of all food items on the tray line were taken; and 3. spoons, forks and trays were not wet at the tray line. This was observed on 10/10/2018 and had the potential to affect 128 of 128 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Food Preparation with a revised date of 9/2017 revealed: .Procedures 1. All staff will practice proper hand washing techniques and glove use. On 10/10/2018 at 11:09 a.m., the surveyor observed (Employee Identifier) EI #14, dietary assistant, touch the trash can lid to put her gloves in the trash can. EI #14 then did not wash her hands prior to putting on a clean pair of gloves and started washing dishes in the three compartment sink. On 10/10/2018 at 11:28 a.m., EI #14 came out of dish room and put on clean gloves. EI #14 did not wash her hands. EI #14 started stirring and taking up chicken. On 10/12/2018 at 12:38 p.m., the surveyor conducted an interview with EI #14, dietary assistant. EI #14 was asked when should staff wash their hands in the kitchen. EI #14 replied, when you walk through the kitchen door. EI #14 was asked should staff wash their hands after pulling off gloves and putting on new gloves. EI #14 replied, yes ma'am. EI #14 was asked why was it important to wash hands while in the kitchen. EI #14 replied, because of a lot of germs. EI #14 was asked what was the facility policy on washing hands in the kitchen. EI #14 replied,when you walk through the door stop at the sink, wash your hands, put a hair net on, and put gloves on. EI #14 was asked what was the potential to the resident when staff did not wash their hands properly in the kitchen. EI #14 replied, germs. EI #14 was asked did she wash her hands after coming out of the dish room and putting on a new pair of gloves. EI #14 replied, no. EI #14 was asked should she have washed her hands. EI #14 replied, yes ma'am. EI #14 was asked what did she do after putting clean gloves on. EI #14 replied, she thought she pulled the chicken up. (EI #14 was talking about the chicken in the fryer) 2) A review of a facility policy titled Food: Preparation, with a revised date of 9/2017, revealed: .Procedures .13. All foods will be held at appropriate temperature, greater than 135 .for hot holding, and less than 41 degree for cold food holding. Temperature for . foods will be recorded at time of service and monitored periodically during meal services periods A review of a document titled, Service Line Checklist with a date of 10/10, revealed there was no documented temperatures recorded to indicate the milk, baked chicken and regular mash potatoes were taken for the lunch meal. On 10/10/2018 at 10:47 a.m., EI #17, the cook, took the temperature of the mash potatoes with the cheese in it. EI #17 did not take the temperature of the second container of mash potatoes with no cheese in it. EI #17 did not take the temperature of the milk, nor the temperature of the baked chicken. EI #17 took all food temperatures on the tray line except the baked chicken, milk and regular mash potatoes. EI #17 also stuck the thermometer through the foil paper when taking the temperature of the rice. On 10/12/2018 at 12:48 p.m., the surveyor conducted an interview with EI #13, the staff who observed the cook take the food temps with the surveyor. EI #13 was asked what was the temperature of the milk, regular mash potatoes and baked chicken. EI #13 replied, she (the cook) did not take it. EI #13 was asked why no temperatures were taken. EI #13 replied, she (the cook) was supposed to take temperatures of everything on the steam table. EI #13 was asked what did the facility policy say regarding taking all food temperatures on the tray line. EI #13 replied, they were supposed to take temperatures of all food items on the tray line; meats, vegetables, starches, pureed foods, grind meats, alternates, everything, the milk, the tea, beverages and desserts. EI #13 was asked why should all food temperatures be taken on the tray line. EI #13 replied, it was important to take the temperatures of foods because of the danger zone. EI #13 said if she did not take the temperature of the foods it could be in the danger zone and the residents could get sick. EI #13 was asked who was responsible for taking food temperatures on the tray line. EI #13 replied, the cook. EI #13 was asked when should food temperatures be taken on the tray line. EI #13 replied, take it twice on the tray line, at the beginning and the middle of the tray line service. EI #13 was asked did she observe the cook stick a thermometer through the foil paper to take the temperature of the rice. EI #13 replied, yes, she did. 3) A review of a facility policy titled, Manual Warewashing with a revised date of 9/2017 revealed: .Procedures 3. All serviceware and cookware will be air dried prior to storage. 10/10/18 at 10:47 a.m., the surveyor observed two forks with water on it and two spoon with water on them. One of the forks with water on it also had a brown spot on it. In other ready to go utensil bags, about four had water in the bags. On 10/10/18 at 11:09 a.m., the surveyor observed water in three food trays and a dome. The surveyor observed the cook wiping the trays out with paper napkins. On 10/12/18 at 12:58 p.m., the surveyor conducted an interview with EI #15 dietary aide. EI #15 was asked what did she observe in utensil bags on some forks and spoons. EI #15 replied, water spots. EI #15 was asked why was the water there. EI #15 replied, the blower was on it, could have been a crunch of time to get the food on the tray line. EI #15 was asked how should utensils be allowed to dry. EI #15 replied, utensils should be placed under the air blower until they are dry. EI #15 was asked what did the facility policy say about serving wet utensil to the residents. EI #15 replied, they should not do it. EI #15 was asked why should wet utensils not be on the residents trays. EI #15 replied, it was unsanitary. EI #15 was asked did she observed wet trays on the tray line. EI #15 replied, yes.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) # 112's Significant Change Minimum Data Set (MDS) assessment, dated 9/4/18, reflected hospice. Findings Include: RI #112 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 10/11/18 at 1:48 PM a review of RI #112's (MONTH) (YEAR) Physician orders [REDACTED]. Hospice 8/29/18 . A review of RI #112's Significant Change MDS assessment, dated 9/4/18, did not indicated hospice service checked. On 10/11/18 at 2:00 PM, an interview was conducted Employee Identifier (EI) #10, Registered Nurse MDS/Care Plan Coordinator. EI #10 was asked if RI #112 was receiving hospice services. EI #10 replied, yes. EI #10 was asked when was RI #112 admitted to hospice. EI #10 replied, 8/29/18. EI #10 was asked if a Significant Change MDS was completed. EI #10 replied, yes. EI #10 was asked if hospice was coded on the 9/4/18 MDS. EI #10 replied, no. When asked why not, EI #10 replied, it was an oversight. EI #10 was asked who was responsible for coding the MDS. EI #10 replied she was. EI #10 was asked what was the risk in the MDS not being coded correctly. EI #10 replied, it did not accurately reflect the resident's condition and services.

Based on record review, interview and the review of a facility policy titled, Medication Administration, the facility failed to ensure a licensed nurse did not prepare medication for Resident Identifier (RI) # 73 and then give the medication to a Certified Nursing Assistant (CNA) to give to the resident. This practice resulted in the CNA accidentally giving the medication to another resident, RI # 175. This occurred on 4/26/18 and was cited as a result of the investigation of complaint # AL 677. Findings Include: A review of an undated facility policy titled, MEDICATION ADMINISTRATION: revealed .POLICY : Medications are administered only by licensed nursing personnel . PR[NAME]EDURES: .11. Give the resident the medication . RI #73 was admitted to facility on 3/17/17 with [DIAGNOSES REDACTED]. A review of RI #73's (MONTH) (YEAR) Physician order [REDACTED].BID (two times a day) .[MEDICATION NAME] .BID .[MEDICATION NAME] 25 milligram BID . [MEDICATION NAME] . BID . A review of RI #73's (MONTH) (YEAR) Medication Administration Record [REDACTED]. RI # 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #175's (MONTH) (YEAR) Physician order [REDACTED]. A review of RI #175's hospital Admission History and Physical revealed: .Date of Service (MONTH) 26- (YEAR) .04/26 23:46 . was accidentally given the wrong medication.According to the nursing home nurse .was given [MEDICATION NAME] an unknown dose, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 25 mg and Senna . On 10/11/18 at 2:50 PM, an interview was conducted with Employee Identifier (EI) #3, CNA. EI #3 was asked if she gave residents medications. EI #3 replied, no because she was not a nurse. EI #3 was asked if she gave medications to RI #175 on 4/26/18. EI #3 replied, she did not know there was medication in the Ensure. The surveyor asked EI #3 to please explain. EI #3 said EI #2 gave her a carton of Ensure and told her to give it to RI #73. EI #3 said she accidentally gave it to RI #175. She said when she went back in the hall another CNA asked where RI #73's Ensure was and EI #3 said she gave it to RI #175. EI #3 went and told EI #2, the nurse. EI #3 said EI #2 yelled at her and went to RI #175's room and took the carton away. EI #2 told her she gave it to the wrong resident, it had RI #73's medicine in it. EI #3 was asked if EI #2 ever asked her to give Ensure with medications to any residents. EI #3 replied, no. On 10/11/18 at 3:35 PM, an interview was conducted with EI #9 Unit Registered Nurse. EI #9 was asked if a CNA gave RI #175 medication. EI #9 explained RI #175's son came to the nurses station questioning why EI #2 took the Ensure from RI #175. EI #9 replied she spoke to EI #2, with her first denying it. She then admitted to putting RI #73's medication in the Ensure and told EI #3 to give it to RI #73. EI #3 gave it to the wrong resident, RI #175. EI #9 was asked how was the CNA responsible for the error. EI #9 replied, she should not have been placed in that situation; it was the fault of EI #2. On 10/11/18 at 3:50 PM, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked if a CNA gave a resident medication. EI #1 replied, yes that was what she was told. The CNA was EI #3 and the nurse was EI #2. EI #1 was asked if the CNA knew medication was in the Ensure carton. EI #1 replied, after the investigation and interview with the nurse and the CNA, it appeared not. EI #1 was asked to give a recap of the occurrence. She reported EI #9 called her after it was over and said EI #2 gave a carton of Ensure to EI #3 to give to RI #73. Instead EI #3 gave it to RI #175. Another CNA had asked where RI #73's Ensure was and EI #3 then went to EI #2, who accused EI #3 of giving the Ensure to the wrong resident. EI #2 went and took the carton from RI #175, then the son started asking questions. EI #2 denied medication was in carton and then admitted to it. When asked how was the CNA at fault, EI #1 said she was not because she did not know medication was in the drink. When asked what EI #2's response was, EI #1 said EI #2 said it was everyone else's fault. When asked if she asked EI #2 was that a usual practice for her, EI #1 said she tried denying it, but EI #1 assumed it was. EI #1 reported she made a comment to EI #2 that if you do wrong eventually it will catch up to you. EI #1 was asked what action was taken when it occurred. She replied, EI #2 was sent home, and an investigation was done. Then they called EI #2 in and asked her some questions and terminated her. EI #1 commented they also reported the incident to the Board of Nursing. When asked what EI #2 was counseled on, EI #1 replied, policies and procedures and expected nurse performance. EI #1 was asked what was the harm in CNAs giving medication. She replied, they are not qualified. EI #1 was asked if a licensed nurse should know that CNAs were not qualified to give medications. She replied, yes. EI #1 was asked if the Medical Doctor was notified. She replied, yes immediately when it was discovered and the MD ordered monitoring of vitals every four hours. The son requested RI #175 be sent out to the hospital for evaluation.

Based on observation, interview, record review and review of facility policy titled, DRESSING CHANGE CLEAN, the facility failed to ensure licensed staff did not: 1. place the wound cleaner bottle on Resident Identifier (RI) #176 and RI #105's bed, then return the bottle to the treatment cart; 2. use the same gloves to clean the wounds and then place the treatment and clean dressing on RI #176 and RI #105 wounds and 3. remove a pen from her uniform pocket with soiled gloves and initial and date the outer dressing, then return the pen to her pocket and remove and use again on another resident. This was observed on 10/10/18 and affected RI #176 and RI #105, two of five residents identified by the facility with pressure ulcers. Findings Include: A review of an undated facility policy titled, DRESSING CHANGE CLEAN revealed .PR[NAME]EDURE: .2. Wash Hands 3. Assemble equipment and take to bedside, cover bedside table with clean towel . 8. Wash hands 9. Open dressing supplies and cleaning solution. Assure that area is clean and free of contaminates. 10. Put on gloves . RI #176 was admitted to the facility 8/2/18. A review of RI #176's (MONTH) (YEAR) Physician order [REDACTED].WITH WOUND CLEANSER DRY APPLY SKIN PREP TO PERIWOUND. COVER WITH SANTYL OINTMENT AND APPLY [MEDICATION NAME] DAILY . On 10/10/18 at 9:20 AM, the surveyor observed Employee Identifier (EI) #4, Licensed Practical Nurse, perform wound care for RI #176. EI #4 gathered supplies to include 4x4s, wound cleaner, barrier, coverderm and a bottle of skin prep. EI #4 took the supplies into the room. EI #4 placed the wound cleaner bottle on RI #176's bed then opened the barrier and placed it on the foot of the resident bed and placed the supplies on the barrier. During the process EI #4 sprayed wound cleaner on some 4x4s and cleaned the wound. EI #4 patted the wound dry with 4x4's and then, with same soiled gloves, picked up the skin prep bottle and sprayed around the wound. EI #4 then, with the same gloves she cleaned the wound with, applied the Santyl ointment and the outer covering. EI #4 then took a pen from her uniform pocket and wrote the date and her initials on the outer dressing. With the same soiled gloves on, EI #4 cleaned up the area, placing the bottle of wound cleaner in her uniform pocket, then washed her hands after discarding the soiled items. She then returned the bottle of wound cleaner to the treatment cart. RI #105 was admitted to the facility 8/18/18. A review of RI #105's (MONTH) (YEAR) Physician order [REDACTED]. DTI RIGHT HEEL CLEANSE WITH WOUND CLEANSER DRY WITH 4 X4 APPLY SKIN PREP .DTI LEFT HEEL . 9/17/18 STAGE 2 PRESSURE INJURY LEFT BUTT[NAME]KS . On 10/10/18 at 9:45 AM, EI #4 was observed performing wound care for RI #105. EI #4 gathered supplies to include a bottle of wound cleaner, skin prep bottle, 4x4s, duoderm, trash bag and gloves. EI #4 took the supplies in RI #105's room and placed the items on the barrier on the overbed table. EI #4 removed the same pen used on RI #176 and predated the duoderm. During the process, EI #4 cleaned both heels with the wound cleaner. EI #4 then placed the wound cleaner bottle on the resident's bed. EI #4, with the same gloves, picked up the bottle of skin prep and sprayed on each heel. EI #4 then, with the same gloves removed the soiled dressing from RI #105's left buttocks. EI #4 removed her gloves and washed her hands and put on clean gloves. EI #4 cleaned the wound on the left buttock with the wound cleaner, that she had picked up off the bed. She then placed the wound cleaner bottle on the barrier. EI #4, with the same soiled gloves, patted the wound dry and then sprayed around the wound with skin prep. EI #4, with the same soiled gloves, then placed the duoderm dressing to the left buttock wound. After cleaning up the area, wearing the same soiled gloves, EI #4 returned the wound cleaner bottle to the treatment cart. On 10/10/18 at 10:00 AM, an interview was conducted with EI #4. EI #4 was asked what was the policy on changing gloves during wound care. EI #4 replied, after cleaning a wound. EI #4 was asked if she changed gloves after cleaning the heels or the buttocks before placing the clean treatment. EI #4 replied, no. EI #4 was asked what was the harm in not changing gloves after cleaning wounds. EI #4 replied, could contaminate the wounds. EI # 4 was asked where did she put the wound cleaner after spraying on the 4x4 for cleaning the heels. EI #4 replied, on the bed. EI #4 was asked where should the cleaner have been placed. EI #4 replied, on the barrier. EI #4 was asked what was the harm in placing it on the resident's bed . EI # 4 replied, contamination. EI #4 was asked if the wound cleaner was used on other residents. EI #4 replied, yes. EI #4 was asked what was the harm in returning the wound cleaner bottle to the treatment cart after having placed it on the resident's bed. EI #4 replied taking it to another resident room could cause contamination. EI #4 was asked what was the harm in using the same pen she had touched with dirty gloves on another resident to date this resident's dressing. EI #4 replied, it could have germs on the pen and then be transferred to the next resident. EI #4 was asked how could not changing gloves after cleaning the wounds and touching clean items with dirty gloves impact these resident's wounds. EI #4 replied, it maybe could alter the healing if it caused infection in them. On 10/11/18 at 5:20 PM, an interview was conducted with EI #11, Infection Control Nurse. EI #11 was asked what was the policy on when to change gloves during wound care. EI #11 replied, change gloves after removing the soiled dressing and after cleaning the wound. EI #11 was asked where should the nurse place the wound cleaner during wound care. EI #11 replied, preferably on a barrier. EI #11 was asked should the wound cleaner be placed on resident's bed then return it to the treatment cart. EI #11 replied, no. EI #11 was asked what was the harm in not changing gloves after cleaning a wound. EI #11 replied, possibly putting dirty back into a clean wound. EI #11 was asked what was the harm in placing the wound cleaner bottle on a resident's bed then return it to the treatment cart. EI #11 replied, cross contamination. EI #11 was asked when should a nurse take a pen from her uniform pocket with the same gloves she had on to clean a wound, then return the pen to her pocket and remove it, then use it for dating another resident's dressing. EI #11 replied, never. When EI #11 was asked why not, he replied, cross contamination.

Based on observations, interview, record reviews and review of facility policy titled, Tube Feedings, the facility failed to ensure Resident Identifier (RI) # 83's and RI #8's tube feeding were running at the correct rates, as ordered by the physician for the tube feeding and the hourly water flush. This was observed on 10/11/2018 and affected two of two residents sampled who were receiving tube feedings Findings Include: A review of a facility policy, no date, titled, Tube Feedings revealed .POLICY: . A physician order [REDACTED]. PR[NAME]EDURE: . Pump Feeding . 4. set prescribed rate . 1) RI #83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #83's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/20/18, revealed: RI #8 had a Brief Interview for Mental Status (BIMS) of severe impairment for daily decision making and short/long term memory deficit. Section K - Swallowing/Nutritional Status indicated RI #8 received tube feedings. A review of RI #83's (MONTH) (YEAR) Physician order [REDACTED]. On 10/11/18 at 10:12 AM, the surveyor observed the tube feeding for RI #83 infusing by the pump at a rate of 50 milliliters per hour (ml/hr) for [MEDICATION NAME] 1.5 and water flush at 30 ml/hr. On 10/11/18 at 11:05 AM, Employee Identifier (EI) #16 Licensed Practical Nurse, was interviewed. She was asked what was the current rate of tube feeding and water flushes for RI #83. EI #16 replied 50 ml/hr for [MEDICATION NAME] 1.5 and 30 ml/hr for water. EI #16 was asked to review the PO for the rates. When asked what were the rates, EI #16 said 55 ml/hrs for [MEDICATION NAME] 1.5 and 55 ml/hr for water. On 10/11/18 at 11:14 AM, the surveyor and EI #16 observed RI #83's tube feeding. EI #16 was asked were the rates on the feeding correct. She replied, no sir. 2) RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #83's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/25/18, revealed: RI #8 had a Brief Interview for Mental Status (BIMS) of severe impairment for daily decision making and short/long term memory deficit. Section K - Swallowing/Nutritional Status indicated RI #8 received tube feedings. A review of RI #8's (MONTH) (YEAR) PO reflected the order for [MEDICATION NAME] 1.5 to run at 50 cc/hr and 40 cc/hr for water. On 10/11/18 at 10:02 AM, the surveyor observed RI #8's tube feed rate at 50 ml/hr for [MEDICATION NAME] 1.5 and water flush at 35 ml/hr. On 10/11/18 at 11:05 AM, an interview was conducted with EI #16. EI #16 was asked what were the tube feeding orders for RI #8. EI #16 stated 50 ml/hr for [MEDICATION NAME] 1.5 and 40 ml/hr for water flushes. On 10/11/18 at 11:26 AM the surveyor and Employee Identifier (EI) #16 observed RI #8's tube feeding. She was asked were the rates correct. EI #16 replied the rate of the tube feeding was correct, but the water was not. EI #16 was asked who was responsible for ensuring these rates were correct on the feeding tubes. EI #16 replied, she was. EI #16 was asked what was the potential harm of not administering tube feeding and water flushes at the ordered rates. EI # 16 replied, fluid overload or underload.

Based on record review, interview and review of the facility Job Description and Performance Standards Position Title Charge Nurse and Position Title Certified Nursing Assistant (CNA),the facility failed to ensure a licensed nurse did not give prepared medication to a CNA to give to a resident, which in turn was given to the wrong resident. This deficiency is cited as a result of the investigation of complaint # AL 677, and affected two of two residents. Findings Include: A review of a facility JOB DESCRIPTION AND PERFORMANCE STANDARDS Charge Nurse revealed .1. Follow established standards of nursing practices and implement facility policies and procedures.18. Administer and document direct resident care, medications and treatments per physicians orders and accurately record all care provided. A review of an undated policy MEDICATION ADMINISTRATION revealed .POLICY: Responsibility of the nursing professional . Medications are administered only by licensed nursing personnel . A review of Job Description for Certified Nursing Assistant revealed .Purpose of this position . is to provide direct care to residents under the supervision of a licensed nurse. A review of a facility Employee Warning Notice revealed . date of incident 4/26/18 time 18:00 Description: LPN mixed resident's medication in 8 ounces of ensure liquid and gave it to a CNA to administer to the resident. CNA subsequently gave it to .the wrong resident, the resident consumed two/ thirds of the bottle . On 10/09/18 at 3:43 PM, an interview was conducted by phone with RI #175's son. The son revealed a CNA entered RI #175's room with carton of what appeared to be Ensure and said to the resident she needed to drink it. Shortly thereafter nurse EI #2 entered the room and took the carton away. He followed the nurse to the station and asked what was wrong. EI #2 replied, medications were in the drink. When he asked what medications the nurse denied medications were in the drink, He said he observed the nurse throw the carton in the trash in the medication room. He asked again, with her denying any medications were in the drink. EI #2 then admitted medications was in the drink and they were not RI #175's medications. On 10/11/18 at 2:50 PM, a interview was conducted with EI #3, CNA. EI #3 was asked how long she had been employed at the facility and how long she had been certified. EI #3 replied, almost a year, to both questions. EI #3 was asked if she provided care for, and what type for RI #175. EI #3 replied, yes mostly at night. She said she worked night shift and came in during the days to do tasks for day shift. EI #3 was asked what were CNA duties. EI #3 replied feed residents, change and toilet residents and just take care of them. EI #3 was asked if she gave residents medications. EI #3 replied, no, because she was not a nurse. EI #3 was asked if she gave medications to RI #175 on 4/26/18. EI #3 replied, she did not know there was medication in the Ensure. The surveyor asked EI #3 to please explain. EI #3 replied EI #2 gave her a carton of Ensure and told her to give it to RI #73. EI #3 said she accidentally gave it to RI #175. She said when she went back in the hall another CNA asked where RI #73's Ensure was and she told the CNA she gave it to RI #175. EI #3 said she went and told EI #2, the nurse. EI #3 said EI #2 yelled at her and went to RI #175's room and took the carton away. EI #3 was asked if EI #2 had ever asked her to give Ensure with medications to any residents. EI #3 replied, no. On 10/11/18 at 3:35 PM, EI #9 Registered Nurse was asked if she recalled RI #175. She replied yes. She was asked if a CNA gave the resident medication. EI #9 said she heard she did. EI #9 was asked to explain what occurred. She reported the son of RI #175 came to the station and said a CNA brought in an Ensure drink for his mother. He said after a while EI #2 came in and abruptly took the carton away and said it had medication in it. EI #9 said she talked to EI #2 and she denied it at first, then said she had put RI #73's medication in it and told EI #3 to give it to RI #73. EI #3 gave it to the wrong resident. EI #9 was asked how was the CNA responsible for the error. EI #9 said EI #3 should not have been placed in that situation, it was the fault of EI #2. EI #9 was asked if EI #2 was counseled. She said yes, she talked to her and told her she was responsible for giving medications. The DON told her to send EI #2 home and not to return until they called her. When asked what was done after discovering the wrong medications were given to the wrong resident, EI #9 said the Medical Doctor was notified and he ordered to monitor vital signs, if the resident's heart rate got low to send her out for a evaluation. The son stayed with the resident asking each time about the vitals and what they were. He then insisted the resident go for an evaluation at hospital. On 10/11/18 3:50 PM, an interview was conducted with EI #1, RN/ Director of Nursing. When asked if she recalled RI # 175, she said yes. EI #1 was asked if a CNA gave a resident medication. She replied, yes that was what she was told. When asked who the aide was, she said EI #3. When asked who the nurse was, she said EI #2. When asked if the CNA knew medications were in the Ensure carton, EI #1 said after the investigation and interviews with the nurse and CNA, it appeared not. EI #1 was asked to give a recap of the incident. She reported that EI #9 called her after it was over and said EI #2 gave a carton of Ensure to EI #3 to give to RI #73, and instead she gave it to RI #175. Another CNA asked where RI #73's Ensure was. EI #1 said EI #3 then went to EI #2, who yelled at EI #3 and accused her of giving the Ensure to the wrong resident, that it had medicine in it. EI #2 went and took the carton from RI #175 and the son started asking questions. EI #2 denied medication was in the carton, then admitted to it. When asked how the CNA was at fault, EI #1 said she was not because she did not know medication was in drink. When asked how EI #2 responded, the DON said EI #2 acted like it was everyone else's fault. When asked if she asked EI #2 if that was a usual practice for her, EI #1 said she tried denying it, but the DON assumed it was. EI #1 said she made a comment to EI #2, if you do wrong eventually it will catch up to you. EI #1 was asked what action was taken when the incident occurred. She reported EI #2 was sent home, the investigation done, then they called EI #2 in and asked some questions and terminated her. EI #1 said they also reported the incident to the Board of Nursing. When asked what EI #2 was counseled on, the DON replied, policies and procedures and expected nurse performance. When asked what was the harm in CNAs giving medication, EI #1 replied, they are not qualified. She was asked if a licensed nurse should know that CNAs were not qualified to give medications. EI #1 replied, yes.

Based on observation, interview, record review and review of facility policy titled, MEDICATION ADMINISTRATION, the facility failed to ensure a licensed staff did not remove gloves from her uniform pocket and put them on prior to administering medications by a gastrostomy tube for Resident Identifier (RI) #30. This was observed during medication administration on 10/10/18 and affected one of five nurses observed. Findings Include: A review of an undated facility policy titled, MEDICATION ADMINISTRATION revealed .PR[NAME]EDURES: 1. c. Clean gloves to be worn as appropriate when risk of contact with secretions/excretions blood or body fluids . RI #20 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #20's (MONTH) (YEAR) Physician order [REDACTED]. at . 1200 . On 10/10/18 at 11:15 AM Employee Identifier (EI) #12, Licensed Practical Nurse, was observed preparing and administering RI #20's medication by gastrostomy tube. EI #12 prepared the medication, took gloves from a box on the medication cart and put them in her uniform pocket. EI #12 went to RI #20's room, washed her hands and removed the gloves from her pocket and put them on. EI #12 then proceeded to administer the medication. On 10/10/18 at 11:30 AM, an interview was conducted with EI #12. EI #12 was asked where did she place the gloves when she took them from the box. EI #12 replied, in her uniform pocket. EI #12 was asked if her uniform pocket was considered clean. EI #12 replied, no. EI #12 was asked what was the harm in using gloves that she had removed from her uniform pocket to administer medication. EI #12 replied, they could be contaminated and then contaminate the medication. On 10/11/18 at 5:20 PM, an interview was conducted with EI #11, Registered Nurse/ Infection control. EI #11 was asked if staff should use gloves pulled from their uniform pocket for medication administration. EI #11 replied, no, the uniform would be considered dirty. EI #11 was asked what would the harm be in using gloves taken from a uniform pocket. EI #11 replied, cross contamination any time going from dirty to clean or clean to dirty.

Based on interview, record review and a review of the facility's policy titled, Abuse Prevention Policy, the facility failed to ensure Resident Identifier (RI) #87 was free from abuse after the facility was made aware of an allegation of verbal abuse involving the resident's room mate, RI #42. This affected RI #87, one of two residents identified for abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention Policy dated 11/28/16, revealed the following: Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . INTERPITATION (INTERPRETATION) . PREVENTION . Observe resident behavior and their reaction to other residents . Place residents in accommodations and environments that keep them calm . React to all allegations . of abuse by residents . Take appropriate actions when abuse . is suspected . PROTECTION . Resident Protection after Alleged Abuse . Examples of ways to protect a resident from harm during an investigation of abuse . may include, but are not limited to: . Temporary (less than 24 hours) separation from other residents if resident's behavior poses a threat of abuse or violence . Protection of . residents from retaliation . A review of an investigative summary submitted to the State dated 02/09/18 regarding resident on resident verbal abuse revealed the following: On 2/4/2018, staff reported that (RI #42) told (RI #87) that it was (his/her) room and (he/she) was going to get up and hit (him/her) as seen in nurses note included for date 2/4/2018. (RI #87) voiced to staff that (he/she) was afraid of (RI #42) . 1. RI #42 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #42's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS also documented RI #42's behavior as physical behavior symptoms directed toward others. A review of RI #42's care plan with a problem onset date of 02/01/16, revealed the following: . is easily agitated with . residents. (He/She) becomes combative (kicking, hitting, biting) . (He/She) cusses . On 02/22/18 at 9:15 AM, RI #42 was awake and alert, up to wheel chair (w/c) at the south nurses station with a cup of coffee in his/her hand. The surveyor asked the resident if he/she was ok. RI #42 replied yes. The resident asked the surveyor if surveyor was ok and the surveyor replied yes. The resident stated, Then leave me alone. RI #42 was observed making jesters with his/her hand indicating the resident did not want to be bothered with anyone. The resident turned the w/c sideways, away from the surveyor. 2. RI #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #87's Quarterly MDS dated [DATE], revealed a BIMS score of 14, indicating RI #87 was cognitively intact. The MDS documented no behavior symptoms for RI #87. On 02/21/18 at 11:30 AM, during an interview with RI #87, the resident stated there was a disagreement with his/her roommate, RI #42. RI #87 stated that RI #42 told him/her that he/she would hit him/her. RI #87 stated he/she became afraid. A review of the facility's Departmental Notes dated 02/04/18, for RI #42 and RI #87, did not reveal a time when RI #87 was separated, monitored or removed from the room with RI #42. On 02/23/18 at 8:03 AM, during an interview with Employee Identifier (EI) #1, DON/Director of Nursing, the surveyor asked, after the facility was made aware of the allegation, what was done by the facility to prevent and protect RI #87. EI #1 replied RI #87 was moved to another room. The surveyor asked what time. EI #1 replied, On 02/04/18. The surveyor asked where was the evidence/documentation to reflect the date and time RI #87 was removed from the room. The surveyor reviewed nurses notes for RI #87 and RI #42. There was no evidence/documentation to reveal when and what time the residents were separated and/or moved to a different room. EI #1 reviewed the report and the computer's nurse's notes and stated, It's not there. The surveyor asked should there be information regarding when and what time the residents were separated. EI #1 replied, Yes, it should be. The surveyor asked based on the facility's Abuse policy for preventing and protecting, was policy /procedure followed. EI #1 replied, No ma'am.

Based on interviews, record review and a review of the facility's policy titled, Abuse Prevention Policy, the facility failed to follow the Abuse policy and procedure for reporting an allegation of abuse, preventing potential for further abuse and protecting the resident during the investigation of an allegation of abuse. This affected Resident Identifier (RI) #42 and RI #87, two residents identified for abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention Policy dated 11/28/16, revealed the following: Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . INTERPITATION (INTERPRETATION) . PREVENTION . Observe resident behavior and their reaction to other residents . Place residents in accommodations and environments that keep them calm . React to all allegations . of abuse by residents . Take appropriate actions when abuse . is suspected . PROTECTION . Resident Protection after Alleged Abuse . Examples of ways to protect a resident from harm during an investigation of abuse . may include, but are not limited to: . Temporary (less than 24 hours) separation from other residents if resident's behavior poses a threat of abuse or violence .Protection of . or residents from retaliation . REPORTING/RESPONSE . Prohibit and prevent retaliation. In response to allegations of abuse, . the facility must: Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made . Prevent further potential abuse, . while the investigation is in process . A review of an investigative summary submitted to the State dated 02/09/18, regarding resident on resident verbal abuse, revealed the following: On 2/4/2018, staff reported that (RI #42) told (RI #87) that it was (his/her) room and (he/she) was going to get up and hit (him/her) as seen in nurses note included for date 2/4/2018. (RI #87) voiced to staff that (he/she) was afraid of (RI #42) . 1. RI #42 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #42's current Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS also documented RI #42's behavior as physical behavior symptoms directed toward others. A review of RI #42's care plan with a problem onset date of 02/01/16, revealed the following: .is easily agitated with . residents. (He/She) becomes combative (kicking, hitting, biting) . (She/He) cusses . 2. RI #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #87's Quarterly MDS dated [DATE], revealed a BIMS score of 14, indicating RI #87 was cognitively intact. The MDS documented no behavior symptoms for RI #87. On 02/21/18 at 11:30 AM, during an interview with RI #87, the resident stated there was a disagreement with his/her room mate, RI #42. RI #87 stated that RI #42 told the resident that he/she would hit him/her. RI #87 stated he/she became afraid. A review of the facility's Departmental Notes dated 02/04/18, for RI #42 and RI #87, did not reveal a time when RI #87 was separated, monitored or removed from the room with RI #42. On 02/22/18 at 9:15 AM, RI #42 was awake and alert, up to wheel chair (w/c) at nurses station, and a cup of coffee was in his/her hand. The surveyor asked the resident if he/she was ok. RI #42 replied yes. RI #42 asked the surveyor if she was ok. The surveyor stated yes, then RI #42 stated, Then leave me alone. RI #42 was observed making jesters with his/her hand indicating he/she did not want to be bothered with anyone. RI #42 then turned his/her w/c sideways, away from the surveyor. On 02/23/18 at 08:03 AM, during an interview with Employee Identifier (EI) #1, DON/Director of Nursing, the surveyor provided a copy of of the abuse policy and the investigative report summary of RI #42 and RI #87 for review. The surveyor asked when and what time was the facility made aware of the allegation of verbal abuse. EI #1 replied, 3:39 AM on 02/04/18. After reviewing the facility's abuse policy, the surveyor asked when should the allegation have been reported to the State. EI #1 replied, By 5:39 AM, within 2 hours. EI #1 further stated it was not reported until 10:33 AM. EI #1 said the facility's policy had not been followed for reporting within the two hour time frame. The surveyor asked after the facility was made aware of the allegation, what was done by the facility to prevent and protect RI #87. EI #1 replied RI #87 was moved to another room. The surveyor asked what time. EI #1 replied, On 02/04/18. The surveyor asked where was the evidence/documentation to reflect date and time RI #87 was removed from the room. The surveyor reviewed the computerized nurses notes for RI #87 and RI #42, no evidence/documentation to reveal when and what time the residents were separated and/or moved to a different room. EI #1 reviewed the report and the computer's nurse's notes and stated, It's not there. The surveyor asked should there be information regarding when and what time the residents were separated. EI #1 replied, Yes, it should be. The surveyor asked based on the facility's Abuse policy for preventing and protecting, was policy /procedure followed. EI #1 replied, No ma'am.

Based on interview, record review, a review of the facility's policy titled, Abuse Prevention Policy, the facility failed to ensure an allegation of verbal abuse was reported with the two hour time frame. This affected Resident Identifier (RI) #42 and RI #87, two of two residents identified for Abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention Policy dated 11/28/16, revealed the following: Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . REPORTING/RESPONSE . Prohibit and prevent retaliation. In response to allegations of abuse, . the facility must: Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made . Prevent further potential abuse, . while the investigation is in process . A review of an investigative summary submitted to the State dated 02/09/18, regarding resident on resident verbal abuse revealed the following: On 2/4/2018, staff reported that (RI #42) told (RI #87) that it was (his/her) room and (he/she) was going to get up and hit (him/her) as seen in nurses note included for date 2/4/2018. (RI #87) voiced to staff that (he/she) was afraid of (RI #42) . 1. RI #42 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #42's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS also documented RI #42's behavior as physical behavior symptoms directed toward others. A review of RI #42's care plan with a problem onset of 02/01/16 revealed the following: .is easily agitated with . residents.( He/She) becomes combative (kicking, hitting, biting) . (He/She) cusses . 2. RI #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #87's Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating RI #87 was cognitively intact. The MDS documented no behavior symptoms for RI #87. On 02/21/18 at 11:30 AM, during an interview with RI #87, the resident stated there was a disagreement with him/her room mate. RI #87 stated RI #42 told him/her that he/she would hit RI #87. RI #87 stated he/she became afraid. A review of the facility's Departmental Notes dated 02/04/2018 for RI #42 and RI #87, did not reveal a time when RI #87 was separated, monitored or removed from the room with RI #42. On 02/22/18 at 09:15 AM, RI #42 was awake and alert, up to wheel chair (w/c) at nurses station, with a cup of coffee in him/her hand. The surveyor asked RI #42 if he/she was ok. RI #42 replied yes. RI #42 asked the surveyor if she was ok. The surveyor stated yes, then RI #42 stated, Then leave me alone. RI #42 was observed making jesters with his/her hand indicating the resident did not want to be bothered with anyone. RI #42 then turned the w/c sideways, away from the surveyor. On 02/23/18 at 08:03 AM, during an interview with Employee Identifier (EI) #1, DON/Director of Nursing, the surveyor provided a copy of of the abuse policy and the investigative report summary of RI #42 and RI #87 for review. The surveyor asked when and what time was the facility made aware of this allegation of verbal abuse. EI #1 replied, 3:39 AM on 02/04/18. After reviewing the facility's abuse policy, the surveyor asked when should the allegation have been reported to the State. EI #1 replied, By 5:39 AM, within 2 hours. EI #1 further stated it was not reported until 10:33 AM. EI #1 said the facility's policy had not been followed for reporting within the two hour time frame.

Based on interviews, record review, a review of the facility's policy titled, Abuse Prevention Policy, the facility failed to ensure: 1. an allegation of resident on resident verbal abuse was reported within the two hour time frame; 2. a resident was protected after the facility was made aware of the allegation of verbal abuse; and 3. to prevent the potential for further abuse during the investigative process. This affected Resident Identifier (RI) #42 and RI #87, two residents identified for abuse. Findings Include: A review of the facility's policy titled, Abuse Prevention Policy dated 11/28/16, revealed the following: Policy: Each resident has the right to be free from abuse, . Residents must not be subject to abuse by anyone, including, but not limited to; . other residents . INTERPITATION (INTERPRETATION) . PREVENTION . Observe resident behavior and their reaction to other residents . Place residents in accommodations and environments that keep them calm . React to all allegations . of abuse by residents . Take appropriate actions when abuse . is suspected . PROTECTION . Resident Protection after Alleged Abuse . Examples of ways to protect a resident from harm during an investigation of abuse . may include, but are not limited to: . Temporary (less than 24 hours) separation from other residents if resident's behavior poses a threat of abuse or violence .Protection of . or residents from retaliation . REPORTING/RESPONSE . Prohibit and prevent retaliation. In response to allegations of abuse, . the facility must: Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made . Prevent further potential abuse, . while the investigation is in process . A review of an investigative summary submitted to the State dated 02/09/18 regarding resident on resident verbal abuse revealed the following: On 2/4/201/, staff reported that (RI #42) told (RI #87) that it was (his/her) room and (he/she) was going to get up and hit (him/her) as seen in nurses note included for date 2/4/2018. (RI #87) voiced to staff that (he/she) was afraid of (RI #42) . 1. RI #42 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #42's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #42 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognition. The MDS also documented RI #42's behavior as physical behavior symptoms directed toward others. A review of RI #42's care plan with a problem onset date of 02/01/16, revealed the following: .is easily agitated with . residents. (He/She) becomes combative (kicking, hitting, biting) . (He/She) cusses . 2. RI #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #87's Quarterly MDS dated [DATE], revealed a BIMS score of 14, indicating RI #87 was cognitively intact. The MDS documented no behavior symptoms for RI #87. On 02/21/18 at 11:30 AM, during an interview with RI #87, the resident stated there was a disagreement with his/her room mate, RI #42. RI #87 stated RI #42 told the resident he/she would hit RI #87. RI #87 stated he/she became afraid. A review of the facility's Departmental Notes dated 02/04/2018 for RI #42 and RI #87, did not reveal a time when RI #87 was separated, monitored or removed from the room with RI #42. On 02/22/18 at 9:15 AM, RI #42 was awake and alert, up to wheel chair (w/c) at nurses station,with a cup of coffee in him/her hand. The surveyor asked RI #42 if he/she was ok. RI #42 replied yes. RI #42 asked the surveyor if she was ok. The surveyor stated yes, then RI #42 stated, Then leave me alone. RI #42 was observed making jesters with his/her hand indicating the resident did not want to be bothered with anyone. RI #42 then turned the w/c sideways, away from the surveyor. On 02/23/18 at 08:03 AM, during an interview with Employee Identifier (EI) #1, DON/Director of Nursing, the surveyor provided a copy of of the abuse policy and the investigative report summary of RI #42 and RI #87 for review. The surveyor asked when and what time was the facility made aware of this allegation of verbal abuse. EI #1 replied, 3:39 AM on 02/04/18. After reviewing the facility's abuse policy, the surveyor asked when should the allegation have been reported to the State. EI #1 replied, By 5:39 AM, within 2 hours. EI #1 further stated it was not reported until 10:33 AM. EI #1 said the facility's policy had not been followed for reporting within the two hour time frame. The surveyor asked, after the facility was made aware of the allegation, what was done by the facility to prevent and protect the RI #87. EI #1 replied RI #87 was moved to another room. The surveyor asked what time. EI #1 replied, On 02/04/18. The surveyor asked where was the evidence/documentation to reflect the date and time RI #87 was removed from the room. The surveyor reviewed the computerized nurses notes for RI #87 and RI #42, no evidence/documentation to reveal when and what time the residents were separated and/or moved to a different room was found. EI #1 reviewed the report and the computer's nurse's notes and stated, It's not there. The surveyor asked should there be information regarding when and what time the residents were separated. EI #1 replied, Yes, it should be. The surveyor asked, based on the facility's Abuse policy for preventing and protecting, was the policy /procedure followed. EI #1 replied, No ma'am.

Based on observation, record review, a review of a facility policy titled, SKIN CARE MANAGEMENT and staff interviews, the facility failed to ensure Resident Identifier (RI) #100 had a Care Plan (CP) in place for a splint to the left hand to prevent skin breakdown. Findings Include: A review of a facility policy titled, SKIN CARE MANAGEMENT with no date, documented: POLICY: All residents who enter the nursing home without pressure ulcers will not develop pressure ulcers . All residents will be assessed on admission and routinely thereafter for risk of skin breakdown. Prevention interventions will be . implemented to prevent the development of pressure wounds. PR(NAME)EDURE: . 2. The degree and areas of risk will direct the plan of care. RI #100 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #100's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2017, revealed RI #100's Brief Interview for Mental Status (BIMS) score of 12, indicating cognition was intact. The MDS also revealed RI #100 was totally dependent on staff for Activities of Daily Living (ADL) and had upper extremity impairment on both sides. A review of RI #100's care plan with a problem onset date of 03/18/2016, and a next review date of 12/2017, documented the following: . Potential for Decline in range of motion (ROM)* To maintain strength and flexibility . * PERFORM passive range of motion (PROM) to bilateral upper extremities (BUE) AND bilateral lower extremities (BLE) IN ALL PLANES 2 SETS OF 10 5X (Times) WEEKLY OR AS TOLERATED. A review of RI #100's Physician order [REDACTED]. palm protector splint daily up to 12 hours . A review of RI #100's Occupational Therapy (OT) - Assistant Progress Update 09/06/2017 documented: . Splinting Muscle . The patient will decrease left upper extremity (LUE) flaccidity with application of functional position splint . On 02/21/2018 at 10:51 a.m., an observation was made of RI #100's left fingers. RI #100's fingers on the left hand were contracted with no splint in the hand. On 02/21/2018 at 12:00 p.m., an observation was made of RI #100's left fingers. All five digits were contracted. RI#100 was asked if he/she could open his/her fingers. RI #100 said he/she could not open his/her fingers. No splint was in the left hand at this time. On 02/22/2018 at 1:00 p.m., an observation was made of RI #100's left fingers and no splint was in the hand. On 02/23/2018 at 9:10 a.m., an observation was made of RI #100's left fingers. A sheepskin splint was attached at the wrist. The fingers were contracted and the splint was not under the fingers. On 02/23/2018 at 9:55 a.m., an interview was conducted with Employee Identifier (EI) # 7 Registered Nurse (RN) Unit Manager (UM). EI #7 was asked what interventions were in place for RI #100's left fingers being contracted. EI #7 said a functional maintenance plan (FMP)was put in place on 02/22/2018 for the left hand splint. EI #7 was asked why was it put in place 02/22/2018 and not before that date. EI #7 said it was the Unit Manager and the nurses' responsibility to ensure therapy was implemented. EI #7 was asked why should splints be on. EI #7 said to keep from getting skin breakdown. On 02/23/2018 at 10:28 a.m., EI #7 RN went with the surveyor to RI #100's room. EI #7 opened RI #100's left fingers and under the left index finger there was a indentation of the fingernail in the skin. Under the thumb was no redness, but on the third digit was an open area, white in color that had clear drainage and no odor. The fourth digit had a reddened area approximately 0.5 cm in size, no open area observed. On 02/23/2018 at 10:32 a.m., EI #7 and EI #8, Licensed Practical Nurse (LPN), went to RI #100's room with surveyor. EI #8, LPN, measured the open area under the third digit using a paper tape measure. EI #8 said the area was 0.3 centimeters x 1.0 centimeters with clear drainage. On 02/23/2018 at 12:05 p.m., an interview was conducted with EI #13, Therapy Administrator. EI #13 was asked what recommendations were made on 09/06/2017 for RI #100. EI #13 said application of a handroll to the left hand. EI #13 was asked, how was it ensured the recommendations were carried out. EI #13 said every patient that had a FMP done, they would speak with restorative or Certified Nursing Assistants (CNA). EI #13 was asked, where was the FMP for RI #100. EI #13 said they could not find the FMP for that resident. EI #13 said he did not think one was done. EI #13 was asked, how did he ensure that a decline in ROM or development of a pressure ulcer did not occur with RI #100. EI #13 replied, he did not have a answer at that time. The surveyor asked why not. EI #13 said he was not there at that time. EI #13 said he began in November 2017. EI #13 said it was an oversight on therapy's part. EI #13 said the other therapist said RI #100 was not compliant with the splint, but there was no documentation to reflect that. EI #13 was asked what was the importance of an FMP for that resident. EI #13 replied, to make sure the contracture did not progress and did not have skin breakdown. EI #13 said it was therapy's policy to have an FMP in place and it was their job to review it. EI #13 said the November 2017 FMP for RI #100 had nothing on it about splinting. EI #13 was asked was the policy followed regarding the FMP for this resident. EI #13 said no. On 02/23/2018 at 10:50 a.m., an interview was conducted with EI #9, RN Infection Control. EI #9 was asked was there a care plan for a splint for the left hand. EI #9 said no and there should have been one.

Based on observation, interview, record review, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a Licensed Practical Nurse/LPN, Employee Identifier (EI) #8 used gloves when administering Resident Identifier (RI) #62's Latanoprost 0.005 % (percent) eye drops on 02/22/18 during the morning medication pass administration. This deficient practice affected RI #62, one of two residents observed for eye drop administration. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING, Ninth Edition, with a copyright date of 2017, pages 660-661, documented: . UNIT V Foundations for Nursing Practice . ADMINISTERING OPHTHALMIC MEDICATIONS . Implementation . STEP . 6. Arrange supplies at bedside; apply gloves . RATIONALE . Ensures organized procedure and reduces transmission of microorganisms . RI #62 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #62's February 2018 Physician order [REDACTED].> . LATANOPROST 0.005% EYE DROPS ONE DROP TO EACH EYE QDAY (every day) . On 02/22/18 at 8:20 a.m., the surveyor observed EI #8 remove RI #62's Latanoprost 0.005% eye drops from the medication cart. EI #8 entered RI #62's room, went to the bathroom and washed her hands, and then administered one drop to RI #62's right eye then the left eye. EI #8 did not have on gloves throughout this procedure. On 02/22/18 at 8:59 a.m., the surveyor read back the above observation of eye drop administration to EI #8. The surveyor asked EI #8 what was the standard of practice nurses used to administer eye drops. EI #8 said it was not the facility's policy to wear gloves when administering eye drops. On 02/23/18 at 9:41 a.m., the surveyor conducted an interview with EI #6, the Registered Nurse Supervisor for the unit RI #62 resided on. The surveyor asked EI #6, what was the standard of practice nurses should use when administering eye drops. EI #6 said the nurse should check the medicine against the MAR (Medication Administration Record), wash their hands, explain to resident what they were going to do, put on gloves and proceed to administer the eye drops as ordered.

Based on observations, a review of the facility document titled, Functional Maintenance Programs, a facility policy titled, Skin Care Management and staff interview, the facility failed to ensure Resident Identifier (RI) #100 did not have a decline in upper range of motion (ROM). This affected one of one residents with limited range of motion. Findings Include: A review of a facility policy titled, SKIN CARE MANAGEMENT with no date, documented: POLICY: All residents who enter the nursing home without pressure ulcers will not develop pressure ulcers . All residents will be assessed on admission and routinely thereafter for risk of skin breakdown. Prevention interventions will be . implemented to prevent the development of pressure wounds. PR(NAME)EDURE: . 2. The degree and areas of risk will direct the plan of care. 3. If risk factors are identified, preventive skin measures will be implemented immediately. 4. All residents will have assessments performed during routine care. The condition of skin will be documented at least weekly, noting any changes. A review of a facility document titled Functional Maintenance Programs with no date documented: . Effective Functional Maintenance Programs (FMP) should be established by the rehab professional . The program allows the nursing staff to assist the resident in maintaining the highest level of function possible . RI #100 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #100's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/2017, revealed RI #100 had upper extremity impairment on one side. A review of RI #100's Significant Change MDS with a ARD of 11/20/2017, revealed RI #100's BIMS score of 12, indicating cognition was intact. The MDS also revealed RI #100 was totally dependent on staff for Activities of Daily Living (ADL) and had upper extremity impairment on both sides. A review of RI #100's care plan with a problem onset date of 03/18/2016, and a next review date of 12/2017, documented the following: . Potential for Decline in range of motion (ROM)* To maintain strength and flexibility . * PERFORM passive range of motion (PROM) to bilateral upper extremities (BUE) AND bilateral lower extremities (BLE) IN ALL PLANES 2 SETS OF 10 5 X WEEKLY OR AS TOLERATED. On 02/21/18 at 10:51 a.m., an observation was made of RI #100's left hand. The fingers were contracted with no splint in the hand. On 02/21/18 at 12:00 p.m., an observation was made of RI #100's left fingers. All five digits were contracted. RI#100 was asked if he/she could open his/her fingers. RI #100 said he/she could not open his/her fingers. No splint was in the left hand at this time. On 02/22/2018 at 1:00 p.m., an observation was made of RI #100's left fingers and no splint was in the hand. On 02/23/2018 at 9:10 a.m., an observation was made of RI #100's left fingers. A sheepskin splint was attached at the wrist. The fingers were contracted and the splint was not under the fingers. On 02/23/2018 at 9:55 a.m., an interview was conducted with Employee Identifier (EI) # 7 Registered Nurse (RN) Unit Manager (UM). EI #7 was asked what interventions were in place for RI #100's left fingers being contracted. EI #7 said a functional maintenance plan was put in place on 02/22/2018 for the left hand splint. EI #7 was asked why was it put in place 02/22/2018 and not before that date. EI #7 said it was the Unit Manager and the nurses responsibility to ensure therapy was implemented. EI #7 was asked why should splints be on. EI #7 said to keep from getting skin breakdown. On 02/23/2018 at 10:28 a.m., EI #7 RN went with the surveyor to RI #100's room. EI #7 opened RI #100's left fingers and under the left index finger there was a indentation of the fingernail in the skin. Under the thumb was no redness, but on the third digit was an open area, white in color and had clear drainage, but no odor. The fourth digit had a reddened area approximately 0.5 cm in size. No open area observed. On 02/23/2018 at 10:32 a.m., EI #7 and EI #8, Licensed Practical Nurse (LPN) went to RI #100's room with surveyor. EI #8 measured the open area under the third digit using a paper tape measure. EI #8 said the area was 0.3 centimeters x 1.0 centimeters with clear drainage. On 02/23/2018 at 12:05 p.m., an interview was conducted with EI #13, Therapy Administrator. EI #13 was asked what recommendations were made on 09/06/2017 for RI #100. EI #13 said application of a handroll to the left hand. EI #13 was asked, how was it ensured the recommendations were carried out. EI #13 said every patient that had a FMP done, they would speak with restorative or Certified Nursing Assistants (CNA). EI #13 was asked, where was the FMP for RI #100. EI #13 said they could not find the FMP for that resident. EI #13 said he did not think one was done. EI #13 was asked, how did he ensure that a decline in ROM or development of a pressure ulcer did not occur with RI #100. EI #13 replied, he did not have a answer at that time. The surveyor asked why not. EI #13 said he was not there at that time. EI #13 said he began in November 2017. EI #13 said it was an oversight on therapy's part. EI #13 said the other therapist said RI #100 was not compliant with the splint, but there was no documentation to reflect that. EI #13 was asked what was the importance of an FMP for that resident. EI #13 replied, to make sure the contracture did not progress and did not have skin breakdown. EI #13 said it was therapy's policy to have an FMP in place and it was their job to review it. EI #13 said the November 2017 FMP for RI #100 had nothing on it about splinting. EI #13 was asked was the policy followed regarding the FMP for this resident. EI #13 said no.

Based on observation, record review, interview and a review of the facility's policy titled, DRESSINGS STERILE, the facility failed to ensure licensed staff cleaned Resident Identifier (RI) # 113's wound in a circular motion, from the inner to the outer aspect, during an observation of wound care. This affected one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, DRESSINGS STERILE without a date, revealed the following: . PR(NAME)EDURE . 16. Cleanse wound as ordered. Use circular motion to cleanse with 4x (by) 4, from inner to outer aspect. DO NOT go back over clean area with same gauze. RI #113 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #113's Quarterly Minimum Data Set, dated dated [DATE],7 revealed a Brief Interview for Mental Status Score of 3, indicating severe impairment in cognition. On 02/23/18 at 9:35 AM, the following was observed during wound care: Employee Identifier (EI) #14, Quality Assurance/QA Nurse and EI #12, Licensed Practical Nurse/LPN washed their hands and applied gloves. EI #14 removed the resident's dressing. Two stage 2 areas to coccyx were observed and measured. EI #14 obtained a 4x4 gauze with wound cleanser, and cleaned the wounds from the top aspect to the bottom aspect. EI #14 obtained a 4x4 gauze and dried the wounds from top to bottom. EI #14 removed her gloves, washed her hands and applied clean gloves. EI #14 then applied a Duoderm dressing. On 02/23/18 at 9:45 AM, during an interview with EI #14, the surveyor asked what direction should a wound be cleaned. EI #14 replied in a circular motion away from the most contaminated area. EI #14 further stated she thought that was what she had done. The surveyor asked EI #14 how did she clean both wounds. EI #14 stated from top to bottom and that could cause cross contamination.

Based on observations, interviews, and a review of facility's policy titled, OXYGEN THERAPY, the facility failed to ensure Oxygen tubing's were replaced and dated appropriately. This affected two of four residents observed for oxygen therapy. Findings Include: A review of a facility policy titled, OXYGEN THERAPY with no date, revealed: .1. O2 (oxygen) .humidifiers will be replaced every (30) thirty days. 2. tubing will be replaced weekly . RI (Resident Identifier) #40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 2/21/18 at 6:04 PM, the surveyor observed the O2 tubing with no date on tubing for RI #40. On 2/22/18 at 9:05 AM, the surveyor observed the O2 tubing for RI #40 with no date on the tubing. On 2/22/18 at 2:35 PM, the surveyor observed the O2 tubing for RI #40 with EI (Employee Identifier) #2, Licensed Practical Nurse/LPN, that had no date on the tubing. On 02/22/18 at 5:25 PM, an interview was conducted with EI #2. EI #2 was asked what did she observe today in regards to O2 tubing in RI #40's room. EI #2 stated there was no date on the tubing. EI #2 was asked when were the tubing's for oxygen changed. EI #2 stated weekly on Wednesdays. EI #2 was asked who was responsible for changing the O2 tubing's. EI #2 stated EI #5, the Supply clerk. EI #2 was asked should the O2 tubing's have a date placed on them. EI #2 stated yes. EI #2 was asked what was the purpose of placing a date on the O2 tubing. EI #2 stated showing last date it was changed. EI #2 was asked if there was a date on the tubing for RI #40. EI #2 stated no. EI #2 was asked what was the potential negative impact of these O2 tubing's not having a date labeled on them. EI #2 stated, not knowing when tubing was last changed increased the risk for infection and respiratory infection. RI #65 was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 2/21/18 at 10:55 AM, the surveyor observed RI #65's O2 water bottle with no date and no water in bottle. The surveyor asked EI #3, Registered Nurse/RN about RI #65's water bottle with no water and no date. EI #3 immediately replaced bottle and dated it. On 2/23/18 at 8:15 AM, an interview was conducted with EI #3. EI #3 was asked what did she see on 2/21/18, in regards to RI #65's humidifier. EI #3 stated the humidifier was empty with no date on the humidifier. EI #3 was asked who was responsible for changing the humidifiers and O2 tubing's. EI #3 stated EI #5, the Supply Clerk changed the O2 tubing and the nurses changed the humidifiers. EI #3 was asked how often were these changed. EI #3 stated, the humidifiers were changed every 30 days or as needed; and the O2 tubing was changed weekly. EI #3 was asked what was the potential harm of not replacing the humidifier. EI #3 stated if there was no water, it could cause dryness of mucous membrane and the possibility of infection.

Based on record review and interview, the facility failed to monitor the PT ([MEDICATION NAME] Time)/INR (International Normalized Ration) level for a resident on anticoagulant therapy in accordance with physician orders, and failed to recognize and/or respond to Resident Identifier (RI) #1's bleeding as a life threatening adverse consequence of anticoagulant therapy. The resident, RI #1, was admitted to the facility on [DATE], with an order for [REDACTED].#1. On 6/22/11, the resident was noted with foul smelling cranberry-colored urine. The facility care givers reported the resident with rectal bleeding on 6/22-6/24/11; the licensed nurses thought RI #1's rectal bleeding was due to hemorrhoids, not anticogulant therapy. The licensed nursing staff treated the rectal bleeding with a [MEDICATION NAME] medication called [MEDICATION NAME]. On 6/24/11, Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), discharged the resident home with the sponsor and informed him that the resident had bleeding from the rectum. According to EI #4 (an LPN), RI #1's sponsor reported that he was taking the resident to the doctor and would let the doctor know. The resident had an INR on hospital admission, dated 6/24/11, of 5.9 and a PT level > (Greater) than 50.0 (Reference 9.0-11.5). RI #1 had bleeding 2 days prior to discharge from the facility. This affected RI #1, 1 of 2 sampled residents on anticoagulant therapy. On 7/8/11 at 6:20 PM, the facility's Owner, Administrator, Assistant Administrator, Medical Director, DON (Director of Nursing), and other department heads were made aware that the surveyor had identified substandard quality of care at an immediate jeopardy level of "J" in F329. The Immediate Jeopardy began on 6/21/11, and was relieved on 7/09/11 at 1:37 PM, when the facility implemented immediate corrective actions to remove the immediacy. The scope and severity level of F 329 was lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance with F329. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission MDS (Minimum Data Set), dated 6/14/11, revealed the BIMS (Brief Interview Mental Status ) checked for severe impairment. The resident required total assistance with ADLs and was incontinent of bowel and bladder. RI #1's "INITIAL ADMISSION CARE PLAN," dated 6/7/11, revealed, "PROBLEM: ANTICOAGULANT THERAPY GOAL: NO S/S (signs and symptoms) HEMORRHAGE APPROACHES: 1. MONITOR FOR S/S HEMORRHAGE IE (in example): BLEEDING GUMS, PETECHIA, EXCESSIVE BRUISING, BLACK TARRY STOOLS 2. PT as ordered 3. NOTIFY MD OF ABOVE S/S 4. KEEP MD AWARE OF LABS" RI #1's admission Physician order [REDACTED]." by EI (Employee Identifier) #2 (an LPN- Licensed Practical Nurse). "Monitor skin qshift c (with) ADL's (Activities of Daily Living), report changes to charge nurse..." A review of RI #1's medical record from 06/07/11 through 06/24/11, revealed that there was no documented evidence of a PT coagulation lab test being requested or obtained by the facility. A Nurse's Note for RI #1 documents, "6/22/11 @ (at) 1530 (3:30 PM) Notified (name of doctor) via (name of nurse-LPN) of resident having foul smelling urine, cranberry colored. New order received for urinalysis-(signed by EI #1)" RI #1's Physician order [REDACTED].#1, a Registered Nurse)." RI #1's Urinalysis report, with a collected date of 6/22/11 and a received date of 06/23/11, documents the following abnormal results: "UA (Urinalysis) COLOR - BLOODY (NORMAL COLOR: YELLOW); UA APPEARANCE - CLOUDY (NORMAL APPEARANCE: CLEAR); ...UA BLOOD - 250 (NORMAL: NEGATIVE...UA RBC (Red Blood Cells) - 25-50 (NORMAL: NONE SEEN...)..." RI #1's Physician Orders, dated 6/23/11, revealed, "D/C (Discharge) Home with home health" A Nurses Notes for RI #1, documents: "6/24/11 1000 (10:00 AM) resident D/C'ed home with primary sponsor- explained medication to sponsor- D/C per private car- sponsor stated he was taking her to MD (Medical Doctor) office now- (an LPN, EI #4's initials) explained to sponsor about resident having bleeding in urine and also from rectum when having BM's (bowel movements)- stated he would tell MD (EI #4's initials)..." On 6/24/11, after the resident was discharged from the facility, RI #1 was admitted to the hospital. RI #1's hospital "HISTORY AND PHYSICAL REPORT," with a service date of 06/24/11, documents: "...HISTORY OF PRESENT ILLNESS This patient, [AGE] years white female, is a patient who was in the nursing home.... The husband says she has been coughing pretty bad. She is extremely confused,.... She also has been having hematuria.... IMPRESSION ...4. Hematuria,... has a pacemaker. PLAN The patient is admitted ...." The resident's hospital "CLINICAL LABORATORY" coagulation report documents the following critically high laboratory results: "Date / Time 06/24/11 1150 (11:50 AM) PT PATIENT > (greater than)50.0 H (high) (Reference Units 9.0 - 11.5 seconds)... INR 5.9 H...." On 7/06/11 at 3:00 PM, EI #1, a Registered Nurse (RN), was interviewed and asked if she was aware of RI #1 having any bleeding. She stated that EI #4 (an LPN- Licensed Practical Nurse) had informed her that RI #1 had rectal bleeding and thought it was from hemorrhoids. EI #1 indicated she was had not been made aware of any rectal bleeding before RI #1's discharge. EI #1 had been off a few days. EI #4 did not tell her about the rectal bleeding until after the resident had already left the building. EI #1 explained that RI #1's spouse had told EI #4 that he was taking the resident to the emergency room . At 4:00 PM on 7/06/11, EI #4 (an LPN) was interviewed and asked when did RI #1's bleeding occur. She stated she was informed by a CNA (Certified Nursing Assistant) who found blood on the resident's brief while doing incontinence care. EI #4 stated RI #1's urine was very dark,like it had blood in it. She was asked when did she find out about the bleeding. EI #4 (an LPN) stated it was on the day the resident was discharged and that she had told the resident's husband about the bleeding. She indicated she thought it was from RI #1's hemorrhoids. EI #4 was asked if she checked RI #1 for bleeding and she stated no and was asked why not. She indicated that the resident's spouse was taking her to the doctor and that he would inform the doctor about the bleeding. She was then asked if she should have checked RI #1 for bleeding before she was discharged if bleeding was reported to her. EI #4 (an LPN) stated, "Yes, perhaps. I just thought it was her hemorrhoids." She was asked if RI #1 had a [DIAGNOSES REDACTED]. EI #4 was asked if the hemorrhoids were bleeding and she stated not that she was aware of. She was asked if the hemorrhoids had been bleeding before and she stated not that she was aware of. EI #4 (an LPN) was asked if she notified the doctor of the resident having bleeding after she was notified. She stated she did not because the resident was going home. At 10:30 AM on 7/07/11, EI #5 (a CNA) was interviewed and asked how was RI #1's condition at the time of her discharge. She stated the resident was bleeding and was wearing a brief. She indicated the resident had a doctor's appointment that day. EI #5 was asked if she was aware if RI #1 had any bleeding. She stated the resident did have bleeding but did not know when it started. She indicated the resident was bleeding the day she left. She stated she reported to the nurse the resident had blood but could not remember who she reported it to. EI #5 was asked how much blood was there and she indicated it was similar to a menstrual-cycle. On 7/07/11 at 11:37 AM, EI #6 (a CNA) was interviewed and asked if she was aware of RI #1 having any bleeding. She affirmed that she was aware and that the bleeding started a couple of weeks after the resident got to the facility. She indicated that she told the nurse about it but could not remember which nurse. EI #6 described the bleeding as a menstrual cycle kind of bleed. Although EI #6 could not recall when and which nurse she told about RI #1's bleeding, she remembered that the nurse tested RI #1's urine for blood; EI #6 recalled that it was close to when the resident went home because she was off when the resident went home. EI #1 (RN) was interviewed again on 7/07/11 at 1:55 PM, and asked if she was made aware of RI #1 bleeding. EI #1 stated that she became aware of the bleeding after RI #1 left the facility. She was asked how she was made aware. She answered that EI #4 (an LPN) told her that the resident's husband called back to the facility and reported that he was taking RI #1 to the ER (emergency room ) because the resident was having rectal bleeding. She was asked why the PT level was not drawn and she stated she did not know why it wasn't drawn. She explained that EI #2 (an LPN) signed off the order for the lab and that when the order is signed off, it is acknowledging it was done. According to this RN (EI #1), the lab is put on the calendar when it should be drawn so when the nurse comes in she will know what needs to be drawn. EI #1 was asked when was the physician's orders [REDACTED]. EI #1 was asked what effect could not drawing the PT lab have on the resident. She stated that if the level was too high the resident could bleed real bad and that is why it is monitored. She stated that [MEDICATION NAME] is given to keep blood level at clotting level. EI #1 indicated that if the PT is too low the resident would be at risk for a blood clot. She was asked who notifies the MD. She indicated that if the lab is critical, the doctor is called. The hospital calls the facility first before faxing the level and they write on the bottom of the lab who they reported it to and then the nurse calls the doctor. At 2:15 PM on 7/07/11, EI #2 (an LPN) was interviewed and asked if she was aware that RI #1 had bleeding. She stated the resident had a little bit of rectal bleeding. EI #2 indicated that on 6/22/11 or 6/23/11, RI #1 had some bright red rectal bleeding and she thought it was from the hemorrhoids. EI #2 stated she found the bleeding. She was asked if the MD was notified of the bleeding. She indicated that she notified the RN Supervisor and was instructed to use [MEDICATION NAME] (a topical medication for hemorrhoids), which was a standing order. She stated she notified the next shift but was not sure which LPN she reported it to. She was asked again when did this occur and she stated a couple of days before the resident was discharged . EI #2 (an LPN) was asked what was the PT lab order for RI #1, and she rsponded that the order indicated PT every 2 weeks. She was asked what was the date of the PT lab order, and she replied that the date was 6/7. EI #2 was asked why was the PT lab not drawn. EI #2 (an LPN) stated that she did not know. She said that she signed the order off, and EI #1 signed off behind her. EI #2 explained that the nurses have a calendar at the desk that tells them what labs have been ordered. She stated she did not know why the lab was not drawn. She was then asked what effect could not drawing a PT lab have on the resident. She stated the blood could get too thin if on [MEDICATION NAME] (a medication given to prolong the bloods clotting time) and could bleed out and if too low it gets too thick and could get a clot. EI #2 (an LPN) was asked when is the MD notified of PT level and she stated when the level is above 11. She was asked who notifies the MD of the PT lab result. She answered that if the lab is critical, the hospital calls the facility and then faxed it to them. The nurse then calls the MD. According to EI #2, the nurse has 30 minutes to notify the physician after the lab result is received. At 4:55 PM on 7/07/11, EI #7 (a CNA) was interviewed and asked if she was aware of RI #1 having any bleeding. EI #7 reported that she saw a smudge of blood on the resident's brief and told the nurse. She identified EI #2 (an LPN) as the nurse that she thinks that she told about RI #1's bleeding. On 7/08/11 at 7:55 AM, EI #1 (an RN) was interviewed again and asked what does "Noted (with initials) indicate on a Physician Order. She stated that it indicated the order has been taken off, it's been done or arranged to be done. It indicated it has been ordered to be done. EI #1 was asked what does the RN signature indicate on the Physician order [REDACTED]. Her signature (RN) at box in on the Physician order [REDACTED]. She was asked about the Nurse's Note written on 6/22/11. "6/22/11 @ (at) 1530 (3:30 PM) Notified (name of doctor) via (name of nurse-LPN) of resident having foul smelling urine, cranberry colored. New order received for urinalysis-(signed by EI #1)" EI #1 (an RN) stated that someone mentioned at the nurse's desk that the resident had foul smelling urine. She spoke to the nurse at the doctor's office and that she would notify the MD and call her back. EI #1 was asked could the cranberry color have indicated blood. She stated it indicated it could have been blood, but that she did not see it. She stated she decided to go ahead and call and get a U/A (Urinalysis). EI #1 (RN) was asked if the PT/INR should have been drawn and she affirmed that it should have, and said that the PT was ordered by the MD. EI #1 (RN) explained that the lab orders are written on the desk calendar with the name, the lab test needed and date. A lab slip is filled out in and put in the lab book. She further explained that there were 3 copies of the lab slip: The pink copy goes to the lab; the white copy goes to registration at the hospital; and, the yellow copy is placed in the pending lab book. According to EI #1(RN), the lab slip is put in a lab book, the staff person gets the lab slip and signs off on it, nurse draws the lab, places it in specimen fridge and the yellow copy is placed in the pending lab book. Then, a courier comes and picks up the labs and takes it to the hospital. EI #1 (an RN) provided the surveyor with the desk top calendar to review for June 2011 that is used by the nurses to indicate the resident name, lab, and date to be drawn. RI #1's name was not listed on any part of the calendar for a lab to be drawn. EI #1 stated that she was not able to locate the yellow pending lab slip for RI #1's PT lab. On 7/08/11 at 11:00 AM, EI #8 (a CNA) was interviewed and asked if she was aware of RI #1 having any bleeding. She stated she had provided care for the resident daily and the resident had bleeding from her bottom but did not know exactly when it started. EI #8 stated she thinks she was bleeding about 2 days before she went home. She indicated the resident was bleeding the same day she went home and that it had been reported to EI #11 (an LPN). EI #8 (CNA) indicated the bleeding was more than a menstrual cycle amount and that the resident would have blood each time the CNAs changed RI #1 which was about every 2 hours. In a telephone interview on 7/07/11 at 10:52 AM, EI #11 (an LPN) was asked if she was aware of RI #1 having any bleeding. She stated she thought it was hemorrhoids but was not sure. She indicated no one had informed her the resident had been bleeding. At 12:15 on 7/08/11, EI #9, the Director of Nursing (DON), was interviewed and asked what effect could not drawing the PT lab level have on a resident. She stated that if abnormal the resident could bleed or clot. She was asked when was she made aware RI #1 had bleeding and she stated the day the resident went home. She was asked when and by whom did she become aware of the bleeding. EI #9 indicated she saw a communication sheet go out to the physician and she called EI #4 (an LPN) and asked if the resident was still having bleeding. According to EI #9 (DON), this was before the resident was sent out. She indicated that the LPN (EI #4) went to check for bleeding and asked the CNA if the resident still had bleeding. EI #9 said that the CNA reported that the resident was still bleeding that morning; but, RI #1's spouse was still taking the resident home. EI #9 stated that she told EI #4 (an LPN) to make sure the spouse knew that RI #1 was still bleeding because he was taking the resident home. According to EI #9, EI #4 informed her (EI #9) that RI #1's spouse said, "Don't worry I'm taking her (RI #1) to doctor office when I leave here." EI #9 (DON) stated the spouse then took RI #1 out of the facility. EI #9 was asked if the MD should have been notified about the bleeding prior to discharge and she stated he was notified, by the communication sheet. She indicated the doctor did not call the facility back after he received communication about the bleeding. EI #9 (DON) stated she was not aware of the bleeding until the day of discharge. She also indicated the facility does not keep a copy of the communication form sent to the doctor's office. EI #9 (DON) was asked why was the PT level not drawn on RI #1. She answered that she did not know and wasn't aware that the PT had not been drawn until after the surveyor entered the facility. She was asked how was RI #1's anticoagulant therapy being monitored. The DON (EI #9) responded that it wasn't; the facility didn't get a PT. EI #9 was asked if the resident had a care plan for anticoagulant therapy and what were the interventions. She stated the resident did have a care plan for anticoagulant therapy. The interventions were to monitor for s/s of hemorrhage, PT as ordered, notify MD of s/s, and keep MD aware of labs. On 7/08/11 at 5:18 PM, the facility's Medical Director, EI #12, was interviewed and asked if he had been informed of RI #1 bleeding. He stated that he was not notified. He replied that it was not the way the facility does things. EI #12 said that it was a failure of the nurse to not check and report it. He stated the nurses should have checked on the resident and let someone know this was going on. EI #12 explained that a resident on [MEDICATION NAME] and having bleeding should be monitored closely and the physician should have been called about it. EI #12 stated that a resident on [MEDICATION NAME] should be monitored. This deficiency is written as a result of the investigation of complaint # AL 631. ********************************************* Allegation of Compliance (AOC) F329 On 7/09/11 at 12:00 PM, the Owner, Administrator, Assistant Administrator, and DON provided the surveyor with an acceptable AOC which documents: 1. How the corrective action will be accomplished for those identified residents affected by the deficient practice- The resident affected by the deficient practice was discharge home on 6/24/2011. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice- A chart review was completed on all residents to identify those that are receiving anticoagulant therapy. All residents receiving anti-coagulant therapy were reviewed for compliance to ensure all labs were obtained per MD orders on 7/8/2011. 3. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur- The policy regarding anticoagulant therapy was updated on 7/8/11 to include: residents receiving anticoagulant therapy will be monitored weekly by the RN supervisor to ensure proper labs have been obtained, LPN's will monitor for signs and symptoms of hemorrhage each shift and record on the MAR (Medication Administration Record), any signs or symptoms of hemorrhage will be reported to the physician. The policy was revised on 7/9/11 to include documentation of notification of resident's sponsor and physician. (Name of Medical Director) recommended to Administration that residents on anticoagulant therapy be monitored weekly to ensure labs are being obtained as ordered. All residents receiving anticoagulant therapy will be monitored for signs and symptoms of hemorrhage every shift by licensed staff. Documentation will be noted on the medication administration record. The Director of Nurses and a Registered Nurse supervisor began in-service education on 7/8/11 for all licensed and direct care staff. All licensed staff before being permitted to work will be in-serviced on reporting any signs and symptoms of hemorrhage to the physician. All direct care staff before being permitted to work will be in serviced on reporting any signs and symptoms of hemorrhage to the nurse. All licensed staff will be inserviced on obtaining [MEDICATION NAME] lab levels as ordered by the physician. The Director of Nurses or her designee will provide the in-service education. The RN supervisor or designee will in-service licensed staff upon hire on the policy regarding anticoagulant therapy. The staff developer or designee will in-service direct care staff upon hire on reporting signs and symptoms of hemorrhage to the nurse. 4. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur- RN supervisors will monitor all residents on anticoagulant therapy weekly for signs and symptoms of hemorrhage to ensure labs are being drawn as ordered. This information will be documented on the Anti-coagulant therapy form. The forms will be turned in monthly to the Director of Nurses. The anticoagulant therapy forms will be reviewed on a monthly basis during the monthly QA (Quality Assurance) meetings with departmental staff and quarterly during the QA meetings with our medical director. The monitoring will be reevaluated after six months by the QA committee. ********************************************* After receiving an acceptable Allegation of Credible Compliance on 07/09/11 at 1:37 PM, various staff members including Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses were interviewed on 7/9/11, regarding in-services received on the topic of monitoring for signs and symptoms of hemorrhage, and, for nursing professionals: reporting any signs and symptoms of hemorrhage to MD, documentation of notification of MD and sponsor, and collecting [MEDICATION NAME] on residents receiving anticoagulant therapy. Staff interviews revealed they had been in-serviced by EI #9 on signs and symptoms of hemorrhaging, when and who to report to, when to notify the physician, and when to obtain PT level. A list of all residents who receive anticoagulant therapy was received along with the date of their last PT lab and when the next PT level was due. The physician order [REDACTED]. Each physician order [REDACTED]. (example) excessive bruising, nose bleed, blood in stool or urine, dark tarry stool). Document any positive findings in nurses notes and notify MD" The monitoring tool titled, "ANTICOAGULANT THERAPY MONITORING FORM (name of hall), was reviewed. It included the resident's name, medication order, lab order, lab due, monitor for s/s hemorrhage, results, order for monitoring on chart and MAR, and nurse signature." On 7/09/11 at 1:37 PM, the Immediate Jeopardy was relieved, and the scope / severity level of F 329 was lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance in F329.