Every finding on record at Andersonville TN Opco LLC

Based on facility policy review, medical record review, and interviews, the facility failed to revise a care plan to include a new fall intervention for 1 resident (Resident #16) of 3 care plans reviewed for falls. The findings include:Review of the facility policy titled, Comprehensive Care Plan, undated, revealed .facility will develop and implement a person-centered care plan for each resident, that includes measurable objectives and time frames to meet resident's medical, nursing, mental, and psychosocial needs .maintains a comprehensive care plan participate in the development of and reviewing and revising of the Comprehensive Care Plan .Review of the facility policy titled, Fall Prevention & Management Program guidelines, undated, revealed .when any resident experiences a fall, the facility will .Review the resident's care plan and update as indicated .Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Osteoporosis, and Adult Failure to Thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) assessment score of 03 which indicated the resident had severe cognitive impairment and had no falls since admission. Review of a facility fall incident report for Resident #16 dated 11/19/2025, revealed .Resident [#16] was going to the bathroom unassisted and slipped from W/C [wheelchair] on right hip . New Intervention .Non-Skid footwear and bowel training program . Review of the Comprehensive Care Plan dated 11/29/2025, revealed Resident #16 .at risk for falls related to weakness . Continued review showed no new intervention had been added after the fall on 11/19/2025. During an interview on 12/2/2025 at 1:15 PM, the MDS Coordinator confirmed the care plan had not been revised to include the new intervention after the fall on 11/19/2025. During an interview on 12/2/2025 at 2:27 PM, the Director of Nursing (DON) confirmed Resident #16's comprehensive care plan had not been revised to include nonskid footwear and a toileting program after a fall on 11/19/2025.

Based on facility policy review, medical record review, and interviews, the facility failed to notify a resident representative of a change in condition for 1 resident (Resident #16) of 6 residents reviewed. The findings include:Review of the facility policy titled, Notification of Changes, undated, revealed .This facility will notify the .resident/resident representative of changes in the resident's condition or status .A facility must immediately .notify .the resident representative(s) when there is .significant change in resident's physical condition .such as deterioration in health .Review of the facility policy titled, Nutrition Guidelines, undated, revealed .Monitoring/revision .interviewing the resident and/or representative to determine if their personal goals and preferences are being met .notify of significant changes in weight, intake .Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Protein-Calorie Malnutrition, and Adult Failure to Thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) assessment score of 03 which indicated the resident had severe cognitive impairment and weight loss. Review of a Dietician Progress Note for Resident #16 dated 8/2/2025, revealed .significant weight loss of 8.3% x 30 days and 11.7% x 90 days .BMI [Body Mass Index] is 17.3 underweight status . Continued review showed no documentation the resident's representative had been notified of the significant weight loss. Review of the Comprehensive Care Plan revised 8/8/2025, revealed Resident #16 .has unplanned/unexpected weight loss r/t [related to] poor food intake . During a telephone interview on 12/2/2025 at 2:56 PM, Resident #16's responsible party/conservator stated he was not notified of the resident's significant weight loss. During an interview on 12/2/2025 at 3:10 PM, the Director of Nursing (DON) confirmed there was no documentation Resident #16's responsible party/conservator had been notified of the resident's significant weight loss.

Based on facility policy review, observations, and interviews, the facility failed to follow infection control practices on 2 of 4 hallways observed. The findings include: Review of the facility policy titled, Infection Control: Hand Hygiene revised 6/2023, revealed, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .This applies to all staff working in all locations within the facility .Hand Hygiene .is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .Review of the facility policy titled, Isolation Precautions guidelines undated, revealed, .Droplet precautions .refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory .contact with respiratory secretions .Droplet Precautions .Healthcare personnel will wear a facemask for close contact with an infectious resident .if there is a risk of exposure .gloves and gown as well as goggles (or face shield) should be worn .During an observation and interview on 12/1/2025 at 11:10 AM, Certified Nursing Assistant (CNA) A and CNA B entered room [ROOM NUMBER]. Observation of signage on the outside of room [ROOM NUMBER]'s door revealed Droplet Precautions. Further observation revealed CNA A and CNA B did not don (apply) goggles or a face shield prior to entering the room. CNA A and CNA B stated the resident in 106 A was COVID positive and was on droplet precautions. CNA A and CNA B confirmed they failed to don goggles or a face shield prior to entering the room. During an observation and interview on 12/1/2025 at 12:30 PM, Restorative CNA C entered room [ROOM NUMBER]. Observation of signage on the outside of room [ROOM NUMBER]'s door revealed Droplet Precautions. Further observation revealed Restorative CNA C did not don gloves, gown, mask, and goggles. Restorative CNA C confirmed she failed to don gloves, gown, mask, and goggles prior to entering the room.During an observation on 12/1/2025 at 12:43 PM, CNA D entered room [ROOM NUMBER] and closed the door to the room. The CNA exited the room, failed to wash or sanitize the hands, retrieved a gait belt from the clean linen cart, and entered room [ROOM NUMBER]. CNA D closed the door to room [ROOM NUMBER], exited the room, and failed to wash or sanitize the hands. CNA D re-entered room [ROOM NUMBER], turned the call light off, exited the room, and failed to wash or sanitize the hands. During an interview on 12/1/2025 at 12:51 PM, CNA D stated when he was in room [ROOM NUMBER], he provided incontinence care to the resident in 200B. He also stated he exited room [ROOM NUMBER], failed to wash or sanitize his hands, and entered room [ROOM NUMBER]. Further interview revealed he transferred a resident in 207B from the wheelchair to the bed. The CNA stated he exited room [ROOM NUMBER], failed to wash or sanitize the hands, re-entered the room, turned off the call light, and exited the room without washing or sanitizing the hands. CNA D confirmed he failed to follow the facility's infection control policy when he failed to wash or sanitize the hands after he provided direct care to resident's in rooms 200B and 207B.During an interview on 12/3/2025 at 3:12 PM, the Director of Nursing confirmed CNA A, CNA B, and Restorative CNA C had not followed infection control practices when they failed to don goggles, face shield, gloves, mask, and gown prior to entering a Droplet precaution room (room [ROOM NUMBER]). Further interview confirmed CNA D failed to follow infection control practices when he failed to wash or sanitize the hands after he provided direct care to resident's in rooms 200B and 207B.

Based on review of facility policy, observations, and interviews, the facility failed to maintain a safe, comfortable, and homelike environment for room [ROOM NUMBER] on the 100 hall and rooms [ROOM NUMBERS] on the 400 hall on 2 of 4 hallways observed for a homelike environment. The findings include: Review of the facility's policy titled, Resident Environmental Quality, undated revealed .It is the policy of this facility to be .maintained to provide a safe .comfortable environment for residents .Resident rooms must be designed and equipped for adequate .comfort, privacy of residents .Preventive maintenance schedules, for the maintenance of the building .should be followed to maintain a safe environment .All facility personnel are responsible for reporting broken, defective or malfunctioning .furnishings immediately upon identification of the issue . During observations on 5/21/2024 at 10:18 AM, in room [ROOM NUMBER], revealed the vertical blinds covering the window were missing blind slats. There was a small opening visible to the outside at the right upper corner of the heating and cooling unit in the wall. During observations on 5/21/2024 at 10:25 AM, in room [ROOM NUMBER], revealed a small opening visible to the outside at the left upper corner of the heating and cooling unit in the wall. During observations on 5/21/2024 at 10:30 AM, in room [ROOM NUMBER], revealed a small opening visible to the outside at the left upper corner of the heating and cooling unit in the wall. During an interview on 5/21/2024 at 10:50 AM, the Administrator, Director of Nursing (DON), and the Maintenance Director, confirmed there was a small opening visible to the outside at the left upper corner of the the heating and cooling unit in the wall in rooms [ROOM NUMBERS]. During an interview on 5/21/2024 at 10:55 AM, the Administrator, DON and Maintenance Director, confirmed there was a small opening visible to the outside at the right upper corner of the heating and cooling unit, confirmed the vertical blinds were missing blind slats in room [ROOM NUMBER], and confirmed the facility had failed to provide an optimal home like environment for the residents.

Based on facility policy review, time punch review, review of staff statements, and interviews the facility failed to maintain a sufficient number of dietary staff to safely and effectively carry out the function of the food and nutrition service for dining during breakfast for 60 of 62 residents. The findings include: Review of the facility policy titled, Professional Staffing, dated 9/2017 revealed, .The Dining Services department will employ sufficient staff with .skill sets to carry out the functions of food and nutrition services . Review of the facility's Midnight Census Report dated 4/15/2022 revealed the facility had a total of 62 residents in the facility on 4/15/2022. Review of the facility's 672 form dated 4/19/2022 revealed the facility had a total of 3 resident's receiving tube feedings (1 of the 3 resident's was on pleasure feedings). During an interview with Dietary Aid (DA) #1 on 4/19/2022 at 2:55 PM, revealed on 4/15/2022 Dietary Manager (DM) #1 and the DA #2 were not in the facility on 4/15/2022. Review of the Dietary Staff Time Sheet and interview on 4/20/2022 at 9:44 AM, the Director of Operations ((DO) (Director of the contracted company used for dietary service in the facility)) revealed DM #1 and DA #2 were scheduled to work in the kitchen on 4/15/2022. Continued interview revealed DM #1 and DA #2 did not come to the facility to prepare breakfast for the residents in the facility on 4/15/2022. The DO revealed the nursing home staff prepared breakfast for the residents in the facility on 4/15/2022. The Administrator notified the Dietary District Manager on the morning of 4/15/2022, the dietary staff had not arrived at the facility to prepare breakfast for the residents. Further interview revealed the Dietary District Manager arrived at the facility at 8:30 AM and worked at the facility until 8:45 PM on 4/15/2022. Continued interview confirmed DM #2 came from another facility and worked in the kitchen between 8:00 AM and 8:30 AM and worked until 8:00 PM on 4/15/2022, and DA #3 was called and worked in the facility from 10:00 AM-8:15 PM. The DO revealed the kitchen was fully staffed for lunch on 4/15/2022. The DO revealed the bacon, eggs, and oatmeal on 4/15/2022, prepared by the facility staff was a nutritious meal. Continued interview confirmed if one of the previous DM's prepared a meal at the facility on 4/15/2022, she would have overseen all aspects of the kitchen as an old DM. This would include cooking resident's food and following the diet orders as prescribed by the physician, and she would be aware of the process to puree and provide different textures of food for the residents safely and effectively. The Director of Operations stated, .Tickets [meal tickets] were fully available [on 4/15/2022] .tickets are printed the day before at 2:00 PM-5:00 PM and placed on the preparation table for dietary staff to use to determine meal and any therapeutic restrictions . The DO confirmed the facility failed to maintain a sufficient number of dietary staff to safely and effectively carry out the function of the food and nutrition services for dining during breakfast on 4/15/2022 until 8:30 AM. Observation on 4/20/2022 at 10:33 AM, of the kitchen preparation table next to the steam table revealed resident meal tickets readily accessible to kitchen staff. Continued observation revealed the Production Count Form which shows the recipe number and the quantity of food required to feed the residents bacon, scrambled eggs, oatmeal (hot cereal), and toast was also located on the preparation table. During an interview on 4/20/2022 at 12:19 PM, with the Resident Care Specialist/Restorative Aid (RCS/RA) and review of the RCS/RA's written statement dated 4/20/2022 revealed on 4/15/2022 at 6:50 AM, revealed she received a call from the Staff Coordinator/Health Care Coordinator (SC/HCC) requesting assistance with breakfast preparation for residents in the facility, and was informed dietary staff had not arrived at the facility. Further interview confirmed the RCS/RA arrived at the facility at 7:03 AM on 4/15/2022, and went directly to the kitchen and assisted the SC/HCC, Administrator, and the Activity Manager (AM) in preparing the residents' breakfast meal. The RCS/RA confirmed the meal tickets were utilized, and the SC/HCC ensured residents received the appropriate meal and fluids as ordered by the physician. Further interview revealed, .The dietary staff showed up a little after 8:00 AM [on 4/15/2022] . During an interview on 4/20/2022 at 12:41 PM, with the AM and review of the AM's written statement dated 4/19/2022, confirmed the dietary staff did not arrive at the facility to provide breakfast for the resident's on 4/15/2022. Further interview confirmed the RCS/RA requested the AM to assist her in preparing breakfast for the residents. Further interview confirmed the staff utilized the resident meal tickets in the kitchen and followed the physician diet orders to provide breakfast to the residents. The AM stated, .We followed the Doctor's orders for the resident meals and ensured resident received the textured food, the right amount, the right plate whether they needed a plate guard, or built-up silverware, a divide plate, or the plate with the edges . The AM confirmed the SC/HCC had been the previoius DM, and she prepared and checked the meal trays for accuracy prior to the trays leaving the kitchen. During an interview on 4/20/2022 at 12:53 PM, with the SC/HCC (the previous DM) and review of her written statement dated 4/20/2022 revealed she arrived at the facility at 6:30 AM on 4/15/2022, and was informed by nursing staff dietary had not arrived at the facility. Further interview revealed she notified the Administrator the dietary staff had not arrived at the facility and was instructed to start preparing the residents' breakfast. The SC/HCC retrieved the emergency keys out of the medication room and went to the kitchen and prepared breakfast for the residents. The SC/HCC stated she worked as the DM at the facility for 9 months and she was knowledgable of how to ensure the residents received the correct diets as ordered by the phyician, and the trays were checked for accuracy. The SC/HCC revealed the dietary staff arrived around 7:40 AM-8:00 AM (4/15/2022). The SC/HCC stated, .When they [dietary staff] came in we had a little food left to be served and eggs to be fixed so the dietary staff finished up .the Manager [DM] quit that morning and the other staff she had to help her called in . The SC/HCC confirmed the facility failed to have a sufficient number of dietary staff to safely carry out the food and nutrition services for dining on 4/15/2022. During an interview on 4/20/2022 at 1:17 PM, the Administrator and review of the Administrator's written statement dated 4/19/2022, revealed she received a telephone call from the SC/HCC on 4/15/2022, and was notified the dietary staff had not arrived at the facility to provide breakfast for the residents. Further interview confirmed the Administrator instructed the SC/HCC, the previous DM in the facility, to start preparing breakfast. The Administrator also stated she notified the Dietary District Manager the dietary staff had not arrived to the facility to prepare breakfast for the residents. The Administrator confirmed the facility failed to maintain a sufficient number of dietary staff to safely and effectively carry out the function of the food and nutrition service for residents dining at breakfast on 4/15/2022.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with undated, expired, open to air, and undated with use by date, in 1 of 2 refrigerators, and in 2 of 2 freezers and failed to maintain a sanitary kitchen with debris in 1 of 3 plastic storage bins, and unsanitary use of food temperature thermometers. The facility failed to maintain a sanitary kitchen with dietary staff not using appropriate hand hygiene, undated, unlabeled, undated with a use by date, and food items stored inappropriately under 1 of 1 steam tables and failed to maintain kitchen equipment in a sanitary manner. The facility failed to maintain a sanitary kitchen with the use of an unsanitary cup at 1 of 1 drink stations in the kitchen with debris in 1 of 2 plastic containers, and open to air food items on counters in the kitchen potentially affecting 59 of 61 residents. The findings include: Review of the facility policy titled, Food Preparation, dated ,d+[DATE] revealed, .All staff will practice proper hand washing techniques and glove use .All food contact equipment, and food contact surfaces will be cleaned and sanitized after every use . Review of the facility's policy titled, Food Storage Dry Goods, dated ,d+[DATE] revealed, .All dry goods will be appropriately stored . Review of the facility policy titled, Environment dated ,d+[DATE] revealed, .All food preparation areas, food service areas .will be maintained in a clean and sanitary condition . Review of the facility policy titled, Equipment, dated ,d+[DATE] revealed All foodservice [food service] equipment will be clean .sanitary .All equipment will be routinely cleaned . Review of the facility policy titled, Food Storage Cold Storage, dated ,d+[DATE] revealed, .All foods will be stored wrapped or in covered containers, labeled and dated . Review of the facility's guideline titled, Labeling and Dating, undated revealed, .Guidelines for Labeling and Dating .All food should be dated upon receipt before being stored .Food labels must include .The food item name .The date of preparation .removal from freezer .Use By dating Guidelines .The manufactures expiration date, when available, is the use by for unopened items . Review of the facility's policy titled, Infection Control Overview Policy, undated revealed, .[Name of the Dietary Contracted Company] promotes the health and safety of all employees, as well as that of the clients we serve .Standard precautions for .dining service employees .Proper hand hygiene . During an observation on [DATE] at 9:40 AM, in the kitchen, of the reach in refrigerator with the Dietary Manager (DM) revealed: - 1 whole peanut butter jelly sandwich undated and available for resident use. - Two ,d+[DATE] peanut butter sandwiches undated and available for resident use. - 1 pack of approximately 20 unopened pieces of salami with a use by date of ,d+[DATE] (expired 3 months ago) available for resident use. - 4 pieces of sliced turkey in a plastic bag undated and available for resident use. - One 2.5-pound bag of shredded mild cheddar cheese open to air and available for resident use. - 1.5-pound bag of shredded mozzarella cheese undated, unlabeled, and available for resident use. - 1 whole cabbage lying on a shelf, not in a container, undated, unlabeled and available for resident use. - 2.5-pound bag of shredded lettuce opened to air, dated [DATE] (17 days old), and with no use by date. During an interview on [DATE] at 9:41 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with undated, expired, open to air, unlabeled, and undated with a use by date food items available for resident use in the reach in refrigerator. During an observation on [DATE] at 9:59 AM, of the kitchen, in the reach in freezer, located near the stove, with the DM revealed: - Approximately 25 pounds of crinkle cut sliced carrots located in a box in a bag open to air and available for resident use. - Approximately 1 pound of raw green beans located in a box in a bag open to air and available for resident use. - Appropriately 15 pounds of whole kernel corn in a bag open to air and available for resident use. - ,d+[DATE] pound of French fries in a bag undated, undated with no use by date, and available for resident use. During an interview on [DATE] at 10:00 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with open to air, undated, and undated with a use by date food items available for resident use in the reach in freezer. During an observation on [DATE] at 10:14 AM, of the kitchen and storage room, with the DM revealed: - One plastic storage bin of packets of saltine crackers with powdered beige debris located in the bottom of the storage bin. During an interview on [DATE] at 10:14 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with beige powdered debris in the plastic storage bin. Continued interview revealed the DM stated the bin should have been emptied and cleaned. During an observation on [DATE] at 10:17 AM, of the kitchen, of the meat freezer located in the storage room, with the DM revealed: - 8 hot dogs in a bag open to air, undated, unlabeled, and available for resident use. - 49 precook Salisbury steak patties located in a box in a bag open to air, undated, unlabeled, undated with a use by date, and available for resident use. - 69 uncooked frozen hamburger patties located in a box in a bag open to air, undated, unlabeled, undated with a use date and available for resident use. During an interview on [DATE] at 10:17 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with open to air, undated, unlabeled, and undated with a use by date food items available for resident use in the meat freezer. During an observation on [DATE] at 11:36 AM, of the kitchen, revealed the DM removed a vegetable quiche prepared for the residents in the facility's lunch from the stove and placed the quiche on the counter preparation station opposite the stove. The DM informed the Dietary Cook (DC) #1 to take the temperature of the quiche. DC #1 picked up the previously used thermometer lying on the steam table surrounded by used alcohol wipes and food debris. The DC #1 then placed the unsantizied thermometer in the center of the quiche. Further observation revealed the quiche was to be served to the residents for lunch on the tray line. During an interview on [DATE] at 11:57 AM, the DM confirmed the facility failed to maintain a sanitary kitchen environment by using an unsanitary food thermometer to test the temperatures of food available for resident use. During an observation on [DATE] at 11:44 AM, in the kitchen, of dietary staff, performing food temperature checks during lunch preparation, revealed the Dietary Aid (DA) #1 donned clean gloves and walked around the kitchen area touching 3 kitchen surface preparation tables while wearing the same gloves. DA #1 then returned to the preparation table located near the steam table while wearing the same unsanitary gloves and retrieved a clean thermometer and placed the thermometer in a cup of water. DA #1 then used the thermometer to obtain food temperatures of one 8-ounce tea and one 8-ounce honey milk. Further observation revealed DA #1 then returned to the food preparation table located next to the steam table then clean the thermometer with alcohol prep pads, walked to the trash can, lifted the lid of the dirty trash and discarded the used alcohol pads while wearing the same unsanitary donned gloves. Continued observation revealed while wearing the same donned gloves the DA #1 obtained the food temperature of cut peaches in one individual desert bowl on the preparation table without removing the unsanitary gloves and without sanitizing her hands. During an interview on [DATE] at 11:49 AM, in the kitchen, DA #1 confirmed she did not remove her gloves, and did not sanitize her hands after touching the preparation tables and trash can lid. During an interview on [DATE] at 11:50 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with staff not performing appropriate hand hygiene while handling resident's foods and while performing food temperature checks on foods available for resident use during lunch. Continued interview revealed the DM stated, She should have washed her hands and changed her gloves. During an observation on [DATE] at 2:03 PM, in the kitchen, on a shelve under the steam table with the DM revealed: - 1 hard plastic cereal bowl with a disposable lid which contained an orange-colored powdered substance undated, unlabeled, undated with a use by date, and available for resident use. - 1 hard plastic cereal bowl with a cracked disposable lid labeled cheese and dated [DATE] (8 days old). Continued observation revealed approximately 3 tablespoons of orange colored cheese with green mold scattered throughout the bowl which was available for resident use. During an interview on [DATE] at 2:09 PM, revealed the DM was unable to name the orange powdered substance located in 1 of the cereal bowls. Continued interview confirmed the cheese was not to be stored at room temperature and should be stored in the refrigerator to prevent spoiling and mold. Further interview confirmed the facility failed to maintain a sanitary kitchen with undated, unlabeled, undated with no use by date, and storage of food items at non appropriate food temperatures. Interview confirmed the food items were available for resident use and should have been discarded. During an observation on [DATE] at 2:11 PM, in the kitchen, of the microwave with the DM revealed: - black and orange food debris inside of the microwave. During an interview on [DATE] at 2:14 PM, the DM confirmed the facility failed to maintain a sanitary kitchen with debris located in the microwave. During an observation on [DATE] at 2:,d+[DATE]:29 PM, of the kitchen, of the resident drink station with the DM revealed: - One 8-ounce white Styrofoam cup covered in dark brown colored debris with the word tea handwritten in a black marker on the cup over 20 times. Continued observation revealed the Styrofoam cup covered 1 of the 3 handles on the right side of the coffee/tea dispenser and touched the spout of the coffee/tea dispenser. - On the metal shelf below the coffee/tea drink station was a clear 20-quart plastic container containing loose packets of tea. Continued observation revealed approximately 4 tablespoons of a loose dark brown powdered substance scattered throughout the container. During an interview on [DATE] at 2:31 PM, the DM confirmed the facility failed to maintain a sanitary kitchen with an unsanitary Styrofoam cup touching the spout and handle of the coffee/tea dispenser, and a container with loose dark brown powdered substance located in the bottom of a food container. The DM stated the container should have been cleaned and emptied when it was soiled. During an observation on [DATE] at 2:33 PM, of the kitchen, of the metal preparation table located next to the refrigerator, with the DM revealed 3 individual sugar cookies and 1 chocolate chip cookie in clear plastic bags open to air and available for resident use. During an interview on [DATE] at 2:35 PM, the DM confirmed the facility failed to maintain a sanitary kitchen with open to air food available for resident use. The DM stated the cookies should be in a tight fitting bag.

Based on review of the facility policy, medical record review, observation and interview the facility failed to maintain infection control practices for 1 resident (#52) of 3 residents observed for wound care. The findings include: Review of the facility policy Clean Dressing Change revised 12/09, revealed .Put on gloves .Remove soiled dressing, place in bag for disposal .Remove/dispose of gloves, wash hands, don clean gloves .Clean wound as ordered .Remove/dispose of gloves, wash hands, don clean gloves .Apply dressing and secure .Remove gloves .Wash hands . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Orders revealed the following: 5/16/19 - [MEDICATION NAME] Powder (medication to treat wound) Apply .every day shift for wound care clean daily with iodine x 3 rinse with (normal saline) x 3 pat dry, apply collagen granules (medication to treat wound) to base of wound bed with (a wound dressing) cover with waterproof silicone dressing. 5/31/19 - Santyl Ointment (medication to debride wound) Apply to areas of slough (dead tissue) .topically every day shift. Observation of Resident #52's wound care on 6/5/19 at 10:15 AM, with the Wound Care Nurse (WCN) in the resident's room, revealed the WCN removed the soiled dressing from the resident's coccyx; removed and discarded the gloves; donned new gloves and did not wash the hands. Continued observation revealed the WCN disinfected the wound with iodine, removed the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN rinsed the wound with a 4 x 4 dressing soaked with normal saline, dried the wound, discarded the gloves and donned new gloves without washing the hands. Continued observation revealed the WCN applied Santyl ointment to the wound, discarded the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN applied the collagen granules to the wound, discarded the gloves, donned new gloves and did not wash the hands. Continued observation revealed the WCN completed the treatment and applied the dressing. Interview with the Wound Care Nurse on 6/5/19 at 10:25 AM, in Resident #52's room, confirmed she failed to wash her hands after glove removal during wound care. Interview with the Director of Nursing on 6/5/19 at 1:37 PM, in the conference room, confirmed during the observation of Resident #52's wound care, the facility's policy for infection control was not maintained when hands were not washed after glove removal.

Based on facility policy review, observation, and interview, the facility failed to ensure staff disinfected hands after glove removal and disinfect hands after the administration of medication for 1 of 3 nurses observed for medication administration. The finding included: Review of the facility policy, Hand Hygiene, last revised 2/2018, revealed Purpose: to decrease the risk of transmission of infection by appropriate hand hygiene .using an alcohol based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient .after removing gloves . Observation of a medication administration on 6/18/18, at 8:05 AM, in the 300 hallway, revealed Licensed Practical Nurse (LPN) #1 had prepared the resident's medication in a plastic medication cup. Continued observation revealed the following: 1. LPN entered the resident's room, gave the medication cup to the resident. 2. Resident swallowed several pills at at time. 3. Resident dropped 1 medication pill on the floor. 4. LPN donned gloves, picked up the 1 medication pill off the floor, removed the gloves with the pill inside the gloves, placed on bedside table. 5. LPN donned another pair of gloves, administered an insulin injection. 6. LPN removed the gloves, exited the room, returned to the medication cart without disinfecting the hands. Interview with LPN #1 on 6/18/18, 8:20 AM, in the 300 hallway, confirmed hands were not disinfected after glove removal nor after the administration of the insulin injection

Based on medical record review and interview, the facility failed to notify the physician of a medication recommendation by a consulting practitioner for one resident (#101) of 29 residents reviewed. The findings included: Resident #101 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status score of 13 points out a possible 15 points. Medical record review of the Behavioral Medicine Progress Note dated 2/07/17, revealed Reason for Visit (Chief complaint): f/u (follow-up) medication review for recent consult to initiate trazadone (antidepressant medication also used to treat [MEDICAL CONDITION]) r/t (related to) [MEDICAL CONDITION]. Medical record review of the facility Order Summary Report dated 4/05/17 revealed no order for the resident to receive [MEDICATION NAME]. Interview with the Director of Nursing on 4/25/2107 at 4:00 PM, in the conference room, confirmed the physician had not been notified of the recommendation from the Behavioral Medicine Progress Note for [MEDICATION NAME], and no order had been written.

Based on review of facility policy, medical record review and interview the facility failed to provide showers per the care plan for 1 Resident (#5), of 4 residents reviewed for Activities of Daily Living, of 5 residents reviewed. The findings included: Review of the facility policy, Routine Resident Care revised June 2008, revealed .Residents receive necessary assistance to maintain good grooming and personal .hygiene .Showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident with a Brief Interview of Mental Status Score of 15/15 (cognitively intact), had no symptoms of [MEDICAL CONDITION], and was dependent for transfers, bathing, and personal hygiene. Medical record review of the current Care Plan revealed Resident #5 was to receive showers twice weekly on Wednesdays and Saturdays. (An average of 8 showers monthly). Medical record review of the Activity of Daily Living (ADL) Flow Sheets dated 6/30/16 to 7/30/16 revealed the resident was not showered on Wednesdays and Saturdays in accordance with the Care Plan, and received only 3 showers in a 30 day period between 6/30/16 to 7/30/16. No showers were documented as performed between 7/16/16 and 7/30/16 (14 consecutive days). Observation and interview with Resident #5 on 8/9/16 at 5:00 PM, in the resident's room, revealed the resident was alert, oriented to place and circumstances. The resident reported he did not regularly receive showers on Wednesdays and Saturdays and reported he frequently was not offered showers on his appointed shower days. Continued observation and interview revealed a noticeable smell of body odor present. The resident also reported the facility frequently delayed his showers. Resident #5 stated he could not recall when he last showered. Interview with the DON on 8/9/16 at 5:30 PM, in the Administrator's Office, confirmed the facility had failed to shower the resident in accordance with the care plan and facility policy, and confirmed no evidence was present in the medical record which indicated the resident had refused showers on the scheduled shower days.

Based on medical record review, review of the Medication Variance Record and interview, the facility failed to be administered in a manner to ensure significant medication errors did not occur for 7 residents (#22, #150, #169, #178, #31, #93, #177) and failed to ensure pain medication was administered prior to wound care for 2 residents (#150, #169) of 16 residents reviewed for medication administration. The facility's failure to ensure significant medication errors did not occur placed all residents in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of Immediate Jeopardy on 4/25/16 at 10:50 AM, in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited an Immediate Jeopardy at F-281 (J); F-309 (J); F-333 (K); F490 (K); F-501 (K); F-520 (K). The facility was cited Substandard Quality of Care at F-309 (J); F-333 (K). The findings included: Interview with the Administrator on 4/25/16 at 1:24 PM, in the conference room confirmed the Administrator had not been involved in the process related to medication errors. Refer to F281 (J), F309 (J), F333(K).

Based on facility policy review, medical record review, review of Medication Variance Report, and interview, the facility failed to prevent significant medication errors for 7 (#22, #150, #169, #178, #31, #93, #177) of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed 7 (#22, #150, #169, #178, #31, #93, #177) residents in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause, serious harm, injury, impairment or death). The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on [DATE] at 10:50 AM in the DON's office. The Immediate Jeopardy is effective [DATE] and is ongoing. The facility was cited F 333 at a scope and severity of (K), which constitutes Substandard Quality of Care. The findings included: Review of facility policy, Medication Administration, revised ,[DATE] revealed Resident Medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug frequency, durations, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], after admission to the hospital after and an overdose of [MEDICATION NAME] sulfate at the facility, with [DIAGNOSES REDACTED]. Medical record review of the [DATE] Physician's Recapitulation Orders revealed .[MEDICATION NAME] (opiate narcotic [MEDICATION NAME], can cause respiratory distress and death when taken in high doses) sol (solution) w/syr (with syringe) .20 mg. (milligrams)/1 ml. (milliliter) solution .1.25 mls (25 mg) sublingually (under the tongue) five times daily routine (7 AM, 12 PM, 5 PM, 10 PM, 3 AM) . Medical record review of a prescription for Resident #22 dated [DATE] revealed [MEDICATION NAME] sulfate 20 mg/5 ml, 6 ml PO/SL (by mouth/sublingually) at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM . Medical record review of the ,[DATE] Medication Record revealed on [DATE] the [MEDICATION NAME] 20 mg/5 ml, 6 ml PO/SL at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM was transcribed onto the Medication Record to reflect the change in the concentration/strength of the [MEDICATION NAME] solution. Review of a Medication Variance Report dated [DATE] at 10:00 AM revealed Resident #22 received the wrong dose (concentration/strength) of [MEDICATION NAME]. Continued review of the Medication Variance Report revealed the resident was to receive [MEDICATION NAME] with a strength of 20 mg/5 ml oral solution, with a dose of 24 mg/6ml, but had received [MEDICATION NAME] 20 mg/ml with a dose of 120 mg/6 ml for 4 doses. Continued review of the Medication Variance Report revealed .Outcome .hospitalization .temporary change in level of consciousness .An error occurred that may have contributed to or resulted in temporary resident harm or required initial or prolonged hospitalization . Review of the Individual Patient's Controlled Substances Record for Resident #22 revealed on [DATE] [MEDICATION NAME] Solution 20 mg/ml was obtained from the facility's emergency supply. Continued review of the Individual Patient's Controlled Substances Record revealed Licensed Practical Nurse (LPN#1) signed out 6 ml (120 mg) of the [MEDICATION NAME] solution for administration to Resident #22 on [DATE] at 12:00 PM, 5:00 PM, and 10:00 PM. Continued review of the Individual Patient's Controlled Substances Record revealed LPN #2 signed out 6 ml (120 mg) of the [MEDICATION NAME] Solution for administration to Resident #22 on [DATE] at 3:00 AM. Medical record review of the [DATE] through [DATE] Medication Record revealed on [DATE] the [MEDICATION NAME] 20 mg/5 ml, 6 ml po/sl was circled as not administered at 7:00 AM. Medical record review of a nursing note dated [DATE] revealed 7AM CNA (Certified Nursing Assistant #7) reports res. (resident) 'acting funny.' Spoke with res & (and) he talked cheerful & knew this nurses name. No distress at present .10 AM-Upon entering room-res presents with decreased LOC (level of consciouness). NP (Nurse Practitioner) & RN (Registered Nurse) Sup (supervisor) notified & following orders in MD (Medical Doctor) orders .12p Res. alert with resp (respirations) @ (at) 16, knows staff & agrees for further TX (treatment) & eval (evaluation) to be trans (transferred) to (named hospital) . Medical record review of the NP progress note dated [DATE] revealed .BP (blood pressure) ,[DATE] .HR (heart rate) 80 .RR (respiratory rate) 4 rpm (respirations per minute) Temp (temperature) 101.4 O2 (oxygen) Sat (saturation) 93% (percent) .RA (room air) .wheezing .awake, able to verbalize .[MEDICATION NAME] (opiate antidote) 0.8 mg IM (intramuscular) given, did not respond, another 0.8 mg given & respirations up to 12/min (minute). Another 1 mg [MEDICATION NAME] given & he improved to 16/min then O2 sat dropped to 83%, O2 applied at 2 LPM (liters per minute) & O2 remains at 93%, B/P dropped to ,[DATE] then improved, 1 mg [MEDICATION NAME] given & he briefly improved for several minutes, then resp. (respirations) decreased with 10 sec. (seconds) periods of apnea-Sent to ER (emergency room ) .1. Acute Respiratory Distress (difficulty breathing requiring medical intervention). 2. Hypoxemia (low level of oxygen). 3. [MEDICAL CONDITION] (malfunction of the brain manifested by an altered mental state). 4. [MEDICAL CONDITION] (low blood pressure). 5. Dyspnea (difficult or labored breathing, shortness of breath) . Medical record review of a NP order dated [DATE] at 10:40 AM revealed [MEDICATION NAME] 1.6 mg IM (intramuscular injection) now, O2 to keep sats (saturation level) at 92% or above, PCXR (portable chest x-ray)-wheezing, fever, [MEDICATION NAME] (inhalation respiratory treatment) 1 unit dose now, [MEDICATION NAME] 1 mg IM again now . Medical record review of a NP's order dated [DATE] at 11:00 AM revealed .Hold [MEDICATION NAME], Give 2 mg [MEDICATION NAME] now. Medical record review of a NP's order dated [DATE] at 11:30 AM revealed Send to ER. Medical record review of an Emergency Department note dated [DATE] revealed .The patient presents to the emergency department after a known overdose, that was accidental .Pt (patient) was at his rehabilitation center and he was given too much [MEDICATION NAME] overnight last night. Pt had decreased LOC and has a history of dementia . Medical record review of a hospital History and Physical dated [DATE] revealed .Chief Complaint: Overdose .apparently was sent into the ER after he was difficult to arouse. There was concern he may have been given 6 times as prescribed (to) him on [MEDICATION NAME] .he was given [MEDICATION NAME] at the facility and has some improvement .He is awake now and is answering questions . Medical record review of a hospital Discharge Summary dated [DATE] revealed .male with multiple medical problems .had a history of [REDACTED].and [MEDICAL CONDITION]. The patient also has mild dementia .was apparently sent to the ER after he was difficult to arouse. There was concern he may have been given 6 times as prescribed on his [MEDICATION NAME] .The patient was admitted for further evaluation and management. Discharge Diagnoses: [REDACTED].The patient's [MEDICATION NAME] has been discontinued. The patient was placed on p.r.n. (as needed) [MEDICATION NAME]. Mentation has improved . Review of facility investigation dated [DATE], prepared by the DON revealed (Resident #22) had a physician's orders [REDACTED]. This concentration is what was being dispensed by the pharmacy. On [DATE], the last dose of this concentration was used at the 7am dose. The pharmacy was contacted and a request was made for CII (Controlled Substance Schedule II) Continuance of Therapy prescription was made. The pharmacy told the nurse that she would have to get the 12N dose from the ER Narcotic Drug Box. The concentration of the [MEDICATION NAME] Solution in the ER Drug box is 100 mg./5 ml. (Resident #22 received 4 doses @ (at) 6ml/dose. Two nurses were involved in administering the wrong dose. When I was notified Friday, [DATE] of the error, I instructed both nurses to meet with the administrator and me on Monday before returning to work. At 8:00 am (LPN #1) came in to review the incident .I questioned her about reading the label and comparing with her MAR (Medication Administration Record). She stated that she was in a hurry and didn't check .10:30 am (LPN #2) came to speak with the administrator and me about the incident that occurred with (Resident #22). LPN #2 said that she gave 6 ml. @ the 3 am dose. When asked if she checked the label for concentration, she said no . Interview with the Physician/Medical Director on [DATE] at 3:25 PM, in the conference room revealed the resident received the [MEDICATION NAME] due to severe general pain everywhere. Continued interview revealed the Physician had been notified the resident had received too much [MEDICATION NAME] on [DATE] and [DATE]. Continued interview revealed the resident also had an infection at the time of the medication error. Continued interview confirmed the wrong concentration of [MEDICATION NAME] had been administered. Continued interview revealed some of the possible side effects of too much [MEDICATION NAME] included respiratory depression, lethargy, and drowsiness. Continued interview revealed on a smaller patient the dosage of [MEDICATION NAME] administered to Resident #22 could have been deadly. Telephone interview with LPN #2 on [DATE] at 10:05 PM revealed LPN #2 didn't usually work on the unit where Resident #22 resided. Continued interview revealed LPN #2 should have noted the concentration of the [MEDICATION NAME]. Interview confirmed LPN #2 had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls (120 mg) to Resident #22 on [DATE] at 3:00 AM. Interview with the NP (who was present on [DATE], when the medication error was identified) on [DATE] at 11:15 AM, in the conference room revealed RN #1 had notified the NP there had been an error in the administration of Resident #22's [MEDICATION NAME]. Continued interview revealed when the NP had first examined the resident on [DATE], the resident was in respiratory distress. Continued interview revealed the resident had shallow breathing and was not breathing as many times per minute as the NP would like. Continued interview revealed the resident's respiratory rate had been 12 per minute and the NP would like the respiratory rate to be 16. Continued interview revealed the NP was at the resident's bedside during the time after the incorrect dosage of [MEDICATION NAME] had been administered to the resident the resident's oxygen saturation level had dropped to 83% and oxygen had been administered to the resident. Further interview revealed while in attendance to the resident it was discovered the resident had an elevated temperature and the NP had thought the resident might have pneumonia. Interview revealed the resident was transferred to the hospital related to fever, the resident's oxygen saturation level and blood pressure had dropped indicating the resident had some other medical condition in addition the incorrect dosage of [MEDICATION NAME] on [DATE]. Telephone interview with LPN #1 on [DATE] at 3:15 PM revealed the facility had used all of Resident #22's [MEDICATION NAME] solution, the pharmacy had been contacted to obtain a code to remove the medication from the facility's ER narcotic box. Continued interview confirmed LPN #1 did not check the medication label and had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls (120 mg) to Resident #22 on [DATE] at 12:00 PM, 5:00 PM, and 10:00 PM (3 consecutive doses). Further interview revealed on the morning of [DATE] CNA (#7) had reported the resident was acting funny however, LPN #1 had spoken to the resident and the resident had said hey nurse (name) and did act a little silly. Interview revealed the 7:00 AM dose of [MEDICATION NAME] on [DATE] was not administered to Resident #22 due to another resident had a medical emergency at that time and LPN #1 was so busy she had not administered the [MEDICATION NAME] to Resident #22. Interview with CNA #7 on [DATE] at 7:35 AM, near the nursing station revealed on [DATE] when the CNA had entered Resident #22's room, the resident was hard to wake up was confused, did not know it was morning, didn't recognize CNA #7, who routinely provided care to the resident, and had reported something was wrong with the resident to LPN #1. In summary: On [DATE] the facility had used all the prescribed [MEDICATION NAME] sulfate solution ordered for Resident #22 on [DATE], notified the pharmacy and obtained [MEDICATION NAME] sulfate from the ER narcotic box. LPN #1 and LPN #2 did not check the label of the [MEDICATION NAME] sulfate to verify concentration/strength, and administered the wrong dosage (120 mg) of the [MEDICATION NAME] sulfate to the resident for 4 consecutive doses ([DATE] at 12:00 PM, 5:00 PM, and 10:00 PM, and on [DATE] at 3:00 AM). The resident suffered respiratory depression, was administered [MEDICATION NAME] at the facility then transferred to the ER. The resident returned to the facility on [DATE]. Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a physician's orders [REDACTED].Start ([MEDICATION NAME]) 1mg SQ (subcutaneous) q 15 m (minutes) (before) wound care BID (twice a day) . Medical record review of the Controlled Drug Record dated [DATE] revealed only 1 dose of the [MEDICATION NAME] 1 mg was signed out as administered on [DATE], [DATE], [DATE], [DATE], [DATE], (instead of 2 doses as ordered prior to wound care missing 5 doses) and no doses of the [MEDICATION NAME] was signed out as administered on [DATE]. Medical record review of the Non Pressure Skin Condition Record dated [DATE] revealed .(continue) wound care .(change) BID (twice a day). Resident (continues) to be resistant to touching or cleaning wound but will allow to some degree if pain med given prior to (treatment) . Interview with the DON on [DATE] at 1:24 PM in the conference room and review of the Controlled Drug Record confirmed the [MEDICATION NAME] was not administered as ordered prior to wound care. Medical record review revealed Resident #169 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #169 was discharged home on [DATE]. Medical record review of the Medication Record dated [DATE] to [DATE] revealed no documentation [MEDICATION NAME] 2 mg/ml, 1 ml sq before wound care was administered. Medical record review of the physician's orders [REDACTED]. 2 mg/ml, 1 ml sq (subcutaneous) 10 min (minutes) b/f (before) wound care daily. Medical record review of the Controlled Drug Record dated [DATE] to [DATE] revealed [MEDICATION NAME] 2 mg/ml, 1 ml sq b/f wound care was signed out 12 times out of 26 doses ordered (14 missed doses). Interview with the Wound Care Registered Nurse on [DATE] at 10:00 AM, in the Conference Room revealed she asked the LPN to medicate the resident prior to wound care, returned to the LPN and asked if the resident had been medicated and proceeded with wound care. Interview with the DON on [DATE] at 9:50 AM in the DON office confirmed there was no documentation on the Medication Record the [MEDICATION NAME] was administered prior to wound care as ordered by the physician (14 doses not administered as ordered. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Physician's Recapitulation Orders dated [DATE] revealed .[MEDICATION NAME] ,[DATE] (2) tabs po q (every) 6 (hours) as needed pain . Medical record review of a Prescription dated [DATE] revealed .[MEDICATION NAME] XXX,[DATE] mg (milligram) 1 tab po QID (4 times daily) PRN (as needed) pain . Medical record review of the Pain Evaluation dated [DATE] revealed .[DIAGNOSES REDACTED].Generalized . Medical record review of the Individual Patient's Controlled Substances Record revealed the resident received 2 [MEDICATION NAME] ,[DATE] mg from [DATE] to [DATE] (4 times tablets daily). Review of the Medication Variance Report dated [DATE] revealed .Medication Involved .[MEDICATION NAME] ,[DATE] .Original MAR (Medication Administration Record) on Admission ,[DATE] (2) tabs QID PRN. On [DATE] (Physician) wrote a new (prescription) for [MEDICATION NAME] 1 tab ,[DATE] po QID PRN/pain .order change for prescription not transcribed to MAR .Actions Taken Pt (patient) has received (2) tabs QID or Q 6 (hours) since admission (without) a change documentation reflecting new (prescription) . Interview with RN (Registered Nurse)/Unit Manager #2 on [DATE] at 2:15 PM, in the hall confirmed the resident received 40 extra tablets of [MEDICATION NAME] from [DATE] to [DATE]. Interview with the DON on [DATE] at 8:10 AM, in the DON's office confirmed a significant medication error had occurred with the resident receiving the extra doses of the [MEDICATION NAME]. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of a Physician's Telephone Order dated [DATE] and timed 10 AM revealed .[MEDICATION NAME] (antibiotic) 80 mg IM (Intramuscular) Q (every) 12. Get trough/peak with 3rd dose (baseline for therapeutic dosing). Medical record review of Physician's Telephone Order dated [DATE] and timed 0930 (9:30 AM) revealed Hold [MEDICATION NAME]. Random [MEDICATION NAME] level in a.m. BMP (Basic Metabolic Panel) and pre-renal azotemia (abnormally high level of nitrogen in the blood). Medical record review of [MEDICATION NAME] Trough, Serum with collection date of [DATE] revealed result of 2.4 ug/mL (micrograms per milliliter), flagged as High with reference interval 0.0 - 2.0. Medical record review of [MEDICATION NAME], Random with collected date of [DATE] and timed 9:06 A.M. revealed result of 2.9 ug/mL. Peak range is 5.0 - 10.0 ug/mL. Trough range is 0.5 - 2.0 ug/mL. Medical record review of the Medication Record revealed the [MEDICATION NAME] was administered at 8:00 PM on [DATE] and at 8:00 AM on [DATE]. Review of a Medication Variance Report dated [DATE] revealed .Date and time Variance Occurred: [DATE] .Medication involved: Order written 0930 (9:30 AM) to hold [MEDICATION NAME] & (and) Obtain Random [MEDICATION NAME] level in AM [DATE]. Not taken off by nurse . Interview with RN #2 Unit Manager on [DATE] at 8:36 AM, in the conference room and review of the Medication Record confirmed the 8:00 PM dose of [MEDICATION NAME] on [DATE] and the 8:00 AM dose of [MEDICATION NAME] on [DATE] was given and should have been held per physician's orders [REDACTED].>Interview with the Medical Director on [DATE] at 9:54 AM, in the conference room confirmed if an order is written to hold the [MEDICATION NAME] the expectation is the dose will be held. Continued interview confirmed the order written by the nurse practitioner to hold the [MEDICATION NAME] was because the [MEDICATION NAME] level was elevated. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Vitamin D level, dated [DATE] revealed .22.4 Low .ng/ml (nanogram/milliliters) .range 30.00 - 100.0 . Medical record review of the Physician's Telephone Orders dated [DATE] revealed Vit (Vitamin) D 50,000 IU (international units) to be given 2 x (times) weeks. Dg (diagnosis) Vit D deficiency. Medical record review of the Medication Record dated [DATE] revealed ''Vitamin D 50,000 IU to be given 2 x per week. Dg: VD (vitamin D) Deficiency. Further review revealed Vitamin D was administered from [DATE] through [DATE]. Medical record review of the facility investigation dated [DATE] revealed .wrong dose .wrong time .vit D . Further review revealed .done BID (twice a day) 2 x a week supposed to be 2 x weekly daily . Further review revealed .order improperly/not flagged as new to be taken off, chart check signed for ,[DATE] . Medical record review of the Medication Record dated [DATE] Vitamin D 50,000 IU to be given 2 x per week dg: VD Deficiency. Interview with the DON on [DATE] at 12:55 PM, in the Conference Room confirmed the Vitamin D was not transcribed from [DATE] until [DATE], transcribed incorrectly resulting in 7 missed doses from [DATE] to [DATE] and from [DATE] to [DATE], 5 incorrect doses (administered 2 times a day instead of once daily twice a week). Continued interview confirmed the facility failed to ensure the correct transcription of the Vitamin D medication. Medical record review revealed Resident #177 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Orders dated [DATE] at 1300 (1:00 PM), revealed .[MEDICATION NAME] (antibiotic) 500 mg po (by mouth) daily x (times) 7 days - UTI (Urinary Tract Infection) . Further review revealed the order signed off by the LPN #3 on [DATE] at 2:15 PM. Medical record review of the facility investigation dated [DATE] revealed .ordered @ (at) 1300 med should have been given by 5 pm. Avail (available) in EBox (emergency medication box) . Medical record review of the Medication Record dated ,[DATE] revealed [MEDICATION NAME] 500 mg po daily x 7 days UTI the first dose administered at 8:00 AM on [DATE]. Interview with the Unit Manager/Registered Nurse (#2) on [DATE] at 2:40 PM, at the 400 Nursing Station revealed the [MEDICATION NAME] was available in the facility to begin antibiotic treatment within 6 hours of when ordered. Interview with LPN #3 on [DATE] at 3:30 PM, in the conference room confirmed the medication order was signed off on [DATE] at 2:15 PM, and LPN #3 failed to administer the antibiotic when it was available for use in the facility.

Based on medical record review and interview, the Quality Assurance (QA) Committee failed to identify and develop plans of action to ensure physician orders [REDACTED].#22, #150, #169, #178, #31, #93, #177) of 16 residents reviewed for medication administration. The facility's failure to ensure significant medication errors did not occurr placed 7 residents (#22, #150, #169, #178, #31, #93, #177) in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 4/25/16 at 10:50 AM, in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited an Immediate Jeopardy at F-281 (J); F-309 (J); F-333 (K); F-490 (K); F-501 (K); F-520 (K). The facility was cited Substandard Quality of Care at F-309 (J); F-333 (K). The findings included: Interview with the Administrator on 4/25/16 at 11:00 AM, in the DON's office confirmed the QA Committee had not identified medication errors as a problem. Further interview confirmed the facility failed to ensure the nurses were following the physician orders [REDACTED]. Interview with the Administrator on 4/25/16 at 11:05 AM in the DON office confirmed pain was identified as a problem but the QA Committee did not develop a plan of care to identify the residents not getting medications as ordered. Further interview confirmed the facility did not develop an audit to identify specific medications or audit medications administered and to ensure the medications were administered as ordered. Refer to F281 (J), F309 (J), F333 (K), F490 (K), F501 (K), F520 (K)

Based on review of the Medical Director Services Agreement, facility policy review, review of facility investigations, medical record review, and interview, the facility failed to ensure the Medical Director participated in the development and implementation of resident care policies to ensure Physician orders [REDACTED]. The facility's failure placed 7 residents (#22, #150, #169, #178, #31, #93, #177) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on April 25, 2016 at 10:50 AM in the DON's office. The Immediate Jeopardy was effective 3/17/16 and is ongoing. The facility was cited Substandard Quality of Care at F309 (J), F333 (K). The findings included: Review of the Medical Director Services Agreement revealed .Duties & (and) Responsibilities of Medical Director .Coordinate medical care in the Facility to insure the adequacy and appropriateness of the medical services provided, for example: Assist the Administrator and Director of Nurses in clinical program development and act as a consultant to the Director of Nurses in matters relating to resident care . Interview with the Medical Director on 4/25/16 at 10:35 AM, in the conference room revealed when asked what recommendations the Medical Director had made to the facility related to medication errors the Medical Director replied the nurses needed to be accountable for their mistakes and What other people do is out of my hands. Refer to F 281 (J), F309 (J) F333 (K), F 490 (K), F 520 (K)

Based on review of the Nursing 2015 Drug Handbook, facility policy review, medical record review, review of a Medication Variance Report, review of the Individual Patient's Controlled Substances Record, and interview, the facility failed to ensure the correct dosage of a medication for 1 resident (#22) of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed Resident #22 in Immediate Jeopardy (A situation which the provider's noncompliance has caused, or is likely to cause, serious harm, injury, impairment or death.) The Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy on April 25, 2016 at 10:50 AM, in the DON's office. The Immediate Jeopardy is effective 3/17/16 and is ongoing. The findings included: Review of the Nursing 2015 Drug Handbook revealed .Traditionally, nurses have been taught the 'five rights' of medication administration. These are broadly stated goals and practices to help individual nurses administer drugs safely .The right dose: Verify that the dose and form to be given is appropriate for the patient, and check the drug label with the prescriber's order . Review of facility policy, Medication Administration, revised 6/08 revealed Resident Medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug frequency, durations, strength, and route. The nurse is responsible to read and follow precautionary or instructions on prescription labels. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], after admission to the hospital after and an overdose of [MEDICATION NAME] sulfate at the facility, with [DIAGNOSES REDACTED]. Medical record review of the March 2016 Physician's Recapitulation Orders revealed .[MEDICATION NAME] (opiate narcotic [MEDICATION NAME], can cause respiratory distress and death when taken in high doses) sul. (solution) w/syr (with syringe) .20 mg. (milligrams)/1ml. (milliliter) solution .1.25 mls (25 mg) sublingually (under the tongue) five times daily routine (7 AM, 12 PM, 5 PM, 10 PM, 3 AM) . Medical record review of a prescription for Resident #22 dated 3/10/16 revealed [MEDICATION NAME] sulfate 20mg/5ml, (6ml) PO/SL (by mouth/sublingually) at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM . Medical record review of the 3/16 Medication Record revealed on 3/10/16 the [MEDICATION NAME] 20 mg/5ml, (6ml) PO/SL at 7 AM, 12 PM, 5 PM, 10 PM, and 3 AM was transcribed onto the Medication Record to reflect the change in the concentration/strength of the [MEDICATION NAME] solution. Review of a Medication Variance Report dated 3/18/16 at 10:00 AM revealed Resident #22 received the wrong dose (concentration/strength) of [MEDICATION NAME]. Continued review of the Medication Variance Report revealed the resident was to receive [MEDICATION NAME] with a strength of 20 mg/5 ml oral solution, with a dose of 24mg/6 ml, but had received [MEDICATION NAME] 20 mg/ml with a dose of 120 mg/6 ml for 4 doses. Continued review of the Medication Variance Report revealed .Outcome .hospitalization .temporary change in level of consciousness .An error occurred that may have contributed to or resulted in temporary resident harm or required initial or prolonged hospitalization . Review of the Individual Patient's Controlled Substances Record, for Resident #22 revealed on 3/17/16 [MEDICATION NAME] Solution 20 mg/ml was obtained from the facility's emergency supply. Continued review of the Individual Patient's Controlled Substances Record revealed Licensed Practical Nurse (LPN) #1 signed out 6 ml (120 mg) of the [MEDICATION NAME] solution for administration to Resident #22 on 3/17/16 at 12:00 PM, 5:00 PM, and 10:00 PM. Continued review of the Individual Patient's Controlled Substances Record revealed LPN #2 signed out 6 ml (120 mg) of the [MEDICATION NAME] Solution for administration to Resident #22 on 3/18/16 at 3:00 AM. Medical record review of the 3/1/16 through 3/31/16 Medication Record revealed on the [MEDICATION NAME] 20 mg/5 ml, (6 ml) po/sl was circled as not administered at 7:00 AM on 3/18/16. Medical record review of a nursing note dated 3/18/16 revealed 7AM CNA (Certified Nursing Assistant #7) reports res. (resident) 'acting funny.' Spoke with res & (and) he talked cheerful & knew this nurses name. No distress at present .10AM-Upon entering room-res presents with decreased LOC (level of consciouness). NP (Nurse Practitioner) & RN (Registered Nurse) Sup (supervisor) notified & following orders in MD (Medical Doctor) orders .12p Res. alert with resp (respirations) @ (at) 16, knows staff & agrees for further TX (treatment) & eval (evaluation) to be trans (transferred) to (named hospital) . Medical record review of the NP progress note dated 3/18/16 revealed .BP (blood pressure) 112/50 .HR (heart rate) 80 .RR (respiratory rate) 4 rpm (respirations per minute) Temp (temperature) 101.4 O2 (oxygen) Sat (saturation) 93% (percent) .RA (room air) .wheezing .awake, able to verbalize .[MEDICATION NAME] (opiate antidote) 0.8 mg IM (intramuscular) given, did not respond, another 0.8 mg given & respirations up to 12/min (minute). Another 1 mg [MEDICATION NAME] given & he improved to 16/min then O2 sat dropped to 83%, O2 applied at 2 LPM (liters per minute) & O2 remains at 93%, B/P dropped to 60/40 then improved, 1 mg [MEDICATION NAME] given & he briefly improved for several minutes, then resp. (respirations) decreased with 10 sec. (seconds) periods of apnea-Sent to ER (emergency room ) .1. Acute Respiratory Distress (difficulty breathing requiring medical intervention). 2. Hypoxemia (low level of oxygen). 3. [MEDICAL CONDITION] (malfunction of the brain manifested by an altered mental status). 4. [MEDICAL CONDITION] (low blood pressure). 5. Dyspnea (difficult or labored breathing, shortness of breath) . Medical record review of a NP order dated 3/18/16 at 10:40 AM revealed [MEDICATION NAME] 1.6 mg IM now, O2 to keep sats at 92% or above, PCXR (portable chest x-ray)-wheezing, fever, [MEDICATION NAME] (inhalation respiratory treatment) 1 unit dose now, [MEDICATION NAME] 1mg IM again now . Medical record review of a NP's order dated 3/18/16 at 11:00 AM revealed .Hold [MEDICATION NAME], Give 2 mg [MEDICATION NAME] now. Medical record review of a NP's order dated 3/18/16 at 11:30 AM revealed Send to ER. Medical record review of an Emergency Department note dated 3/18/16 revealed .The patient presents to the emergency department after a known overdose, that was accidental .Pt (patient) was at his rehabilitation center and he was given too much [MEDICATION NAME] overnight last night. Pt had decreased LOC and has a history of dementia . Medical record review of a hospital History and Physical dated 3/18/16 revealed .Chief Complaint: Overdose .apparently was sent into the ER after he was difficult to arouse. There was concern he may have been given 6 times as prescribed him on [MEDICATION NAME] .he was given [MEDICATION NAME] at the facility and has some improvement .He is awake now and is answering questions . Medical record review of a hospital Discharge Summary dated 3/23/16 revealed .male with multiple medical problems .had a history of [REDACTED].and [MEDICAL CONDITION]. The patient also has mild dementia .was apparently sent to the ER after he was difficult to arouse. There was concern he may have been given 6 times (the dose) as prescribed on his [MEDICATION NAME] .The patient was admitted for further evaluation and management. Discharge Diagnoses: [REDACTED].The patient's [MEDICATION NAME] has been discontinued. The patient was placed on p.r.n. (as needed) [MEDICATION NAME]. Mentation has improved . Review of a facility investigation dated 3/21/16, prepared by the Director of Nursing (DON), revealed (Resident #22) had a physician's orders [REDACTED]. This concentration is what was being dispensed by the pharmacy. On 3/17/16, the last dose of this concentration was used at the 7am dose. The pharmacy was contacted and a request was made for CII (Controlled Substance Schedule II) Continuance of Therapy prescription was made. The pharmacy told the nurse that she would have to get the 12N dose from the ER Narcotic Drug Box. The concentration of the [MEDICATION NAME] Solution in the ER Drug box is 100 mg./5ml. (Resident #22) received 4 doses @ (at) 6ml/dose. Two nurses were involved in administering the wrong dose. When I was notified Friday, March 18, 2016 of the error, I instructed both nurses to meet with the administrator and me on Monday before returning to work. At 8:00 am (LPN #1) came in to review the incident .I questioned her about reading the label and comparing with her MAR (Medication Administration Record). She stated that she was in a hurry and didn't check .10:30 am (LPN #2) came to speak with the administrator and me about the incident that occurred with (Resident #22). LPN #2 said that she gave 6 ml. @ the 3 am dose. When asked if she checked the label for concentration, she said no . Interview with the Physician/Medical Director on 4/18/16 at 3:25 PM in the conference room revealed the resident received the [MEDICATION NAME] due to severe general pain everywhere. Continued interview revealed the Physician had been notified the resident had received too much [MEDICATION NAME] on 3/17/16 and 3/18/16. Further interview revealed the resident also had an infection at the time of the medication error. Interview confirmed the wrong concentration of [MEDICATION NAME] had been administered. Continued interview revealed some of the possible side effects of too much [MEDICATION NAME] included respiratory depression, lethargy, and drowsiness. Interview revealed on a smaller patient the dosage of [MEDICATION NAME] administered to Resident #22 could have been deadly. Telephone interview with LPN #2 on 4/18/16 at 10:05 PM revealed LPN #2 didn't usually work on the unit where Resident #22 resided. Continued interview revealed LPN #2 should have noted the concentration of the [MEDICATION NAME]. Interview confirmed LPN #2 had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls (120 mg) to Resident #22 on 3/18/16 at 3:00 AM. Interview with the Nurse Practitioner (who was present on 3/18/16, when the medication error was identified) on 4/19/16 at 11:15 AM in the conference room revealed RN #1 had notified the NP there had been an error in the administration of Resident #22's [MEDICATION NAME]. Continued interview revealed when the NP had first examined the resident on 3/18/16, the resident was in respiratory distress. Further interview revealed the resident had shallow breathing and was not breathing as many times per minute as the NP would like. Interview revealed the resident's respiratory rate had been 12 per minute and the NP would like the respiratory rate to be 16. Continued interview revealed the NP was at the resident's bedside during the time after the incorrect dosage of [MEDICATION NAME] had been administered to the resident, and the resident's oxygen saturation level had dropped to 83% and oxygen had been administered to the resident. Further interview revealed while in attendance to the resident it was discovered the resident had an elevated temperature and the NP had thought the resident might have pneumonia. Interview revealed the resident was transferred to the hospital related to fever, the resident's oxygen saturation level and blood pressure had dropped indicating the resident had some other medical condition in addition to the incorrect dosage of [MEDICATION NAME] on 3/18/16. Telephone interview with LPN #1 on 4/19/16 at 3:15 PM revealed the facility had used all of Resident #22's [MEDICATION NAME] solution, the pharmacy had been contacted to obtain a code to remove the medication from the facility's ER narcotic box. Continued interview confirmed LPN #1 did not check the medication label and had incorrectly administered [MEDICATION NAME] Solution 20 mg/ml, 6 mls. (120 mg) to Resident #22 on 3/17/16 at 12:00 PM, 5:00 PM, and 10:00 PM (3 consecutive doses). Continued interview revealed on the morning of 3/18/16 a CNA had reported the resident was acting funny however, LPN #1 had spoken to the resident and the resident had said hey nurse (name) and did act a little silly. Continued interview revealed the 7:00 AM dose of [MEDICATION NAME] was not administered to Resident #22 on 3/18/16 due to another resident had a medical emergency at that time and LPN #1 was so busy she had not administered the [MEDICATION NAME] to Resident #22. Interview with CNA #7 on 4/25/16 at 7:35 AM near the nursing station revealed on 3/18/16 when the CNA had entered Resident #22's room, the resident was hard to wake up was confused, did not know it was morning, didn't recognize CNA #7, who routinely provided care to the resident, and had reported something was wrong with the resident to LPN #1. In summary: On 3/17/16 the facility had used all the prescribed [MEDICATION NAME] sulfate solution ordered for Resident #22 on 3/17/16, notified the pharmacy and obtained [MEDICATION NAME] sulfate from the ER narcotic box. LPN #1 and LPN #2 did not check the label of the [MEDICATION NAME] sulfate to verify concentration/strength, and administered the wrong dosage (120 mg) of the [MEDICATION NAME] sulfate to the resident for 4 consecutive doses (3/17/16 at 12:00 PM, 5:00 PM, and 10:00 PM, and on 3/18/16 at 3:00 AM). The resident suffered respiratory depression, was administered [MEDICATION NAME] at the facility then transferred to the ER. The resident returned to the facility on [DATE].

Based on review of facility policy, medical record review, Controlled Drug Record review, and interview, the facility failed to administer scheduled pain medication prior to wound care for 2 (#150, #169) residents of 16 residents reviewed for medication administration of 42 residents reviewed. The facility's failure placed Residents #150 and #169 in Immediate Jeopardy (A situation which the provider's noncompliance has caused or is likely to cause serious harm, injury, impairment or death). The Administrator and the Director of Nursing were informed of the Immediate Jeopardy on 4/25/16 at 10:50 AM, in the Director of Nursing's office. The Immediate Jeopardy was effective from 3/17/16 and is ongoing. The findings included: Review of facility policy, Medication Administration, revised 4/08 revealed .Resident Medications are administered in an accurate .timely .manner .records the name, dose, route, and time .on the Medication Administration Record [REDACTED] Review of facility policy, Pain Management, revised 8/12 revealed .The goal of the Pain Management Program is that pain is identified and treated effectively and consistently .be proactive to make sure the resident achieves relief and remains free from pain .The Licensed Nurse when administering scheduled or routine pain medications, will record the drug administration . Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Pain Evaluation dated 12/14/15 revealed .[DIAGNOSES REDACTED].Facial Wound .how much time have you experienced pain or hurting over the last 5 days .Frequently . Medical record review of the Non Pressure Skin Condition Record dated 12/15/15 and signed by wound care nurse revealed .wound to (right) jaw (and) partial mouth (second to) gunshot wound .Has severe pain . Medical record review of a physician's orders [REDACTED].Start ([MEDICATION NAME]) 1 mg (milligram) SQ (subcutaneous) q (every) 15 m (minutes) (before) wound care BID (twice a day) . Medical record review of the Controlled Drug Record dated 12/17/15 revealed only 1 dose of the [MEDICATION NAME] 1mg was signed out as administered on 12/19/15, 12/21/15, 12/23/15, 12/24/15, 12/25/15, (instead of 2 doses as ordered prior to wound care missing 5 doses) and no doses of the [MEDICATION NAME] was signed out as administered on 12/30/15. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed the resident had pain almost constantly. Medical record review of the Pain Evaluation dated 12/21/15 revealed .How much of the time have you experienced pain or hurting over the last 5 days .Almost Constantly .location .jaw, knee .back . Medical record review of the Non Pressure Skin Condition Record dated 12/21/15 and signed by wound care nurse revealed .(continue) wound care .(change) BID Resident (continues) to be resistant to touching or cleaning wound but will allow to some degree if pain med given prior to (treatment) . Medical record review of the Nurse Practitioner's Progress Note dated 12/21/15 revealed .Pain-generalized-much improved (with) [MEDICATION NAME] scheduled . Interview with the Director of Nursing (DON) on 4/20/16 at 1:24 PM, in the conference room and review of the Controlled Drug Record confirmed the [MEDICATION NAME] was not administered as ordered prior to wound care. Interview with the Physician on 4/21/16 at 2:32 PM, in the conference room confirmed the resident required pain medication prior to the wound care. Interview with the Wound Care Nurse on 4/22/16 at 8:01 AM, in the conference room confirmed the resident had pain during wound care. Medical record review revealed Resident #169 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #169 was discharged on [DATE]. Medical record review of the Pain Evaluation (Admission) dated 2/11/16 revealed .res (resident) denies pain - even when asked .offer meds (medications) .according to brother-in-law - res may have to be encouraged to take meds . Medical record review of the physician's orders [REDACTED]. NS (Normal Saline) Pat dry Pack wounds c (with) damp to dry [MEDICATION NAME] cover c abd pad & [MEDICATION NAME] (tape) Medical record review of the physician's orders [REDACTED]. Continued review revealed [MEDICATION NAME] 5/325 mg 1 tab po q 3 hours prn (as needed) pain. Further review revealed [MEDICATION NAME] 2 mg/ml, 1 ml 10 min b/f (before) wound care daily. Medical record review of the Medication Record dated for 3/2016 revealed no documentation [MEDICATION NAME] 2mg/ml (milligrams/milliters) 1 ml sq before wound care had been administered. Medical record review of the Controlled Drug Record dated 3/7/16 to 3/28/16 revealed [MEDICATION NAME] 2 mg/ml 1 ml sq b/f wound care was signed out 12 times out of 26 doses ordered (15 missed doses). Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status as a ''5'' (cognitive impairment), pain occasionally and rated as a 5 (on a 1 to 10 pain scale). Medical record review of the Care Plan - Pain dated 3/11/16 revealed .pain actual .administer [MEDICATION NAME] as ordered .medicate resident for pain prior to treatments . Medical record review of the physician's orders [REDACTED]. Medical record review of a Discharge Note dated 3/31/16 revealed .stay was complicated with pain management, depression . Interview with the Wound Care Registered Nurse on 4/20/16 at 10:00 AM, in the Conference Room revealed she instructed the medication nurse on duty to medicate the resident prior to wound care, returned to the medication nurse on duty to ask if the resident had been medicated, and had proceeded with wound care. Further interview confirmed the resident would .sometimes complain of pain .she would point at her umbilical area . Interview with the Medical Director/Physican on 4/21/16 at 2:30 PM, in the Conference Room confirmed Resident #169 would not ask for pain medication .she cried .she would never ask for it . Interview with the DON on 4/22/16 at 9:50 AM, in the DON office and review of the medication record of 3/16 confirmed no documentation of [MEDICATION NAME] administered prior to wound care on 3/4/16, 3/5/16, 3/6/16, 3/11/16, 3/13/16, 3/19/16, 3/20/16, 3/22/16, 3/23/16, 3/24/16, 3/25/16, 3/26/16, 3/27/16, 3/29/16, and 3/30/16. Further interview confirmed the facility failed to monitor and administer scheduled pain medication prior to wound care. Interview with the Medical Director/Physician on 4/25/16 at 9:50 AM, in the Conference Room confirmed she was not aware Resident #169 did not receive the scheduled [MEDICATION NAME] prior to wound care on a daily basis as ordered.

Based on facility policy review, medical record review, and interview, the facility failed to maintain a complete and accurate medical record for 6 residents (#22, #178, #169, #17, #150, #125) of 42 residents reviewed. The findings included: Review of facility policy, Medication Administration, revised 6/08 revealed .Record the name, dose, route, and time of medication on the Medication Administration Record [REDACTED]. Review of facility policy, [MEDICAL CONDITION] Management, dated 2012 revealed .in accordance with state regulation: the Licensed Nurse will institute the appropriate Behavior Monitoring form associated with the drug category .To identify/target behaviors .document number of episodes of behaviors . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse Practitioner's (NP) order dated 3/18/16 at 10:40 AM revealed [MEDICATION NAME] (opiate antidote) 1.6 mg (milligram) IM (intramuscular injection) now .[MEDICATION NAME] 1mg IM again now . Medical record review of a NP order dated 3/18/16 at 11:00 AM revealed .Give 2 mg [MEDICATION NAME] now. Medical record review of the 3/18/16 through 3/31/16 Medication Record revealed no documentation the resident had received the [MEDICATION NAME]. Interview with the Director of Nursing (DON), on 4/18/16 at 8:40 AM, in the DON's office confirmed there was no documentation on the 3/18/16 through 3/31/16 Medication Record the resident had received any [MEDICATION NAME] on 3/18/16. Telephone interview with Licensed Practical Nurse (LPN) #1 on 4/18/16 at 10:05 AM revealed LPN #1 had administered the [MEDICATION NAME] 1.6 mg IM to the resident on 3/18/16. Interview with the facility's Wound Care Nurse on 4/18/16 at 10:30 AM, in the DON's office revealed the Wound Care Nurse had administered [MEDICATION NAME] 1 mg IM and [MEDICATION NAME] 2 mg to Resident #22 on 3/18/16. Continued interview confirmed the Wound Care Nurse had not documented the administration of the [MEDICATION NAME] onto the 3/18/16 through 3/31/16 Medication Record. Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of Physician's Telephone Orders dated 12/16/15 and timed 12:30 PM revealed .Start [MEDICATION NAME] 7.5 mg PEG (Percutaneous Endoscopic Gastrostomy) Q 8 hours scheduled .Start 1 mg SQ q 15 m (minutes) (before) wound care BID (twice a day) . Medical record review of Physician's Telephone order dated 12/31/15 and timed 1000 (10 AM) revealed .Change routine [MEDICATION NAME] before wound care to prn before wound care at current dose/route. Medical record review of the Medication Record dated 12/16/15-12/31/15 revealed no documentation the [MEDICATION NAME] 0.1 ml had been administered 15 minutes before wound care. Continued review of the Medication Record revealed no documentation why the [MEDICATION NAME] had not been administered. Interview with the DON on 4/20/16 at 1:24 PM, in the conference room and review of the Medication Record confirmed the [MEDICATION NAME] was not documented as administered 12/16/15-12/31/15. Continued interview confirmed the facility failed to ensure complete documentation of the Medication Record. Medical record review revealed Resident #169 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #160 was discharged on [DATE]. Medical record review of the physician's orders [REDACTED]. 2 mg/ml (milliliters), 1 ml sq (subcutaneous) 10 min (minutes) b/f (before) wound care daily. Medical record review of the Medication Record dated 3/4/16 to 3/30/16 revealed no documentation of administration of [MEDICATION NAME] to Resident #169. Medical record review of the Controlled Drug Record dated 3/7/16 to 3/28/16 revealed [MEDICATION NAME] 2 mg/ml 1 ml sq b/f wound care was signed out 12 times. Interview with the DON on 4/22/16 at 9:50 AM, in the DON's office confirmed the [MEDICATION NAME] was not documented on the Medication Record from 3/4/16 to 3/30/16. Further interview confirmed the facility failed to ensure the medication record was complete. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Physician's Recapitulation Orders dated 7/17/15 revealed .[MEDICATION NAME] 5/325 (2) tabs po (by mouth) q (every) 6 (hours) as needed pain . Medical record review of a Prescription dated 7/24/15 revealed .[MEDICATION NAME] .5/325 mg 1 tab po QID (4 times daily) PRN (as needed) pain . Review of the Medication Variance Report dated 7/24/15 revealed .Medication Involved .[MEDICATION NAME] 5/325 .Original Medication Administration Record [REDACTED]. On 7/24/15 (Physician) wrote a new (prescription) for [MEDICATION NAME] 1 tab 5/325 po QID PRN/pain .order change for prescription not transcribed to MAR .Actions Taken Pt (patient) has received (2) tabs QID or Q 6 (hours) since admission (without) a change documentation reflecting new (prescription) . Medical record review of the Medication Administration Record [REDACTED]. Review of the Individual Patient's Controlled Substances Record revealed the following: 7/24/15-4 doses [MEDICATION NAME] signed out, 7/27/15-5 doses [MEDICATION NAME] signed out, 7/28/15-4 doses [MEDICATION NAME] signed out, 7/29/15-3 doses [MEDICATION NAME] signed out, 7/30/15-4 doses [MEDICATION NAME] signed out. Interview with the DON on 4/20/16 at 10:00 AM, in the DON's office confirmed the Prescription for the change in dosage of the [MEDICATION NAME] had been placed in the file bin and had not been discovered promptly. Interview with the DON on 4/21/16 at 12:45 AM, in the DON's office confirmed the documentation on the Medication Administration Record [REDACTED] Medical record review revealed Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Record for 2/16 revealed: [MEDICATION NAME] (narcotic pain medication) 10 mg/325 mg 1 tablet by mouth 6 times daily with 2 doses not documented as administered. [MEDICATION NAME] Diskus ([MEDICATION NAME] inhaler) 250 mcg (micrograms)/50 mcg powder. Inhale 2 puff twice daily with 1 dose not documented as administered. Carvedilol (cardiac medication) 12.5 mg tablets,1 tablet by mouth twice daily with 2 doses not documented as administered. Duloxetine (antidepressant) HCL 60 mg capsule, 1 cap by mouth twice daily with 2 doses not documented as administered. [MEDICATION NAME] Sodium (low [MEDICAL CONDITION] medication) 125 mcg tablet, 1 tab by mouth every day with 1 dose not documented as administered. Medical record review of the Medication Record for 3/16 revealed: [MEDICATION NAME] (medication to lower blood pressure) 5 mg tablet, 1 tab by mouth every day with 1 dose not documented as administered. [MEDICATION NAME] (anti-psychotic medication) 10 mg tablet, 1 tab by mouth at bedtime with 5 doses not documented as administered. [MEDICATION NAME] (anti-depressant medication) HCL 150 mg tablet, 1 tab by mouth at bedtime with 5 doses not documented as administered. Carvedilol with 6 doses not documented as administered. Duloxetine with 5 doses not documented as administered. Medical record review of the Medication Record for 4/16 revealed: Carvedilol with 5 doses not documented as administered. Duloxetine with 4 doses not documented as administered. [MEDICATION NAME] with 4 doses not documented as administered. [MEDICATION NAME] (diuretic) 20 mg tablet, 1 tab by mouth every morning with 4 doses not documented as administered. [MEDICATION NAME] (steroid) 2.5 mg 1 po q am with 4 doses not documented as administered. [MEDICATION NAME] (anticonvulsant) 25 mg 1 po 1 am, on every even day x (times) 10 doses, the d/c (discontinue) with 4 doses doses not documented as administered. Interview with the DON on 4/21/16 at 9:05 AM, in the front office confirmed the medications for Resident #17 were not documented as administered for the months of 2/16, 3/16, and 4/16. Continued interview confirmed the facility failed to ensure complete and accurate documentation of the medication record. Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] .50 mg tablet 1.5 (75 mg) tab by mouth every morning . [MEDICATION NAME] .0.25 mg 2 tabs (0.5 mg) by mouth every evening (10 PM) . [MEDICATION NAME] .0.25 mg 1 tab by mouth twice daily (8 AM & 4 PM) . Medical record review of the Behavior/Intervention Monthly Flow Record dated 4/1/16 revealed no documentation for behaviors on day shift or night shift for 4/11/16, 4/12/16, 4/13/16, 4/14/16, 4/15/16, and 4/17/16. Interview with LPN #10 on 4/20/16 at 10:06 AM, on the 100 Hall revealed .The nurses assess for behaviors every shift and we document the behavior or zero if the resident is not having any behaviors . Interview with the DON on 4/21/2016 at 8:55 AM, in the conference room confirmed the facility failed to document behaviors every shift for Resident #125.

Based on facility policy review, medical record review, observation, and interview, the facility failed to administer medications in a sanitary manner for 1 Resident (#26) of 30 observed opportunities, failed to provide meal services in a sanitary manner for 2 residents on 2 halls of 4 halls observed, and failed to follow physician's orders [REDACTED].#99) of 1 resident observed for isolation precautions. The findings included: Review of facility policy, Medication Administration, revised 6/08 revealed Resident Medications are administered in .sanitary manner .Follow sanitary practices . Review of facility policy, Hand Hygiene, dated 2012 revealed .To decrease the risk of transmission of infection by appropriate hand hygiene .Handwashing .the most important single procedure for preventing healthcare associated infections .after providing care to a resident . Review of facility policy, Contact Precautions, dated 2012 revealed .use contact precautions in addition to standard precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment .Hand hygiene should be completed prior to donning gloves .Gloves should be worn when entering the room .Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately .Contact Precautions .Multi-drug resistant organisms . Observation on 4/18/16 at 8:50 AM, during medication administration on the 100 Hall revealed Licensed Practical Nurse (LPN) #7 dropped a pill on top of the medication cart, picked up the pill with bare hands, placed the pill in the medication cup with the resident's other medications, and administered the medication to Resident #26. Interview with LPN #7 on 4/18/16 at 8:52 AM, on the 100 Hall confirmed she dropped the pill on top of the medication cart, then picked up the pill, placed the pill in the medication cup with the resident's other medications, and administered the medication to the resident. Interview with the Director of Nursing (DON) on 4/22/16 at 8:36 AM, in the DON's office revealed staff are expected to obtain and administer another pill and destroy the pill that was dropped. Continued interview with the DON confirmed the facility failed to administer medications in a sanitary manner for Resident #26. Observation on 4/18/16 at 12:14 PM on the 300 Hall revealed Certified Nursing Assistant (CNA) #1 set up the lunch tray for Resident #61, repositioned the resident, and left the room without washing or sanitizing her hands. CNA #1 then retrieved Resident #105's tray from the cart, set up the tray for Resident #105 and repositioned the resident. Interview with CNA #1 on 4/18/16 at 12:17 PM, on the 300 Hall confirmed she did not sanitize or wash her hands between resident contact. Interview with the DON on 4/22/16 at 8:36 AM, in the DON's office revealed the staff were expected to wash or sanitize the hands after every resident contact. Continued interview with the DON confirmed the facility failed to provide meal services in a sanitary manner. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Telephone Orders dated 4/10/16 revealed .Peg (percutaneous endoscopic gastrostomy) site culture . Medical record review of a laboratory report dated 4/11/16 revealed .Staphylococcus aureus .Methicillin resistant (MRSA) .Heavy growth .Abnormal .Beta [DIAGNOSES REDACTED] Streptococcus, group B .Abnormal . Medical record review of Physician's Telephone Orders dated 4/13/16 revealed .MRSA peg site .use isolation precautions for MRSA wound . Observation on 4/18/16 at 12:04 PM, outside Resident #99's room revealed no Isolation Cart with personal protective equipment (PPE) or signage on the door to alert anyone that Resident #99 was on isolation precautions. Interview with LPN #7 on 4/18/15 at 12:05 PM, on the 100 Hall revealed .he should be in isolation for MRSA .no one would know .in isolation . Observation on 4/18/16 at 12:17 PM, outside Resident #99's room revealed CNA #6 walked into Resident #99's room to deliver tray to roommate. Continued observation revealed CNA #6 assisted the resident in bed, touched the privacy curtain between the residents, rearranged the blankets on the bed, and walked out of the room without washing hands or putting any PPE on prior to entry. CNA #6 walked to the lunch cart, pulled a resident tray out and handed the tray to another CNA and walked to the computer on the wall and began charting without washing the hands. Interview with CNA #6 on 4/16/16 at 12:17 PM, on the 100 Hall revealed .no I did not wash my hands before going into the resident's room or when I came out of the resident's room . Continued interview revealed .I did not know the resident was in isolation because there is no sign on the door or an isolation cart . Interview with the DON on 4/22/16 at 8:45 AM, in the DON's office confirmed the facility failed to place the resident in isolation per physician's orders [REDACTED].

Based on medical record review and interview, the facility failed to provide sufficient staff to meet the needs of the residents in a timely manner for 7 residents (#22, #2, #17, #61, #26, #176, #7) of 20 interviewable residents who were dependent for needs of 42 residents reviewed. The findings included: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's significant change in status assessment Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was independent with daily decision making, required extensive assist of 2 persons required with bed mobility and toileting. Interview with Resident #22 on 4/21/16 at 1:00 PM, in the resident's room revealed it often took a long time for the call light to be answered on all shifts. Continued interview revealed the resident usually needed to use the bedpan or be removed off the bedpan when the call light was pressed. Continued interview with Resident #22 revealed the staff would tell him they needed another person working. Continued interview revealed often it was approximately 1 hour before assistance was obtained to be removed from the bedpan. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's annual MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, was totally dependent with 2 person assist required with transfer, dressing, and personal hygiene. Interview with Resident #2 on 4/21/16 at 1:15 PM, in the resident's room revealed the resident had given up 1 of her 3 a week showers because the facility did not have enough staff at times. Continued interview revealed the staff would tell her there was only 1 Certified Nursing Assistant (CNA) on her hall. Continued Interview revealed the resident was not receiving her weekend shower due to the facility not having enough staff on weekends. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #17's quarterly MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, required extensive assistance of 1 person with bed mobility and personal hygiene, and was totally dependent with 1 person assistance with toileting. Interview with Resident #17 on 4/21/16 at 1:40 PM, in the resident's room revealed the resident did not think the facility had enough staff on any shift and it would take 2-3 hours for the staff to get a bedpan for the resident. Continued interview revealed the weekends were worse and the staff would tell Resident #17 they were aware of her waiting a long time but they were short staffed. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #61's quarterly MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, required 2 person assistance with transfer, and required extensive 2 person assistance with bed mobility and dressing. Interview with Resident #61 on 4/21/16 at 2:10 PM, in the resident's room revealed the resident had a physician order [REDACTED]. Continued Interview revealed when the resident needed assistance with changing his [MEDICATION NAME] (an opening in the abdomen to allow urine to flow to the outside of the body) or [MEDICAL CONDITION] (an opening in the abdominal wall through which digested food passes) bag due to leaking the staff would want to try to reinforce the bag to his skin instead of assisting him in changing the bag. Continued interview revealed this happened all the time on weekends and the staff would tell him they were short staffed or they were the only CNAs working. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #26's significant change in status assessment MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making and required extensive assistance of 2 person with bed mobility and toileting. Interview with Resident #26 on 4/22/16 at 9:22 AM, in the resident's room revealed the resident did not think the facility had enough staff at times during the week and staffing was worse on weekends. Continued interview revealed it would take too long for staff to answer the call light and come change her brief when needed. Continued interview with Resident #26 revealed the staff would tell her they were the only CNAs working. Medical record review revealed Resident #176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #176 on 4/22/16 at 10:10 AM, in the resident's room revealed it took approximately 1 hour to receive her pain medication. Continued interview revealed staff would inform her they forgot her medication or they were so busy due to being the only one working the hall. Interview with the MDS Coordinator on 4/25/16 at 8:00 AM, in the MDS Coordinator's office revealed .(Resident #176) admission MDS has yet to be entered into the computer with an ARD (assessment reference date) .resident scored 15 (indicating the resident was independent with daily decision making) on BIMS . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's significant change in status assessment MDS dated [DATE] revealed the resident scored 15 out of 15 on the BIMS, indicating the resident was independent with daily decision making, required extensive assistance of 2 person with bed mobility, and required total dependence of 2 person with toileting. Interview with Resident #7 on 4/22/16 at 10:10 AM, in the resident's room revealed nurses and CNAs' work 2 halls and it often took a long time for staff to bring the bed pan or remove the bed pan when needed. Continued interview revealed the resident had been left on the bedpan for over 1 hour. Continued interview revealed the staff would comment they were short staffed. Interview with CNA #4 on 4/22/16 at 10:18 AM, on the 100 Hall revealed CNA #4 was working the 200 Hall and was coming to ask for help from the CNA on the 100 Hall. Continued interview revealed the facility did not have sufficient staff to meet the needs of the residents on the weekends and when staff called out. Interview with CNA #5 on 4/22/16 at 10:23 AM, on the 100 Hall revealed there had been times when CNA #5 had told residents he/she would return to provide care after taking care of other residents. Continued interview revealed CNA #5 had worked short staffed when staff had called in sick. Interview with CNA #1 on 4/22/16 at 10:30 AM, on the 300 Hall revealed there had been times when CNA #1 had told residents he/she would return to provide care after taking care of other residents. Interview with CNA #2 on 4/22/16 at 10:33 AM, on the 300 Hall revealed there had been times when CNA #2 had told residents he/she could not give them a bath due to not enough staff. Continued interview revealed there were times when the facility did not have sufficient staff to meet the needs of the residents in a timely manner. Interview with CNA #3 on 4/22/16 at 10:40 AM, on the 400 Hall revealed there had been times when CNA #3 did not have enough help to meet the needs of the residents in a timely manner, especially on weekends. Continued interview with CNA #3 revealed .feel stressed when we are short staffed . Interview with Licensed Practical Nurse (LPN) #8 on 4/22/16 at 10:42 AM, on the 400 Hall confirmed there were times the facility did not have sufficient staff to meet the needs of the residents in a timely manner, especially on weekends. Interview with LPN #9 on 4/22/16 at 10:46 AM, on the 300 Hall revealed there were times when there was insufficient staff to meet the needs of the residents in a timely manner, especially when nurses had to work 2 hallways. Continued interview revealed when nurses work 2 hallways it was easier to make a medication error, especially on the weekends. Further interview confirmed LPN #9 was aware of times when there was insufficient staff available to complete showers and residents had to wait for pain medication. Interview revealed LPN #9 was aware Resident #61 was not gotten up out of bed due to insufficient staffing. Interview with LPN #6 on 4/22/16 at 10:57 AM, on the 200 Hall revealed LPN #6 was aware of times when there was insufficient staff available to meet the needs of the residents in a timely manner, especially on second shift. Continued interview confirmed LPN #6 was aware of times when there was insufficient staff available to complete showers on weekends and residents had to wait for pain medication. Interview with LPN #7 on 4/22/16 at 11:03 AM, on the 100 Hall confirmed there were times the facility did not have sufficient staff to meet the needs of the residents in a timely manner. Continued interview revealed LPN #7 was aware of times when there was insufficient staff available to give pain medication to residents in a timely manner. Continued interview with LPN #7 revealed .when stressed there is a higher likelihood to make a medication error . Interview with the Director of Nursing (DON) on 4/22/16 at 11:06 AM, in the DON's office revealed residents were not to be left on bedpans for 1 hour, residents were not to wait for a bedpan 2-3 hours, residents were not to be told there were residents ahead of them when care was requested, residents were not to wait 1 hour for pain medication, and residents were not to wait in getting their briefs changed. Continued interview confirmed the facility was not staffed with as many nurses or CNAs on the weekend as during the week and staffing was not adequate to meet the needs of the residents in a timely manner.

Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to notify the State Survey and Certification Agency of an allegation of abuse for 1 resident (#22) of 3 residents reviewed for an allegation of abuse of 42 residents reviewed. The findings included: Review of facility policy, Abuse & Neglect Prohibition, revised 6/13 revealed .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing .The facility will report all allegations and substantiated occurrences of abuse .to the state agency .as designated by state law . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored an 11 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderately impaired cognitive skills. Medical record review of the significant change of status MDS dated [DATE] revealed the resident scored 14 on the BIMS indicating the resident was independent with daily decision making. Review of a facility investigation dated 3/7/16 .in regards to the 'incident' on March 3: With that being said, this is a recount of (Resident #22's) experience: It started off that the blinds were closed and couldn't see outside, so I leaned over to look outside (and my bed was up how I like it). I fooled around and my legs came off the bed, so I pushed the button to get help. So this guy came in and put my legs back on and said that I've messed up again. After that, he came to the end of the bed and started messing with my controls and putting my bed down. I asked what he was doing and he told me I couldn't have my bed up. I've been here for [AGE] years and never been told that. He lowered the bed and said 'I'll fix it so you can't ever raise it again.' After that, I probably told him he was acting like a pest. I wasn't happy. He was standing by the other bed, came running over, jumps on top of me, grabs me, and holds my arms, laughing like crazy . Interview with the Administrator on 4/19/16 at 3:30 PM, in the conference room revealed the facility had problems with computer compatibility to report the allegation of abuse, (Administrator became aware of the allegation of abuse on 3/4/16, when the resident's son contacted the Administrator) which occurred on 3/3/16. Continued interview confirmed the facility did not try to report the allegation of abuse to the State Survey and Certification Agency until 3/7/16 or 3/8/16.