Every finding on record at Arkansas Health Center

Based observation, interview, and record review, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; ensure cold dairy products were maintained at 41 degrees Fahrenheit or below to prevent the growth of bacteria; dietary staff washed their hands before handling clean equipment or food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 155 residents who received meals from 1 of 1 kitchen (Total Census:157). The findings are: 1. On [DATE] at 09:25 AM, two opened boxes of cobbler dough sheets were on a shelf in the walk-in refrigerator. Neither box was covered or sealed. 2. On [DATE] at 09:29 AM, an opened gallon of soy sauce was on a shelf in the kitchen. The manufacturer specification on the gallon documented, Refrigerate after opening for quality. 3. On [DATE] at 11:01 AM, a carton of orange juice in a cabinet on [NAME] Court had an expiration date of [DATE]. 4. On [DATE] at 11:18 AM, a packet of ginger soy chicken mix in the cabinet on Cedar Court had an expiration date of [DATE]. 5. On [DATE] at 11:51 AM, the temperature of the dairy products taken out of the food cart on Pine Court to serve to the residents for the lunch meal were checked and read by the Registered Dietitian with the following results: a. Nutritional shake - 60 degrees Fahrenheit. The manufacturer specification on the box documented thaw and keep refrigerated. b. Milk - 49 degrees Fahrenheit. 6. On [DATE] at 11:54 AM, Dietary Employee (DE) #1 was wearing gloves when he/she plugged the toaster cord into the outlet, contaminating the gloves. Without washing hands, DE #1 placed slices of bread in the toaster, then removed the slices of bread from the toaster and placed them on the plate. DE #1 then used the same contaminated gloved hand to pick up a slice of bread and used it to top a turkey sandwich. At 12:04 PM the surveyor asked DE #1, what should you have done after touching dirty objects and before handling food items. DE #1 stated, I should have changed gloves and washed my hand. 7. A facility policy titled, Employee Cleanliness documented, .Hands should be washed according to proper procedures. a. Beginning shift. b. After breaks. c. After disposing of trash or food. d. Before putting on gloves. e. Any other time deemed necessary . 44852 8. On [DATE] at 11:54 AM, Certified Nursing Assistant (CNA) #2 was observed moving between two residents (Residents #61, and #67) who required assistance with dining. CNA #2 rearranged their chairs, moving them into place for ease in feeding. Without sanitizing hands, CNA #2 peeled and handed a banana to a resident, then turned to another resident to complete the process of thickening his drink. Hands were not sanitized between residents. CNA #2 continued to set up the resident's tray, offering food items and fluids. CNA #2 turned back toward the resident on the right, picked up their spoon and provided a bite of vegetable and then banana. At 11:58 AM, CNA #2 walked around the resident on her right and proceeded to assist a third resident at the table. During the entirety of the meal CNA #2 did not sanitize hands. 9. On [DATE] at 11:59 PM, CNA #3 provided assistance with tray set up and feeding for two residents (Residents #95, and #150). CNA #3 moved between residents, bringing bites of food to their mouth. CNA #3 did not sanitize hands between assisting residents. 10. On [DATE] at 12:05 PM, CNA #4 provided assistance to 2 residents during the noon meal. CNA #4 brings the spoon to the mouth of the resident on the right then returns the spoon to the plate. CNA #4 then turns to the resident on their left, picks up the spoon and brings the bite of food to the resident's mouth and then returns the spoon to the plate. CNA #4 was observed to not sanitize hands between residents. At 12:15 PM, CNA #4 holds the hand of the resident on to the right. CNA #4 returned to the resident on the left without sanitizing hands. 11. On [DATE] at 12:08 PM, CNA #5 used a bare hand to hold the edge of a slice to bread to spread butter. CNA #5 then picked up the slice of bread with a bare hand and moved the bread from one plate to the next. 12. On [DATE] at 12:10 PM, CNA #6 placed a slice of bread on the bare palm of their hand to spread butter. Upon completion CNA #6 used both bare, unsanitized hands to fold the bread in half and give it to a resident. 13. On [DATE] at 12:34 PM, Licensed Practical Nurse (LPN) #1 was asked when a CNA should sanitize their hands during the feeding process. LPN #1 stated, They need to sanitize between residents, when changing tasks, when they encounter something soiled. LPN #1 was asked about holding a food item in bare hands. LPN #1 stated, I would think they need to have on gloves. 14. On [DATE] at 12:45 PM, CNA #6 was asked when hands should be washed or sanitized when providing resident assistance during meals. CNA #6 stated, You are supposed to sanitize hands between residents. When asked about the appropriateness of holding a food item in a bare hand the CNA stated, Yeah, you aren't supposed to do that.

Based on observation, interview, and record review, the facility failed to ensure privacy was maintained for 1 (Resident #11) of 7 sampled residents who resided on Pine [NAME] and utilized the bathroom on their hallway; a lunch tray or substitute was served sequentially for 1 (Resident #128) of 17 sampled residents who received a meal tray on the Cedar Unit and failed to ensure Certified Nursing Assistants (CNA) were seated when providing assistance with eating for 5 (Residents #67, #150, #128, #61, and #52) of 10 sampled residents who resided on the Cedar Unit. The findings are: 1. Resident #11 had diagnoses of Epilepsy and Epileptic Syndromes with Complex Partial Seizures, Major Depressive Disorder, Anxiety Disorder, Altered Mental Status, unspecified, and Constipation. The resident received a score of 10 (8-12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). a. On 02/26/24 at 12:40 PM, Resident #11 was observed sitting on the toilet when CNA #9 went in to assist Resident #11 with pulling up the resident's pants and putting on a new brief. The automatic door remained open, allowing the resident to be seen from the hallway. The stall door was opened, and CNA #9 was assisting Resident #11 just outside the stall. There was no privacy curtain between the open stall and the hallway. The automatic door closure holds the door open for 24 seconds before closing, which allows anyone in the hallway to see directly into the stall. Another resident pushed the automatic door open, exposing Resident #11 a second time to the Surveyor who was standing in the hallway, just outside the bathroom. b. On 02/27/24 at 12:00 PM, the automatic door was observed opening and staying open for 24 seconds as a resident entered. The bathroom with the automatic door closure did not have a privacy curtain, leaving residents exposed to anyone standing or passing in the hallway. c. On 02/29/24 at 10:04 AM, the Surveyor tested the time the door remained open. Once the button was pushed and the door started opening, giving a clear view to the stall, it took 24 seconds to close. d. On 02/29/24 at 10:07 AM, CNA #8 was asked if there was a problem with the way the door closes. CNA #8 stated, It leaves the person exposed. It should be closed so they are covered. I should push the wheelchair away and shut the door. The other bathroom has a privacy curtain, but this one does not, I don't know why. The Surveyor asked, would it be better to have a privacy curtain. CNA #8 nodded yes and said probably. The Surveyor asked what is the issue with this door remaining open. CNA #8 stated It is a privacy issue. e. On 5/11/2022, Resident #11 ' s Care Plan identifies problems with communication and memory; Resident #11 exhibits Cognitive Impairments as evidence by poor decision-making skills and difficulty understanding others at times; it identifies a goal on 05/22/2024 of Resident #11 to have positive experiences in daily; have a routine without overly demanding tasks and without becoming overly stressed; the care plan identifies Resident #11 to have Activity of Daily Living (ADL) self-care deficit, requiring assistance from staff to complete ADL tasks, due to cognitive and communication deficits, and physical limitations complicated by psychotic disorder. Resident #11 is identified to be a 1 person stand-pivot assist with gait belt for all transfers, as Resident will allow. Resident #11 had a bowel and bladder management program due to the resident being incontinent of both bowel and bladder due to Other psychotic disorder not due to a substance or known physiological condition, decreased physical mobility and cognitive decline; Resident #11 has complications related to incontinence this quarter; and Resident #11 may use adult incontinent briefs, which will be checked and change as frequently as needed to prevent any skin related problems. f. The facility policy, Activities of Daily Living (ADL), provided by the Director of Nursing (DON) on 2/29/24 at 2:52 PM documented, .(d) (1). Privacy is provided to each resident . g. The facility policy, Resident/Elder Rights, provided by the DON on 3/1/24 at 8:00 AM documented, .Privacy .Your privacy will include: personal care . 2. Resident #128 had diagnoses of Schizophrenia and Diabetes Mellitus. On the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/23 the resident received a score of 14 (13-15 indicates cognitively intact) on a BIMS and was dependent on staff for assistance for eating. a. On 2/26/24 at 11:45 AM, Resident #128 was observed sitting at the dining table awaiting his lunch tray. At 11:53 AM, the other residents at the assist table where Resident #128 was seated had received their lunch trays. Multiple staff members were overheard by this Surveyor to say that they are having problems locating a tray on the cart for this resident. Resident #128 was observed to wave his/her arms and in a frustrated tone express the belief that there was a tray which has been previously unnoticed by the staff remaining on the cart. b. On 2/26/24 at 12:07 PM, Resident #128 was told that their tray was mistakenly given to someone else and that another tray would be provided. Resident #128 was not offered fluids or alternatives. c. On 2/26/24 at 12:24 PM, Resident #128 received a tray, 31 minutes after the rest of the residents at the table were served. 3. On 02/26/24 at 11:54 AM, CNA #2 moved between two residents sitting at the assist table. CNA #2 was standing while feeding the residents. At 11:58 AM, CNA #2 moved to a third resident at the table and continued to stand while assisting the resident with lunch. a. On 02/26/24 at 12:05 PM, CNA #4 moved between two residents, standing while assisting them with their noon meal. b. On 02/28/24 at 12:34 PM, Licensed Practical Nurse (LPN) #1 was asked where a CNA should position themselves when providing meal assistance. LPN #1 stated, They should sit down beside or across from the resident. c. On 2/28/24 at 12:45 PM, CNA #6 was asked where a CNA should position themselves while assisting a resident with meals. CNA #6 stated, You should sit down beside them. You should make conversation, tell them what they are about to receive. d. On 3/1/24 at 8:00 AM, the Director of Nursing (DON) provided a policy titled, Meal Service. It documented, Purpose: The purpose of this policy is to ensure adequate nutrition for the residents within long term care guidelines . All possible efforts will be made to make mealtimes pleasant. e. A policy titled, Resident/Elder Rights documented, .The residents/elders of [Facility] have the right to a dignified existence . [Facility] will protect and promote the rights of their residents . Dignity - [Facility] will treat you with dignity and respect in full recognition of your individuality . 49596

Based on observation, interview, and record review the facility failed to ensure resident clothing was clean and maintained in a respectable manner to promote dignity and self-confidence for 1 (Resident #87) sampled resident who were dependent on staff for care, and failed to ensure residents fingernails were trimmed and cleaned to promote good hygiene for 1 (Resident #93) sampled resident who were dependent on staff for nail care. This had the potential to affect 33 residents who were dependent on staff for care The findings are: 1. Resident #87 had a diagnosis of Hemiplegia, unspecified affecting right dominant side. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9-19-2023 documented a Brief Interview Mental Status (BIMS) score of 10 (8-12 indicates moderate cognitive impairment). a. On 2/26/24 at 7:26 PM, Resident #87 was wearing a t-shirt that had spots of spilled food that were white and dry. b. On 2/27/24 at 11:33 AM, Resident #87 was wearing a lightweight jacket that had spilled food on the front of it, dried on, white in color. c. On 2/28/24 at 9:44 AM, Resident #87 was wearing a lightweight jacket that had spilled food on the front of it, dried on, white in color. d. The Care Plan with a review date of 1/4/22 for Resident #87 documented a self-care deficit: the Resident required limited assistance from staff to complete ADL (Activities of Daily Living) tasks, d/t (due to) cognitive and communication deficits, and physical limitations complicated by Dementia in other diseases classified elsewhere with behavioral disturbance Note: Major Neurocognitive d/t TBI (Traumatic Brain Injury). e. On 02/28/24 at 2:24 PM, the Surveyor asked Registered Nurse (RN) #2, when are resident clothes changed. RN #2 said after they eat, if needed. When they get up in the morning, after they receive their shower. f. On 02/28/24 at 02:28 PM, the Director of Nursing (DON) provided a policy titled Activities of Daily Living (ADL) that documented, 4. PROCEDURE. A. Hygiene. 1. Resident self image is maintained . 6. Frequent showers or baths are scheduled and assistance provided when required . 2. Resident #93 had diagnoses of Schizoaffective Disorder, Bipolar Type and Type 2 Diabetes without complications. A Quarterly MDS with an ARD of 12/12/2023 documented a BIMS of 10. a. On 02/26/24 at 08:33 PM, Resident #93's fingernails were dirty, 1/4 inch long, with a dark substance under the nails. b. On 02/28/24 at 11:02 AM, Resident #93's fingernails were 1/4 inch long, with a dark substance under the nails. c. On 02/28/24 at 11:06 AM, Resident #93 was asked if staff cut and clean their fingernails when they shower. Resident #93 stated, No, they do not have time. The Surveyor asked if the resident refused to let the CNA in the shower perform nail care. Resident #93 stated, No. The Resident confirmed they were diabetic. d. On 02/28/24 at 12:20 PM, the Surveyor asked RN #2 when residents had their fingernails trimmed. RN #2 stated, Weekly. The Surveyor asked for documentation of when residents fingernails were last cut. RN #2 stated, I do not have paperwork showing that the residents nails were cut. I have asked [Resident #93] if I can cut them today, resident has agreed. e. On 02/28/24 at 01:15 PM, the Administrator provided a policy titled, Nail Care that documented, .4. Procedure .e. Clip resident's nails without injuring the surrounding skin .

Based on observation, interview, and record review, the facility failed to ensure smoking assessment interventions were followed for 1 (Resident #149) sampled resident. The findings are: Resident #149 had a diagnosis of Chronic obstructive pulmonary disease, unspecified. A Significant Change Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 1-9-2024 documented a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicates moderate cognitive impairment). On 02/28/24 at 09:48 AM, Resident #149 was observed outside smoking and was not wearing a smoking apron. The Care Plan with a review dated of 2/6/2024 documented Resident is at risk for injury to self and others related to smoking-must wear smoking apron and be directly supervised at ALL times . Resident must wear smoking apron and be directly supervised at ALL times . Enforce smoking restrictions. On 02/28/24 at 09:56 AM, the Surveyor asked Certified Nursing Assistant (CNA) #7, does the resident (Resident #149) require a smoking apron. CNA #7 stated, I do not know, I will have to check . On 02/28/24 at 01:33 PM, the Director of Nursing (DON) provided a policy titled, Resident Smoking that documented, .Documentation from the assessment will be included in the initial and quarterly Care Plan specifying Supervised or Unsupervised Smoker, or requires smoking apron or other adaptive or enabling device . Protective equipment will be made available for the individuals requiring this type of equipment .

Based on observation, interview, and record review, the facility failed to ensure and maintain their Schedule II-V medications in a permanently affixed compartment. The findings are: 1. On 2/29/2024 at 9:30 AM, on the Aspen East/West Halls the Surveyor observed the narcotic box, locked in the refrigerator, behind the locked medication room door. The narcotic box was locked, but not permanently affixed to the refrigerator that it was stored in. 2. On 2/29/24 at 2:03 PM, on the Elm Unit, Licensed Practical Nurse (LPN) #3 unlocked the refrigerator in the medication storage room and put the narcotic box on the counter. There were 7 vials of Ativan (a controlled substance) in the medication lock box. The narcotic box was not permanently affixed to the refrigerator. a. On 2/29/24 at 2:18 PM, on the [NAME] Unit, LPN #4 unlocked the refrigerator and walked out of the medication storage room with the box. LPN #4 stated, The nurse is on break, and I got to go find the key. The narcotic box was not permanently affixed to the refrigerator. b. On 2/29/24 at 2:49 PM, Registered Nurse (RN) #1 opened the narcotic box on the [NAME] Unit. There were 11 vials of Ativan and 1 bottle of Ativan in the narcotic box. The narcotic box was not permanently affixed to the refrigerator. 46723

Based on observations, interview, and record review, the facility failed to ensure handrolls were applied to 1 (Resident #8) of 2 sampled residents who had an order for hand rolls. The findings are: 1. Resident #8 had a diagnosis of Primary generalized (osteo)arthritis. A significant Change Minimum Data Set (MDS) with Assessment Reference Date of 1/26/24 documented functional limitations to upper and lower extremities. A Staff Interview for Mental Status (SAMS) documented the resident was moderately cognitively impaired. A Care Plan with review date of 2/5/24 documented, .Bilateral Hand Rolls at all times as resident will Tolerate/Allow with the Exception of During Bathing Times . On 02/29/24 at 10:58 AM, Resident #8 was in the sitting room with no hand rolls in the resident's hands. On 2/29/24 at 11:00 AM, the Surveyor asked Registered Nurse (RN) #1 if Resident #8 was supposed to have hand rolls in place. RN #1 stated, Sometimes [the resident] will allow them and sometimes [the resident] will refuse. Also, [the resident] will open his/her hands up and let them fall out. The Surveyor asked, Did [Resident #8] refuse them today? RN #1 stated, I don't know. On 2/29/24 at 11:06 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if Resident #8 was supposed to have hand rolls in place. CAN #1 stated, I don't know for sure. The Surveyor asked, Did you assist him up today? CNA #1 stated, No, I helped transfer [the resident] from [the] chair into the other chair so that [the resident] could go to his/her appointment. The Surveyor asked, Do you know if [the resident] refused them today? CNA #1 stated, I'm not sure. On 3/1/24 at 8:00 AM, a policy received from the Director of Nurses (DON) titled, Positioning, Splints, Pressure Relieving devices and Body Alignment, documented, 4.2. Have proper equipment to relieve pressure and maintain body alignment (for example, blue boots, pillows, handroll, etc.) .

Based on observation, record review and interview, the facility failed to ensure foods stored in a dry storage area was covered to minimize the potential for cross contamination for residents who received meals from 1 of 1 kitchen; expired snacks were promptly removed/ discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination. These failed practices had the potential to affect 174 residents who received meals from the kitchen (total census: 184) as documented on a list provided by the Registered Dietitian. The findings are: 1.The following items were observed uncovered or expired: a. On [DATE] at 10:08 AM, An opened box was on a cart in the kitchen. The box was not covered. b. On [DATE] at 10:12 AM, A box that contained 15 bags of assorted chips in a cabinet on [named unit] had an expiration date of ,d+[DATE]. 2. The following observations were made in the kitchen: a. On [DATE] at 10:19 AM, Dietary Employee #1 was wearing gloves on her hands. She picked a log of ham and placed it on the cutting board on the counter. She used a knife to open the wrap that covered the ham, contaminating the meat. She did not change her gloves or wash her hands. She used the contaminated knife to slice the meat. She placed slices of ham in a grinder and ground the ham to be served to the residents. At 9:06 AM, The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. b. On [DATE] at 7:01 AM, Dietary Employee #2 pushed a cart that contained boxes of beef base into the refrigerator. She did not wash her hands, she picked up a pan with her thumb inside the pan and placed it on the counter. She scooped macaroni and cheese into the pan to be served to the residents for lunch. c. On [DATE] at 7:07 AM, Dietary Employee #2 turned on the food preparation sink faucet and obtained water. She turned off the sink with her bare hand. She did not wash her hands, she picked up a spoon by the tip that goes into the food and used it to transfer mixed vegetables from the kettle into a pan to be pureed and served to the residents on pureed diets. d. On [DATE] at 10:00 AM, Dietary Employee #3 turned on the food preparation sink, rinsed the tomatoes, then she turned off the faucet., she picked up gloves and placed them on her hands which contaminated the gloves. She used her contaminated hand to pick up the tomatoes, sliced them, and placed them in a bowl to be served to the residents. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 3. The facility policy on hand washing provided by the Registered Dietitian on [DATE] at 3:07 PM documented, 'Before putting on gloves and between glove change. Any other time deemed necessary.

Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a decline in Activities of Daily Living (ADLs) for 1 (Resident #180) of 8 (R #10, R #17, R #20, R #46, R #54, R #123, R #152, and R #180) sampled residents. This failed practice had the potential to affect all 65 residents that reside on [named] Unit as documented on the [named] Unit Resident Census which was provided by Licensed Practical Nurse (LPN) #2 on 11/14/22 at 10:05 AM. The findings are: Resident #180 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date (ARD) of 10/19/22 documented Resident #180 scored a 6 on a Brief Interview for Mental Status (BIMS) (0-6 Indicates Severely Cognitively Impaired) and required total dependence with toileting and eating and extensive assistance with transfers and bed mobility. 1. Chart review on 11/16/22, showed the most current Significant Change in Status MDS was dated 11/16/22. 2. On 11/16/22 review of the October 2019 Resident Assessment Instrument (RAI), Page 47 showed, . An SCSA (Significant Change in Status Assessment) is appropriate if there are . two or more areas of decline or two or more areas of improvement . 3. On 11/16/22 at 01:34 PM, The Surveyor asked the MDS Coordinator, What is a Significant Change in Status MDS? She answered, When 2 or more care levels are identified as a decline or improvement in 2 or more areas then the Interdisciplinary team met and decide if a significant change needs to be done. The Surveyor asked her to review Resident #180's previous MDSs for a Significant Change MDS. She did then and responded, Then once it's been identified then I have 14 days to open it up then 14 days to complete it so I'm only 1 day behind. a. The RAI Manual page 2-7 which was provided by the MDS Coordinator documented, . Guidelines for Determining Significant Change in Resident Status . Decline in two or more of the following Overall deterioration of resident's condition; resident receives more support (e.g., in ADLs .) .

Based on observation, interview and record review the facility failed to ensure resident's fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 1 resident (R #3) of 6 (R #3, R #16, R #20, R #48, R #104, and R #158) sampled residents on the unit who were dependent for nail care. The findings are: 1.Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 09/08/2022 documented a BIMS (Brief Interview for Mental Status) of 10 (8-12 indicates moderately impaired), total assistance of two people required for bathing and extensive assistance of one person required for personal hygiene. a. On 11/14/22 at 10:28 AM, Resident #3 was sitting up in a wheelchair in the day room. She had her hands hanging down on both sides of the chair. The fingernails on each hand were greater than 1/4 inch past her fingertips. The nails on her 3rd [third] and 4th [fourth] finger of her right hand and the thumb and 3rd finger of her left hand were jagged and rough. b. On 11/15/22 at 9:10 AM, Resident #3 was lying in bed, her fingernails remained long and jagged. c. The Care Plan with a revision date of 12/22/21 documented, Resident is extensive to total assistance from one or more staff with all ADL (Activities of Daily Living) care due to Cognitive and Physical deficits related to Multiple Mental and Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Check toenails and fingernails according to schedule or as needed and provide appropriate care . d. On 11/16/22 at 8:36 AM, The surveyor asked Registered Nurse (RN)#1, Who is responsible for nail care? RN #1 stated, This is my second day here; I haven't done any here. But normally, the nurses do the diabetics, and the assistants can do everyone else. The Surveyor then asked, What can happen if nails are left long and jagged? She stated, They could scratch themselves which could cause an infection. RN #1 stated, I'll notify the RN Supervisor (RN #2) and get that taken care of today. e. On 11/16/22 at 8:43 AM, The RN Supervisor (RN #2) was in the day room. The surveyor asked RN #2, When is nail care provided? She replied, We check them during care and provide it as needed. R #3 was in the day room and the surveyor asked her to describe R #3's nails, she looked at her hands and stated Oh, they do need trimming, I'll get that taken care of. f. On 11/17/22 at 11:30 AM, The (Named) Unit Master Bath Schedule was provided by the Administrator which documented R #3 received a bath on Wednesday and Friday.

Based on Observation, Interview and Record review the facility failed to ensure that 1 resident (Resident #17) was repositioned, range of motion preformed, and incontinent care provided while up in wheelchair. This failed practice had the potential to affect 4 (R #17, R #25, R #26, and R #36) residents that resided on the (named East and West) Units who were totally dependent on staff for ADL's (Activities of Daily Living) as indicated on a list provided by the Director of Nursing (DON) on 11/17/22 at 8:58 AM. The findings are: 1. Resident # 17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/22 showed the resident scored a 00 (00 indicated a severe cognitive deficit) on the Brief Interview of Mental Status (BIMS), the resident was totally dependent for toileting and eating and required extensive assistance for transfers and bed mobility. 2. Review of Physicians orders on 11/16/22 at 09:30 AM, showed, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Padding on wheelchair to prevent skin injury. Every Shift Enablers & and Other Device. 3. Review of the Care Plan on 11/16/22 at 09:35 AM, with a start date of 4/20/22 and last reviewed/revised on 10/28/22 showed, Category skin PROBLEM: At risk for alterations in skin integrity r/t poor safety awareness, fragile skin and incontinence of bowel and bladder. Target Date: 01/18/2023 (Short Term Goal) GOAL: Resident's skin will remain intact through the review date. Start Date: 09/27/2022 APPROACH: May be up in Wheelchair with Dycem under and on top of Raised Foam Cushion, Padded Lap Tray with Velcro Strap, and Foot Box when out of bed. Padding on wheelchair to prevent skin injury. Start Date: 06/07/2022 APPROACH: Provide incontinence care for bowel and bladder every 2 hours and as needed Start Date:06/07/2022 APPROACH: Use pressure relieving measures with repositioning every 2 hours and as needed to maintain comfort and functional alignment. 4. The following observations were made of Resident #17: a.On 11/14/22 at 10:05 AM, R #17 was in Day Room with a lap top tray attached to the wheelchair. The Resident was unable to undo the tray. b. On 11/14/22 at 01:05 PM, R #17 remained in the dining room with the tray attached. c. On 11/15/22 at 07:57 AM, R #17 was in day room in chair with tray attached to w/c [wheelchair]. d. On 11/15/22 at 09:00 AM, Resident #17 was going to get her hair cut in her w/c then back to dining/day room. e. On 11/15/22 at 01:25 PM, R #17 was put to bed on her left side. f. On 11/16/22 at 08:06 AM, R #17 was in the dining room in her w/c with the tray attached. g. On 11/16/22 at 08:09 AM, R #17 was assisted to her room and a call light was placed within her reach. 5. The following interviews were conducted regarding Resident #17: a. On 11/15/22 at 01:30 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2, Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA #2 stated, No. b. On 11/15/22 at 1:33 PM, the Surveyor asked CNA #5, have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA#5 stated, No. The Surveyor asked Surveyor asked CNA #5, Why is the tray being used for Resident #17? She stated, to keep her in her chair; she leans forward and its dangerous. The Surveyor asked CNA #5, Has Administration tried anything prior to using the tray? She stated, I don't know. c. On 11/15/22 at 1:35 PM, The Surveyor asked CNA #4, Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25PM? The CNA stated, No. d. On 11/15/22 at 1:36 PM, The surveyor asked the Restorative Nursing Assistant (CNA #6), Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA #6 stated, no. e. On 11/15/22 at 1:47 PM, the Surveyor asked CNA #3, Have you changed or repositioned Resident #17 any time today before she was laid down at 1:25 PM? CNA #3 stated, No. f. On 11/17/22 at 08:40 AM, the Surveyor asked the DON, How often do you expect your staff to check for residents who are incontinent or need to be repositioned? She stated, Every 2 hours. Surveyor asked DON, Is it ever ok for a totally dependent resident to sit and not be checked on for longer than 2 hours? She stated, no. g. On 11/17/22 at 10:00 AM, The Surveyor asked Registered Nurse (RN #3), How do you monitor the staff to ensure the residents are being repositioned or given peri care? She responded, Making rounds, opening doors, and checking behind doors. The Surveyor asked RN #3, How often should a resident be checked on for incontinent care or repositioning? She stated, Every (q) 2 hours. The Surveyor asked, Is it ok for a totally dependent resident to sit and not be checked for longer than 2 hours? She stated, no. The surveyor asked RN #3 What could potentially occur from prolonged sitting? She stated, Develop a pressure sore. 6. On 11/17/22 at 08:58 AM, a form provided by the DON titled, POSITIONIG IN CHAIR POLICY B .Resident remains in a sitting position no longer than two hours at a time before repositioning, unless otherwise ordered .

Based on observation, record review and interview the facility failed to ensure indwelling catheter drainage bags were kept below the level of the bladder to prevent potential infection risk and secured to prevent pulling and potential for meatal injury for one resident (Resident #61) of three sample residents (Resident #51, #61, #71) reviewed. This failed practice had the potential to affect three residents who had catheters according to a list provided by the Director of Nursing (DON) on 11/17/22 at 8:10 AM. The findings are: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/22 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). a. On 11/14/22 at 10:37 AM, Resident #61 was lying in bed with eyes closed, the foley catheter drainage bag tubing was coming from the left leg of his pants at the left ankle and was stretched tight across the mattress over to the wheelchair sitting adjacent to the bed and secured on the armrest of the wheelchair with a hook. The drainage bag was slightly above the level of the bladder. b. On 11/16/22 at 8:02 AM, Resident #61 was lying in bed on his right side. The foley catheter drainage bag tubing was coming out of the left pant leg at the ankle. The tubing was stretched tight across the bed to the arm rest of the wheelchair sitting adjacent to the bed. The catheter tubing had a white and pink colored substance in the tubing. Certified Nursing Assistant (CNA) #1 emptied the catheter drainage bag. The catheter leg band was loose and just above left knee, the catheter ran out of an incontinent brief on left side thigh area. The Surveyor asked CNA #1 if it was acceptable for the catheter tubing to be pulled tight and hanging from armrest of the wheelchair with the leg band loose, above the knee and not preventing the catheter from pulling on urinary meatus. CNA #1 stated. No, it isn't and removed the foley drainage bag from the armrest of wheelchair and secured it underneath the wheelchair. CNA #1 stated, This is how it is supposed to be secured, below the bladder. The Surveyor asked, If the facility usually used incontinent briefs for residents who had indwelling catheters? CNA #1 stated, No, but resident # 61 is incontinent of bowel. c. On 11/16/22 at 1:00 PM, review of Resident #61's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . d. On 11/16/22 at 1:10 PM, review of progress notes dated 07/05/2022 at 09:28 documented, .New orders: per [Dr] . resident to be transported to (Named) emergency room (ER) due to continued bacterial growth in urine after being treated with [MEDICATION(S)] and [MEDICATION(S)] as well as previous oral antibiotics . e. On 11/16/22 at 2:30 PM, review of Resident #61's Care Plan with a start date of 1/18/21 documented, . Approach: Use a catheter strap. Assure enough slack is left in the catheter between the meatus and strap. Approach: Position bag below level of bladder. Approach: Avoid obstructions in the drainage. Start Date 1/18/2021 f. On 11/17/22 at 9:38 AM, The Surveyor interviewed the DON and asked, If it was facility practice to use incontinent briefs for residents with indwelling catheters with bowel incontinence? She stated, Yes, we do use incontinent briefs on bowel incontinent residents with catheters. The Surveyor asked, If it is acceptable for catheter drainage bags to be secured at or above level of the bladder and pulled tight without being secured to prevent pulling on urinary meatus? The DON stated, No it is not. I need to see if the resident transfers himself. g. On 11/17/22 at 9:00 AM, the facility policy Urinary Catheter Insertion and Removal NS 701 was reviewed and documented .o. secure catheter to inner thigh of resident with a leg strap to prevent movement and urethral, as resident will allow .p.3. Collection bags are always kept below the level of the bladder .

Based on observation and interview, the facility failed to ensure food items stored in the freezer were covered and sealed and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 198 residents who received meals from the kitchen (total census: 209), as documented on a list provided by the Registered Dietitian 7/22/2021 at 2:21 p.m. The findings are: 1. On 7/22/21 at 6:50 a.m. Dietary Employee #1 removed bags of eggs from the refrigerator and placed them on the counter. Without washing her hands, she picked up a pan, with her fingers touching inside the pan, and placed it on the counter to be used to store cooked food. At 10:00 a.m., Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? She stated, I should have washed my hands. 2. On 7/22/21 at 7:18 a.m., Dietary Employee #2 pushed a cart that contained a pan of carrots toward the counter, then without washing his hands, picked up a clean blender blade. He attached it to the base of the blender to be used in pureeing food items to be served to the residents who received a pureed diet for lunch meal. 3. On 7/22/2021 at 8:24 a.m., the following observations were made in the walk-in freezer: a. There were 2 open boxes of pizza stored on a rack in the freezer. The boxes were not covered or sealed. b. An open box of hot dogs was stored on a rack in the freezer. The box was not covered or sealed. c. An open box of hamburger patties was stored on a rack in the freezer. The box was not covered or sealed. 4. On 7/22/2021 at 9:15 a.m., Dietary Employee #2 was wearing gloves on his hands. He picked up the cord to the meat slicer and plugged it into a socket. He removed the gloves and discarded them. Without washing his hands, he removed gloves from the glove box and placed them on his hands, contaminating the gloves in the process. He removed paper wrapping from a ham, placed the ham on the meat slicer and sliced it to be used for the residents' lunch meal. At 10:01 a.m., Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment or food items? He stated, I should have changed gloves and washed my hands. 5. The facility's handwashing policy, provided by the Registered Dietitian on 7/22/2021 at 2:51 p.m., documented, .Hands should be washed according to proper procedures . before beginning shift and before putting on gloves .

Based on observation, record review, and interview, the facility failed to ensure urinary catheter bags were in a privacy bag or otherwise concealed from view of other residents / visitors, to promote dignity for 2 (Residents #87 and #170) of 9 (Residents #126, #89, #170, #157, #124, #165, #87, #177, and #195) sampled residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #130) of 3 (Residents #131, #106 and #130) sampled residents who resided on the Elm Wing and required assistance with eating. The findings are: 1. Resident #87 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 30-day Medicare Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/6/21 documented the resident was moderately impaired in cognitive skills for daily decision-making per a staff assessment of mental status (SAMS), required extensive assistance of 2-plus persons for bed mobility, was totally dependent on 2-plus persons for transfer, and had an indwelling catheter. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care dated 8/31/20 documented, .Make sure that my catheter bag is covered to maintain privacy . c. On 7/20/21 at 9:29 A.M., the resident was lying in bed with the head of bed (HOB) elevated. The suprapubic catheter drainage bag, with a yellow substance draining into it, was hanging on the side of the bed facing the hallway. The door to the room was open and there was no privacy bag to conceal the catheter drainage bag from view. 2. Resident #170 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/21 documented the resident scored 8 (8-12 indicates moderate impairment) on a BIMS, was totally dependent for bed mobility and transfers, and had an indwelling urinary catheter. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan dated as initiated 1/20/21 documented, .Bowel and Bladder Management . I carry the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Please keep my catheter drainage bag covered to maintain dignity . c. On 07/19/21 at 12:08 P.M., Resident #170 was sitting in a geriatric chair in her room. Her indwelling catheter drainage bag was suspended from the left side of the geriatric chair, with approximately 200 cubic centimeters (cc) of lemon colored liquid in the bag. No privacy bag was in place to cover the drainage bag. d. On 07/20/21 at 10:54 A.M., Resident #170 was lying in bed. Her indwelling catheter drainage bag was suspended from the right side of the bed frame, with approximately 400 cc of amber colored fluid in the bag. No privacy bag was in place to cover the bag. 3. On 7/22/21 at 10:26 A.M., the ADON was asked if urinary catheter bags should be placed in a privacy bag or covering. She stated, Yes. When asked why, she stated, For privacy. 4. Resident #130 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/21 documented the resident scored 8 (8-12 indicates moderately impaired) on a brief interview for mental status (BIMS) and required limited assistance with eating. a. The Comprehensive Care Plan dated as initiated on 4/7/2020 documented, .I am able to feed myself with set-up and supervision most of the time, but I need the staff to assist me with eating at times because I can get distracted . b. On 07/19/21 at 12:29 P.M., Certified Nursing Assistant (CNA) #1 was feeding the resident at a table in the dining room. The CNA was standing over the resident and conversing with another staff member, not making eye contact, or engaging with the resident. Registered Nurse (RN) #5, the Unit Manager, was asked, Should she be standing while feeding the resident? She replied, Yes, they do sometimes. It just depends on what all they are doing when assigned to the dining room. She is an agency CNA. She's not ours. c. On 7/22/21 at 10:30 A.M., the ADON was asked, Should staff stand over residents when assisting with meals? She responded, No, they should be sitting at eye level for dignity. d. On 7/22/21 at 1:05 P.M., the Director of Nursing (DON) provided a document titled, Feeding A Resident which documented, .Give the resident your complete attention. Sit so you are at the same level of the resident when possible .

Based on observation, interview, and record review, the facility failed to ensure a pressure-relieving device (PRD) was in place as ordered by the physician, to minimize the potential for pressure ulcer development for 1 (Resident #88) of 18 (Residents #8, #83, #47, #108, #170, #96, #406, #149, #70, #106, #130, #195, #28, #182, #88, #124, #87, and #177) sampled residents who required pressure relieving devices. The facility also failed to ensure weekly skin assessments were consistently performed to prevent potential delays in identifying and addressing new or worsening skin breakdown for 1 Resident (Resident #88) of 1 sampled resident who had new skin breakdown identified during the survey. The findings are: Resident #88 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/21 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), was totally dependent with bed mobility, and transfers, was at risk for pressure ulcer development, had one Stage 3 pressure ulcer and had a pressure reducing device for the chair and bed. a. The Comprehensive Care Plan dated as initiated on 9/24/2020 documented, .POSITIONING: Resident cannot position or reposition herself while in or out of bed . CHANGED: 10/31/2020 Resident needs to wear Bilateral Blue Heel Boots as she tolerates except during bathing . SKIN: INITIATED 9/24/2020 Provide any enablers/pillows/devices as needed to help promote proper body alignment and prevent further pressure issues . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The Braden Scale dated as observed 5/13/21 and completed 5/24/21 documented the resident's pressure ulcer risk score was 12, with a score of 10-12 indicating a high risk for pressure ulcer development. d. As of 7/5/21 at 3:47 P.M., the most recent Body Audit in the resident's Electronic Medical Record (EMR) was dated 7/5/21 at 3:47 p.m. and documented, .Resident continues with scratch marks to both hips r/t [related to] resident self-scratching. Resident has gloves but continues to take them off. Will continue to monitor. No other skin breakdown was documented on the 7/5/21 Body Audit. e. On 07/19/21 at 11:54 A.M., the resident was lying in bed with eyes closed. The blue heel boots were in a Geri-chair at the bedside. f. On 07/20/21 at 10:36 A.M., Registered Nurse (RN) #1 was asked, Does [Resident #88] have any pressure sores? RN #1 stated, She used to have an area on her coccyx that has healed. I've been told she has new areas that I'm going to look at and measure. The surveyor accompanied RN #1 to the resident's room to observe the resident's skin. There were open areas to both feet that had the appearance of ruptured blisters, one laterally on her right great toe and one laterally on the bony prominence below her right great toe. She also had one area on the bony prominence below her left great toe. The areas were measured by the RN. No dressings were in place, but the blue heel boots were in use. g. A Progress Note dated 7/20/21 at 2:05 P.M. documented, At 0645 [6:45 A.M.] this am during report, it was reported to this nurse that resident had three 'blister like areas' to left and right great toe areas. This nurse assessed as follows: .small open red open area 0.5cm [centimeters] x [by] 0.5cm observed to Left 1st Metatarsal, small red open area 0.5cm x 0.5cm observed to Right Toe Pad, Clear fluid filled pocket 1cm x 1cm observed to Right 1st Metatarsal. This nurse noted that the blue heel boots were not properly placed, blue boots applied bilaterally per orders with proper placement, [physician] notified and received the following orders: 1) Left 1st Metatarsal: Cleanse with [MEDICATION(S)], pat dry, apply TAO [Triple Antibiotic Ointment], cover with small Band-Aid change Q [every] shift and PRN [as needed] x [for] 7 days then reassess 2) Right 1st Metatarsal: cleanse with [MEDICATION(S)], pat dry, apply TAO, cover with large band aid change Q shift and PRN x [times] 7 days then reassess 3) Right Great Toe Pad: cleanse with [MEDICATION(S)], pat dry, apply TAO, cover with small band aid change Q shift and PRN then reassess x 7 days. Treatments applied per doctors order . Ensure proper placement of Blue Heel Boots and continue current interventions in place. h. On 07/21/21 at 09:10 A.M., RN #2 was asked to show the surveyor the Body Audits completed for this resident. RN #2 looked in a binder at the desk that was titled, High Risk Body Audits, and there were no audits in the binder for Resident #88. RN #2 stated, These are our nightly body audits for residents who are at high risk. She is not in here; she is not on the list of high-risk residents. She was asked, How often should this resident receive body audits? She replied, Weekly is the standard if they are not found to be at high risk. RN #2 was asked, What qualifies a resident to be in that binder or to be considered high risk? RN #3, who was also present for the interview, stated, We go by the Braden Scales that are done quarterly. She reported she performed a body audit yesterday and did measurements of the resident's wounds, notified the physician, obtained treatment orders, and started an in-service for the staff. RN #3 was asked to look at the quarterly Braden Scale for this resident, then was asked, So, this resident has a history of pressure injury, a Braden Score of 12, and a new pressure-related injury. Should she be in this [high-risk] binder for nightly body audits? RN #3 stated, I'll call the doctor right now and get the order for nightly body audit for her. She was asked to look in the chart and tell me when the last body audit was performed for this resident prior to 7/20/21. She looked in a binder and stated the resident was scheduled to have body audits done weekly on Mondays during day shift. She looked in the resident's chart, and the most recent body audit was documented on 7/5/21. She stated, It looks like the one that was due on 7/12/21 was missed. She was asked, Does the system trigger the body audits? She replied, No, we go by this schedule in the book. Whoever is working that shift is responsible for the body audit. i. On 7/22/21 at 1:05 P.M., the Director of Nursing provided a document titled, Skin Integrity and Assessment, which documented, .Policy: Residents will be assessed for pressure ulcer risk. Residents determined to be at risk will have preventive measures in place . HIGH RISK FOR PRESSURE ULCER (Braden Scale of 12 or less) will have daily body audits performed . The high-risk body audits will be maintained in a notebook at the nurse's station labeled 'high risk' .

Based on observation, record review and interview, the facility failed to ensure 3 of 3 clothes dryers in the laundry room located on the first floor remained free of excessive lint build-up to decrease the potential for fire. This failed practice had the potential to affect 209 residents, according to the Resident Census and Conditions of Residents form dated 07/20/21. The findings are: On 07/20/21 at 10:15 a.m., three electric clothes dryers were in the clean area of the laundry room. Laundry Aide #1 (LA #1) opened the lint trap of Dryer #1. There was approximately a ½ inch build-up of lint in the bottom of Dryer #1 and on the lint trap. LA #1 was asked, Can you tell me what you see? LA #1 stated, Lint. LA #1 was asked, What could happen with the lint build-up? LA #1 stated, It could cause a fire. LA #1 was asked, How often are the lint traps cleaned? LA #1 stated, They're cleaned after each load. a. On 07/20/21 at 10:22 a.m., LA #1 opened the lint trap of Dryer #2. There was a ½ inch build-up of lint in the bottom of Dryer #2 and on the lint trap. b. On 07/20/21 at 10:25 a.m., LA #1 opened the lint trap of Dryer #3. There was a ½ inch build-up of lint in the bottom of Dryer #3 and on the lint trap. c. On 07/22/21 at 10:45 a.m., the Administrator was asked, Should there be a build-up of lint in the dryers? The Administrator stated, No. The Administrator was asked, What can happen when there is a build-up of lint? The Administrator stated, It can cause a fire. d. The facility's Rules for Safe Operation of Dryer, provided by the Program Manager on 07/22/21 at 1:05 p.m., documented, .3. Always keep the lint screen clean .4. Clean the lint screen daily .A clothes dryer produces combustible lint and should be exhausted outside the building. The dryer and area around the dryer should be kept free of lint.

Based on observation and interview, the facility failed to ensure enteral feeding formula was administered or disposed of prior to the Use By date, to prevent potential illness for 1 (Resident #88) of 7 (Residents #106, #195, #88, #178, #124, #165, and #87) sampled residents who received tube feedings. The findings are: Resident #88 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), totally dependent with bed mobility and eating, had a feeding tube, and received 51% or more of the total caloric intake via tube feeding. a. The Comprehensive Care Plan dated as initiated [DATE] documented, Resident was sent to the hospital in August of 2020 because of not taking in liquids by mouth. While at the hospital her family made the decision to have a G [gastrostomy] tube placed. All medications, supplements and nutrition are administered per G-tube . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ [at] 180 mL/4hr [180 milliliters every 4 hours] bolus with H2O [water] @ 50 mL/hr [milliliters per hour] continuous via pump. c. On [DATE] at 9:20 A.M., during an inspection of the medication room with Registered Nurse (RN) #2, there were 3 bottles of [MEDICATION(S)] 1.5 that were expired. RN #2 was asked, Who on this floor receives [MEDICATION(S)] 1.5? She checked, then stated, No resident on the floor receives that. We used to have a resident who did, but he has discharged . I will throw those away right now. She threw the bottles in the trash. She was asked to accompany the surveyor to Resident # 88's room to check the date on the bottle of Glucerna that was being administered. A bottle of Glucerna 1.5 was hanging on a pole and infusing via percutaneous endoscopic gastrostomy (PEG) tube at a rate of 999ml/hr (for bolus feedings of 180 ml every 4 hours). The front label on the bottle recorded that it was hung on [DATE]. The Use By date on the label was [DATE]. RN #2 asked the surveyor, Does that say [DATE]? The surveyor replied, That is what it says. She stated, I'll get that changed right now. She exited the room. The bottle had clumps of formula that had collected at the top of the bottle. d. On [DATE] at 1:05 P.M., the Director of Nursing (DON) provided an email that contained partial manufacturer's instructions for the Glucerna 1.5, which documented, .All liquid medical foods, regardless of type of administration system, require careful handling because they can support microbial growth .

Based on observation, record review, and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 1 (Resident #170) of 2 (Residents #170 and #406) sampled residents who lived on Pine Court and received oxygen therapy. This failed practice had the potential to affect 9 residents who lived on Pine Court and had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. Resident #170 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/21 documented the resident scored 8 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS), was dependent for all activities of daily living, and received oxygen therapy. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] > [greater than] 90% . b. The Care Plan dated as initiated 1/20/21 documented, Medical Needs . Respiratory: .I do have a need for humidified O2 at 2L via nasal cannula . my Nurse may administer for me for shortness of breath . Goal: I will be free from increased breathing problems and not require routine medication to manage this problem . c. On 07/20/21 at 10:55 A.M., Resident #170 was lying in bed with oxygen in use via nasal cannula; the flow meter was set between 1 and 1.5 liters per minute. d. On 07/21/21 at 10:26 A.M., Resident #170 was lying in bed with oxygen in use at 1.5 liters via nasal cannula. e. On 7/21/21 at 11:15 A.M., Licensed Practical Nurse (LPN) #1 was asked to accompany the surveyor to Resident #170's room. Once in the room, LPN #1 was asked, What is the oxygen flow rate? LPN #1 checked the flow meter and stated, It is set at 1.5 liters. LPN #1 was asked, What should the resident's oxygen flow rate be? LPN #1 stated, It should be set at 2 liters. LPN #1 was asked, Who is responsible for ensuring the resident's oxygen is set at the correct flow rate? LPN #1 stated, The nurses are responsible. LPN #1 was asked, How often should the resident's oxygen flow rate be checked? LPN #1 stated, I should check it whenever I come into the room. LPN #1 was asked, Should doctor's orders for a resident's oxygen flow rate be followed? LPN #1 stated, Yes, they should. f. On 7/21/21 at 11:20 A.M., LPN #2 was asked, Who is responsible for ensuring the residents' oxygen is set at the correct flow rate? LPN #2 stated, The nurses are responsible. LPN #2 was asked, How often should the residents' oxygen flow rate be checked? LPN #2 stated, It should be checked every shift and as needed to make sure the patient has not touched it and it is set correctly. LPN #2 was asked, Should doctor's orders for a resident's oxygen flow rate be followed? LPN #2 stated, Yes they should. g. On 7/21/21 at 11:25 A.M., Registered Nurse (RN) #4 was asked, Who is responsible for ensuring the residents' oxygen is set at the correct flow rate? RN #4 stated, The floor nurses. RN #4 was asked, How often should the residents' oxygen flow rate be checked? RN #4 stated, Every shift at least. RN #4 was asked, Should doctor's orders for residents' oxygen flow rates be followed? RN #4 stated, Absolutely, they should be followed.

Based on observation, record review, and interview, the facility failed to ensure proper infection prevention and control practices were implemented to prevent the development and transmission of COVID-19 and other communicable diseases and infections as evidence by wearing a face mask and when wearing the face mask to cover the nose. These failed practices had the potential to affect 232 residents who resided in the facility, according to the resident roster provided by the Director of Nursing (DON) on 6/15/2020. The findings are: 1. On 6/15/2020 at 10:20 a.m., there were 2 staff members in the facility van without masks on located westbound on Interstate-30. The van followed this surveyor to the facility. The staff applied their masks after they exited the van. An ambulatory resident exited the van without a mask on. A photograph of the van driver applying the face mask and the resident not wearing a face mask was taken at this time. a. On 6/15/2020 at 11:13 a.m., Office Personnel #1 was observed with no mask on. Office Personnel #1 was asked, Where is your mask? Office Personnel #1 stated, At my desk. b. On 6/15/2020 at 11:14 a.m., Office Personnel #2 was observed behind a desk with no mask on. c. On 6/15/2020 at 11:30 a.m., the Administrator came to speak to the surveyors with the mask below his nose. d. On 6/15/2020 at 11:51 a.m., located on Cedar Court, Environmental Services #1 walked from the hall to the common area with a mask on the face but not covering the nose. e. On 6/15/2020 at 11:51 a.m., located on Cedar Court, Activity Director #1 walked from the hall to the common area, with a mask on the face but not covering the nose. He was asked, Are you supposed to have a mask on covering your nose? He stated, Yes. f. On 6/15/2020 at 11:52 a.m., located on the Pines Unit, Certified Nursing Assistant (CNA) #1 had on a cloth mask that was positioned below her nose and was walking among the residents in the dining room area. CNA #1 was asked, What is the correct position for your mask? The CNA #1 stated, It should be pulled up. CNA #1 immediately pulled up her mask. g. On 6/15/2020 at 12:00 p.m., during rounds on Oak Court Rehab, Therapist #1, was observed at a resident's table setting up lunch. Her face mask connector was over her left ear hanging off her face. She was asked her name. She placed the mask connector over the right ear. She was asked, Are you supposed to wear the mask like that? Stated No. Not really. h. On 6/15/2020 at 12:34 p.m., Registered Nurse (RN) #1 was at the nurse's station on Oak Court with her mask below her nose. She was asked if she was supposed to wear it like that? Stated, No. It won't stay up. 2. On 6/15/2020 at 12:30 p.m., a review of the facility's Policy for COVID-19 / Undiagnosed Respiratory Illness Infection Control provided by the Assistant Director of Nursing (ADON) documented, .to wear cloth face masks in public and when caring for ALL residents. For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were sealed, labeled and dated, expired/leftover food items were promptly removed/ discarded by the expiration or use by dates, and foods were dated as when received to assure first in first out usage to prevent potential for food bone illness for residents who received food from 3 of 6 kitchens, 1 of 6 ice machines were maintained clean and sanitary condition to prevent potential contamination of resident beverages and dietary staff washed their hands before handling clean equipment or food items to decrease the potential for food borne illness for residents who received food from 6 of 6 kitchens. These failed practices had the potential to affect 226 residents who received meals from all 8 kitchens, (Total Census: 240) as documented on the list provided by the Registered Dietitian dated [DATE]. The findings are: 1. On [DATE] at 10:27 a.m., in the 80 kitchen, there were 2 egg crates on a shelf in the refrigerator. The eggs were stored above the gallons of milk. There was no date as when the eggs were received and stored. 2. On [DATE] at 10:35 a.m., in the 80 kitchen, a zip lock bag that contained meat loaf was on a shelf in the freezer. The bag was not completely sealed. 3. On [DATE] at 10:45 a.m., in the 80 kitchen, a box of shredded lettuce was on a rack in the walk-in refrigerator with an expiration date of [DATE]. 4. On [DATE] at 11:29 a.m., the following observations were made in the kitchen on Elm: a. A box with 4 cartons of diced peaches was on a shelf in the refrigerator with an expiration date of [DATE]. b. There was a rubber container on a shelf in the refrigerator with a name written on the lid. The bowl contained leftover chocolate cake with white icing on it. The date of storage written on the lid of leftover chocolate cake was documented [DATE]. The In-house Registered Dietician stated, It has been there for too long. I will toss it. c. On [DATE] at11:44 a.m., the ice machine in the dining room on Elm court had an accumulation of pink residue inside the internal spout. Registered Dietician was asked to wipe the pink substance inside the spout. She did so, and the pink residue easily transferred to the white paper towel. Registered Dietician stated, It was punch that splashes into the ice machine spout when they come and get ice in their cups. d. On [DATE] at 10:49 a.m., Registered Dietician was asked how often you clean the ice machine in the dining room on Elm and who uses the ice from the ice machine? She stated, The residents use it. 5. On [DATE] at 11:59 a.m., the following observations were made in the kitchen on Cedar Court: a. A bottle of ensure on a self in the refrigerator had an expiration date of [DATE]. Another bottle of ensure on the shelf had an expiration date of [DATE]. A carton of ensure was on a shelf in the refrigerator with an expiration date of [DATE]. b. A carton of cottage cheese on a shelf in the refrigerator had an expiration date of [DATE]. c. A zip lock bag that contained leftover food items such as ground ham, diced onions, cucumber and a bowl of discolored mushy salad had used by [DATE] written on the bags. d. An open box of pizza was on a shelf in the refrigerator with a name written on the box. The box had [DATE] written on it. 6. On [DATE] at 12:22 p.m., the following observations were made in the kitchen on Pine Court: a. A box with 4 cartons of key lime yogurt was on the shelf in the refrigerator with an expirations date of [DATE]. b. Another single carton of key lime yogurt was on a shelf in the refrigerator with an expiration date of [DATE]. c. A carton of blueberry yogurt was on a shelf in the refrigerator with an expiration date of [DATE]. d. A 46 fluid ounce of Vanilla Latte was on a shelf in the refrigerator with an expiration date of [DATE]. 7. On [DATE] at 6:50 a.m., Dietary Employee #1 used his mouth to blow the gloves open contaminating it. He placed contaminated gloves on his hands, picked up clean pans and stacked them on a rack with his fingers inside the pans. 8. On [DATE] at 7:30 a.m., Dietary Employee #2 pushed a utility cart with a pan of chopped meat towards the counter. She placed clean gloves on her hands contaminating the gloves. She scooped chopped meat into a meat grinder then, used her gloved hand to push meat into a grinder to be ground and served to the residents on mechanical soft diets. 9. On [DATE] at 8:32 a.m., Dietary Employee #1 picked up a water hose and rinsed off leftover food inside the blender bowl. He placed the blender bowl and the blade in a rack and pushed it into the dish washing machine to wash. When the dish washer had stopped. He removed the gloves from his hands. He turned on the hand washing sink and washed his hands. He turned off the faucet with his wet hands, then pulled tissue from the dispenser and dried his hands. Without washing his hands properly, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 10. On [DATE] at 8:45 a.m., Dietary Employee #3 pushed a utility cart towards the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. At 8:49 a.m., Dietary Employee #3 was asked what should you have done after touching dirty objects before handling clean equipment. She stated, Washed my hands.

Based on record reviews and interviews, the facility failed to ensure the Comprehensive Minimum Data Set (MDS) was coded correctly for the use of blood thinners for 3 (Residents #196, #6, and #172) of 3 sampled residents who had a physician's orders [REDACTED].#2 on 2/13/20 at 2:54 PM. The findings are: 1. Resident #172 had [DIAGNOSES REDACTED]. The Annual MDS with an Assessment Reference Date (ARD) of 7/17/19 documented the resident had modified independence for decision making on the Staff Assessment for Mental Status (SAMS). The resident received anticoagulant medication 7 of 7 days during the lookback period. a. A physician's orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 75mg (milligram) 1-tab (tablet) oral once a day . b. A Care Plan dated 5/1/19 documented, . I also take a medication that could cause me to bruise easier . c. On 02/13/20 at 09:57 AM, LPN #2 was asked, What anticoagulant does this resident take? She answered, [MEDICATION NAME]. She was asked, Is this an anticoagulant? She answered, No it is an antiplatelet. She was asked, What does the RAI (Resident Assessment Instrument) manual say about the coding of anticoagulants? She answered, It specifically says code [MEDICATION NAME] and low molecular [MEDICATION NAME]. Do not code Aspirin or [MEDICATION NAME] as an anticoagulant. She was asked, Would you consider this an MDS coding error? She answered, Yes. 2. Resident #6 [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/16/19 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The resident received anticoagulant medication 7 of 7 days during the lookback period. a. A physician's orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 75mg 1-tab oral once a day . b. A Care Plan dated 10/30/19 documented, . I take an anticoagulation medicine . c. On 02/13/20 at 09:57 AM, LPN #2 was asked, What anticoagulant does this resident take? She answered, [MEDICATION NAME]. She was asked, Is this an anticoagulant? She answered, No it is an antiplatelet. She was asked, Would you consider this an MDS coding error? She answered, Yes. 3. Resident #196 [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 7/21/19 documented the resident had moderately impaired decision-making ability on the SAMS. The resident received anticoagulant medication 7 of 7 days during the lookback period. a. A physician's orders [REDACTED]. [MEDICATION NAME] (Aspirin-[MEDICATION NAME]) capsule, ER (extended release) multiphase 12 hr. (hour); 25-200 mg; amt (amount): 1; oral Twice A Day . b. A Care Plan dated 7/31/19 documented, . I have had a stroke in the past and my doctor has given an order for [REDACTED]. c. On 02/13/20 at 09:57 AM, LPN #2, was asked, What anticoagulant is this resident taking? She answered, [MEDICATION NAME] and that is not really an anticoagulant. The Director of Nursing stated, Yes, it is. It is an anticoagulant because of the aspirin properties, and the resident is taking it for [MEDICAL CONDITION]. LPN #2 was asked, What does the RAI manual say about the coding of anticoagulants? She answered, It specifically says code [MEDICATION NAME] and low molecular [MEDICATION NAME]. Do not code aspirin or [MEDICATION NAME] as an anticoagulant. She was asked, Would you consider this an MDS coding error? She answered, Yes. 4. A document, titled MDS Coding for Anticoagulants provided by the MDS Supervisor on 2/13/20 at 2:54 PM documented, . Anticoagulant (e.g. (for example) [MEDICATION NAME], or low-molecular weight [MEDICATION NAME]): . Do not code antiplatelet medication such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here .

Complaint # (AR 883) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure a resident was physically secured while in the shower chair to prevent accidents / injuries for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents who were at risk for falls and required assistance with bathing. The facility failed to provide adequate supervision for Resident #1, who had a known history of leaning forward while seated. This failed practice resulted in past noncompliance at the level of actual harm to Resident #1, who had a known history of leaning forward while seated, and who fell off the shower chair onto the floor in the shower room resulting in the resident sustaining a [MEDICAL CONDITION], and had the potential to cause more than minimal harm to 63 residents who were at risk for falls and required assistance with bathing, according to a list provided by the Director of Nursing (DON) on 12/18/19 at 12:18 p.m. The facility corrected the deficient practice prior to the survey entrance. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/19 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS), required extensive assistance from 2 people for transfers and bathing, and had not had any falls since admission / entry or reentry, or the prior assessment. a. The Care Guide / Care Plan dated 11/6/19 documented, .Dated Initiated: 11/13/19 .- Mobility . I continue to work with Hab/Rehab (Rehabilitation) 2 times weekly for standing task / ambulation with the assist of 2 people and gait belt, as I will allow . My caregivers move me about the unit / facility as I no longer can propel myself while up in my wheelchair with cushion .left leg rest with bracket covered . and dycem above and below cushion at all times when I am out of bed . My wheelchair seat also continues to be lowered in the back . b. The Fall Risk Assessment with an Observation Date of 11/6/19 documented a score of 14. The Fall Risk Assessment documented a total score of 12 or more indicated high risk for falls. c. A Nurse's Note dated 11/18/19 at 2:08 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .Resident observed sitting up in wc (wheelchair) this shift forward leaning. Numerous attempts to reposition unsuccessful. At times, resident picks and fidgets with her pants leaning forward. Resident would not safely participate in Hab / Rehab this shift. Resident observed during toilet transfer to bear no weight and forward lean. During transport from her room to the Dining Room, resident stiffens and straightens out her body, planting her feet to the floor making transport difficult. New order received and noted. Therapy seating screen due to forward leaning, feet planting during transport in wc . d. A Nurse's Note dated 11/20/19 at 2:25 p.m. documented, .CNA (Certified Nursing Assistant) came to this nurse stating resident fell in shower room. Upon entering shower room, this nurse observed resident lying on her right side on floor holding head up. Immediately notified (Registered Nurse #1). After RN (Registered Nurse) assessed, this nurse assisted with getting resident dressed and back in wheelchair. Administered [MEDICATION NAME] 200 mg (milligram) 2 tabs (tablets) d/t (due to) facial grimacing / moaning when hip is touched or moved. Contacted (physician) at 2:10 p.m. and received order for x-ray of right hip . Long Term safety plan . OT (Occupational Therapy) to eval (evaluate) shower chair safety vs (versus) possible shower gurney . e. An OT Progress Note dated 11/20/19 at 2:47 p.m. documented, .Resident had a fall while sitting in the shower chair. Resident leaned too far forward and fell while staff was unable to prevent. It is documented that she is leaning in her chair and remains physically stiff at times making it hard for her to stay back in her chair while sitting upright. R (Resident) recently because a Marissa lift due to her inability to help transfer at times. Due to her increase in dependence from staff, resident would be safest in a geri-chair with cushion and showered on a gurney. Recommendation . Resident may use geri-chair with cushion that is reclined at all times unless staff is present when she is placed upright. Resident may use shower gurney for all showers . f. A Nurse's Note dated 11/20/19 at 3:45 p.m. documented, .Results of right hip x-ray received and noted. Results show fracture involving right femoral subcapital region with no displacement and no dislocation . New orders to send to ER (emergency room ) . g. A Hospital X-Ray of the right hip dated 11/20/19 documented, .Right subcapital femoral neck fracture . h. The Hospital Physician Discharge Summary dated 11/25/19 documented, .admitted after a fall and sustained a right [MEDICAL CONDITION] . ortho (Orthopedics) has been consulted and has seen her . 11/22/19 . She had surgery yesterday and is doing well today . i. On 12/16/19 at 11:14 a.m., Resident #1 was reclined in a geri-chair with her eyes closed. j. On 12/16/19 at 2:11 p.m., Certified Nursing Assistant (CNA) #1 was asked about the incident on 11/20/19 involving (Resident #1). She stated, We were giving her a shower in the tub. She was on the tub chair. It's like a seat that's got wheels on it. It's a shower chair but you can put it inside the tub. We put her in the tub. (Resident #1) always sits kind of leaning over. Like forward. We've been trying to get her on a gurney for a while. For the longest. She was asked if by gurney she meant a shower bed. She stated, Yes. She was asked why that had not happened. She stated, I don't know why it didn't happen. I guess it was in the process of happening. She just normally leans over. She was asked how long the resident had been like that. She stated, Ever since I have been here on showers, she's been like that. We have talked to (LPN #1) about it. We were in the tub, we got her out of the tub in preparation to dry her up. And then (CNA #2) went across the room to get a brief. Mind you she's like this (leaning over) position. At that time, I had noticed the chair (tub chair) wasn't locked, and it rolls really easy, so what I did . I went around to try to lock it, and as I did, she leaned forward, and I couldn't reach her to catch her. But she leans at all times. And her leaning took her on out of the chair. She was asked how long she had been on the shower team. She stated, About 4 months. She was asked what she meant by the resident being in the process of being approved for a shower gurney. She stated, A lot of talking was going on in general. The CNAs were talking about how bad she needed to be in one. Like .in the middle of working on it. She was asked who she was talking about that was working on this process. She stated, (LPN #1) . We have been telling (RN #1) about it and she's been trying to help us. We knew it wasn't safe. For her and for us. She was asked why it would take so long to get the resident approved for a gurney if she needed one. She stated, I guess it could be a long process because we have to tell (RN #1), and she has to tell (LPN #1) and then on to therapy. She was asked if it was so unsafe to have the resident in the tub chair instead of the gurney, why did she get far enough away from the resident in the shower room for her to fall out. She stated, Because I never thought she would come out that quick. It was within a second. I was right there. I had my hand on the chair. It shocked me. She was asked what interventions had been implemented since the incident. She stated, She's a gurney now and we have no problem with her. She will still raise up, but we lay her back down and that's not an issue. She was asked if she had been in-serviced since the incident. She stated, No. Not that I know of. They've not asked me to sign anything. k. On 12/16/19 at 2:36 p.m., the tub chair was in the shower room where the incident occurred. CNA #1 demonstrated where she was when the incident occurred and where CNA #2 was located at the time of the incident. (The Surveyor took a photograph of the shower chair at this time.) l. On 12/16/19 at 2:40 p.m., CNA #3 was asked how long she had been on the shower team. She stated, Since (MONTH) (2019). She was asked if she was working when the incident occurred with (Resident #1) on 11/20/19. She stated, No. I was not here that day. She was asked about the functional status of (Resident #1) prior to the incident. She stated, We were trying to get her in a geri-chair because she had a problem with leaning over. I think OT (Occupational Therapy) came and evaluated her but did not approve her for a geri chair, even though she leaned all the time. I don't know why they didn't. She was asked if she had spoken with someone about the resident needing to be in a shower gurney instead of a tub chair. She stated, Yes. We went to (LPN #1) and (RN #1). (LPN #1) is totally against the gurney. She wants to get rid of them in general. (RN #1) I don't know what she said about it. She didn't really say anything to me about it. She was asked why LPN #1 was against the resident using a gurney. She stated, Apparently, they're saying we can't afford them. But we have such heavy care residents that need them. It is not safe to put them in the shower chair. I'm not going to do that. She was asked what interventions had been implemented to prevent recurrences since the incident. She stated, Since the incident, she's on a gurney and has a geri chair. She was asked if she had been in-serviced about supervision or positioning residents on shower chairs. She stated, I remember an in-service, but I don't remember how far back it was. m. On 12/16/19 at 2:57 p.m., RN #1 was asked what she remembered about the incident that occurred on 11/20/19 involving (Resident #1). She stated, She was in the floor when I walked in there. When we assessed her, she was just quietly laying there. I checked her out. Her legs were even, she could move her arms. She did not complaint of pain during the assessment. She was up in the chair before we knew she was hurting. (Mobile X-Ray company) came and said it was fractured so we sent her out. Her assessment checked out fine. She was asked to explain the process of getting a resident evaluated for the shower gurney. She stated, I have to have a doctor's order. OT has to come and assess and make a recommendation. She was asked if that had happened for (Resident #1). She stated, We were in the process of trying to get her assessed if I'm not mistaken. I believe she was on the list. She was asked how far along the resident was in this process. She stated, I don't know. I would have to look and see if there's an order yet. For her, I can say when I watched her in the Day Room she didn't lean all the time. She was asked if she remembered how long ago it was that the CNAs mentioned the resident was leaning forward and they felt she needed to be on a gurney. She stated, It would be right around the time of the incident. n. On 12/16/19 at 3:46 p.m., LPN #1 was asked about (Resident #1). She stated, She was admitted on Pine to me. When she first came in, she was ambulatory . She came in feeding herself. She's had a slow decline. We were doing a 2-person transfer, but that was getting a little difficult, so we went to a split, either using 2 person or they can use a Marissa lift. Like if they turn her to pivot and she's able to do that, then that's fine. If not, they use the Marissa. We did split because she could still do some things. With full blown Marissa, that takes some things away from her. So, on over in the afternoon, the Marissa was more common because she was more tired. I would say . I did her change in condition for the fracture on the 4th of December. We were seeing a little bit more progression around the mid part of (MONTH) as far as it being a little more difficult for her to stand and to assist with transfers. She was using the Marissa a little more than the stand and pivot around the middle of November. Also, she was leaning a little more in the wheelchair. I talked to her daughter . I am very involved with the family because I like to get their input. I asked her if she would be opposed to us trying a geri-chair. She said she wasn't opposed to it, so we tried it out a little bit. I had therapy come down and they watched her in it. I think at that point they lowered her seat in the wheelchair because she kept trying to sit up in the geri-chair. We did some footrests on the wheelchair at that point. We did that for a little bit, and we had actually just called therapy back down to look at possibly doing a geri-chair again, and then the fall happened .We do need to maintain their safety, I also feel they need their independence . LPN #1 was asked how far along in the process the resident was on being evaluated for the shower gurney. She stated, Therapy was actually in the process of changing her to a total lift. The incident happened on a Care Plan day. I don't know exactly what time therapy was down there looking at her that day. I know when we got the word that there was a fracture, we were getting the orders for the change to a lift and geri-chair and gurney. She was asked what interventions had been implemented to prevent recurrences since the incident. She stated, Therapy ordered the drop seat in the wheelchair on the 18th (12/18/19). She was asked if the tub chair had a drop seat. She stated, No. She was asked how the tub chair could have been safe for the resident if it didn't have a drop seat, yet her wheelchair had one for her safety. She stated, I can't answer that. At that point, we were already using the Marissa lift 100% of the time because she was leaning. She was asked if staff had asked her about approving a shower gurney for (Resident #1) instead of the resident using the shower / tub chair. She stated, I don't know anything about the shower gurney for her. They usually do ask me, and I try to follow up . I can't honestly say they've talked to me about a gurney for (Resident #1). They have talked to me about a geri-chair, but as far as a gurney . I can't honestly answer that. We have seven people now on a gurney, eight I think including her. o. On 12/17/19 at 11:03 a.m., Occupational Therapist #1 was asked what she knew about (Resident #1). She stated, They had been talking about her leaning in her chair. She was asked how long staff had been talking about that. She stated, Maybe a couple of weeks. She was asked who had been talking about it. She stated, (LPN #1). She was talking about her leaning. When we went down there, she was sitting upright in her wheelchair, and she was still walking with rehab (rehabilitation). So, we didn't feel like it was right at the time to put her in a geri-chair because she was still able to stand and pivot and do some things. She was asked if she had been approached about the possibility of allowing the resident to use a shower gurney instead of a tub chair. She stated, The only thing that had been mentioned was her wheelchair. Nothing had been mentioned to me about the tub chair until she fell . The only thing we got an order for [REDACTED]. She stated, Yes. p. On 12/17/19 at 12:16 p.m., CNA #2 was asked about (Resident #1) and how she normally sits in a chair. She stated, She leans forward. All the time. She was asked if the resident leaned forward all the time before the incident. She stated, Yes. She was asked how long the resident had been leaning forward prior to the incident. She stated, It had been a while. I took care of her regularly even though I worked the other hall. She would have good days and bad days. A good hour and a bad hour. It wasn't consistent. The day that happened . we showered her in the afternoon. She usually starts out doing pretty good, but as the day goes on, she starts leaning more. We got her in there and put her in the tub chair. You have to have an order for [REDACTED]. We were getting her dressed. (CNA #1) was in there with me. She had lotioned her up. I was going to get a brief and was pretty much on my way back across the room. It happened so fast. I have racked my brain to try to figure out how I could have done things differently. The chair was kind of at an angle where I kind of could see, but couldn't, if you know what I mean. She was asked where CNA #1 was. She stated, She was right there at the shower chair. With her. I don't know if she was pulling it out or what. Her upper body was dressed, and we just needed to put a brief on her. Her pants were on but not pulled up because we needed to put the brief on her. She was asked if she was aware of there being a process involved in trying to get the resident a shower gurney to use instead of the tub chair. She stated, The only thing I know is that I can say I have been a personal advocate . she was a split transfer. I was having back problems. I had been encouraging the CNAs to use the lift more on her. It was the process of getting her up to a standing position. Once you get her up, she did pretty good. I didn't work the shower team very often, so I don't know much about the process of getting her to the gurney. She was asked, based on her knowledge of the resident, if the gurney would have been more appropriate for the resident instead of the tub chair. She stated, Absolutely. Just the leaning alone made it unsafe. If she had been on the gurney, we wouldn't be having this conversation right now. It hurt me so bad to see that happen to her. She was asked if the leaning had been going on more than a couple of days prior to the incident. She stated, Yes . q. A facility Quality Assurance (QA) Action Plan provided by the Director of Nursing (DON) on 12/18/19 at 11:58 a.m., documented, .Approaches / QA Procedures . All Pine Court residents and records were reviewed by RN / Designee to identify any other residents' status from their baseline that require two staff assist with transfers, remain in direct contact (hands on resident) with the resident for direct supervision during bathing to ensure safety. In-service with Pine Court direct care staff regarding NS 905 Lifting and Transferring resident with emphasis with supervision with bathing: The staff should always upon release of the harness / seatbelt, the resident has to physically secure (when) the resident in the whirlpool shower chair along with direct supervision . Starting 11/21/19, ADON (Assistant Director of Nursing) / Designee to monitor a resident bath 5 days a week for 8 weeks. Any negative findings will be corrected immediately . r. On 12/18/19 at 12:43 p.m., CNA #1 and CNA #4 were observed giving a resident a shower. No problems were noted.

Complaint # (AR 572) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure speech therapy recommendations to address a choking episode were promptly discussed with the physician and interdisciplinary team (IDT) to determine if they should be added to the plan of care and implemented and failed to ensure subsequent shifts were informed of the choking incident to ensure they were aware of the need to closely monitor the resident during meal service for 1 (Resident #1) of 1 case mix resident who had a choking episode during meal time in the past 30 days. This failed practice resulted in past noncompliance at the level of immediate jeopardy to Resident #1, who had a choking episode, and had the potential to cause more than minimal harm to 1 resident who had a choking episode in the past 30 days, according to the list provided by the Administrator on [DATE]. The findings are: Resident #1 was admitted to the facility on [DATE] under the care of Adult Protective Services and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident scored 10 (,[DATE] indicates moderate impairment) on a Brief Interview for Mental Status; required supervision and setup help only with eating; had no natural teeth or fragments; and had no swallowing disorder. a. A Speech Therapy Screening dated [DATE] documented, He (Resident) was screened for speech, language, cognition, hearing and dysphasia. He is able to hear conversational speech without difficulty. Speech is fluent and intelligible. He is able to communicate his wants and needs and understand conversational speech without difficulty. He has good STM (short term memory) and LTM (long term memory) recall as he is able to recall 3 words within 5 min (minutes) and long past. He does demonstrate poor decision-making skills as he is impulsive. He has good oral and lingual range of motion for eating, does not have any dentition. He is able to chew and swallow solid and thin liquids without difficulty. He states that he does not want dentures. No deficits needing speech . b. A Progress Note dated [DATE] and signed by Registered Nurse (RN) #1 documented, XXX[DATE] . 13:00 (1:00 p.m.) (Recorded as Late Entry on [DATE] at 11:06 a.m.) . This RN (Registered Nurse) was sitting in the Dining Room with a resident when I heard some noise in another part of room. I was unable to see what was happening. I got up and observed resident having difficulty swallowing. CNA (Certified Nursing Assistant #1) was standing behind resident and asked to do the [MEDICATION NAME] maneuver. He did try times 2 to 3 times without success. Resident then coughed up the food and began breathing without problem. Resident then stated he had been eating too fast and needed to slow down. RN encouraged him to do so, and he said he would. RN asked again if he was ok, and he stated 'yes' . c. A Progress Note dated [DATE] at 12:30 documented, .(Recorded as Late Entry on [DATE] at 9:31 a.m.) . Per staff, resident was sitting at his table coughing. Staff came to resident and asked resident if he could talk. Resident did not respond and continued to cough. Staff started doing the [MEDICATION NAME] on resident. It was not very effective. Resident continued to cough, and a piece of turkey came out. RN on unit and assessed resident. Speech notified about incident . d. A Speech Therapy Note dated [DATE] (a Friday) at 10:40 a.m. documented, .Swallowing . (Resident #1) was evaluated for changes in swallowing function secondary to recent choking episode. He is on a solid diet and thin liquids, has no dentition. (Resident #1) consumes large bites and demonstrates very quick / impulsive eating behavior. He demonstrates adequate mastication although with quick eating behavior can place too much food in mouth at one time. His usual pattern is to drink at the end of the meal. He demonstrates no s/s (signs / symptoms) of aspiration with fluids. He demonstrates STM (short term memory) recall of choking and understands. Upon admission the resident was not interested in dentures, but stated he was interested in getting dentures, if possible, to help with chewing . Recommendations: 1. Change diet to Regular Chopped. 2. Refer for Dental consult for dentures. 3. Resident to be in area of supervision with meals and snacks. 4. Give verbal cues to slow down, smaller bites if stuffing mouth is observed . e. A Speech Therapy Recommendation dated [DATE] documented Registered Nurse (RN) #1 was provided the Dietary Recommendation by the Speech Therapist and called the Dietician regarding the diet. The recommendations were placed in the physician's book to be reviewed. There was no documentation the recommendations were reported to the oncoming shift or that any efforts were made to consult the physician by any means other than placing the recommendations in his communication book. f. A Nurse's Note dated [DATE] documented at the end of the evening meal, at 5:20 p.m., Resident #1 was found nonresponsive by Certified Nursing Assistants (CNAs) #1, #2 and #3. CNA #2 began chest compressions, CNA #3 used the AMBU (Airway Mask Bag Unit) bag, and Licensed Practical Nurse (LPN) #1 went to get the crash cart. The resident was transported to the hospital and was admitted with a [DIAGNOSES REDACTED]. g. The Hospital Notes dated [DATE] documented, .admitted [DATE] . Severe Septic Shock secondary to Aspiration Pneumonia . Upon intubation . still have significant pieces of food bolus around the airway and coming out of the airway . h. On [DATE] at 12:50 p.m., Licensed Practical Nurse (LPN) #1 stated she had been employed by the facility for approximately 5 years, had been a CNA for 3 years, and an LPN for 2 years. LPN #1 was asked if she had taken care of (Resident #1). LPN #1 stated, Yes. He was, baseline, was confused pretty much all times. He could verbalize at times, very confused for the most part. He didn't have any issue that was brought to my attention. He was changed frequently he could go to bathroom with prompting and was limited to extensive assistance with care. He could feed himself. No issue was brought to my attention. The CNAs set up his trays and he could feed himself. She was asked, were you working when he choked the first time? LPN #1 stated, I was not made aware of that there was any choking issue until I came back on Sunday ([DATE]) after the incident on Saturday ([DATE]). I had been off for a week. My first day back was on Saturday, [DATE]. I had received report of his previous choking, and there was nothing on the Hot Rack, nothing in report. I was not made aware that he was to be monitored closely. It was during dinner. I was told the next day, [DATE], of the recommendations. i. On [DATE] at 1:04 p.m., CNA #1 stated he had been employed 8 years, and was trained in CPR, with the certification expiring in (MONTH) 2019. CNA #1 stated, The incident occurred as we were getting ready to clean up for supper. My co-worker was trying to arouse the resident. I checked and there was no pulse. I checked the code status. He was in a wheelchair so we, myself and 2 coworkers, lifted the resident on to the floor. I did the compressions, and (CNA #2) and I switched out on compressions. CNA #1 was asked, was the resident was on a special diet? CNA #1 stated, No. He was on a regular diet. CNA #1 was asked, what was on his tray? CNA #1 stated, I didn't set his tray up, so I'm not sure, but he was on a regular diet before. CNA #1 was asked, were you given any special instructions? CNA #1 stated, No. We weren't given any instruction that we had to watch him or anything like that. We found out about him having to have the [MEDICATION NAME] after this incident. That would have been nice to have had that information on Sunday, [DATE]. j. On [DATE] at 1:24 p.m., CNA #2 stated he had been employed by the facility approximately 3 years. CNA #2 was asked if he was certified in CPR. CNA #2 stated, Yes. I was just recertified (MONTH) 12, 2019. CNA #2 was asked regarding the incident with (Resident #1). CNA #2 stated, The meal service was coming to a close. I was wiping residents' faces. He was turned away from us, and his lips were blue with foam coming from his mouth. I called his name, looked at the code status, and proceeded with CPR as we were supposed to. CNA #2 was asked, Do you know what he was served? CNA #2 stated, It was baked chicken. He got a whole piece of chicken. CNA #2 stated the chicken was then cut up into small pieces. CNA #2 was asked, were you given any special instruction regarding (Resident #1) when you came to work on Saturday, ,[DATE]/ 19? CNA #2 stated, No. k. On [DATE] at 2:17 p.m., CNA #4 was asked about the incident with (Resident #1). CNA #4 stated, I was feeding a resident and (Resident #1) was sitting at the at the semi-circle tray table. I did set up his tray and I cut up his chicken about the tip of pinky size pieces. I didn't know he was supposed to be on chopped. I was feeding and he was unresponsive. I called his name and called for help. We checked for a pulse he had a faint pulse, and we got him to the ground. I started moving residents back while they were doing CPR. CNA #4 was asked, were you given any special instructions when you came to work? CNA #4 stated, No. l. On [DATE] at 1:48 p.m., Registered Nurse (RN) #1 was notified via telephone. RN #1 stated he had been employed by the facility for approximately 5 years. RN #1 was asked about the incident with (Resident #1). RN #1 stated, When we get recommendations from therapy, we look at it and put it in the book for the Doctor to sign the next day because that is our practice. RN #1 was asked, what about the recommendations given on Friday, ([DATE]) from Therapy? RN #1 stated, We looked at it to see if there was anything that needed to be done right then. I had called (Dietician #1) to let her know that we had this recommendation. RN #1 was asked, did you write an order? RN #1 stated, No, because the doctor had not reviewed the recommendation. The Speech Therapist had also called the Dietician. RN #1 was asked why the other recommendations were not put in place. RN #1 stated, It is our policy to put the recommendation in the Doctor book to be signed. The first incident of choking had not been documented, and I documented the incident as a late entry on [DATE]. Electronic copies of training records for RN #1 were provided by the Director of Nursing (DON) on [DATE] at 4:42 p.m. They documented the following: 1.) A New Employee Orientation Checklist dated and signed by RN #1 on [DATE] documented a list of topics that were covered during orientation. The topic, Resident Change of Condition was initialed by RN #1. The form documented, My initials and signature below indicate that I have received instruction on these topics and have been given a chance to ask questions . 2.) An In-service Training form dated [DATE] documented, Title of Training . Notification of Changes . The Centers for Medicare and Medicaid Services (CMS) regulation and guidance for Notification of Changes was attached. 3.) An In-service Training Request form dated [DATE] documented, .lack of proper documentation in nurses' notes following an event 'No Matrix Note, No Physician' notification of Change of Condition . The form was signed by RN #1 on [DATE]. 4.) An In-service Training form dated [DATE] through [DATE] documented, .Title of Training: Change of condition . The form was signed by RN #1 to indicate his attendance. The facility's Change of Condition Reporting policy and procedure was attached. m. The facility removed the immediate jeopardy and corrected the failed practices on [DATE], prior to initiation of the complaint investigation survey, as evidenced by the following: 1.) The facility's Quality Assurance (QA) Action Plan dated [DATE] documented, .Resident (Name) had a choking event which is considered a change of condition, the nurse failed to assess, notify the physician along with the resident responsible party, lacked appropriate documentation of the event (I&A) (Incident and Accident Report), Nurse's Notes and resident was not placed on the hot rack for post event monitoring . Any resident that displays a Significant C[NAME] (Change of Condition) will be assessed by a licensed nurse with physician / responsible party notification and hot rack monitoring per facility protocol . Approaches . All (Facility) residents and records were reviewed by RN (Registered Nurse) / Designee to identify any other residents that should have been determined, that there has been a significant change in the resident's physical or mental condition . No negative findings . In-service with direct care staff regarding . Change of Condition Reporting . All resident changes and / or special observations will be communicated during staff report with all staff (Nurses and CNA) Emphasis . A resident choking event is considered a change of condition . The physician must be notified along with the responsible party and appropriate documentation of the event (I&A) and in the Nurse's Notes . The resident must be placed on the Hot Rack for post event monitoring . On-going . Emergency QA meeting held with DON (Director of Nursing), ADON (Assistant Director of Nursing), Program Manager, Relieving RN (Registered Nurse), MDS (Minimum Data Set) Supervisor (Adm (Administrator) and Clinical Director via phone / email) . Starting [DATE] MDS Coordinator to review all residents returning from the hospital with Significant Changes and determine that there has been a significant change in the resident's physical or mental condition 5 days a week for 8 weeks . Negative findings will be corrected immediately . Starting [DATE] RN / Designee to review 4 resident's records for Hot Rack documentation per week times 8 weeks to determine if C[NAME] (Change of Condition) assessment is needed according to facility / CMS guidelines . Any negative findings will be corrected immediately . Submitting finding to QA weekly . MDS Supervisor / MDS Coordinators to review an additional 2 records in general regarding C[NAME] and to review for the correct resident status and target completion dates to ensure the proper process is completed within the regulated timeframe 5 days a week for 8 weeks . Submitting finding to QA weekly . (Facility) LPN (Licensed Practical Nurse) Sup (Supervisor) and RN (Registered Nurse) will be in-serviced 1:1 (one-on-one) by ADON / Designee regarding importance of a nursing assessment following any choking episode. If the nurse is unable to address in a timely manner, follow the Chain of Command for assistance with any resident assessment, physician and family notification and documentation of resident status along with placing the resident on the Hot Rack for follow-up monitoring . 2.) An In-service Training form dated [DATE] documented, Title of Training: Speech Therapy Recommendations. Any time ST (Speech Therapy) is consulted due to a resident choking when eating an order must be written as soon as a Diet Change is recommended (such as regular to chopped, chopped to puree, etc . The form was signed by RN #1 and all of the Licensed Practical Nurses (LPNs) on the Oak Unit. 3.) An In-service Training form dated [DATE] documented, Title of Training . Change of Condition . Emphasis: A resident choking event is considered a change if (sic) condition, the physician must be notified along with the responsible party and appropriate documentation of the event (I&A) and in the nurse's notes. The resident must be placed on the hot rack for post event monitoring . The form was signed by RN #1 and all of the LPNs on the Oak Unit.

Complaint # (AR 690) was substantiated, all or in part, in these findings: Based on record review and interview, the facility failed to ensure residents were free from neglect, as evidenced by a licensed nurse crushing medications and mixing them in food, then leaving the food accessible to cognitively impaired residents, which resulted in possible missed medications for the resident for whom the medication was ordered and possible ingestion of the medications by the wrong resident for 2 (Residents #1 and #3) of 6 (Residents #1, #2, #3, #4, #5, and #6) case mix residents who resided on the Pine Unit and received their medications from Licensed Practical Nurse (LPN) #1. The facility failed to immediately implement effective protective measures to prevent further neglect, as evidenced by a reoccurrence of the failed practice by another licensed nurse (LPN #3), who, 4 days after the initial incident, mixed medications with a resident's meal and then left the tray unattended after the resident refused to eat, resulting in the medication-laced tray being given to another resident for 2 (Residents #2 and #3) of 6 (Residents #1, #2, #3, #4, #5, and #6) case mix residents who resided on the Pine Unit and received medications from LPN #3. This failed practices resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death for Residents #2 and #3, who potentially ingested food that was left unattended by staff and contained medications ordered for other residents, and had the potential to cause more than minimal harm to 49 residents who resided on the Pine Unit and received medications from LPNs #1 and #3, as documented on a list provided by the Director of Nursing (DON) on 7/13/18 at 2:30 p.m. The Administrator Designee was informed of the past immediate jeopardy condition on 7/12/18 at 6:04 p.m. The findings are: l. The facility policy titled, Medication Administration: General Guidelines, provided by the Director of Nursing (DON) on 7/12/18 at 5:04 p.m., documented, .3. Policy .medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so . This policy provides general procedures to follow for the administrations of all medications, which is in addition to the specific procedures for each type of medication administration . 4. Procedure . 1. Medications are prepared, administered and recorded only by licensed nursing and medical personnel authorized by state laws and regulations to administer medications . 5. Medications are administered at the time they are prepared . 8. The 6 R's (rights) are used when administering medications . Right Resident . Right Medication .Right Dosage . Right Time . Right Route . Right dosage form . Residents are identified before medication is administered . 11. Only the licensed or legally authorized personnel who prepares a medication may administer it . The individual records the administration on the resident's MAR (Medication Administration Record) at the time the medication is given (i.e. (such as) immediately after administering the medications . 30. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines .a. A physician order [REDACTED]. Remain with the resident until it is certain that the medication is taken . The facility policy titled, Maltreatment Prevention, provided by the Administrator on 7/11/18 at 3:00 p.m., documented, .Neglect . Failure to provide any goods and services necessary for resident care that could result in mental anguish or distress . Protection .Employees, volunteers, residents, and resident representatives should voice any knowledge of, or concerns related to possible maltreatment without fear of retribution .When notified of possible maltreatment, the Administrator on call will direct immediate action to protect the resident and / or residents. Protective actions may include, but are not limited to: Separation of the resident and / or residents from any potential or perceived threat; temporary or permanent reassignment; removal of an employee or resident allegedly involved in the maltreatment; and / or resident relocation or transfer . Whenever the alleged perpetrator is an employee, the employee is to have no contact with the resident allegedly involved . The accused employee, at the Administrator's discretion, may be placed on investigation-status leave during the period of investigation . the nursing supervisor will . seek direction regarding immediate precautionary measures and a longer-range safety plan to minimize the potential for harm to others . interventions may include .separation; redirection; one-to-one observation; visual observation; time-check observation . The physician on duty will be consulted immediately . 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was independent with locomotion on the unit, used a wheelchair for mobility, and was independent with set-up help for eating. a. The Care Plan with a revised date of 6/14/18 documented, .Nutrition and Hydration . I (Resident) am served a regular ground diet with thin liquids and I eat in the dining with my neighbors . I am able to feed myself after my caregivers setup my tray . My appetite is good but please continue to monitor me closely during meals because due to the effects of my Dementia, I have been noted to pick food items off of my neighbors trays because I think it is my tray . Changed . 6/14/2018 . My diet has been changed to a Pureed diet . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] OTC (over-the-counter) tablet 3 mg (milligrams) tablet (give) 2 tabs (tablets) (6 mg) oral at bedtime . 21:00 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg 1 tab oral every 12 hours 0900 (9:00 a.m.) and 2100 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] capsule 100 mg 1 cap oral .Special Instructions . Hold if increased sedation . four times a day 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless clinically contraindicated . This apples to crushed meds give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds (medications) with meals, as needed . every shift . PRN (as needed) . 7a to 7p (7:00 a.m. to 7:00 p.m.) PRN (as needed) 7p to 7a (7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. d. A Nurses Progress Note dated 6/28/18 at 23:53 (11:53 p.m.) documented, .Resident received from the nurse a bedtime snack of egg salad in a sandwich with crushed HS (hour of sleep / bedtime) meds (medications) mixed in it. Per LPN's report, resident ate most of it but went to the bathroom, leaving the food on the table. At 2040 (8:40 p.m.) staff observed another resident (Resident #3) sitting at the table in front of the sandwich. Unable to determine if, or how much of, resident's sandwich was eaten . 3. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/2/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was independent with transfer, walking in room, walking in corridor, and locomotion on the unit, did not require mobility device, and was independent for eating with set up help only. a. The Care Plan dated 5/9/18 documented, .Mental Wellness . Some of the behaviors I have exhibited are noted when I take others belongings that I have found because I think the belongings are mine . Refusal of Care .Please be aware that I have had problems with refusal of care such as lab draws, personal care, and / or routine medications . Changed .4/28/18 . I have been observed placing nonedible things in my mouth . Changed . 6/25/18 . Please be aware that my Nurse may give my meds with meals as often as necessary due to my non-compliance .Please have my Nurse stay with me during my meal to ensure compliance with my medications . Safety Notes . Please continue to monitor me to ensure my safety . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg (give) 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m.) . A physician's orders [REDACTED].Oysco 500 Vit D (Calcium [MEDICATION NAME] / Vitamin D3) tablet 500 mg / 2 units 1 tablet oral twice a day 0900 (9:00 a.m., 1700 (5:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg (give) 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 25 mg (give) 1 tab oral three times a day 0900 (9:00 a.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] capsule 100 mg (give) 1 cap (capsule) oral . Special Instructions . Hold if increased sedation . Four time a day 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless contraindicated. This applies to crushed meds. Give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds with meals, as needed, every shift . PRN (as needed) 7a to 7p (7:00 a.m. to 7:00 p.m.) .PRN 7p to 7a (7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]#1's medication-laced sandwich. d. The (MONTH) (YEAR) Medication Administration Record [REDACTED].[MEDICATION NAME] tablet 25 mg 1 tab oral; [MEDICATION NAME] capsule 100 mg 1 cap oral; [MEDICATION NAME] tablet 10 mg 1 tab oral; Oysco 500 D (Calcium [MEDICATION NAME] / Vitamin D3) tablet, 500 mg / 1250 mg) / 2 units oral; [MEDICATION NAME] tablet 10 mg 1 tab, oral . These medications were mixed with the resident's meal tray, which was inadvertently given to Resident #2 (refer to Incident Reports below). 4. Resident #2 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 5/23/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, and was dependent with one person assistance for eating. a. The Care Plan with a revised date of 6/6/18 documented, .Nutrition and Hydration . I (Resident) require staff to spoon feed me all of meals as I can no longer feed myself related to my progressed Dementia and I eat in the dining room with my neighbors .I am able to eat a Regular Pureed diet . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless clinically contraindicated . This applies to crushed meds, give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds with meals as needed . Every shift PRN (as needed) 7a to 7p (7:00 a.m. to 7:00 p.m.) PRN, 7p to 7a . )7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. This was in addition to any medication the resident may have ingested after receiving Resident #3's meal tray (refer to incident reports below). 5. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities Office of Long Term Care (OLTC), Division of Medical Service form (DMS) 762 dated 6/28/18 documented, .Date of Incident . 6/28/18 . Time of Incident . 8:40 p.m . Resident (Resident #1) received from a nurse (LPN #1) a bedtime snack of egg salad in a sandwich with HS (bedtime) medication crushed and mixed in it (the sandwich), including [MEDICATION NAME] 100 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 3 mg x (times) 2 tabs (tablets) (6 mg total). Resident (#1) ate most of it, but went to the bathroom and left the plate on the table and another resident, (Resident #3), was found by staff sitting at the table with the peer's (Resident #1) sandwich in front of her. No witness as to whether resident (Resident #3) ate the remainder of the sandwich. (LPN #1) did not stay with resident (Resident #1) and did not remove the food when resident left the table. Resident unaware of the incident, no MA (sic affects) noted . Staff LPN (LPN #1) placed on administrative leave pending investigation, results to be forwarded to OLTC (Office of Long Term Care) via form 762 . Facility wide staff in service provided for nurses to remain with resident while administering meds (medications) with / without food . a. An Office of Long-Term Care (OLTC) Witness Statement Form dated 6/28/18, and signed by Certified Nursing Assistant (CNA) #1 documented, .Name of Resident(s) . (Resident #3) . While returning into the dayroom / dining room from being in a resident's room . we noticed (Resident #1)'s sandwich (with her meds in it) in front of (Resident #3). We notified LPN immediately . b. An OLTC Witness Statement Form dated 6/28/18 and signed by Licensed Practical Nurse (LPN) #2 documented, .Name of Resident(s) . (Resident #3) . I was at nurses' station on phone with (Pharmacy) dealing with medication issue when CNAs, (CNA #1) and (CNA #2), came and informed me that (Resident #3) and got ahold of (Resident #1)'s sandwich which had (Resident #1)'s 2100 (9:00 p.m.) medications in it. (Resident #1) had left table to take herself to bathroom and left her sandwich, and CNA found it almost gone, just 2 small pieces of crust on plate in front of (Resident #3). As soon as I got off phone, I went to find West Hall nurse (LPN #1) and (Registered Nurse (RN) #1), as they were with who had fallen to inform of above about (Resident #3). Nobody observed (Resident #3) eat any part of sandwich, but resident did state she ate . c. An OLTC Witness Statement Form dated 6/28/18 and signed by LPN #1 documented, .Name of Resident(s) . (Resident #1) . Resident medication was crushed ([MEDICATION NAME] 10 mg) Resident capsule ([MEDICATION NAME] 100 mg was) opened by this nurse and [MEDICATION NAME] 1 mg tab (tablet) was crushed (and) put in egg salad and on bread. Resident ate the majority of her sandwich and a very small amt (amount) was left on plate, and another resident (Resident #3) picked up the remains of bread up and ate it per CNA staff. (Bread ends). I watched resident eat the majority of her sandwich . 1.) On 7/12/18 at 2:35 p.m., CNA #1 was asked, Can you tell me about the incident regarding (Resident #3) eating (Resident #1)'s bedtime snack which had her medications in it? CNA #1 stated, She (LPN #1) had put the med (medications) in the sandwich and she gave it to her (Resident #1), and me and another CNA, (CNA #2), we were doing snacks that night, and there had been another resident fall, so (LPN #1) was taking care of them, so we were there, but then we had to leave because another resident's alarm was going off, so the sandwich was left there with (Resident #1). But then, (Resident #1) got up and went to the bathroom and (Resident #3) ate her sandwich. I didn't see her (Resident #3) eat the sandwich, but I asked her if she did, and she said she did. I know she has Alzheimer's and everything, but can tell us some things. Anyway, we knew the medicine was in the sandwich, so we got worried. CNA #1 was asked, How did you know the medication was in the sandwich? CNA #1 stated, Because that's how she gets her medicine. CNA #1 was asked, Has this happened before, that you know of? CNA #1 stated, This is the first time this situation has happened to me, and that's why I panicked. 2.) On 7/12/18 at 4:50 p.m., the Director of Nursing (DON) was asked, Is it common practice for the nurses to put crushed medications into the resident's meals or snacks? The DON stated, There are only a few residents who require that. The DON was asked, What staff members are responsible for administering medications with / without food? The DON stated, The nurse who got it ready for them. The DON was asked, What can you tell us about the incident that occurred with (LPN #1) and (Residents #1 and #3)? The DON stated, I was called on the phone about it that night, and it was my understanding that (Resident #3) didn't eat much of the sandwich. The DON was asked, But you are certain that (LPN #1) did prepare medication, put it into food, and left the food / medication unattended? The DON stated, Oh yeah, she did it, but as far as all the details of the investigation, I don't know all the details, but I know she did do it. The DON was asked, What are the possible negative outcomes for residents who are allowed access to medications that are not prescribed to him / her? The DON stated, Well, it could be bad, all the way up to death, if they were allergic or something. The DON was asked, What has the facility done to prevent accidental medication ingestion from recurring? The DON stated, Well, because the deal with (LPN #1) happened during off hours, it was at night, there was an in-service initiated that night and then we sent the in-services out on the units. 6. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/2/18 documented, .Date of Incident . 7/2/18 Time of Incident . 6:10 p.m . Resident (Resident #3) refused her 1700 (5:00 p.m.) meds (medications) when (LPN #3) tried to administer them, so the nurse mixed the resident's meds with the food on the resident's supper tray. (Resident #3) refused the tray requesting other food, and her tray with meds in the food, was given to another resident (Resident #2), whose tray was thrown away as resident was asleep at the time. (Resident #3)'s 1700 (5:00 p.m.) meds included [MEDICATION NAME], Calcium / Vitamin D. Peer (Resident #2) ate 4 to 5 bites of barbequed pork mixed with resident's meds. (LPN #3) placed on administrative leave pending investigation for failure to supervise residents during med (medication) administration. LPN in-serviced on need to supervise residents after mixing meds with food. At 1810 (6:10 p.m.), it was discovered that resident (Resident #2) was given another resident's tray with 1700 (5:00 p.m.) medications crushed and mixed with the food . Resident not aware of the event . a. An Office of Long-Term Care (OLTC) Witness Statement Form dated 7/2/18, and signed by CNA #3, documented, .Name of Resident(s) . (Resident #2) . I (CNA #3) came off 1:1 (one-to-one observation) with another resident, and the daughter of (Resident #2) came up to me asking for (Resident #2's) tray. It had r/r (resident refused) on it, so I said 'she refused'. She said she wanted to try to see if she would eat, so I was looking, and (CNA #4) asked how she ate her food. I said pureed, so she said, 'here is a tray'. So I said, 'here is one' and took it down to (Resident #2's) room with the daughter, set her up and got her ready to eat. I asked the daughter if she wanted me to stay and feed her, or her to do it. She said she would, so I left. Then later, during last round, I went to change (Resident #2) and her tray was still there, so I was going to take it to the kitchen, when I noticed the green meds (medications) chopped in the barbeque. So I asked (LPN #4), her nurse, if she had meds in her food. She said, 'no, I don't do that', so it was already in the food for the other resident (Resident #3), and we didn't know . b. An OLTC Witness Statement Form dated 7/2/18 and signed by CNA #4 documented, .Name of Resident(s) . (Resident #2) . On 7/2/18 resident did not want to eat so her tray was dumped. 30 min (minutes) later her daughter came in and requested a tray for her mother, and I took (Resident #3's) ticket off because it was the same diet as (Resident #2). A CNA asked her 'did she want her to feed her mother' and she said 'no I can do it' so the daughter fed her mother. At 1840 (6:40 p.m.) I was told that medicine was put into the food without us knowing it . c. An OLTC Witness Statement Form dated 7/2/18 and signed by LPN #4 documented, .Name of Resident(s) . (Resident #2) . At 1810 (6:10 p.m.) (CNA #3) notified me that when she picked up the dinner tray from (Resident #2)'s room she noticed there was some crushed medication in the food. (CNA #3) gave me the bowl with the crushed meds and I then notified (Registered Nurse (RN) #1). (CNA #3) stated that (Resident #2) refused her tray earlier and it was thrown away. When (Resident #2's) daughter arrived she requested another tray to try and get her mom to eat. Another resident (Resident #3) had refused her dinner tray, and it was left on the food cart. Because both residents have the same diet, this tray was given to (Resident #2). (Resident #2)'s daughter fed her and no one was aware there was medication in the food . d. An OLTC Witness Statement Form dated 7/2/18 and signed by LPN #3 documented, .Name of Resident(s) . (Resident #2) . I tried several (times) to give (Resident #3) her meds, unable to do so. (Medications were) placed in the resident's food to give to her when the tray was passed. I had another resident fall, and staff gave the resident's food to another resident before I could return . 1.) On 7/12/18 at 11:06 a.m., LPN #3 was asked, Can you tell me about (Resident #2) getting (Resident #3's) tray and medications that had been put in the meat? LPN #3 stated, They had moved (Resident #3) to my side, and that morning, the nurse told me they have her on our side now. I knew that her meds were crushed always. At supper, she would not take her medications in applesauce, and I tried a couple of more times. I said, 'I don't know how to give her meds'. The CNAs said 'we put it in her food'. Well, they had brought the trays, and I put it (the medications) in her pork. I was going to give it to her. The tray was on the meal cart. I walked over to the meal cart and sprinkled the meds in the pork. I was called to another room where the resident fell and I had to go take care of that. We had an RN Supervisor down there at the time, but she was dealing with another incident. So, I had to go deal with (the fall) immediately. I was still in there, and (RN #1) called me over. She had her (the resident's) tray and she asked me if I had put the meds in there, and I said 'yeah'. The majority of the pork was still on the tray. They told me what happened, and I got put on administrative leave. LPN #3 was asked, Did you tell anybody that the meds were in the pork? LPN #3 stated, No, I did not. I did not get a chance to. LPN #3 was asked, Are there any other residents who receive their medications in their meal? LPN #3 stated, No, that is the first one I had ever done that way. LPN #3 was asked, Have you heard of other nurses putting meds in residents' meals? LPN #3 stated, No, not really. LPN #3 was asked, What happened? LPN #3 stated, They called the ADON (Assistant Director of Nursing) and she talked to me and told me that there had been an incident like this happen before and asked me if I had not seen the in-service. I told her that I was not aware of the other incident, and I had not seen the in-service. 2.) On 7/12/128 at 11:18 a.m., CNA #3 was asked, Can you tell us about (Resident #2) getting (Resident #3)'s tray and medication that had been put in the meat? CNA #3 stated, I had been 1-1 (one-on-one observation) with another resident. So, I came out of that room, and (Resident #2)'s daughter asked me 'has my mother ate (sic)?' I went and looked for her tray and could not find it. (Resident #2)'s daughter said she seems irritated. Her ticket had 'refused' written on it. She usually eats 50 to 100 percent for me, so that surprised me. I don't even know what is going on, so I am trying to figure it out. I asked (an aide) and she was surprised too. (CNA #4) came up behind me and asked me 'what is her diet?' and I said 'pureed' and she said, 'here is one'. Her daughter sat down and was about to start feeding her. After meals were completely all done, I went in there and the daughter had left, so I was going to get her tray out of her room when I saw green specks in the barbeque. I pulled (LPN #4) out and asked her if she put anything in her (the resident's) food, and she said she didn't, and she took it from there. CNA #3 was asked, Can you estimate the percentage of the pork that was eaten? CNA #3 stated, There were bites taken of the pork. There may have been about 3 spoon bites out of the pork. CNA #3 was asked, Was that the only food item that had the medication in it? CNA #3 stated, That is the only food item I saw green specks in it, but the beans and the potatoes, they were all gone. CNA #3 was asked, What else was on the tray? CNA #3 stated, Pureed bread which was not touched. CNA #3 was asked, What was the resident doing when you went into the room to get the tray? CNA #3 stated, She was asleep. 3.) On 7/12/18 at 11:34 a.m., CNA #4 was asked, Can you tell me about (Resident #2) getting (Resident #3)'s tray and medication that had been put in the meat? CNA #4 stated, About 6:10 p.m., (Resident #2)'s daughter came in and said my mother has not been fed. She said, 'I will wake her and feed her'. (Resident 3)'s tray was on the cart and they eat the same diet, so we were like, she can have this tray. One of the aides asked her if she wanted her to feed her mother, and she said 'no'. The daughter knew this was not her mother's tray, and I took the tray card off of it and handed it to (CNA #3). After a while, I walked in the kitchen area and (LPN #4) and another person was standing there looking at the bowl of pork and discussing it. There was medicine in the pork. All the beans were gone and all the potatoes. I did not have any way of knowing there was medicine in the food. I saw the bowl when they were talking about it, and to me it looked like the pork had only been stirred around in. It did not look to me that any of the pork had been fed to her. CNA #4 was asked, Do you know who noticed the medication in the pork? CNA #4 stated, The daughter took the bowl of pork to (LPN #4) and told her that there was medicine in it. She told them that she had fed her 7 to 8 bites of the pork, but it did not look like it had been eaten out of to me. All of the beans and potatoes were gone. The nurse had said that she only put it in the pork. 4.) On 7/12/18 at 12:23 p.m., LPN #4 was asked, What do you know about the incident with (Resident #2) getting (Resident #3)'s tray and the medications that had been placed in her food? LPN #4 stated, The girls went to go ask (Resident #2) if she wanted to eat. The daughter said she didn't think her mom ate and that she wanted a tray to feed her. (Resident #3) had refused her tray, so they gave her tray to (Resident #2). LPN #4 was asked, Who brought it to your attention? LPN #4 stated, (CNA #3) brought it to my attention since (Resident #2) is my patient, but I don't put meds in food. I asked the other nurse, and she said 'yeah, I put it in there'. LPN #4 was asked, Is that normal practice? LPN #4 stated, We have 3 residents who have orders. I don't do it, but I don't know if everybody else does. LPN #4 was asked, What has the facility told you the policy is on giving medications in food? LPN #4 stated, I have been told that if they want it in their food that's fine, but that we need to stand there until the food is gone so that another resident doesn't get a hold of it. LPN #4 was asked, What are the possible dangers of residents getting other residents' medications? LPN #4 stated, Allergic reactions, and possibly all the way up to death. 7. On 7/12/18 at 4:33 p.m., the DON was asked, The first occurrence of a nurse putting crushed meds in food with possible ingestion by an unattended resident was on 6/28/18; however, when the second occurrence took place on 7/2/18, (LPN #3), who had left the medications unattended, reported that she had not received the in-service that was implemented following the 6/28/18 incident. Can you tell me how many nurses missed the in-service? And why? The DON stated, Our agency people come in through guest relations, and since this happened after hours, they started the in-services that night. The in-service was on the units, but it had not gotten in the agency in-service book, and that is why (LPN #3) had not had the in-service. 8. The facility removed the immediate jeopardy and corrected the failed practices on 7/6/18, prior to the survey, by implementing the following written corrective action plan, and as evidenced by the subsequent observations and record reviews by the surveyor: a. On 7/3/18, the DON sent out a notification to all licensed nursing personnel regarding the expectations of nursing staff in regard to meal refusals, and proper notifications of nurses following meal refusal. Medications being administered according to the MAR (Medication Administration Record) per MD (Medical Doctor) order, and Nurse must stay with resident if there is an order for [REDACTED].>b. On 7/5/18, the DON requested a facility wide signed in-service regarding the expectations of nursing staff in regard to meal refusals, and proper notification of nurses following meal refusal. Medications being administered according to the MAR per MD order and Nurse must stay with resident if there is an order for [REDACTED].>c. An in-service specific to Pine Court Nurses was sent out on 7/5/18 with a Target Completion Date of 7/16/18. d. Facility wide in-service was initiated on 7/5/18 to be completed by 7/13/18 with all nursing, rehab (Rehabilitation) and social workers regarding Meal Tray Discarding and Requesting Additional Trays. e. On 7/5/18, the DON requested supervisors to monitor meal services on both the breakfast and lunch meal service to begin on 7/6/18, 3 times a week for at least 4 weeks and the need for continued monitoring will be re-evaluated. f. On 7/6/18, the DON implemented monitoring of med pass and / or med pass with meals / snacks to ensure the nurse is staying

Complaint # (AR 690) was substantiated, all or in part, in these findings: Based on record review and interview, the facility failed to ensure effective measures were implemented to protect residents from further potential neglect after a licensed nurse crushed medications, mixed them in food, then left the food accessible to cognitively impaired residents for 2 (Residents #1 and #3) of 6 (Residents #1, #2, #3, #4, #5 and #6) case mix residents who resided on the Pine Unit and received their medications from Licensed Practical Nurse (LPN) #1, which resulted in a subsequent incident of possible neglect 4 days later for 1 (Resident #2) of 6 (Residents #1, #2, #3, #4, #5, and #6) case mix residents who resided on the Pine Unit and received medications from LPN #3. The failed practices resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death for Residents #2 and #3, who potentially ingested food that was left unattended by staff and contained medications ordered for other residents, and had the potential to cause more than minimal harm to 49 residents who resided on the Pine Unit and received medications from LPNs #1 and #3, as documented on a list provided by the Director of Nursing (DON) on 7/13/18 at 2:30 p.m. The Administrator Designee was informed of the past immediate jeopardy condition on 7/12/18 at 6:04 p.m. The findings are: l. The facility policy titled, Medication Administration: General Guidelines, provided by the Director of Nursing (DON) on 7/12/18 at 5:04 p.m., documented, .3. Policy .medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so . This policy provides general procedures to follow for the administrations of all medications, which is in addition to the specific procedures for each type of medication administration . 4. Procedure . 1. Medications are prepared, administered and recorded only by licensed nursing and medical personnel authorized by state laws and regulations to administer medications . 5. Medications are administered at the time they are prepared . 8. The 6 R's (rights) are used when administering medications . Right Resident . Right Medication .Right Dosage . Right Time . Right Route . Right dosage form . Residents are identified before medication is administered . 11. Only the licensed or legally authorized personnel who prepares a medication may administer it . The individual records the administration on the resident's MAR (Medication Administration Record) at the time the medication is given (i.e. (such as) immediately after administering the medications . 30. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines .a. A physician order [REDACTED]. Remain with the resident until it is certain that the medication is taken . 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was independent with locomotion on the unit, used a wheelchair for mobility, and was independent with set-up help for eating. a. The Care Plan with a revised date of 6/14/18 documented, .Nutrition and Hydration . I (Resident) am served a regular ground diet with thin liquids and I eat in the dining with my neighbors . I am able to feed myself after my caregivers setup my tray . My appetite is good but please continue to monitor me closely during meals because due to the effects of my Dementia, I have been noted to pick food items off of my neighbors trays because I think it is my tray . Changed . 6/14/2018 . My diet has been changed to a Pureed diet . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] OTC (over-the-counter) tablet 3 mg (milligrams) tablet (give) 2 tabs (tablets) (6 mg) oral at bedtime . 21:00 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg 1 tab oral every 12 hours 0900 (9:00 a.m.) and 2100 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] capsule 100 mg 1 cap oral .Special Instructions . Hold if increased sedation . four times a day 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless clinically contraindicated . This apples to crushed meds give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds (medications) with meals, as needed . every shift . PRN (as needed) . 7a to 7p (7:00 a.m. to 7:00 p.m.) PRN (as needed) 7p to 7a (7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. d. A Nurses Progress Note dated 6/28/18 at 23:53 (11:53 p.m.) documented, .Resident received from the nurse a bedtime snack of egg salad in a sandwich with crushed HS (hour of sleep / bedtime) meds (medications) mixed in it. Per LPN's report, resident ate most of it but went to the bathroom, leaving the food on the table. At 2040 (8:40 p.m.) staff observed another resident (Resident #3) sitting at the table in front of the sandwich. Unable to determine if, or how much of, resident's sandwich was eaten . 3. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/2/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was independent with transfer, walking in room, walking in corridor, and locomotion on the unit, did not require mobility device, and was independent for eating with set up help only. a. The Care Plan dated 5/9/18 documented, .Mental Wellness . Some of the behaviors I have exhibited are noted when I take others belongings that I have found because I think the belongings are mine . Refusal of Care .Please be aware that I have had problems with refusal of care such as lab draws, personal care, and / or routine medications . Changed .4/28/18 . I have been observed placing nonedible things in my mouth . Changed . 6/25/18 . Please be aware that my Nurse may give my meds with meals as often as necessary due to my non-compliance .Please have my Nurse stay with me during my meal to ensure compliance with my medications . Safety Notes . Please continue to monitor me to ensure my safety . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg (give) 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m.) . A physician's orders [REDACTED].Oysco 500 Vit D (Calcium [MEDICATION NAME] / Vitamin D3) tablet 500 mg / 2 units 1 tablet oral twice a day 0900 (9:00 a.m., 1700 (5:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg (give) 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 25 mg (give) 1 tab oral three times a day 0900 (9:00 a.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] capsule 100 mg (give) 1 cap (capsule) oral . Special Instructions . Hold if increased sedation . Four time a day 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless contraindicated. This applies to crushed meds. Give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds with meals, as needed, every shift . PRN (as needed) 7a to 7p (7:00 a.m. to 7:00 p.m.) .PRN 7p to 7a (7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]#1's medication-laced sandwich. d. The (MONTH) (YEAR) Medication Administration Record [REDACTED].[MEDICATION NAME] tablet 25 mg 1 tab oral; [MEDICATION NAME] capsule 100 mg 1 cap oral; [MEDICATION NAME] tablet 10 mg 1 tab oral; Oysco 500 D (Calcium [MEDICATION NAME] / Vitamin D3) tablet, 500 mg / 1250 mg) / 2 units oral; [MEDICATION NAME] tablet 10 mg 1 tab, oral . These medications were mixed with the resident's meal tray, which was inadvertently given to Resident #2 (refer to Incident Reports below). 4. Resident #2 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 5/23/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, and was dependent with one person assistance for eating. a. The Care Plan with a revised date of 6/6/18 documented, .Nutrition and Hydration . I (Resident) require staff to spoon feed me all of meals as I can no longer feed myself related to my progressed Dementia and I eat in the dining room with my neighbors .I am able to eat a Regular Pureed diet . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless clinically contraindicated . This applies to crushed meds, give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds with meals as needed . Every shift PRN (as needed) 7a to 7p (7:00 a.m. to 7:00 p.m.) PRN, 7p to 7a . )7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. This was in addition to any medication the resident may have ingested after receiving Resident #3's meal tray (refer to incident reports below). 5. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities Office of Long Term Care (OLTC), Division of Medical Service form (DMS) 762 dated 6/28/18 documented, .Date of Incident . 6/28/18 . Time of Incident . 8:40 p.m . Resident (Resident #1) received from a nurse (LPN #1) a bedtime snack of egg salad in a sandwich with HS (bedtime) medication crushed and mixed in it (the sandwich), including [MEDICATION NAME] 100 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 3 mg x (times) 2 tabs (tablets) (6 mg total). Resident (#1) ate most of it, but went to the bathroom and left the plate on the table and another resident, (Resident #3), was found by staff sitting at the table with the peer's (Resident #1) sandwich in front of her. No witness as to whether resident (Resident #3) ate the remainder of the sandwich. (LPN #1) did not stay with resident (Resident #1) and did not remove the food when resident left the table. Resident unaware of the incident, no MA (sic affects) noted . Staff LPN (LPN #1) placed on administrative leave pending investigation, results to be forwarded to OLTC (Office of Long Term Care) via form 762 . Facility wide staff in service provided for nurses to remain with resident while administering meds (medications) with / without food . a. An Office of Long-Term Care (OLTC) Witness Statement Form dated 6/28/18, and signed by Certified Nursing Assistant (CNA) #1 documented, .Name of Resident(s) . (Resident #3) . While returning into the dayroom / dining room from being in a resident's room . we noticed (Resident #1)'s sandwich (with her meds in it) in front of (Resident #3). We notified LPN immediately . b. An OLTC Witness Statement Form dated 6/28/18 and signed by Licensed Practical Nurse (LPN) #2 documented, .Name of Resident(s) . (Resident #3) . I was at nurses' station on phone with (Pharmacy) dealing with medication issue when CNAs, (CNA #1) and (CNA #2), came and informed me that (Resident #3) and got ahold of (Resident #1)'s sandwich which had (Resident #1)'s 2100 (9:00 p.m.) medications in it. (Resident #1) had left table to take herself to bathroom and left her sandwich, and CNA found it almost gone, just 2 small pieces of crust on plate in front of (Resident #3). As soon as I got off phone, I went to find West Hall nurse (LPN #1) and (Registered Nurse (RN) #1), as they were with who had fallen to inform of above about (Resident #3). Nobody observed (Resident #3) eat any part of sandwich, but resident did state she ate . c. An OLTC Witness Statement Form dated 6/28/18 and signed by LPN #1 documented, .Name of Resident(s) . (Resident #1) . Resident medication was crushed ([MEDICATION NAME] 10 mg) Resident capsule ([MEDICATION NAME] 100 mg was) opened by this nurse and [MEDICATION NAME] 1 mg tab (tablet) was crushed (and) put in egg salad and on bread. Resident ate the majority of her sandwich and a very small amt (amount) was left on plate, and another resident (Resident #3) picked up the remains of bread up and ate it per CNA staff. (Bread ends). I watched resident eat the majority of her sandwich . 1.) On 7/12/18 at 2:35 p.m., CNA #1 was asked, Can you tell me about the incident regarding (Resident #3) eating (Resident #1)'s bedtime snack which had her medications in it? CNA #1 stated, She (LPN #1) had put the med (medications) in the sandwich and she gave it to her (Resident #1), and me and another CNA, (CNA #2), we were doing snacks that night, and there had been another resident fall, so (LPN #1) was taking care of them, so we were there, but then we had to leave because another resident's alarm was going off, so the sandwich was left there with (Resident #1). But then, (Resident #1) got up and went to the bathroom and (Resident #3) ate her sandwich. I didn't see her (Resident #3) eat the sandwich, but I asked her if she did, and she said she did. I know she has Alzheimer's and everything, but can tell us some things. Anyway, we knew the medicine was in the sandwich, so we got worried. CNA #1 was asked, How did you know the medication was in the sandwich? CNA #1 stated, Because that's how she gets her medicine. CNA #1 was asked, Has this happened before, that you know of? CNA #1 stated, This is the first time this situation has happened to me, and that's why I panicked. 2.) On 7/12/18 at 4:50 p.m., the Director of Nursing (DON) was asked, Is it common practice for the nurses to put crushed medications into the resident's meals or snacks? The DON stated, There are only a few residents who require that. The DON was asked, What staff members are responsible for administering medications with / without food? The DON stated, The nurse who got it ready for them. The DON was asked, What can you tell us about the incident that occurred with (LPN #1) and (Residents #1 and #3)? The DON stated, I was called on the phone about it that night, and it was my understanding that (Resident #3) didn't eat much of the sandwich. The DON was asked, But you are certain that (LPN #1) did prepare medication, put it into food, and left the food / medication unattended? The DON stated, Oh yeah, she did it, but as far as all the details of the investigation, I don't know all the details, but I know she did do it. The DON was asked, What are the possible negative outcomes for residents who are allowed access to medications that are not prescribed to him / her? The DON stated, Well, it could be bad, all the way up to death, if they were allergic or something. The DON was asked, What has the facility done to prevent accidental medication ingestion from recurring? The DON stated, Well, because the deal with (LPN #1) happened during off hours, it was at night, there was an in-service initiated that night and then we sent the in-services out on the units. 6. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/2/18 documented, .Date of Incident . 7/2/18 Time of Incident . 6:10 p.m . Resident (Resident #3) refused her 1700 (5:00 p.m.) meds (medications) when (LPN #3) tried to administer them, so the nurse mixed the resident's meds with the food on the resident's supper tray. (Resident #3) refused the tray requesting other food, and her tray with meds in the food, was given to another resident (Resident #2), whose tray was thrown away as resident was asleep at the time. (Resident #3)'s 1700 (5:00 p.m.) meds included [MEDICATION NAME], Calcium / Vitamin D. Peer (Resident #2) ate 4 to 5 bites of barbequed pork mixed with resident's meds. (LPN #3) placed on administrative leave pending investigation for failure to supervise residents during med (medication) administration. LPN in-serviced on need to supervise residents after mixing meds with food. At 1810 (6:10 p.m.), it was discovered that resident (Resident #2) was given another resident's tray with 1700 (5:00 p.m.) medications crushed and mixed with the food . Resident not aware of the event . a. An Office of Long-Term Care (OLTC) Witness Statement Form dated 7/2/18, and signed by CNA #3, documented, .Name of Resident(s) . (Resident #2) . I (CNA #3) came off 1:1 (one-to-one observation) with another resident, and the daughter of (Resident #2) came up to me asking for (Resident #2's) tray. It had r/r (resident refused) on it, so I said 'she refused'. She said she wanted to try to see if she would eat, so I was looking, and (CNA #4) asked how she ate her food. I said pureed, so she said, 'here is a tray'. So I said, 'here is one' and took it down to (Resident #2's) room with the daughter, set her up and got her ready to eat. I asked the daughter if she wanted me to stay and feed her, or her to do it. She said she would, so I left. Then later, during last round, I went to change (Resident #2) and her tray was still there, so I was going to take it to the kitchen, when I noticed the green meds (medications) chopped in the barbeque. So I asked (LPN #4), her nurse, if she had meds in her food. She said, 'no, I don't do that', so it was already in the food for the other resident (Resident #3), and we didn't know . b. An OLTC Witness Statement Form dated 7/2/18 and signed by CNA #4 documented, .Name of Resident(s) . (Resident #2) . On 7/2/18 resident did not want to eat so her tray was dumped. 30 min (minutes) later her daughter came in and requested a tray for her mother, and I took (Resident #3's) ticket off because it was the same diet as (Resident #2). A CNA asked her 'did she want her to feed her mother' and she said 'no I can do it' so the daughter fed her mother. At 1840 (6:40 p.m.) I was told that medicine was put into the food without us knowing it . c. An OLTC Witness Statement Form dated 7/2/18 and signed by LPN #4 documented, .Name of Resident(s) . (Resident #2) . At 1810 (6:10 p.m.) (CNA #3) notified me that when she picked up the dinner tray from (Resident #2)'s room she noticed there was some crushed medication in the food. (CNA #3) gave me the bowl with the crushed meds and I then notified (Registered Nurse (RN) #1). (CNA #3) stated that (Resident #2) refused her tray earlier and it was thrown away. When (Resident #2's) daughter arrived she requested another tray to try and get her mom to eat. Another resident (Resident #3) had refused her dinner tray, and it was left on the food cart. Because both residents have the same diet, this tray was given to (Resident #2). (Resident #2)'s daughter fed her and no one was aware there was medication in the food . d. An OLTC Witness Statement Form dated 7/2/18 and signed by LPN #3 documented, .Name of Resident(s) . (Resident #2) . I tried several (times) to give (Resident #3) her meds, unable to do so. (Medications were) placed in the resident's food to give to her when the tray was passed. I had another resident fall, and staff gave the resident's food to another resident before I could return . 1.) On 7/12/18 at 11:06 a.m., LPN #3 was asked, Can you tell me about (Resident #2) getting (Resident #3's) tray and medications that had been put in the meat? LPN #3 stated, They had moved (Resident #3) to my side, and that morning, the nurse told me they have her on our side now. I knew that her meds were crushed always. At supper, she would not take her medications in applesauce, and I tried a couple of more times. I said, 'I don't know how to give her meds'. The CNAs said 'we put it in her food'. Well, they had brought the trays, and I put it (the medications) in her pork. I was going to give it to her. The tray was on the meal cart. I walked over to the meal cart and sprinkled the meds in the pork. I was called to another room where the resident fell and I had to go take care of that. We had an RN Supervisor down there at the time, but she was dealing with another incident. So, I had to go deal with (the fall) immediately. I was still in there, and (RN #1) called me over. She had her (the resident's) tray and she asked me if I had put the meds in there, and I said 'yeah'. The majority of the pork was still on the tray. They told me what happened, and I got put on administrative leave. LPN #3 was asked, Did you tell anybody that the meds were in the pork? LPN #3 stated, No, I did not. I did not get a chance to. LPN #3 was asked, Are there any other residents who receive their medications in their meal? LPN #3 stated, No, that is the first one I had ever done that way. LPN #3 was asked, Have you heard of other nurses putting meds in residents' meals? LPN #3 stated, No, not really. LPN #3 was asked, What happened? LPN #3 stated, They called the ADON (Assistant Director of Nursing) and she talked to me and told me that there had been an incident like this happen before and asked me if I had not seen the in-service. I told her that I was not aware of the other incident, and I had not seen the in-service. 2.) On 7/12/128 at 11:18 a.m., CNA #3 was asked, Can you tell us about (Resident #2) getting (Resident #3)'s tray and medication that had been put in the meat? CNA #3 stated, I had been 1-1 (one-on-one observation) with another resident. So, I came out of that room, and (Resident #2)'s daughter asked me 'has my mother ate (sic)?' I went and looked for her tray and could not find it. (Resident #2)'s daughter said she seems irritated. Her ticket had 'refused' written on it. She usually eats 50 to 100 percent for me, so that surprised me. I don't even know what is going on, so I am trying to figure it out. I asked (an aide) and she was surprised too. (CNA #4) came up behind me and asked me 'what is her diet?' and I said 'pureed' and she said, 'here is one'. Her daughter sat down and was about to start feeding her. After meals were completely all done, I went in there and the daughter had left, so I was going to get her tray out of her room when I saw green specks in the barbeque. I pulled (LPN #4) out and asked her if she put anything in her (the resident's) food, and she said she didn't, and she took it from there. CNA #3 was asked, Can you estimate the percentage of the pork that was eaten? CNA #3 stated, There were bites taken of the pork. There may have been about 3 spoon bites out of the pork. CNA #3 was asked, Was that the only food item that had the medication in it? CNA #3 stated, That is the only food item I saw green specks in it, but the beans and the potatoes, they were all gone. CNA #3 was asked, What else was on the tray? CNA #3 stated, Pureed bread which was not touched. CNA #3 was asked, What was the resident doing when you went into the room to get the tray? CNA #3 stated, She was asleep. 3.) On 7/12/18 at 11:34 a.m., CNA #4 was asked, Can you tell me about (Resident #2) getting (Resident #3)'s tray and medication that had been put in the meat? CNA #4 stated, About 6:10 p.m., (Resident #2)'s daughter came in and said my mother has not been fed. She said, 'I will wake her and feed her'. (Resident 3)'s tray was on the cart and they eat the same diet, so we were like, she can have this tray. One of the aides asked her if she wanted her to feed her mother, and she said 'no'. The daughter knew this was not her mother's tray, and I took the tray card off of it and handed it to (CNA #3). After a while, I walked in the kitchen area and (LPN #4) and another person was standing there looking at the bowl of pork and discussing it. There was medicine in the pork. All the beans were gone and all the potatoes. I did not have any way of knowing there was medicine in the food. I saw the bowl when they were talking about it, and to me it looked like the pork had only been stirred around in. It did not look to me that any of the pork had been fed to her. CNA #4 was asked, Do you know who noticed the medication in the pork? CNA #4 stated, The daughter took the bowl of pork to (LPN #4) and told her that there was medicine in it. She told them that she had fed her 7 to 8 bites of the pork, but it did not look like it had been eaten out of to me. All of the beans and potatoes were gone. The nurse had said that she only put it in the pork. 4.) On 7/12/18 at 12:23 p.m., LPN #4 was asked, What do you know about the incident with (Resident #2) getting (Resident #3)'s tray and the medications that had been placed in her food? LPN #4 stated, The girls went to go ask (Resident #2) if she wanted to eat. The daughter said she didn't think her mom ate and that she wanted a tray to feed her. (Resident #3) had refused her tray, so they gave her tray to (Resident #2). LPN #4 was asked, Who brought it to your attention? LPN #4 stated, (CNA #3) brought it to my attention since (Resident #2) is my patient, but I don't put meds in food. I asked the other nurse, and she said 'yeah, I put it in there'. LPN #4 was asked, Is that normal practice? LPN #4 stated, We have 3 residents who have orders. I don't do it, but I don't know if everybody else does. LPN #4 was asked, What has the facility told you the policy is on giving medications in food? LPN #4 stated, I have been told that if they want it in their food that's fine, but that we need to stand there until the food is gone so that another resident doesn't get a hold of it. LPN #4 was asked, What are the possible dangers of residents getting other residents' medications? LPN #4 stated, Allergic reactions, and possibly all the way up to death. 7. On 7/12/18 at 4:33 p.m., the DON was asked, The first occurrence of a nurse putting crushed meds in food with possible ingestion by an unattended resident was on 6/28/18; however, when the second occurrence took place on 7/2/18, (LPN #3), who had left the medications unattended, reported that she had not received the in-service that was implemented following the 6/28/18 incident. Can you tell me how many nurses missed the in-service? And why? The DON stated, Our agency people come in through guest relations, and since this happened after hours, they started the in-services that night. The in-service was on the units, but it had not gotten in the agency in-service book, and that is why (LPN #3) had not had the in-service. 8. The facility removed the immediate jeopardy and corrected the failed practices on 7/6/18, prior to the survey, by implementing the following written corrective action plan, and as evidenced by the subsequent observations and record reviews by the surveyor: a. On 7/3/18, the DON sent out a notification to all licensed nursing personnel regarding the expectations of nursing staff in regard to meal refusals, and proper notifications of nurses following meal refusal. Medications being administered according to the MAR (Medication Administration Record) per MD (Medical Doctor) order, and Nurse must stay with resident if there is an order for [REDACTED].>b. On 7/5/18, the DON requested a facility wide signed in-service regarding the expectations of nursing staff in regard to meal refusals, and proper notification of nurses following meal refusal. Medications being administered according to the MAR per MD order and Nurse must stay with resident if there is an order for [REDACTED].>c. An in-service specific to Pine Court Nurses was sent out on 7/5/18 with a Target Completion Date of 7/16/18. d. Facility wide in-service was initiated on 7/5/18 to be completed by 7/13/18 with all nursing, rehab (Rehabilitation) and social workers regarding Meal Tray Discarding and Requesting Additional Trays. e. On 7/5/18, the DON requested supervisors to monitor meal services on both the breakfast and lunch meal service to begin on 7/6/18, 3 times a week for at least 4 weeks and the need for continued monitoring will be re-evaluated. f. On 7/6/18, the DON implemented monitoring of med pass and / or med pass with meals / snacks to ensure the nurse is staying with resident while medication is given and residents are safe. Monitoring will be completed 3 times a week for at least 4 weeks, and the need for continued monitoring will be re-evaluated. g. On 7/12/18, the survey team performed Medication Administration Observation with a Medication Error Rate of 0%. Additionally, Resident #3's Care Plan was reviewed and documented the following revision: .7/3/18 . I have been place (placed on) Line of Sight during meals due to my intrusive behaviors. Please monitor and document appropriately . Nutrition and Hydration . I am served a regular pureed diet and can feed myself after my tray is set up . Because I have a [DIAGNOSES REDACTED]. Please supervise me during meals . On 7/12/18 at approximately 2045 (8:45 p.m.), LPNs #1 and #3 were again placed on administrative leave, per nursing administration.

Complaint # (AR 690) was substantiated, all or in part, in these findings: Based on record review and interview, the facility failed to ensure physician orders [REDACTED].#1 and #3) of 6 (Residents #1, #2, #3, #4, #5, and #6) case mix residents who resided on the Pine Unit and received medications from Licensed Practical Nurse (LPN) #1 and for 2 (Residents #2 and #3) of 6 (Residents #1, #2, #3, #4, #5, and #6) case mix residents who resided on the Pine Unit and received medications from LPN #3. The failed practices resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death for Residents #2 and #3, who potentially ingested medications that were ordered for other residents, and had the potential to cause more than minimal harm to 49 residents who had resided on the Pine Unit, and received medications from LPNs #1 and #3, as documented on a list provided by the Director of Nursing (DON) on 7/13/18 at 2:30 p.m. The Administrator Designee was informed of the past immediate jeopardy condition on 7/12/18 at 6:04 p.m. The findings are: l. The facility policy titled, Medication Administration: General Guidelines, provided by the Director of Nursing (DON) on 7/12/18 at 5:04 p.m., documented, .3. Policy .medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so . This policy provides general procedures to follow for the administrations of all medications, which is in addition to the specific procedures for each type of medication administration . 4. Procedure . 1. Medications are prepared, administered and recorded only by licensed nursing and medical personnel authorized by state laws and regulations to administer medications . 5. Medications are administered at the time they are prepared . 8. The 6 R's (rights) are used when administering medications . Right Resident . Right Medication .Right Dosage . Right Time . Right Route . Right dosage form . Residents are identified before medication is administered . 11. Only the licensed or legally authorized personnel who prepares a medication may administer it . The individual records the administration on the resident's MAR (Medication Administration Record) at the time the medication is given (i.e. (such as) immediately after administering the medications . 30. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines .a. A physician order [REDACTED]. Remain with the resident until it is certain that the medication is taken . 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was independent with locomotion on the unit, used a wheelchair for mobility, and was independent with set-up help for eating. a. The Care Plan with a revised date of 6/14/18 documented, .Nutrition and Hydration . I (Resident) am served a regular ground diet with thin liquids and I eat in the dining with my neighbors . I am able to feed myself after my caregivers setup my tray . My appetite is good but please continue to monitor me closely during meals because due to the effects of my Dementia, I have been noted to pick food items off of my neighbors trays because I think it is my tray . Changed . 6/14/2018 . My diet has been changed to a Pureed diet . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] OTC (over-the-counter) tablet 3 mg (milligrams) tablet (give) 2 tabs (tablets) (6 mg) oral at bedtime . 21:00 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg 1 tab oral every 12 hours 0900 (9:00 a.m.) and 2100 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] capsule 100 mg 1 cap oral .Special Instructions . Hold if increased sedation . four times a day 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless clinically contraindicated . This apples to crushed meds give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds (medications) with meals, as needed . every shift . PRN (as needed) . 7a to 7p (7:00 a.m. to 7:00 p.m.) PRN (as needed) 7p to 7a (7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. d. A Nurses Progress Note dated 6/28/18 at 23:53 (11:53 p.m.) documented, .Resident received from the nurse a bedtime snack of egg salad in a sandwich with crushed HS (hour of sleep / bedtime) meds (medications) mixed in it. Per LPN's report, resident ate most of it but went to the bathroom, leaving the food on the table. At 2040 (8:40 p.m.) staff observed another resident (Resident #3) sitting at the table in front of the sandwich. Unable to determine if, or how much of, resident's sandwich was eaten . e. These medication errors were significant based on the classification of the medications and the potential for overdose of duplicated medications. 3. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/2/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), was independent with transfer, walking in room, walking in corridor, and locomotion on the unit, did not require mobility device, and was independent for eating with set up help only. a. The Care Plan dated 5/9/18 documented, .Mental Wellness . Some of the behaviors I have exhibited are noted when I take others belongings that I have found because I think the belongings are mine . Refusal of Care .Please be aware that I have had problems with refusal of care such as lab draws, personal care, and / or routine medications . Changed .4/28/18 . I have been observed placing nonedible things in my mouth . Changed . 6/25/18 . Please be aware that my Nurse may give my meds with meals as often as necessary due to my non-compliance .Please have my Nurse stay with me during my meal to ensure compliance with my medications . Safety Notes . Please continue to monitor me to ensure my safety . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg (give) 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m.) . A physician's orders [REDACTED].Oysco 500 Vit D (Calcium [MEDICATION NAME] / Vitamin D3) tablet 500 mg / 2 units 1 tablet oral twice a day 0900 (9:00 a.m., 1700 (5:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg (give) 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m) . A physician's orders [REDACTED].[MEDICATION NAME] tablet 25 mg (give) 1 tab oral three times a day 0900 (9:00 a.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].[MEDICATION NAME] capsule 100 mg (give) 1 cap (capsule) oral . Special Instructions . Hold if increased sedation . Four time a day 0900 (9:00 a.m.), 1300 (1:00 p.m.), 1700 (5:00 p.m.), 2100 (9:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless contraindicated. This applies to crushed meds. Give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds with meals, as needed, every shift . PRN (as needed) 7a to 7p (7:00 a.m. to 7:00 p.m.) .PRN 7p to 7a (7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]#1's medication-laced sandwich. d. The (MONTH) (YEAR) Medication Administration Record [REDACTED].[MEDICATION NAME] tablet 25 mg 1 tab oral; [MEDICATION NAME] capsule 100 mg 1 cap oral; [MEDICATION NAME] tablet 10 mg 1 tab oral; Oysco 500 D (Calcium [MEDICATION NAME] / Vitamin D3) tablet, 500 mg / 1250 mg) / 2 units oral; [MEDICATION NAME] tablet 10 mg 1 tab, oral . These medications were mixed with the resident's meal tray, which was inadvertently given to Resident #2 (refer to Incident Reports below). 4. Resident #2 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 5/23/2018 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, and was dependent with one person assistance for eating. a. The Care Plan with a revised date of 6/6/18 documented, .Nutrition and Hydration . I (Resident) require staff to spoon feed me all of meals as I can no longer feed myself related to my progressed Dementia and I eat in the dining room with my neighbors .I am able to eat a Regular Pureed diet . b. The Physician order [REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] tablet 10 mg 1 tab oral twice a day 0900 (9:00 a.m.), 1700 (5:00 p.m.) . A physician's orders [REDACTED].May crush and administer all meds (medications) concurrently unless clinically contraindicated . This applies to crushed meds, give PO (by mouth) or Per Tube (feeding tube) . A physician's orders [REDACTED].May give meds with meals as needed . Every shift PRN (as needed) 7a to 7p (7:00 a.m. to 7:00 p.m.) PRN, 7p to 7a . )7:00 p.m. to 7:00 a.m.) . c. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. This was in addition to any medication the resident may have ingested after receiving Resident #3's meal tray (refer to incident reports below). d. These medication errors were significant based on the classification of the medications involved and the potential for adverse consequences related to receiving another resident's medications. 5. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities Office of Long Term Care (OLTC), Division of Medical Service form (DMS) 762 dated 6/28/18 documented, .Date of Incident . 6/28/18 . Time of Incident . 8:40 p.m . Resident (Resident #1) received from a nurse (LPN #1) a bedtime snack of egg salad in a sandwich with HS (bedtime) medication crushed and mixed in it (the sandwich), including [MEDICATION NAME] 100 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 3 mg x (times) 2 tabs (tablets) (6 mg total). Resident (#1) ate most of it, but went to the bathroom and left the plate on the table and another resident, (Resident #3), was found by staff sitting at the table with the peer's (Resident #1) sandwich in front of her. No witness as to whether resident (Resident #3) ate the remainder of the sandwich. (LPN #1) did not stay with resident (Resident #1) and did not remove the food when resident left the table. Resident unaware of the incident, no MA (sic affects) noted . Staff LPN (LPN #1) placed on administrative leave pending investigation, results to be forwarded to OLTC (Office of Long Term Care) via form 762 . Facility wide staff in service provided for nurses to remain with resident while administering meds (medications) with / without food . a. An Office of Long-Term Care (OLTC) Witness Statement Form dated 6/28/18, and signed by Certified Nursing Assistant (CNA) #1 documented, .Name of Resident(s) . (Resident #3) . While returning into the dayroom / dining room from being in a resident's room . we noticed (Resident #1)'s sandwich (with her meds in it) in front of (Resident #3). We notified LPN immediately . b. An OLTC Witness Statement Form dated 6/28/18 and signed by Licensed Practical Nurse (LPN) #2 documented, .Name of Resident(s) . (Resident #3) . I was at nurses' station on phone with (Pharmacy) dealing with medication issue when CNAs, (CNA #1) and (CNA #2), came and informed me that (Resident #3) and got ahold of (Resident #1)'s sandwich which had (Resident #1)'s 2100 (9:00 p.m.) medications in it. (Resident #1) had left table to take herself to bathroom and left her sandwich, and CNA found it almost gone, just 2 small pieces of crust on plate in front of (Resident #3). As soon as I got off phone, I went to find West Hall nurse (LPN #1) and (Registered Nurse (RN) #1), as they were with who had fallen to inform of above about (Resident #3). Nobody observed (Resident #3) eat any part of sandwich, but resident did state she ate . c. An OLTC Witness Statement Form dated 6/28/18 and signed by LPN #1 documented, .Name of Resident(s) . (Resident #1) . Resident medication was crushed ([MEDICATION NAME] 10 mg) Resident capsule ([MEDICATION NAME] 100 mg was) opened by this nurse and [MEDICATION NAME] 1 mg tab (tablet) was crushed (and) put in egg salad and on bread. Resident ate the majority of her sandwich and a very small amt (amount) was left on plate, and another resident (Resident #3) picked up the remains of bread up and ate it per CNA staff. (Bread ends). I watched resident eat the majority of her sandwich . 1.) On 7/12/18 at 2:35 p.m., CNA #1 was asked, Can you tell me about the incident regarding (Resident #3) eating (Resident #1)'s bedtime snack which had her medications in it? CNA #1 stated, She (LPN #1) had put the med (medications) in the sandwich and she gave it to her (Resident #1), and me and another CNA, (CNA #2), we were doing snacks that night, and there had been another resident fall, so (LPN #1) was taking care of them, so we were there, but then we had to leave because another resident's alarm was going off, so the sandwich was left there with (Resident #1). But then, (Resident #1) got up and went to the bathroom and (Resident #3) ate her sandwich. I didn't see her (Resident #3) eat the sandwich, but I asked her if she did, and she said she did. I know she has Alzheimer's and everything, but can tell us some things. Anyway, we knew the medicine was in the sandwich, so we got worried. CNA #1 was asked, How did you know the medication was in the sandwich? CNA #1 stated, Because that's how she gets her medicine. CNA #1 was asked, Has this happened before, that you know of? CNA #1 stated, This is the first time this situation has happened to me, and that's why I panicked. 2.) On 7/12/18 at 4:50 p.m., the Director of Nursing (DON) was asked, Is it common practice for the nurses to put crushed medications into the resident's meals or snacks? The DON stated, There are only a few residents who require that. The DON was asked, What staff members are responsible for administering medications with / without food? The DON stated, The nurse who got it ready for them. The DON was asked, What can you tell us about the incident that occurred with (LPN #1) and (Residents #1 and #3)? The DON stated, I was called on the phone about it that night, and it was my understanding that (Resident #3) didn't eat much of the sandwich. The DON was asked, But you are certain that (LPN #1) did prepare medication, put it into food, and left the food / medication unattended? The DON stated, Oh yeah, she did it, but as far as all the details of the investigation, I don't know all the details, but I know she did do it. The DON was asked, What are the possible negative outcomes for residents who are allowed access to medications that are not prescribed to him / her? The DON stated, Well, it could be bad, all the way up to death, if they were allergic or something. The DON was asked, What has the facility done to prevent accidental medication ingestion from recurring? The DON stated, Well, because the deal with (LPN #1) happened during off hours, it was at night, there was an in-service initiated that night and then we sent the in-services out on the units. 6. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/2/18 documented, .Date of Incident . 7/2/18 Time of Incident . 6:10 p.m . Resident (Resident #3) refused her 1700 (5:00 p.m.) meds (medications) when (LPN #3) tried to administer them, so the nurse mixed the resident's meds with the food on the resident's supper tray. (Resident #3) refused the tray requesting other food, and her tray with meds in the food, was given to another resident (Resident #2), whose tray was thrown away as resident was asleep at the time. (Resident #3)'s 1700 (5:00 p.m.) meds included [MEDICATION NAME], Calcium / Vitamin D. Peer (Resident #2) ate 4 to 5 bites of barbequed pork mixed with resident's meds. (LPN #3) placed on administrative leave pending investigation for failure to supervise residents during med (medication) administration. LPN in-serviced on need to supervise residents after mixing meds with food. At 1810 (6:10 p.m.), it was discovered that resident (Resident #2) was given another resident's tray with 1700 (5:00 p.m.) medications crushed and mixed with the food . Resident not aware of the event . a. An Office of Long-Term Care (OLTC) Witness Statement Form dated 7/2/18, and signed by CNA #3, documented, .Name of Resident(s) . (Resident #2) . I (CNA #3) came off 1:1 (one-to-one observation) with another resident, and the daughter of (Resident #2) came up to me asking for (Resident #2's) tray. It had r/r (resident refused) on it, so I said 'she refused'. She said she wanted to try to see if she would eat, so I was looking, and (CNA #4) asked how she ate her food. I said pureed, so she said, 'here is a tray'. So I said, 'here is one' and took it down to (Resident #2's) room with the daughter, set her up and got her ready to eat. I asked the daughter if she wanted me to stay and feed her, or her to do it. She said she would, so I left. Then later, during last round, I went to change (Resident #2) and her tray was still there, so I was going to take it to the kitchen, when I noticed the green meds (medications) chopped in the barbeque. So I asked (LPN #4), her nurse, if she had meds in her food. She said, 'no, I don't do that', so it was already in the food for the other resident (Resident #3), and we didn't know . b. An OLTC Witness Statement Form dated 7/2/18 and signed by CNA #4 documented, .Name of Resident(s) . (Resident #2) . On 7/2/18 resident did not want to eat so her tray was dumped. 30 min (minutes) later her daughter came in and requested a tray for her mother, and I took (Resident #3's) ticket off because it was the same diet as (Resident #2). A CNA asked her 'did she want her to feed her mother' and she said 'no I can do it' so the daughter fed her mother. At 1840 (6:40 p.m.) I was told that medicine was put into the food without us knowing it . c. An OLTC Witness Statement Form dated 7/2/18 and signed by LPN #4 documented, .Name of Resident(s) . (Resident #2) . At 1810 (6:10 p.m.) (CNA #3) notified me that when she picked up the dinner tray from (Resident #2)'s room she noticed there was some crushed medication in the food. (CNA #3) gave me the bowl with the crushed meds and I then notified (Registered Nurse (RN) #1). (CNA #3) stated that (Resident #2) refused her tray earlier and it was thrown away. When (Resident #2's) daughter arrived she requested another tray to try and get her mom to eat. Another resident (Resident #3) had refused her dinner tray, and it was left on the food cart. Because both residents have the same diet, this tray was given to (Resident #2). (Resident #2)'s daughter fed her and no one was aware there was medication in the food . d. An OLTC Witness Statement Form dated 7/2/18 and signed by LPN #3 documented, .Name of Resident(s) . (Resident #2) . I tried several (times) to give (Resident #3) her meds, unable to do so. (Medications were) placed in the resident's food to give to her when the tray was passed. I had another resident fall, and staff gave the resident's food to another resident before I could return . 1.) On 7/12/18 at 11:06 a.m., LPN #3 was asked, Can you tell me about (Resident #2) getting (Resident #3's) tray and medications that had been put in the meat? LPN #3 stated, They had moved (Resident #3) to my side, and that morning, the nurse told me they have her on our side now. I knew that her meds were crushed always. At supper, she would not take her medications in applesauce, and I tried a couple of more times. I said, 'I don't know how to give her meds'. The CNAs said 'we put it in her food'. Well, they had brought the trays, and I put it (the medications) in her pork. I was going to give it to her. The tray was on the meal cart. I walked over to the meal cart and sprinkled the meds in the pork. I was called to another room where the resident fell and I had to go take care of that. We had an RN Supervisor down there at the time, but she was dealing with another incident. So, I had to go deal with (the fall) immediately. I was still in there, and (RN #1) called me over. She had her (the resident's) tray and she asked me if I had put the meds in there, and I said 'yeah'. The majority of the pork was still on the tray. They told me what happened, and I got put on administrative leave. LPN #3 was asked, Did you tell anybody that the meds were in the pork? LPN #3 stated, No, I did not. I did not get a chance to. LPN #3 was asked, Are there any other residents who receive their medications in their meal? LPN #3 stated, No, that is the first one I had ever done that way. LPN #3 was asked, Have you heard of other nurses putting meds in residents' meals? LPN #3 stated, No, not really. LPN #3 was asked, What happened? LPN #3 stated, They called the ADON (Assistant Director of Nursing) and she talked to me and told me that there had been an incident like this happen before and asked me if I had not seen the in-service. I told her that I was not aware of the other incident, and I had not seen the in-service. 2.) On 7/12/128 at 11:18 a.m., CNA #3 was asked, Can you tell us about (Resident #2) getting (Resident #3)'s tray and medication that had been put in the meat? CNA #3 stated, I had been 1-1 (one-on-one observation) with another resident. So, I came out of that room, and (Resident #2)'s daughter asked me 'has my mother ate (sic)?' I went and looked for her tray and could not find it. (Resident #2)'s daughter said she seems irritated. Her ticket had 'refused' written on it. She usually eats 50 to 100 percent for me, so that surprised me. I don't even know what is going on, so I am trying to figure it out. I asked (an aide) and she was surprised too. (CNA #4) came up behind me and asked me 'what is her diet?' and I said 'pureed' and she said, 'here is one'. Her daughter sat down and was about to start feeding her. After meals were completely all done, I went in there and the daughter had left, so I was going to get her tray out of her room when I saw green specks in the barbeque. I pulled (LPN #4) out and asked her if she put anything in her (the resident's) food, and she said she didn't, and she took it from there. CNA #3 was asked, Can you estimate the percentage of the pork that was eaten? CNA #3 stated, There were bites taken of the pork. There may have been about 3 spoon bites out of the pork. CNA #3 was asked, Was that the only food item that had the medication in it? CNA #3 stated, That is the only food item I saw green specks in it, but the beans and the potatoes, they were all gone. CNA #3 was asked, What else was on the tray? CNA #3 stated, Pureed bread which was not touched. CNA #3 was asked, What was the resident doing when you went into the room to get the tray? CNA #3 stated, She was asleep. 3.) On 7/12/18 at 11:34 a.m., CNA #4 was asked, Can you tell me about (Resident #2) getting (Resident #3)'s tray and medication that had been put in the meat? CNA #4 stated, About 6:10 p.m., (Resident #2)'s daughter came in and said my mother has not been fed. She said, 'I will wake her and feed her'. (Resident 3)'s tray was on the cart and they eat the same diet, so we were like, she can have this tray. One of the aides asked her if she wanted her to feed her mother, and she said 'no'. The daughter knew this was not her mother's tray, and I took the tray card off of it and handed it to (CNA #3). After a while, I walked in the kitchen area and (LPN #4) and another person was standing there looking at the bowl of pork and discussing it. There was medicine in the pork. All the beans were gone and all the potatoes. I did not have any way of knowing there was medicine in the food. I saw the bowl when they were talking about it, and to me it looked like the pork had only been stirred around in. It did not look to me that any of the pork had been fed to her. CNA #4 was asked, Do you know who noticed the medication in the pork? CNA #4 stated, The daughter took the bowl of pork to (LPN #4) and told her that there was medicine in it. She told them that she had fed her 7 to 8 bites of the pork, but it did not look like it had been eaten out of to me. All of the beans and potatoes were gone. The nurse had said that she only put it in the pork. 4.) On 7/12/18 at 12:23 p.m., LPN #4 was asked, What do you know about the incident with (Resident #2) getting (Resident #3)'s tray and the medications that had been placed in her food? LPN #4 stated, The girls went to go ask (Resident #2) if she wanted to eat. The daughter said she didn't think her mom ate and that she wanted a tray to feed her. (Resident #3) had refused her tray, so they gave her tray to (Resident #2). LPN #4 was asked, Who brought it to your attention? LPN #4 stated, (CNA #3) brought it to my attention since (Resident #2) is my patient, but I don't put meds in food. I asked the other nurse, and she said 'yeah, I put it in there'. LPN #4 was asked, Is that normal practice? LPN #4 stated, We have 3 residents who have orders. I don't do it, but I don't know if everybody else does. LPN #4 was asked, What has the facility told you the policy is on giving medications in food? LPN #4 stated, I have been told that if they want it in their food that's fine, but that we need to stand there until the food is gone so that another resident doesn't get a hold of it. LPN #4 was asked, What are the possible dangers of residents getting other residents' medications? LPN #4 stated, Allergic reactions, and possibly all the way up to death. 7. On 7/12/18 at 4:33 p.m., the DON was asked, The first occurrence of a nurse putting crushed meds in food with possible ingestion by an unattended resident was on 6/28/18; however, when the second occurrence took place on 7/2/18, (LPN #3), who had left the medications unattended, reported that she had not received the in-service that was implemented following the 6/28/18 incident. Can you tell me how many nurses missed the in-service? And why? The DON stated, Our agency people come in through guest relations, and since this happened after hours, they started the in-services that night. The in-service was on the units, but it had not gotten in the agency in-service book, and that is why (LPN #3) had not had the in-service. 8. The facility removed the immediate jeopardy and corrected the failed practices on 7/6/18, prior to the survey, by implementing the following written corrective action plan, and as evidenced by the subsequent observations and record reviews by the surveyor: a. On 7/3/18, the DON sent out a notification to all licensed nursing personnel regarding the expectations of nursing staff in regard to meal refusals, and proper notifications of nurses following meal refusal. Medications being administered according to the MAR (Medication Administration Record) per MD (Medical Doctor) order, and Nurse must stay with resident if there is an order for [REDACTED].>b. On 7/5/18, the DON requested a facility wide signed in-service regarding the expectations of nursing staff in regard to meal refusals, and proper notification of nurses following meal refusal. Medications being administered according to the MAR per MD order and Nurse must stay with resident if there is an order for [REDACTED].>c. An in-service specific to Pine Court Nurses was sent out on 7/5/18 with a Target Completion Date of 7/16/18. d. Facility wide in-service was initiated on 7/5/18 to be completed by 7/13/18 with all nursing, rehab (Rehabilitation) and social workers regarding Meal Tray Discarding and Requesting Additional Trays. e. On 7/5/18, the DON requested supervisors to monitor meal services on both the breakfast and lunch meal service to begin on 7/6/18, 3 times a week for at least 4 weeks and the need for continued monitoring will be re-evaluated. f. On 7/6/18, the DON implemented monitoring of med pass and / or med pass with meals / snacks to ensure the nurse is staying with resident while medication is given and residents are safe. Monitoring will be completed 3 times a week for at least 4 weeks, and the need for continued monitoring will be re-evaluated. g. On 7/12/18, the survey team performed Medication Administration Observation with a Medication Error Rate of 0%. Additionally, Resident #3's Care Plan was reviewed and documented the following revision: .7/3/18 . I have been place (placed on) Line of Sight during meals due to my intrusive behaviors. Please monitor and document appropriately . Nutrition and Hydration . I am served a regular pureed diet and can feed myself after my tray is set up . Because I have a [DIAGNOSES REDACTED]. Please supervise me during meals . On 7/12/18 at approximately 2045 (8:45 p.m.), LPNs #1 and #3 were again placed on administrative leave, per nursing administration.

Complaint # (AR 611) was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure a ventilator-dependent resident was immediately assessed and that manual respiratory support was provided with an ambu-bag during an approximately 2 to 2.5-minute period when the ventilator was malfunctioning, to prevent [MEDICAL CONDITION] and related complications, and failed to accurately communicate the incident to emergency medical personnel to facilitate appropriate treatment for 1 (Resident #1) of 5 (Residents #,[DATE]) case mix residents who were ventilator-dependent. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1, whose ventilator ceased to function for approximately 2 to 2.5 minutes, resulting in the resident suffering hypoxic [MEDICAL CONDITION], and had the potential to cause more than minimal harm to 6 residents who were ventilator-dependent, according to a list provided by the Administrator on [DATE] at 11:55 a.m. The Administrator was notified of the Immediate Jeopardy condition on [DATE] at 12:45 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date ARD) of [DATE] documented the resident had minimal difficulty hearing, had clear speech, was usually understood and understood others, had modified independence in cognitive skills for daily decision making per a staff assessment, received oxygen therapy, suctioning and [MEDICAL CONDITION] care and required the use of a ventilator. a. The Care Plan dated [DATE] documented, .Communication and Memory . I am able to make my needs known but I have some difficulty at times, as I am dependent on a ventilator to breathe. I usually speak in a whisper. I am able to understand the content and message of our conversation if I am able to hear you, but I do have a slight hearing problem . b. A Nursing Progress Note dated [DATE] at 8:40 a.m. documented, R (Resident) transferred by clinic staff and nurse to (Hospital) for eval (evaluation) for diverting [MEDICAL CONDITION]. c. A Nurses Note dated [DATE] at 12:33 p.m. documented, .R had apt (appointment) with (Hospital) to eval diverting [MEDICAL CONDITION]. She has returned and lab has been drawn . R tolerated trip well and settled down. d. A Nursing Progress Note dated [DATE] at 2:05 p.m. documented, Prior to EMS (Emergency Medical System) arrival resident exhibited signs of [MEDICAL CONDITION] activity with head moving from side to side. Staff reported resident was being transferred from chair back to bed when activity began. SaO2 (oxygen saturation) was taken when resident in bed and was in high 80s. O2 (Oxygen) began to drop and went into mid 60s for 30 seconds or less, then back up into the 90s. Resident continued to move head from side to side. (Physician) notified and order received to transfer resident to ER (emergency room ). (Name) SW (Social Worker) contacted resident's daughter and informed her at (1:55 p.m.). Resident had dilated pupils and was non-responsive. VS (vital signs) ,[DATE], Pulse of 94 and SaO2 of 98% on 3 LPM (liters per minute) and on vent (ventilator). Skin warm, dry to touch. e. A Hospital emergency room Record dated [DATE] at 2:37 p.m. documented, .Presenting Problems: Cardiac and/or Respiratory Arrest . Diagnosis (5:30 p.m.) Final: Primary: Altered Mental Status Unspecified, Additional: Bacterial Pneumonia . Pleural Effusion . [MEDICAL CONDITION] without Septic Shock, UTI (Urinary Tract Infection) . f. An Attending Consulting Physician's Hospital Note dated [DATE] documented, History of the present illness: (Resident #1) is a [AGE] year-old female (Nursing Home) patient with a known past history of stroke resulting in [MEDICAL CONDITION] and ventilator dependence. She was admitted after being found in her room disconnected from her chronic ventilation and in [MEDICAL CONDITION], and was coded there, resuscitated and transported to (Hospital). Subsequently, the patient has been unresponsive back on the ventilator and then subsequently began displaying twitching of the face and limbs. Electroencephalogram was done on [DATE] and was markedly abnormal with diffuse background slowing consistent with [MEDICAL CONDITION] with high voltage myoclonic twitch and [MEDICAL CONDITION] activity. Subsequently the patient was started on low-dose levetiracetam 500 milligrams twice a day and [MEDICATION NAME] 100 milligrams every eight hours. Magnetic resonance imaging was done recently demonstrating a midbrain ischemic stroke which is in the area that would be suspected to have occurred earlier in view of the patient's [MEDICAL CONDITION] and ventilator dependence. The exact location of prior stroke and the date of the stroke is unknown. The finding of diffuse background slowing and immediate myoclonic and [MEDICAL CONDITION] activity post hypoxic [MEDICAL CONDITION] is a grim finding . Impression: Acute severe hypoxic [MEDICAL CONDITION] with subsequent [MEDICAL CONDITION] and emergence of hypoxic [MEDICAL CONDITION] and [DIAGNOSES REDACTED] . g. A Nursing Progress Note dated [DATE] at 5:18 p.m. documented, Pt (Patient) back from hospital at (6:34 p.m.) on [DATE]. Pt remains unresponsive, but no [MEDICAL CONDITION] activity reported. Turned and positioned every 2 hours. Pt. ventilator dependent. See progress notes. Will continue to monitor. h. A Care Plan revision dated [DATE] documented, .At some point during my most recent hospital stay, I suffered a hypoxic episode. This has left me unresponsive. I am unable to speak to you and the extent of my brain function is unknown . i. A Physician's Note dated [DATE] at 1:27 p.m. documented, (Resident #1) remains mentally responsive since coming back from the hospital after suffering a septic episode and [MEDICAL CONDITION]. I will talk to family members on Thursday or Friday this week and anticipate a discussion about placing her under a DNR (Do Not Resuscitate) order. (Resident #1) has no functional capacity at this time and she really should not be resuscitated at least in my professional opinion. She remains stable but she is not alert and is not likely to ever regain enough function to have any significant existence on this planet for the rest of her life. j. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident was in a persistent vegetative state with no discernible consciousness, received oxygen therapy, suctioning and [MEDICAL CONDITION] care and required the use of a ventilator. k. A Physician's Progress Note dated [DATE] at 7:35 a.m. documented, (Resident #1) is noted to have a temperature of 101. She received Tylenol. Today her heart has regular rhythm and normal auscultation . Plan: We will obtain CXR (chest x-ray) . l. A Progress Note dated [DATE] at 3:52 p.m. documented, CXR results back indicating large right pleural effusion with adjacent atelectasis and/or pneumonia . Order obtained to send to ER for eval/tx (evaluation/treatment) due to pneumonia. m. A Physician's Progress Note dated [DATE] at 2:30 p.m. documented, .S (Subjective): The Patient is in a coma and cannot communicate with us. O: (Objective): Physical exam was not done today but per recent neurological evaluation she essentially brain dead and we are currently awaiting family members to make a decision on if and when we can take off of the ventilator. A: (Assessment): The patient is currently comatose, secondary to multiple etiologies. P (Plan): As noted above, family members have been notified and will be making a decision in regard to taking her off of the ventilator in the near future. n. A Nursing Progress Note dated [DATE] at 2:37 (a.m. or p.m. not specified) documented, This RN received report (at) 01:50 (1:50 a.m.) hrs from (name) of (hospital) ICU (intensive Care Unit) stating (Resident #1) died previous to 6:30 p.m. on [DATE] . o. On [DATE] at 1:00 p.m., Respiratory Therapist (RT) #1 was asked if she was aware of an incident that occurred with Resident #1 on [DATE] and stated, A vent resident (Resident #1) was sent to a doctor appointment for a [MEDICAL CONDITION] evaluation. Some CNAs (Certified Nurse Assistants) told me that she got disconnected. I was told that (Registered Nurse (RN) #1) did not have an ambu bag. I was told she was never bagged. I was told by (RN #2) to tell y'all that the temperature probe came out and she stayed [MEDICATION NAME]. p. On [DATE] at 4:00 p.m., CNA #1 was asked if she was present during an incident with Resident #1 on [DATE] and stated, .I helped get her in her chair in her room to be transported in the van. The alarm on the vent went off when she was in the van. We were all seated. Myself, the man driving the van, I don't know his name, and (RN #1). (RN #1) was in the front seat. He asked me what the vent said. I can't remember what it said but I read it off to him. He asked if her chest was moving and I told him no. The CNA was asked if there was an ambu bag in the van and stated, I did not see an ambu bag in the van. No ambu bag was used on her during the incident. (RN #1) gets out of his seat and comes to the back of the van from the outside. He opened the back doors. (CNA #2) came out to go on break. I was waving at her to get her attention and (RN #1) told her to go get (Licensed Practical Nurse (LPN) #1). She was the LPN working as the (respiratory) therapist that day. During this time, the resident still had no chest movement. (CNA #2) ran inside and got (LPN #1) and I would say (LPN #1) was out there in a minute to a minute and a half. (LPN #1) got the vent working in about 5 seconds. Her chest started moving up and down. After the vent started working, she had her eyes closed and wouldn't respond when I was talking to her. She never opened her eyes while going to the appointment or after arriving at the clinic. When we got back, we were pushing her to her room and our supervisor (RN #2) was following us, and (CNA #2) came in to help me put her to bed, and we told (RN #2) what happened earlier. We put her to bed and did her vital signs and we noticed when putting her to bed her mouth was drooping and she was drooling and started shaking. During this time, she had not responded after the incident. She was responsive prior to the (ventilator) alarm going off. (RN #2) was told she wasn't breathing from the time the alarm went off to when (LPN #1) was found and she came out there. I would say from the time alarm went off until (LPN #1) came out it was 4 to 5 minutes. I was just panicking. I was looking around in the van for an ambu bag because (RN #1) never got in the back of the van and he stood outside. I have been trained to use the ambu bag. After she was sent back to the facility, she never was like herself . She coded in the ambulance before they left. When they asked me to write a statement (written statement dated [DATE]) I asked why we didn't write it that day. No one told me why. I was told it was investigated and she lost oxygen in the ambulance and never in the van. q. On [DATE] at 4:38 p.m., the Director of Nursing (DON) was asked about the incident on [DATE] and stated, I was never informed that the resident was not breathing in the van. r. On [DATE] at 5:27 p.m., RN #1 was asked to describe the incident that occurred on [DATE] with Resident #1 and stated, They were buckling her up in the wheelchair in the back of the van. The alarm went off low pressure. I asked (CNA #1) what the vent said. I don't remember. (CNA #1) was looking for any leaks. I was standing beside the van at the side doors. I wasn't standing at the back of the van. I did not use an ambu bag. It was in the center console up front. I didn't feel the need to use it. I did ask her (CNA #1) if her chest was moving after I got into the van. I was behind the resident looking to see if any hoses were disconnected. I'm not sure if her chest was moving at this time. I asked if her chest had been moving after we got the vent back in service. She (CNA #1) said, 'I don't think so'. My estimation of time was 45 seconds to 60 seconds before (LPN #1) got out there and got it going. The alarm was alarming approximately 15 seconds when (CNA #2) came out. (LPN #1) got out there in approximately 30 to 45 seconds is how I remember it. Even though the alarm was going off, she still was receiving oxygen. RN #1 was asked if there was no rise and fall of the resident's chest, how the ventilator could have provided oxygen. There was no response from RN #1. s. On [DATE] at 5:05 p.m., RN #2 was asked about the incident with Resident #1 on [DATE] and stated, I did not know about the incident until she returned from the clinic. (CNA #2) had to run down and get (LPN #1), because the alarm was going off. I asked them what kind of alarm and they said they didn't know. (LPN #1) went out and reconnected it, and it was fine. I thought the van had moved and they came back. I was not aware the van had not left. I would have hoped that (RN #1) would have reported to me if she was without air. (RN #1) told me she was never without air. I think (LPN #1) told me she was not without air. The reason it took so long to report to the DON and ADON (Assistant Director of Nursing) was I was concerned about the heater coil wire. t. On [DATE] at 5:39 p.m., CNA #2 was asked if she remembered an incident that occurred on [DATE] with Resident #1 and stated, I went outside to take my break, and the van was there, and (CNA #1) was banging on the window, telling me to go get (LPN #1). It took me a minute to 2 minutes to find (LPN #1). She was in the respiratory area. I told her to go outside to the van now, and she went. When I went back outside after getting (LPN #1), (RN #1) was outside the van. The CNA was asked if she was present and assisted with the resident after her return from her appointment and if she heard RN #2 being provided with information regarding the incident in the van. The CNA stated, What I heard (CNA #1) tell (RN #2) was that she (resident) wasn't breathing in the van, and she told (RN #2) that she should have not gone to the doctor's office and should have been brought back inside. (RN #2) didn't say anything. u. On [DATE] at 6:10 p.m., the ADON was asked if she was aware of an incident that occurred on [DATE] involving Resident #1 and stated RN #2 did not inform her of the [DATE] incident until [DATE] when she was rounding on the unit with RT #1. She also stated, (RT #1) told me she was concerned they used the loading dock instead of the door outside the vent nurses station. v. On [DATE] at 9:05 a.m., LPN #1 was asked about the incident involving Resident #1 on [DATE] and stated, I was in a resident's room giving an updraft at the time (CNA #2) came and got me. She said that (Resident #1 and RN #1) needed me. Her vent was alarming low pressure. She was in the back of the van in her wheelchair. I don't remember her skin color. I didn't look at her chest; the vent was alarming and I was wanting to get it on as quickly as possible. (CNA #1) was in the van in the back with (Resident #1). (RN #1) was outside the van. They left after I got the vent hooked up. It took approximately 30 seconds to get outside and approximately 5 seconds to get the vent hooked up. I did not do an assessment of the resident after the vent was hooked back up. (RN #1) may have. A cap that goes over the heater wire was open. I closed it and the vent started working. This is on the vent tubing. No one had told me how long it had been alarming. With him (RN #1) being my supervisor, I left it in his hands. I never saw him in the back with the resident. When they pulled off and came back around for the pulse ox (oximeter), he was in the front. I know her pulse ox was low, but it was coming up. LPN #1 was asked what should be done during an incident such as this and stated, When this happens, and until you find the issue with the vent, she should have been being bagged. Usually the issue is found in 3 to 5 seconds. She was in the van and had to wait until someone came to get me. She should have been being bagged at this time. I asked, when I was asked to do a witness statement approximately a week after the incident, why I was having to do it now, a week later, and (RN #2) said just to cover us in case something happens. w. On [DATE] at 10:58 a.m., CNA #1, RN #1, RN #2, LPN #1 and CNA #2 participated in a group interview, as follows: 1.) CNA #1 was asked to describe how the resident was loaded onto the van on [DATE] and stated, We put her in the van at the dock area. The alarm went off. (CNA #2) came out and (RN #1) told her to go get (LPN #1). I told her to hurry, and she ran and got (LPN #1). 2.) RN #1 stated, I didn't see the need to bag her. It took approximately one minute for (LPN #1) to get out there. I saw no change in her whatsoever. We had been gone to Little Rock approximately 2 to 3 hours. When we got her back, she started drooling and had [MEDICAL CONDITION] activity. Looked like one eye was wide open and one eye was drooping. I didn't think the incident on the van needed any intervention. 3.) CNA #1 stated, She was here approximately 10 minutes and (RN #2) asked us to lay her down and take her vital signs. We saw some signs and symptoms of [MEDICAL CONDITION] or stroke. The ambulance was called. We told (RN #2) the vent had went off and her chest was not moving and she was not acting the same to me. 4.) RN #1 stated, I reported this to (RN #2), about the alarm going off. I did not assess her respirations. After the vent was corrected by (LPN #1), we got to the HR (Human Resources) building. Made the decision to go back and get a pulse ox reading, due to she was not acting right and unable to palpate a pulse. 5.) LPN #1 stated, We take an ambu bag, [MEDICAL CONDITION], suction machine, gloves and saline with transports. 6.) RN #1 stated, I had all the equipment in a bag in the back of the van, except for the ambu bag, and it was in the console of the van. 7.) RN #2 and LPN #1 stated, If the problem is not immediately identified, the resident should be bagged. 8.) RN #1 stated, In retrospect, I should have assessed the patient. I couldn't because I was behind her. I could only see her skin color. I did ask (CNA #1) if her chest was moving and she said 'no'. 9.) RN #1 and RN #2 both stated, I did not report to her doctor or the ER (emergency room ) about the incident. 10.) RN #2 stated, If I had been in (RN #1's) place, I would have been assessing the resident as well as trying to fix the problem. Even though the alarm was sounding, you do realize the resident continued to receive oxygen? RN #2 was asked by the surveyor how the resident could be receiving oxygen if the resident's chest was not rising and falling to indicate ventilation was occurring. RN #2 did not respond. 11.) CNA #1 stated, I don't remember (RN #1) getting up in the van. 12.) RN #1 stated, I was outside of the van, and (CNA #1) started panicking; I got in the van looking for any tubes being disconnected. No vital signs were taken during this time. That's why we came back to check a pulse ox, because she wasn't responding. We don't have a blood pressure cuff in the van. 13.) CNA #2 stated, It took me about 1 to 2 minutes to find (LPN #1). 14.) LPN #1 stated, It took me approximately 35 seconds to get to (Resident #1) and 5 seconds to fix the problem. x. On [DATE] at 1:30 p.m., the Staff Development RN was asked what would be expected from staff in an incident such as the one on [DATE] involving Resident #1. He stated, An assessment would be necessary. I would not be able to assess a resident from behind. If a CNA told me a resident's chest was not moving, I would be on top of that, ambu bag, assessing and everything. The RN was asked if he had conducted any in-services regarding this incident and stated, I have not in-serviced any staff in regards to the incident that occurred on [DATE] with (Resident #1). y. The Immediate Jeopardy was removed and the scope/severity reduced to G on [DATE] at 7:00 p.m., when the facility implemented the following Plan of Removal: 1.) On [DATE] at 1530 p.m. (3:30 p.m.), all Willow Court residents were thoroughly assessed by licensed nurses. All ventilator equipment tubing/cords was checked to ensure all were properly connected. 2.) Training Required for Nursing Staff at (Facility Name): a. On [DATE] at 1530 (3:30 p.m.) an immediate in-service training was initiated to all (facility) staff regarding identification of Maltreatment, Change of Condition and chain of Command reporting. b. On [DATE] at 1530, all licensed staff on Willow Court was in-serviced by Staff Development/designee regarding van/clinic transport and providing adequate oxygenation by use of ambu bag assistance to ventilator residents for alarms sounding greater than 60 seconds or oxygenation saturation that is less than 80% with nursing assessment, MD (Medical Doctor) notification and matrix note entry. c. Staff Development/Designee will provide ongoing training to those on leave, new hires and agency staff who are assigned to Willow Court by Staff Development/Designee. d. On [DATE] at 1830 (6:30 p.m.) the RN/Designee provided training at shift change at 1830 prior to the employees reporting to the floor to begin assignment. All other staff will be trained prior to their next scheduled shift by the RN/Designee. 3.) Monitoring for Nursing Staff a. On [DATE] at 1630 (4:30 p.m.) the involved RNs, LPNs, RT and CNAs were removed from duty and placed on administrative leave pending further investigation. b. Supervisor/Designee will conduct random daily QA (Quality Assurance) rounds on ventilator residents on Willow Court to ensure appropriate care is being provided and no maltreatment is alleged. This will be monitored daily for (6) six weeks; then monitoring will be reduced to (3) three times a week for (4) four weeks, then once weekly times (4) four weeks. c. Supervisor/Designee will document QA rounds weekly on monitoring form regarding any inappropriate care and or maltreatment. This will be monitored daily for (6) six weeks; then monitoring will be reduced to (3) three times a week for (4) four weeks, then once weekly times (4) four weeks. d. DON/Designee will make daily observation rounds to ensure compliance as outlined above. These DON/Designee rounds will be documented weekly on the DON/Designee Observation monitoring form. This will be monitored daily for (6) six weeks; then monitoring will be reduced to (3) times a week for (4) four weeks, then once weekly times (4) four weeks. e. DON/Designee will review unit monitoring forms weekly to ensure rounds are being conducted as outlined above. The DON/Designee rounds will be documented weekly on the DON/Designee Observation monitoring form. This will be monitored daily for (6) six weeks; then monitoring will be reduced to (3) three times a week for (4) four times, then once weekly times (4) four weeks. f. During observation rounds all negative findings/any failed practices will be immediately corrected and will include re-education and documentation training. 4.) Protection of Residents Any time an allegation of failed practice is identified for failing to ventilate a vent dependent resident, the employee involved will be placed on Administrative leave until the investigation is fully completed. 5.) Training Required for Licensed Staff at (facility name): a. On [DATE] at 1530 in-service training was started by Staff Development/Designee, with all (facility) staff on duty regarding proper reporting of Maltreatment, Change of Condition and Chain of Command. b. On [DATE] at 1530 in-service training was started by Staff Development/Designee with all licensed nurses, regarding van/clinic transport and providing adequate oxygenation by use of ambu bag assistance to ventilator residents for alarms sounding greater than 60 seconds or oxygenation saturation that is less than 80% with nursing assessment, MD notification and matrix note entry. c. On [DATE] at 1530 Staff Development/Designee provided in -service training to licensed nurses regarding thorough investigation of reports of Maltreatment and proper reporting, and submission of 1910s (Incident Report forms) to the Office of Long Term Care per regulation. All other staff will be trained prior to their next scheduled shift by the RN/Designee. d. Staff Development/Designee will provide ongoing training to licensed staff on leave and any new hires.

Complaints # and # were substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure Residents #1 and #5 received the necessary care and services to attain or maintain the highest practicable physical well-being. The facility failed to ensure significant changes in condition were thoroughly assessed, monitored and the physician was immediately consulted to ensure prompt treatment for 2 (Residents #1 and #5) of 2 case-mix residents who experienced significant changes in condition. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death due to delay in treatment for [REDACTED]. The Administrator was notified of the Immediate Jeopardy on 8/30/11 at 5:53 p.m. The findings are: 1. The facility's policy and procedure titled "Change of Condition Reporting" provided by the Assistant Director of Nursing (ADON) on 8/30/11 at 10:20 a.m. documented: "PURPOSE: The purpose of this policy is to establish guidelines for recognizing, assessing, reporting and documenting changes in a resident's condition. SCOPE: Nursing POLICY: It is the policy of Arkansas Health Center that all licensed nurses are trained in recognizing and assessing changes in conditions. It is also the policy of Arkansas Health Center that the physician and the resident's responsible party be notified of changes in the resident's condition in a timely manner. PROCEDURE: 1. Definition of a Change in Condition includes but is not limited to the following: Any problem requiring special observation or nursing interventions ... 2. Assessing changes in condition includes but is not limited to the following: Any direct care nursing employee who recognizes or sees a resident in distress will immediately notify a licensed nurse. The licensed nurse will conduct a thorough assessment of the resident's condition utilizing the following guidelines: Start the assessment with ABCs of good care...In the first few seconds it takes to assess the ABCs, a general feel of whether or not the resident is in significant distress can be established: ...If the resident is NOT in immediate/significant distress, continue with a head to toe assessment. A good assessment starts at the head and moves down the body. ... 3. Notifying physician and resident representative of changes in condition: After the head to toe assessment is completed, the nurse will utilize nursing judgment to determine the overall sense of acuity. If this is an emergency, call 911 immediately and notify the physician, RN (Registered Nurse) Supervisor and family. If this is not an emergency, determine the acuity of the change. Does the resident exhibit a significant change in condition? According to Federal Regulation F157, 'a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and/or a need to alter treatment significantly' as well as accidents resulting in jury that has the potential for requiring physician intervention and a decision to transfer or discharge the resident from the facility require immediate notification to the physician and resident representative .... The licensed nurse will continue to monitor and notify the physician of any further changes in condition or lack of response to the ordered interventions as deemed necessary. ...4. Documenting changes in condition should include but is not limited to the following: Accurately and completely record all change of condition events in the nurse's notes in a timeline method. Describe the change in condition and a description of the assessment findings. ...Record any new orders received or interventions initiated ..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/11 documented the resident had severely impaired cognitive skills for daily decision-making per a staff assessment of mental status (never/rarely made decisions), scored 3 on a Patient Health Questionnaire (PHQ-9) (1-4 indicates minimal depression), had the ability to express himself that was limited to making some concrete requests, could respond adequately to simple, direct communication only and required total assistance with transfers, dressing and personal hygiene. a. Nurses Notes dated 8/18/11 at 0700 (7:00 a.m.) and signed by RN # 2 documented, "Called to unit to assess (resident), observed in floor lying on R (right) side-non-verbal when asked questions- ROM (range of motion) on lower extremities. R expressed no facial grimace or indications of pain, rotation of foot, assisted back to chair per CNA (Certified Nurse Assistant) and LPN (Licensed Practical Nurse) staff- R tolerated well- no indications of pain- (physician) notified- no new orders at present." b. Nurses' Notes dated 8/21/11 at 9:30 a.m. and signed by LPN #1 documented, the resident had altered mental status, no new orders were received and that the nurse was instructed to monitor for further changes. Nurses' Notes dated 8/21/11 documented Resident #1 left the facility at 2:00 p.m. via ambulance. The History and Physical dated 8/21/11 and dictated by the Neurosurgeon documented, "admitting [DIAGNOSES REDACTED].# 1) ...was taken to the local ER (emergency room ) and CT (computed tomography) Scan of the Head was obtained, which showed a very large subdural hematoma involving the right frontoparietal region with a significant compression of the brain and mass effect and compression and shift across midline; Physical Exam: On admission (Resident # 1) was deeply unconscious...not responding to deep painful stimuli except with occasional moaning. He had some stiffness in his neck as well. He had no purposeful movements in all extremities. His breathing was with occasional shallow episodes which could be due to increased intracranial pressure; Impression: Subdural hematoma with acute neurological deterioration and significant brain compression and mass effect across the midline; Plan: Proceed with insertion of an external subdural drain through a twist drill on the right frontal region to alleviate the pressure on the brain as a "Life Saving Procedure." c. The DHS (Department of Human Services) Incident Report, dated 8/21/11 and generated by the facility's Risk Management documented, "Under type of report; Initial Written 8/22/11, Follow up; 8/23/11, Follow up 8/24/11...Date of Incident - 8/21/11, Time of Incident- 5:45 p.m.; ... Narrative: August 22, 2011 4:23 p.m....Yesterday afternoon,...(Resident #1) had a change in condition and was transported to the hospital. He was diagnosed with [REDACTED]. LPN #1 has been placed on administrative leave, pending investigation outcome. (Resident #1) remains in the hospital at this time. If this investigation determines other perpetrators, additional administrative leaves will be initiated per protocol...August 24, 2011 9:06 a.m. Investigation ongoing at present, (Resident #1) had a fall on 8/18/11/which was witnessed. Observers reported that he fell from his wheelchair slowly, onto his side, and did not hit his head. Immediate assessment resulted in no injury being determined at that time. Per facility protocol, monitoring, including hot rack documentation per shift and vital signs, was initiated. Although vital signs remained stable, some care givers observed a change in his (Resident #1) usual behaviors. Nursing staff monitored him and initially deemed his condition to represent normal deviations associated with his diagnosed [MEDICAL CONDITION]. Sunday morning 8/21/11, he (Resident #1) did not eat breakfast; the attending physician was notified and ordered (named) Resident # 1's transfer to the local emergency room . He was then transferred to (another hospital) where he was evaluated for Hospice care vs (versus) surgery. His guardian/Public Guardian (name) was kept informed, and his family was also notified. (Resident #1) subsequently determined to have sustained a subdural hematoma, frontal lobe, stable at this time. At this time, no direct correlation between the fall and the subsequent condition has been established. At this time, it appears that (Resident #1's) fall may have represented a condition decline rather than the cause of the subsequent brain bleed. Monitoring is ongoing." On 8/31/11 at 9:00 a.m., RN #4 (QA/Risk Management) was asked, "During your investigation of the incident, did you determine that he resident was assessed and the physician was notified in a timely manner?" RN # 4 stated, "According to nurse's notes and I talked to (LPN #1), he (Resident #1) was on the hot rack for the fall that he had received on 8/18/11. I asked her (LPN #1) if she had received reports that he was having changes? She said, 'Yes.' She said that the change she observed was on Friday and Saturday (he was quieter), she felt like it was an Alzheimer's phase." The surveyor asked RN # 4 if the LPN was qualified to make that determination. RN #4 stated, "Well, I do think she should have made her observation and reported it to her supervisor." RN #4 was asked if a nurse could diagnose. RN #4 stated, "No. I talked to her (LPN #1) on 8/22/11. When I got the report, I did have some concerns...the witness statements... I reviewed reports, witness statements, Incident Report (8/21/11), nurse's notes, vital sign sheet, body audit for 7/21/11-8/21/11, hospital records, also physician progress notes [REDACTED]." RN #4 was asked how the final determination was made to bring LPN #1 back to work on Wednesday 8/24/11. RN #4 stated, "Everything I reviewed, I discussed with Administration...we did feel that (LPN #1) may not have used the best judgement but she felt that he was stable on Friday and Saturday. Based on vital signs and nurses notes, I thought it looked like he was stable also." RN #4 was asked what the facility's policy was for the LPN to do for a change of condition. RN #4 stated, "To call RN and do assessment and report to MD (medical doctor). Either one of them, the RN or LPN can report to the MD." RN #4 was asked what the physician's instructions were to LPN #1 (a.m. call). RN #4 stated, "(Physician) told her (LPN #1) to monitor him for further changes." RN #4 was asked, "Once the physician gave (LPN#1) those instructions, what was she supposed to do?" RN #4 stated, "Periodically check on the resident, checking VS, mental status." RN #4 was asked, "Where did LPN #1document her ongoing assessment of the resident. RN # 4 stated, "I did not find that. No I don't see any documentation." RN #4 was asked who obtained the assessment and notified the MD of the resident's condition. RN #4 stated, "(LPN #2). d. The following witness statements that were attached to the Accident/Incident Report documented that LPN #1 was informed on multiple occasions, by multiple members of the facility's staff that Resident #1 was exhibiting changes in his usual condition: 1) A Witness Statement dated 8/21/11 at 1751 (5:51 p.m.) and signed by CNA #2 documented, "(Resident #1) had a change of condition when coming on shift 8/19/11 and CNAs notified (LPN #1) of change of condition. It was said that resident had fall Thursday 8/18/11 and resident continued to have a changing condition through the weekend and LPN #2 was passing meds on west hall and (CNA #1) notified her (LPN #2) about the concerns of (Resident #1's) condition and resident was sent to the hospital 8/21/11." 2) A Witness Statement dated 8/21/11 at 6:40 p.m. and signed by CNA #4 documented, "Today I realized that his (Resident #1) face was different, he would not stay awake at the table for breakfast, or lunch. (Resident #1) wouldn't eat or talk today. That's all I noticed today and I talked to the nurse about it." 3) A Witness Statement dated 8/21/11 at 5:55 p.m. and signed by CNA #5 documented, "I have no knowledge of (Resident #1) falling. But since I've been back to work on Friday the 19th, he was different. Not responding, not opening eyes, not eating, Sat. (Saturday) the 20th same thing, and Sunday the 21st, today the same thing." 4) A Witness Statement dated 8/21/11 at 1755 (5:55 p.m.) and signed by CNA #1 documented, "When coming onto work Fri (Friday) 8/19/11 (Resident #1) had a change in condition. It was said that he had fell Thurs. (Thursday) on day shift. I went to (LPN #1) about my concerns in his condition. On Sat (Saturday) (Resident # 1) condition was still changing. We reported to (LPN #1) again about our concerns. On Sunday (Resident #1) was cont. (continuing) to change in condition....On morning med pass (LPN #2) was helping (LPN #1) with her med (medication) pass. I went to (LPN #2) with my concern about (Resident #1). She (LPN # 2) checked his vital signs and assessed him. (LPN #2) came to me around lunch and said that they were sending (Resident #1) out." On 8/31/11 at 11:35 a.m., CNA #1 was asked, "Did you have any concerns about (Resident #1) having a change of condition?" CNA #1 stated, "Yes, Friday (8/18/11) when I came on at 6:00 a.m., I saw the resident at 7:10 a.m. and noticed a change. He was sitting in his wheel chair with his head down; he had drool coming out of his mouth on his shirt. I was pushing him to the breakfast table and he wouldn't lift his feet. I told (LPN #1) directly as I was pushing him from the breakfast around 8:00 a.m., that there was something wrong with this man. (LPN #1) didn't say anything. Approximately 3 times I told (LPN #1) that there was a change in the resident. On Saturday (8/20/11), I told (LPN #1) that there was a change in (Resident #1) about 5 times. (LPN #1) said that it was probably another stage of dementia, 'His dementia is getting worse.' I did not see (LPN #1) check the resident except when she gave him his meds and they (medications) were dripping down his face in his shirt. On Sunday (8/21/11), I told (LPN #1) at breakfast around 7:00 a.m. that something is wrong. Resident was holding food in his mouth and letting it drip. (LPN #1) said, 'It was another onset of dementia.' After that (LPN #1) didn't do anything for the resident. Me and another CNA told the other LPN on the unit (LPN #2) and she helped the resident." 5) A Witness Statement dated 8/21/11 and signed by LPN #2 documented, "(LPN #1) had a 1910 (report) to write and after I gave my AM (morning) medication, (LPN #1) asked me if I would help her finish hers (medication administration) since she was running behind. She said she had only had a few to give maybe 3-4 left. I said yes. I took her medication cart and went down west hall to give the meds she hadn't given. I had given a couple of meds when she (CNA #1) came up to me. Then (CNA #2) walked up. They both told me (Resident # 1) had fallen Wednesday or Thursday reported to them that morning 18th (8/18/11) in report. When they got on the floor they noticed a change in (Resident #1) and had been trying to get (LPN #1) to do something for him and (LPN #1) would tell them to take his vital signs and his vital signs were 'OK'. I asked 'what was the change'? They said 'he won't respond to us when we talk to him. He keeps his eyes closed all time, doesn't help us get him up like he usually does. He won't open his hands or lift his legs when we push him in his wheel chair. He is like dead weight.' I went to (Resident #1's) room with (CNA #1) and called him by name, he wouldn't respond. I then tried to get him to open his mouth and he wouldn't. I then asked (CNA #1) if he hit his head when he fell and (CNA # 1) said they didn't say in report given. I asked her to go get me the B/P (blood pressure) cuff and we would do his vital signs. (LPN #1) came to the door after (CNA #1) brought the vital sign equipment, and said, 'What are you doing?' I told her I was checking his vital signs and something wasn't right and (something) needed to be done. (RN Supervisor #1) was at the desk helping (LPN #1) do the 1910 (report) and told (LPN #1) that if there was a change in his condition she needed to call the doctor. (LPN #1) said that his (Resident #1) vital signs are normal and he is having a Alzheimer's phase. I then went back to west hall and finished giving medication. (CNA #1 and CNA #2) again reported, 'We have been trying for two days and this morning to get (LPN #1) to do something for (Resident #1). At lunch (Resident #1) was in the wheel chair at the table, would not eat or drink anything, the muscles in his neck were tight. I told (LPN #1), 'You know (Resident #1) did not take his medicine this morning. He won't even open his mouth.' I heard (CNA #3) tell (LPN #1), 'Something is not right with (Resident #1).' (LPN #1) said, 'I will try to get him (Resident #1) take his medication.' I did proceed to give the rest of the meds on east hall. When I finished my meds and went back to check on (Resident #1) and he was drooling from his mouth. I then asked (LPN #1) what (physician) had said and (LPN #1) replied, 'He said just to monitor him and call back if anything changes.' She (LPN #1) then said, 'I told (physician), his (Resident #1) vital signs were OK and I don't see any reason to send him out.' (CNA #1, CNA #6) and I put (Resident #1) back to bed and took his vital signs again. His pulse and blood pressure was up from previous and he was still drooling from his mouth. I went and told (LPN #1) my findings, (LPN #1) said, 'His vital signs are OK and he always spits like he is drooling and I just feel like it's a phase of his Alzheimer's, he is going through.' I told (LPN #1) I was going to call (physician) myself that something was wrong. He (Resident #1) was not acting right. I asked (LPN #1) if she told (physician) about the fall and she said, 'No, because the I&A (incident/accident report) doesn't say he fell .' I looked at his chart and on the 18th there was a fall. I called (physician) and explained my concerns and told (physician) about the fall and told (physician) there was definitely a change in (Resident #1). He wanted to know if I would feel better sending him out and I said, 'Yes, something is wrong with him'. (Physician) said, 'Send him out.' I then told (LPN #1) we were sending him out. (RN Supervisor #1) came and wanted to know why we were sending him out. I told her, she checked him and said he (Resident #1) had rales. She (RN Supervisor #1) said she would write the nurse's notes. I did the body work and papers to send him out. When we found out what happened from the ER, I told (LPN #1) when she was in the med (medication) room, I asked her (LPN #1) if she was OK? And she said, 'No, I am upset with (CNA #1 and #2) for going over my head and getting you to take care of (Resident #1) and send him out.' I told (LPN #1) that CNAs (#1 and #2) have been trying for two days to get you to do something for (Resident #1) and she (LPN#1) didn't, so they didn't know what else to do but come to me to get help for the resident. (LPN #1) didn't reply." On 8/31/11 at 10:35 p.m., the surveyor asked LPN #2 if she had any concerns regarding LPN #1's care of Resident #1 on 8/21/11? LPN # 2 stated, "Yes, I had concerns. I felt like that (LPN #1) should have done something about (Resident #1's) declining condition when the CNAs first told her about that. I couldn't understand why she waited 2 1/2 days and had not done anything. That she told them (CNAs), there were two, that his vital signs were fine and that she felt like it was a phase of his Alzheimer's that he was going through. During Sunday Morning, I reported to (LPN #1) that something was bad wrong with (Resident #1) and that she needed to do something about it. She told me, 'I know that something is wrong with him but it is a phase of his Alzheimer's that he is going through.' I told her that I knew that there was something wrong with him besides his Alzheimer's. Approximately at 9:30 a.m., (RN #1), who was the RN Supervisor, said, '(LPN #1), if there is a change in his condition, you need to call the doctor.' At noon (11:00 a.m.-11:45 a.m.), I noticed that (Resident #1) was in a wheelchair at the dining room table and his head was down, he was slumped over to the right. I heard (CNA #3) tell (LPN #1) that (Resident #1) was not eating, or opening his mouth and that she was afraid to try to feed him, he would not respond to her. I told (LPN #1), you know he didn't take his medicine this morning and I felt like there was something seriously wrong and something needed to be done for him. (LPN #1) replied, 'Yes, I know he didn't take his medicine and I'll try to give him his noon meds.' I again told (LPN #1) that he wasn't acting right and there was something wrong with him and something needed to be done. About 10 minutes later, I saw (Resident #1) still at the dinning room table, still slumped over and he was drooling from the right side of his mouth. I told (LPN #1) he is drooling from his mouth and that is something that he hasn't been doing. (LPN #1) replied to me, 'He is spitting and when he spits it looks like he is drooling.' Approximately 12:30 p.m., two CNAs and I put him to bed, took his vital signs and they were elevated from previous. I told (LPN #1) what the vital signs were and asked her if she had called the doctor. (LPN #1) told me that (physician) had told her to watch him and if there was any change, call him back. (LPN #1) then stated that she told the doctor that his vital signs were fine and she saw no reason to send him out. I told (LPN #1) then that I was going to call the doctor myself, that there was something wrong with him (Resident #1) and I called the doctor and told him that I did not know what was wrong with him but something bad was wrong with him. We sent him out." LPN #2 was asked if LPN #1 assisted with the resident's transfer to the hospital. LPN #2 stated, "No, she was upset with me. She took the transfer paper and slapped it on the desk and left the unit. I don't know where she went. I did all the paper work, body audit. (LPN #1) came back up to the floor after approximately 10 minutes. I had told the CNAs to get (Resident #1) ready for transfer. (RN #1) came up to me and said, 'Why are you sending him out, is there a change in his condition?' I told her and showed her his vital signs and she went down to check him, came back to the desk and said, 'Yes, he has rales, send him out and I'll do the nurse's notes.' And then she left the floor. I finished all the paper work, called for the ambulance ... I felt that something should have been done for this man way before Sunday, when the CNAs first reported a change of condition to (LPN #1) ...." 6) A Witness Statement dated 8/21/11 at 1745 (5:45 p.m.) and signed by LPN #1 documented, "I have no knowledge of any falls or injury to the R (Resident #1) other than the fall that is documented on 8/18/11 and was passed on to me in Report." e. On 8/25/11 at 2: 15 p.m., during initial rounds of the facility Registered Nurse #6 stated, "Resident requires total assist with activities of daily living, makes noises but doesn't speak, experienced a fall last Thursday (8/18/11) and had a change of condition last Sunday (8/21/11) and was sent to the hospital and he came back to the facility this Tuesday (8/23/11)." The (hospital) History and Physical dated 8/29/11 documented, "Chief Complaint: [MEDICAL CONDITION] and diminished level of consciousness. Pt (patient) is status previous drainage of subdural hematoma on the right side with evidence of a new subdural with improvement on the CT Scan; New Onset: Chronic subdural on the left side..." f. Nurses' Notes dated 8/30/11 at 3:00 p.m. documented, "received resident back to Oak Court from (hospital) via stretcher ... new orders noted." g. On 8/30/11 at 12:10 p.m., the Risk Management Director was asked what action was taken regarding LPN #1. The Risk Manager Director stated, "She was placed on administrative leave 8/22/11, the Monday following the incident. (LPN #1) is back at work." The Risk Management Director stated, "I know that it is alleged that LPN #1 (named) was told of condition changes and did nothing." h. On 8/30/11 at 2:50 p.m., the Administrator was asked why LPN #1 was placed on administrative leave. The Administrator stated, "On 8/22/11, (RN #4 QA(Quality Assurance)/Risk Management) came to me and said that there may have been some concerns with (LPN #1). We may want to put her on administrative leave. I told (RN #4), if you have some concerns, go ahead and place her on administrative leave. I understood the investigation is completed but the report is not done." The Administrator was asked when LPN #1 came back to work. The Administrator stated that he did not know, but the DON (Director of Nursing) would get that information." On 8/30/11 at 2:55 p.m., the DON stated, "(LPN #1) returned to work on 8/24/11. Her regular schedule to work." i. On 8/30/11 at 2:10 p.m., LPN #1 was asked how long she had been an LPN. She stated, "I work the 7 a.m.-7 p.m. This month it will be [AGE] years working here. I have been an LPN for [AGE] years." LPN #1 was asked when she was first made aware of a change of condition in Resident #1. LPN #1 went to obtain the resident's chart. At 2:15 p.m., while reviewing the nursing documentation, she stated, "On 8/21/11...that he was more drowsy, that was when I first noticed a change, at breakfast about 7:30 a.m." LPN #1 had to stop the interview to do some work and the surveyors agreed to talk with LPN #1 at a later time. On 8/30/11 at 4:05 p.m., LPN #1 continued the interview and stated, "I was giving meds (medications) (on 8/21/11), I was called away from giving meds to fill out a form for another resident. Around 9:30 a.m., a CNA had told me that he (Resident #1) didn't look right. I don't remember who the CNA was. That was the first time that anybody had ever reported anything about the resident after the fall on 8/18/11. To my recollection, yes." LPN #1 was asked if at any time since the fall any other CNA had reported any changes in the resident. LPN #1 stated, "Not that I remember. I am very familiar with (Resident #1). I went down there and checked him about 9:30 a.m. That was when I called the (Physician). I told him about his (Resident #1's) altered mental status, that he did not follow commands. The MD told me to monitor and check vital signs. No, I did not write that (what the doctor instructed) as an order." LPN #1 was asked when she saw the resident again. LPN #1 stated, "Around 11:00 a.m. with RN #1. I don't know what the RN said (regarding Resident #1's condition)." LPN #1 was asked if she gave Resident #1's medications Sunday morning. LPN #1 stated, "No, (LPN #2) told me around 9:30 a.m. he did not take his meds. I went back to his room about 9:30 a.m., crushed his meds but he did not take his meds." LPN #1 was asked when LPN # 2 told her (LPN #1) about her evaluation of Resident #1. LPN # 1 said, "(LPN #2) said that she was going to call the doctor herself." On 8/30/11 at 4:30 p.m., LPN #1 was asked how she determined if a resident had a change of condition. LPN #1 stated, "Continue to monitor." LPN #1 was asked if Resident #1 experienced a change of condition. LPN #1 stated, "I would say he did have a change of condition." LPN #1 was asked who was responsible for monitoring the resident. LPN #1 stated, "The nurse assigned to the resident, which was me." j. On 8/30/11 at 4:35 p.m., the DON was asked, "Did you determine that there were any problems with the delay of care for (Resident #1)?" The DON stated, "I can tell you what my concern was... It was later in the day on Monday afternoon that I got a call from Risk Management. They were beginning to tell me about the issue with (LPN #1). That is when they were telling me that during their investigation they had received some information through witness statements of CNAs. They had learned that the CNAs had some interaction with (LPN #1). (Resident #1) had had what they thought was a change of condition that was relayed to (LPN #1). I think that they thought that (LPN #1) was blowing them off." The DON was asked if it was only the CNAs that had expressed some concern regarding a change of condition for Resident #1. The DON stated, "No, there was another (LPN #2) that was assigned to the unit. I think she also noticed something was different with the resident." The DON was asked if she had read the witness statements. The DON stated, "Not all of them. What I told (my group) was if (LPN #1) had had that many people saying something was different or wrong with a resident, she should have at least called the RN on duty on Friday, Saturday and Sunday." The DON was asked if she participated in the investigation. The DON stated, "No." The DON was asked what was determined and who made the determination regarding LPN #1. The DON stated, "Risk Management determined that (LPN #1) should be in-serviced to notify the RN Supervisor of any change in a resident's condition. (RN #5 ) gave the in-service to her (LPN #1) to sign." The DON was asked who monitored (LPN #1) to make sure that she informed the Supervisor of any change of condition. The DON stated, "I am not sure we set up any monitoring." k. On 8/30/11 at 5:10 p.m., RN #6 stated, "I just read the inservice to (LPN #1) and she signed it and got a copy. I sent the original to Risk Management and gave a copy to her supervisor (RN #1)." LPN #1 signed an In-Service Training regarding "Incident involving (Resident #1)' dated 8/24/11 that documented, "Training regarding; Importance of contacting Supervisor when any change in condition is observed by you or is reported to you by other staff. A head to toe assessment will be completed by the assigned nurse. If concerns are not addressed to the satisfaction of all staff involved, they are to continue to follow the chain of command in reporting and documenting resident's general functioning and status." l. On 8/30/11 at 5:00 p.m., the DON stated,"(RN #1) told me that she is not doing any formal monitoring of (LPN #1)." 1) On 8/30/11 at approximately 5:15 p.m., RN #1 stated, "I don't have any documentation of monitoring (LPN #1)... I will. I should have made up a follow up form...I did an evaluation for burn-out Wednesday or Thursday." 2) On 8/30/11 at approximately 5:30 p.m., RN #6 was asked, "What was your recommendation?" RN #6 stated, "That she (LPN #1) take some time off for relaxation. When I was talking to her and asked her if she felt like she was burned out. She (LPN #1) said, 'I might be.' I asked if she wanted to take some time off and she said that she already had a little bit of time off, I recommended that she take more time off. She will not work after today (8/30/11) until 9/12/11." 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/10/11 documented the resident scored 12 (8-12 indicates moderately impaired) on the Breif Interview for Mental Status, was independent for bed mobility, transfer, locomotion in a wheelchair on and off of the unit, dressing, eating and toilet use, required supervision for personal hygiene and bathing, had no impairment for functional limitation in range of motion of the upper extremities and continent of bladder. a. The Resident Care Plan last updated 7/21/11 documented, "Resident is independent with most all ADLs (activities of daily living) exc