Every finding on record at Barnes Healthcare

50505 Based on record review, interviews, and facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 7 (Residents #5, # 25, #16, #27, #41, #14, #22) of 11 sample mix residents. The findings are: Review of Resident #5's Admission Record noted the resident was admitted on [DATE] with diagnoses of peripheral vascular disease (PVD) (slow and progressive disorder of the blood vessels), cerebral infarction(stroke) and presence of cardiac pacemaker. Review of Resident #5's Order Summary Report dated 1/8/2024 noted [anti-platelet medication name] Tablet 75 milligrams (MG) give 1 tablet by mouth one time a day for blood clot prevention; [nonsteroidal anti-inflammatory (NSAID) medication name] enteric coated (EC) tablet delayed release 81 MG give 1 tablet by mouth one time a day for prophylactic. Review of Resident #5's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2024 noted in section N0415. High Risk Drug Classes: Use and Indication E. Anticoagulant Yes. Review of Resident #25's Admission Record noted the resident was admitted on [DATE] with a diagnosis of pleural effusion (a collection of fluid around the lungs). Review of Resident #25's Order Summary Report dated 1/8/2025 noted [NSAID medication name] 81 oral tablet chewable give 1 tablet through gastrostomy tube (G-Tube) one time a day for pain. Review of Resident #25's annual MDS with an ARD of 12/11/2024 noted Section N0415. High Risk Drug Classes: Use and Indication E. Anticoagulant Yes. Review of Resident #16's Admission Record noted the resident was admitted on [DATE] with a diagnosis of stroke (cerebral infarction). Review of Resident #16's Order Summary Report dated 1/6/2025 noted [NSAID medication name] oral tablet give 325 milligrams (mg) by mouth one time a day for blood thinner. Review of Resident #16's quarterly MDS with an ARD of 11/26/2024 noted in section N0415. High Risk Drug Classes: Use and Indication E. Anticoagulant yes. Review of the Admission Record indicated the facility admitted Resident #27 with diagnoses that included atherosclerotic heart disease, cerebral infarction, peripheral vascular disease and insomnia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. The MDS was marked for anticoagulant and hypnotic use. A review of Resident #27's Care Plan, initiated on 05/21/2020, revealed the resident had a potential for pressure ulcers status post cerebral infarction with left hemiparesis; makes only slight changes in body positioning; incontinent of bowel and bladder, during a move, skin probably slides to some extent against the sheets; thin fragile skin, taking routine full strength aspirin due to her history of cerebral infarction and myocardial infarction, with potential for easily tearing and/or bleeding. Resident #27's skin bruises easily related to [NSAID medication name therapy. Interventions included: to assist with showers/baths 3 times per week and prn. Observe for and report to nurses of any changes in skin integrity and ensure that Resident #27's skin is thoroughly clean and dry. Insomnia and the use of [over the counter (OTC) supplement name] were not included in the care plan A review of the Order Summary Report, revealed Resident #27 had orders for [NSAID medication name] 325 mg, give 1 tablet by mouth one time a day for cerebral infarction and [OTC supplement name] 3 mg, give 3 tablets by mouth in the evening for insomnia. A review of the Medication Administration Record (MAR) revealed Resident #27 was receiving [NSAID medication name] 325 mg 1 tablet every day for cerebral infarction and [OTC supplement name] 3 mg, 3 tablets every evening for insomnia. A review of the Admission Record indicated the facility admitted Resident #41 with diagnoses that included paranoid schizophrenia, mild dementia with behavioral symptoms, and essential hypertension. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. The MDS was marked for anticoagulant use and weight loss of 5% or more in the last month or loss of 10% or more in the last six months. A review of Resident #41's Care Plan, initiated on 01/23/2024, revealed the resident had a significant weight loss. Interventions included: obtain weights as indicated/as ordered and inform MD of significant weight loss, offer snacks as ordered/per resident's request and assist resident to eat, provide diet as ordered, and refer to dietician for possible diet modification(s). No care plan was noted for aspirin use of deep vein thrombosis (DVT) prophylaxis. A review of the Order Summary Report revealed Resident #41 had orders for enteric coated [NSAID medication name] 81 mg delayed release, give 1 tablet by mouth one time a day for DVT prophylaxis. A review of the Medication Administration Record (MAR), revealed Resident #41 was receiving enteric coated [NSAID medication name] 81 mg delayed release, give 1 tablet by mouth one time a day for DVT prophylaxis. A review of weight list, indicated Resident #41 had a weight gain. Resident #41's previous month weight was taken on 12/05/2024 with a weight of 149.2. Weight on 06/03/2024 was 140. During an observation of the resident smoke break on 1/7/2025 at 1:31 PM, the surveyor observed Resident #14 did not have on a smoking apron. Two staff were present during the smoke break. Staff had residents ' cigarettes and a lighter. Smoking ashtray was present along with a fire extinguisher. Review of Resident #14's Assessments did not note the resident was assessed for smoking. Review of Resident #14's Admission Record noted the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of Resident #14's Care Plan with a date of 7/16/2024 noted Resident #14 was a risk for potential injuries and health complications related to history of smoking. Cigarettes and lighters to be kept at the nurses station and given to resident upon request. Complete smoking assessment quarterly to assess safety of smoking outside. Provide resident with assistance needed. Provide resident/ family with education regarding proper places to smoke and provide education regarding risk of smoking and benefits of quitting. Provide resident/ family with education regarding risks of smoking. Review of Resident #14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/1/2025 did not note in section J tobacco use. Review of Resident #22's Admission Record noted the resident was admitted on [DATE] with a diagnosis of schizoaffective disorder. Review of Resident #22's Annual MDS with an ARD of 11/10/2024 noted Psychiatric/ Mood Disorder I5950. Psychotic disorder (other than schizophrenia) Yes; 16000. Schizophrenia Yes. During an interview with the Director of Nursing (DON) on 1/7/2025 at 1:34 PM, she confirmed no smoking assessment was completed, and the resident should have had one completed prior to smoking. The DON confirmed that the resident should have been assessed for smoking for safety purposes. During an interview with the MDS Coordinator on 1/9/2025 at 9:00 AM, she confirmed Resident #14's MDS did not indicate the resident was a tobacco user and it should. During an interview with the Director of Nursing (DON) on 1/9/2025 at 9:24 AM, she confirmed Resident #14's MDS should indicate the resident is a smoker. During an interview with the MDS Coordinator on 1/9/2025 at 9:14 AM she confirmed Resident #22 does not have a diagnosis of Schizophrenia and that the resident has a diagnosis of schizoaffective disorder. The MDS Coordinator confirmed the MDS with an ARD of 11/10/2024 should have indicated Schizoaffective not Schizophrenia as the resident is not Schizophrenic. During an interview on 01/09/2025 at 9:29 AM, the MDS Coordinator explained that the importance of coding the MDS accurately was to ensure medications were administered correctly and that errors could be made and that it was for the residents' well-being and that weights should be accurately recorded in the MDS. The MDS coordinator confirmed that the [NSAID medication name] was coded as an anticoagulant and the [OTC supplement name] was coded as a hypnotic for Resident #27 and that Resident #41 did not have a weight loss but a weight gain and was coded incorrectly and the [NSAID medication name] was coded as an anticoagulant. During an interview with the Director of Nursing (DON) on 1/9/2025 at 9:37 AM, she confirmed Resident #22 does not have a diagnosis of Schizophrenia and that the resident has a diagnosis of other schizoaffective disorders. She confirmed the MDS with an ARD of 11/10/2024 should not have indicated Schizophrenia because the resident does not have a diagnosis of Schizophrenia. During an interview on 01/09/2025 at 10:00 AM, the Director of Nursing (DON) confirmed medications were coded incorrectly on the MDS and that the MDS Coordinator was responsible for ensuring accuracy of the MDS. The DON confirmed that Resident #27's MDS had been coded incorrectly for the [NSAID medication name] use, that it should have been marked as an antiplatelet and that [OTC supplement] was not a hypnotic medication as marked on the MDS. The DON confirmed that Resident #41's MDS was coded incorrectly for [NSAID medication name] use as an anticoagulant and that the resident had a weight gain, not a weight loss. During an interview with the MDS Coordinator on 1/9/2025 at 10:25 AM, she confirmed Residents #5, #25, #16, #41 and #27 should not have had [NSAID mediation name] coded on the MDS as an anticoagulant and that it should have been coded as an antiplatelet.

50505 Based on record review, interview, and facility document review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed prior to admission to ensure the resident received the needed care and services in the most appropriate setting for 3 (Residents #16, #22,#32) of 4 sampled residents whose records were reviewed for PASRR screening information. The findings are: Review of Resident #16's [company name] letter, submitted by another facility, dated 5/14/2018, for a Level I application and the resident was considered a change of condition. Review of Resident #16's Division of Medical Services (DMS) 787 dated 6/11/2018 noted in Section II the resident had a diagnosis of Mental Retardation (MR)/ Intellectual Development disorder (IDD). Mental Retardation developed before the resident reached age 18, and the resident had a Developmental Disability before reaching the age of 22. Mental Illness section noted Resident #16 has a diagnosis of schizophrenia has received treatment within the last two years at a mental hospital. The DMS 787 also documented that the resident has a diagnosis of dementia. Review of Resident #16's DMS-780 dated 6/11/2018 noted the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition- (DSM-IV) was utilized to substantiate the following diagnosis of dementia (including Alzheimer's, cognitive disorder, alcohol/ drug and other related disorders). Major neurocognitive disorder, IDD list for dementia diagnosis. The diagnosis was made on the basis of a mental status examination. Behavior, history or physical findings that lead to the dementia diagnosis: Refusing meds, mood lability, psychosis, poor safety awareness. Diagnosis of dementia first made in 2015. Section II B. note the resident has a diagnosis of Schizophrenia, is the primary diagnosis and existed prior to the onset of dementia. Review of Resident #16's Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria (DHHS-703) dated 6/11/2018 noted the resident has a diagnosis of schizophrenia and IDD Mental disorder. The document noted it was electronically processed on 6/12/2018 and emailed to medical needs. Review of Resident #16's Division of Provider Services and Quality Assurance (DPSQA) Office of Long Term Care (OLTC) letter dated June 15,2018 noted they were unable to process the application for nursing home care due to lack of information in following area(s) and or additional information is needed to accurately review the application: Licensed Practical Nurse (LPN) signature missing and completed Minimum Data Set (MDS). Because of these items, the processing of the application was being delayed and to avoid further delay resubmit by 6/28/2018. Review of Resident #16's Admission Record with an admitted [DATE] noted diagnoses of schizophrenia and a mental disorder. Review of Resident #16's Update Diagnosis with a date of 3/8/2022 noted a diagnosis of schizophrenia as a primary admitting diagnosis. Review of Resident #16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/2024 noted the resident had a score of 9 (08-13 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS). Section I. Active Diagnosis Psychiatric/ Mood Disorder I6000. Schizophrenia yes. Review of Resident #16's electronic chart documented no PASRR II, or exemption located on the electronic chart. During an interview with the MDS Coordinator on 1/7/2025 at 2:59 PM, this surveyor requested Resident #16's Pre-Admission Screening documents and [company name] letter that would indicate either a Level II or exempt from a Level II PASRR. The MDS Coordinator revealed 2018 was the last time Resident #16 was seen for [company name]/ Med Needs and that she did not have a copy of the paperwork that indicated whether or not the resident had a Level II PASRR for diagnoses of schizophrenia and intellectual or developmental disability (IDD) Disorder and that there was no Level II exempt or instructions for specialized services. During an interview with the Director of Nursing (DON) on 1/9/2025 at 9:31 PM, she confirmed a PASSR should have been submitted for Resident #16 to the Office of Long-Term Care (OLTC) for the resident to receive a Level II for schizophrenia diagnosis. Review of Resident #22's [company name] letter submitted by another facility dated 6/28/2018 for a Level I application and the resident was considered a change of condition. Review of Resident #22's Admission Record noted the resident was admitted on [DATE] with a diagnosis of schizoaffective disorder. Review of Resident #22's Division of Medical Services (DMS) 787 dated 11/8/2022 noted in Mental Illness section noted Resident #22 had a diagnosis of schizoaffective and there was presenting evidence of disturbance in orientation, affect, mood or behavior that suggested mental illness. The DMS 787 also documented the resident had no diagnosis of dementia. Review of Resident #22's DMS-780 dated 11/13/2022 was not completed. Review of Resident #22's Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria (DHHS-703) dated 10/28/2022 noted the resident had a diagnosis of schizoaffective disorder. Review of Resident #22's annual MDS with an ARD of 11/10/2024 noted a score of 11 (8-12 indicates moderate cognitive impairment) on the BIMS. Section I. Active Diagnosis Psychiatric/ Mood Disorder I5950. Psychotic disorder (other than schizophrenia) Yes; 16000. schizophrenia Yes. Review of Resident #22's electronic chart documented no PASRR II, or exemption located on the electronic chart. During an interview with the MDS Coordinator on 1/7/25 at 2:59 PM, this surveyor requested Resident #22's Pre-Admission Screening documents and [company name] letter that would indicate either a Level II or exempt from a Level II PASRR. The MDS Coordinator revealed 2018 was the last time Resident #22 was seen for [company name]/ Med Needs and that she did not have a copy of the paperwork the indicated whether or not the resident had a Level II PASRR for a diagnosis of schizoaffective disorder and that there was no Level II exempt or instructions for specialized services. During an interview with the Director of Nursing (DON) on 1/9/2025 at 9:37 PM, she confirmed a PASSR should have been submitted to the Office of Long-Term Care (OLTC) for Resident #22 to receive a Level II for a schizoaffective diagnosis. A review of the Admission Record, indicated the facility admitted Resident #32 with diagnoses that included schizophrenia, vascular dementia, mood disorder, anxiety disorder, and psychosis. Resident #32's actual admitted to the facility was 07/13/2020. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Active diagnoses were marked for mood disorder, anxiety disorder, psychotic disorder, schizophrenia. The admission 5-day MDS with an ARD of 07/20/2020 did not have schizophrenia marked. A review of Resident #32's Care Plan, initiated on 05/21/2024, revealed the resident had a risk for adverse reactions from behavior disturbances as related to vascular dementia with behavioral disturbance, schizophrenia, psychosis and mood disorder. Interventions included: administer and monitor effectiveness of medications as prescribed by physician; anticipate needs and provide them before the resident becomes overly stressed; educate resident on other effective coping skills for dealing with feelings; explain care in advance to resident; intervene during behavioral outbursts to protect the safety of the resident and others; investigate/monitor the need for psychological/psychiatric support. Provide services if desired by the resident/family and ordered by the physician; monitor and document any non-pharmacological interventions used to deter behavior prior to as needed medication administration; observe and record changes in behavioral symptoms; provide resident with diversional activities when behavioral symptoms arise; provide resident with one-on-one attention as needed; and reinforce positive behavior. Preadmission screening and resident review were not mentioned in the care plan. A review of a Physician's Progress Note, dated 08/13/2020, revealed the resident had a past medical history of major neurocognitive disorder with behaviors, schizophrenia, hypothyroidism, hypertension, mood lability, and anxiety. A review of Medical Diagnosis on 01/07/2025, revealed that Resident #32 had the primary diagnosis of schizophrenia added on 06/03/2022. A review of the PASRR, a letter dated 05/19/2020 from [company name] stated it was determined Resident #32 was a non-PASRR client. Upon reviewing the entire information sent in for the PASRR, only one diagnosis was given: mild neurocognitive disorder and was marked no for having a diagnosis or history of mental illness (schizophrenia). During an interview on 01/08/2025 at 8:44 AM, the Director of Nursing (DON) confirmed there had been no PASRR completed after the 05/19/2020 PASRR and confirmed that Resident #32 entered the facility on 07/13/2020.

50505 Based on observations, interviews, and record review, it was determined the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 6 (Residents #32, 22, 27, 3, 7, 14) of 19 sampled residents whose Care Plans were reviewed. The findings include: A review of the Admission Record, indicated the facility admitted Resident #32 with diagnoses that included schizophrenia, vascular dementia with behavior disturbance, psychosis, mood disorder, convulsions, anxiety disorder, and abnormal weight loss. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. Resident #32 was marked as having 2 or more falls since admit or prior assessment. A review of Resident #32's Care Plan, initiated on 06/22/2023, revealed the resident had a high potential for fall and/or fall-related injuries due to strong history of falling, (intermittently causing hematoma's to forehead), and diagnosis of dementia with behavior disturbances, decreased safety awareness, routine psychotropic medications per physician orders, Vitamin D deficiency with potential for bone demineralization an or pathological fractures. Falls listed on care plan for Resident #32: 04/24/2024; 06/20/2024; 07/22/2024; 09/03/2024; 10/01/2024 and 01/02/2025. Interventions included: anticipate and meet Resident #32's needs; encourage Resident #32 to sit on the side of the bed for a few moments prior to rising and assist as indicated; frequent observation by staff due to resident's inability to use call light, but keep call light within reach in room to encourage resident to press for assistance, staff to respond in a timely manner; resident assessed with no injury apparent, no pain indicated, assisted to couch to rest; keep pathways clean and free of clutter; labs per physician orders; bed needs to be in lowest position while resident is in it for safety and comfort, pharmacy to review medications monthly with recommendations to the physician as indicated (these interventions were added in 2023). Intervention added 01/31/2024: the resident was assessed for injuries, none found. Resident redirected to another activity; non-skid socks placed on resident's feet. Maintenance requested to secure mini refrigerator. Most recent fall was recorded on 01/02/2025 with no interventions in place. A review of the Order Summary Report, revealed Resident #32 had been admitted to Hospice; Receiving [antiparkinson medication name] 25/100 milligrams (mg), 1 tablet by mouth 3 times a day; [anticonvulsant medication name] 125 mg, 4 capsules by mouth 3 times a day; [antidepressant medication name] 50 mg, 1 tablet one time a day; [antipsychotic medication name] 0.5 mg, 1 tablet by mouth every 12 hours and [opioid pan relieving medication name] 20 milligrams(mg)/milliliter(ml), 0.25 ml by mouth every 4 hours as needed for pain. A review of an Activity of Daily living task list revealed Resident #32 had no tasks developed for interventions for falls. The Director of Nursing (DON) was asked to review the incident reports for falls for Resident #32 on 07/22/2024; 09/03/2024; 10/01/2024, and 01/02/2025. After reviewing, the DON confirmed there were no immediate action interventions on the incident reports except for 07/22/2024, nor were there interventions placed on the care plans for any of the incidents. Review of Resident #22's Admission Record dated 10/28/2022 note a diagnosis of swelling (edema), and schizoaffective disorder. Review of Resident #22's Order Summary Reported dated 12/6/2025 noted [diuretic medication name] oral tablet 20 Milligrams (Mg) give 1 tablet by mouth two times a day for edema. Review of Resident #22's Care Plan with a revision date of 11/29/2024 did not note medication or black box warning for [diuretic medication name], diagnosis of edema, and Resident #22's diagnosis of schizoaffective disorder. A review of the Admission Record, indicated the facility admitted Resident #27 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, anxiety disorder, psychosis, major depressive disorder, and insomnia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. Resident #27 was marked as receiving an antipsychotic, antianxiety, antidepressant, hypnotic, and anticoagulant. A review of Resident #27's Care Plan, initiated on 03/07/2023, revealed the resident had an alteration in behavioral status following cerebral infarction as evidenced by refusals of care and has impulsiveness with little or no safety awareness placing Resident #27 at risk for further falls; yells out loudly, potentially disturbing others and when approached and questioned, will state that nothing is needed; and frequently kicks right lower extremity against the bed/specialized geriatric chair or the wall with risk for injury. Interventions included: administer and monitor effectiveness of medications as prescribed by physician, intervene during behavioral outbursts to protect the safety of the resident and others. No black box warnings were noted. Resident #27's care plan revealed the resident had potential for impaired skin integrity/pressure ulcers status post cerebral infarction with left hemiparesis; makes only slight changes in body positioning, decreased physical mobility, risk for nutritional deficit and frequently kicks the right lower extremity against bed/specialized geriatric chair or the wall with risk for injury. Interventions included: assess and record changes in skin status. Report pertinent changes to the physician, complete skin risk assessment quarterly; provide diet as ordered and monitor nutritional status and dietary needs, and standard pressure reducing mattress to bed. Contracture and contracture management was not included in care plan. A review of the Order Summary Report, revealed Resident #27 had [NSAID medication name] 325 mg, 1 tablet by mouth one time a day; [benzodiazepine medication name]1 mg, 1 tablet by mouth every 12 hours; [anti-Parkinson ' s and anticholinergic agent name] 0.5 mg, 1 tablet by mouth two times a day; [anticonvulsant medication name] 125 mg, 2 capsules by mouth two times a day; [antidepressant medication name] 10 mg, 1 tablet by mouth one time a day; [over the counter supplement name] 3 mg, 3 tablets by mouth in the evening; and [antipsychotic medication name] 2 mg, 1 tablet by mouth two times a day. A review of Medication Administration Record (MAR), revealed Resident #27 had been receiving [NSAID medication name], [antidepressant medication name], [over the counter supplement name], [benzodiazepine medication name], [anti-Parkinson ' s and anticholinergic medication name], and [anticonvulsant medication name]. A review of an Activity of Daily living task Clean left hand and between fingers. Passive Range of Motion (PROM) to left elbow, wrist, and fingers. Place hand roll in left hand, ensuring all fingers are open around the roll, revealed Resident #27 had a contracture to the left hand. During an observation on 01/06/2025 at 10:50 AM, Resident #27 had no handroll observed, no device observed in left hand, obvious contracture noted. During an observation on 01/08/2025 at 10:30 AM, Resident #27 had no hand roll or device to the left hand. No device or handroll was noted to in or on the bed or on the tabletops in the room. During an interview on 01/08/2025 at 11:19 AM, the Certified Nursing Assistant (CNA) #11 stated that Resident #27 has a hand roll, but that the resident refuses to use at times. CNA #11 stated, I don't document the refusals, and the nurses document the refusals. When asked if refusals are reported to the nurse, CNA #11 stated, I don't report it to the nurse. CNA #11 was asked where the hand roll was in the room and CNA #11 searched the room, closet, drawers, and bed of resident and the hand roll was not located in Resident #27's room. When asked how CNAs knew what care needed to be provided to the residents', CNA #11, reported, I ask the nurse what needs to be done. The DON reviewed the care plan for Resident #27 and confirmed there were no black box warnings listed in the care plan and that the MDS Coordinator was responsible for care planning black box warnings. When asked what the importance of documenting the black box warnings, the DON stated, to know what adverse reactions to watch for. Review of Resident #3's Admission Record dated 6/7/2019 noted diagnoses of major depressive disorder, anxiety, asthma, chronic obstructive pulmonary disease (COPD), atrial fibrillation (A-Fib), irritable bowel syndrome with constipation, chronic pain. Review of Resident #3's Order Summary Report dated 1/8/2025 noted [diuretic medication name] oral tablet 20 milligrams (Mg) give 1 tablet by mouth one time a day every Monday, Wednesday, Friday, Sunday for swelling (edema); [anticoagulant medication name] oral tablet 2.5 Mg give 1 tablet by mouth two times a day for A-fib; [opioid agonist medication name] oral tablet 50 Mg give 1 tablet by mouth three times a day for chronic pain; [benzodiazepine medication name] tablet 1 Mg give 1 tablet by mouth two times a day for anxiety; [irritable bowel syndrome agent medication name] capsule 290 microgram (mcg) give 1 capsule by mouth one time a day for Irritable Bowel Syndrome (IBS); [antidepressant medication name] oral tablet Extended Release 24 Hour 300 Mg give 1 tablet by mouth one time a day for depression/anxiety Do not crush; [leukotriene modifier medication name] Tablet 10 Mg Give 1 tablet by mouth one time a day. Review of Resident #3's Care plan dated 12/31/2019 does not note medications or black box warnings for [diuretic medication name], [anticoagulant medication name], [opioid agonist medication name], [benzodiazepine medication name], [irritable bowel syndrome agent medication name], [antidepressant medication name], and [leukotriene modifier medication name]. The Care plan noted the resident is taking psychotropic medications that have been discontinued. A review of an Admission Record indicated the facility admitted Resident #7 with chronic kidney disease stage 3 (kidneys have mild to moderate damage and has difficulty filtering waste and excess fluid from the blood). The quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 10/20/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of Resident #7 ' s Care Plan, revealed that multiple areas in intervention where black box warnings did not reveal details to monitor. Black box warning and medication were not reference in Care Plan. No warnings for symptoms to monitor. Review of Resident #14's Admission Record noted the resident was admitted on [DATE] with a diagnosis of repeated falls. Review of Resident #14's Care Plan dated 7/16/2024 noted Resident #14 is at high risk for falls/injuries related to previous history of falls, unsteady gait, obesity, osteoarthritis, and chronic pain. The care plan noted falls on: 7/15/24 Actual fall without injury 8/13/24 Actual fall with injury to right hand 9/15/24 Actual fall with minor injury 9/18/24 Actual fall without injury 9/26/24 Actual fall without injury 9/27/24 Actual fall without injury 11/3/24 Found on floor 11/20/24 Witnessed fall 11/23/24 Witnessed fall 12/1/24 Unwitnessed fall 12/4/24 Fall with no injury 12/6/24 Witnessed fall-skin tear 12/22/24 Fall with no injury x 2 12/26/24 Fall with no injury 12/31/24 Found on floor, no injury 1/1/25 Found on floor, no injury Care plan interventions include: Assess for and record any additional fall risk factors Date Initiated: 7/16/2024 Frequent monitoring and anticipation of needs if resident is unable to or forgets to use call light Date Initiated: 7/16/2024 Instruct resident to move or change positions slowly Date Initiated: 7/16/2024 Interventions: Resident to have low bed with floor mats Date Initiated: 7/16/2024 Resident has a cane/walker and uses it when he has strength to ambulate without falling. Date Initiated: 12/13/2024 Review of Resident #14's Progress Notes dated 8/13/2024 at 9:54 AM, noted Resident #14 fell into dresser. No injuries noted. Staff discussed with the resident sitting up on side of bed for a few minutes before attempting to ambulate. Review of Resident #14's Progress Notes dated 9/15/2024 at 8:50 AM, noted Resident #14 reported fell in the morning and stated right hand was hurting. Right hand noted to be swollen and some bruising around knuckles. The resident reported it hurt to try to bend fingers. New order received for right hand x-ray. Review of Resident #14's Progress Notes dated 9/26/2024 at 10:56 AM, noted Resident #14 had fallen in the bathroom across the hallway from Resident 14's room. Review of Resident #14's Progress Notes dated 9/27/2024 at 8:24 AM, noted Resident #14 was found on the floor in the bedroom. Review of Resident #14's Progress Notes dated 11/3/2024 at 3:03 PM, noted Resident #14 slid out of wheelchair. Resident #14 was observed to have 2 skin tears to left forearm. The resident instructed to lock wheelchair, do not overreach or call for help. Review of Resident #14's Progress Notes dated 11/20/2024 at 11:06 AM, noted Resident #14 slipped and fell in shower. No injuries noted. Educated resident to ask for assist while transferring in shower room. Review of Resident #14's Progress Notes dated 11/24/2024 at 3:57 PM, noted Resident #14 denies pain, no bruising or skin tears. No change in mobility related to fall on 11/23. Review of Resident #14's Progress Notes dated 12/6/2024 at 6:38 PM, noted Resident #14 was observed hitting the floor and rolled to side just inside the doorway. Resident #14 revealed sliding into the floor. Small skin tear to right forearm noted. Resident #14 was instructed to use cane or walker when going to the bathroom. Review of Resident #14's Progress Notes dated 12/9/2024 at 8:47 PM noted Resident #14 had no injuries noted from previous fall on 12/6/24. Encouraged to use call light for transfers. Review of Resident #14's Progress Notes dated 12/22/2024 at 3:36 PM noted Resident #14 was using the commode and attempted to get up and slid off the commode to the floor between commode and sink. No injuries noted. Commode Rails requested for safety. Review of Resident #14's Progress Notes dated 12/26/2024 at 1:01 PM noted the resident was found on the floor with arms and head on the floor sticking out of room in hallway. Resident #14 was assessed for injury and skin tears noted to back of right forearm. Resident encouraged to use call light and ask for assist from staff for transfer needs Review of Resident #14's Progress Notes dated 12/26/2024 at 1:07 PM Noted Resident #14 was found on stomach in room. Review of Resident #14's Progress Notes dated 12/26/2024 at 7:18 PM noted staff will continue to monitor the resident and instructed to use call light and ask for help if feeling week to help prevent falls. Review of Resident #14's Progress Notes dated 1/1/2025 at 7:34 PM noted the resident slid out of bed. No injuries noted. No interventions listed. Review of Resident #14's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/1/2025 noted section J1800. Has the resident had any falls since admission/ entry or reentry or Prior Assessment (OBRA or Scheduled PPS), which ever is more recent? Yes. During an interview with Resident #14 on 1/7/2025 at 9:08 AM, Resident #14 confirmed they had multiple falls recently. Resident #14 confirmed no injuries were sustained. This surveyor did not observe any fall interventions in the residents room. During an interview on 01/08/2025 at 8:44 AM, the Director of Nursing (DON) stated the fall process was as follows: investigate to find out what the resident was trying to do, assess the resident, if needed provide first aid or medical care or send to hospital, provide interventions. Confirmed that this information would be documented in the incident record as well as a progress note and the care plan. During an interview with the MDS Coordinator on 1/9/2025 at 9:00 AM, she confirmed Resident #14 did not have fall interventions listed on the care plan for falls that occurred on 8/13/2024; 9/15/2024; 9/18/2024; 9/20/2024; 9/26/2024; 9/27/2024; 11/03/2024; 11/20/2024; 11/23/2024; 12/1/2024; 12/14/2024; 12/22/2024; 12/26/2024; 12/31/2024 and 1/1/2025. She confirmed there should be interventions on the care plan for each fall so if one intervention does not work they could try something else to prevent falls. During an interview with the MDS Coordinator on 1/9/2025 at 9:04 PM, she confirmed medications that require black box warnings were not listed on the residents care plans for medications that have black box warnings. She confirmed the medications with black box warnings should be on the care plans, and the purpose of the warning is due to possible drug interactions. During an interview with the DON on 1/9/2025 at 9:24 AM, she confirmed Resident #14 did not have fall interventions listed on the care plan for falls that occurred on 8/13/2024; 9/15/2024; 9/18/2024; 9/20/2024; 9/26/2024; 9/27/2024; 11/03/2024; 11/20/2024; 11/23/2024; 12/1/2024; 12/14/2024; 12/22/2024; 12/26/2024; 12/31/2024 and 1/1/2025. She confirmed there should be fall interventions on the care plan, so staff were aware of what needed to be done to prevent additional falls. During an interview on 01/09/2025 at 9:29 AM, the MDS Coordinator confirmed that the MDS Coordinator was responsible for the comprehensive care plan and that fall interventions should be added to the care plan soon after the fall occurs. The MDS Coordinator was unaware that black box warnings needed to be included in the comprehensive care plan and agreed that contractures should be care planned with interventions to prevent worsening. During an interview on 01/09/2025 at 10:00 AM, the DON confirmed that the MDS Coordinator was responsible for care planning the black box warnings to the care plan. During an interview with the DON on 1/9/2025 at 9:33 AM, she confirmed medications that require a black box warning were not listed on the residents care plans for medications that have black box warnings. She confirmed the medications with black box warnings should be on the care plans, so staff was aware of what side effects to watch for. During an interview with the MDS Coordinator on 1/9/2025 at 10:25 AM, she confirmed Resident #22 was not care planned for edema or schizoaffective disorder and that the resident was care planned for schizophrenia. 51477

Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure that residents who smoke have a smoking assessment for 2 (Resident #14, #41) of 2 sample mix residents reviewed for smoking and to ensure hand rolls were used for residents with contractures for 1 (Resident #27) of 1 sample mix residents reviewed for contractures and to ensure specialized shampoo was used during showers as ordered by physician instead of regular body wash for 1 (Resident #47) of 1 resident reviewed for ADL (activities of daily living) care for dependent residents. The finding are: During an interview with Resident #14 on 1/7/2025 9:11 AM, the resident stated there are smoking times and confirmed staff keep cigarettes and lighters. Resident #14 confirmed that they don't wear an apron when smoking. Review of Resident #14's Admission Record noted the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of Resident #14's Care Plan with a date of 7/16/2024 noted Resident #14 was a risk for potential injuries and health complications related to history of smoking. Cigarettes and lighters to be kept at the nurses ' station and given to resident upon request. Complete smoking assessment quarterly to assess safety of smoking outside. Provide resident with assistance needed. Provide resident/ family with education regarding proper places to smoke and provide education regarding risk of smoking and benefits of quitting. Provide resident/ family with education regarding risks of smoking. Review of Resident #14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/1/2025 does not note in section J. Tobacco use. During an observation of Resident #14 during smoke break on 1/7/2025 at 1:31 PM, this surveyor observed Resident #14 did not have on a smoking apron while smoking. Review of Resident #14's Assessments does not note the resident was assessed for smoking. A review of the Admission Record, indicated the facility admitted Resident #41 with diagnoses that included paranoid schizophrenia, mild dementia with behavioral disturbance, and depression. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. A review of Resident #41's Care Plan, initiated on 05/15/2024, revealed the resident had a risk for potential injuries and health complications related to resident is a recent smoker with a history of smoking inside the building at previous facility and being caught outside in the smoke area after smoke break again smoking. Interventions included provide resident with assistance needed to smoke outside of facility and complete smoking assessment quarterly to assess safety of smoking outside. During an observation on 01/07/2025 at 1:15 PM, Resident #41 was outside with staff assistance. Staff lit Resident #41's cigarette, and no smoking apron was used. Resident #41 was supervised by staff. A review of the Admission Record, indicated the facility admitted Resident #27 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder, psychosis, cerebral infarction (CVA), peripheral vascular disease and myocardial infarction. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #27 had a BIMS score of 5. which indicated the resident had severe cognitive impairment. The MDS was marked for Resident #27 as having impairment to upper and lower extremity and requiring passive range of motion (ROM). A review of Resident #27's Care Plan, initiated 05/21/2020, revealed the resident had a potential for pressure ulcers status post CVA with left hemiparesis, makes only slight changes in body positioning. Interventions included: assist with showers/baths three times per week and as needed. Observe for and report to nurses any changes in skin integrity and ensure skin is thoroughly clean and dry. A review of the Order Summary Report revealed Resident #27 had an order for weekly skin assessment on Wednesdays. A review of the Activities of Daily Living (ADL) Task Record, revealed Resident #27 had the task: Clean left hand and between fingers. Passive Range of Motion (PROM) to left elbow, wrist, and fingers. Place hand roll in left hand, ensuring all fingers are open around the roll. Documentation reviewed from 12/08/2024 through 01/06/2025. During these times, 7 times were documented as not applicable, with 7 times applied and 14 times being refused and 1 time with no documentation available. During an observation on 01/06/2025 at 10:50 AM, Resident #27 was noted to have contracture of the left hand. No handroll or device was observed in the resident's left hand. During an observation on 01/08/2025 at 10:30 AM, Resident #27 had no handroll or device in left hand. No device or handroll was observed on the bed or on the table or on top of the cabinet in the resident's room. A review of a facility policy titled, Medication Policy, revised in April 2007 stated, all the resident's clinical record must have an order for over-the-counter medications and if ordered will be supported by the appropriate care processes and practices. A review of the Admission Record, indicated the facility admitted Resident #47 with diagnoses that included down syndrome, seizures, abnormal weight loss and dysphagia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) of 0 and no staff assessment for mental status had been completed. A review of Resident #47's Care Plan, revised on 10/09/2023, revealed the resident had a slight risk for impaired skin integrity/pressure ulcers, related to incontinent episodes, risk for nutritional deficit. Intervention included: assess and record changes in skin status and to assist resident with showers twice weekly, PRN and upon request. Intervention was added on 12/18/2023 which included medicated external shampoo (ketoconazole topical 1%, apply to affected areas topically as needed for every shower use in place of body wash. A review of the Order Summary Report, revealed Resident #47 had an order dated 12/11/2023, Ketoconazole 1% topical shampoo, apply to affected areas topically as needed for every shower, use in place of body wash. A review of Treatment Administration Record (TAR), revealed Resident #47 had Ketoconazole 1% topical shampoo, apply to affected areas topically as needed every shower, use in place of body wash. TARs were reviewed from 12/11/2023 until May 29,2024 with no signatures present to show the medicated shampoo had ever been used. A review of an Activity of Daily living task Bathing, May 2024, revealed Resident #47 had the intervention/task of Bathing on Tuesday, Thursday, Saturday and PRN. Baths were documented as being given on 5/2, 5/4, 5/7, 5/11, 5/14, 5/16, 5/21, 5/25, 5/28. Documentation was not provided for 5/18 and 5/23, and the resident was unavailable per documentation for 5/9. A review of Progress Notes revealed no documentation written regarding the medicated shampoo being ordered. A review of the skin observation tool for the following dates in 2024, 1/2, 2/7, 3/2, 4/5, 5/3, 5/10, 5/18, 5/24, and 5/29 indicated that the resident had psoriasis patches present. During an interview with the Director of Nursing (DON) on 1/7/2025 at 1:34 PM, she confirmed no smoking assessment had been completed for Resident #14 and the resident should have had one completed prior to smoking. The DON confirmed the resident should have been assessed for smoking for safety purposes. The DON also reviewed the last smoking evaluation completed on Resident #41 and confirmed that no smoking evaluation had been completed since 12/01/2023. DON was unsure as to how often the evaluation was to be completed. After reviewing the care plan, DON confirmed that the smoking evaluation should be completed quarterly. During an interview on 01/08/2025 at 11:19 AM, the certified nursing assistant (CNA) #11 stated that Resident #27 had a hand roll, but that the resident refuses to use it at times. CNA. #11 stated, I don't document the resident's refusals, the nurses document it. I don't report it to the nurse. CNA #11 confirmed the hand roll was not in Resident #27's room. During an interview on 01/09/2025 at 08:45, the Treatment Nurse stated that the medicated shampoo is on the nurse's medication carts and certified nursing assistants (C.N.A.) use during showers. Treatment nurse confirmed the medicated shampoo should be signed out on the TAR when used. During an interview on 01/09/2025 at 08:45, the Director of Nursing (DON) agreed with the Treatment nurse on the medicated shampoo being on the medication carts and that the C.N.A.'s use during showers. DON confirmed that the medicated shampoo should be signed out on the TAR when used. During an interview on 01/09/25 at 9:29 AM, the MDS Coordinator confirmed that contractures should be included on the care plan with interventions to prevent worsening and agreed that quarterly smoking assessments should be completed on any resident that smokes. A policy for positioning was not provided during the survey. 50505

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure adequate nutrition and hydration was provided for dependent residents for 1 (Resident #47) of 1 resident reviewed for nutrition and hydration status and weight loss. Findings include: A review of the facility policy titled, Assistance with Meals, revised in September 2013, indicated that residents would receive assistance with meals to meet the individual needs of the resident and that resident who could not feed themselves would be fed with attention to safety, comfort, and dignity. A review of the Admission Record indicated the facility admitted Resident #47 with diagnoses that included down syndrome, seizures, abnormal weight loss, and dysphagia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) of 0 and no staff assessment for mental status (SAMS) had been completed. Resident #47 was coded as having a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A review of weights revealed Resident #47 admitted to the facility on [DATE] and discharged [DATE]. Resident #47 weighed 170.4 on 06/26/2023 and on 04/17/2024 weighed 124.8. A review of Resident #47's Care Plan, initiated on 07/03/2023, revealed the resident was at risk for decline in nutrition/hydration status related to new admission to facility, medications that have the potential to alter appetite, and body mass index (BMI). Interventions included: assist resident as needed with eating, monitor oral intake and weigh routinely per facility policy, notify physician and family/responsible party of significant weight changes, and dietary recommendations as needed. A review of the Order Summary Report revealed Resident #47 was on a regular diet, regular consistency with a dietary supplement drink with breakfast and dinner, a fortified donut with breakfast, and a strawberry dietary supplement drink as a snack before dinner. Resident #47 was also taking a multivitamin with minerals once a day. A review of the Medication Administration Record (MAR), revealed Resident #47 was receiving a multivitamin with minerals daily and was documented. A review of an activities of daily living (ADL) task for May 2024 Nutrition: Eating, revealed Resident #47 had the task for 3 times per day with 18 times not being documented. A review of an ADL task for May 2024 Nutrition: Fluids, revealed Resident #47 had the task for 3 times per day with 17 times not being documented. A review of an ADL task for May 2024 Nutrition: Supplements, revealed Resident #47 had the task 2 times per day with 15 times not being documented. A review of an ADL task for May 2024 Nutrition: Snacks, revealed that Resident #47 had only been offered snacks 6 times and was documented. During an interview on 01/09/2025 at 9:54 AM, Licensed Practical Nurse (LPN) #5 stated that the Certified Nursing Assistants (CNA)s document nutrition and hydration and that the nurses do not have access to see the CNA charting. LPN #5 stated that if an alert was triggered on the computer for the residents consuming less than 25% of a meal, documentation would be done at that time. LPN #5 stated the CNAs were asked to offer snacks, different food, and fluids if the resident was not eating and I make notes in the computer. During an interview on 01/09/2025 at 9:58 AM, CNA #10 stated it was important to document nutrition and hydration so that the nurse can see if the resident was not eating or drinking and alert the nurse to see if something is wrong. CNA #10 confirmed that water should be offered every time someone goes into the resident's room. During an interview on 01/09/2025 at 10:05 AM, the Director of Nursing (DON) reviewed the ADL record for May 2024. When asked what the importance was for accurate nutrition and hydration documentation, the DON responded, It would be important for health and general well-being, and it would show the care that was actually provided. The DON agreed there were many missing areas of documentation on the ADL record for Resident #47. The DON stated that Resident #47 liked snack food and not actual food from the kitchen and that Resident #47 had stopped eating prior to discharge.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food items stored in the freezer were covered, sealed, dated; manufacturer specification was followed; kitchen ceiling tiles were replaced, cleaned to provide a sanitary environment for food preparation; floors, dish washer, kitchen walls, were free of chipped and stains and dietary staff washed their hands before they handled clean equipment or food for 1 of 1 meal observed. The findings are: 1. On 1/6/25 at 10:01 AM, the following observations were made on a rack above the food preparation counter: a. An opened bag of cornmeal. The bag was not sealed. b. An opened box of baking soda. c. An opened bottle of dill weed. 2. On 1/06/25 at 10:11 AM, the following observations were made on a shelf in the 2-door freezer: a. An opened box of hamburger patties. The bag was not covered or sealed. b. An opened box of catfish. The box was not covered or sealed. c. An opened box of cod fish. The box was not covered or sealed. d. An opened box of veggie sausage. The box was not sealed or covered. e. An opened box of black bean burgers. The box was not sealed or covered. 3. On 1/06/25 at 10:17 AM, the following observations were made on a shelf in the 2nd freezer: a. An opened box of biscuits. The box was not covered or sealed. b. An opened box of dinner rolls. The box was not covered or sealed. c. An opened box of vegetable blend. The box was not covered or sealed. 4. On 1/6/25 at 10:22 AM, an opened gallon of soy sauce was on a shelf in the storage room. The manufacturer's specifications on the gallon indicated to refrigerate after opening. 5. On 1/6/25 at 10:39 AM, Dietary [NAME] (DC) #1 opened the oven door and looked at the food items inside the oven, contaminating her hands. Without washing hands, DC #1 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. DC #1 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment she stated she should have washed her hands. 6. On 1/6/25 at 10:51 AM, the following observations were made in the kitchen areas: a. The wall in the dishwashing machine had sage color on it. b. The wall below the dish washing room was chipped, exposing the cement. c. The ceiling tiles throughout the kitchen had brown stains on it. d. The floors in several areas of the kitchen were chipped, exposing the cement. e. The floor in front of the oven was warped and had black stains on it. f. The ceiling tiles were loose in some areas. g. A floor tile was missing around the area leading to the dishwashing machine. 7. On 1/6/25 1 at1:18 AM, DC #2 removed a carton of drinks from the refrigerator and placed it on the counter, contaminating his hands. Without washing his hands, he picked up glasses by their rims and placed them on the trays to be used portioning beverages to be served to the residents for lunch. DC #2 interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment he stated he should have washed his hands. 8. On 1/6/25 at 12:15 PM, Dietary Aide (DA) #3 who was on the tray line assisting with noon meal was observed to pick up cartons of supplements and placed them on the trays, contaminating his hands. Without washing his hands, DA #3 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment he stated he should have washed his hands. 9. On 1/6/25 at 12:36 PM, the following observations were made on a shelf in the refrigerator: and freezer in the breakroom on 300- hall: a. A glass of milk. There was no date when it was stored. b. A glass of apple juice. There was no date to indicate when it was stored. c. An opened box of butter pecan ice cream on a shelf in the freezer has freezer burn. The Dietary Manager was interviewed and was asked if she can describe the appearance of the ice cream, and she confirmed ice cream has freezer burn. It looked like it had melted and then refrozen. 10. On 1/6/25 at 12:40 PM, the metal area above the ice machine panel located in the breakroom in the business hallway where ice forms before dropping into the ice collect had a layer of a black and gray residue that had settled on it. The Dietary Manager was asked if she could wipe the area. She did so, and the black and gray residue easily transferred to the tissue. The Dietary Manager was interviewed and was asked if she can describe what was observed, she stated it was dirty and yucky. The Dietary Manager was interviewed and was asked who used the ice from the machine located in the break room on 300-hall and how often the ice machine was cleaned. She stated the CNAs (Certified Nursing Assistants) used it to fill water pitchers in the residents ' rooms. The kitchen staff also used it to fill beverages served to the residents at meals and she cleans the ice machine once a month 11. A review of facility policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, initiated 2017, provided by the Dietary Manager on 1/6/2025 indicated, employees should wash their hands whenever entering or re-entering the kitchen, before coming in contact any food surfaces and after engaging in other activities that contaminate the hands.

Based on observation, interviews, record review, and policy the facility failed to ensure bed linens were maintained in clean condition for two (Resident #28 and #36) of seven residents sampled for safe, clean, and comfortable homelike environment. The findings are: A review of Resident #28 ' s admission report showed Resident #28 had diagnoses of bipolar, depressive episodes, stroke, and psychosis. A review of Resident #36 ' s admission report showed Resident #36 had diagnoses of Alzheimer's disease, dementia, and schizophrenia. During observations on 1/6/2025 at 10:37AM and 2:45PM, Resident #36 ' s bed on the right side of the room was covered with a blue bed spread that had white unknown substance scattered on top of the cover. The folded blue blanket at the head of the bed had an unknown dried smeared white stain on the top right corner. The side of the bed cover that hung towards the floor had unknown brownish stains along the middle third of the linen. During observations on 1/6/2025 at 10:38AM and 2:46PM, on the left side of Resident #36 ' s room, a second bed contained unknown substances of black and brown specks grouped together on the bottom right corner with unknown black spots scattered along the left side length of the bed. During observations on 1/6/2025 at 10:40AM and 2:48PM a bed on the right side of Resident #28 ' s room against the wall, in the center of the bed linen was a dried yellowish-brown stain. Certified Nursing Aide (CNA) #8 was interviewed in person on 1/9/2025 at 7:05AM. CNA #8 stated residents will get their bed linens changed after showers or accidents. Some of the residents prefer to change their own sheets and will ask for clean bed linens. When linens are dirty on non-shower days the linens are to be changed. CNA #7 was interviewed in person on 1/9/2025 at 7:15AM. CNA #7 stated, bed linens are changed as needed, after showers or if residents ask for clean linens on non-shower days. Residents with their own bed linens will ask for their linens to be changed. Laundry will return linens to resident's room. When laundry is unable to have linens back the same day it is explained to residents that laundry still has the linens and facility linens are provided. Licensed Practical Nurse (LPN) #5 was interviewed in person on 1/9/2025 at 7:20AM. LPN #5 stated, residents have their sheets changed on shower days and as needed. Registered Nurse (RN) #6 was interviewed in person on 1/9/2025 at 7:30AM. RN #6 confirmed bed linens are changed on shower days, or any time linens are soiled. Residents that had soiled their bed will ask me for clean linens due to not wanting others to know. The clean linens are provided. Residents with personal bed linens are changed the same way as facility linens. Residents with personal linens are provided facility linens if laundry was unable to return them the same day. The Director of Nursing (DON) was interviewed in person on 1/9/2025 at 7:48AM. The DON confirmed staff should have changed the bed linens in [resident ' s room number] due to linens had been soiled. The bed on the other side of the room was also dirty. The DON was interviewed in person on 1/9/2025 at 7:51AM and stated, the bed in [resident ' s room number] did need to be changed. The Administrator was interviewed in person on 1/9/2025 at 7:55AM and confirmed that both beds in Resident #36 ' s room looked dirty and needed to be changed. The Administrator was interviewed in person on 1/9/2025 at 7:57AM and confirmed the bed on the right side of Resident #28 ' s room against the wall, should be changed. A review of facility policy titled Policy and Practices for Infection Control showed: 1. The facility's infection control policies and practices apply equal to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payor source. 2. The objective of our infection control policies and practices are to: a. Prevent, detect, investigate and control infections in the facility b. Maintain a safe, sanitary, and comfortable environment for personnel, residents. Visitors and the general public f. Provide guidelines for the safe cleaning ad reprocessing of reusable resident-care equipment.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure preadmission screening and resident review (PASRR) was completed for 1 (Resident #32) of 1 resident reviewed for preadmission screening due to diagnosis. Findings include: On 01/08/2025 at 9:30 AM, the Director of Nursing (DON), stated the facility did not have a policy for Preadmission Screening and Resident Review. A review of the Admission Record, indicated the facility admitted Resident #32 with diagnoses that included schizophrenia, vascular dementia, mood disorder, anxiety disorder, and psychosis. Resident #32's actual admitted to the facility was 07/13/2020. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Active diagnoses were marked for mood disorder, anxiety disorder, psychotic disorder, schizophrenia. The admission 5-day MDS with an ARD of 07/20/2020 did not have schizophrenia marked. A review of Resident #32's Care Plan, initiated on 05/21/2024, revealed the resident had a risk for adverse reactions from behavior disturbances as related to vascular dementia with behavioral disturbance, schizophrenia, psychosis and mood disorder. Interventions included: administer and monitor effectiveness of medications as prescribed by physician; anticipate needs and provide them before the resident becomes overly stressed; educate resident on other effective coping skills for dealing with feelings; explain care in advance to resident; intervene during behavioral outbursts to protect the safety of the resident and others; investigate/monitor the need for psychological/psychiatric support. Provide services if desired by the resident/family and ordered by the physician; monitor and document any non-pharmacological interventions used to deter behavior prior to as needed medication administration; observe and record changes in behavioral symptoms; provide resident with diversional activities when behavioral symptoms arise; provide resident with one-on-one attention as needed; and reinforce positive behavior. Preadmission screening and resident review were not mentioned in the care plan. A review of the PASRR, a letter dated 05/19/2020 from [company name] stated it was determined Resident #32 was a non-PASRR client. Upon reviewing the entire information sent in for the PASRR, only one diagnosis was given: mild neurocognitive disorder and was marked no for having a diagnosis or history of mental illness (schizophrenia). During an interview on 01/08/2025 at 8:44 AM, the Director of Nursing (DON) confirmed there had been no PASRR completed after the 05/19/2020 PASRR and confirmed that Resident #32 entered the facility on 07/13/2020.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure family/responsible party and resident were included in the care plan process for 1 (Resident #47) of 1 resident reviewed for care plan meetings. The findings include: A review of the Admission Record, indicated the facility admitted Resident #47 with diagnoses that included down syndrome, abnormal weight loss, seizures, dysphagia, anxiety disorder, and insomnia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident had severe cognitive impairment. The MDS was marked resident and family participation in assessment and goal setting. A review of Resident #47's Care Plan, initiated on 07/03/2023, revealed the resident/family or physician had determined the resident had a need for long term care. Interventions included: educate resident/family of benefits of nursing home care. A review of Progress Notes on 01/08/2025, from 01/01/2024 through 05/29/24, revealed no care plan meeting notes in the medical record for Resident #47. A review of Miscellaneous Paperwork scanned into the electronic medical record for Resident #47 revealed no care plan meeting information. During an interview on 01/09/2025 at 09:29 AM, the MDS Coordinator stated that the care plan meetings were set up by the Social Director (SD) and that assistance was now being provided in the process by the MDS coordinator. When asked who should be included in the invitation, the MDS coordinator confirmed that it should include the families, social, assistant director of nursing or director of nursing, dietary, MDS coordinator and the resident. During an interview on 01/09/2025 at 10:00 AM, the Director of Nursing (DON) stated that care plan meetings were set up by the MDS Coordinator and the SD. During an interview on 01/09/2025 at 10:40 AM, the SD was unable to locate any documentation, notes, or verification for family invitations being sent for Resident #47. No records were found prior to June 2024. The SD stated that letters were sent out to the family and if the resident was cognitive, they were given a letter as well and that a copy of the letter was kept with memos written on the copied letter if no one was going to attend or any other note that needed to be kept. The SD confirmed that the actual care plan meeting, with signatures included, was now being kept and was scanned into the electronic medical record. No policy was provided for the care planning process during the survey.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure treatment was provided for the left foot for 1 (Resident #47) of 1 resident reviewed for skin and wound treatments and care. Findings include: A review of a facility policy titled, Medication Policy, revised in April 2007 stated, all the resident's clinical record must have an order for over-the-counter medications and if ordered will be supported by the appropriate care processes and practices. A review of the Admission Record, indicated the facility admitted Resident #47 with diagnoses that included down syndrome, seizures, abnormal weight loss and dysphagia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) of 0 and no staff assessment for mental status had been completed. No area was marked for issues with the feet. A review of Resident #47's Care Plan, revised on 10/09/2023, revealed the resident had a slight risk for impaired skin integrity/pressure ulcers, related to incontinent episodes, risk for nutritional deficit. Interventions included: assess and record changes in skin status and assist resident with showers twice weekly, PRN and upon request. Intervention for treatment to the left foot, first and 2nd toenail was not included in the care plan. A review of the Order Summary Report, revealed Resident #47 had an order from 01/25/2024, for Povidone-Iodine external solution, apply to nailbed, topically every 24 hours as needed for left foot, 1st and 2nd toenail until healed. A review of Treatment Administration Record (TAR), revealed Resident #47 had a treatment order in place for Povidone-Iodine external solution, apply to nailbed, topically every 24 hours as needed for left foot, 1st and 2nd toenail until healed. TARs from January 2024-May 2024 indicated the treatment was only provided once on 01/25/2024. A review of Progress Notes indicated Resident #47 had documentation on 01/25/2024, First and 2nd left (L) toenail not connected to nail bed. Nails removed. Beds cleaned with povidone-iodine per physician orders. No redness, swelling, pain, or drainage at sites. Tolerated without difficulty. No other documentation regarding left foot was found from February-May 2024. A review of the skin observation tool for the following dates in 2024, 1/2, 2/7, 3/2, 4/5, 5/3, 5/10, 5/18, 5/24, and 5/29 indicated that the resident had psoriasis patches present. No mention of toenails of left foot mentioned on the skin observation tool. During an interview on 01/09/2025 at 8:49 AM, the Director of Nursing (DON) was unable to state the reason as to why the Povidone-Iodine was not documented on the TAR. The DON stated that the treatment nurse was not working at the facility at the time the resident resided in the facility. The DON confirmed that the nurses should have signed the TAR off if the treatment was provided.

Based on observation, interviews, record review, and facility policy review, it was determined that the facility failed to ensure the medication regimen was free from unnecessary medications without adequate indications for its use for 1(Resident #7) of 1 resident reviewed for unnecessary medications. Findings Included: Review of a facility policy titled, Medication Therapy Policy, no date indicated Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. A review of an Admission Record indicated the facility admitted Resident #7 with chronic kidney disease stage 3 (kidneys have mild to moderate damage and have difficulty filtering waste and excess fluid from the blood) The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/20/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During a record review, Resident #7 ' s order summary, revealed three medications without proper indications for their use. Orders read as follows: [Antidepressant medication name] 12.5mg give 12.5mg by mouth at bedtime [Thyroid hormone medication name] 175mcg give 1 tablet by mouth one time a day [Antidiabetic medication name] 500mg give 1 tablet by mouth 2 times a day No indications for use we present on the orders. During an interview on 01/09/25 09:22 AM the MDS Coordinator revealed the importance of ensuring the diagnosis for each resident is linked to the medication in the orders so the medication can reveal what it is used for. The MDS Coordinator also revealed that not having a diagnosis properly linked to medication could affect the care of the resident and all medications such be linked appropriately.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. The findings are: 1. On 1/6 /25 at 12:35 PM, a #12 (3 ounces) scoop was used by Dietary [NAME] (DC) #4 in the mechanical soft yogurt baked chicken for serving. The menu for the 01/06/25 lunch meal indicated 4 ounces per serving, a difference of 1 ounce. 2. On 1/6/25 at 12:37 PM, the menu for the lunch meal indicated 4 ounces for pureed yogurt baked chicken and 1 pureed wheat dinner roll. A #12 scoop (3 ounces) was used in the pureed yogurt baked chicken for meal service, a difference of 1 ounce. No pureed dinner roll was served to pureed diets. There were no substitutions served to the residents in place of a dinner roll. 3. On 1/6/25 At 1:03 PM, DC #1 was interviewed and was asked why no dinner roll was served to the residents on pureed diets. DC #1 stated she was told by the previous Dietary Manager not to serve bread to the residents on pureed diets. DC #1 was asked if substitutions were given in place of dinner rolls. DC #1 confirmed that she did not give extra food items in place of dinner rolls. 4. On 1/6/25 at 1:09 PM, DC #4 was asked what scoop size she had used to serve ground meat and pureed meat. DC #4 stated she used a #12 scoop. When asked if she had reviewed the menu beforehand to ensure she was using the correct serving scoop and to confirm how many servings she gave to each resident, DC #1 stated she had not reviewed the menu and that she gave one serving to each resident.

Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure staff did not place dirty meal trays on the meal transport cart while clean trays were still on the metal transport cart being served to residents to avoid cross-contamination. The findings are: During an observation of the lunch meal on 1/6/2025 at 12:54 PM, this surveyor observed Certified Nursing Assistant (CNA) #9 placed lunch meal trays that were dirty, due to the residents already consuming the meal, on the meal transport cart with four (4) resident meal trays that still needed to be served to the residents. During an interview with CNA #9 on 1/6/2025 at 12:54 PM, he confirmed that he should not place dirty meal trays on the meal cart with meal trays that had not been served to the residents. During an interview with the Director of Nursing (DON) on 1/9/2025 at 9:43 AM, the DON confirmed that staff should not place dirty meal trays on the meal cart with meal trays that had not been served to the residents due to it being an infection control issue. Review of the facility policy titled, Policies and Practices- Infection Control, with a revision date of July 2014 noted Policy Statement This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation 1. This facility's infection control policies and practices apply equally to all personnel. 2. The objective of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter.

Based on record review, resident and staff interview, facility document review, and facility policy review, it was determined that the facility failed to provide quarterly statements of their trust account managed by the facility to the resident or their representative for 34 (Residents #1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36) of 41 residents reviewed for trust account statements. Findings include: A review of the facility's undated policy titled, Resident Trust Fund Policy indicated, The purpose of this policy is to provide uniform guidelines for the management of the Resident Trust Account .Accurate records will be kept of resident's money and are available upon request .A quarterly statement of financial transactions will be available for residents and mailed to their responsible party . During an interview on 04/26/2024 at 9:56 am, Resident #11 confirmed not receiving quarterly statements. During an interview on 04/26/2024 at 10:01 am, Resident #7 confirmed not receiving any quarterly statements. During an interview on 4/26/24 at 10:05 am, Resident #10 confirmed not receiving quarterly statements. During an interview on 4/26/24 at 11:11 am, the Director of [NAME] Office Manager (DBOM) confirmed the residents and/or the resident representatives did not receive quarterly statements for an undetermined amount of time. During an interview on 04/30/2024 at 10:41 am, Resident #13 confirmed not receiving quarterly statements. During an interview on 04/30/2024 at 11:01 am, Resident #15 confirmed not receiving quarterly statements and verbalized requesting balances multiple times with the Business Office Manager (BOM). During an interview on 04/30/2024 at 11:17 am, Resident #5 confirmed not receiving quarterly statements. Resident #5 verbalized not being able to obtain money from account for almost a year after admission. Resident #5 verbalized the SSD (Social Service Director) informed resident of account balances when resident requested a balance and placed the information on a sticky note.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure residents were free of misappropriation of resident funds for 34 (Residents #1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, and 36) of 41 residents reviewed for misappropriation of resident funds. Findings include: A review of the facility's undated policy titled, Resident Trust Fund Policy, Revised 03/2024 indicated, The purpose of this policy is to provide uniform guidelines for the management of the Resident Trust Account. 4.Accurate records will be kept of resident's money and are available upon request . 14. The Trust Account Representative will provide all receipts to the business Office on a daily/weekly basis and key all withdrawals. Business Office staff will reconcile the RTA [Resident Trust Account] Petty Cash Box. 15. A separate individual other than Trust Account Representative and Business Office staff will reconcile the RTA Petty Cash box on a weekly basis. All reconciliations of RTA Petty Cash Box is kept within the Business Office. 16. The Trust Account Representative will print a daily RTA Trial Balance every morning prior to any withdrawals are given, to ensure the residents have funds they can withdraw.19. Monthly Reconciliations will be provided upon request . A review of a facility policy titled, Resident Trust Fund Policy, dated 03/2018, indicated, The purpose of this policy is to provide uniform guidelines for the management of the Resident Trust Account . 4. Accurate records will be kept of resident's money and are available upon request . 5. Reimbursement to family members or other parties will only be reimburse with proof of a receipt. a. Resident funds cannot be given to anyone without proof of receipt.7. Receipts for all transaction shall be kept with Trust Account records. A Receipt Book will be kept for all Cash withdrawals. Receipt book will not be co-mingled and kept with the Resident Trust Petty Cash box at all times. A separate receipt book will be kept for all check/money orders received to be deposited into resident s account. a. Carbon Receipts will be used i. [NAME] Copy goes to resident/family. ii. Carbon copy stays in receipt books.15. Administration will then generate print checks to replenish RTA Petty Cash Box. a. A copy of the withdrawal record and all related receipts/backup documentation will be kept together and then filed. 16. A separate individual other than Trust Account Representative and Business Office stall will reconcile the RTA Petty Cash box on a weekly basis or as replenishment checks are issues. All reconciliation of RTA Petty Cash Box is kept within the Business Office. 17. The Trust Account Representative will print a daily RTA Trial Balance every morning prior to any withdrawals are given, to ensure the residents have funds they can withdraw.20. Witness Signatures cannot be the individual that hands out funds to resident's or the vendor performing services. 21. Monthly Reconciliations will be provided upon request . 22. Segregation of Duties are as followed: a. Employee A hands out funds to resident from Resident Petty Cash Box. b. Employee B keys all receipts deducting funds from Resident Accounts. c. Employee B keys and mails all deposits received for Resident Accounts. d. Employee C reviews/reconciles/prints all Check Requests. A review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised on 03/31/2024, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigation are documented and reported.6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Reporting Results of Investigation .2.The resident and/or representative are notified of the outcome immediately upon conclusion of investigation. Corrective Action .2. If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated . A review of the 2024 facility documented fraudulent charges, revealed thirty-four residents had fraudulent charges to their trust account with a balance of $4,452.72 in fraudulent charges. A review of Incident Letter to Police revealed the Director of [NAME] Office Manager documented, .In summary, it is my determination that there was in fact misappropriation of funds of 49 residents. I have provided a breakdown by year totaling the amount of legitimate and fraudulent transactions. I have concluded that the total amount of misappropriated funds is $181,384.19 . During an interview on 04/24/2024 at 11:25 am, the Administrator verbalized Resident #2 was transferred to a sister facility after an allegation of possible physical abuse. The Administrator verbalized the abuse was unfounded. The Administrator stated Resident #2's family had contacted the sister facility regarding the resident's trust account and was informed the account/money had not been transferred yet. The resident's family member reached out to our Social Service Director (SSD) and asked about the money. The SSD informed the family they could come by her house and pick up Resident #2's money. Resident #2's family member notified the sister facility of the incident. The sister facility contacted our facility, and our facility began an investigation. The facility immediately suspended the SSD and [NAME] Office Manager (BOM) because they generally handle the resident's money. The Administrator was asked to explain the process of residents obtaining money after making a request. The Administrator verbalized The BOM would request the money from our corporate office through the computer. If the resident had money in their trust account, the corporate office would send a check to the BOM. The BOM would then go cash the check to obtain the money. When the BOM returned to the facility with money it would be given to the SSD, and both would sign off on the exchange sheet. The SSD would obtain a witness and the resident and all three would sign off on the exchange sheet. The exchange sheet would then be given back to the BOM to be placed in the resident's file. We currently have someone from our corporate office here at the facility assisting in the investigation and we have contacted the police. During an interview on 04/25/2024 at 12:20 pm, the Director of [NAME] Office Manager (DBOM) confirmed there had been misappropriation of resident trust funds starting in the year 2019 through the present. The DBOM confirmed a spreadsheet was made with each resident amount that is actual resident usage and fraudulent amounts. The DBOM confirmed the fraudulent amounts did not have an original receipt, or the receipts were photocopied and confirmed resident signatures. The DBOM confirmed there were no issues found with resident's liability. The DBOM confirmed most of the fraudulent amounts came from the stimulus checks residents received. During an interview on 04/25/2024 at 3:10 pm, the Administrator was asked what process had been put into place to prevent misappropriation of funds happening in the future. The Administrator confirmed the facility has placed a fourth person instead of three people that will handle all the transactions. The Administrator confirmed all the transactions will come to him to review before and after the transactions occur and will review the request with all paperwork and will follow up with the resident to ensure they receive the money or products purchased. During an interview on 04/26/2024 at 9:56 am, Resident #11 confirmed not receiving quarterly statements. Resident #11 confirmed being upset due to only having $86.00 in the trust account and feels there should be more. A review of Resident #11's Quarterly Statement, revealed Resident #11 had a balance of $46.13 in the resident's trust account. A review of the 2024 facility documented fraudulent charges, revealed Resident #11 had $75.00 in fraudulent charges. During an interview on 04/26/2024 at 10:01 am, Resident #7 confirmed not receiving any quarterly statements. Resident #7 confirmed the resident had difficulty getting money when requested. Resident #7 verbalized the resident requested $20.00 the last time the resident requested money and only received $15.00. Resident #7 denies missing any appointments due to money. A review of Resident #7's Quarterly Statement, revealed Resident #7 had a balance of $27.73 in the resident's trust account. A review of the 2024 facility documented fraudulent charges, revealed Resident #7 had $164.46 in fraudulent charges to the resident's trust account. During an interview on 04/26/2024 at 10:05 am, Resident #10 confirmed not receiving quarterly statements and denies missing any appointment due to money. A review of the Quarterly Statement, revealed Resident #10 had a balance of $106.34 in trust account. A review of the 2024 facility documented fraudulent chargers, revealed Resident #10 had $100.00 in fraudulent charges to trust account. During an interview on 04/26/2024 at 10:12 am, Resident #8 was unable to communicate due to cognition. A review of the Quarterly Statement, revealed Resident #8 had a balance of $174.93 in the resident's trust account. A review of the 2024 facility documented fraudulent charges, revealed Resident #8 had $100.00 in fraudulent charges to the resident's trust account. During an interview on 04/26/2024 at 11:11 am, the DBOM was asked who was responsible for the oversight of the resident trust money. The DBOM stated the SSD handed out the money from the resident cash box. The SSD went shopping for personal needs items and tobacco. The SSD provided receipts to the BOM. The BOM would key in receipts, doctor bills or any type of vendor that came in under resident's name, requested replenishes and any type of check that was put into the system. The BOM would reconcile the batch, replenish the cash box and the checks and she would go cash the checks. All checks were made out to the BOM and the BOM signed the back of the check. The DBOM was asked if anyone from the corporate office completed any audits of the resident trust accounts. The DBOM confirmed an audit had not been completed in over a year. The DBOM was asked what the plan was to repay residents their money that was fraudulently obtained from staff at the facility. The DBOM verbalized the facility was contacting the bond companies to obtain their process for filing a claim. Once that information has been verified, the facility will repay the resident with the bond money and/or the management company money. The timeframe for completion is approximately 60 days per the DBOM. During an interview on 04/30/2024 at 10:41 am, Resident #13 confirmed not receiving quarterly statements and denies missing any appointments due to money. A review of the Quarterly Statement, revealed Resident #13 had a balance of $460.57 in the resident's trust account. A review of the 2024 facility documented fraudulent charges, revealed Resident #13 had $40.00 in fraudulent charges to the resident's trust account. During an interview on 04/30/2024 at 11:01 am, Resident #15 confirmed not receiving quarterly statements and verbalized requesting balances multiple times from Business Office Manager (BOM). A review of the Quarterly Statement, revealed Resident #15 had a balance of $31.07 in the resident's trust account. A review of the 2024 facility documented fraudulent charges, revealed Resident #15 had $181.46 in fraudulent charges to the resident's trust account. During an interview on 04/30/2024 at 11:17 am, Resident #5 confirmed not receiving quarterly statements. Resident #5 verbalized not being able to obtain money from account for almost a year after admission. Resident #5 verbalized the SSD (Social Service Director) informed resident of account balances when resident requested a balance and placed the information on a sticky note. A review of the Quarterly Statement, revealed Resident #5 had a balance of $81.92 in the resident's trust account. A review of the 2024 facility documented fraudulent charges, revealed Resident #5 had $204.00 in fraudulent charges to the resident's trust account.

44852 46723 47912 Based on observation, interview, and record review the facility failed to ensure the vent-a-hood in the kitchen was kept free of a buildup of grease, grime and debris which could result in improper functioning and/or fire resulting in serious injury, serious harm, serious impairment, or death. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 05:02 PM. The facility also failed to ensure potentially hazardous items were stored in a secure location to prevent potential access by cognitively impaired, independently mobile residents for 1 (Resident #19/31) of 1 sampled resident; the mattress fit the bed for 1 (Resident #23) of 1 resident to prevent the potential for harm; and oxygen cylinders containing oxygen were stored and secured in an oxygen holder to prevent the potential for accidents/hazards. The findings are: 1. On 12/05/23 at 02:10 PM, the vent-a-hood was observed to be covered in grease and contained a film of dust and debris. The film of debris and dust was so thick that it looked fuzzy and was rough to the touch. The grease extended into the vent. The grease had dripped along the edges. The vent was also covered in grime and grease. The shelf above the range was sticky with grease and grime. a. On 12/05/23 at 2:12 PM, a sticker on the front of the vent-a-hood from [Company Name] Pressure Washing and Vent Hood Cleaning documented had been serviced in April 2022. The expiration date is 180 days from the last service. There was also a blackened area on October 2024. b. On 12/06/23 at 05:02 PM, an Immediate Jeopardy was called due to the facility's failure to ensure that the vent-a-hood was maintained in a manner to prevent the potential for improper functioning and or/fire. The Administrator was informed that a plan of removal including the cleaning of the vent-a-hood and a plan to maintain fire safety until the unit can be inspected by a reputable service was received. A Plan of Removal was presented at 6:21 PM. The vent hood was cleaned, and the nursing and maintenance staff-maintained fire watch every 30 minutes until the facility was able to have the vent hood inspected. c. On 12/06/23 at 06:31 PM, the Administrator provided an invoice for the inspection of the vent-a-hood dated 11/14/23. The service was for inspection of the vent hood but did not include cleaning. 2. A review of an Admission Record indicated the facility admitted Resident #31 with a diagnosis that included major depressive disorder. a. The Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview. The resident required extensive assistance with activities of daily living (ADLs). b. On 12/05/23 at 02:09 PM, a blue plastic container containing a used and opened bottle of electric shave solution, a bottle of aftershave and a tube of toothpaste was observed on the built in cabinet in Resident #31's room and was not contained. c. On 12/05/23 at 02:55 PM, a blue plastic container containing a used and opened bottle of electric shave solution, a bottle of lotion, a bottle of aftershave and a tube of toothpaste was observed on the built in cabinet in Resident #31's room and was not contained. d. On 12/05/23 at 04:58 PM, a blue plastic container containing a used and opened bottle of electric shave solution, a bottle of aftershave and a tube of toothpaste was observed on the bed in Resident #31's room. e. On 12/08/23 at 9:12 AM, the Director of Nursing (DON) was asked where personal care items such as lotions, aftershave, cologne, and toothpaste are supposed to be stored when not in use? The DON stated, Out of reach of the residents. The DON was asked why should personal care items be contained and free from residents access. The DON stated, For the safety of the residents. 3. A review of an Admission Record indicated the facility admitted Resident #23 with a diagnosis of paranoid schizophrenia. a. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. b. On 12/05/23 at 02:08 PM, Resident #23 was lying in bed. The mattress did not fit the bed frame. There was a 12 inch gap between the foot board and the mattress and a 12 inch gap between the headboard and the mattress. Resident #23 was asked how long had he been here. Resident #23 replied about 5 years. Resident #23 was asked how long he had been in this room in this bed. Resident #23 stated not long I was in another room before this one. c. On 12/05/23 at 03:00 PM, Resident #23 was lying in bed. The mattress did not fit the bed frame. There was a 12 inch gap between the foot board and the mattress and a 12 inch gap between the headboard and the mattress. d. On 12/06/23 at 9:23 AM, Maintenance #1 was asked to measure the gap between the end of the mattress to the footboard and the gap between the end of the head of the mattress and the headboard of Resident #23's bed. Per Maintenance #1's measurements, the gap between the end of the mattress to the footboard measured 4.5 inches and the gap between the head of the mattress and the headboard measured 6 inches. 4. On 12/05/23 at 4:39 PM, Resident #24 was sitting in a wheelchair with cigarettes and vape on the bedside table. a. On 12/07/2023 at 1:33 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 if the residents are allowed to keep their cigarette's, lighter, and vapes in their room with them. LPN #1 said, No cigarettes, but the vapes are cared planned. b. On 12/08/2023 at 1:03 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 how are the tobacco products, vapes, and lighters stored and who takes the residents out to smoke. LPN #2 said the cigarettes and lighters are kept under lock and key, at the nurse's station and the CNA's take the residents out to smoke. e. The Director of Nursing provided their Smoking Policy on 12/7/2023 at 10:32 AM which documented, .15. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision . 5. On 12/07/23 at 09:46 AM, observed an oxygen cylinder not contained in a metal oxygen cylinder holder in the oxygen storage room on hall 400. The door to the oxygen storage room was unlocked and there were residents rolling down the hallway in wheelchairs. a. On 12/07/23 at 10:28 AM, observed the 400 hall oxygen storage room remained unlocked. There was a coded lock on the door that was not working. There was an oxygen cylinder observed that contained oxygen and was not properly stored in an oxygen cylinder holder. The cylinder was standing up between an oxygen concentrator and multiple cylinders in cylinder holders that contained oxygen. There were residents observed in wheelchairs in the hallway passing by. b. On 12/07/23 at 02:45 PM, the Surveyor asked Registered Nurse (RN) #1 if the oxygen storage room on hall 400 should be locked. RN #1 answered, Yes, it should be locked. The Surveyor asked how oxygen cannisters should be stored safely. RN #1 answered, They should be upright in an eggcrate. The Surveyor asked what could happen if oxygen was not stored properly. RN #1 answered, It could catch on fire or cause an accident. The Surveyor asked who was responsible for checking to make sure oxygen is stored safely. RN #1 answered, The nurses. The Surveyor asked how often oxygen is checked. RN #1 answered, I don't know. I'm not sure who they have the contract with.

44852 Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a clean condition to minimize the risk of food borne illness; food products were used or removed prior to their expiration dates/viability; hands were washed between clean and dirty tasks and prior to applying gloves; dishes and utensils were cleaned prior to being used for residents during meal service; and food was stored in a manner that was free of exposure/contamination due to the presence of insects or rodents. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on [DATE] at 05:02 PM. The facility also failed to ensure orange was stored in the refrigerator and hand washing was practiced when feeding residents snacks. The findings are: On [DATE] at 02:05 PM Surveyors observed initial kitchen rounds with Dietary Aide #1. The Hand Washing sink was located directly next to the 3-compartment sink. A large stack of baking sheets and other cooking vessels were stacked on top of the basin preventing proper hand washing. On [DATE] at 2:08 PM, the floor of the kitchen was covered with a variety of debris. Despite being on wheels, the worktables had been moved as the layer of dirt and food particles was more dense in the corners and closer to the wheels. On the wall just above where the insulated domes were stored was a piece of wooden trim that extended down the wall. The ledge formed by the trim was covered in dirt, grime and a dead fly. On [DATE] at 2:16 PM, the deep fryer was uncovered. The inner shelf was covered in food particles and a layer of gummy grease. The fat was a dark brown color with food particles floating on top. The floor between the fryer and the range was covered in grease and grime as was the wall behind the range. On [DATE] at 2:17 PM, located in the two-door refrigerator was a ,d+[DATE] steam table pan that included 6 leftover fried eggs. There was no date on the eggs. A saucepan was identified as holding the leftover boiled eggs that were spilled before the eggs could be counted. The container was not dated. On [DATE] at 2:25 PM, the following was observed in the first two door refrigerator: 9 packages of flour tortillas opened [DATE] were expired as of [DATE]. In the second two door refrigerator the following was observed: three 8-ounce servings of whole milk were not dated. Dietary Aide #2 was asked when the milk was portioned. She stated, This morning, because I poured them. The Surveyor asked how another worker would know the age of the milk. The Cook stated, I guess they wouldn't. I should have put a date on it. A one gallon pitcher of tea, with no date and the spout turned open to air and contaminants; 1 gallon of lime juice that was half full and expired [DATE]; a 5 pound container which was ,d+[DATE] full of sour cream had a use by date of [DATE]; a large plastic resealable bag of peaches containing about 3 cups with the date of [DATE] written on top. The Cook was asked how long leftovers are used, and she stated, I'm not sure. On [DATE] at 2:35 PM the following observations were made in the Dry Storage area: a 27 quart plastic container containing grits was labeled with a tag that recorded prepared [DATE], with a plastic scoop protruding from the dry grits; two opened peanut butter containers with missing use by dates. The rim of the containers and the lid were covered with what appeared to be peanut butter which extended out the outside of each container; Strawberry syrup was noted in a plastic gallon container, the label date was unreadable except the 4, expired [DATE]; A large plastic tub containing approximately 1 pound of lasagna noodles was not dated. On [DATE] at 2:43 PM, a large plastic tub had a label that said, [DATE], low calorie. The rest of the label was unreadable. The tub held a white, powder like substance with black specks. Several packets of nondairy creamer had been dropped into the middle of the powder mixture. Located toward the back of the tub was what appeared to be two dead insects. The Cook stated, They look like bugs. The floor under the shelves of the dry storage area was observed to be caked with a black gummy substance which contained various pieces of food, debris, dead insects, and what appeared to be other evidence of pests. On [DATE] at 2:45 PM, located on a rack next to the freezer multiple packages of bread were observed. The first bag contained ,d+[DATE] loaf of sliced bread which was not dated or sealed. A second loaf contained ,d+[DATE] loaf of sliced bread was not dated or sealed. No use by dates could be located on the bags. On [DATE] at 2:51 PM, the following was observations were made in the first two door freezer: a package of round lunch meat. Dietary Aide #2 could not identify the exact food product. The stack of sliced meat was observed to be covered in ice particles and was a variety of shades of pink and brown. No date could be found on the packaging; a 1-gallon plastic resealable bag contained what Dietary Aide #2 reported to be beef brisket. The date on the bag was unreadable. The food product was covered in ice crystals. When asked to describe the product the cook stated, It looks like its frost bit.; a 1-gallon plastic resealable bag of beef tips labeled [DATE]. When Dietary Aide #2 was asked to describe the bag, she stated, Its' frost bit.; a quart bag of three hot dogs dated [DATE]. When Dietary Aide #2 was asked to describe it, she again described the product as frost bit; two pounds of hash brown patties with no date, DA #2 described it as frost bit; 2 pounds of fish in a plastic resealable bag, dated [DATE]; a 5-pound bag of curly fries was ,d+[DATE] full, labelled [DATE] and was sealed. When Dietary Aide #2 was asked to describe the food product, she stated it was frost bit. On [DATE] at 3:00 PM, the bottom of the one door freezer was observed be covered in food particles/pieces and spilled liquid. Located on top of the Dessert Refrigerator were 9 packages of 12 hot dog buns which were not dated. Dietary Aide #2 reported that the buns were removed from the freezer the previous evening tonight's meal. When asked how other workers would know when the bread was removed from the freezer, Dietary Aide #2 stated, They won't since it's not dated. The Surveyor then observed 2 frozen pizza crust labelled [DATE], the last numeral was unreadable. When asked to describe the product, Dietary Aide #2 stated it was frost bite. The bottom of the one door freezer contained ,d+[DATE] inches of ice. Held in the ice was various food, debris, and labels. The ice had a yellow area in the back left corner. On [DATE] at 4:43 PM, the Dietary Manager was observed to don gloves without washing her hands. She proceeded to obtain a plastic resealable bag out of the two-door refrigerator. With the contaminated gloves, the Dietary Manager reached into the bag and retrieved a head of iceberg lettuce. After placing the lettuce on the cutting board, the Dietary Manager obtained a canvas roll that contained several knives. She unrolled the holder, took out a knife, rolled the holder back up and returned it to an area above the 3-compartment sink. The Dietary Manager proceeded to chop the lettuce. She used both contaminated hands to scoop the lettuce into a bowl. Dietary Aide #2 was observed gathering items for dinner with gloved hands. Contaminated gloves were used to reach into the bag of hot dog buns, obtain a bun and place on the plate for every resident who had the polish sausage for dinner. Contaminated gloves were also used to place the insulated dome over the dinner plate. Fingers were placed inside the dome of each tray. On [DATE] at 10:54 AM, Dietary Aide #3 was observed to place trays along the tray line. The trays were visibly wet and many of them were littered with food particles. On [DATE] at 11:05 AM, Dietary Aide #2 took the temperature of each lunch item. She inserted the probe and when finished she wiped the probe on a paper towel. The same paper towel was used multiple times. Dietary Aide #2 was observed to place her ungloved hands on her chin and neck rubbing her chin multiple times. She then placed her gloves on her hands without washing them to serve the lunch meal. The menu called for 3 ounces of chicken. The Dietary Manager was asked to provide a scale so the chicken pieces could be weighed. The Dietary Manager said that they have no scale for use in the kitchen. On [DATE] at 11:06 AM, observation of additional dry food products that were in the large plastic tubs in the dry storage area revealed the following: Upon lifting the lid of the tub containing granulated sugar, a dead fly was observed to be laying on top. Dietary Aide #2 stated, I don't know when anyone has used this sugar. On [DATE] at 11:15 AM, the attention of the Dietary Manager was called to the bag of approximately 3 cups of peaches in the refrigerator with the date of [DATE] and was asked what the facility's policy was concerning the use of leftovers. She stated, I'm going to say two days, so this needs to be thrown out. On [DATE] at 11:20 AM, the Dietary Manager was asked to about the pan under the steam table. She described that the steam pans were known to leak and that the pan was placed there to catch the water. Water was observed to be dripping from two spots and splashing on the shelf below. When asked how long the pans had been dripping, the Dietary Manager stated, I think, pretty much since I've been here. On [DATE] at 11:33 AM, observed a resident sitting in the area just outside of the dish room. To the left was the window into the dish room through which the dirty trays are passed. To the right was an open rack which contained two trays from the morning meal which had been served. The resident was holding a glass of milk and a bowl which contained cooked cereal. When asked what he was eating the resident replied, I'm just having some milk and some grits. The Director of Nursing (DON) approached the area and was asked what the possible harm was to a resident who consumed food off a dirty tray. She stated, Bacteria. The resident asked, Did I do something wrong? I was just hungry. On [DATE] at 5:02 PM, Immediate Jeopardy was called concerning maintaining a clean environment to minimize the risk of food borne illness, that food is used prior to their expiration date and that hands were washed prior to and between clean and dirty tasks, that dishes and utensils were cleaned prior to use and that food is stored in a manner that is free from exposure/contamination due to insects or rodents. On [DATE] at 5:10 PM, the Administrator was asked how often he enters the kitchen area of the facility. He stated, Three or four times per day. We have all new kitchen staff that we hired from scratch. The issue with the steam table is new. I'm not necessarily in the freezers. On [DATE] at 10: 40 AM, a Policy titled, Food Receiving and Storage documented, .Policy Interpretation and Implementation 1. Food Services, or other designated staff, will maintain clean food storage areas at all times.4. Non-refrigerated foods .will be stored ., free of insects and rodents and kept clean.7. All foods stored in the refrigerator or freezer will be covered, labeled and dated, (use by date) . The Immediate Jeopardy was removed on [DATE] at 10:18 AM when the following Plan of Removal was implemented: Step #1 Upon notification of failure to ensure that kitchen was maintained in a clean condition to minimize the risk of food borne illness, that food products were used or removed prior to expiration dates, that hands were washed between clean and dirty task, that hands were washed prior to applying gloves, that dishes and utensils were cleaned prior to being used for resident meal service, that food is stored in a manner that is free of exposure/contamination due to insects or rodents. On [DATE] Dietary Manager discarded all food that was expired, or freezer burned. On [DATE] the Maintenance director fixed all freezers and refrigerators that had ice built up to ensure that food could be stored safely with no risks of exposure or contamination. On [DATE] the Dietary Staff cleaned all freezers and refrigerators removing all ice and debris that could have led to contamination of food stored. On [DATE] the dietary staff cleaned all equipment that is used in food storage and preparation to ensure a clean sanitary environment for food preparation. On [DATE] the Administrator in serviced the Dietary Manager to the proper hand washing and proper use of gloves to ensure a sanitary environment for food preparation and service. On [DATE] the Dietary Manager in serviced staff to the proper hand washing and use of gloves to ensure a sanitary environment for food preparation and service, that dishes and utensils would be cleaned prior to being used for resident meal service, that food is stored in a manner that is free of exposure/contamination due to insects or rodents. On [DATE] Maintenance supervisor inspected kitchen to ensure the kitchen was free of rodents with no negative findings noted. Step #2 on [DATE] the Administrator in serviced the Dietary Manager to the proper hand washing and use of gloves to ensure a sanitary environment for food preparation and service. On [DATE]O23 the Dietary Manager in serviced staff to the proper hand washing and use of gloves to ensure a sanitary environment for food preparation and service, that dishes and utensils would be cleaned prior to being used for resident meal service, that food is stored in a manner that is free of exposure/contamination due to insects or rodents. Starting on [DATE] the Dietary Manager will monitor daily 5 x per week on an ongoing basis to ensure proper use of gloves and hand washing for food preparation and service, proper storing and discarding of food before expiration date and that all dishes and utensils are cleaned properly before being used for meal service. Starting on [DATE] the Maintenance supervisor will inspect the kitchen 5 x per week for 6 weeks to ensure that the kitchen is free of rodents and will continue to monitor on a on going basis. Step #3 On ,d+[DATE].2023 at 5:45pm, Medical Director notified of confirmation of Immediate Jeopardy. Updated on findings, reviewed plan of removal and education provided Dietary Manager and Maintenance Supervisor. On [DATE] at 10:30 AM, the Dietary Manager was asked to describe the proper way to store food. She stated, It should always be put in a sealed container and dated. When asked to identify when hands should be washed, the Dietary Manager stated, When you come into the kitchen, when you change what you are doing, when you go to the rest room, all the time. The Dietary Manager was asked if she had completed a Saniserve class as she was charged with educating her staff. She stated, I have asked the Administrator to enroll me in that class. He said he would, and he told me they would help me get my certification. The Surveyor asked when she had accepted the position. She stated, I was hired as a cook in July and was offered this position. I was told I could get certified, but he [Administrator] still hasn't told me anything about a date to start my classes. The Dietary Manager was asked if there was a cleaning schedule that was used in the kitchen. She stated, I just started making a schedule last night. Review of a facility policy titled, Handwashing/Hand Hygiene, revised [DATE] specified, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .b. Before and after direct contact with residents; .h. Before moving from contaminated body site to a clean body site during resident care; i. After contact with resident's intact skin; j. After contact with blood or bodily fluids; .m. After removing gloves; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals.8. Hand hygiene is the final step after removing and disposing of personal protective equipment . 2. On [DATE] at 03:01 PM, a one gallon plastic picture filled with orange liquid and a one gallon picture with 1 quart of orange liquid were sitting on the cabinet on the secure unit. The gallon pictures were not labeled or dated. The gallon pictures were not refrigerated and not on ice. 3. A review of an Admission Record indicated the facility admitted Resident #37 with a diagnosis that included neurocognitive disorder with Lewy bodies. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident had severe cognitive impairment. Review of Resident #37's Care Plan, initiated [DATE] revealed the resident was at risk for decline in nutrition/hydration status related to cognitive deficit. Interventions included assist resident as needed with eating. On [DATE] at 05:09 PM, Certified Nursing Assistant (CNA) #6 was observed putting a used meal tray on the meal cart. CNA #6 did not perform hand hygiene. CNA #6 sat down next to Resident # 37 and picked up the silverware and assisted Resident #37 with her meal. CNA #6 did not perform hand hygiene. On [DATE] at 1:33 PM, observed CNA #7 exit from a Resident's Room with her left bare hand filled with goldfish cracker snacks. CNA #7 was picking one goldfish cracker snack from the left bare hand using the right bare hand and feeding it to Resident #37. CNA #7 sat down in a chair next to Resident #37 and using her right bare hand, removed a goldfish cracker snack from the left bare hand and fed it to Resident #37. CNA #7 was also observed eating the goldfish cracker snacks. On [DATE] at 1:37 PM, CNA #7 was asked why should staff not touch residents' food with their bare hands? CNA #7 stated, Because of germs. CNA #7 was asked why did you give Resident #37 goldfish cracker snacks with your bare hands? CNA #7 stated, I gave them to [Resident #37], and I gave them with my bare hands, that's not what [Resident #37] supposed to eat. I know I'm not supposed to do that. On [DATE] at 2:42 PM, Licensed Practical Nurse (LPN) #3 was asked why staff should not give residents food from their bare hands? LPN #3 stated, Germs and infection control. LPN #3 was asked why should staff sit at eye level while assisting residents with eating? LPN #3 stated, Most elders vision is impaired, and it helps residents eat. LPN #3 was asked how is orange juice supposed to be stored when not in use? LPN #3 stated, In the refrigerator. LPN #3 was asked why should orange juice be refrigerated or on ice? LPN #3 stated, To prevent bacteria. On [DATE] at 12:22 PM, the Infection Control Preventionist (ICP) was asked why staff should not feed residents food from their own bare hands and why should staff perform hand hygiene before assisting residents with meals. The ICP stated, For infection control and to keep infection rates down.

Based on observation, interview, and record review the facility failed to ensure essential equipment in the kitchen was maintained in safe, operational order to ensure food was kept at a safe temperature to minimize the risk of food borne illness. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility due to the potential risk for food borne illness The Administrator was notified on 12/6/23 at 5:02 PM. The findings are: On 12/5/23 at 2:51 PM, in the first two door freezer there was a thick layer of ice observed in the bottom underneath multiple boxes of food items. The ice was covered in a variety of debris including food stuff. The ledge and bottom of the freezer contained dust and debris which extended to the vent and grate in the front of the freezer. The right side of the freezer contained a layer of ice 2 to 3 inches thick. Adhered to the bottom of the freezer was a bag containing a bright red food product that had been liquid at one time. The Dietary Aide was unable to dislodge the bag from the bottom of the freezer and was also unable to identify what was in the bag. There was no visible date on the bag. The bottom of the one door freezer contained 2 to 3 inches of ice. In the ice was various food, debris, and labels. The ice had a yellow area in the back left corner. On 12/5/23 at 4:25 PM, a large steam table pan was sitting on a shelf under the steam table. The pan contained a variety of food particles in various sizes. The shelf contained multiple areas where water had been present and then dried. The glass partition along the back of the steam table was covered in a thick layer of grime, grease, and dried food. The partition was held together on the right corner extending approximately 1/3 of the way down with black duct tape. The duct tape was also being used to hold the top of the glass in the frame. On 12/6/23 at 11:10 AM, in the first two door refrigerator, a layer of water 1 to 11/2 inches deep covered the bottom of the appliance. A large cookie sheet which had previously contained chicken thawing for today's lunch, remained in the bottom of the refrigerator on top of the water and contained multiple food particles. The top of the refrigerator contained a black substance which covered the grate over the fan and extended to the top of the refrigerator. When asked how long the water had been a problem, the Dietary Manager stated that the water accumulating had been an issue since she began working at the facility in July. When asked if she had reported the issue, she stated, Yes, to maintenance, and I think the Administrator knows. On 12/6/23 at 5:02 PM, an Immediate Jeopardy was called due to the facility failing to ensure all essential equipment was maintained in good working order. The Immediate Jeopardy was removed on 12/08/23 at 10:37 AM when the following Plan of Removal was implemented: Step #1: Upon notification of failure to ensure essential equipment was maintained in safe, operational order. On 12-6-2023 the maintenance supervisor repaired a hose that drains the water from the three of the freezers that had frozen water standing in the bottom. On 12-6-2023 Dietary staff removed all frozen water and debris from all three freezers. On 12-6-2023 the Maintenance Supervisor cleaned the drain tube on both refrigerators that were not allowing proper draining of water that attributed to standing water in the bottom of both fridges. On 12-6-2023 the Dietary staff removed all water and debris from both fridges. All fridges and freezers did previously and currently have internal thermometer located inside of each fridge and freezer. On 12-6-2023 the Administrator purchased 4 new steam table pans to replace the old pans that contributed to the two small leaks that were noticed under the steam table. One of the old pans appeared to have small pin holes that was causing the leak. All leaks in all equipment have been fixed with no negative outcomes noted. Step #2: Dietary Staff and Maintenance supervisor were in-serviced by Administrator on 12/7/2O23 as to the requirement to maintain all equipment in safe and operational order. Starting on 12-7-2023 the Maintenance Supervisor will monitor all equipment located in the Dietary Department 5 x per week for 6 weeks to ensure that all equipment is working properly in safe, operational manner. Starting on 12-7-2023 the Dietary Manager will monitor daily 5 x per week on an ongoing basis to ensure proper functioning of all equipment located in the Dietary Department. Step #3: On 12-6-2023 at 5:45 pm, Medical Director notified of confirmation of Immediate Jeopardy. Updated on findings, reviewed plan of removal and education provided Dietary Manager and Maintenance Supervisor. On 12/8/23 at 10:45 AM the Dietary Manager reported that the issues with the refrigerator/freezer involved a small tube that had become dislodged, allowing the water to drain back into the unit vs. out. She stated, I don't think it was really hard to fix once someone looked at it.

Based on observation, record review, and interview, the facility failed to ensure resident's dependent on staff for activities of daily living (ADLs), were provided assistance to protect and promote the rights and dignity of 2 (Residents #38 and #26) of 2 sampled residents. The findings are: Review of a facility policy titled, Resident Rights, dated December 2016 specified, .Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .b. be treated with respect, kindness, and dignity . 1. A review of Resident #38's Admission Record indicated the facility admitted Resident #38 with a diagnosis that included schizophrenia. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #38 had a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required 1 person to physically assist with eating. Review of Resident #38's Care Plan, revised on 6/22/2023, revealed the resident was at risk for decline in nutrition/hydration status. Interventions included, assist the resident as needed with eating and offer snacks per facility policy. On 12/06/23 at 11:32 AM, a gallon picture filled with orange juice was sitting in the cabinet on the Secure Unit and was not refrigerated or on ice. Certified Nursing Assistant (CNA) #7 poured 240 cc (cubic centimeters) of orange juice into a styrofoam cup. CNA #7 walked over to Resident #38 and stood in front and to the side of the resident. CNA #7 proceeded to feed Resident #38 an oatmeal pie snack and sips of orange juice until the oatmeal pie and 120 ccs of orange juice was consumed by Resident #38. On 12/06/23 at 11:36 AM, CNA #7 was asked why did you stand over Resident #38 while assisting with the orange juice and the oatmeal pie? CNA #7 stated, You have to be above [Resident #38] or [Resident #38] gets upset and grabs you. CNA #7 was asked why should staff assist residents with eating and drinking at eye level? CNA #7 verbally confirmed that staff sat down with the rest of the residents because they understand what you're saying, and that they are supposed to eat. 2. A review of Resident #26's Admission Record indicated the facility admitted Resident #26 with diagnoses of diabetes mellitus and schizophrenia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. A review of Resident #26's Physician Orders, for the month of December 2023, revealed an order dated 3/7/2023, for admission to memory unit deemed appropriate. Review of Resident #26's Care Plan initiated on 1/3/2023 revealed the resident was incontinent of bowel and bladder related to cognitive deficit. Interventions included, check frequently on rounds, and as needed (PRN) for incontinence and provide the amount of assistance that is needed, provide with adult protective garments (if desired) to help maintain dignity for any incontinent episode that may occur, provide with amount of assist that is needed for toileting, incontinent care frequently, on and rounds, and PRN. On 12/06/23 at 1:41 PM, Certified Nursing Assistant (CNA) #7 was observed from the hallway on the Secure Unit pull Resident #26's pants down. Resident #26 pants fell landing on the floor, exposing Resident #26's bare legs and brief. CNA #7 did not pull a privacy curtain or close the door. On 12/06/23 at 1:56 PM, CNA #7 was asked why should the door be closed when providing/assisting residents with incontinent care? CNA #7 stated, For their privacy. I took [Resident #26] in there to check the brief. On 12/06/23 at 2:42 PM, Licensed Practical Nurse (LPN) #3 was asked why should the privacy curtain be pulled/the door be closed when assisting residents with incontinent care? LPN #3 stated, For privacy and dignity. On 12/06/23 at 1:33 PM, CNA #7 was observed exiting a room on the secure unit with the left bare hand filled with fish shaped crackers. CNA #7 picked one fish shaped cracker from the left hand with the right bare hand and fed it to Resident #37. CNA #7 sat down in a chair next to Resident #37 and used the right bare hand to remove a fish shaped cracker from the left bare hand and fed it to Resident #37 and was observed to eat some herself. On 12/06/23 at 1:37 PM, CNA #7 was asked why should staff not touch residents' food with their bare hands? CNA #7 stated, Because of germs. CNA #7 was asked why did you give Resident #37 fish shaped cracker with your bare hands? CNA #7 stated, I gave them to [Resident #37], and I gave them with my bare hands. That's not what [Resident #37] is supposed to eat. I know I'm not supposed to do that. On 12/06/23 at 2:42 PM, Licensed Practical Nurse (LPN) #3 was asked, why should staff not give residents food from their bare hands. LPN #3 stated, Germs and infection control. LPN #3 was asked why should staff sit at eye level while assisting residents with eating. LPN #3 stated, Most elders vision is impaired, and it helps residents eat. LPN #3 was asked how is orange juice supposed to be stored when not in use? LPN #3 stated, In the refrigerator. LPN #3 was asked why should orange juice be refrigerated or on ice? LPN #3 stated, To prevent bacteria. On 12/27/23 at 12:22 PM, the Infection Control Preventionist (ICP) was asked why should staff not feed residents food from their own bare hands and why should staff perform hand hygiene before assisting residents with meals. The ICP stated, For infection control and to keep infection rates down.

47912 Based on observation, record review, and interview, the facility failed to maintain a safe, functional, sanitary, and homelike environment for the residents to promote dignity and prevent the potential injury or spread of disease. The findings are: On 12/05/23 at 02:02 PM, 6 window blinds on the Secure Unit were torn with missing panes. Pictures were taken. On 12/05/23 at 02:04 PM, observed a brown recliner with torn and peeling vinyl exposing the foam on the left and right arm pads and the headrest, a black recliner with torn and peeling vinyl exposing foam on the left and right arm pads and a wire hanging 4 feet from the ceiling in the shape of a noose was observed in the Common Area of the Secure Unit. On 12/05/23 at 02:06 PM, the privacy curtain in room [ROOM NUMBER] was tied in a knot and not connected to the track on the ceiling. On 12/05/23 at 02:57 PM, a wire hanging 4 feet from the ceiling in the shape of a noose observed in the common area of the secure unit. (Photo taken.) On 12/05/23 at 03:02 PM, observed an electrical outlet with no cover in the common area of the Secure Unit. On 12/05/23 at 03:06 PM, a drain cover 15 feet from the fire door in the middle of the hall on the Secure Unit was not secure and exposed a 3 foot hole in the floor. (Photo taken.) On 12/05/23 at 03:08 PM, 5 feet of wall from the fire door on the right side, with no baseboard that exposed the wall and sheetrock on the Secure Unit. (Photo taken.) On 12/05/23 at 03:09 PM, 4 feet of handrail on the right side of the wall, outside of room [ROOM NUMBER] that was not secure and sticking out 6 inches. (Photo taken.) On 12/05/23 at 03:11 PM, 7 feet of handrail on the wall between the Shower Room and room [ROOM NUMBER] that was not secure and was sticking out 8 inches from the wall with screws exposed. (Photo taken.) On 12/05/23 at 03:12 PM, the handrail between the Shower Room and room [ROOM NUMBER] was not secure and loose. 12/06/23 at 08:51 AM, observed a wire hanging 4 feet from the ceiling in the shape of a noose in the common area of the Secure Unit. A brown recliner with torn and peeling vinyl exposing the foam on the left and right arm pads and the headrest. A black recliner with torn and peeling vinyl exposing the foam on the left and right arm pads. On 12/06/23 at 11:27 AM, on the Secure Unit a resident was reclining in a brown recliner. The recliner's left and right arm pads and the headrest had torn and peeling vinyl that exposed the foam. On 12/06/23 at 11:23 AM, a wire hanging 4 feet from the ceiling in the shape of a noose was observed in the Dining Room of the Secure Unit. Maintenance #1 was asked what the wire was and what does it go to? Maintenance #1 stated, I don't know. On 12/06/23 at 1:32 PM, observed a resident sitting in a brown recliner on the Secure Unit. The left and right arm pads and the headrest of the recliner had torn and peeling vinyl that exposed foam. On 12/06/23 at 7:19 PM, observed from the outside of the facility, a window on the Secure Unit that had cracks and was taped with a hole in the middle where the cracks meet. Certified Nursing Assistant (CNA) #8 was asked what happened to the window. CNA #8 stated, I didn't know it was broke. I've only been here since June. On 12/07/23 at 9:11 AM, Maintenance #1 was asked what happened to the cracked window on the back wall on the Secure Unit? Maintenance #1 stated, I believe it happened before I got here. Maintenance #1 was asked if it was ever reported and why it had not been replaced. Maintenance #1 stated, It has been reported and a glass company came out and looked at it. They replaced two other glass windows in the facility, but they never came back out to fix this one. Maintenance #1 was asked to measure the 4th three paned window on the back wall of the dining room on the secure unit. Per Maintenance #1's measurement, the middle of the glass windowpane measured 40 inches by 63.5 inches. Maintenance #1 was asked to measure the hole in the middle of the glass windowpane. Per Maintenance #1's measurements the hole in the glass windowpane was 0.5 inches by 0.5 inches. Maintenance #1 was asked about the window blinds in the dining room of the secure unit, and why were they ripped, torn, and missing slats. Maintenance #1 stated, I have replaced blinds twice since I've been here. Maintenance #1 was asked how long he had been employed at the facility. Maintenance #1 stated, Since July. Maintenance #1 was asked if the brown and black recliners in the dining room on the secure unit were the facilities recliners. Maintenance #1 stated, Yes, they've been here since I've been here. Maintenance #1 was asked if the handrails in the hall on the secure unit had been reported to be loose. Maintenance #1 stated, It was reported a rail was loose in the past and I fixed them before, and I fixed them the day you came in and someone reported that you were looking at them. Maintenance #1 was asked if the drain cover at the end of the hall near the double doors on the secure unit had been reported to be loose and why they are not secure. Maintenance #1 stated, No, it had not been reported and I'd have to get with the Administrator about why it's not secured. Maintenance #1 was asked how things were reported that needed to be fixed and who do they report it to. Maintenance #1 stated, They are supposed to write in the maintenance logbook, but they don't always do that. Sometimes they will tell me, and if it's a quick fix, I'll fix it, then write it in the book. Maintenance #1 was asked if the missing baseboard near the double doors on the secure unit had been reported. Maintenance #1 stated, No, it has not. Maintenance #1 was asked to measure the missing baseboard. Per Maintenance #1's measurements the area measured 47 and 3 quarters inches in length by 4 inches tall. On 12/07/23 at 9:13 AM, a picture was taken of the broken and taped, middle glass windowpane, with a hole in the middle of the glass, in the dining room of the secure unit. On 12/07/23 at 9:23 AM, Maintenance #1 was asked to measure the gap between the end of the mattress to the footboard and the gap between the end of the head of the mattress and the headboard of Resident #23's bed. Per Maintenance #1 the measurements of the gap between the end of the mattress to the footboard measured 4.5 inches and the gap between the head of the mattress and the headboard measured 6 inches. On 12/07/23 at 9:28 AM, Maintenance #1 was asked what happened to the blue wire that was hanging from the ceiling in the dining room on the secure unit. Maintenance #1 stated, I put it back into the ceiling, I'm not sure what it went to. On 12/07/23 at 9:33 AM, the sewer drain cover at the end of the hall near the dining room on the secure unit was observed to be loose and not secured. The drain cover was lifted, and a black liquid substance was observed. There was a pungent smell of sewer. Maintenance #1 was asked what the drain went to. Maintenance #1 stated it was the main sewer line that runs down the middle of the facility through the 400 Hall. Maintenance #1 was asked to measure just above the liquid line of the drain hole. Per Maintenance #1 the measurement was just 10 inches below the floor level. Maintenance #1 was asked how often the sewer lines get clogged up. Maintenance #1 stated, I'm down here 2 or 3 times a week, secure unit, and normally unclogging a toilet on a daily basis. Maintenance #1 was asked why the facility wasn't using the newer part of the facility, the front area near the Administrator's office. Maintenance #1 stated, They were renovating the other part of the building, then due to low census, they quit working on it. Maintenance #1 was asked when it rains does the facility flood and where. Maintenance #1 stated, Yes, in the main dining room, and under the heat and air units. On 12/07/23 at 9:40 AM, Maintenance #1 was asked why Resident #38 doesn't have a heater/air conditioner in the room. Maintenance #1 stated, He tears them apart, he needs a power cord. Maintenance #1 was asked if the power cord was ordered and when. Maintenance #1 stated, I sent the picture to the Administrator, and he said he'd get with [Name], but I haven't heard anything else about it. Maintenance #1 was asked who [Name] was. Maintenance #1 stated, Not sure, someone over the Administrator I guess. Maintenance #1 was asked how many heater/air conditioner units in the facility, that were out, needed power cords. Maintenance #1 stated, Two on the secure unit and 1 room on the other side of the double doors on 400 Hall. Maintenance #1 was asked why Resident #38's bathroom was locked with a chain. Maintenance #1 stated, Because he tears things up. On 12/07/23 at 9:47 AM, Maintenance #1 was asked why room [ROOM NUMBER]'s bathroom was not locked or blocked off due to the black liquid in the toilet, no toilet tank lid, and other hazards in the bathroom. Maintenance #1 stated, That bathroom was not supposed to be used because I was told the last maintenance man got a snake [used to unclog lines] stuck in the toilet. On 12/05/23 at 01:58 PM, in room [ROOM NUMBER] the bathroom had a compartment door opened underneath the mirror. There was paint peeling from the bottom and the left side of the compartment with multiple rusted areas observed. There was an uncontained toothbrush with the bristles in contact with the rusted area, and a tube of toothpaste lying on the rusted surface in the compartment. The paper towel dispenser was full of paper, but not working. On 12/05/23 at 01:59 PM, in room [ROOM NUMBER], there was a mattress on the floor next to the bed. The covering on the mattress was ripped and there was cotton gauzelike material that was stained light orange around the edges. The gauzelike material was ripped, and covering a blue foam mattress that was showing on one corner. The blue foam had several gouges in it. On 12/05/23 at 5:08 PM, the mattress on the floor remained the same. On 12/07/23 at 11:37 AM, the Surveyor asked Maintenance #1 if he knew about the recliner footrest in room [ROOM NUMBER]A not working. The Maintenance #1 answered, No. I didn't know about that, but I will get it taken care of right away. 12/07/23 at 02:48 PM, Maintenance #1 stopped the Surveyor in the hallway to ask what was wrong with the recliner in room [ROOM NUMBER]A. The Surveyor accompanied Maintenance #1 to room [ROOM NUMBER]A. The Resident explained that the footrest would not stay up. Maintenance #1 communicated with the Resident as he assessed the recliner from underneath. The recliner was missing a spring, and the Resident's family had brought the recliner in. It was not a facility own recliner. Maintenance #1 told the resident that he would replace the spring. 12/07/23 at 09:46 AM, the Surveyor observed an oxygen cylinder not contained in a metal oxygen caddy in an oxygen storage room on hall 400. The door to the oxygen storage room was unlocked and there were residents rolling down the hallway in wheelchairs. 12/07/23 at 10:28 AM, the 400 Hall oxygen storage room remained unlocked. There was a coded lock on the door that was not working. There was an oxygen cylinder observed that contained oxygen and was not properly stored in an oxygen caddy. The cylinder was standing up between an oxygen concentrator that was not in use, and multiple cylinder in caddies that contained oxygen. There were residents observed in wheelchairs in the hallway passing by. 12/07/23 at 02:45 PM, the Surveyor asked Registered Nurse (RN) #1 if the oxygen storage room on hall 400 should be locked. RN #1 answered, Yes, it should be locked. The Surveyor asked how oxygen cannisters should be stored safely. RN #1 answered, They should be upright in an eggcrate The Surveyor asked what could happen if oxygen was not stored properly. RN #1 answered, It could catch on fire or cause an accident. The Surveyor asked who was responsible for checking to make sure oxygen is stored safely. RN #1 answered, The nurses. The Surveyor asked how often oxygen is checked. RN #1 answered, I don't know. I'm not sure who they have the contract with. 12/08/23 at 09:51 AM, observed a rolling cart with a large crack that was bowing in under the weight of a blue ice chest that was sitting on top. The crack was visible on the outer edge and had a gap with sharp edges on either side. There were 2 basins stacked together and a water jug on the second shelf underneath the cracked top shelf. There were visible red, black, and dark brown stains and spots visible on the second shelf. [NAME] Young On 12/05/23 at 03:24 PM, during initial rounds, a two-cabinet door wardrobe for in room [ROOM NUMBER]B was missing the top drawer. The resident had personal items in the bottom drawer, but the bottom of the second drawer was broken. Clothes were visible from the bottom drawer. A tile in the left corner of the ceiling was pushed open. On 12/05/23 at 03:43 PM, a square cut out of sheetrock was observed 1 inch from an electrical outlet that was currently in use on the 400 Hall beside nurse's station. On 12/06/23 at 02:49 PM, the second observation of room [ROOM NUMBER]B, the wardrobe had been replaced with a different wardrobe. The ceiling tile in the left corner of the room had either been replaced or had been closed. It was no longer open. The Resident was seated in a wheelchair in his room. The Surveyor said I see you got a new wardrobe. The Resident said yes, that other one had been broken since I've been here. I don't know why it hadn't been replaced before now. The Surveyor asked if the broken wardrobe was an inconvenience. The Resident said not really, but I like the new one better. On 12/07/23 at 09:08 AM, the Surveyors were making observations on the 500 Hall, starting at the end of the hall by room [ROOM NUMBER]. Down the hall from the Exit door, there were 12 handrails on the right side of the hall. The 4th one down had a 2x4 behind it and the screw was showing 1 inch from the wall. The 7th handrail was pulling loose from the sheetrock wall. The 8th handrail's plastic bracket was loose from the wood at the end of the rail. There were 11 handrails on the left side. The 4th handrail down from the door had a screw missing and was loose from the wall. On 12/07/23 at 09:19 AM, in room [ROOM NUMBER], there was a square hole cut out of the wall on the left side of the door with television cables extending out the hole. The resident in Bed B was asked are you bothered by the hole cutout. The Resident stated, Not really. I want to be in this room because I've been in other rooms, and this is the only one that doesn't leak when it rains. On 12/07/23 at 09:25 AM, in room [ROOM NUMBER], two broken drawers were placed on both sides of Bed B's wardrobe. A cardboard box was lying on the floor containing clothes, a pink plastic basin with personal items (lotion, deodorant, a vape and a bottle containing 1/3 inch of anticavity mouthwash. On the bathroom floor there was a plastic basin containing a brown and yellow stained brief wadded up, clear plastic gloves and a tube of an unknown substance, covered with a folded clean brief, (photo taken). The bathroom had a pungent odor and a plastic gallon jug containing 1 inch of peri wash. On 12/07/23 at 09:40 AM, an unlocked Hopper room contained plastic shower chairs, a 1/2 full gallon jug of a calcium, lime, and rust stain remover placed on the inside of the closet on the floor (photo taken), a plastic bag containing a dirty mop head (photo taken), In room [ROOM NUMBER]A beside the foot of the bed was an electrical outlet that was pulled out 2 inches at the bottom of the outlet from the wall. There was something plugged into it. On 12/07/23 at 09:42 AM, in room [ROOM NUMBER] A, the rolling bedside table leg base was corroded with a brown substance spattered all over it. A lighter was stuck under a package of disposable wipes on the bedside table. On 12/07/23 at 09:58 AM, across the hall from room [ROOM NUMBER] was an unlocked bathroom, the plastic covering to the ceiling light was missing, exposing light bulbs and wires. Inside the bathroom, a plastic 3 drawer bin had a broken top. The top drawer contained 1 disposable razor, 1 can of shaving cream and toothpaste, the second drawer contained 2 cans of shaving cream. On 12/07/23 at 10:00 AM, in room [ROOM NUMBER]B there was a brown stain on the ceiling tile over the resident's bed. The bedside table belonging to the resident in A bed had a package of cupcakes dated 10/24/23, a 1-inch piece of cigarette, a debit/credit card and on the nightstand was a driver's license. On 12/07/23 at 10:13 AM, in room [ROOM NUMBER] a razor in a plastic glass, 3 cans of shaving cream and empty pill cups were on the nightstand beside resident's bed. On 12/07/23 at 10:15 AM, on the 3rd observation of the linen closet, the closet was unlocked with 2 gallon jugs of peri wash, (1 contained 1 inch of peri wash and the other was a full bottle), an 8 ounce bottle of hand sanitizer, and 1/2 box of individual packages of barrier cream. On 12/07/23 at 04:00 PM, the Surveyors went to the Nurse's Station between halls 400 and 500. There was a counter with cabinets and a sink. The cabinet under the sink was open. The floor under the sink cabinet was black and looked wet and had a hole 1foot x 2 feet' that had a hammer lying in shards of wood. On 12/08/23 at 09:16 AM, CNA #5 was observed coming into the shower room. The Surveyor asked if drains in the showers were ever backed up. CNA #5 said yes, sometimes when it rains or when they get clogged. The shower room had a pungent smell, and the shower had a yellow, brownish substance on the tile in the corner. On 12/08/23 at 10:30 AM, Housekeeper #1 was observed pushing the housekeeping cart out in the hall. Housekeeper #1 was asked which area of the facility are you responsible for? Housekeeper #1 said I am responsible for the 400 and 500 halls. The Surveyor asked how often are the resident's rooms cleaned? Housekeeper #1 said every day for sure, actually several times during the day. It depends on the resident. Some need to be cleaned up after more than others. The Surveyor asked how often the residents' bathrooms are cleaned. Housekeeper #1 said every day and as needed. Housekeeper #1 was asked what things do you clean during the day? Housekeeper #1 said I disinfect surfaces, doorknobs, drawers, tables, sweep the room and bathroom, change the trash, make sure there is soap and paper towels and check under the beds for crumbs or miscellaneous. On 12/08/23 at 10:51 AM, Housekeeper #2 was observed seated in a chair looking at a phone in the Housekeeping Room. Housekeeper #2 was asked, Which area of the facility are you responsible for? Housekeeper #2 said I clean the Unit. The Surveyor asked how often are the resident's rooms cleaned? Housekeeper #2 said Every day. Some of the residents' rooms and bathrooms need to be cleaned more than others. The Surveyor asked when you see something in the resident's room or bathroom that needs to be repaired what do you do? Housekeeper #2 said I report it to maintenance. The Surveyor asked do you write it down on something? Housekeeper #2 said no, I verbally tell maintenance. On 12/08/23 at 10:54 AM, Housekeeper #3 was observed mopping a resident's room. The Housekeeper #3 was asked how often the resident's rooms were cleaned. Housekeeper #3 said I clean every room in the morning, starting in one room and work my way down the hall, then I work my way back up the hall on the other side. I work from 7:00 AM to 3:00PM.

Complaint # (AR 169) and Complaint # (AR 310) was substantiated, all or in part, with these findings: A. Based on observation, record review and interview, the facility failed to ensure resident plans of care were reviewed by the interdisciplinary team and revised to address aggressive behaviors to provide staff with appropriate interventions to minimize the potential for resident-to-resident altercations for 5 (Residents #1, #2, #7, #9 and #10) of 5 case mix residents who had episodes of aggressive behaviors toward others. The failed practice resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Residents #1, #2, #7, #9 and #10 and had the potential to cause more than minimal harm to 13 residents who resided on the secure wing, as documented on a list provided by the Administrator on 8/23/17. The Administrator was informed of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. Resident #1 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/17 documented the resident had no speech, was rarely/never understood, had short/long term memory problems, had severely impaired cognitive skills for daily decision-making per a staff assessment for mental status, was inattentive, wandered daily which significantly intruded on the privacy and activities of others, had daily preferences including having family or a close friend involved in discussions about care, required supervision with set up help only for bed mobility, transfers and ambulating on the unit, received antipsychotic medications on 6 of the past 7 days. a. Nurses Notes dated 5/23/17 at 10:10 a.m. documented, MD (Medical Doctor) made rounds + (and) NOS (new orders) D/C (discontinue) previous [MEDICATION NAME] order (and change) to QD (every day) R/T (related to) Dementia (with) Beh (behavioral) dist (disturbance) (and) drowsiness. Order processed . Nurses Notes dated 5/24/17 at 10:00 a.m. documented, .0 (no) real (changes) in mood, (no) behaviors noted at this time . Nurses Notes dated 5/24/17 at 10:00 p.m. documented, .Resident showing signs of combativeness when attempting to strike staff who was attempting to remove (resident) from exit door. Resident calmed down and was able to be redirected by staff . Nurses Notes dated 5/25/17 at 3:45 p.m. documented, 1. D/C [MEDICATION NAME] (antipsychotic). 2. D/C [MEDICATION NAME] (sedative) (at) hs (bedtime). 3. D/C Mirtazepine (antidepressant). 4. (Change) [MEDICATION NAME] to BID (twice daily) PRN (as needed) per APN (Advanced Practice Nurse) on rounds. Orders processed. Will notify family (drowsiness) . Nurses Notes dated 6/1/17 at 2:10 p.m. documented, New orders - [MEDICATION NAME] (antidepressant) qhs (every night at bedtime) 7.5 mg (milligrams). [MEDICATION NAME] (antipsychotic) 0.25 mg PO (by mouth) qhs . Nurses Notes dated 6/8/17 at 9:30 a.m. documented, .(Resident) is a 'wanderer' and requires frequent re-directing and removal from other (resident) rooms . (Resident) continues to get behind nurses station and stand over staff and attempt to remove items off desk and or touch nurses inappropriately . b. Nurses Notes dated 6/9/17 at 6:45 a.m. documented, Resident walk up to a CNA (Certified Nursing Assistant) sitting in dining room and punch the CNA in the face . There was no documentation of any intervention or added supervision implemented at this time to monitor the resident for further aggressive behaviors. An Incident/Accident Report dated 6/9/17 at 7:10 a.m. documented, Exact Location of Incident/Accident be specific: Small dining area 400 hall . Describe exactly what happened: .Reported per staff members and hospice care worker on site that this R (resident) walked up to another resident and pinched the other R's leg L (left) other resident was in w/c (wheelchair) . Redirection out of other residents' personal space and move to lock down unit as soon as possible. The back of the Incident/Accident Report documented, Has it been documented, communicated, and Care Planned? Yes. Does the MDS reflect the interventions and same as care planned? Per MDS. Date of follow-up on interventions: (blank) . c. The Plan of Care updated on 6/9/17 documented, Behavioral Symptoms . Redirect resident PRN (as needed), Keep environment calm and relaxed, meet physiological needs and remove to private area when agitated. 5/21/17 Family reports resident's behavior includes sitting and lying in floor . Fall/Safety Risk/elopement risk . Observe on rounds (every) 30-60 minutes . Mood State: Assess, monitor & (and) document mood changes . The Plan of Care did not identify aggressive physical behaviors as a problem and did not document any interventions to address physical aggression or combative behaviors. d. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Exact Location of Incident/Accident Be specific: Feeders (residents who require assistance with eating) dining room . Became very aggressive after children left from visiting (resident) . Describe exactly what happened: .R (resident's) children just left facility from visiting. (Resident) walked in dining room when he pushed another resident up against a wall and started punching him repeatedly in stomach and chest until CNA stepped in between them to separate them . interventions . Attempt to keep residents apart . The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Does the MDS reflect the interventions and same as care planned? (blank). Date of follow-up on interventions: (blank). The Nurses Notes dated 6/11/17 at 4:00 p.m. regarding the above incident documented, .Called (physician) to get a [MEDICATION NAME] 1 mg IM (intramuscular injection) order to help calm (resident). (Resident) was 1 on 1 until (resident) went to sleep. (With) CNAs after altercation . 2200 (10:00 p.m.) (Resident) has continued to be 1 on 1 with CNAs until (resident) finally fell asleep . e. Nurses Notes dated 6/15/17 on the 7:00 a.m. to 3:00 p.m. (7/3) shift documented, Behaviors grabbing staff, grabbing wheelchair and putting self face to face with staff. Resident requires constant monitoring to avoid falls and aggression towards residents. Nurses Notes dated 6/23/17 (not timed) documented, R continues to grab at people . Nurses Notes dated 6/26/17 on the 7/3 shift documented, Ambulates self and makes repetitive walks around hallway and dining area. Often wanders into other resident rooms and gets into other residents and staff personal space with intimidating stare . Frequent re-direction needed. Nurses Notes dated 6/27/17 on the 7/3 shift documented, Frequent redirection of resident required to remove from other residents' rooms and personal space. Resident continuous to grab at staff and other residents. Nurses Notes dated 6/29/17 on the 7/3 shift documented, Resident ambulates self throughout halls repetitively. Frequently redirection to prevent resident from grabbing staff and other resident. f. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident approached another resident who was sitting on the piano bench in the east D/R (dining room) area and resident began hitting the other resident. Staff intervened immediately . interventions .closely observe resident when he enters the space of other vulnerable resident and remove resident immediately. The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Date of follow-up on interventions: (blank) . Nurses Notes dated 6/30/17 (not timed) documented, Resident continues with behaviors of walking up to staff and other residents grabbing sometimes aggressively - difficulty with trying to get resident to release his grip on whatever article of clothing or item he has grabbed onto. g. An Incident/Accident Report dated 7/5/17 at 7:30 a.m. documented, Resident walked up to another resident and hit that resident (Resident #2) in the right eye . interventions . Keep away from close proximity of others. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . h. An Incident/Accident Report dated 7/9/17 at 11:00 p.m. documented, location of incident / accident . dining room . Resident hit another resident (Resident #2) in the right inner arm . no injuries or bruises noted . interventions . Keep both patients separated from each other and keep surrounding area free from incidents. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . The Nurses Notes dated 7/9/17 at 11:00 p.m. regarding the above incident documented, .CNA states he hit resident in the right arm. Noticed resident agitation. Resident throwed (sic) chair in dining room, pacing the floor. [MEDICATION NAME] 0.5 mg PO given . h. Nurses notes dated 7/14/17 at 9:45 a.m. documented, Continues with aggressive behaviors of grabbing and pulling at w/c (wheelchair)/med cart/staff /etc (etcetera) - resident attempted to hit this nurse during am (morning) med (medication) pass . ambulating in continuous circling of hallway . i. A Weekly Summary dated 7/28/17 documented, .No (changes) - no new orders - (Resident) behaviors / wandering / grabbing / hitting others continues. (Resident) requires frequent redirection out of others' personal space and intervention from (resident) grabbing and not letting go of people's clothing / items / etc. (et cetera) . j. On 8/6/17 at 2:45 p.m., the resident was wandering up and down the hall and the east dining room where other residents were present. k. On 8/7/17 at 10:00 a.m., the resident was wandering aimlessly up and down the hall and in the dining room where other residents were present. At 10:03 a.m., the resident ambulated into room [ROOM NUMBER]. There was no one in the room. The resident returned to wandering aimlessly in hallways and dining room where other residents were present. l. On 8/8/17 at 7:40 a.m., the resident was in the dining room being spoonfed. Resident #2 was seated at the same table as this resident. According to the Incident / Accident Report dated 7/5/17, these 2 residents were involved in an altercation in which Resident #2 was punched in the eye. m. On 8/8/17 at 9:00 a.m., the resident was wandering up to other residents in the dining room, grabbing their clothes. n. On 8/8/17 at 11:42 a.m., the Director of Nursing (DON) was asked. What are the interventions for keeping residents safe on the secure wing? The DON stated, Keep (aggressive residents) separated from others. She was then asked, How do you do that? and stated, We usually send the aggressor out (to hospital or geriatric-psychiatric unit). As of 8/8/17 at 11:42 a.m., there was no documentation in the clinical record to indicate the resident had ever been transferred to a hospital or geriatric-psychiatric (geri-psych) facility for evaluation of his physically aggressive behaviors, and the Plan of Care had not been updated to address the resident's repeated aggressive behaviors and resident-to-resident altercations. o. Nurses Notes dated 8/8/17 at 6:45 p.m. documented, DON spoke (with) spouse (name) regarding need to do a geri-psych eval (evaluation). Spouse agreeable . p. On 8/9/17 at 10:50 a.m., the Director of Nursing was asked to provide any available documentation to demonstrate that this resident had been sent out (or received a geri-psych evaluation) after demonstrating aggressive behaviors, at any time since admission. As of 8/10/17 at 10:00 a.m., no documentation had been provided. 2. Resident #2 resided on the secure unit and had a [DIAGNOSES REDACTED]. The MDS with an ARD of 6/27/17 documented the resident understood others and was sometimes understood, scored 6 (0-7 indicates severe impairment) on the brief interview for mental status, had signs/symptoms of inattention and disorganized thinking that fluctuated, had behaviors of verbal behavioral symptoms directed toward others and wandering daily, required extensive assistance of two-plus persons for transfers, did not ambulate in the past 7 days and had one fall without injury. a. The Plan of Care updated 7/2/17 documented, Behavioral Symptoms . interventions . Redirect resident PRN (as needed), Keep environment calm & (and) relaxed, Meet Physiological needs, remove to private when agitated . Encourage diversional activities. b. An Incident/Accident report dated 7/4/17 at 7:15 a.m., documented, Resident was hit in his right eye area by another resident (Resident #1) that was walking past. c. Nurses Notes dated 7/9/17 at 11:00 p.m. documented, Called to 300 dining area found patient in wheelchair calmly. CNA stated a Resident (Resident #1) hit him in his right inner arm. d. Nurses Notes dated 7/11/17 at 8:00 p.m., documented, Resident very agitated this shift lunging at staff and other residents swinging at staff. The related witness statements documented the following: 1.) 7/11/17 at 8:35 p.m., Resident threw nurse to the floor. She tried to stop him for going into another room, punching and cursing. 2.) 7/11/17 at 10:10 p.m. documented, Resident has been very combative and aggressive all this shift. Waiting til the resident got the medicine from nurse and calmed down a bit. We asked the resident if he wanted to go to bed, he said no!! and slammed the door. A minute later the chair alarm was going off and went in room resident fell out of his chair. e. Nurses Notes dated 7/13/17 at 2:30 p.m. documented, Resident agitated, escalated to yelling disturbing the other residents and attempting to strike people. f. Nurses Notes dated 7/13/17 at 7:30 p.m. documented, Observed this resident in wheelchair attempting to go in and out of other residents' rooms looking for his keys 'going to load it' so he and family could go on a boating trip. Screaming at the other residents and staff cursing and threatening. g. On 8/7/17 at 8:30 a.m., the resident was at a table in the dining room. Two of his table mates were exchanging verbal behaviors and hitting at one another. There was no nurse or CNA in the dining area. A housekeeper was there and observed the behaviors, but did not intervene or report it to the nurse or staff. h. Nurses Notes dated 8/10/17 on the 11:00 p.m. to 7:00 a.m. (11-7) shift documented, Continues to call out for (wife's name) and hitting at staff members and other residents. i. As of 8/10/17, there had been no revisions to the plan of care since 7/2/17 to address the resident's physically aggressive behaviors. 3. Resident #7 resided on the secure unit and had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 6/14/17 documented the resident had short/long term memory problems, had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was inattentive and had disorganized thinking continuously, exhibited physical behavioral symptoms and verbal behaviors that occurred 1-2 times in the past 7 days and wandering that occurred daily and was independent with ambulation. a. The Plan of Care updated 6/19/17 documented, At risk for behaviors r/t (related to) . TBI ([MEDICAL CONDITION]) and does not understand his surroundings. He often will go in a room inappropriately or become combative with staff during care . interventions . Report increased behaviors to MD (Medical Doctor), Pharmacy to review medications per policy, Encourage him to participate in activity with rock music, SSD (Social Services Department) to visit PRN, Allow him to express frustration redirect when attempting to enter other resident room, Activity to provided one on one weekly and offer HS (bed time) snack. b. An Incident/Accident Report dated 3/1/17 at 12:10 p.m. documented, As this nurse got to the DR (dining room), Resident was on his hands and knees. Witness stated another resident got up from his w/c (wheelchair) and hit this resident in the mouth with his fist, knocking resident down . interventions . other resident placed one-on-one. c. An Incident/Accident Report dated 3/6/17 at 8:00 a.m. documented, Resident was hit on the back of his head by another resident . interventions . Neuro checks started and resident to sit in a different area than resident that hit him. d. An Incident/Accident Report dated 3/20/17 at 12:20 a.m. documented, Resident walked up to another resident and struck resident x (times) 2 in the shoulder. The intervention was documented as, Attempt to keep residents apart. e. An Incident/Accident Report dated 3/23/17 at 12:15 p.m. documented, This resident was into other resident's personal space while other resident was in w/c at table in the DR. Other resident was yelling 'Get Away' this resident then hit other resident on the top of her head. The intervention documented Keep resident away from other residents as much as possible. f. An Incident/Accident Report dated 3/29/17 at 7:40 a.m. documented, this resident went up to other resident from behind, hit other resident on top of head, other resident then began hitting this resident in face and shoulder. Was separated immediately. The interventions documented, Separate Residents, Observe residents and keep them apart and gave resident a magazine to look at. g. An Incident/Accident Report dated 3/30/17 at 8:50 a.m. documented, CNA reported resident walked up to another resident and stumbled bumping other resident wheelchair, other resident struck resident in stomach. The interventions documented, Residents separated. Attempt to keep residents apart. h. An Incident/Accident Report dated 4/4/17 at (not timed) documented, Reported to this nurse per CNA that resident in an altercation with another resident. When the other resident pushed this resident down and resident fell in a sitting position to the floor. The intervention documented, Observe resident closely when in common area and intervene in a timely manner when resident noted to be wandering into other residents' space. Remove resident to a safe space and impose one-on-one with resident when necessary. i. An Incident/Accident Report dated 4/6/17 at 8:30 a.m. documented, Report per staff this resident was hitting other resident in common area on Central. This resident walked up into other resident personal space other resident starting hitting at this resident and this resident was swinging arms. The intervention documented Attempt redirection when getting in others personal space. j. An Incident/Accident Report dated 4/12/17 at 9:15 a.m. documented, Staff reported other resident hit this resident in the side. The intervention documented, Re-direct away from other resident. k. An Incident/Accident Report dated 4/13/17 at 7:30 a.m. documented, Staff reported this resident was in DR walking with staff to be seated for breakfast and passed by other resident sitting in chair and hit other resident in right cheek. The interventions documented, keep resident arm's length from other residents and offer private dining. l. An Incident/Accident Report dated 5/8/17 (not timed) documented Resident went over to table where another resident was sitting at DR table. The other resident started to hit him in the scrotum with his fist and then this resident hit the other resident on his shoulder. The interventions documented, Monitor resident at regular intervals when in DR to prevent him from standing over resident and touching and moving over them. Assist pt. (patient) to table and encourage him to sit down, offer snack until breakfast or other meal can be served. m. Nurses Notes dated 6/3/17 at 5:05 p.m. documented, Staff member reported to this nurse that resident pressed on the leg of another resident who then grabs this resident by his head, at which time the resident hit the other resident in the head. n. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Resident (Resident #1) came over and pushed him up against a wall and punched him repeatedly in the stomach and chest until (CNA) stepped in between them to separate them. The interventions documented, Attempt to keep residents apart. o. Nurses Notes dated 6/19/17 at 11:00 (p.m. or a.m. not specified) documented Wanders throughout facility gets in others personal space causing altercations often with other residents. p. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident sitting on piano bench in east DR area when another resident (Resident #1) walked up to him and started hitting him. Staff intervened immediately. Resident obtained 3 scratches to left side of neck. The intervention documented, Observe resident and ensure that resident is not sharing the same space with other residents that are prone to be combative. q. On 8/9/17 at 4:05 p.m., the resident was wandering up and down the hallway and in the dining room. r. As of 8/9/17, there had been no revisions added to the behavioral plan of care since 6/19/17 to address the resident's frequent aggressive behaviors and to protect the resident from aggression by other residents. 4. Resident #9 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/9/17 documented the resident had short/long term memory problems, was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status, had verbal behavioral symptoms directed toward others and required supervision with ambulation. a. The Plan of Care updated 3/16/17 did not address any behavior issues. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, Staff reported this resident was pushed down and then kicked in left hip thigh area. Resident was reported to have hit his head on chair during fall. Resident sitting in chair with discolored area to right side top of head with swelling. Refer to paragraph 'b' of Resident #10's findings below, which indicates this altercation began with Resident #9 striking Resident #10 prior to being pushed down and kicked by Resident #10. The hospital's emergency room attending attestation dated 7/31/17 documented the resident presented to the emergency department, with fall and assault victim, had a CT (computed tomography) without contrast . No traumatic injury or acute intracranial process. c. As of 8/7/17, there was no documentation on the Plan of Care to address aggressive or combative behaviors for this resident. 5. Resident #10 was admitted to the secure unit on 7/20/17 with a [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/27/17 documented the resident scored 3 (0-7 indicates severely impaired) on a brief interview for mental status, had no behaviors, was independent with ambulation in the room and required supervision with ambulation in the corridor. a. The Plan of Care updated 7/29/17 documented, Behavioral Symptoms . Redirect resident PRN, Keep environment calm and relaxed, meet physiological needs, remove resident to private area when agitated and encourage diversional activities. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, CNAs reported other resident (Resident #9) hit this resident (Resident #10) who pushed the other resident (Resident #9) who fell down and then this resident (Resident #10) kicked him (Resident #9) in left hip/thigh area while he was down .Placed one on one at this time, awaiting management direction. c. Nurses Notes dated 8/1/17 at 6:10 (no a.m. or p.m.) documented, Resident taken laundry barrel and dumped what was inside, cursing all the time, refused any one close for care. Very aggressive one-on-one this a.m. d. Nurses Notes dated 8/1/17 at 6:50 (no a.m. or p.m.) documented, Received orders to send resident to (geri-psych facility) for eval and TX (treatment). Spoke to (name) at (geri-psych facility) ok to send resident having behavior issues kicked another resident in the head charging at the staff cursing. Called (transport service) to transport resident. Resident refusing care from staff pulling at peg (percutaneous endoscopic gastrostomy) tube sling milk and stomach contents everywhere. 6. On 8/7/17 at 9:40 a.m., Licensed Practical Nurse (LPN) #1 was asked about adequate staffing on the secure unit to supervise aggressive residents and stated, I need 3 CNAs, but they won't give me that. The Housekeeper is the CNA Supervisor, and we have written staff up for not staying on the hall, but she throws them (write-ups) away. 7. On 8/7/17 at 10:40 a.m., the Director of Nursing (DON) was asked, Do you have a policy and/or procedure for admission to the secure unit? The DON stated, We don't have a policy /procedure; we decided if they are a danger or [MEDICAL CONDITION], or [MEDICAL CONDITION], we all talk about it and we decide. If any doubt, we forward the information to Corporate, and then we make the decision. The DON was asked, Is any special treatment provided on the unit? The DON stated, No. 8. On 8/7/17 at 11:10 a.m., CNA #1, who worked on the secure unit, was asked Have you had any training to deal with aggressive residents? The CNA stated, No. 9. On 8/7/17 at 11:12 a.m., CNA #2, who was working on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, No. 10. On 8/7/17 at 11:15 a.m., CNA #3, who worked on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, Not here, but I did at another facility. 11. On 8/8/17 at 9:00 a.m., Licensed Practical Nurse (LPN) #2 stated she switched CNA #3 (who was assigned to 200 hall) and CNA #4 (who was assigned to the secure unit), because CNA #3 normally worked the secure unit and would stay down there to work as assigned and had a better rapport with the residents on the secure unit. The LPN stated that CNA #4 would not stay on the unit when assigned and would leave the unit multiple times, but that CNA #4 had, thrown a fit and refused the change in assignment. 12. On 8/10/17 at 8:20 a.m., the facility's Policy/Procedure (P/P) for Mood and Behavior was provided by Administrator. The policy documented, It is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. The Objective documented, The objective of the Mood and Behavior P/P is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. The plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being. Any mood and behavior symptoms will be documented by the interdisciplinary team .as well as interventions attempted and outcome. 13. The Immediate Jeopardy was removed on 8/9/17 at 1:00 p.m., and the scope/severity reduced to E when the following plan of removal was implemented. a. (Resident #1) will be admitted to Geri-psych per physician's orders [REDACTED]. b. Supervision of staff remaining on the secured unit will be documented by the Administrator / DON / Designee every 15 minutes to ensure that the scheduled (staff) are actually there. c. Education of all staff on identifying and managing behaviors, completing an I&A (incident/accident report) on resident to resident altercations and reporting resident to resident altercations to DON and Administrator will occur by the Administrator/designee. d. All residents with behaviors with cognitive impairment will be assess by Speech Therapy. All resident with mental illness [DIAGNOSES REDACTED]. e. Evaluate the resident to determine who are the aggressive residents and determine what interventions need to be in place f. An I&A will be completed on any Resident to Resident altercations. g. Any Resident to Resident incident will be reported to the Administrator and DON immediately. The perpetrator will be placed on 1:1 monitoring per the facility policy and documented on the flow sheet. h. Any Resident to Resident injury will be reported to OLTC (Office of Long Term Care). i. The Incident and Intervention will be placed on the 24-hour report so that all shifts are aware. j. The nurse will be instructed to start the Interventions which could include 1:1 (one on one) monitoring, k. All I&As will be reviewed by the Administrator/designee in morning Stand-up and Start-up to ensure proper intervention is in place. l. All interventions will be placed on the care plan by the MDS Coordinator directed after the Stand-up and Start-up meeting and verified by the Administrator/designee. m. Interventions will be communicated to staff daily on the closet care plan that will be updated daily by the MDS Coordinator and verified by the Administrator/designee. In-Servicing by the DON/designee will begin on 8/9/17 at 1:00 pm and will be completed by 3:00 pm on behavior identification and how to manage them. Any staff not present will be in-serviced prior to being allowed to provide care. Monitoring of Resident Behaviors will occur by the Administrator/DON/designee 2x per day, 5 days per week for the next 4 weeks or until compliance is achieved. Monitoring of ensuring I&As are completed for all Resident to Resident altercations and interventions are in place will be documented. B. Based on observation, record review and interview, the facility failed to ensure interventions were consistently evaluated and revised appropriately post fall and at least quarterly to prevent recurrent falls and minimize the potential for fall-related injuries for 3 (Residents #1, #2 and #7) of 4 (Residents #1, #2, #7 and #9) case mix residents who had a history of [REDACTED]. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #1, #2, and #7 who had repeated falls, and had the potential to cause more than minimal harm to 13 residents who resided on the secure wing, according to a list provided by the Administrator on 8/23/17. The Administrator was notified of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. Resident #1 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/26/17 documented the resident had short/long term memory problems, was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status, required supervision with set up help only for bed mobility, transfers and ambulating on the unit, and had a fall without injury since admission or prior assessment. a. An Incident/Accident Report dated 5/27/17 at 9:15 p.m. documented, Called to resident's room by CNA, found patient on left side in the floor . interventions . Safety mattress beside pt. (patient's) bed, Bed alarm to alert staff of pt. out of bed and no [DIAGNOSES REDACTED] of environment especially resident's room. b. An Incident/Accident Report dated 6/1/17 at 11:55 p.m. documented, Call to resident room, observed resident on floor with laceration to forehead 2 cm (centimeter) long and 1/10 cm wide. There was no assessment/investigation completed to identify causative factors and no documentation interventions were developed to prevent further potential falls or minimize the potential for fall-related injuries. c. A physician's orders [REDACTED].

Complaint # (AR 169) and Complaint # (AR 310) was substantiated, all or in part, with these findings: A. Based on observation, record review and interview, the facility failed to ensure supervision and adequate competent staff were provided on the secure unit to promptly intervene when residents exhibited aggressive behaviors and prevent resident-to-resident altercations, failed to ensure staff who worked on the secure unit were trained on dementia care and how to intervene with residents who exhibited aggressive behaviors, failed to ensure residents who had a history of [REDACTED].#1, #2, #7, #9 and #10) of 5case mix residents who had aggressive behaviors. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm injury or death to Residents #1, #2, #7, #9 and #10, and had the potential to cause more than minimal harm to 13 residents who resided on the secure unit, as documented on a list provided by the Administrator on 8/23/17. The Administrator was notified of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. Resident #1 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/17 documented the resident had no speech, was rarely/never understood, had short/long term memory problems, had severely impaired cognitive skills for daily decision-making per a staff assessment for mental status, was inattentive, wandered daily which significantly intruded on the privacy and activities of others, had daily preferences including having family or a close friend involved in discussions about care, required supervision with set up help only for bed mobility, transfers and ambulating on the unit, received antipsychotic medications on 6 of the past 7 days. a. Nurses Notes dated 5/23/17 at 10:10 a.m. documented, MD (Medical Doctor) made rounds + (and) NOS (new orders) D/C (discontinue) previous Hydroxyzine order (and change) to QD (every day) R/T (related to) Dementia (with) Beh (behavioral) dist (disturbance) (and) drowsiness. Order processed . Nurses Notes dated 5/24/17 at 10:00 a.m. documented, .0 (no) real (changes) in mood, (no) behaviors noted at this time . Nurses Notes dated 5/24/17 at 10:00 p.m. documented, .Resident showing signs of combativeness when attempting to strike staff who was attempting to remove (resident) from exit door. Resident calmed down and was able to be redirected by staff . Nurses Notes dated 5/25/17 at 3:45 p.m. documented, 1. D/C Risperdal (antipsychotic). 2. D/C Clonazepam (sedative) (at) hs (bedtime). 3. D/C Mirtazepine (antidepressant). 4. (Change) Hydroxyzine to BID (twice daily) PRN (as needed) per APN (Advanced Practice Nurse) on rounds. Orders processed. Will notify family (drowsiness) . Nurses Notes dated 6/1/17 at 2:10 p.m. documented, New orders - Remeron (antidepressant) qhs (every night at bedtime) 7.5 mg (milligrams). Risperdal (antipsychotic) 0.25 mg PO (by mouth) qhs . Nurses Notes dated 6/8/17 at 9:30 a.m. documented, . (Resident) is a 'wanderer' and requires frequent re-directing and removal from other (resident) rooms . (Resident) continues to get behind nurses station and stand over staff and attempt to remove items off desk and or touch nurses inappropriately . b. Nurses Notes dated 6/9/17 at 6:45 a.m. documented, Resident walk up to a CNA (Certified Nursing Assistant) sitting in dining room and punch the CNA in the face . There was no documentation of any intervention or added supervision implemented at this time to monitor the resident for further aggressive behaviors. An Incident/Accident Report dated 6/9/17 at 7:10 a.m. documented, Exact Location of Incident/Accident Be specific: Small dining area 400 hall . Describe exactly what happened: .Reported per staff members and hospice care worker on site that this R (resident) walked up to another resident and pinched the other R's leg L (left) other resident was in w/c (wheelchair) . Redirection out of other residents' personal space and move to lock down unit as soon as possible. The back of the Incident/Accident Report documented, Has it been documented, communicated, and Care Planned? Yes. Does the MDS reflect the interventions and same as care planned? Per MDS. Date of follow-up on interventions: (blank) . c. The Plan of Care updated on 6/9/17 documented, Behavioral Symptoms . Redirect resident PRN (as needed), Keep environment calm and relaxed, meet physiological needs and remove to private area when agitated. 5/21/17 Family reports resident's behavior includes sitting and lying in floor . Fall/Safety Risk/elopement risk . Observe on rounds (every) 30-60 minutes . Mood State: Assess, monitor & (and) document mood changes . The Plan of Care did not identify aggressive physical behaviors as a problem and did not document any interventions to address physical aggression or combative behaviors. d. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Exact Location of Incident/Accident Be specific: Feeders (residents who require assistance with eating) dining room . Became very aggressive after children left from visiting (resident) . Describe exactly what happened: .R (resident's) children just left facility from visiting. (Resident) walked in dining room when he pushed another resident up against a wall and started punching him repeatedly in stomach and chest until CNA stepped in between them to separate them . interventions . Attempt to keep residents apart . The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Does the MDS reflect the interventions and same as care planned? (blank). Date of follow-up on interventions: (blank). The Nurses Notes dated 6/11/17 at 4:00 p.m. regarding the above incident documented, .Called (physician) to get a Lorazepam 1 mg IM (intramuscular injection) order to help calm (resident). (Resident) was 1 on 1 until (resident) went to sleep. (With) CNAs after altercation . 2200 (10:00 p.m.) (Resident) has continued to be 1 on 1 with CNAs until (resident) finally fell asleep . e. Nurses Notes dated 6/15/17 on the 7:00 a.m. to 3:00 p.m. (7/3) shift documented, Behaviors grabbing staff, grabbing wheelchair and putting self face to face with staff. Resident requires constant monitoring to avoid falls and aggression towards residents. Nurses Notes dated 6/23/17 (not timed) documented, R continues to grab at people . Nurses Notes dated 6/26/17 on the 7/3 shift documented, Ambulates self and makes repetitive walks around hallway and dining area. Often wanders into other resident rooms and gets into other residents and staff personal space with intimidating stare . Frequent re-direction needed. Nurses Notes dated 6/27/17 on the 7/3 shift documented, Frequent redirection of resident required to remove from other residents' rooms and personal space. Resident continuous to grab at staff and other residents. Nurses Notes dated 6/29/17 on the 7/3 shift documented, Resident ambulates self throughout halls repetitively. Frequently redirection to prevent resident from grabbing staff and other resident. f. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident approached another resident who was sitting on the piano bench in the east D/R (dining room) area and resident began hitting the other resident. Staff intervened immediately . interventions .closely observe resident when he enters the space of other vulnerable resident and remove resident immediately. The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Date of follow-up on interventions: (blank) . Nurses Notes dated 6/30/17 (not timed) documented, Resident continues with behaviors of walking up to staff and other residents grabbing sometimes aggressively - difficulty with trying to get resident to release his grip on whatever article of clothing or item he has grabbed onto. g. An Incident/Accident Report dated 7/5/17 at 7:30 a.m. documented, Resident walked up to another resident and hit that resident (Resident #2) in the right eye . interventions . Keep away from close proximity of others. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . h. An Incident/Accident Report dated 7/9/17 at 11:00 p.m. documented, location of incident / accident . dining room . Resident hit another resident (Resident #2) in the right inner arm . no injuries or bruises noted . interventions . Keep both patients separated from each other and keep surrounding area free from incidents. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . The Nurses Notes dated 7/9/17 at 11:00 p.m. regarding the above incident documented, .CNA states he hit resident in the right arm. Noticed resident agitation. Resident throwed (sic) chair in dining room, pacing the floor. Clonazepam 0.5 mg PO given . i. Nurses notes dated 7/14/17 at 9:45 a.m. documented, Continues with aggressive behaviors of grabbing and pulling at w/c (wheelchair)/med cart/staff /etc (etcetera) - resident attempted to hit this nurse during am (morning) med (medication) pass . ambulating in continuous circling of hallway . j. A Weekly Summary dated 7/28/17 documented, .No (changes) - no new orders - (Resident) behaviors / wandering / grabbing / hitting others continues. (Resident) requires frequent redirection out of others' personal space and intervention from (resident) grabbing and not letting go of people's clothing / items / etc. (et cetera) . k. On 8/6/17 at 2:45 p.m., the resident was wandering up and down the hall and the east dining room where other residents were present. l. On 8/7/17 at 10:00 a.m., the resident was wandering aimlessly up and down the hall and in the dining room where other residents were present. At 10:03 a.m., the resident ambulated into room 307. There was no one in the room. The resident returned to wandering aimlessly in hallways and dining room where other residents were present. m. On 8/8/17 at 9:00 a.m., the resident was wandering up to other residents in the dining room, grabbing their clothes. n. On 8/8/17 at 11:42 a.m., the Director of Nursing (DON) was asked. What are the interventions for keeping residents safe on the secure wing? The DON stated, Keep (aggressive residents) separated from others. She was then asked, How do you do that? and stated, We usually send the aggressor out (to hospital or geriatric-psychiatric unit). As of 8/8/17 at 11:42 a.m., there was no documentation in the clinical record to indicate the resident had ever been transferred to a hospital or geriatric-psychiatric (geri-psych) facility for evaluation of his physically aggressive behaviors, and the Plan of Care had not been updated to address the resident's repeated aggressive behaviors and resident-to-resident altercations. o. Nurses Notes dated 8/8/17 at 6:45 p.m. documented, DON spoke (with) spouse (name) regarding need to do a geri-psych eval (evaluation). Spouse agreeable . p. On 8/9/17 at 10:50 a.m., the Director of Nursing was asked to provide any available documentation to demonstrate that this resident had been sent out (or received a geri-psych evaluation) after demonstrating aggressive behaviors, at any time since admission. As of 8/10/17 at 10:00 a.m., no documentation had been provided. 2. Resident #2 resided on the secure unit and had a [DIAGNOSES REDACTED]. The MDS with an ARD of 6/27/17 documented the resident understood others and was sometimes understood, scored 6 (0-7 indicates severe impairment) on the brief interview for mental status, had signs/symptoms of inattention and disorganized thinking that fluctuated, had behaviors of verbal behavioral symptoms directed toward others and wandering daily, required extensive assistance of two-plus persons for transfers, did not ambulate in the past 7 days and had one fall without injury. a. The Plan of Care updated 7/2/17 documented, Behavioral Symptoms . interventions . Redirect resident PRN (as needed), Keep environment calm & (and) relaxed, Meet Physiological needs, remove to private when agitated . Encourage diversional activities. b. An Incident/Accident report dated 7/4/17 at 7:15 a.m., documented, Resident was hit in his right eye area by another resident (Resident #1) that was walking past. c. Nurses Notes dated 7/9/17 at 11:00 p.m. documented, Called to 300 dining area found patient in wheelchair calmly. CNA stated a Resident (Resident #1) hit him in his right inner arm. d. Nurses Notes dated 7/11/17 at 8:00 p.m., documented, Resident very agitated this shift lunging at staff and other residents swinging at staff. The related witness statements documented the following: 1.) 7/11/17 at 8:35 p.m., Resident threw nurse to the floor. She tried to stop him for going into another room, punching and cursing. 2.) 7/11/17 at 10:10 p.m. documented, Resident has been very combative and aggressive all this shift. Waiting til the resident got the medicine from nurse and calmed down a bit. We asked the resident if he wanted to go to bed, he said no!! and slammed the door. A minute later the chair alarm was going off and went in room resident fell out of his chair. e. Nurses Notes dated 7/13/17 at 2:30 p.m. documented, Resident agitated, escalated to yelling disturbing the other residents and attempting to strike people. f. Nurses Notes dated 7/13/17 at 7:30 p.m. documented, Observed this resident in wheelchair attempting to go in and out of other residents' rooms looking for his keys 'going to load it' so he and family could go on a boating trip. Screaming at the other residents and staff cursing and threatening. g. On 8/7/17 at 8:30 a.m., the resident was at a table in the dining room. Two of his table mates were exchanging verbal behaviors and hitting at one another. There was no nurse or CNA in the dining area. A housekeeper was there and observed the behaviors, but did not intervene or report it to the nurse or staff. h. Nurses Notes dated 8/10/17 on the 11:00 p.m. to 7:00 a.m. (11-7) shift documented, Continues to call out for (wife's name) and hitting at staff members and other residents. i. As of 8/10/17, there had been no revisions to the plan of care since 7/2/17 to address the resident's physically aggressive behaviors. 3. Resident #7 resided on the secure unit and had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 6/14/17 documented the resident had short/long term memory problems, had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was inattentive and had disorganized thinking continuously, exhibited physical behavioral symptoms and verbal behaviors that occurred 1-2 times in the past 7 days and wandering that occurred daily and was independent with ambulation. a. The Plan of Care updated 6/19/17 documented, At risk for behaviors r/t (related to) . TBI (traumatic brain injury) and does not understand his surroundings. He often will go in a room inappropriately or become combative with staff during care . interventions . Report increased behaviors to MD (Medical Doctor), Pharmacy to review medications per policy, Encourage him to participate in activity with rock music, SSD (Social Services Department) to visit PRN, Allow him to express frustration redirect when attempting to enter other resident room, Activity to provided one on one weekly and offer HS (bed time) snack. b. An Incident/Accident Report dated 3/1/17 at 12:10 p.m. documented, As this nurse got to the DR (dining room), Resident was on his hands and knees. Witness stated another resident got up from his w/c (wheelchair) and hit this resident in the mouth with his fist, knocking resident down . interventions . other resident placed one-on-one. c. An Incident/Accident Report dated 3/6/17 at 8:00 a.m. documented, Resident was hit on the back of his head by another resident . interventions . Neuro checks started and resident to sit in a different area than resident that hit him. d. An Incident/Accident Report dated 3/20/17 at 12:20 a.m. documented, Resident walked up to another resident and struck resident x (times) 2 in the shoulder. The intervention was documented as, Attempt to keep residents apart. e. An Incident/Accident Report dated 3/23/17 at 12:15 p.m. documented, This resident was into other resident's personal space while other resident was in w/c at table in the DR. Other resident was yelling 'Get Away' this resident then hit other resident on the top of her head. The intervention documented Keep resident away from other residents as much as possible. f. An Incident/Accident Report dated 3/29/17 at 7:40 a.m. documented, this resident went up to other resident from behind, hit other resident on top of head, other resident then began hitting this resident in face and shoulder. Was separated immediately. The interventions documented, Separate Residents, Observe residents and keep them apart and gave resident a magazine to look at. g. An Incident/Accident Report dated 3/30/17 at 8:50 a.m. documented, CNA reported resident walked up to another resident and stumbled bumping other resident wheelchair, other resident struck resident in stomach. The interventions documented, Residents separated. Attempt to keep residents apart. h. An Incident/Accident Report dated 4/4/17 at (not timed) documented, Reported to this nurse per CNA that resident in an altercation with another resident. When the other resident pushed this resident down and resident fell in a sitting position to the floor. The intervention documented, Observe resident closely when in common area and intervene in a timely manner when resident noted to be wandering into other residents' space. Remove resident to a safe space and impose one-on-one with resident when necessary. i. An Incident/Accident Report dated 4/6/17 at 8:30 a.m. documented, Report per staff this resident was hitting other resident in common area on Central. This resident walked up into other resident personal space other resident starting hitting at this resident and this resident was swinging arms. The intervention documented Attempt redirection when getting in others personal space. j. An Incident/Accident Report dated 4/12/17 at 9:15 a.m. documented, Staff reported other resident hit this resident in the side. The intervention documented, Re-direct away from other resident. k. An Incident/Accident Report dated 4/13/17 at 7:30 a.m. documented, Staff reported this resident was in DR walking with staff to be seated for breakfast and passed by other resident sitting in chair and hit other resident in right cheek. The interventions documented, keep resident arm's length from other residents and offer private dining. l. An Incident/Accident Report dated 5/8/17 (not timed) documented Resident went over to table where another resident was sitting at DR table. The other resident started to hit him in the scrotum with his fist and then this resident hit the other resident on his shoulder. The interventions documented, Monitor resident at regular intervals when in DR to prevent him from standing over resident and touching and moving over them. Assist pt. (patient) to table and encourage him to sit down, offer snack until breakfast or other meal can be served. m. Nurses Notes dated 6/3/17 at 5:05 p.m. documented, Staff member reported to this nurse that resident pressed on the leg of another resident who then grabs this resident by his head, at which time the resident hit the other resident in the head. n. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Resident (Resident #1) came over and pushed him up against a wall and punched him repeatedly in the stomach and chest until (CNA) stepped in between them to separate them. The interventions documented, Attempt to keep residents apart. o. Nurses Notes dated 6/19/17 at 11:00 (p.m. or a.m. not specified) documented Wanders throughout facility gets in others personal space causing altercations often with other residents. p. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident sitting on piano bench in east DR area when another resident (Resident #1) walked up to him and started hitting him. Staff intervened immediately. Resident obtained 3 scratches to left side of neck. The intervention documented, Observe resident and ensure that resident is not sharing the same space with other residents that are prone to be combative. q. On 8/9/17 at 4:05 p.m., the resident was wandering up and down the hallway and in the dining room. r. As of 8/9/17, there had been no revisions added to the behavioral plan of care since 6/19/17 to address the resident's frequent aggressive behaviors and to protect the resident from aggression by other residents. 4. Resident #9 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/9/17 documented the resident had short/long term memory problems, was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status, had verbal behavioral symptoms directed toward others and required supervision with ambulation. a. The Plan of Care updated 3/16/17 did not address any behavior issues. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, Staff reported this resident was pushed down and then kicked in left hip thigh area. Resident was reported to have hit his head on chair during fall. Resident sitting in chair with discolored area to right side top of head with swelling. Refer to paragraph 'b' of Resident #10's findings below, which indicates this altercation began with Resident #9 striking Resident #10 prior to being pushed down and kicked by Resident #10. The hospital's emergency room attending attestation dated 7/31/17 documented the resident presented to the emergency department, with fall and assault victim, had a CT (computed tomography) without contrast . No traumatic injury or acute intracranial process. c. As of 8/7/17, there was no documentation on the Plan of Care to address aggressive or combative behaviors for this resident. 5. Resident #10 was admitted to the secure unit on 7/20/17 with a [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/27/17 documented the resident scored 3 (0-7 indicates severely impaired) on a brief interview for mental status, had no behaviors, was independent with ambulation in the room and required supervision with ambulation in the corridor. a. The Plan of Care updated 7/29/17 documented, Behavioral Symptoms . Redirect resident PRN, Keep environment calm and relaxed, meet physiological needs, remove resident to private area when agitated and encourage diversional activities. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, CNAs reported other resident (Resident #9) hit this resident (Resident #10) who pushed the other resident (Resident #9) who fell down and then this resident (Resident #10) kicked him (Resident #9) in left hip/thigh area while he was down .Placed one on one at this time, awaiting management direction. c. Nurses Notes dated 8/1/17 at 6:10 (no a.m. or p.m.) documented, Resident taken laundry barrel and dumped what was inside, cursing all the time, refused any one close to provide care. Very aggressive one-on-one this a.m. d. Nurses Notes dated 8/1/17 at 6:50 (no a.m. or p.m.) documented, Received orders to send resident to (geri-psych facility) for eval and TX (treatment). Spoke to (name) at (geri-psych facility) ok to send resident having behavior issues kicked another resident in the head charging at the staff cursing. Called (transport service) to transport resident. Resident refusing care from staff pulling at peg (percutaneous endoscopic gastrostomy) tube sling milk and stomach contents everywhere. 6. On 8/7/17 at 9:40 a.m., Licensed Practical Nurse (LPN) #1 was asked about adequate staffing on the secure unit to supervise aggressive residents and stated, I need 3 CNAs, but they won't give me that. The Housekeeper is the CNA Supervisor, and we have written staff up for not staying on the hall, but she throws them (write-ups) away. 7. On 8/7/17 at 10:40 a.m., the Director of Nursing (DON) was asked, Do you have a policy and/or procedure for admission to the secure unit? The DON stated, We don't have a policy /procedure; we decided if they are a danger or schizophrenic, or bipolar, we all talk about it and we decide. If any doubt, we forward the information to Corporate, and then we make the decision. The DON was asked, Is any special treatment provided on the unit? The DON stated, No. 8. On 8/7/17 at 11:10 a.m., CNA #1, who worked on the secure unit, was asked Have you had any training to deal with aggressive residents? The CNA stated, No. 9. On 8/7/17 at 11:12 a.m., CNA #2, who was working on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, No. 10. On 8/7/17 at 11:15 a.m., CNA #3, who worked on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, Not here, but I did at another facility. 11. On 8/8/17 at 9:00 a.m., Licensed Practical Nurse (LPN) #2 stated she switched CNA #3 (who was assigned to 200 hall) and CNA #4 (who was assigned to the secure unit), because CNA #3 normally worked the secure unit and would stay down there to work as assigned and had a better rapport with the residents on the secure unit. The LPN stated that CNA #4 would not stay on the unit when assigned and would leave the unit multiple times, but that CNA #4 had, thrown a fit and refused the change in assignment. 12. On 8/10/17 at 8:20 a.m., the facility's Policy/Procedure (P/P) for Mood and Behavior was provided by the Administrator. The policy documented, It is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. The Objective documented, The objective of the Mood and Behavior P/P is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. The plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being. Any mood and behavior symptoms will be documented by the interdisciplinary team .as well as interventions attempted and outcome. 13. The Immediate Jeopardy was removed on 8/9/17 at 1:00 p.m., and the scope/severity reduced to E when the following plan of removal was implemented. a. (Resident #1) will be admitted to Geri-psych per physician's orders [REDACTED]. b. Supervision of staff remaining on the secured unit will be documented by the Administrator / DON / Designee every 15 minutes to ensure that the scheduled (staff) are actually there. c. Education of all staff on identifying and managing behaviors, completing an I&A (incident/accident report) on resident to resident altercations and reporting resident to resident altercations to DON and Administrator will occur by the Administrator/designee. d. All residents with behaviors with cognitive impairment will be assess by Speech Therapy. All resident with mental illness [DIAGNOSES REDACTED]. e. Evaluate the resident to determine who are the aggressive residents and determine what interventions need to be in place f. An I&A will be completed on any Resident to Resident altercations. g. Any Resident to Resident incident will be reported to the Administrator and DON immediately. The perpetrator will be placed on 1:1 monitoring per the facility policy and documented on the flow sheet. h. Any Resident to Resident injury will be reported to OLTC (Office of Long Term Care). i. The Incident and Intervention will be placed on the 24-hour report so that all shifts are aware. j. The nurse will be instructed to start the Interventions which could include 1:1 (one on one) monitoring, k. All I&As will be reviewed by the Administrator/designee in morning Stand-up and Start-up to ensure proper intervention is in place. l. All interventions will be placed on the care plan by the MDS Coordinator directed after the Stand-up and Start-up meeting and verified by the Administrator/designee. m. Interventions will be communicated to staff daily on the closet care plan that will be updated daily by the MDS Coordinator and verified by the Administrator. B. Based on observation, record review and interview, the facility failed to ensure falls were investigated to determine causative factors, interventions were developed based on those causative factors and were evaluated for effectiveness, planned fall prevention interventions were consistently implemented, and adequate competent staff were available on the secure unit to supervise residents and minimize the potential for further falls / injuries for 3 (Residents #1, #2 and #7) of 4 (Residents #1, #2, #9 and #7) case mix residents who had a history of [REDACTED]. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #1, #2, and #7, who experienced repeated falls, and had the potential to cause more than minimal harm to 13 residents who resided on the secure unit, according to a list provided by the Administrator on 8/23/17. The Administrator was notified of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. Resident #1 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/26/17 documented the resident had short/long term memory problems, was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status and had a fall without injury since admission or prior assessment, required supervision with set up help only for bed mobility, transfers and ambulating on the unit. a. An Incident/Accident Report dated 5/27/17 at 9:15 p.m. documented, Called to resident's room by CNA, found patient on left side in the floor . interventions . Safety mattress beside pt. (patient's) bed, Bed alarm to alert staff of pt. out of bed and no [DIAGNOSES REDACTED] of environment especially resident's room. b. An Incident/Accident Report dated 6/1/17 at 11:55 p.m. documented, Call to resident room, observed resident on floor with laceration to forehead 2 cm (centimeter) long and 1/10 cm wide. There was no assessment/investigation completed to identify causative factors and no documentation interventions were developed to prevent further potential falls or minimize the potential for fall-related injuries. c. A physician's orders [REDACTED]. d. An Incident/Accident Report dated 6/9/17 at 6:00 p.m. documented, Called to another resident room found resident lying on the floor . interventions . Monitor more closely and(TRUNCATED)

Complaint # (AR 169) and Complaint # (AR 310) was substantiated, all or in part, with these findings: A. Based on observations, record reviews and interviews, the facility's Administration and Nursing Administration failed to identify and intervene to correct ongoing failures to ensure supervision and adequate competent staff were provided on the secure unit to promptly intervene when residents exhibited aggressive behaviors and prevent resident-to-resident altercations, staff who worked on the secure unit were trained on dementia care and how to intervene with residents who exhibited aggressive behaviors, residents who had a history of [REDACTED].#1, #2, #7, #9 and #10) of 5 case mix residents who had aggressive behaviors. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm injury or death to Residents #1, #2, #7, #9 and #10, and had the potential to cause more than minimal harm to 14 residents who resided on the secure unit, as documented on a list provided by the Interim Administrator on 8/22/17. The Interim Administrator was notified of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. The Job Description for the Chief Executive Officer (CEO), provided by the Interim Administrator on 8/10/17 at 8:20 a.m., documented, To lead and direct the overall operation of the facility in accordance with government regulations and company policies with focus on maintaining excellent care for the residents . 2. The Job Description for the Director of Nursing, provided by the Interim Administrator on 8/10/17 at 8:20 a.m., documented, To lead and direct the overall operations of the facility in accordance with government regulations. Oversees regular rounds to monitor the delivery of care . 3. Resident #1 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/17 documented the resident had no speech, was rarely/never understood, had short/long term memory problems, had severely impaired cognitive skills for daily decision-making per a staff assessment for mental status, was inattentive, wandered daily which significantly intruded on the privacy and activities of others, had daily preferences including having family or a close friend involved in discussions about care, required supervision with set up help only for bed mobility, transfers and ambulating on the unit, received antipsychotic medications on 6 of the past 7 days. a. Nurses Notes dated 5/23/17 at 10:10 a.m. documented, MD (Medical Doctor) made rounds + (and) NOS (new orders) D/C (discontinue) previous [MEDICATION NAME] order (and change) to QD (every day) R/T (related to) Dementia (with) Beh (behavioral) dist (disturbance) (and) drowsiness. Order processed . Nurses Notes dated 5/24/17 at 10:00 a.m. documented, .0 (no) real (changes) in mood, (no) behaviors noted at this time . Nurses Notes dated 5/24/17 at 10:00 p.m. documented, .Resident showing signs of combativeness when attempting to strike staff who was attempting to remove (resident) from exit door. Resident calmed down and was able to be redirected by staff . Nurses Notes dated 5/25/17 at 3:45 p.m. documented, 1. D/C [MEDICATION NAME] (antipsychotic). 2. D/C [MEDICATION NAME] (sedative) (at) hs (bedtime). 3. D/C Mirtazepine (antidepressant). 4. (Change) [MEDICATION NAME] to BID (twice daily) PRN (as needed) per APN (Advanced Practice Nurse) on rounds. Orders processed. Will notify family (drowsiness) . Nurses Notes dated 6/1/17 at 2:10 p.m. documented, New orders - [MEDICATION NAME] (antidepressant) qhs (every night at bedtime) 7.5 mg (milligrams). [MEDICATION NAME] (antipsychotic) 0.25 mg PO (by mouth) qhs . Nurses Notes dated 6/8/17 at 9:30 a.m. documented, .(Resident) is a 'wanderer' and requires frequent re-directing and removal from other (resident) rooms . (Resident) continues to get behind nurses station and stand over staff and attempt to remove items off desk and or touch nurses inappropriately . b. Nurses Notes dated 6/9/17 at 6:45 a.m. documented, Resident walk up to a CNA (Certified Nursing Assistant) sitting in dining room and punch the CNA in the face . There was no documentation of any intervention or added supervision implemented at this time to monitor the resident for further aggressive behaviors. An Incident/Accident Report dated 6/9/17 at 7:10 a.m. documented, Exact Location of Incident/Accident Be specific: Small dining area 400 hall . Describe exactly what happened: .Reported per staff members and hospice care worker on site that this R (resident) walked up to another resident and pinched the other R's leg L (left) other resident was in w/c (wheelchair) . Redirection out of other residents' personal space and move to lock down unit as soon as possible. The back of the Incident/Accident Report documented, Has it been documented, communicated, and Care Planned? Yes. Does the MDS reflect the interventions and same as care planned? Per MDS. Date of follow-up on interventions: (blank) . c. The Plan of Care updated on 6/9/17 documented, Behavioral Symptoms . Redirect resident PRN (as needed), Keep environment calm and relaxed, meet physiological needs and remove to private area when agitated. 5/21/17 Family reports resident's behavior includes sitting and lying in floor . Fall/Safety Risk/elopement risk . Observe on rounds (every) 30-60 minutes . Mood State: Assess, monitor & (and) document mood changes . The Plan of Care did not identify aggressive physical behaviors as a problem and did not document any interventions to address physical aggression or combative behaviors. d. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Exact Location of Incident/Accident Be specific: Feeders (residents who require assistance with eating) dining room . Became very aggressive after children left from visiting (resident) . Describe exactly what happened: .R (resident's) children just left facility from visiting. (Resident) walked in dining room when he pushed another resident up against a wall and started punching him repeatedly in stomach and chest until CNA stepped in between them to separate them . interventions . Attempt to keep residents apart . The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Does the MDS reflect the interventions and same as care planned? (blank). Date of follow-up on interventions: (blank). The Nurses Notes dated 6/11/17 at 4:00 p.m. regarding the above incident documented, .Called (physician) to get a [MEDICATION NAME] 1 mg IM (intramuscular injection) order to help calm (resident). (Resident) was 1 on 1 until (resident) went to sleep. (With) CNAs after altercation . 2200 (10:00 p.m.) (Resident) has continued to be 1 on 1 with CNAs until (resident) finally fell asleep . e. Nurses Notes dated 6/15/17 on the 7:00 a.m. to 3:00 p.m. (7/3) shift documented, Behaviors grabbing staff, grabbing wheelchair and putting self face to face with staff. Resident requires constant monitoring to avoid falls and aggression towards residents. Nurses Notes dated 6/23/17 (not timed) documented, R continues to grab at people . Nurses Notes dated 6/26/17 on the 7/3 shift documented, Ambulates self and makes repetitive walks around hallway and dining area. Often wanders into other resident rooms and gets into other residents and staff personal space with intimidating stare . Frequent re-direction needed. Nurses Notes dated 6/27/17 on the 7/3 shift documented, Frequent redirection of resident required to remove from other residents' rooms and personal space. Resident continuous to grab at staff and other residents. Nurses Notes dated 6/29/17 on the 7/3 shift documented, Resident ambulates self throughout halls repetitively. Frequently redirection to prevent resident from grabbing staff and other resident. f. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident approached another resident who was sitting on the piano bench in the east D/R (dining room) area and resident began hitting the other resident. Staff intervened immediately . interventions .closely observe resident when he enters the space of other vulnerable resident and remove resident immediately. The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Date of follow-up on interventions: (blank) . Nurses Notes dated 6/30/17 (not timed) documented, Resident continues with behaviors of walking up to staff and other residents grabbing sometimes aggressively - difficulty with trying to get resident to release his grip on whatever article of clothing or item he has grabbed onto. g. An Incident/Accident Report dated 7/5/17 at 7:30 a.m. documented, Resident walked up to another resident and hit that resident (Resident #2) in the right eye . interventions . Keep away from close proximity of others. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . h. An Incident/Accident Report dated 7/9/17 at 11:00 p.m. documented, location of incident / accident . dining room . Resident hit another resident (Resident #2) in the right inner arm . no injuries or bruises noted . interventions . Keep both patients separated from each other and keep surrounding area free from incidents. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . The Nurses Notes dated 7/9/17 at 11:00 p.m. regarding the above incident documented, .CNA states he hit resident in the right arm. Noticed resident agitation. Resident throwed (sic) chair in dining room, pacing the floor. [MEDICATION NAME] 0.5 mg PO given . h. Nurses notes dated 7/14/17 at 9:45 a.m. documented, Continues with aggressive behaviors of grabbing and pulling at w/c (wheelchair)/med cart/staff /etc (etcetera) - resident attempted to hit this nurse during am (morning) med (medication) pass . ambulating in continuous circling of hallway . i. A Weekly Summary dated 7/28/17 documented, .No (changes) - no new orders - (Resident) behaviors / wandering / grabbing / hitting others continues. (Resident) requires frequent redirection out of others' personal space and intervention from (resident) grabbing and not letting go of people's clothing / items / etc. (et cetera) . j. On 8/6/17 at 2:45 p.m., the resident was wandering up and down the hall and the east dining room where other residents were present. k. On 8/7/17 at 10:00 a.m., the resident was wandering aimlessly up and down the hall and in the dining room where other residents were present. At 10:03 a.m., the resident ambulated into room [ROOM NUMBER]. There was no one in the room. The resident returned to wandering aimlessly in hallways and dining room where other residents were present. l. On 8/8/17 at 9:00 a.m., the resident was wandering up to other residents in the dining room, grabbing their clothes. m. On 8/8/17 at 11:42 a.m., the Director of Nursing (DON) was asked. What are the interventions for keeping residents safe on the secure wing? The DON stated, Keep (aggressive residents) separated from others. She was then asked, How do you do that? and stated, We usually send the aggressor out (to hospital or geriatric-psychiatric unit). As of 8/8/17 at 11:42 a.m., there was no documentation in the clinical record to indicate the resident had ever been transferred to a hospital or geriatric-psychiatric (geri-psych) facility for evaluation of his physically aggressive behaviors, and the Plan of Care had not been updated to address the resident's repeated aggressive behaviors and resident-to-resident altercations. n. Nurses Notes dated 8/8/17 at 6:45 p.m. documented, DON spoke (with) spouse (name) regarding need to do a geri-psych eval (evaluation). Spouse agreeable . o. On 8/9/17 at 10:50 a.m., the Director of Nursing was asked to provide any available documentation to demonstrate that this resident had been sent out (or received a geri-psych evaluation) after demonstrating aggressive behaviors, at any time since admission. As of 8/10/17 at 10:00 a.m., no documentation had been provided. 4. Resident #2 resided on the secure unit and had a [DIAGNOSES REDACTED]. The MDS with an ARD of 6/27/17 documented the resident understood others and was sometimes understood, scored 6 (0-7 indicates severe impairment) on the brief interview for mental status, had signs/symptoms of inattention and disorganized thinking that fluctuated, had behaviors of verbal behavioral symptoms directed toward others and wandering daily, required extensive assistance of two-plus persons for transfers, did not ambulate in the past 7 days and had one fall without injury. a. The Plan of Care updated 7/2/17 documented, Behavioral Symptoms . interventions . Redirect resident PRN (as needed), Keep environment calm & (and) relaxed, Meet Physiological needs, remove to private when agitated . Encourage diversional activities. b. An Incident/Accident report dated 7/4/17 at 7:15 a.m., documented, Resident was hit in his right eye area by another resident (Resident #1) that was walking past. c. Nurses Notes dated 7/9/17 at 11:00 p.m. documented, Called to 300 dining area found patient in wheelchair calmly. CNA stated a Resident (Resident #1) hit him in his right inner arm. d. Nurses Notes dated 7/11/17 at 8:00 p.m., documented, Resident very agitated this shift lunging at staff and other residents swinging at staff. The related witness statements documented the following: 1.) 7/11/17 at 8:35 p.m., Resident threw nurse to the floor. She tried to stop him for going into another room, punching and cursing. 2.) 7/11/17 at 10:10 p.m. documented, Resident has been very combative and aggressive all this shift. Waiting til the resident got the medicine from nurse and calmed down a bit. We asked the resident if he wanted to go to bed, he said no!! and slammed the door. A minute later the chair alarm was going off and went in room resident fell out of his chair. e. Nurses Notes dated 7/13/17 at 2:30 p.m. documented, Resident agitated, escalated to yelling disturbing the other residents and attempting to strike people. f. Nurses Notes dated 7/13/17 at 7:30 p.m. documented, Observed this resident in wheelchair attempting to go in and out of other residents' rooms looking for his keys 'going to load it' so he and family could go on a boating trip. Screaming at the other residents and staff cursing and threatening. g. On 8/7/17 at 8:30 a.m., the resident was at a table in the dining room. Two of his table mates were exchanging verbal behaviors and hitting at one another. There was no nurse or CNA in the dining area. A housekeeper was there and observed the behaviors, but did not intervene or report it to the nurse or staff. h. Nurses Notes dated 8/10/17 on the 11:00 p.m. to 7:00 a.m. (11-7) shift documented, Continues to call out for (wife's name) and hitting at staff members and other residents. i. As of 8/10/17, there had been no revisions to the plan of care since 7/2/17 to address the resident's physically aggressive behaviors. 5. Resident #7 resided on the secure unit and had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 6/14/17 documented the resident had short/long term memory problems, had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was inattentive and had disorganized thinking continuously, exhibited physical behavioral symptoms and verbal behaviors that occurred 1-2 times in the past 7 days and wandering that occurred daily and was independent with ambulation. a. The Plan of Care updated 6/19/17 documented, At risk for behaviors r/t (related to) . TBI ([MEDICAL CONDITION]) and does not understand his surroundings. He often will go in a room inappropriately or become combative with staff during care . interventions . Report increased behaviors to MD (Medical Doctor), Pharmacy to review medications per policy, Encourage him to participate in activity with rock music, SSD (Social Services Department) to visit PRN, Allow him to express frustration redirect when attempting to enter other resident room, Activity to provided one on one weekly and offer HS (bed time) snack. b. An Incident/Accident Report dated 3/1/17 at 12:10 p.m. documented, As this nurse got to the DR (dining room), Resident was on his hands and knees. Witness stated another resident got up from his w/c (wheelchair) and hit this resident in the mouth with his fist, knocking resident down . interventions . other resident placed one-on-one. c. An Incident/Accident Report dated 3/6/17 at 8:00 a.m. documented, Resident was hit on the back of his head by another resident . interventions . Neuro checks started and resident to sit in a different area than resident that hit him. d. An Incident/Accident Report dated 3/20/17 at 12:20 a.m. documented, Resident walked up to another resident and struck resident x (times) 2 in the shoulder. The intervention was documented as, Attempt to keep residents apart. e. An Incident/Accident Report dated 3/23/17 at 12:15 p.m. documented, This resident was into other resident's personal space while other resident was in w/c at table in the DR. Other resident was yelling 'Get Away' this resident then hit other resident on the top of her head. The intervention documented Keep resident away from other residents as much as possible. f. An Incident/Accident Report dated 3/29/17 at 7:40 a.m. documented, this resident went up to other resident from behind, hit other resident on top of head, other resident then began hitting this resident in face and shoulder. Was separated immediately. The interventions documented, Separate Residents, Observe residents and keep them apart and gave resident a magazine to look at. g. An Incident/Accident Report dated 3/30/17 at 8:50 a.m. documented, CNA reported resident walked up to another resident and stumbled bumping other resident wheelchair, other resident struck resident in stomach. The interventions documented, Residents separated. Attempt to keep residents apart. h. An Incident/Accident Report dated 4/4/17 at (not timed) documented, Reported to this nurse per CNA that resident in an altercation with another resident. When the other resident pushed this resident down and resident fell in a sitting position to the floor. The intervention documented, Observe resident closely when in common area and intervene in a timely manner when resident noted to be wandering into other residents' space. Remove resident to a safe space and impose one-on-one with resident when necessary. i. An Incident/Accident Report dated 4/6/17 at 8:30 a.m. documented, Report per staff this resident was hitting other resident in common area on Central. This resident walked up into other resident personal space other resident starting hitting at this resident and this resident was swinging arms. The intervention documented Attempt redirection when getting in others personal space. j. An Incident/Accident Report dated 4/12/17 at 9:15 a.m. documented, Staff reported other resident hit this resident in the side. The intervention documented, Re-direct away from other resident. k. An Incident/Accident Report dated 4/13/17 at 7:30 a.m. documented, Staff reported this resident was in DR walking with staff to be seated for breakfast and passed by other resident sitting in chair and hit other resident in right cheek. The interventions documented, keep resident arm's length from other residents and offer private dining. l. An Incident/Accident Report dated 5/8/17 (not timed) documented Resident went over to table where another resident was sitting at DR table. The other resident started to hit him in the scrotum with his fist and then this resident hit the other resident on his shoulder. The interventions documented, Monitor resident at regular intervals when in DR to prevent him from standing over resident and touching and moving over them. Assist pt. (patient) to table and encourage him to sit down, offer snack until breakfast or other meal can be served. m. Nurses Notes dated 6/3/17 at 5:05 p.m. documented, Staff member reported to this nurse that resident pressed on the leg of another resident who then grabs this resident by his head, at which time the resident hit the other resident in the head. n. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Resident (Resident #1) came over and pushed him up against a wall and punched him repeatedly in the stomach and chest until (CNA) stepped in between them to separate them. The interventions documented, Attempt to keep residents apart. o. Nurses Notes dated 6/19/17 at 11:00 (p.m. or a.m. not specified) documented Wanders throughout facility gets in others personal space causing altercations often with other residents. p. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident sitting on piano bench in east DR area when another resident (Resident #1) walked up to him and started hitting him. Staff intervened immediately. Resident obtained 3 scratches to left side of neck. The intervention documented, Observe resident and ensure that resident is not sharing the same space with other residents that are prone to be combative. q. On 8/9/17 at 4:05 p.m., the resident was wandering up and down the hallway and in the dining room. r. As of 8/9/17, there had been no revisions added to the behavioral plan of care since 6/19/17 to address the resident's frequent aggressive behaviors and to protect the resident from aggression by other residents. 6. Resident #9 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/9/17 documented the resident had short/long term memory problems, was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status, had verbal behavioral symptoms directed toward others and required supervision with ambulation. a. The Plan of Care updated 3/16/17 did not address any behavior issues. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, Staff reported this resident was pushed down and then kicked in left hip thigh area. Resident was reported to have hit his head on chair during fall. Resident sitting in chair with discolored area to right side top of head with swelling. Refer to paragraph 'b' of Resident #10's findings below, which indicates this altercation began with Resident #9 striking Resident #10 prior to being pushed down and kicked by Resident #10. The hospital's emergency room attending attestation dated 7/31/17 documented the resident presented to the emergency department, with fall and assault victim, had a CT (computed tomography) without contrast . No traumatic injury or acute intracranial process. c. As of 8/7/17, there was no documentation on the Plan of Care to address aggressive or combative behaviors for this resident. 7. Resident #10 was admitted to the secure unit on 7/20/17 with a [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/27/17 documented the resident scored 3 (0-7 indicates severely impaired) on a brief interview for mental status, had no behaviors, was independent with ambulation in the room and required supervision with ambulation in the corridor. a. The Plan of Care updated 7/29/17 documented, Behavioral Symptoms . Redirect resident PRN, Keep environment calm and relaxed, meet physiological needs, remove resident to private area when agitated and encourage diversional activities. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, CNAs reported other resident (Resident #9) hit this resident (Resident #10) who pushed the other resident (Resident #9) who fell down and then this resident (Resident #10) kicked him (Resident #9) in left hip/thigh area while he was down .Placed one on one at this time, awaiting management direction. c. Nurses Notes dated 8/1/17 at 6:10 (no a.m. or p.m.) documented, Resident taken laundry barrel and dumped what was inside, cursing all the time, refused any one close to provide care. Very aggressive one-on-one this a.m. d. Nurses Notes dated 8/1/17 at 6:50 (no a.m. or p.m.) documented, Received orders to send resident to (geri-psych facility) for eval and TX (treatment). Spoke to (name) at (geri-psych facility) ok to send resident having behavior issues kicked another resident in the head charging at the staff cursing. Called (transport service) to transport resident. Resident refusing care from staff pulling at peg (percutaneous endoscopic gastrostomy) tube sling milk and stomach contents everywhere. 8. On 8/7/17 at 9:40 a.m., Licensed Practical Nurse (LPN) #1 was asked about adequate staffing on the secure unit to supervise aggressive residents and stated, I need 3 CNAs, but they won't give me that. The Housekeeper is the CNA Supervisor, and we have written staff up for not staying on the hall, but she throws them (write-ups) away. 9. On 8/7/17 at 10:40 a.m., the Director of Nursing (DON) was asked, Do you have a policy and/or procedure for admission to the secure unit? The DON stated, We don't have a policy /procedure; we decided if they are a danger or [MEDICAL CONDITION], or [MEDICAL CONDITION], we all talk about it and we decide. If any doubt, we forward the information to Corporate, and then we make the decision. The DON was asked, Is any special treatment provided on the unit? The DON stated, No. 10. On 8/7/17 at 11:10 a.m., CNA #1, who worked on the secure unit, was asked Have you had any training to deal with aggressive residents? The CNA stated, No. 11. On 8/7/17 at 11:12 a.m., CNA #2, who was working on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, No. 12. On 8/7/17 at 11:15 a.m., CNA #3, who worked on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, Not here, but I did at another facility. 13. On 8/8/17 at 9:00 a.m., Licensed Practical Nurse (LPN) #2 stated she switched CNA #3 (who was assigned to 200 hall) and CNA #4 (who was assigned to the secure unit), because CNA #3 normally worked the secure unit and would stay down there to work as assigned and had a better rapport with the residents on the secure unit. The LPN stated that CNA #4 would not stay on the unit when assigned and would leave the unit multiple times, but that CNA #4 had, thrown a fit and refused the change in assignment. 14. On 8/10/17 at 8:20 a.m., the facility's Policy/Procedure (P/P) for Mood and Behavior was provided by the Interim Administrator. The policy documented, It is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. The Objective documented, The objective of the Mood and Behavior P/P is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. The plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being. Any mood and behavior symptoms will be documented by the interdisciplinary team .as well as interventions attempted and outcome. 15. The Immediate Jeopardy was removed on 8/9/17 at 1:00 p.m., and the scope/severity reduced to E when the following plan of removal was implemented. a. (Resident #1) will be admitted to Geri-psych per physician's orders [REDACTED]. b. Supervision of staff remaining on the secured unit will be documented by the Administrator / DON / Designee every 15 minutes to ensure that the scheduled (staff) are actually there. c. Education of all staff on identifying and managing behaviors, completing an I&A (incident/accident report) on resident to resident altercations and reporting resident to resident altercations to DON and Administrator will occur by the Administrator/designee. d. All residents with behaviors with cognitive impairment will be assess by Speech Therapy. All resident with mental illness [DIAGNOSES REDACTED]. e. Evaluate the resident to determine who are the aggressive residents and determine what interventions need to be in place f. An I&A will be completed on any Resident to Resident altercations. g. Any Resident to Resident incident will be reported to the Administrator and DON immediately. The perpetrator will be placed on 1:1 monitoring per the facility policy and documented on the flow sheet. h. Any Resident to Resident injury will be reported to OLTC (Office of Long Term Care). i. The Incident and Intervention will be placed on the 24-hour report so that all shifts are aware. j. The nurse will be instructed to start the Interventions which could include 1:1 (one on one) monitoring, k. All I&As will be reviewed by the Administrator/designee in morning Stand-up and Start-up to ensure proper intervention is in place. l. All interventions will be placed on the care plan by the MDS Coordinator directed after the Stand-up and Start-up meeting and verified by the Administrator/designee. m. Interventions will be communicated to staff daily on the closet care plan that will be updated daily by the MDS Coordinator and verified by the Administrator. B. Based on observation, record review and interview, the facility's Administration and Nursing Administration failed to identify and intervene to correct ongoing failures to ensure falls were investigated to determine causative factors, interventions were developed based on those causative factors and were evaluated for effectiveness, planned fall prevention interventions were consistently implemented, and adequate competent staff were available on the secure unit to supervise residents and minimize the potential for further falls / injuries for 3 (Residents #1, #2 and #7) of 4 (Residents #1, #2, #9 and #7) case mix residents who had a history of [REDACTED]. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #1, #2, and #7, who experienced repeated falls, and had the potential to cause more than minimal harm to 13 residents who resided on the secure unit, according to a list provided by the Interim Administrator on 8/23/17. The Interim Administrator was notified of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. The Job Description for the Chief Executive Officer (CEO), provided by Interim Administrator on 8/10/17 at 8:20 a.m., documented, To lead and direct the overall operation of the facility in accordance with government regulations and company policies with focus on maintaining excellent care for the residents . 2. The Job Description for the Director of Nursing, provided by Interim Administrator on 8/10/17 at 8:20 a.m., documented, To lead and direct the overall operations of the facility in accordance with government regulations. Oversees regular rounds to monitor the delivery of care . 3. Resident #1 resided on the secure unit and had (TRUNCATED)

Complaint # (AR 169) and Complaint # (AR 310) was substantiated, all or in part, with these findings: A. Based on observation, record review and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to identify quality deficiencies and put corrective action plans in place with regard to ongoing failures to ensure supervision and adequate competent staff were provided on the secure unit to promptly intervene when residents exhibited aggressive behaviors and prevent resident-to-resident altercations, staff who worked on the secure unit were trained on dementia care and how to intervene with residents who exhibited aggressive behaviors, residents who had a history of [REDACTED].#1, #2, #7, #9 and #10) of 5 case mix residents who had aggressive behaviors. The failed practices resulted in immediate jeopardy, which caused, or could have caused serious harm injury or death to Residents #1, #2, #7, #9 and #10, and had the potential to cause more than minimal harm to 13 residents who resided on the secure unit, as documented on a list provided by the Interim Administrator on 8/23/17. The Interim Administrator was notified of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. Resident #1 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/17 documented the resident had no speech, was rarely/never understood, had short/long term memory problems, had severely impaired cognitive skills for daily decision-making per a staff assessment for mental status, was inattentive, wandered daily which significantly intruded on the privacy and activities of others, had daily preferences including having family or a close friend involved in discussions about care, required supervision with set up help only for bed mobility, transfers and ambulating on the unit, received antipsychotic medications on 6 of the past 7 days, a. Nurses Notes dated 5/23/17 at 10:10 a.m. documented, MD (Medical Doctor) made rounds + (and) NOS (new orders) D/C (discontinue) previous [MEDICATION NAME] order (and change) to QD (every day) R/T (related to) Dementia (with) Beh (behavioral) dist (disturbance) (and) drowsiness. Order processed . Nurses Notes dated 5/24/17 at 10:00 a.m. documented, .0 (no) real (changes) in mood, (no) behaviors noted at this time . Nurses Notes dated 5/24/17 at 10:00 p.m. documented, .Resident showing signs of combativeness when attempting to strike staff who was attempting to remove (resident) from exit door. Resident calmed down and was able to be redirected by staff . Nurses Notes dated 5/25/17 at 3:45 p.m. documented, 1. D/C [MEDICATION NAME] (antipsychotic). 2. D/C [MEDICATION NAME] (sedative) (at) hs (bedtime). 3. D/C Mirtazepine (antidepressant). 4. (Change) [MEDICATION NAME] to BID (twice daily) PRN (as needed) per APN (Advanced Practice Nurse) on rounds. Orders processed. Will notify family (drowsiness) . Nurses Notes dated 6/1/17 at 2:10 p.m. documented, New orders - [MEDICATION NAME] (antidepressant) qhs (every night at bedtime) 7.5 mg (milligrams). [MEDICATION NAME] (antipsychotic) 0.25 mg PO (by mouth) qhs . Nurses Notes dated 6/8/17 at 9:30 a.m. documented, . (Resident) is a 'wanderer' and requires frequent re-directing and removal from other (resident) rooms . (Resident) continues to get behind nurses station and stand over staff and attempt to remove items off desk and or touch nurses inappropriately . b. Nurses Notes dated 6/9/17 at 6:45 a.m. documented, Resident walk up to a CNA (Certified Nursing Assistant) sitting in dining room and punch the CNA in the face . There was no documentation of any intervention or added supervision implemented at this time to monitor the resident for further aggressive behaviors. An Incident/Accident Report dated 6/9/17 at 7:10 a.m. documented, Exact Location of Incident/Accident Be specific: Small dining area 400 hall . Describe exactly what happened: .Reported per staff members and hospice care worker on site that this R (resident) walked up to another resident and pinched the other R's leg L (left) other resident was in w/c (wheelchair) . Redirection out of other residents' personal space and move to lock down unit as soon as possible. The back of the Incident/Accident Report documented, Has it been documented, communicated, and Care Planned? Yes. Does the MDS reflect the interventions and same as care planned? Per MDS. Date of follow-up on interventions: (blank) . c. The Plan of Care updated on 6/9/17 documented, Behavioral Symptoms . Redirect resident PRN (as needed), Keep environment calm and relaxed, meet physiological needs and remove to private area when agitated. 5/21/17 Family reports resident's behavior includes sitting and lying in floor . Fall/Safety Risk/elopement risk . Observe on rounds (every) 30-60 minutes . Mood State: Assess, monitor & (and) document mood changes . The Plan of Care did not identify aggressive physical behaviors as a problem and did not document any interventions to address physical aggression or combative behaviors. d. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Exact Location of Incident/Accident Be specific: Feeders (residents who require assistance with eating) dining room . Became very aggressive after children left from visiting (resident) . Describe exactly what happened: .R (resident's) children just left facility from visiting. (Resident) walked in dining room when he pushed another resident up against a wall and started punching him repeatedly in stomach and chest until CNA stepped in between them to separate them . interventions . Attempt to keep residents apart . The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Does the MDS reflect the interventions and same as care planned? (blank). Date of follow-up on interventions: (blank). The Nurses Notes dated 6/11/17 at 4:00 p.m. regarding the above incident documented, .Called (physician) to get a [MEDICATION NAME] 1 mg IM (intramuscular injection) order to help calm (resident). (Resident) was 1 on 1 until (resident) went to sleep. (With) CNAs after altercation . 2200 (10:00 p.m.) (Resident) has continued to be 1 on 1 with CNAs until (resident) finally fell asleep . e. Nurses Notes dated 6/15/17 on the 7:00 a.m. to 3:00 p.m. (7/3) shift documented, Behaviors grabbing staff, grabbing wheelchair and putting self face to face with staff. Resident requires constant monitoring to avoid falls and aggression towards residents. Nurses Notes dated 6/23/17 (not timed) documented, R continues to grab at people . Nurses Notes dated 6/26/17 on the 7/3 shift documented, Ambulates self and makes repetitive walks around hallway and dining area. Often wanders into other resident rooms and gets into other residents and staff personal space with intimidating stare . Frequent re-direction needed. Nurses Notes dated 6/27/17 on the 7/3 shift documented, Frequent redirection of resident required to remove from other residents' rooms and personal space. Resident continuous to grab at staff and other residents. Nurses Notes dated 6/29/17 on the 7/3 shift documented, Resident ambulates self throughout halls repetitively. Frequently redirection to prevent resident from grabbing staff and other resident. f. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident approached another resident who was sitting on the piano bench in the east D/R (dining room) area and resident began hitting the other resident. Staff intervened immediately . interventions .closely observe resident when he enters the space of other vulnerable resident and remove resident immediately. The back of the report documented, Has it been documented, communicated and Care Planned? (blank). Date of follow-up on interventions: (blank) . Nurses Notes dated 6/30/17 (not timed) documented, Resident continues with behaviors of walking up to staff and other residents grabbing sometimes aggressively - difficulty with trying to get resident to release his grip on whatever article of clothing or item he has grabbed onto. g. An Incident/Accident Report dated 7/5/17 at 7:30 a.m. documented, Resident walked up to another resident and hit that resident (Resident #2) in the right eye . interventions . Keep away from close proximity of others. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . h. An Incident/Accident Report dated 7/9/17 at 11:00 p.m. documented, location of incident / accident . dining room . Resident hit another resident (Resident #2) in the right inner arm . no injuries or bruises noted . interventions . Keep both patients separated from each other and keep surrounding area free from incidents. The back of the report documented, Has it been documented, communicated, and Care Planned? (blank). Date of follow-up on interventions: (blank) . The Nurses Notes dated 7/9/17 at 11:00 p.m. regarding the above incident documented, .CNA states he hit resident in the right arm. Noticed resident agitation. Resident throwed (sic) chair in dining room, pacing the floor. [MEDICATION NAME] 0.5 mg PO given . i. Nurses notes dated 7/14/17 at 9:45 a.m. documented, Continues with aggressive behaviors of grabbing and pulling at w/c (wheelchair)/med cart/staff /etc (etcetera) - resident attempted to hit this nurse during am (morning) med (medication) pass . ambulating in continuous circling of hallway . j. A Weekly Summary dated 7/28/17 documented, .No (changes) - no new orders - (Resident) behaviors / wandering / grabbing / hitting others continues. (Resident) requires frequent redirection out of others' personal space and intervention from (resident) grabbing and not letting go of people's clothing / items / etc. (et cetera) . k. On 8/6/17 at 2:45 p.m., the resident was wandering up and down the hall and the east dining room where other residents were present. l. On 8/7/17 at 10:00 a.m., the resident was wandering aimlessly up and down the hall and in the dining room where other residents were present. At 10:03 a.m., the resident ambulated into room [ROOM NUMBER]. There was no one in the room. The resident returned to wandering aimlessly in hallways and dining room where other residents were present. m. On 8/8/17 at 9:00 a.m., the resident was wandering up to other residents in the dining room, grabbing their clothes. n. On 8/8/17 at 11:42 a.m., the Director of Nursing (DON) was asked. What are the interventions for keeping residents safe on the secure wing? The DON stated, Keep (aggressive residents) separated from others. She was then asked, How do you do that? and stated, We usually send the aggressor out (to hospital or geriatric-psychiatric unit). As of 8/8/17 at 11:42 a.m., there was no documentation in the clinical record to indicate the resident had ever been transferred to a hospital or geriatric-psychiatric (geri-psych) facility for evaluation of his physically aggressive behaviors, and the Plan of Care had not been updated to address the resident's repeated aggressive behaviors and resident-to-resident altercations. o. Nurses Notes dated 8/8/17 at 6:45 p.m. documented, DON spoke (with) spouse (name) regarding need to do a geri-psych eval (evaluation). Spouse agreeable . p. On 8/9/17 at 10:50 a.m., the Director of Nursing was asked to provide any available documentation to demonstrate that this resident had been sent out (or received a geri-psych evaluation) after demonstrating aggressive behaviors, at any time since admission. As of 8/10/17 at 10:00 a.m., no documentation had been provided. 2. Resident #2 resided on the secure unit and had a [DIAGNOSES REDACTED]. The MDS with an ARD of 6/27/17 documented the resident understood others and was sometimes understood, scored 6 (0-7 indicates severe impairment) on the brief interview for mental status, had signs/symptoms of inattention and disorganized thinking that fluctuated, had behaviors of verbal behavioral symptoms directed toward others and wandering daily, required extensive assistance of two-plus persons for transfers, did not ambulate in the past 7 days and had one fall without injury. a. The Plan of Care updated 7/2/17 documented, Behavioral Symptoms . interventions . Redirect resident PRN (as needed), Keep environment calm & (and) relaxed, Meet Physiological needs, remove to private when agitated . Encourage diversional activities. b. An Incident/Accident report dated 7/4/17 at 7:15 a.m., documented, Resident was hit in his right eye area by another resident (Resident #1) that was walking past. c. Nurses Notes dated 7/9/17 at 11:00 p.m. documented, Called to 300 dining area found patient in wheelchair calmly. CNA stated a Resident (Resident #1) hit him in his right inner arm. d. Nurses Notes dated 7/11/17 at 8:00 p.m., documented, Resident very agitated this shift lunging at staff and other residents swinging at staff. The related witness statements documented the following: 1.) 7/11/17 at 8:35 p.m., Resident threw nurse to the floor. She tried to stop him for going into another room, punching and cursing. 2.) 7/11/17 at 10:10 p.m. documented, Resident has been very combative and aggressive all this shift. Waiting til the resident got the medicine from nurse and calmed down a bit. We asked the resident if he wanted to go to bed, he said no!! and slammed the door. A minute later the chair alarm was going off and went in room resident fell out of his chair. e. Nurses Notes dated 7/13/17 at 2:30 p.m. documented, Resident agitated, escalated to yelling disturbing the other residents and attempting to strike people. f. Nurses Notes dated 7/13/17 at 7:30 p.m. documented, Observed this resident in wheelchair attempting to go in and out of other residents' rooms looking for his keys 'going to load it' so he and family could go on a boating trip. Screaming at the other residents and staff cursing and threatening. g. On 8/7/17 at 8:30 a.m., the resident was at a table in the dining room. Two of his table mates were exchanging verbal behaviors and hitting at one another. There was no nurse or CNA in the dining area. A housekeeper was there and observed the behaviors, but did not intervene or report it to the nurse or staff. h. Nurses Notes dated 8/10/17 on the 11:00 p.m. to 7:00 a.m. (11-7) shift documented, Continues to call out for (wife's name) and hitting at staff members and other residents. i. As of 8/10/17, there had been no revisions to the plan of care since 7/2/17 to address the resident's physically aggressive behaviors. 3. Resident #7 resided on the secure unit and had [DIAGNOSES REDACTED]. The Quarterly MDS with ARD of 6/14/17 documented the resident had short/long term memory problems, had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was inattentive and had disorganized thinking continuously, exhibited physical behavioral symptoms and verbal behaviors that occurred 1-2 times in the past 7 days and wandering that occurred daily and was independent with ambulation. a. The Plan of Care updated 6/19/17 documented, At risk for behaviors r/t (related to) . TBI ([MEDICAL CONDITION]) and does not understand his surroundings. He often will go in a room inappropriately or become combative with staff during care . interventions . Report increased behaviors to MD (Medical Doctor), Pharmacy to review medications per policy, Encourage him to participate in activity with rock music, SSD (Social Services Department) to visit PRN, Allow him to express frustration redirect when attempting to enter other resident room, Activity to provided one on one weekly and offer HS (bed time) snack. b. An Incident/Accident Report dated 3/1/17 at 12:10 p.m. documented, As this nurse got to the DR (dining room), Resident was on his hands and knees. Witness stated another resident got up from his w/c (wheelchair) and hit this resident in the mouth with his fist, knocking resident down . interventions . other resident placed one-on-one. c. An Incident/Accident Report dated 3/6/17 at 8:00 a.m. documented, Resident was hit on the back of his head by another resident . interventions . Neuro checks started and resident to sit in a different area than resident that hit him. d. An Incident/Accident Report dated 3/20/17 at 12:20 a.m. documented, Resident walked up to another resident and struck resident x (times) 2 in the shoulder. The intervention was documented as, Attempt to keep residents apart. e. An Incident/Accident Report dated 3/23/17 at 12:15 p.m. documented, This resident was into other resident's personal space while other resident was in w/c at table in the DR. Other resident was yelling 'Get Away' this resident then hit other resident on the top of her head. The intervention documented Keep resident away from other residents as much as possible. f. An Incident/Accident Report dated 3/29/17 at 7:40 a.m. documented, this resident went up to other resident from behind, hit other resident on top of head, other resident then began hitting this resident in face and shoulder. Was separated immediately. The interventions documented, Separate Residents, Observe residents and keep them apart and gave resident a magazine to look at. g. An Incident/Accident Report dated 3/30/17 at 8:50 a.m. documented, CNA reported resident walked up to another resident and stumbled bumping other resident wheelchair, other resident struck resident in stomach. The interventions documented, Residents separated. Attempt to keep residents apart. h. An Incident/Accident Report dated 4/4/17 at (not timed) documented, Reported to this nurse per CNA that resident in an altercation with another resident. When the other resident pushed this resident down and resident fell in a sitting position to the floor. The intervention documented, Observe resident closely when in common area and intervene in a timely manner when resident noted to be wandering into other residents' space. Remove resident to a safe space and impose one-on-one with resident when necessary. i. An Incident/Accident Report dated 4/6/17 at 8:30 a.m. documented, Report per staff this resident was hitting other resident in common area on Central. This resident walked up into other resident personal space other resident starting hitting at this resident and this resident was swinging arms. The intervention documented Attempt redirection when getting in others personal space. j. An Incident/Accident Report dated 4/12/17 at 9:15 a.m. documented, Staff reported other resident hit this resident in the side. The intervention documented, Re-direct away from other resident. k. An Incident/Accident Report dated 4/13/17 at 7:30 a.m. documented, Staff reported this resident was in DR walking with staff to be seated for breakfast and passed by other resident sitting in chair and hit other resident in right cheek. The interventions documented, keep resident arm's length from other residents and offer private dining. l. An Incident/Accident Report dated 5/8/17 (not timed) documented Resident went over to table where another resident was sitting at DR table. The other resident started to hit him in the scrotum with his fist and then this resident hit the other resident on his shoulder. The interventions documented, Monitor resident at regular intervals when in DR to prevent him from standing over resident and touching and moving over them. Assist pt. (patient) to table and encourage him to sit down, offer snack until breakfast or other meal can be served. m. Nurses Notes dated 6/3/17 at 5:05 p.m. documented, Staff member reported to this nurse that resident pressed on the leg of another resident who then grabs this resident by his head, at which time the resident hit the other resident in the head. n. An Incident/Accident Report dated 6/11/17 at 3:45 p.m. documented, Resident (Resident #1) came over and pushed him up against a wall and punched him repeatedly in the stomach and chest until (CNA) stepped in between them to separate them. The interventions documented, Attempt to keep residents apart. o. Nurses Notes dated 6/19/17 at 11:00 (p.m. or a.m. not specified) documented Wanders throughout facility gets in others personal space causing altercations often with other residents. p. An Incident/Accident Report dated 6/29/17 at 3:00 p.m. documented, Resident sitting on piano bench in east DR area when another resident (Resident #1) walked up to him and started hitting him. Staff intervened immediately. Resident obtained 3 scratches to left side of neck. The intervention documented, Observe resident and ensure that resident is not sharing the same space with other residents that are prone to be combative. q. On 8/9/17 at 4:05 p.m., the resident was wandering up and down the hallway and in the dining room. r. As of 8/9/17, there had been no revisions added to the behavioral plan of care since 6/19/17 to address the resident's frequent aggressive behaviors and to protect the resident from aggression by other residents. 4. Resident #9 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/9/17 documented the resident had short/long term memory problems, was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status, had verbal behavioral symptoms directed toward others and required supervision with ambulation. a. The Plan of Care updated 3/16/17 did not address any behavior issues. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, Staff reported this resident was pushed down and then kicked in left hip thigh area. Resident was reported to have hit his head on chair during fall. Resident sitting in chair with discolored area to right side top of head with swelling. Refer to paragraph 'b' of Resident #10's findings below, which indicates this altercation began with Resident #9 striking Resident #10 prior to being pushed down and kicked by Resident #10. The hospital's emergency room attending attestation dated 7/31/17 documented the resident presented to the emergency department, with fall and assault victim, had a CT (computed tomography) without contrast . No traumatic injury or acute intracranial process. c. As of 8/7/17, there was no documentation on the Plan of Care to address aggressive or combative behaviors for this resident. 5. Resident #10 was admitted to the secure unit on 7/20/17 with a [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/27/17 documented the resident scored 3 (0-7 indicates severely impaired) on a brief interview for mental status, had no behaviors, was independent with ambulation in the room and required supervision with ambulation in the corridor. a. The Plan of Care updated 7/29/17 documented, Behavioral Symptoms . Redirect resident PRN, Keep environment calm and relaxed, meet physiological needs, remove resident to private area when agitated and encourage diversional activities. b. An Incident/Accident Report dated 7/31/17 at 6:56 p.m. documented, CNAs reported other resident (Resident #9) hit this resident (Resident #10) who pushed the other resident (Resident #9) who fell down and then this resident (Resident #10) kicked him (Resident #9) in left hip/thigh area while he was down .Placed one on one at this time, awaiting management direction. c. Nurses Notes dated 8/1/17 at 6:10 (no a.m. or p.m.) documented, Resident taken laundry barrel and dumped what was inside, cursing all the time, refused any one close to provide care. Very aggressive one-on-one this a.m. d. Nurses Notes dated 8/1/17 at 6:50 (no a.m. or p.m.) documented, Received orders to send resident to (geri-psych facility) for eval and TX (treatment). Spoke to (name) at (geri-psych facility) ok to send resident having behavior issues kicked another resident in the head charging at the staff cursing. Called (transport service) to transport resident. Resident refusing care from staff pulling at peg (percutaneous endoscopic gastrostomy) tube sling milk and stomach contents everywhere. 6. On 8/7/17 at 9:40 a.m., Licensed Practical Nurse (LPN) #1 was asked about adequate staffing on the secure unit to supervise aggressive residents and stated, I need 3 CNAs, but they won't give me that. The Housekeeper is the CNA Supervisor, and we have written staff up for not staying on the hall, but she throws them (write-ups) away. 7. On 8/7/17 at 10:40 a.m., the Director of Nursing (DON) was asked, Do you have a policy and/or procedure for admission to the secure unit? The DON stated, We don't have a policy /procedure; we decided if they are a danger or [MEDICAL CONDITION], or [MEDICAL CONDITION], we all talk about it and we decide. If any doubt, we forward the information to Corporate, and then we make the decision. The DON was asked, Is any special treatment provided on the unit? The DON stated, No. 8. On 8/7/17 at 11:10 a.m., CNA #1, who worked on the secure unit, was asked Have you had any training to deal with aggressive residents? The CNA stated, No. 9. On 8/7/17 at 11:12 a.m., CNA #2, who was working on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, No. 10. On 8/7/17 at 11:15 a.m., CNA #3, who worked on the secure unit, was asked, Have you had any training to deal with aggressive residents? The CNA stated, Not here, but I did at another facility. 11. On 8/8/17 at 9:00 a.m., Licensed Practical Nurse (LPN) #2 stated she switched CNA #3 (who was assigned to 200 hall) and CNA #4 (who was assigned to the secure unit), because CNA #3 normally worked the secure unit and would stay down there to work as assigned and had a better rapport with the residents on the secure unit. The LPN stated that CNA #4 would not stay on the unit when assigned and would leave the unit multiple times, but that CNA #4 had, thrown a fit and refused the change in assignment. 12. On 8/10/17 at 8:20 a.m., the facility's Policy/Procedure (P/P) for Mood and Behavior was provided by the Interim Administrator. The policy documented, It is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. The Objective documented, The objective of the Mood and Behavior P/P is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. The plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being. Any mood and behavior symptoms will be documented by the interdisciplinary team .as well as interventions attempted and outcome. 13. The Immediate Jeopardy was removed on 8/9/17 at 1:00 p.m., and the scope/severity reduced to E when the following plan of removal was implemented. a. (Resident #1) will be admitted to Geri-psych per physician's orders [REDACTED]. b. Supervision of staff remaining on the secured unit will be documented by the Administrator / DON / Designee every 15 minutes to ensure that the scheduled (staff) are actually there. c. Education of all staff on identifying and managing behaviors, completing an I&A (incident/accident report) on resident to resident altercations and reporting resident to resident altercations to DON and Administrator will occur by the Administrator/designee. d. All residents with behaviors with cognitive impairment will be assess by Speech Therapy. All resident with mental illness [DIAGNOSES REDACTED]. e. Evaluate the resident to determine who are the aggressive residents and determine what interventions need to be in place f. An I&A will be completed on any Resident to Resident altercations. g. Any Resident to Resident incident will be reported to the Administrator and DON immediately. The perpetrator will be placed on 1:1 monitoring per the facility policy and documented on the flow sheet. h. Any Resident to Resident injury will be reported to OLTC (Office of Long Term Care). i. The Incident and Intervention will be placed on the 24-hour report so that all shifts are aware. j. The nurse will be instructed to start the Interventions which could include 1:1 (one on one) monitoring, k. All I&As will be reviewed by the Administrator/designee in morning Stand-up and Start-up to ensure proper intervention is in place. l. All interventions will be placed on the care plan by the MDS Coordinator directed after the Stand-up and Start-up meeting and verified by the Administrator/designee. m. Interventions will be communicated to staff daily on the closet care plan that will be updated daily by the MDS Coordinator and verified by the Administrator. 14. On 8/9/17 at 2:30 p.m., the Interim Administrator was asked if any QAA Committee documentation regarding the behaviors / resident-to-resident altercations had been located and stated, No. B. Based on observation, record review and interview, the facility's QAA Committee failed to identify quality deficiencies and put corrective action plans in place with regard to ongoing failures to ensure falls were investigated to determine causative factors, interventions were developed based on those causative factors and were evaluated for effectiveness, planned fall prevention interventions were consistently implemented, and adequate competent staff were available on the secure unit to supervise residents and minimize the potential for further falls / injuries for 3 (Residents #1, #2 and #7) of 4 (Residents #1, #2, #9 and #7) case mix residents who had a history of [REDACTED]. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #1, #2, and #7, who experienced repeated falls, and had the potential to cause more than minimal harm to 13 residents who resided on the secure unit, according a list provided by the Interim Administrator on 8/23/17. The Interim Administrator was notified of the immediate jeopardy condition on 8/9/17 at 11:15 a.m. The findings are: 1. Resident #1 resided on the secure unit and had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/17 documented the resident had no speech, was rarely/never understood, had short/long term memory problems, had severely impaired cognitive skills for daily decision-making per a staff assessment for mental status, was inattentive, wandered daily which significantly intruded on the privacy and activities of others, had daily preferences including having family or a close friend involved in discussions about care, required supervision with set up help only for bed mobility, transfers and ambulating on the unit, received antipsychotic medications on 6 of the past 7 days. a. An Incident/Accident Report dated 5/27/17 at 9:15 p.m. documented, Called to resident's room by CNA, found patient on left side in the floor . interventions . Safety mattress beside pt. (patient's) bed, Bed alarm to alert staff of pt. out of bed and no c(TRUNCATED)

Based on observation, record review and interview, the facility failed to ensure necessary care and services were promptly provided to address complaints of pain related to hemorrhoids, as evidenced by failure to ensure the physician-ordered treatment was promptly initiated and consistently provided to treat the resident's bleeding hemorrhoids and control the resident's pain for 1 (Resident #2) of 1 case mix resident who had physician orders [REDACTED].#2 who had bleeding hemorrhoids that were causing him pain, and had the potential to affect 3 residents who had physician orders [REDACTED]. The findings are: A. Resident #2 had a [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 6/27/17 documented the resident understood others and was sometimes understood, scored 6 (0-7 indicates severe impairment) on a brief interview for mental status, was incontinent of bowel and bladder. a. A physician's orders [REDACTED]. b. As of 8/7/17 at 1:30 p.m., the physician order [REDACTED].>c. On 8/7/17 at 2:00 p.m., Licensed Practical Nurse (LPN) #1 was on the phone with the pharmacy. The Nurse was checking on the Preparation H that had been ordered on [DATE]. The Nurse stated she had faxed the order to the pharmacy twice a week since it was ordered and had talked to the Director of Nursing (DON) and the Preparation H had still not been received for the resident. The Nurse stated the resident had been, and was still, in miserable pain and that she had done everything she could do. The LPN provided a copy of a Medication Order form dated 7/25/17 where the Preparation H was initially requested from the pharmacy. d. On 8/8/17 at 10:00 a.m., a pharmacy representative was interviewed via telephone. The representative stated they could not send over-the-counter medications to this facility without permission from the DON. At 10:40 a.m., the DON was asked about the Preparation H order. She stated that she knew about the order since 7/20/17 during the stand-up meeting, but that it, .didn't register to me that I had to approve it. The DON stated she would tell the pharmacy to bring the Preparation H, or would get it at a local department store. e. On 8/8/17 at 10:50 a.m., LPN #1 discovered the Preparation H in another medication cart, with documentation that it had been delivered on 8/7/17. She went to administer the medication. At this time, when the residents brief was removed, there was a hard, formed stool in the brief, with bright red blood stains on the inside of the incontinent brief. There were 2 external hemorrhoids at the rectal area. The resident complained of pain whenever the area was touched. f. The August 2017 MAR indicated [REDACTED] B. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided to address a resident's complaint of possible insect bites, as evidenced by failure to promptly assess newly identified welts on the resident's skin and report the areas to the physician for possible treatment orders for 1 (Resident #4) of 1 case mix resident who reported possible insect bites. The failed practice had the potential to affect 1 resident who reported possible insect bites in the last 30 days, according to a list provided by Interim Administrator on 8/23/17. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 4/26/17 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, was independent with bed mobility, transfers, walking in room or corridor, locomotion on and off unit, toilet use, and dressing and had no non-pressure related skin issues. a. On 8/6/17 at 2:45 p.m., during initial rounds with Registered Nurse (RN) #1, the resident was walking in the hallway, approached the RN, and stated he woke up with, .bite marks from bugs this morning. There were red bumps on his right shoulder. He also stated that he had seen bugs in his room. b. On 8/7/17 at 8:45 a.m., the resident was lying in bed watching TV. He was asked about the bugs in his room. He stated, I haven't seen any bugs today. c. On 8/7/17 at 12:35 p.m., the resident approached the Nurses' Station and informed Licensed Practical Nurse (LPN) #10 that he had red bumps on his arm and needed something for itching and that it had, .been itching for a few days. LPN #10 stated, You didn't say anything Friday (8/4/17). She looked at the resident's arm and asked him if he had been outside. He stated, No. She stated, It's probably a mosquito bite, but I will call the doctor. The resident stated, Let's see how this turns out. This was a period of approximately 22 hours after the resident initially reported the reddened bumps to RN #1 on 8/6/17. d. As of 8/7/17 at 2:03 p.m., there was no documentation in the Nurses' Notes or elsewhere in the clinical record of an assessment of the bumps to the resident's shoulder or of physician notification regarding the resident's complaint of insect bites. The surveyor informed the DON, at this time, that the resident had reported the bumps to RN #1 on 8/6/17, and that there was no documentation of an assessment in the clinical record. The DON was then asked, Do you expect your nurses to do an assessment on skin concerns? The DON stated, Yes. e. On 8/7/17 at 2:15 p.m., the DON completed a skin assessment on the resident. There were 4 small red bumps on his right shoulder and 3 small red bumps on his right leg.

Based on observation, record review and interview, the facility failed to ensure physician-ordered medications were promptly acquired and administered to treat hemorrhoids, to prevent exacerbation of the resident's condition and control the resident's pain for 1 (Resident #2) of 1 case mix resident who had physician orders [REDACTED].#2 who had bleeding hemorrhoids that were causing him pain, and had the potential to affect 3 residents who had physician orders [REDACTED]. The findings are: Resident #2 had a [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 6/27/17 documented the resident understood others and was sometimes understood, scored 6 (0-7 indicates severe impairment) on a brief interview for mental status, was incontinent of bowel and bladder. a. A physician's orders [REDACTED]. b. As of 8/7/17 at 1:30 p.m., the physician order [REDACTED].>c. On 8/7/17 at 2:00 p.m., Licensed Practical Nurse (LPN) #1 was on the phone with the pharmacy. The Nurse was checking on the Preparation H that had been ordered on [DATE]. The Nurse stated she had faxed the order to the pharmacy twice a week since it was ordered and had talked to the Director of Nursing (DON) and the Preparation H had still not been received for the resident. The Nurse stated the resident had been, and was still, in miserable pain and that she had done everything she could do. The LPN provided a copy of a Medication Order form dated 7/25/17 where the Preparation H was initially requested from the pharmacy. d. On 8/8/17 at 10:00 a.m., a pharmacy representative was interviewed via telephone. The representative stated they could not send over-the-counter medications to this facility without permission from the DON. At 10:40 a.m., the DON was asked about the Preparation H order. She stated that she knew about the order since 7/20/17 during the stand-up meeting, but that it, .didn't register to me that I had to approve it. The DON stated she would tell the pharmacy to bring the Preparation H, or would get it at a local department store. e. On 8/8/17 at 10:50 a.m., LPN #1 discovered the Preparation H in another medication cart, with documentation that it had been delivered on 8/7/17. She went to administer the medication. At this time, when the residents brief was removed, there was a hard, formed stool in the brief, with bright red blood stains on the inside of the incontinent brief. There were 2 external hemorrhoids at the rectal area. The resident complained of pain whenever the area was touched. f. The August 2017 MAR indicated [REDACTED]

Complaint # (AR 850) was substantiated, all or in part, with these findings: A. Based on observation, record review, and interview, the facility failed to ensure a transfer was conducted with a sit-to-stand mechanical lift and 2-staff assistance as per the plan of care, which resulted in the resident falling onto the side of the bed with the staff member on top of her, and failed to ensure staff reported the fall and waited for a licensed nurse to assess the resident for injury prior to moving the resident, to prevent further potential injury for 1 (Resident #1) of 1 case mix resident who required the use of a sit-to-stand mechanical lift for transfer. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who sustained a fracture to the right femur when staff conducted a 1-person manual transfer and fell with the resident, then placed the resident back in bed without informing a licensed nurse of the incident. The failed practices also had the potential to cause more than minimal harm to 2 residents who required 2-person transfers with the use of a mechanical sit-to-stand lift at the time of the incident, as documented on a list provided by the Director of Nursing (DON) on 3/23/17. The facility removed the Immediate Jeopardy on 3/6/17 prior to the survey entrance date; however, current failed practices existed related to mechanical lift transfers at the time of the survey (refer to Part B of this deficiency). The Administrator was informed of the Immediate Jeopardy condition on 3/24/17 at 4:23 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/17 documented the resident scored 8 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on 1 person assistance for bed mobility, was totally dependent on 2 person assistance for transfers, and had no falls since admission or prior assessment. a. The Comprehensive Care Plan dated as initiated on 11/17/16 documented, .Falls / Safety Risk / Elopement .Goal . Resident will remain free of injury . Use lift for transfers . The Comprehensive Care Plan did not document which type of mechanical lift was to be used in transferring the resident. b. A physician order [REDACTED].May begin to WBAT (weight bear as tolerated) BLE (bilateral lower extremities) start with assistance (at) all times until safe. Use of assistive device. ROM (range of motion) bilateral knees, (and) ankles, hips RTC (return to clinic) 6 weeks . c. The Lift Designation Form dated 1/26/17 documented, .the resident could require using the sit-to-stand lift. The resident requires assistance with lifting, but is not a candidate for the Hoyer Lift . R (Resident) has fractures of bilateral tibia / fibula . d. An Office of Long Term Care (OLTC) Incident and Accident Next Day Reporting Form, Division of Medical Services (DMS) form 7734, dated 3/6/17 documented, .Date and Time of Incident . 3/2/17, Date and Time of Discovery . 3/3/17 at 1:30 p.m . Date Incident was reported to OLTC (Office of Long Term Care) . 3/6/17 at 6:30 a.m . Resident . (Resident #1) . Type of Abuse . Neglect . On 3/3/17, When in therapy, Resident reported, 'When I stood up, I slipped on some food and fell on the bed, not the floor and (Certified Nursing Assistant( (CNA #1) fell on top of me.' (Licensed Practical Nurse (LPN) #1) heard and immediately asked about pain and movement . Who was in the room? . Resident became reluctant to answer and stopped responding. She (LPN #1) notified RN (Registered Nurse) Supervisor, Administrator. Started investigation . (Certified Nursing Assistant (CNA) #1) was interviewed and suspended pending investigation . APN (Advanced Practice Nurse) was notified and x-rays were ordered for knee, and then followed by x-ray of femur . In conclusion of the investigation, it was determined that (CNA #1 and CNA #2) transferred the resident inappropriately and did not follow the plan of care due to the resident refusal. A second (CNA #2) was determined to have been in the room and finished assisting putting resident in bed during the inappropriate transfer when (CNA #1) landed on top of resident in the bed. (CNA #2) was also suspended pending the investigation. Neither CNA reported this event to anyone. Both terminated due to failure to follow care plan, failure to report resident refusal of care plan measures, and failure to report the event. All staff were in-serviced on reporting an incident and following the care plan, the importance of communication and reporting of refusal of care. Abuse in-service was also completed. Body audits and cognitive resident interviews completed with no other reports from residents of them being transferred incorrectly and no injuries of residents identified. e. A Witness Statement from CNA #1 dated 3/3/17 documented, At 7:00 p.m. another aide and myself entered (Resident #1's) room to put her to bed. (Resident) stated she did not want to use the stand-up lift. (Resident) was worried 'it wouldn't work.' I had talked to her therapist who told me she was doing well with transferring with gait belt. I put gait belt around (Resident) with other aide there to assist. The transfer went well. Resident was placed in bed w/o (without) injury and complaint. f. A Witness Statement from CNA #2 (not dated) documented, I asked if (Resident #1) was ready for bed she said, 'Yes.' Was getting ready to put (her) to bed. (Resident #1) said she didn't want Sit-to-Stand (lift) used so other (CNA #1) pivoted her into bed from wheelchair and when transfer (from wheelchair) was done, sat down beside her and (Resident) asked for Nurse for Pain Pill because her knee hurt. I'm normally not the Resident's CNA and I thought she was ok, nothing wrong, and the regular CNA told me about the closet care plan and said they normally did this. g. A Witness Statement from (Certified Occupational Therapist Aide, COTA) dated 3/3/17 documented, R (Resident) was in OT (Occupational Therapy) and (Resident #1) stated CNA transferred her to bed. When she transferred she twisted her knee and fell into the bed. She (Resident) said she was having pain in her R (Right) knee. h. A Witness Statement from (Registered Nurse Supervisor #1) dated 3/4/17 documented, Went to visit with resident about any concerns she may have. Met up in hallway coming from therapy. We went to her room for the visit. I asked her (Resident) about her knee. She pointed to the right knee. Old scar noted, no redness or bruising observed. She stated she fell off the porch years ago and had surgery on her knees. They bother her all the time. I asked her if she was having any concerns we needed to talk about. (Resident #1) stated, only the batteries to the lift sometimes does not work. The Resident was asked if anything had happened the day before or anytime recently with anyone or her care. (Resident) stated, 'No, only issue was the lift batteries.' No other complaints or concerns voiced. I assured her the batteries for the lift would be checked. On 3/4/17 I worked as weekend Supervisor. On 3/4/17 a faxed report (x-ray) was received by the Charge Nurse. The Charge Nurse had faxed the x-ray report to the APN (Advanced Practice Nurse), Admin (Administrator) and DON (Director of Nursing) was notified. Orders were received from APN to transfer (Resident #1) to ER (emergency room ) at local hospital (name). The faxed report indicated a moderate right femur fracture. Spouse was notified as well. I had notified the Administrator, Director of Nursing, Advanced Practice Nurse, Spouse. i. A Radiology Report by mobile x-ray dated 3/3/17 documented, .Knee AP (anteroposterior) or lat (lateral) 1 to 2 v (views), Right; .Conclusion, Modest arthritis of the right knee. Grossly intact hardware across the chronic fracture of the proximal tibia. Mildly displaced distal femur fracture may be acute . The Radiology Report by mobile x-ray dated 3/3/17 documented, .Femur min (minimum) views Right: .Conclusion . Modestly displaced right femur fracture as described . j. The Hospital Clinical Records for the hospital admission of 3/4/17 documented, .Admission 3/4/17 . Admission Diagnosis .Closed fracture of distal end of femur .unspecified fracture morphology, initial encounter .3/4/17, Pre-op (pre-operative) Diagnosis . Right extra-articular distal femur fracture closed.Procedure ORIF (Open Reduction Internal Fixation) Femur Distal .Activity .no weight bearing on right leg .reinforce dressing PRN (as needed) .follow-up with (physician) in 2 weeks . k. On 3/23/17 at 1:10 p.m., CNA #3 was asked about the incident during the transfer for Resident #1 and stated, (Resident #1) was in the Therapy Department, and the Therapist asked if we knew what happened to (Resident #1). The Therapist stated that the resident stated (CNA #1) got her up and wasn't using the lift and fell on the resident. I reported this to the Nurse, (LPN #2), and she informed the Administrator (Former Administrator). l. On 3/24/17 at 1:38 p.m., The Minimum Data Set Coordinator, Licensed Practical Nurse (MDS/LPN) #2 was asked who was responsible for updating the residents' Comprehensive Care Plans and stated, I do, and the Nurses also can update the Care Plans. The MDS/LPN Coordinator was asked, When you look at the Care Plan, should you be able to tell how the resident is to be transferred? The MDS/LPN Coordinator stated, Yes. The MDS/LPN Coordinator was asked if Resident #1's Care Plan documented how Resident #1 was to be transferred. The MDS/LPN Coordinator stated, No, but the staff are trained. The MDS/LPN Coordinator was asked if she had conducted any training regarding the mechanical lift. The MDS/LPN Coordinator stated, Yes, the Sit-to-Stand, the Hoyer Lift, and gait belt transfers. She stated she had done the training with all the new employees, now they are trained with the CNA they are assigned to work with. The MDS/LPN Coordinator stated, It was about 3 to 4 weeks ago we did a general in-service with 1 and 2 person transfers with the gait belt, bed mobility, incontinent care, and handwashing . m. On 3/24/17 at 2:45 p.m., the Director of Nursing (DON) stated she had been employed with the facility for approximately 6 weeks. The DON was asked about the incident involving Resident #1 on 3/2/17. The DON stated she was not involved in the investigation and that it was handled by the former Administrator. The DON was asked, Who trains the staff regarding the use of the mechanical lift? The DON stated, The (MDS/LPN Coordinator) did a skills class in January (2017). The new CNAs are trained by the person they are assigned to work with. The DON was asked, Who does the Transfer Assessments? The DON stated, The (MDS/LPN Coordinator) does most of the assessments, and the nurses do the assessments on admission. The DON stated the sit-to-stand lift had been taken out of commission and was not currently being used. n. The facility removed the Immediate Jeopardy and reduced the scope / severity to G on 3/6/17, by implementing corrective actions as follows: 1.) The OLTC Incident and Accident Next Day Reporting Form dated 3/6/17 documented, .(Certified Nursing Assistant (CNA) #1) was interviewed and suspended pending investigation . (CNA #2) was also suspended pending the investigation. Neither CNA reported this event to anyone. Both terminated due to failure to follow care plan, failure to report resident refusal of care plan measures, and failure to report the event. All staff were in-serviced on reporting an incident and following the care plan, the importance of communication and reporting of refusal of care . Body audits and cognitive resident interviews completed with no other reports from residents of them being transferred incorrectly and no injuries of residents identified . 2.) An Office of Long Term Care Incident and Accident Reporting Form (Form 7734) dated 3/6/17 documented CNAs #1 and #2 were terminated on 3/6/17. 3.) An in-service sheet dated 3/9/17 documented, A review of all resident transfer assessments, lift assessments, fall risk assessments, Braden Scales, CNAs Care Plans and chart Care Plans were reviewed for all 23 residents. Updates were completed as needed. The Transfer Training and Lift Training in-service was signed by 39 employees on 3/10/17. 4.) Observation Check Lists dated 3/6/17 through 3/13/17 documented the DON and MDS Coordinator observed and checked CNAs off on skills related to transfers with gait belts and mechanical lift transfers. B. Based on observation, record review and interview, the facility failed to ensure a mechanical lift was utilized in accordance with the manufacturer's instructions and that the brakes of the resident's wheelchair were locked during a transfer to prevent potential injury for 1 (Resident #1) of 4 (Residents #1, #3, #4 and #5) case mix residents who required the Invacare Mechanical Lift for transfers. This failed practice had the potential to cause more than minimal harm to 4 residents who required the Invacare Mechanical Lift for transfers, as documented on a list provided by the DON on 3/24/17. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/17 documented the resident scored 8 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on 1 person assistance for bed mobility, was totally dependent on 2 person assistance for transfers, and had no falls since admission or prior assessment. a. The Comprehensive Care Plan dated as revised on 3/11/17 documented, .Falls / Safety Risk / Elopement .Goal . Resident will remain free of injury . Use lift for transfers . b. The Certified Nursing Assistant (CNA) Care Plan (not dated) documented, the sit-to-stand lift was marked out and Hoyer Lift Only was hand-written on the bottom of the CNA Care Plan page. c. The manufacturer's instructions for the Invacare Reliant 450 Mechanical Lift, provided by the Director of Nursing (DON) on 3/24/17, documented, .Lifting the patient . Warning .When using the adjustable base lift, the legs must be in the maximum opened / locked positon before lifting the patient . Transferring the Patient . Warning . Wheelchair wheel locks MUST be in a locked position before lowering the patient into the wheelchair for transport . d. On 3/23/17 at 8:20 a.m., Certified Nursing Assistants (CNAs) #5 and #6 transferred Resident #1 from the bed to a wheelchair with the Invacare 450 Mechanical Lift. The resident was lying in bed, and the CNAs placed a medium blue lift pad with dark blue trim under the resident. The strap of the lift pad between the resident's legs was crossed. The legs / base of the lift was under the bed and the legs of the lift were not opened. CNA #5 operated the lift controls and CNA #6 remained next to the resident. CNA #5 moved the Invacare mechanical lift out from under the bed with the legs of the lift in the closed position and rolled the lift approximately 4 feet from the bed before stopping to open the legs of the lift in order to position them around the resident's wheelchair. CNA #6 stood behind the wheelchair, and without locking the wheelchair brakes, CNA #5 lowered the resident into the wheelchair. The wheelchair moved slightly while the resident was being lowered into it; however, CNA #5 stabilized the chair and prevented it from rolling out from under the resident. e. On 3/23/17 at 1:10 p.m., CNA #3 was asked, When using the Invacare lift, how should the legs of the lift be positioned when moving from bed to chair? CNA #3 stated, They should be open, so that was the way we were taught. That is so the weight can be balanced to keep the lift from tipping over. CNA #3 was asked, Should the wheelchair be locked? CNA #3 stated, Yes, to keep the wheelchair from moving. f. On 3/23/17 at 1:17 p.m., Certified Nursing Assistant (CNA) #4 was asked, When you are transferring a resident from the bed to the wheelchair with the Invacare Lift, how should the legs of the lift be positioned? CNA #4 stated, They should be opened to balance, so the weight will balance out. CNA #4 was asked if the wheelchair should be locked when transferring a resident from the bed to the wheelchair with the mechanical lift and stated, Yes. g. On 3/24/17 at 1:38 p.m., the Minimum Data Set Coordinator (Licensed Practical Nurse #2) was asked was asked if she had conducted any training regarding the mechanical lifts. The LPN stated, Yes, the Sit-to-Stand, the Hoyer Lift, and gait belt transfers. She stated she had done the training with all of the new employees, and, .it was about 3 to 4 weeks ago, we did a general in-service with 1 and 2 person transfers with the gait belt, bed mobility, incontinent care, and handwashing. It was a few weeks ago, maybe 3 or 4 weeks, they changed out the lift to the Invacare Lift, and they did training with a few staff, but not all of the staff were in-serviced on the Invacare lift. The LPN was asked, When the staff are transferring the resident from the bed to a wheelchair, how should the legs of the mechanical lift be positioned? The LPN stated, The legs should be open when they start lifting the resident up. The LPN was asked if the wheelchair brakes should be locked during transfers and stated, Yes. h. On 3/24/17 at 2:45 p.m., the Director of Nursing (DON) was asked about the transfer method for Resident #1 and stated, After readmission with the fracture to the femur, (Resident #1) is now a Hoyer Lift . (Facility) recently changed mechanical lifts; I don't know the exact date. There was a person from the company came and did an in-service with some of the staff, but not all of the staff, on the new lift (Invacare Lift).

Complaint # (AR 585) and # (AR 590) were substantiated, all or in part, in these findings. A. Based on observations, record review and interview, the facility failed to ensure high risk medications ([MEDICATION NAME]) were monitored for potential toxic levels and were given or held as prescribed by the physician to ensure accuracy of using lab results to determine most effective dose for 3 of 3 (Residents #17, #11 and #12) case mix residents who received anticoagulant therapy. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 1 (Resident #17) who expired [DATE] with a critically high INR and 2 (Residents #11 and #12) who had orders for [MEDICATION NAME] and no consistent PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) monitoring. The failed practice had the potential to cause more than minimal harm for 5 residents who received anticoagulant therapy. The facility was notified of the Immediate Jeopardy on [DATE] at 9:53 a.m. The findings are: 1. Resident #17 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,[DATE] cognitively intact) on a Brief Interview for Mental Status (BIMS); was independent with activities of daily living, and received anticoagulant therapy 2 days of the past 7 days. a. A physician's order dated [DATE] documented, Warfare Sodium 6 mg (milligrams) give 1 tablet by mouth one time a day for [MEDICAL CONDITION] give with 7.5 mg tab = (equals) 13.5 mg. Another physician's order dated [DATE] documented, [MEDICATION NAME] Sodium tablet 7.5 mg give 1 tablet one time a day for [MEDICAL CONDITION]. Give with 6 mg to = 13.5 mg. b. The temporary plan of care for the resident dated [DATE] did not address the Anticoagulant therapy or the risk factors associated with anticoagulant therapy. c. The [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. One time only for therapeutic levels for 1 day. This was administered one time on [DATE]. However, there was no physician order in the clinical record to do this. d. The [DATE] MAR indicated [REDACTED]. The [DATE] MAR indicated [REDACTED]. e. A PT/INR results dated [DATE] documented the [MEDICATION NAME] as 49 (10XXX,[DATE].1 normal range) and the INR as 4.45 (0XXX,[DATE].2 normal range). The physician wrote on the lab sheet to hold ([MEDICATION NAME]) and repeat (PT/INR) in 3 days. f. On [DATE] the PT/INR was drawn and the results were [MEDICATION NAME] 15.8 and the INR as 1.39. The physician wrote on the lab slip to increase to 11 mg for one week and then repeat the INR. (The [DATE] MAR indicated [REDACTED] A physician's telephone order dated [DATE] documented, [MEDICATION NAME] 11 mg po (oral) x (times) 1 week and repeat PT/INR as scheduled. The [DATE] MAR indicated [REDACTED]. g. The next PT/INR's were drawn on [DATE], [DATE], and [DATE] and the physician initialed the lab slips. A telephone order that was not dated documented, Increase [MEDICATION NAME] 10.5 mg x one week and repeat PT/INR x 7 days. h. Nurses notes dated [DATE] at 7:53 p.m., documented, Lab results called to on call APN (Advanced Practice Nurse) at 12:40 p.m. No N.O. (new orders) received at this time. Resident later observed to be lethargic VS (vital signs) 100.3, 85, 20 ,[DATE], pulse ox 70 to 93% on O2 (oxygen). Order received to TF (transfer) to hospital. EMS (Emergency Medical Services) notified of transfer at 1:56 a.m. i. On [DATE] the resident was readmitted to the facility with orders for [MEDICATION NAME] 7.5 mg give 2 tablets to = 15 mg and [MEDICATION NAME] 06 mg/0.6Ml (milliliter) - give 0.6 ml SQ (subcutaneous) daily. PT/INR daily until INR is between 2.0 - 3.0, then once therapeutic level reached D/C (discontinue) [MEDICATION NAME]. The [DATE] MAR indicated [REDACTED]. The [DATE] MAR indicated [REDACTED]. However, the pharmacy stated that they sent out 7 doses on [DATE]. j. The next PT/INR dated [DATE] documented INR of 1.85. The physician hand wrote an order Increase to 15.5 mg daily x 7 days and repeat PT/INR. The August [DATE] documented the resident received 15 mg of [MEDICATION NAME] instead of 15.5 mg from [DATE] - [DATE], [DATE], and [DATE] - [DATE] at 5 p.m. (held on [DATE], [DATE], and [DATE]). The MAR indicated [REDACTED]. k. The next PT/INR was drawn on [DATE] and the INR was documented as 1.94. A physician's order dated [DATE] to documented, D/C (discontinue) [MEDICATION NAME] R/T (related to ) INR 2.3. (INR results was 1.94 not 2.3) l. The PT/INR results dated [DATE] documented the INR was 3.16. The PT/INR results dated [DATE] documented the INR as 4.04. There was no documentation on the lab sheet or the nurses notes that the physician or APN was notified of these results. A physician's order dated [DATE] at 10:06 a.m. documented to hold [MEDICATION NAME] for 2 days. Note: The [DATE] MAR indicated [REDACTED]. m. Nurses notes dated [DATE] at 5:54 p.m., documented, At 4:55 p.m., call placed to on-call APN and report given of concern about [MEDICATION NAME] dose with last INR greater that 4.0 (the one done on [DATE]). Received order to send R (resident) to ER (emergency room ) for PT/INR lab draw. Order noted DON (Director of Nursing) and Administrator notified of TF (transfer) order. R (Resident) informed order to TF to ER (emergency room ) for lab draw, and the need to find out where the current INR was before resuming dose. R made informed decision to refuse TF for lab draw. At 5:09 p.m., APN informed of R's refusal to TF out for lab. Received order to hold [MEDICATION NAME] until lab draw results received tomorrow. FU (follow-up) with on-call. Note: The [DATE] MAR indicated [REDACTED]. n. Nurses notes dated [DATE] at 6:55 p.m., documented, CNA (Certified Nursing Assistant) reported R was not breathing. Observed R in bed, w/o (with-out) respiration or pulse. Code Blue room [ROOM NUMBER] east paged over intercom. Call placed to (local ambulance service) report given this is (LPN) at (name of facility) (address of facility), I have a code blue situation in room [ROOM NUMBER] east. It is a bariatric patient send assistance. CPR initiated, EMS (emergency medical services) arrived, report given R TF to stretcher per staff and EMS. R out of building at 7:13 p.m. (family member) notified of TR at 7:15 p.m. Report called to (initials of hospital), Dr (name) notified of pronouncement at 8:19 p.m APN notified at 8:20 p.m o. A lab result collected on [DATE] at 1:10 p.m. documented INR of 6.02 High and [MEDICATION NAME] 53.4 High. This form documented, Results successfully called to (initials of lab contracted by the facility) at 8:21 p.m. On [DATE] at 4:00 p.m., the Director of Nurses stated she called the lab and they told her that the reason the facility was not notified of the High INR was that they had no telephone number or anyway to contact the facility. 2. Resident # 11 had a [DIAGNOSES REDACTED]. The Annual MDS with ARD of [DATE] documented the resident scored of 6 (,[DATE] indicates severely impaired) on the BIMS, required limited assistance with bed mobility and extensive assistance with dressing, was independent with the remainder of activities of daily living and received an anticoagulant 7 of the past 7 days. a. The Plan of Care developed [DATE] documented a problem of, The resident is on anticoagulant Therapy [MEDICATION NAME] with interventions that included Administer Anticoagulant medications as ordered by the physician and Labs as ordered. Report abnormal lab results to MD. b. A physician's order dated [DATE] documented, [MEDICATION NAME] 4 mg daily x 1 week. Repeat PT/INR as scheduled. c. A Lab report dated [DATE] documented the PT ([MEDICATION NAME]) as 17.8 and the INR as 1.57. There was a physician's order dated [DATE] to increase the [MEDICATION NAME] to 5 mg daily and continue weekly PT/INR. The [DATE] MAR indicated [REDACTED]. d. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 5.5 mg daily and repeat PT/INR in 7 days. e. The next PT/INR was drawn on [DATE] (5 days later than when ordered). f. The [MEDICATION NAME] results dated [DATE] documented 40.3 and the INR was 3.64. There was a hand written order on the lab slip that documented, Hold PT/INR ([MEDICATION NAME]? not clarified by facility) x 2 days and repeat PT/INR. The [DATE] MAR indicated [REDACTED]. g. A physician's order dated [DATE] documented, D/C (discontinue ) [MEDICATION NAME] 5.5 mg and start [MEDICATION NAME] 4 mg one po at 5:00 p.m. and redraw PT/INR on [DATE]. h. The next PT/INR was drawn on [DATE], four days later than ordered. 3. Resident #12 had a [DIAGNOSES REDACTED]. a. The Plan of Care updated on [DATE] documented a problem of, Daily anticoagulant as per MD orders for CAD ([MEDICAL CONDITION]) with potential for easily bleeding and or bruising with interventions that included Administer meds as ordered, obtain and monitor/diagnostic work as ordered. Report results to MD and follow-up as ordered. b. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 10 mg daily for 7 days and Repeat PT/INR as scheduled. c. Lab results dated [DATE] documented [MEDICATION NAME] 15.3 and INR 1.34. There was a hand written order on the form to increase [MEDICATION NAME] to 10.5 mg daily and repeat PT/INR in 7 days. The [DATE] MAR indicated [REDACTED]. The [DATE] MAR indicated [REDACTED]. d. On [DATE] at 2:00 p.m., the resident's medication from the cart was reviewed. There was only one card of [MEDICATION NAME] 10 mg in the cart. On [DATE] at 11:25 a.m., the pharmacy tech stated that the [MEDICATION NAME] 0.5 mg was sent out on the 11th. She further stated that they send enough for 7 doses and then received information from the facility that it was discontinued on [DATE]. There was no documentation in the nurses notes or lab slips that the dose was decreased to 10 mg. The [DATE] MAR indicated [REDACTED]. e. The next PT/INR was drawn on [DATE] instead of on the 17th as ordered. 4. On [DATE] at 4:00 p.m., the Director of Nurses stated that lab company had notified her on [DATE] that they would no longer draw lab because they had not been paid. She stated that she called the corporate office and they told her, You are there, you handle it. She stated that she notified the local hospitals and they would not do it. She stated that she then called the Health Department and they told her that she would need more training. She stated she found a business card for the lab services that were now contracted with the facility. 5. According to the Nursing 2015 Drug Handbook, [MEDICATION NAME] is a Anticoagulants. For Administration of oral [MEDICATION NAME] PT/INR determinations are essential for proper control. The black Box warning documented [MEDICATION NAME] can cause major or fatal bleeding. Regularly monitor INR in all patients. 6. The Immediate Jeopardy was removed , and the Scope/Severity was lowered to an H on [DATE] at 3:00 p.m., when the facility implemented the following plan of removal. a. The Director of Nursing/Assistant Director of Nursing and RN (Registered Nurse) Treatment Nurse were inserviced on the protocol for PT/INR and the PT/INR deviation sheet by the Corporate Quality Improvement Coordinator on [DATE] at 11:00 a.m. The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. b. Each of the five (5) residents medical records, who are on anticoagulation therapy were checked by Assistant Director of Nursing and/or RN Treatment nurse on [DATE] from 2:30 p.m., to 4:00 p.m. for correct orders, electronic medical record and medication cart accuracy. c. All resident receiving [MEDICATION NAME] were assessed on [DATE] from 11:15 a.m. to 2:26 p.m. by the Assistant Director of Nursing and/or Registered Nurse treatment nurse with no abnormal findings. d. The medication carts (3) were audited for correct [MEDICATION NAME] dosages for the five (5) residents on [DATE] by the Assistant Director of Nursing and/or RN Treatment Nurse e. The PT/INR deviation sheet was put into use by the Assistant Director of Nurses and/or RN Treatment nurse on [DATE] at 11:15 a.m. All nurses working the current shift were inserviced on the PT/INR deviation sheet by the Assistant Director of Nurses and/or RN Treatment Nurse on [DATE] at 11:15 a.m. The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. All other licensed nurses will be inserviced by the Assistant Director of Nurses and/or RN Treatment Nurse before beginning his/her assigned shift and outgoing to include new employees and any employees returning from leave or absence. f., The physician, Medical Director, was contacted on [DATE] at 11:30 a.m., by the Director of Nursing for all residents on anticoagulation therapy and an order was obtained to draw PT/INR. The lab company was contacted by the Director of Nursing and on [DATE] arrived in the facility to draw stat PT/INR's on all residents on anticoagulation therapy on [DATE] at 3:00 p.m. g. The pharmacy was notified by the Director of Nursing on [DATE] and arrived at 2:00 p.m., of issue and a consultant pharmacist conducted an audit of all medications to assure appropriate labs are being drawn for therapeutic medication levels h. The Director of Nursing and/or Assistant Director of Nursing will audit all [MEDICATION NAME] orders dosages given and any labs associated with [MEDICATION NAME] for 3 months. The DON/ ADON will audit 5 x week for 3 months starting on [DATE]. Results from audit will be presented at the monthly QAPI meeting for further evaluation and any abnormal findings will immediately be corrected and reported to Administrator and Medical Director. B. Based on observation, record review and interview, the facility failed to ensure that laboratory work was performed to monitor for potentially harmful blood dyscrasias and to ensure pharmacy could continue to send the medication for 3 of 3 (Resident #13, #21, #22) case mix residents who had orders for [MEDICATION NAME]. This failed practice had the potential to cause more than minimal harm for 3 residents in the facility who had orders for [MEDICATION NAME] according to the list provided by the Director of Nursing on [DATE]. The findings are: 1. Resident #13 had [DIAGNOSES REDACTED]. a. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet 100 mg: Give 1.5 tablet by mouth at bedtime . (start date [DATE]). [MEDICATION NAME] tablet 50 mg. Give 1 tablet by mouth one time a day . (start date [DATE]) . CBC (complete blood count) with diff (differential) with absolute neuraphil (sic) count weekly x 6 months. Start Date [DATE]. b. The clinical record had copies of lab results for a CBC with Diff that was performed on [DATE], [DATE], [DATE] and [DATE]. There were no results in the record for any CBC with Diff after [DATE], order would not have been discontinued until [DATE]. c. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed on [DATE] and documented as follows: [DATE] 21:52 (9:52 p.m.) WBC (White Blood Count) (with) Diff (differential) faxed to Central Pharmacy. [DATE] 21:15 (9:15 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 9:06 a.m. Unavailable at this time. [DATE] 9:07 a.m. Unavailable at this time. f. On [DATE] at 8:45 a.m., Registered Nurse (RN) #1 was asked, Why are there skips in the [MEDICATION NAME] (administration)? RN #1 stated, I'm not sure why. [MEDICATION NAME] is an antipsychotic and needs a CBC. Copies of the CBC with diff performed since [DATE] were requested but not provided by the time of exit. 2. Resident # 22 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the Resident scored 11 (,[DATE] indicates moderately impaired) on the BIMS; had inattention and disorganized thinking that fluctuated; had no behaviors; and received antipsychotic, antianxiety, antidepressant and hypnotic drugs daily. a. The Plan of Care created on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t (due to) daily use of antipsychotic as per MD orders for her DX (diagnosis) of [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder; . Interventions: Administer anti-psychotic as per MD order monitoring and observing for adverse side effects, notifying MD as indicated . b. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet: Give 150 mg by mouth at bedtime . (Start date [DATE]) . [MEDICATION NAME] tablet: Give 50 mg by mouth in the morning . (Start date [DATE]) . There were no documented orders for a CBC with Differential to be drawn weekly to monitor for blood dyscrasias with [MEDICATION NAME]. c. A CBC with Diff dated [DATE] was in the clinical record. There were no results for any CBC with Diff in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The [DATE] MAR indicated [REDACTED]. f. The electronic medical record progress notes documented as follows: [DATE] 6:25 a.m. Refused AM (morning) meds. [DATE] 20:01 (8:01 p.m.) Blood drawn - have not received med. (medication) from pharmacy. [DATE] 00:58 (a.m.) . Resident up in w/c (wheelchair) in DR (dining room) at this time. Talking to people that are not there. Also making loud animal sounds and screaming at herself. [DATE] 21:13 (9:13 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:49 (a.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:53 (a.m.) Not available. g. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results in the clinical record, but copies were not provided by the time of exit. 3. Resident #21 had [DIAGNOSES REDACTED]. a. The [DATE] Order Summary Report documented, [MEDICATION NAME] Tablet 100 mg 3.5 tablets by mouth at bedtime . CBC Q week every day shift every Mon (Monday) for [MEDICATION NAME] Refill. b. The Plan of Care revised on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t daily use of antipsychotic as per MD orders for his dx of [MEDICAL CONDITION]. Interventions: Administer antipsychotic medication as ordered by physician. Monitor for side effects and effectiveness . c. A CBC with Diff dated [DATE] was in the resident's clinical record. There were no results for any other CBC performed in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed and documented as follows: [DATE] 19:57 (7:57 p.m.) Unable to administer. [MEDICATION NAME] (sic) not available. [DATE] 20:11 (8:11 p.m.) Gamma Lab here to venipuncture resident for CBC. [DATE] 23:57 (11:57 p.m.) Received results of CBC/diff and was faxed to (Name of pharmacy). [DATE] 20:06 (8:06 p.m.) Blood drawn - haven't received med from pharm (pharmacy). [DATE] 21:11 (9:11 p.m.) Scheduled lab not drawn nor scheduled [MEDICATION NAME] not available at this time. f. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results ([DATE]) in the clinical record, but copies were not provided by the time of exit. 4. On [DATE] at 4:00 p.m., the Director of Nurses stated that lab company had notified her on [DATE] that they would no longer draw lab because they had not been paid. She stated that she called the corporate office and they told her You are there, you handle it. She stated that she notified the local hospitals and they would not do it. She stated that she then called the Health Department and they told her that she would need more training. She stated that she found a business card for the lab services that are now contracted with the facility. 5. On [DATE] at 1:53, a telephone interview with a pharmacy representative from Pharmacy #1 was conducted. Pharmacist #1 was asked, Is there a reason the [MEDICATION NAME] was not sent to the residents? Pharmacist #1 stated, Probably the blood work. Pharmacist #1 was asked, Do they (the facility) fax the blood work to the pharmacy and then you dispense? The Pharmacist stated, We enter the blood work into a national [MEDICATION NAME] database. We can't dispense it unless we have a CBC with differential.

Complaint # (AR 585) and # (AR 590) were substantiated, all or in part, in these findings. A. Based on observations, record review and interview, the facility failed to ensure Residents #17, #11, and #12 were free of significant medication errors. The facility failed to ensure [MEDICATION NAME] (a high risk medication) was administered or held per the physician's order 3 of 3 (Residents #17, #11 and #12) case mix residents who received anticoagulant therapy. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 1 (Resident #17) who expired [DATE] with a critically high INR and 2 (Residents #11 and #12) who had orders for [MEDICATION NAME] and no consistent PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) monitoring. The failed practice had the potential to cause more than minimal harm 5 residents received anticoagulation therapy. The facility was notified of the Immediate Jeopardy on [DATE] at 9:53 a.m. The findings are: 1. Resident #17 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident scored 15 (a score of ,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); was independent with activities of daily living, and received anticoagulant therapy 2 days of the past 7 days. a. A physician's order dated [DATE] documented, Warfare Sodium 6 mg (milligrams) give 1 tablet by mouth one time a day for [MEDICAL CONDITION] give with 7.5 mg tab = (equals) 13.5 mg. Another physician's order dated [DATE] documented, [MEDICATION NAME] Sodium tablet 7.5 mg give 1 tablet one time a day for [MEDICAL CONDITION]. Give with 6 mg to = 13.5 mg. b. The [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. One time only for therapeutic levels for 1 day. This was administered one time on [DATE]. However, there was no physician order in the clinical record to do this. d. The [DATE] MAR indicated [REDACTED]. The [DATE] MAR indicated [REDACTED]. e. A PT/INR results dated [DATE] documented the [MEDICATION NAME] as 49 (10XXX,[DATE].1 normal range) and the INR as 4.45 (0XXX,[DATE].2 normal range). The physician wrote on the lab sheet to hold ([MEDICATION NAME]) and repeat (PT/INR) in 3 days. f. The PT/INR was drawn on [DATE] and the results were [MEDICATION NAME] 15.8 and the INR as 1.39. The physician wrote on the lab slip to increase to 11 mg for one week and then repeat the INR. (The [DATE] MAR indicated [REDACTED] A physician's telephone order dated [DATE] documented [MEDICATION NAME] 11 mg po (oral) x (times) 1 week and repeat PT/INR as scheduled. The [DATE] MAR indicated [REDACTED]. g. The next PT/INR's were drawn on [DATE], [DATE] and [DATE] and the physician initialed the lab slips. A telephone order that was not dated documented, Increase [MEDICATION NAME] 10.5 mg x one week and repeat PT/INR x 7 days. h. Nurses notes dated [DATE] at 7:53 p.m., documented, Lab results called to on call APN (Advanced Practice Nurse) at 12:40 p.m. No N.O. (new orders) received at this time. Resident later observed to be lethargic VS (vital signs)100.3, 85, 20 ,[DATE], pulse ox 70 to 93% on O2 (oxygen). Order received to TF (transfer) to hospital. EMS (Emergency Medical Services) notified of transfer at 1:56 a.m. i. The resident was re-admitted to the facility on [DATE] with orders for [MEDICATION NAME] 7.5 mg give 2 tablets to = 15 mg and [MEDICATION NAME] 06 mg/0.6Ml (milliliter) - give 0.6 ml SQ (subcutaneous) daily. PT/INR daily until INR is between 2.0 - 3.0, then once therapeutic level reached D/C (discontinue) [MEDICATION NAME]. The [DATE] MAR indicated [REDACTED]. The [DATE] MAR indicated [REDACTED]. However, the pharmacy stated that they sent out 7 doses on [DATE]. j. The next PT/INR dated [DATE] documented INR of 1.85. The physician hand wrote an order Increase to 15.5 mg daily x 7 days and repeat PT/INR. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. k. The next PT/INR was drawn on [DATE] and the INR was documented as 1.94. A physician's order dated [DATE] documented, D/C (discontinue) [MEDICATION NAME] R/T (related to ) INR 2.3. (INR results was 1.94 not 2.3) l. The PT/INR results dated [DATE] documented the INR at 3.16. The PT/INR results dated [DATE] documented the INR as 4.04. There was no documentation on the lab sheet or the nurses notes that the physician or APN was notified of these results. A physician's order dated [DATE] at 10:06 a.m. documented to hold [MEDICATION NAME] for 2 days. Note: The [DATE] MAR indicated [REDACTED]. m. Nurses notes dated [DATE] at 5:54 p.m., documented, At 4:55 p.m., call placed to on-call APN and report given of concern about [MEDICATION NAME] dose with last INR greater that 4.0 (the one done on [DATE]). Received order to send R (resident) to ER (emergency room ) for PT/INR lab draw. Order noted DON (Director of Nursing) and Administrator notified of TF (transfer) order. R (Resident) informed order to TF to ER (emergency room ) for lab draw, and the need to find out where the current INR was before resuming dose. R made informed decision to refuse TF for lab draw. At 5:09 p.m., APN informed of R's refusal to TF out for lab. Received order to hold [MEDICATION NAME] until lab draw results received tomorrow. FU (follow-up) with on-call. Note: The [DATE] MAR indicated [REDACTED]. n. Nurses notes dated [DATE] at 6:55 p.m., documented, CNA (Certified Nursing Assistant) reported R was not breathing. Observed R in bed, w/o (with-out) respiration or pulse. Code Blue room [ROOM NUMBER] east paged over intercom. Call placed to (local ambulance service) report given this is (name of LPN) at (name of facility) (address of facility), I have a code blue situation in room [ROOM NUMBER] east. It is a bariatric patient send assistance. CPR initiated, EMS arrived, report given R TF to stretcher per staff and EMS. R out of building at 7:13 p.m. (name of family member) notified of TR at 7:15 p.m. Report called to (initials of hospital), Dr (name) notified of pronouncement at 8:19 p.m. APN notified at 8:20 p.m. o. A lab results collected on [DATE] at 1:10 p.m. documented INR of 6.02 High and [MEDICATION NAME] 53.4 High. This form documented, Results successfully called to (initials of lab contracted by the facility) at 8:21 p.m. 2. Resident #11 had a [DIAGNOSES REDACTED]. The Annual MDS with ARD of [DATE] documented the resident scored of 6 (,[DATE] indicates severe impairment) on a BIMS, required limited assistance with bed mobility and extensive assistance with dressing, was independent with the remainder of activities of daily living, and received an anticoagulant 7 days in the past 7 days. a. The Plan of Care developed [DATE] documented a problem of, The resident is on anticoagulant Therapy [MEDICATION NAME] with interventions that included Administer Anticoagulant medications as ordered by the physician and labs as ordered. Report abnormal lab results to MD. b. A physician's order dated [DATE] documented, [MEDICATION NAME] 4 mg daily x 1 week. Repeat PT/INR as scheduled. c. A lab report dated [DATE] documented the PT ([MEDICATION NAME]) as 17.8 and the INR as 1.57. There was a physician's order dated [DATE] to increase the [MEDICATION NAME] to 5 mg daily and continue weekly PT/INR. The [DATE] MAR indicated [REDACTED]. d. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 5.5 mg daily and repeat PT/INR in 7 days. e. The next PT/INR was drawn on [DATE] (5 days later than when ordered). f. On [DATE] the [MEDICATION NAME] was 40.3 and the INR was 3.64. There was a hand written order on the lab slip that documented, Hold PT/INR ([MEDICATION NAME]? not clarified by facility) x 2 days and repeat PT/INR. The [DATE] MAR indicated [REDACTED]. g. A physician's order dated [DATE] documented, D/C (discontinue ) [MEDICATION NAME] 5.5 mg and start [MEDICATION NAME] 4 mg one po at 5:00 p.m. and redraw PT/INR on [DATE]. h. The next PT/INR was drawn on [DATE], four days later than ordered. 3. Resident #12 had a [DIAGNOSES REDACTED]. a. The Plan of Care updated on [DATE] documented a problem of, Daily anticoagulant as per MD orders for CAD ([MEDICAL CONDITION]) with potential for easily bleeding and or bruising with interventions that included Administer meds as ordered, obtain and monitor/diagnostic work as ordered. Report results to MD and follow-up as ordered. b. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 10 mg daily for 7 days and Repeat PT/INR as scheduled. c. Lab results dated [DATE] documented [MEDICATION NAME] 15.3 and INR 1.34. There was a hand written order on the form to increase [MEDICATION NAME] to 10.5 mg daily and repeat PT/INR in 7 days. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. On [DATE] at 2:00 p.m., the resident's medication from the cart was reviewed. There was only one card of [MEDICATION NAME] 10 mg in the cart. On [DATE] at 11:25 a.m., the pharmacy tech stated that the [MEDICATION NAME] 0.5 mg was sent out on the 11th. She further stated that they send enough for 7 doses and then received information from the facility that it was discontinued on [DATE]. There was no documentation in the nurses notes or lab slips that the dose had been decreased to 10 mg. The MAR indicated [REDACTED]. e. The next PT/INR was drawn [DATE] instead of on the 17th as ordered. 5. The Immediate Jeopardy was removed , and the Scope/Severity was lowered to an H on [DATE] at 3:00 p.m., when the facility implemented the following plan of removal. a. The Director of Nursing/Assistant Director of Nursing and RN (Registered Nurse) Treatment Nurse were inserviced on the protocol for PT/INR and the PT/INR deviation sheet by the Corporate Quality Improvement Coordinator on [DATE] at 11:00 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. b. Each of the five (5) residents medical records, who are on anticoagulation therapy were checked by Assistant Director of Nursing and/or RN Treatment nurse on [DATE] from 2:30 p.m., to 4:00 p.m for correct orders, Electronic medical record and medication cart accuracy. c. All residents receiving [MEDICATION NAME] were assessed on [DATE] from 11:15 a.m., to 2:26 p.m by the Assistant Director of Nursing and/or Registered Nurse treatment nurse with no abnormal findings. d. The medication carts (3) were audited for correct [MEDICATION NAME] dosages for the five (5) residents on [DATE] by the Assistant Director of Nursing and/or RN Treatment Nurse e. The PT/INR deviation sheet was put into use by the Assistant Director Of Nurses and/or RN Treatment nurse on [DATE] at 11:15 a.m All nursing working the current shift were inserviced on the PT/INR deviation sheet by the Assistant Director of Nurses and/or RN Treatment Nurse on [DATE] at 11:15 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. All other licensed nurses will be inserviced by the Assistant Director of Nurses and/or RN Treatment Nurses before beginning his/her assigned shift and outgoing to include new employees and any employees returning from leave or absence. f., The physician, Medical Director, was contacted on [DATE] at 11:30 a.m., by the Director of Nursing for all residents on anticoagulation therapy and an order was obtained to draw PT/INR. The lab company was contacted by the Director of Nursing and on [DATE] arrived in the facility to draw stat PT/INR's on all residents on anticoagulation therapy on [DATE] at 3:00 p.m g. The pharmacy was notified by the Director of Nursing on [DATE] and arrived at 2:00 p.m., of issue and a consultant pharmacist conducted an audit of all medications to assure appropriate labs are being drawn for therapeutic medication levels h. The Director of Nursing and/or Assistant Director of Nursing will audit all [MEDICATION NAME] orders dosages given and any labs associated with [MEDICATION NAME] for 3 months. The DON/ ADON will audit 5 x week for 3 months starting on [DATE]. Results from audit will be presented at the monthly QAPI meeting for further evaluation and any abnormal findings will immediately be corrected and reported to Administrator and Medical Director. B. Based on observation, record review and interview, the facility failed to ensure residents were free from significant medication errors for 1 (Resident #15) of 2 (Residents #10 and #15) case mix residents who had orders for [MEDICATION NAME] R insulin and for 3 (Residents # 13, 21, and 22) of 3 case mix residents who had orders for [MEDICATION NAME]. These failed practices had the potential to cause more than minimal harm to 4 residents in the facility who had orders for [MEDICATION NAME] R insulin and 3 residents in the facility who had orders for [MEDICATION NAME] according to the lists provided by the Director of Nursing on [DATE]. The findings are: 1. Resident #15 had [DIAGNOSES REDACTED]. The Admission MDS with ARD dated [DATE] documented the resident was oriented to person, place, time and situation and was verbally appropriate. a. The [DATE] Medication Administration Record [REDACTED]. until [DATE] x 7 days then reassess. Start date [DATE]. b. The Order Summary Report for [DATE] documented, Insulin Regular Human Solution. Inject as per sliding scale: if ,[DATE] = 3 units; 200 - 249 = 5 units; 250 - 299 = 7 units; 300 - 349 = 9 units; 350 - 399 = 11 units. Notify provider for FSBS (Finger Stick Blood Sugar) less than 70 mg/dl and greater than 400 mg/dl, subcutaneously before meals and at bedtime for Diabetes Mellitus Insulin Regular [MEDICATION NAME] Solution. c. On [DATE] at 8:20 a.m., Licensed Practical Nurse (LPN) #1 performed a finger stick blood sugar on Resident #15 with a result of 315. The physician's orders documented the resident would require 9 units of [MEDICATION NAME] R insulin. LPN #1 stated, I'm going to call the MD or Nurse Practitioner and let them know the resident is scheduled to get the blood sugars after the meal. The sliding scale insulin was not given to the resident. LPN #1 stated, I didn't have the insulin (the resident) needs in the building. This was a significant error based on the classification of the drug. 2. Resident #13 had [DIAGNOSES REDACTED]. a. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet 100 mg: Give 1.5 tablet by mouth at bedtime . (start date [DATE]). [MEDICATION NAME] tablet 50 mg. Give 1 tablet by mouth one time a day . (start date [DATE]) CBC (complete blood count) with diff (differential) with absolute neuraphil (sic) count weekly x 6 months. Start Date [DATE]. b. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. c. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. The electronic medical record progress notes were reviewed on [DATE] and documented as follows: [DATE] 21:52 (9:52 p.m.) WBC (White Blood Count) (with) Diff faxed to Central Pharmacy. [DATE] 21:15 (9:15 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 9:06 a.m. Unavailable at this time. [DATE] 9:07 a.m. Unavailable at this time. e. On [DATE] a 1:53 p.m , the pharmacy provider representative, Pharmacist #1, stated that a 7 day supply of [MEDICATION NAME] was sent to the facility on [DATE] for Resident #13, and none had been sent since. f. On [DATE] at 2:00 p.m., LPN #6 was asked for a copy of any [MEDICATION NAME] that Resident #13 had in the medication cart. LPN #6 provided a copy of an empty med card for [MEDICATION NAME] that was dispensed on [DATE] that contained 7 doses of [MEDICATION NAME] 150 mg. LPN #6 was asked, If the [MEDICATION NAME] was delivered on [DATE], would the last dose be given on [DATE]? LPN #6 stated, I suppose so. LPN #3 was asked, Is there [MEDICATION NAME] in the building for the resident? LPN #6 stated, No. A total of 5 doses were not given between [DATE] and [DATE]. g. This was a significant error based on the frequency of the error. 3. Resident #22 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored 11 (,[DATE] indicates moderately impaired) on the BIMS; had inattention and disorganized thinking that fluctuated, had no behaviors; and received antipsychotic, antianxiety, antidepressant and hypnotic drugs daily. a. The Plan of Care created on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t (due to) daily use of antipsychotic as per MD orders for her DX (diagnosis) of [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder; . Interventions: Administer anti-psychotic as per MD order monitoring and observing for adverse side effects, notifying MD as indicated. b. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet: Give 150 mg by mouth at bedtime . (Start date [DATE]) . [MEDICATION NAME] tablet: Give 50 mg by mouth in the morning . (Start date [DATE]) . c. The [DATE] MAR indicated [REDACTED]. d. The [DATE] Medication Administration Record [REDACTED]. e. The electronic medical record progress notes documented as follows: [DATE] 6:25 a.m. Refused AM (morning) meds. [DATE] 20:01 (8:01 p.m.) Blood drawn - have not received med. (medication) from pharmacy. [DATE] 00:58 (a.m.) . Resident up in w/c (wheelchair) in DR (dining room) at this time. Talking to people that are not there. Also making loud animal sounds and screaming at herself. [DATE] 21:13 (9:13 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:49 (a.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:53 (a.m.) Not available. f. On [DATE] at 1:53 p.m., a pharmacy representative, Pharmacist #1, from the company that supplied the facility with medication was interviewed via the telephone. Pharmacist #1 stated that a 7 day supply of the morning and bedtime dose of [MEDICATION NAME] was sent to the facility on [DATE] and on [DATE]. The 7 day supply sent on [DATE] would have been depleted on [DATE]. There was no [MEDICATION NAME] in the facility to administer to the resident from [DATE] until the medication was sent on [DATE]. On [DATE], the [DATE] MAR indicated [REDACTED]. A total of 10 doses (5 morning and 5 bedtime) of [MEDICATION NAME] were not administered to the resident. This was significant based on the frequency of the error. 3. Resident #21 had [DIAGNOSES REDACTED]. a. The [DATE] Order Summary Report documented, [MEDICATION NAME] Tablet 100 mg 3.5 tablets by mouth at bedtime . CBC Q week every day shift every Mon (Monday) for [MEDICATION NAME] Refill. b. The Plan of Care revised on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t daily use of antipsychotic as per MD orders for his dx of [MEDICAL CONDITION]. Interventions: Administer antipsychotic medication as ordered by physician. Monitor for side effects and effectiveness . c. The [DATE] MAR indicated [REDACTED]. d. The electronic medical record progress notes were reviewed and documented as follows: [DATE] 19:57 (7:57 p.m.) Unable to administer. [MEDICATION NAME] (sic) not available. [DATE] 20:11 (8:11 p.m.) Gamma Lab here to venipuncture resident for CBC. [DATE] 23:57 (11:57 p.m.) Received results of CBC/diff and was faxed to (Name of pharmacy). [DATE] 20:06 (8:06 p.m.) Blood drawn - haven't received med from pharm (pharmacy). [DATE] 21:11 (9:11 p.m.) Scheduled lab not drawn nor scheduled [MEDICATION NAME] not available at this time. e. On [DATE] at 1:53 p.m., a pharmacy representative, Pharmacist #1, from the company that supplied the facility with medication was interviewed via the telephone. Pharmacist #1 stated that a 7 day supply of [MEDICATION NAME] was sent to the facility on [DATE] and on [DATE]. The 7 day supply sent on [DATE] would have been depleted on [DATE]. A total of 7 doses of [MEDICATION NAME] 100 mg 3.5 tablets at bedtime were not administered to the resident between [DATE] and [DATE]. f. This was significant based on the frequency of the error.

Complaint # (AR 590) and Complaint # (AR 585) were substantiated, all or in part, in these findings. Based on observation, record review and interview, the facility failed to ensure funds were promptly provided to allow for effective facility administration to maintain Lab Services to ensure high risk medications ([MEDICATION NAME]) were monitored for potential toxic levels for 3 of 3 (Residents #17, #11 and #12) case mix residents who received anticoagulant therapy. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 1 (Resident #17) who expired [DATE] with a critically high INR and 2 (Residents #11 and #12) who had orders for [MEDICATION NAME] and no consistent PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) monitoring. The failed practice had the potential to cause more than minimal harm 5 residents who received anticoagulation therapy. The facility was notified of the Immediate Jeopardy on [DATE] at 9:53 a.m. The facility also failed to ensure that laboratory work was performed to monitor for potentially harmful blood dyscrasias and to ensure pharmacy could continue to send the medication for 3 of 3 (Resident #13, #21, and #22) case mix residents who had orders for [MEDICATION NAME]. This failed practice had the potential to cause more than minimal harm for 3 residents in the facility who had orders for [MEDICATION NAME] according to the list provided by the Director of Nursing (DON) on [DATE]. The findings are: 1. On [DATE] at 4:00 p.m., the DON stated the previous lab company had notified her on [DATE] that they would no longer draw lab because they had not been paid. She stated that she called the corporate office and they told her, You are there, you handle it. She stated that she notified the local hospitals and they would not do it. She stated that she them called the Health Department and they told her that she would need more training. She stated that she found a business card for the lab services that are now contracted with the facility. On [DATE] at 4:17 p.m., a representative from the lab that refused to draw anymore lab since [DATE] was interviewed. This person stated that the reason they stopped was because they had not received any payment since 2013. 2. On [DATE] at 1:10 p.m., the DON was asked, Who is your pharmacy consultant? The DON stated, We will have Pharmacy #2 on [DATE]st. The DON was asked, Is there no pharmacy consultant (now)? The DON stated, Pharmacy #1 saw the residents this month. The DON was asked, What is the problem with Pharmacy #1 providing meds (medications)? The DON stated, They haven't been paid. 3. According to the Nursing 2015 Drug Handbook, [MEDICATION NAME] is a Anticoagulants. For Administration of oral [MEDICATION NAME] PT/INR determinations are essential for proper control. The black Box warning documented [MEDICATION NAME] can cause major or fatal bleeding. Regularly monitor INR in all patients. 4. Resident #17 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); was independent with activities of daily living, and received anticoagulant therapy 2 days of the past 7 days. a. A physician's order dated [DATE] documented, [MEDICATION NAME] Sodium 6 mg (milligrams) give 1 tablet by mouth one time a day for [MEDICAL CONDITION] give with 7.5 mg tab = (equals) 13.5 mg. Another physician's order dated [DATE] documented, [MEDICATION NAME] Sodium tablet 7.5 mg give 1 tablet one time a day for [MEDICAL CONDITION]. Give with 6 mg to = 13.5 mg. b. The temporary plan of care for the resident dated [DATE] did not address the Anticoagulant therapy or the risk factors associated with anticoagulant therapy. c. The [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. One time only for therapeutic levels for 1 day. This was administered one time on [DATE]. However, there was no physician order in the clinical record to do this. d. The [DATE] MAR indicated [REDACTED]. The June MAR indicated [REDACTED]. e. A PT/INR results dated [DATE] documented the [MEDICATION NAME] as 49 (10XXX,[DATE].1 normal range) and the INR as 4.45 (0XXX,[DATE].2 normal range). The physician wrote on the lab sheet to hold ([MEDICATION NAME]) and repeat (PT/INR) in 3 days. f. The PT/INR results dated [DATE] was [MEDICATION NAME] 15.8 and the INR as 1.39. The physician wrote on the lab slip to increase to 11 mg for one week and then repeat the INR. (The [DATE] MAR indicated [REDACTED] A physician's telephone order dated [DATE] documented [MEDICATION NAME] 11 mg po (oral) x (times) 1 week and repeat PT/INR as scheduled. The [DATE] MAR indicated [REDACTED]. g. The next PT/INR's were drawn on [DATE], [DATE] and [DATE] and the physician initialed the lab slips. A telephone order that was not dated documented, Increase [MEDICATION NAME] 10.5 mg x one week and repeat PT/INR x 7 days. h. Nurses notes dated [DATE] at 7:53 p.m., documented, Lab results called to on call APN (Advanced Practice Nurse) at 12:40 p.m No N.O. (new orders) received at this time. Resident later observed to be lethargic VS (vital signs) 100.3, 85, 20 ,[DATE], pulse ox 70 to 93% on O2 (oxygen). Order received to TF (transfer) to hospital. EMS (Emergency Medical Services) notified of transfer at 1:56 a.m. i. On [DATE] the resident was readmitted to the facility with orders for [MEDICATION NAME] 7.5 mg give 2 tablets to = 15 mg and [MEDICATION NAME] 06 mg/0.6Ml (milliliter) - give 0.6 ml SQ (subcutaneous) daily. PT/INR daily until INR is between 2.0 -3.0, then once therapeutic level reached D/C (discontinue) [MEDICATION NAME]. The [DATE] MAR indicated [REDACTED]. The August MAR indicated [REDACTED]. However, the pharmacy stated that they sent out 7 doses on [DATE]. j. The next PT/INR dated [DATE] documented INR of 1.85. The physician hand wrote an order Increase to 15.5 mg daily x 7 days and repeat PT/INR. The August [DATE] documented the resident received 15 mg of [MEDICATION NAME] instead of 15.5 mg from [DATE] - [DATE], [DATE], and [DATE] - [DATE] at 5 p.m. (held on [DATE], [DATE], and [DATE]). The MAR indicated [REDACTED]. k. The next PT/INR was drawn on [DATE] and the INR was documented as 1.94. A physician's order dated [DATE] to documented, D/C (discontinue) [MEDICATION NAME] R/T (related to ) INR 2.3. (INR results was 1.94 not 2.3) l. The PT/INR results dated [DATE] documented the INR at 3.16. The PT/INR results dated [DATE] documented the INR as 4.04. There was no documentation on the lab sheet or the nurses notes that the physician or APN was notified of these results. A physician's order dated [DATE] at 10:06 a.m. documented to hold [MEDICATION NAME] for 2 days. Note: The [DATE] MAR indicated [REDACTED]. m. Nurses notes dated [DATE] documented, At 4:55 p.m., call placed to on-call APN and report given of concern about [MEDICATION NAME] dose with last INR greater that 4.0 (the one done on [DATE]). Received order to send R (resident) to ER (emergency room ) for PT/INR lab draw. Order noted DON (Director of Nursing) and Administrator notified of TF (transfer) order. R (Resident) informed order to TF to ER (emergency room ) for lab draw, and the need to find out where the current INR was before resuming dose. R made informed decision to refuse TF for lab draw. At 5:09 p.m., APN informed of R's refusal to TF out for lab. Received order to hold [MEDICATION NAME] until lab draw results received tomorrow. FU (follow-up) with on-call. Note: The [DATE] MAR indicated [REDACTED]. n. Nurses notes dated [DATE] at 6:55 p.m., documented, CNA (Certified Nursing Assistant) reported R was not breathing. Observed R in bed, w/o (with-out) respiration or pulse. Code Blue room [ROOM NUMBER] east paged over intercom. Call placed to (local ambulance service) report given this is (name of LPN) at (name of facility) (address of facility), I have a code blue situation in room [ROOM NUMBER] east. It is a bariatric patient send assistance. CPR initiated, EMS arrived, report given R TF to stretcher per staff and EMS. R out of building at 7:13 p.m. (name of family member) notified of TR at 7:15 p.m. Report called to (initials of hospital), Dr (name) notified of pronouncement at 8:19 p.m APN notified at 8:20 p.m. o. A lab results collected on [DATE] at 1:10 p.m. documented INR of 6.02 High and [MEDICATION NAME] 53.4 High. This form documented, Results successfully called to (initials of lab contracted by the facility) at 8:21 p.m On [DATE] at 4:00 p.m., the Director of Nurses stated that she called the lab and they told her that the reason the facility was not notified of the High INR was that they had no telephone number or anyway to contact the facility. 5. Resident #11 had a [DIAGNOSES REDACTED]. The Annual MDS with ARD of [DATE] documented the resident scored of 6 (,[DATE] indicates severe impairment) on the BIMS, required limited assistance with bed mobility and extensive assistance with dressing, was independent with the remainder of activities of daily living, and received an anticoagulant 7 days in the past 7 days. a. The Plan of Care developed [DATE] documented a problem of, The resident is on anticoagulant Therapy [MEDICATION NAME] with interventions that included Administer Anticoagulant medications as ordered by the physician and Labs as ordered. Report abnormal lab results to MD. b. A physician's order dated [DATE] documented, [MEDICATION NAME] 4 mg daily x 1 week. Repeat PT/INR as scheduled. c. A lab report dated [DATE] documented the PT as 17.8 and the INR as 1.57. There was a physician's order dated [DATE] to increase the [MEDICATION NAME] to 5 mg daily and continue weekly PT/INR. The [DATE] MAR indicated [REDACTED]. d. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 5.5 mg daily and repeat PT/INR in 7 days. e. The next PT/INR was drawn on [DATE] (5 days later than when ordered). f. The lab results dated [DATE] documented the [MEDICATION NAME] was 40.3 and the INR was 3.64. There was a hand written order on the lab slip that documented, Hold PT/INR ([MEDICATION NAME]? not clarified by facility) x 2 days and repeat PT/INR. The [DATE] MAR indicated [REDACTED]. g. A physician's order dated [DATE] documented, D/C (discontinue) [MEDICATION NAME] 5.5 mg and start [MEDICATION NAME] 4 mg one po at 5:00 p.m. and redraw PT/INR on [DATE]. h. The next PT/INR was drawn on [DATE], four days later than ordered. 6. Resident #12 had a [DIAGNOSES REDACTED]. a. The Plan of Care updated on [DATE] documented a problem of, Daily anticoagulant as per MD orders for CAD ([MEDICAL CONDITION]) with potential for easily bleeding and or bruising with interventions that included Administer meds as ordered, obtain and monitor/diagnostic work as ordered. Report results to MD and follow-up as ordered. b. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 10 mg daily for 7 days and Repeat PT/INR as scheduled. c. Lab results dated [DATE] documented [MEDICATION NAME] 15.3 and INR 1.34. There was a hand written order on the form to increase [MEDICATION NAME] to 10.5 mg daily and repeat PT/INR in 7 days. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. On [DATE] at 2:00 p.m., the resident's medication from the cart was reviewed. There was only one card of [MEDICATION NAME] 10 mg in the cart. On [DATE] at 11:25 a.m., the pharmacy tech stated that the [MEDICATION NAME] 0.5 mg was sent out on the 11th. She further stated that they send enough for 7 doses and then received information from the facility that it was discontinued on [DATE]. There was no documentation in the nurses notes or lab slips that the dose had been decreased to 10 mg. The MAR indicated [REDACTED]. e. The next PT/INR was drawn [DATE] instead of on the 17th as ordered. 7. Resident #13 had [DIAGNOSES REDACTED]. a. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet 100 mg: Give 1.5 tablet by mouth at bedtime . (start date [DATE]). [MEDICATION NAME] tablet 50 mg. Give 1 tablet by mouth one time a day . (start date [DATE]) . CBC (complete blood count) with diff (differential) with absolute neuraphil (sic) count weekly x 6 months. Start Date [DATE]. b. The clinical record had copies of lab results for a CBC with Diff that was performed on [DATE], [DATE], [DATE] and [DATE]. There were no results in the record for any CBC with Diff after [DATE] order would not have been discontinued until [DATE]. c. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed on [DATE] and documented as follows: [DATE] 21:52 (9:52 p.m.) WBC (White Blood Count) (with) Diff (differential) faxed to Central Pharmacy. [DATE] 21:15 (9:15 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 9:06 a.m. Unavailable at this time. [DATE] 9:07 a.m. Unavailable at this time. f. On [DATE] at 8:45 a.m., Registered Nurse (RN) #1 was asked, Why are there skips in the [MEDICATION NAME] (administration)? RN #1 stated, I'm not sure why. [MEDICATION NAME] is an antipsychotic and needs a CBC. Copies of the CBC with diff performed since [DATE] were requested but not provided by the time of exit. 8. Resident #22 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored 11 (,[DATE] indicates moderately impaired) on the BIMS; had inattention and disorganized thinking that fluctuated; had no behaviors; and received antipsychotic, antianxiety, antidepressant and hypnotic drugs daily. a. The Plan of Care created on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t (due to) daily use of antipsychotic as per MD orders for her DX (diagnosis) of [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder; . Interventions: Administer anti-psychotic as per MD order monitoring and observing for adverse side effects, notifying MD as indicated . b. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet: Give 150 mg by mouth at bedtime . (Start date [DATE]) . [MEDICATION NAME] tablet: Give 50 mg by mouth in the morning . (Start date [DATE]) . There were no documented orders for a CBC with Differential to be drawn weekly to monitor for blood dyscrasias with [MEDICATION NAME]. c. A CBC with Diff dated [DATE] was in the clinical record. There were no results for any CBC with Diff in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The [DATE] MAR indicated [REDACTED]. f. The electronic medical record progress notes documented as follows: [DATE] 6:25 a.m. Refused AM (morning) meds. [DATE] 20:01 (8:01 p.m.) Blood drawn - have not received med. (medication) from pharmacy. [DATE] 00:58 (a.m.) . Resident up in w/c (wheelchair) in DR (dining room) at this time. Talking to people that are not there. Also making loud animal sounds and screaming at herself. [DATE] 21:13 (9:13 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:49 (a.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:53 (a.m.) Not available. g. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results in the clinical record, but copies were not provided by the time of exit. 9. Resident #21 had [DIAGNOSES REDACTED]. a. The [DATE] Order Summary Report documented, [MEDICATION NAME] Tablet 100mg 3.5 tablets by mouth at bedtime . CBC Q week every day shift every Mon (Monday) for [MEDICATION NAME] Refill. b. The Plan of Care revised on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t daily use of antipsychotic as per MD orders for his dx of [MEDICAL CONDITION]. Interventions: Administer antipsychotic medication as ordered by physician. Monitor for side effects and effectiveness . c. A CBC with Diff dated [DATE] was in the resident's clinical record. There were no results for any other CBC performed in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed and documented as follows: [DATE] 19:57 (7:57 p.m.) Unable to administer. [MEDICATION NAME] (sic) not available. [DATE] 20:11 (8:11 p.m.) Gamma Lab here to venipuncture resident for CBC. [DATE] 23:57 (11:57 p.m.) Received results of CBC/diff and was faxed to (Name of pharmacy). [DATE] 20:06 (8:06 p.m.) Blood drawn - haven't received med from pharm (pharmacy). [DATE] 21:11 (9:11 p.m.) Scheduled lab not drawn nor scheduled [MEDICATION NAME] not available at this time. f. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results ([DATE]) in the clinical record, but copies were not provided by the time of exit. 10. On [DATE] at 1:53, a telephone interview with a pharmacy representative, Pharmacist #1 was asked, Is there a reason the [MEDICATION NAME] was not sent to the residents? Pharmacist #1 stated, Probably the blood work. Pharmacist #1 was asked, Do they (the facility) fax the blood work to the pharmacy and then you dispense? The Pharmacist stated, We enter the blood work into a national [MEDICATION NAME] database. We can't dispense it unless we have a CBC with differential. 11. The Immediate Jeopardy was removed , and the Scope/Severity was lowered to an H on [DATE] at 3:00 p.m., when the facility implemented the following plan of removal. a. The Director of Nursing/Assistant Director of Nursing and RN (Registered Nurse) Treatment nurse were inserviced on the protocol for PT/INR and the PT/INR deviation sheet by the Corporate Quality Improvement Coordinator on [DATE] at 11:00 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. b. Each of the five (5) residents medical records, who are on anticoagulation therapy were checked by Assistant Director of Nursing and/or RN Treatment nurse on [DATE] from 2:30 p.m., to 4:00 p.m for correct orders, Electronic medical record and medication cart accuracy. c. All resident receiving [MEDICATION NAME] were assessed on [DATE] from 11:15 a.m., to 2:26 p.m by the Assistant Director of Nursing and/or Registered Nurse treatment nurse with no abnormal findings. d. The medication carts (3) were audited for correct [MEDICATION NAME] dosages for the five (5) residents on [DATE] by the Assistant Director of Nursing and/or RN Treatment Nurse e. The PT/INR deviation sheet was put into use by the Assistant Director Of Nurses and/or RN Treatment nurse on [DATE] at 11:15 a.m All nursing working the current shift were inserviced on the PT/INR deviation sheet by the Assistant Director of Nurses and/or RN Treatment Nurse on [DATE] at 11:15 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. All other licensed nurses will be inserviced by the Assistant Director of Nurses and/or RN Treatment Nurses before beginning his/her assigned shift and outgoing to include new employees and any employees returning from leave or absence. f., The physician, medical Director, was contacted on [DATE] at 11:30 a.m., by the Director of Nursing for all residents on anticoagulation therapy and an order was obtained to draw PT/INR. The lab company was contacted by the Director of Nursing and on [DATE] arrived in the facility to draw stat PT/INR's on all residents on anticoagulation therapy on [DATE] at 3:00 p.m g. The pharmacy was notified by the Director of Nursing on [DATE] and arrived at 2:00 p.m., of issue and a consultant pharmacist an audit of all medications to assure appropriate labs are being drawn for therapeutic medication levels h. The Director of Nursing and/or Assistant Director of Nursing will audit all [MEDICATION NAME] orders dosages given and any labs associated with [MEDICATION NAME] for 3 months. The DON/ ADON will audit 5 x week for 3 months starting on [DATE]. Results from audit will be presented at the monthly QAPI meeting for further evaluation and any abnormal findings will immediately be corrected and reported to Administrator and Medical Director.

Complaint # (AR 585) and Complaint # (AR 590) were substantiated, all or in part, in these findings. Based on observations, record review and interview, the facility failed to ensure laboratory services were promptly provided to ensure high risk medications ([MEDICATION NAME]) were monitored for potential toxic levels for 3 of 3 (Residents #17, #11 and #12) case mix residents who received anticoagulant therapy. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 1 (Resident #17) who expired [DATE] with a critically high INR and 2 (Residents #11 and #12) who had orders for [MEDICATION NAME] and no consistent PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) monitoring. The failed practice had the potential to cause more than minimal harm 5 residents who recieved anticoagulant therapy. The facility was notified of the Immediate Jeopardy on [DATE] at 9:53 a.m. The facility also failed to ensure that laboratory work was performed to monitor for potentially harmful blood dyscrasias and to ensure pharmacy could continue to send the medication for 3 of 3 (Resident #13, #21, and #22) case mix residents who had orders for [MEDICATION NAME]. This failed practice had the potential to cause more than minimal harm for 3 residents in the facility who had orders for [MEDICATION NAME] according to the list provided by the Director of Nursing on [DATE]. The findings are: 1. On [DATE] at 4:00 p.m., the Director of Nurses stated the previous Lab company had notified her on [DATE] that they would no longer draw lab because they had not been paid. She stated that she called the corporate office and they told her, You are there, you handle it. She stated that she notified the local hospitals and they would not do it. She stated that she them called the Health Department and they told her that she would need more training. She stated that she found a business card for the Lab services that are now contracted with the facility. 2. On [DATE] at 4:17 p.m., a representative from the lab that refused to draw anymore lab since [DATE] was interveiwed. This person stated that the reason they stopped was because they had not received any payment since 2013. 3. According to the Nursing 2015 Drug Handbook, [MEDICATION NAME] is a Anticoagulants. For Administration of oral [MEDICATION NAME] PT/INR determinations are essential for proper control. The black Box warning documented [MEDICATION NAME] can cause major or fatal bleeding. Regularly monitor INR in all patients. 4. Resident #17 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); was independent with activities of daily living, and received anticoagulant therapy 2 days of the past 7 days. a. A physician's order dated [DATE] documented, [MEDICATION NAME] Sodium 6 mg (milligrams) give 1 tablet by mouth one time a day for [MEDICAL CONDITION] give with 7.5 mg tab = (equals) 13.5 mg. Another physician's order dated [DATE] documented, [MEDICATION NAME] Sodium tablet 7.5 mg give 1 tablet one time a day for [MEDICAL CONDITION]. Give with 6 mg to = 13.5 mg. b. The temporary plan of care for the resident dated [DATE] did not address the Anticoagulant therapy or the risk factors associated with anticoagulant therapy. c. The [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. One time only for therapeutic levels for 1 day. This was administered one time on [DATE]. However, there was no physician order in the clinical record to do this. d. The [DATE] MAR indicated [REDACTED]. The June MAR indicated [REDACTED]. e. A PT/INR results dated [DATE] documented the [MEDICATION NAME] as 49 (10XXX,[DATE].1 normal range) and the INR as 4.45 (0XXX,[DATE].2 normal range). The physician wrote on the lab sheet to hold ([MEDICATION NAME]) and repeat (PT/INR) in 3 days. f. The PT/INR results dated [DATE] was [MEDICATION NAME] 15.8 and the INR as 1.39. The physician wrote on the lab slip to increase to 11 mg for one week and then repeat the INR. (The [DATE] MAR indicated [REDACTED] A physician's telephone order dated [DATE] documented [MEDICATION NAME] 11 mg po (oral) x (times) 1 week and repeat PT/INR as scheduled. The [DATE] MAR indicated [REDACTED]. g. The next PT/INR's were drawn on [DATE], [DATE] and [DATE] and the physician initialed the lab slips. A telephone order that was not dated documented, Increase [MEDICATION NAME] 10.5 mg x one week and repeat PT/INR x 7 days. h. Nurses notes dated [DATE] at 7:53 p.m., documented, Lab results called to on call APN (Advanced Practice Nurse) at 12:40 p.m No N.O. (new orders) received at this time. Resident later observed to be lethargic VS (vital signs) 100.3, 85, 20 ,[DATE], pulse ox 70 to 93% on O2 (oxygen). Order received to TF (transfer) to hospital. EMS (Emergency Medical Services) notified of transfer at 1:56 a.m. i. On [DATE] the resident was readmitted to the facility with orders for [MEDICATION NAME] 7.5 mg give 2 tablets to = 15 mg and [MEDICATION NAME] 06 mg/0.6Ml (milliliter) - give 0.6 ml SQ (subcutaneous) daily. PT/INR daily until INR is between 2.0 -3.0, then once therapeutic level reached D/C (discontinue) [MEDICATION NAME]. The [DATE] MAR indicated [REDACTED]. The August MAR indicated [REDACTED]. However, the pharmacy stated that they sent out 7 doses on [DATE]. j. The next PT/INR dated [DATE] documented INR of 1.85. The physician hand wrote an order Increase to 15.5 mg daily x 7 days and repeat PT/INR. The August [DATE] documented the resident received 15 mg of [MEDICATION NAME] instead of 15.5 mg from [DATE] - [DATE], [DATE], and [DATE] - [DATE] at 5 p.m. (held on [DATE], [DATE], and [DATE]). The MAR indicated [REDACTED]. k. The next PT/INR was drawn on [DATE] and the INR was documented as 1.94. A physician's order dated [DATE] to documented, D/C (discontinue) [MEDICATION NAME] R/T (related to ) INR 2.3. (INR results was 1.94 not 2.3) l. The PT/INR results dated [DATE] documented the INR at 3.16. The PT/INR results dated [DATE] documented the INR as 4.04. There was no documentation on the lab sheet or the nurses notes that the physician or APN was notified of these results. A physician's order dated [DATE] at 10:06 a.m. documented to hold [MEDICATION NAME] for 2 days. Note: The [DATE] MAR indicated [REDACTED]. m. Nurses notes dated [DATE] documented, At 4:55 p.m., call placed to on-call APN and report given of concern about [MEDICATION NAME] dose with last INR greater that 4.0 (the one done on [DATE]). Received order to send R (resident) to ER (emergency room ) for PT/INR lab draw. Order noted DON (Director of Nursing) and Administrator notified of TF (transfer) order. R (Resident) informed order to TF to ER (emergency room ) for lab draw, and the need to find out where the current INR was before resuming dose. R made informed decision to refuse TF for lab draw. At 5:09 p.m., APN informed of R's refusal to TF out for lab. Received order to hold [MEDICATION NAME] until lab draw results received tomorrow. FU (follow-up) with on-call. Note: The [DATE] MAR indicated [REDACTED]. n. Nurses notes dated [DATE] at 6:55 p.m., documented, CNA (Certified Nursing Assistant) reported R was not breathing. Observed R in bed, w/o (with-out) respiration or pulse. Code Blue room [ROOM NUMBER] east paged over intercom. Call placed to (local ambulance service) report given this is (name of LPN) at (name of facility) (address of facility), I have a code blue situation in room [ROOM NUMBER] east. It is a bariatric patient send assistance. CPR initiated, EMS arrived, report given R TF to stretcher per staff and EMS. R out of building at 7:13 p.m. (name of family member) notified of TR at 7:15 p.m. Report called to (initials of hospital), Dr (name) notified of pronouncement at 8:19 p.m APN notified at 8:20 p.m. o. A lab results collected on [DATE] at 1:10 p.m. documented INR of 6.02 High and [MEDICATION NAME] 53.4 High. This form documented, Results successfully called to (initials of lab contracted by the facility) at 8:21 p.m On [DATE] at 4:00 p.m., the Director of Nurses stated that she called the lab and they told her that the reason the facility was not notified of the High INR was that they had no telephone number or anyway to contact the facility. 5. Resident #11 had a [DIAGNOSES REDACTED]. The Annual MDS with ARD of [DATE] documented the resident scored of 6 (,[DATE] indicates severe impairment) on the BIMS, required limited assistance with bed mobility and extensive assistance with dressing, was independent with the remainder of activities of daily living, and received an anticoagulant 7 days in the past 7 days. a. The Plan of Care developed [DATE] documented a problem of, The resident is on anticoagulant Therapy [MEDICATION NAME] with interventions that included Administer Anticoagulant medications as ordered by the physician and Labs as ordered. Report abnormal lab results to MD. b. A physician's order dated [DATE] documented, [MEDICATION NAME] 4 mg daily x 1 week. Repeat PT/INR as scheduled. c. A lab report dated [DATE] documented the PT as 17.8 and the INR as 1.57. There was a physician's order dated [DATE] to increase the [MEDICATION NAME] to 5 mg daily and continue weekly PT/INR. The [DATE] MAR indicated [REDACTED]. d. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 5.5 mg daily and repeat PT/INR in 7 days. e. The next PT/INR was drawn on [DATE] (5 days later than when ordered). f. The lab results dated [DATE] documented the [MEDICATION NAME] was 40.3 and the INR was 3.64. There was a hand written order on the lab slip that documented, Hold PT/INR ([MEDICATION NAME]? not clarified by facility) x 2 days and repeat PT/INR. The [DATE] MAR indicated [REDACTED]. g. A physician's order dated [DATE] documented, D/C (discontinue) [MEDICATION NAME] 5.5 mg and start [MEDICATION NAME] 4 mg one po at 5:00 p.m. and redraw PT/INR on [DATE]. h. The next PT/INR was drawn on [DATE], four days later than ordered. 6. Resident #12 had a [DIAGNOSES REDACTED]. a. The Plan of Care updated on [DATE] documented a problem of, Daily anticoagulant as per MD orders for CAD ([MEDICAL CONDITION]) with potential for easily bleeding and or bruising with interventions that included Administer meds as ordered, obtain and monitor/diagnostic work as ordered. Report results to MD and follow-up as ordered. b. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 10 mg daily for 7 days and Repeat PT/INR as scheduled. c. Lab results dated [DATE] documented [MEDICATION NAME] 15.3 and INR 1.34. There was a hand written order on the form to increase [MEDICATION NAME] to 10.5 mg daily and repeat PT/INR in 7 days. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. On [DATE] at 2:00 p.m., the resident's medication from the cart was reviewed. There was only one card of [MEDICATION NAME] 10 mg in the cart. On [DATE] at 11:25 a.m., the pharmacy tech stated that the [MEDICATION NAME] 0.5 mg was sent out on the 11th. She further stated that they send enough for 7 doses and then received information from the facility that it was discontinued on [DATE]. There was no documentation in the nurses notes or lab slips that the dose had been decreased to 10 mg. The MAR indicated [REDACTED]. e. The next PT/INR was drawn [DATE] instead of on the 17th as ordered. 7. Resident #13 had [DIAGNOSES REDACTED]. a. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet 100 mg: Give 1.5 tablet by mouth at bedtime . (start date [DATE]). [MEDICATION NAME] tablet 50 mg. Give 1 tablet by mouth one time a day . (start date [DATE]) . CBC (complete blood count) with diff (differential) with absolute neuraphil (sic) count weekly x 6 months. Start Date [DATE]. b. The clinical record had copies of lab results for a CBC with Diff that was performed on [DATE], [DATE], [DATE] and [DATE]. There were no results in the record for any CBC with Diff after [DATE] order would not have been discontinued until [DATE]. c. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed on [DATE] and documented as follows: [DATE] 21:52 (9:52 p.m.) WBC (White Blood Count) (with) Diff (differential) faxed to Central Pharmacy. [DATE] 21:15 (9:15 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 9:06 a.m. Unavailable at this time. [DATE] 9:07 a.m. Unavailable at this time. f. On [DATE] at 8:45 a.m., Registered Nurse (RN) #1 was asked, Why are there skips in the [MEDICATION NAME] (administration)? RN #1 stated, I'm not sure why. [MEDICATION NAME] is an antipsychotic and needs a CBC. Copies of the CBC with diff performed since [DATE] were requested but not provided by the time of exit. 8. Resident #22 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored 11 (,[DATE] indicates moderately impaired) on the BIMS; had inattention and disorganized thinking that fluctuated; had no behaviors; and received antipsychotic, antianxiety, antidepressant and hypnotic drugs daily. a. The Plan of Care created on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t (due to) daily use of antipsychotic as per MD orders for her DX (diagnosis) of [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder; . Interventions: Administer anti-psychotic as per MD order monitoring and observing for adverse side effects, notifying MD as indicated . b. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet: Give 150 mg by mouth at bedtime . (Start date [DATE]) . [MEDICATION NAME] tablet: Give 50 mg by mouth in the morning . (Start date [DATE]) . There were no documented orders for a CBC with Differential to be drawn weekly to monitor for blood dyscrasias with [MEDICATION NAME]. c. A CBC with Diff dated [DATE] was in the clinical record. There were no results for any CBC with Diff in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The [DATE] MAR indicated [REDACTED]. f. The electronic medical record progress notes documented as follows: [DATE] 6:25 a.m. Refused AM (morning) meds. [DATE] 20:01 (8:01 p.m.) Blood drawn - have not received med. (medication) from pharmacy. [DATE] 00:58 (a.m.) . Resident up in w/c (wheelchair) in DR (dining room) at this time. Talking to people that are not there. Also making loud animal sounds and screaming at herself. [DATE] 21:13 (9:13 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:49 (a.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:53 (a.m.) Not available. g. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results in the clinical record, but copies were not provided by the time of exit. 9. Resident #21 had [DIAGNOSES REDACTED]. a. The [DATE] Order Summary Report documented, [MEDICATION NAME] Tablet 100mg 3.5 tablets by mouth at bedtime . CBC Q week every day shift every Mon (Monday) for [MEDICATION NAME] Refill. b. The Plan of Care revised on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t daily use of antipsychotic as per MD orders for his dx of [MEDICAL CONDITION]. Interventions: Administer antipsychotic medication as ordered by physician. Monitor for side effects and effectiveness . c. A CBC with Diff dated [DATE] was in the resident's clinical record. There were no results for any other CBC performed in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed and documented as follows: [DATE] 19:57 (7:57 p.m.) Unable to administer. [MEDICATION NAME] (sic) not available. [DATE] 20:11 (8:11 p.m.) Gamma Lab here to venipuncture resident for CBC. [DATE] 23:57 (11:57 p.m.) Received results of CBC/diff and was faxed to (Name of pharmacy). [DATE] 20:06 (8:06 p.m.) Blood drawn - haven't received med from pharm (pharmacy). [DATE] 21:11 (9:11 p.m.) Scheduled lab not drawn nor scheduled [MEDICATION NAME] not available at this time. f. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results ([DATE]) in the clinical record, but copies were not provided by the time of exit. 10. On [DATE] at 1:53, a telephone interview with a pharmacy representative, Pharmacist #1 was asked, Is there a reason the [MEDICATION NAME] was not sent to the residents? Pharmacist #1 stated, Probably the blood work. Pharmacist #1 was asked, Do they (the facility) fax the blood work to the pharmacy and then you dispense? The Pharmacist stated, We enter the blood work into a national [MEDICATION NAME] database. We can't dispense it unless we have a CBC with differential. 11. The Immediate Jeopardy was removed , and the Scope/Severity was lowered to an H on [DATE] at 3:00 p.m., when the facility implemented the following plan of removal. a. The Director of Nursing/Assistant Director of Nursing and RN (Registered Nurse) Treatment nurse were inserviced on the protocol for PT/INR and the PT/INR deviation sheet by the Corporate Quality Improvement Coordinator on [DATE] at 11:00 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. b. Each of the five (5) residents medical records, who are on anticoagulation therapy were checked by Assistant Director of Nursing and/or RN Treatment nurse on [DATE] from 2:30 p.m., to 4:00 p.m for correct orders, Electronic medical record and medication cart accuracy. c. All resident receiving [MEDICATION NAME] were assessed on [DATE] from 11:15 a.m., to 2:26 p.m by the Assistant Director of Nursing and/or Registered Nurse treatment nurse with no abnormal findings. d. The medication carts (3) were audited for correct [MEDICATION NAME] dosages for the five (5) residents on [DATE] by the Assistant Director of Nursing and/or RN Treatment Nurse e. The PT/INR deviation sheet was put into use by the Assistant Director Of Nurses and/or RN Treatment nurse on [DATE] at 11:15 a.m All nursing working the current shift were inserviced on the PT/INR deviation sheet by the Assistant Director of Nurses and/or RN Treatment Nurse on [DATE] at 11:15 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. All other licensed nurses will be inserviced by the Assistant Director of Nurses and/or RN Treatment Nurses before beginning his/her assigned shift and outgoing to include new employees and any employees returning from leave or absence. f., The physician, medical Director, was contacted on [DATE] at 11:30 a.m., by the Director of Nursing for all residents on anticoagulation therapy and an order was obtained to draw PT/INR. The lab company was contacted by the Director of Nursing and on [DATE] arrived in the facility to draw stat PT/INR's on all residents on anticoagulation therapy on [DATE] at 3:00 p.m g. The pharmacy was notified by the Director of Nursing on [DATE] and arrived at 2:00 p.m., of issue and a consultant pharmacist an audit of all medications to assure appropriate labs are being drawn for therapeutic medication levels h. The Director of Nursing and/or Assistant Director of Nursing will audit all [MEDICATION NAME] orders dosages given and any labs associated with [MEDICATION NAME] for 3 months. The DON/ ADON will audit 5 x week for 3 months starting on [DATE]. Results from audit will be presented at the monthly QAPI meeting for further evaluation and any abnormal findings will immediately be corrected and reported to Administrator and Medical Director.

Complaint # (AR 590) and Complaint # (AR 585) were substantiated, all or in part, in these findings. Based on observations, record review and interview the Quality Assessment and Assurance Committee failed to identify quality deficiencies as evidenced by the facility failure to ensure high risk medications ([MEDICATION NAME]) were monitored for potential toxic levels and were given or held as prescribed by the physician to ensure accuracy of using lab results to determine most effective dose for 3 of 3 (Residents #17, #11 and #12) case mix residents who received anticoagulant therapy. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to 1 (Resident #17) who expired [DATE] with a critically high INR and 2 (Residents #11 and #12) who had orders for [MEDICATION NAME] and no consistent PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) monitoring. The failed practice had the potential to cause more than minimal harm 5 residents who received anticoagulant therapy. The facility was notified of the Immediate Jeopardy on [DATE] at 9:53 a.m. The facility also failed to ensure that laboratory work was performed to monitor for potentially harmful blood dyscrasias and to ensure pharmacy could continue to send the medication for 3 of 3 (Resident #13, #21, and #22) case mix residents who had orders for [MEDICATION NAME]. This failed practice had the potential to cause more than minimal harm for 3 residents in the facility who had orders for [MEDICATION NAME] according to the list provided by the Director of Nursing on [DATE]. The findings are: 1. On [DATE] at 9:00 a.m., the Administrator was interviewed regarding the QA &A Committee. He stated, All department heads, the Medical Director and the Assistant Director of Nursing were on the QA&A Committee. He was asked, Did the QA&A committee recognize any areas of concern related to [MEDICATION NAME] (anticoagulant therapy) and lab? He stated, Part of the committee did, discussed with the Medical Director. He was asked, What was the action plan? He stated that it was to secure labs and get labs drawn. He stated that the committee did not identify any issues with medication administration. On [DATE] at 9:00 a.m., the Medical Director (member of the QA&A Committee) was interviewed. He was asked, Have you had any issues with the facility related to lab services? He stated, They told me they were switching in the last 2 weeks. I don't know where to call to get results. I'm not certain today where to send the lab to. He was asked, Have you had any problems with PT/INR's? He stated, I'm trying to remember. I guess it's the same lab thing. There was no evidence that the facility attempted to send the residents to a clinic or to the hospital outpatient to get labs drawn. On [DATE] at 4:00 p.m., the Director of Nurses stated the previous lab company had notified her on [DATE] that they would no longer draw lab because they had not been paid. She stated that she called the corporate office and they told her, You are there, you handle it. She stated that she notified the local hospitals and they would not do it. She stated that she them called the Health Department and they told her that she would need more training. She stated that she found a business card for the lab services that are now contracted with the facility. On [DATE] at 4:17 p.m., a representative from the lab that refused to draw anymore lab since [DATE] was interviewed. This person stated that the reason they stopped was because they had not received any payment since 2013. 2. According to the Nursing 2015 Drug Handbook, [MEDICATION NAME] is a Anticoagulants. For Administration of oral [MEDICATION NAME] PT/INR determinations are essential for proper control. The black Box warning documented [MEDICATION NAME] can cause major or fatal bleeding. Regularly monitor INR in all patients. 3. Resident #17 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 15 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); was independent with activities of daily living, and received anticoagulant therapy 2 days of the past 7 days. a. A physician's order dated [DATE] documented, [MEDICATION NAME] Sodium 6 mg (milligrams) give 1 tablet by mouth one time a day for [MEDICAL CONDITION] give with 7.5 mg tab = (equals) 13.5 mg. Another physician's order dated [DATE] documented, [MEDICATION NAME] Sodium tablet 7.5 mg give 1 tablet one time a day for [MEDICAL CONDITION]. Give with 6 mg to = 13.5 mg. b. The temporary plan of care for the resident dated [DATE] did not address the Anticoagulant therapy or the risk factors associated with anticoagulant therapy. c. The [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. One time only for therapeutic levels for 1 day. This was administered one time on [DATE]. However, there was no physician order in the clinical record to do this. d. The [DATE] MAR indicated [REDACTED]. The June MAR indicated [REDACTED]. e. A PT/INR results dated [DATE] documented the [MEDICATION NAME] as 49 (10XXX,[DATE].1 normal range) and the INR as 4.45 (0XXX,[DATE].2 normal range). The physician wrote on the lab sheet to hold ([MEDICATION NAME]) and repeat (PT/INR) in 3 days. f. The PT/INR results dated [DATE] was [MEDICATION NAME] 15.8 and the INR as 1.39. The physician wrote on the lab slip to increase to 11 mg for one week and then repeat the INR. (The [DATE] MAR indicated [REDACTED] A physician's telephone order dated [DATE] documented [MEDICATION NAME] 11 mg po (oral) x (times) 1 week and repeat PT/INR as scheduled. The [DATE] MAR indicated [REDACTED]. g. The next PT/INR's were drawn on [DATE], [DATE] and [DATE] and the physician initialed the lab slips. A telephone order that was not dated documented, Increase [MEDICATION NAME] 10.5 mg x one week and repeat PT/INR x 7 days. h. Nurses notes dated [DATE] at 7:53 p.m., documented, Lab results called to on call APN (Advanced Practice Nurse) at 12:40 p.m No N.O. (new orders) received at this time. Resident later observed to be lethargic VS (vital signs) 100.3, 85, 20 ,[DATE], pulse ox 70 to 93% on O2 (oxygen). Order received to TF (transfer) to hospital. EMS (Emergency Medical Services) notified of transfer at 1:56 a.m. i. On [DATE] the resident was readmitted to the facility with orders for [MEDICATION NAME] 7.5 mg give 2 tablets to = 15 mg and [MEDICATION NAME] 06 mg/0.6Ml (milliliter) - give 0.6 ml SQ (subcutaneous) daily. PT/INR daily until INR is between 2.0 -3.0, then once therapeutic level reached D/C (discontinue) [MEDICATION NAME]. The [DATE] MAR indicated [REDACTED]. The August MAR indicated [REDACTED]. However, the pharmacy stated that they sent out 7 doses on [DATE]. j. The next PT/INR dated [DATE] documented INR of 1.85. The physician hand wrote an order Increase to 15.5 mg daily x 7 days and repeat PT/INR. The August [DATE] documented the resident received 15 mg of [MEDICATION NAME] instead of 15.5 mg from [DATE] - [DATE], [DATE], and [DATE] - [DATE] at 5 p.m. (held on [DATE], [DATE], and [DATE]). The MAR indicated [REDACTED]. k. The next PT/INR was drawn on [DATE] and the INR was documented as 1.94. A physician's order dated [DATE] to documented, D/C (discontinue) [MEDICATION NAME] R/T (related to ) INR 2.3. (INR results was 1.94 not 2.3) l. The PT/INR results dated [DATE] documented the INR at 3.16. The PT/INR results dated [DATE] documented the INR as 4.04. There was no documentation on the lab sheet or the nurses notes that the physician or APN was notified of these results. A physician's order dated [DATE] at 10:06 a.m. documented to hold [MEDICATION NAME] for 2 days. Note: The [DATE] MAR indicated [REDACTED]. m. Nurses notes dated [DATE] documented, At 4:55 p.m., call placed to on-call APN and report given of concern about [MEDICATION NAME] dose with last INR greater that 4.0 (the one done on [DATE]). Received order to send R (resident) to ER (emergency room ) for PT/INR lab draw. Order noted DON (Director of Nursing) and Administrator notified of TF (transfer) order. R (Resident) informed order to TF to ER (emergency room ) for lab draw, and the need to find out where the current INR was before resuming dose. R made informed decision to refuse TF for lab draw. At 5:09 p.m., APN informed of R's refusal to TF out for lab. Received order to hold [MEDICATION NAME] until lab draw results received tomorrow. FU (follow-up) with on-call. Note: The [DATE] MAR indicated [REDACTED]. n. Nurses notes dated [DATE] at 6:55 p.m., documented, CNA (Certified Nursing Assistant) reported R was not breathing. Observed R in bed, w/o (with-out) respiration or pulse. Code Blue room [ROOM NUMBER] east paged over intercom. Call placed to (local ambulance service) report given this is (name of LPN) at (name of facility) (address of facility), I have a code blue situation in room [ROOM NUMBER] east. It is a bariatric patient send assistance. CPR initiated, EMS arrived, report given R TF to stretcher per staff and EMS. R out of building at 7:13 p.m. (name of family member) notified of TR at 7:15 p.m. Report called to (initials of hospital), Dr (name) notified of pronouncement at 8:19 p.m APN notified at 8:20 p.m. o. A lab results collected on [DATE] at 1:10 p.m. documented INR of 6.02 High and [MEDICATION NAME] 53.4 High. This form documented, Results successfully called to (initials of lab contracted by the facility) at 8:21 p.m On [DATE] at 4:00 p.m., the Director of Nurses stated that she called the lab and they told her that the reason the facility was not notified of the High INR was that they had no telephone number or anyway to contact the facility. 4. Resident #11 had a [DIAGNOSES REDACTED]. The Annual MDS with ARD of [DATE] documented the resident scored of 6 (,[DATE] indicates severe impairment) on the BIMS, required limited assistance with bed mobility and extensive assistance with dressing, was independent with the remainder of activities of daily living, and received an anticoagulant 7 days in the past 7 days. a. The Plan of Care developed [DATE] documented a problem of, The resident is on anticoagulant Therapy [MEDICATION NAME] with interventions that included Administer Anticoagulant medications as ordered by the physician and Labs as ordered. Report abnormal lab results to MD. b. A physician's order dated [DATE] documented, [MEDICATION NAME] 4 mg daily x 1 week. Repeat PT/INR as scheduled. c. A lab report dated [DATE] documented the PT as 17.8 and the INR as 1.57. There was a physician's order dated [DATE] to increase the [MEDICATION NAME] to 5 mg daily and continue weekly PT/INR. The [DATE] MAR indicated [REDACTED]. d. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 5.5 mg daily and repeat PT/INR in 7 days. e. The next PT/INR was drawn on [DATE] (5 days later than when ordered). f. The lab results dated [DATE] documented the [MEDICATION NAME] was 40.3 and the INR was 3.64. There was a hand written order on the lab slip that documented, Hold PT/INR ([MEDICATION NAME]? not clarified by facility) x 2 days and repeat PT/INR. The [DATE] MAR indicated [REDACTED]. g. A physician's order dated [DATE] documented, D/C (discontinue) [MEDICATION NAME] 5.5 mg and start [MEDICATION NAME] 4 mg one po at 5:00 p.m. and redraw PT/INR on [DATE]. h. The next PT/INR was drawn on [DATE], four days later than ordered. 5. Resident #12 had a [DIAGNOSES REDACTED]. a. The Plan of Care updated on [DATE] documented a problem of, Daily anticoagulant as per MD orders for CAD ([MEDICAL CONDITION]) with potential for easily bleeding and or bruising with interventions that included Administer meds as ordered, obtain and monitor/diagnostic work as ordered. Report results to MD and follow-up as ordered. b. A physician's order dated [DATE] documented, Increase [MEDICATION NAME] to 10 mg daily for 7 days and Repeat PT/INR as scheduled. c. Lab results dated [DATE] documented [MEDICATION NAME] 15.3 and INR 1.34. There was a hand written order on the form to increase [MEDICATION NAME] to 10.5 mg daily and repeat PT/INR in 7 days. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. On [DATE] at 2:00 p.m., the resident's medication from the cart was reviewed. There was only one card of [MEDICATION NAME] 10 mg in the cart. On [DATE] at 11:25 a.m., the pharmacy tech stated that the [MEDICATION NAME] 0.5 mg was sent out on the 11th. She further stated that they send enough for 7 doses and then received information from the facility that it was discontinued on [DATE]. There was no documentation in the nurses notes or lab slips that the dose had been decreased to 10 mg. The MAR indicated [REDACTED]. e. The next PT/INR was drawn [DATE] instead of on the 17th as ordered. 6. Resident #13 had [DIAGNOSES REDACTED]. a. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet 100 mg: Give 1.5 tablet by mouth at bedtime . (start date [DATE]). [MEDICATION NAME] tablet 50 mg. Give 1 tablet by mouth one time a day . (start date [DATE]) . CBC (complete blood count) with diff (differential) with absolute neuraphil (sic) count weekly x 6 months. Start Date [DATE]. b. The clinical record had copies of lab results for a CBC with Diff that was performed on [DATE], [DATE], [DATE] and [DATE]. There were no results in the record for any CBC with Diff after [DATE] order would not have been discontinued until [DATE]. c. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. d. The [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed on [DATE] and documented as follows: [DATE] 21:52 (9:52 p.m.) WBC (White Blood Count) (with) Diff (differential) faxed to Central Pharmacy. [DATE] 21:15 (9:15 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 9:06 a.m. Unavailable at this time. [DATE] 9:07 a.m. Unavailable at this time. f. On [DATE] at 8:45 a.m., Registered Nurse (RN) #1 was asked, Why are there skips in the [MEDICATION NAME] (administration)? RN #1 stated, I'm not sure why. [MEDICATION NAME] is an antipsychotic and needs a CBC. Copies of the CBC with diff performed since [DATE] were requested but not provided by the time of exit. 7. Resident #22 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of [DATE] documented the resident scored 11 (,[DATE] indicates moderately impaired) on the BIMS; had inattention and disorganized thinking that fluctuated; had no behaviors; and received antipsychotic, antianxiety, antidepressant and hypnotic drugs daily. a. The Plan of Care created on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t (due to) daily use of antipsychotic as per MD orders for her DX (diagnosis) of [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder; . Interventions: Administer anti-psychotic as per MD order monitoring and observing for adverse side effects, notifying MD as indicated . b. The Order Summary Report for [DATE] documented, [MEDICATION NAME] tablet: Give 150 mg by mouth at bedtime . (Start date [DATE]) . [MEDICATION NAME] tablet: Give 50 mg by mouth in the morning . (Start date [DATE]) . There were no documented orders for a CBC with Differential to be drawn weekly to monitor for blood dyscrasias with [MEDICATION NAME]. c. A CBC with Diff dated [DATE] was in the clinical record. There were no results for any CBC with Diff in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The [DATE] MAR indicated [REDACTED]. f. The electronic medical record progress notes documented as follows: [DATE] 6:25 a.m. Refused AM (morning) meds. [DATE] 20:01 (8:01 p.m.) Blood drawn - have not received med. (medication) from pharmacy. [DATE] 00:58 (a.m.) . Resident up in w/c (wheelchair) in DR (dining room) at this time. Talking to people that are not there. Also making loud animal sounds and screaming at herself. [DATE] 21:13 (9:13 p.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:49 (a.m.) [MEDICATION NAME] (sic) not available. [DATE] 05:53 (a.m.) Not available. g. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results in the clinical record, but copies were not provided by the time of exit. 8. Resident #21 had [DIAGNOSES REDACTED]. a. The [DATE] Order Summary Report documented, [MEDICATION NAME] Tablet 100mg 3.5 tablets by mouth at bedtime . CBC Q week every day shift every Mon (Monday) for [MEDICATION NAME] Refill. b. The Plan of Care revised on [DATE] documented, Focus: (Name of Resident) has a potential for adverse side effects d/t daily use of antipsychotic as per MD orders for his dx of [MEDICAL CONDITION]. Interventions: Administer antipsychotic medication as ordered by physician. Monitor for side effects and effectiveness . c. A CBC with Diff dated [DATE] was in the resident's clinical record. There were no results for any other CBC performed in the record since that date. d. The [DATE] MAR indicated [REDACTED]. e. The electronic medical record progress notes were reviewed and documented as follows: [DATE] 19:57 (7:57 p.m.) Unable to administer. [MEDICATION NAME] (sic) not available. [DATE] 20:11 (8:11 p.m.) Gamma Lab here to venipuncture resident for CBC. [DATE] 23:57 (11:57 p.m.) Received results of CBC/diff and was faxed to (Name of pharmacy). [DATE] 20:06 (8:06 p.m.) Blood drawn - haven't received med from pharm (pharmacy). [DATE] 21:11 (9:11 p.m.) Scheduled lab not drawn nor scheduled [MEDICATION NAME] not available at this time. f. On [DATE] at 8:45 a.m., RN #1 was asked for copies of any CBC with Diff since the date on the results ([DATE]) in the clinical record, but copies were not provided by the time of exit. 9. On [DATE] at 1:53, a telephone interview with a pharmacy representative, Pharmacist #1 was asked, Is there a reason the [MEDICATION NAME] was not sent to the residents? Pharmacist #1 stated, Probably the blood work. Pharmacist #1 was asked, Do they (the facility) fax the blood work to the pharmacy and then you dispense? The Pharmacist stated, We enter the blood work into a national [MEDICATION NAME] database. We can't dispense it unless we have a CBC with differential. 10. The Immediate Jeopardy was removed , and the Scope/Severity was lowered to an H on [DATE] at 3:00 p.m., when the facility implemented the following plan of removal. a. The Director of Nursing/Assistant Director of Nursing and RN (Registered Nurse) Treatment nurse were inserviced on the protocol for PT/INR and the PT/INR deviation sheet by the Corporate Quality Improvement Coordinator on [DATE] at 11:00 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. b. Each of the five (5) residents medical records, who are on anticoagulation therapy were checked by Assistant Director of Nursing and/or RN Treatment nurse on [DATE] from 2:30 p.m., to 4:00 p.m for correct orders, Electronic medical record and medication cart accuracy. c. All resident receiving [MEDICATION NAME] were assessed on [DATE] from 11:15 a.m., to 2:26 p.m by the Assistant Director of Nursing and/or Registered Nurse treatment nurse with no abnormal findings. d. The medication carts (3) were audited for correct [MEDICATION NAME] dosages for the five (5) residents on [DATE] by the Assistant Director of Nursing and/or RN Treatment Nurse e. The PT/INR deviation sheet was put into use by the Assistant Director Of Nurses and/or RN Treatment nurse on [DATE] at 11:15 a.m All nursing working the current shift were inserviced on the PT/INR deviation sheet by the Assistant Director of Nurses and/or RN Treatment Nurse on [DATE] at 11:15 a.m The inservice included verification by the nurse that the results of the PT/INR were confirmed before giving the medication and if the lab was out of parameters or there was no results then they are to contact the physician to determine medication order for [MEDICATION NAME] and other items noted. All other licensed nurses will be inserviced by the Assistant Director of Nurses and/or RN Treatment Nurses before beginning his/her assigned shift and outgoing to include new employees and any employees returning from leave or absence. f., The physician, medical Director, was contacted on [DATE] at 11:30 a.m., by the Director of Nursing for all residents on anticoagulation therapy and an order was obtained to draw PT/INR. The lab company was contacted by the Director of Nursing and on [DATE] arrived in the facility to draw stat PT/INR's on all residents on anticoagulation therapy on [DATE] at 3:00 p.m g. The pharmacy was notified by the Director of Nursing on [DATE] and arrived at 2:00 p.m., of issue and a consultant pharmacist an audit of all medications to assure appropriate labs are being drawn for therapeutic medication levels h. The Director of Nursing and/or Assistant Director of Nursing will audit all [MEDICATION NAME] orders dosages given and any labs associated with [MEDICATION NAME] for 3 months. The DON/ ADON will audit 5 x week for 3 months starting on [DATE]. Results from audit will be presented at the monthly QAPI meeting for further evaluation and any abnormal findings will immediately be corrected and reported to Administrator and Medical Director.

Complaint # (AR 137) was substantiated (all or in part) in these findings: Based on observation, record review and interview, the facility failed to ensure acceptable parameters of nutritional status were maintained by failing to ensure eating assistance was consistently provided for 1 (Resident #5) of 2 (Residents #5 and #8) case mix residents who required assistance with eating and by failing to ensure dietary recommendations were promptly implemented to decrease the potential for further weight loss for 3 (Residents #4, #5 and #8) of 5 (Residents #4 through #8) case mix residents who were recommended for dietary supplements. The failed practices resulted in actual harm for Resident #5, who was not provided recommended dietary supplements, nor consistently assisted to eat, resulting in a significant weight loss. The failed practices also had the potential to cause more than minimal harm to 13 residents who were assessed as being at risk for weight loss, according to a list provided by the Director of Nursing (DON) on 4/24/15 at 2:30 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/10/15 documented the resident scored 4 (0-7 indicates severe cognitive impairment) on the brief interview for mental status (BIMS), required extensive assistance of one person for eating, had 3 unstageable pressure ulcers, was at risk for developing pressure ulcers and weighted 297. a. The lab report dated 3/27/15 documented, "Protein, Total - 5.5 L (low) ...(reference range): 5.7 - 8.2 [MEDICATION NAME], Serum - 2.9 L ...(reference range) 3.2 - 4.8..." b. The Care Plan last updated 4/3/15 documented, "...I have impaired cognitive function / dementia or impaired thought processes r/t (related to) Dementia ...Administer medications as ordered. Monitor / document for side effects and effectiveness." The Care Plan did not address nutritional status or weight loss. c. A Monthly Weight Report printed from the facility's computerized clinical records on 4/22/15 at 10:29 a.m. documented the resident's weights as follows: October 2014: 284.7 pounds November 2014: 295.1 pounds December 2014: 297.1 pounds January 2015: 300.4 pounds February 2015: 300.2 pounds March 2015: 303.0 pounds April 2015: 255.5 pounds. The resident's weight had increased or remained stable from October 2014 through March 2015; however, the resident experienced a 15.6% weight loss from March to April 2015. d. The Registered Dietitian Note dated 4/7/15 documented, "....Referred to me today due to multiple PU (pressure ulcers) of size and stages and weight loss. Diet is Mechanical Soft with chopped meats. Meds (medications) include Multivitamin with minerals, [MEDICATION NAME], and ProStat 30 ml (milliliter) BID (twice a day) estimated needs - 2750 - 3000 kcals (kilocalories), 178 gram of protein, and 3400 ml free fluids. Weight is 255.5 (pounds) down from 303 (pounds). This weight loss is questionable. Elder was hospitalized on ,[DATE] and readmitted on ,[DATE]. There may have been some diuresis but I question the 47.5 (pound). Please reweigh resident and add Mighty Shake at lunch and supper if weight loss is accurate." e. A Weekly Summary dated 4/13/15 at 9:45 a.m. documented, " ...Requires staff to fees (feed) him at times appetite fair ..." f. A Health Status Note dated 4/20/15 at 8:51 p.m. documented, " ...requires one to feed him ..." g. On 4/21/14 at 5:25 p.m., the resident was in bed with the head of the bed elevated. The resident's supper tray had been placed in front of him on a bedside table. The resident received a mechanical soft diet of ground corn dog, mac-n-cheese, carrots, fruit cocktail and one carton of milk. There was no mighty shake on his meal tray. The resident was picking at his shirt and the sheet on his bed, unaware of his surroundings. The resident was not feeding himself. He was asked if he was hungry. He stated, "I stay hungry." The resident was asked if he had food in front of him. He stated, "Not right now, I don't." The Surveyor waited in the resident's room until staff entered, 25 minutes later. 1) On 4/21/15 at 5:50 p.m., the Activity Director entered the room and saw the surveyor. She looked around the room and saw that the resident was not feeding himself. The Activity Director asked the surveyor, "Has anyone been in here to feed him?" She was informed not since the surveyor had been in the room. 2) On 4/21/15 at 5:55 p.m., Certified Nursing Assistant (CNA) #1 came into the room to feed the resident. She was asked, Is this resident supposed to have assistance when eating? CNA #1 stated, "It varies. Sometimes he will feed himself." CNA #1 was informed the resident had not fed himself for 30 minutes. CNA #1 made no comment and began to feed the resident. Resident #5 ate 50 to 75% of his supper tray, once the CNA assisted him. h. On 4/22/14 at 12:30 p.m., the resident was in his wheelchair at the dining room table. CNA #2 was feeding the resident. The resident received a mechanical soft diet of barbeque chicken with green beans, mashed potatoes, chocolate cake, juice and milk. The resident did not receive a mighty shake. i. On 4/23/15 at 12:58 p.m., the Dietary Manager (DM), employed since October 2014, was asked about the resident's weight loss. The DM stated, "That fell between the ADON (Assistant Director of Nursing) and DON before. I just recently started putting the weights in the computer..." The DM stated he was unaware of the resident's significant weight loss and the 4/7/15 Registered Dietitian (RD) recommendation for the mighty shake at lunch and supper until yesterday, 4/22/15, when Administration brought it to his attention. j. On 4/23/15, the resident was reweighed and he weighed 242 pounds, which was an additional 13-pound (5.28%) weight loss since the April 2015 monthly weight was documented. The resident had a 20.1% weight loss in one month. 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/19/15 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on the BIMS and required set up with meals. a. The Registered Dietician (RD) note dated 3/17/15 at 11:14 a.m. documented, "Wt. (weight) 203 (pounds) down from 217 (pounds) in 30 days. Dx (diagnosis) include DM (Diabetes Mellitus) type 2 [MEDICAL CONDITION](hypertension). Medication include [MEDICATION NAME] R and [MEDICATION NAME]. Diet LCS (Low Concentrated Sweet) Mechanical soft. Elder feeds self with good appetite. Recommend adding SF (Sugar Free) Ice Cream at lunch and supper." b. The resident's weights copied on 4/22/15 at 10:29 a.m. documented in March 2015 the resident weighed 205 pounds and in April 2015 he weighed 199.5 pounds. The resident had a 2.68% weight loss in one month. c. On 4/21/15 at 5:10 p.m., during the supper meal, and on 4/22/15 at 12:30 p.m., during the lunch meal service, the resident did not receive sugar free ice cream on her meal tray. d. On 4/24/15 at 11:55 a.m., the resident was eating lunch in the dining room. There was no sugar free ice cream on her lunch tray. Sugar free ice cream was not listed on the resident's tray card. e. On 4/24/15 at 12:05 p.m., the DM was asked why the resident did not receive sugar free ice cream on her lunch meal trays. The DM looked at the computer to verify the Registered Dietician recommended the sugar free ice cream and then stated, "Yes, she is supposed to get it. I probably just forgot..." 3. Resident #8 had [DIAGNOSES REDACTED]. The 14-Day MDS with an ARD of 3/6/15 documented the resident scored 1 (0-7 indicates severe cognitive impairment) on the BIMS and required set up help only for eating. a. The Care Plan dated 11/19/14 documented, "ADL (activities of daily living) Function / Rehab (rehabilitation) Potential: Assist with meals as needed." b. A Dietary Note dated 4/7/15 at 3:48 p.m. documented, "Elder weight has declined and consideration is being given to placement of G (gastrostomy) tube, but the family is refusing at this time. They are concerned that she doesn't like the foods provided by the kitchen. Dietary will add peanut butter or meat salad sandwich with lunch and supper tray and add 1 tablespoon of peanut butter to the mighty shakes..." c. On 4/21/15 at 5:23 p.m., the resident was in the dining room for dinner. Her tray contained pureed corndog, carrots, macaroni and cheese, peaches, a carton of fat free chocolate milk and a carton of unopened mighty shake. The resident's tray card documented, "Add peanut butter and jelly sandwich with each meal." There was no sandwich on the tray. The resident's daughter, who was feeding the resident, stated she has to ask for the sandwich at every meal because it is never on the tray. She also stated the mighty shake is seldom on the tray. d. On 4/22/15 at 12:20 p.m., the resident was in the dining room for lunch. Her tray contained pureed barbecue chicken, green beans, mashed potatoes, a peanut butter and jelly sandwich, a carton of fat free chocolate milk, an unopened mighty shake and pureed cake. The resident ate approximately 50% of the meal. e. On 4/23/15 at 1:00 p.m., the Dietary Manager was asked about the Registered Dietician recommendation of adding peanut butter due to weight loss and RD who was responsible for adding the peanut butter to the resident's mighty shake. He stated, "The kitchen does that." He was asked why the resident received the mighty shakes unopened, since that would indicate the peanut butter had not been added. He stated, "I didn't get that recommendation until the 21st. The RD will give the recommendation to nursing, but then nursing has to send me a change form." He was asked how the kitchen staff found out about the changes. He stated, "I usually tell them about the changes, but with the staff turnover it's been crazy. We recently started a new tray card system and I can't just go in and add stuff to the tray card any more. I'm in the process of developing a list of special request residents." f. The resident's weights were provided on 4/22/12 by RN #2 and documented the following: November 2014 - 144.2 pounds December 2014 - 141.8 pounds January 2015 - 137.3 pounds February 2015 - 136.3 pounds March 2015 - 133.2 pounds April 2015 - 130.1 pounds g. On 4/23/15, the resident was reweighed and weighed 134 pounds. From November 2014 to 4/23/15 (5 months), the resident experienced a 7.0% weight loss. From January 2015 to 4/23/15 (3 months), the resident experienced a 2.4% weight loss. From March 2015 to 4/23/15 (1 month), the resident experienced a weight gain.

Complaint # (AR 606) was substantiated (all or in part) with these findings: Based on observation, interview and record review, the facility failed to ensure the soap and sanitizer dispenser were filled to cleanse and sanitize the dishes between use, failed to ensure dish washing supplies were available for use at all times, and failed to ensure the 3 compartment sink was operational as a backup to sanitize dishes in order to reduce the potential for food borne illnesses. The facility also failed to ensure the kitchen was free of pests to prevent potential contamination of residents' food; food items stored in the dry storage and refrigerator were sealed and dated to facilitate first-in-first-out (FIFO) stock rotation and timely use or disposal to prevent food borne illness; the kitchen area was free of water leaks from the ceiling and no build up residue in the corners; the ice machine and scoop in the kitchen were maintained in clean condition and stored off the counter to prevent potential contamination of resident food or beverages; and dietary employees washed their hands appropriately after leaving and reentering the kitchen and before initiating or continuing a task to prevent potential contamination of residents food. The failure to ensure soap and sanitizer were used to assure dishes were sanitized resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to 73 residents who were provided meals from 1 of 1 kitchen (total census 77 including 4 residents who received nothing by mouth) as documented on the Diet Roster dated 11/3/14. The facility was informed of the Immediate Jeopardy on 11/5/14 at 10:40 a.m. The findings are: 1. On 11/3/14 at 1:05 p.m., during the initial tour of the kitchen, the 5 gallon Ultra Klene Detergent for Energy Efficient Machines container of detergent was not attached to the dish machine and was empty. There was a dried purple/pink residue at the bottom of the container. The detergent dispensing tube was not attached to any detergent. There was no suds to indicate soap in the machine. Lids and pans were being washed in the machine. The clear tubing for sanitizer was not attached and sanitizer dripped from the tubing to the floor. The Dietary Manager stated, "We were waiting for it to get empty. We just finished tray line and sent our trays to the halls. The last cart has gone out." The Surveyor and the Dietary Manager observed no other containers of dish detergent or sanitizer in the kitchen or in the storage cottage. The hand-washing sink in the kitchen had no lever/knob on the hot water side. The Dietary Manager (DM) stated, "I was told that we couldn't use this sink as a hand-washing sink because it was too close to the 3-compartment sink. The 3-compartment sink was set up for soap to be dispensed in the first sink and sanitizer in the third sink. The rinse (middle sink) had been adjusted to accommodate hand-washing. The 3 compartment sink could not be used as a backup to clean and sanitize the dishes since the middle sink was used for handwashing. The DM stated, "We wash our hands in the middle sink." The surveyor observed Dietary Employees #3, #4, and #5 washing their hands in the middle compartment during the 11/3/14 evening meal preparation and Dietary Employee #1 on 11/4/14 at 5:30 a.m. a. On 1/3/14 at 1:15 p.m., Dietary Employee #4 stated she was going to check the dish machine because, "There ain't no more soap." b. On 1/3/14 at approximately 3:08 p.m., a litmus test strip was used to test sanitizer from the low temperature dish machine. The strip did not change in color indicating that no sanitizer was dispensing during the dish machine cycle. The sanitizer tube/line was detached and leaking sanitizer onto the floor. The Dietary Manager stated, "(Dietary Employee #2) washed dishes this morning. He's gone. His shift ends at 12:30 p.m." 1) On 11/4/14 at 8:35 a.m., Dietary Employee #2 was asked if he washed dishes on the previous morning (11/3/14). He stated, "Yes." When asked what kind of soap was used to wash the dishes, he pointed to the power soak dispenser, used for the soaking of dirty dishes and flatware. When explained that the detergent for dish machine from the detergent provider in the 5 gallon bucket had no soap, but a dried purple stain in the bottom, he replied, "I don't know, he (Dietary Manager) puts it in." 2) On 11/5/14 at 5:00 a.m., Dietary Employee #2 came to the facility conference room and stated, "I need to talk to you about that thing." When asked if he was referring to the 5 gal container that held the detergent used to wash the dishes for the dish machine he indicated yes and stated the soap was empty...they had no dish detergent to wash dishes. When asked if the dishes were washed without soap he replied, "Yes." c. On 11/3/14 at 4:40 p.m., the (dish machine provider) Representative arrived to check the sanitizer line on the dish machine. d. A (Detergent/Dishmachine Provider) statement dated 9/30/14 documented $451.67 past due on account for 6/14/14 - 8/11/14. At 5:15 p.m., the DM stated the (Detergent/Dishmachine Provider) representative said he came because "State was in the building. " On 11/5/14 at 5:20 p.m., Dietary Employee #4 stated the Dietary Manager had called the detergent/dish machine provider 3 times before surveyors entered, but he wouldn't come...he came one time and was rude stating, "I didn't ask you that" when she (Dietary Employee #4) tried to tell him about the dish machine. e. The Dishwasher Temperature/Chemical Record for 10/01/14 thru 11/4/14 was received from the Administrator on 11/5/14. The Record documented on 10/1/14 through 10/31/14 "200" in each column under wash, rinse and chemical for breakfast, lunch and dinner for a low temperature dishmachine except for the chemical for the dinner meal on 10/6/14 and 10/7/14 which there was no documentation. The Record documented on 11/1/14 through 11/4/14 "200" in each column under wash, rinse and chemical for breakfast, lunch and dinner and "200" in each column under wash, rinse and chemical on 11/5/14 for a chemical dishmachine. On 11/5/14 at 3:08 p.m., the Dietary Manager (DM) was asked why no one had initialed the Dishwasher Temperature/Chemical Record until 10/8/14, the DM stated, "That was my first day." He also stated the 'wash' and 'rinse' recorded on the form were supposed to be temperatures from the thermometers located on the bottom of the machines. "I'm in-servicing on that now." He also stated that the staff was not aware that wash/rinse was temperature. He was informed that the chemical strip did not register on 11/3/14 and the form documented 200 part per million. He was asked if the facility had used paper plates. He stated, "No." Paper plates and other paper products were observed in the closet. When asked if paper plates had been used for residents at a meal, he stated, "Not since I've been here." f. On 11/4/14 at 9:55 a.m., the Administrator provided a statement from the dish machine provider dated 9/30/14 that documented $451.67 past due on account for 6/11/14 - 9/11/14. On 11/5/14 at 11:40 a.m., the Administrator provided invoices from the facility ' s food supplier that documented the facility received a 5 gallon container of dish soap on 9/9/14, on 9/26/14, and on 10/14/14. On 11/5/14 at 3:08 p.m., the Dietary Manager stated that a 5 gallon container of dish soap would last approximately 3 weeks. g. On 11/5/14 at 4:25 p.m., the Immediate Jeopardy was removed and the scope and severity lowered to an "F", after the facility began implementation of the following Plan of Removal: 1) Immediately on 11/3/14, dietary staff removed all dishes from service. The Dietary Manager went to Sysco to pick up soap on 11/3/14., invoice # (Attachment #1). The vendor Sysco was last paid on 10/24/14 and is in good standing. All dishes were washed, rinsed and sanitized on 11/3/14 by the dietary staff. (Dish Machine Company) came to the facility on [DATE] to repair the sanitizer line (Attachment #2) to the dish machine. The vendor, (Dish Machine Company) was last paid on 11/5/14 by credit card with a credit balance of 81.44. The Dietary Manager tested the dishwasher for chemicals at 5:15 p.m. with no negative findings. On 11/3/14, Dietary Manager and staff thoroughly cleaned and sanitized the kitchen throughout the day. Dietary Manager was in-serviced by the Administrator on 11/3/14 to ensure that equipment is functioning properly with all necessary supplies. 2) All resident were assessed for signs and symptoms of infection on 11/5/14 by the DON (Director of Nursing) and ADON (Assistant Director of Nursing) and RN (Registered Nurse) Supervisor with no negative findings. 3) The Dietary Manager in-serviced dietary staff on proper procedure for "Dishwasher Sanitizing Checks" on 11/5/14 at 1:40 pm. (Dish Machine Company) Representative performed an in-service on 11/5/14 at 4:25 p.m. with Administrator, Dietary Manager and Dietary staff on how to operate the dishwasher equipment. All in-services done before going on the floor and on-going to include new employees and any employees returning from leave. 4) The Administrator/Registered Dietitian will monitor the Dietary Manager to ensure proper functioning of the dish machine and that chemicals for dish machine are readily available. Dietary Manager will monitor the dietary staff for the proper functioning of the dish machine and that chemicals for dish machine are present. 2. On 11/3/14 the following observations were made: a. At 1:15 p.m. in the kitchen, the black panel inside the ice machine had a black slimy substance that was easily removed when wiped 3 different times with a white paper towel. b. At 1:30 p.m. in the two door refrigerator in the kitchen, a pimento cheese sandwich was wrapped in a plastic wrap and was not dated. c. At 1:30 p.m. following observations were made in the dry storage area: 1) One 50 pound bag of quick cooking rolled oats was on the floor in the store room and had no date. The DM stated, "It came in on Thursday". 2) Three boxes containing 8 four ounce packages per box of honey thickener, had no date. 3) Twelve one pound bags of marshmallows in a case had no dates on 8 of the bags. 4) Twenty-one cans of Rotel tomatoes in the original box had no dates on each can. 5) A bag of buns on the bread rack, containing eight hot dog buns were left open exposing the contents to air and pests. Another bag of buns on the bread rack had no date on the bag. d. At 2:35 p.m., the metal ice scoop used to scoop ice for residents was lying on a counter next to the ice machine uncovered. Lying on the counter near the scoop was a dirty, gray towel, a fan and 40 stacked juice glasses. e. On 11/3/14 at 3:02 p.m., Dietary Employee #3 took over making turkey sandwiches for dinner when Dietary Employee #4 went on break. Dietary Employee #3 made 4 more sandwiches, got another case of the frozen bags of turkey from the freezer, touched his clothing on his stomach as he donned gloves after washing hands, then with gloved hands touched handle on Maximum refrigerator and got a case of frozen turkey slices, made 20 more turkey sandwiches by opening and removing buns and placing on original clear plastic bags that the buns were packaged in without washing hands. At 2:50 p.m., there was a build-up of a semi dried brown substance in a corner next to the 2 door refrigerator in the kitchen. A small brown baby roach crawled across the floor into the build up next to the 2 door refrigerator in the kitchen. At 3:15 p.m., two small sized brown roaches crawled back and forth across the floor from underneath the gray metal box used as a junction to connect the wash sink and sanitizer sink of the three compartment sink. At 3:37 p.m., Dietary Employee #5 returned to the kitchen from lunch with a large Sonic drink in hand and stored the drink in the 2-door refrigerator. At 4:00 p.m., one light brown medium roach crawled across the dish room floor. f. On 11/4/14 at 5:00 a.m., flies swarmed throughout the kitchen area. 3. On 11/5/14 at 5:00 a.m., water dripped constantly from around an approximate 4 feet x 2 feet light fixture in the kitchen in front of the steam table onto the floor below. There was a large puddle of water measuring approximately 2.5 feet x 1/2 foot on the floor underneath the light fixture., Dietary Employee #1 was asked about the leaking and stated "We usually put blankets down, but were told not to put nothing down...I'll get a mop and mop it up." At 3:50 p.m., a white blanket had been placed underneath the light fixture in the kitchen in front of the steam table.

Complaint # (AR 606) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure funds were promptly provided to allow for effective facility administration to maintain routine dish machine soap purchase for cleaning dishes and utensils for resident meals, failed to ensure sanitizer was connected to the dish machine and failed to ensure routine pest control in 1 of 1 kitchen. This failed practice resulted in an Immediate Jeopardy which caused or was likely to cause serious injury, impairment or death for 73 residents who were provided meals from 1 of 1 kitchen(total census 77 including 4 residents who received nothing by mouth) as documented on the Diet Roster dated 11/3/14. The facility was informed of the Immediate Jeopardy on 11/5/14 at 10:40 a.m. The findings are: 1. On 11/5/14 at 11:40 a.m., the Administrator provided a job description for " Executive Director " that documented, " General Purpose: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility ' s business objectives ...Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services ...Manage facility budgets and business practices to include labor costs, payables, and receivables... " On 11/5/14 at 11:40 a.m., the Administrator provided a job description for " Dietary Manager " that documented, " General Purpose: Manage the operation of the Dietary Department to include staffing, food ordering, and preparation, food delivery and clean-up in accordance with facility policies, physician orders, resident care plans and appropriate regulations ...Maintain records, manage budget and supplies. Monitor equipment and work areas to verify they are maintained in a clean, safe and orderly manner; maintain strict adherence to procedures regarding cleaners or hazardous materials or objects; verify universal precautions and infection control, isolation, fire, safety and sanitation practices and procedures are followed; and promptly address any hazardous conditions and equipment. Monitor food preparation and food storage areas to be sure that health and sanitation regulations are being met ...Create and implement procedures for department equipment to be operated only by trained, authorized personnel in a safe manner. " 2. On 11/3/14 at 1:05 p.m., during the initial tour of the kitchen, the 5 gallon Ultra Klene Detergent for Energy Efficient Machines container of detergent was not attached to the dish machine and was empty. There was a dried purple/pink residue at the bottom of the container. The detergent dispensing tube was not attached to any detergent. There was no suds to indicate soap in the machine. Lids and pans were being washed in the machine. The clear tubing for sanitizer was not attached and sanitizer dripped from the tubing to the floor. The Dietary Manager stated, "We were waiting for it to get empty. We just finished tray line and sent our trays to the halls. The last cart has gone out." The Surveyor and the Dietary Manager observed no other containers of dish detergent or sanitizer in the kitchen or in the storage cottage. The hand-washing sink in the kitchen had no lever/knob on the hot water side. The Dietary Manager (DM) stated, "I was told that we couldn't use this sink as a hand-washing sink because it was too close to the 3-compartment sink. The 3-compartment sink was set up for soap to be dispensed in the first sink and sanitizer in the third sink. The rinse (middle sink) had been adjusted to accommodate hand-washing. The 3 compartment sink could not be used as a backup to clean and sanitize the dishes since the middle sink was used for handwashing. The DM stated, "We wash our hands in the middle sink." The surveyor observed Dietary Employees #3, #4, and #5 washing their hands in the middle compartment during the 11/3/14 evening meal preparation and Dietary Employee #1 on 11/4/14 at 5:30 a.m. a. On 1/3/14 at 1:15 p.m., Dietary Employee #4 stated she was going to check the dish machine because, "There ain't no more soap." b. On 1/3/14 at approximately 3:08 p.m., a litmus test strip was used to test sanitizer from the low temperature dish machine. The strip did not change in color indicating that no sanitizer was dispensing during the dish machine cycle. The sanitizer tube/line was detached and leaking sanitizer onto the floor. The Dietary Manager stated, "(Dietary Employee #2) washed dishes this morning. He's gone. His shift ends at 12:30 p.m." 1) On 11/4/14 at 8:35 a.m., Dietary Employee #2 was asked if he washed dishes on the previous morning (11/3/14). He stated, "Yes." When asked what kind of soap was used to wash the dishes, he pointed to the power soak dispenser, used for the soaking of dirty dishes and flatware. When explained that the detergent for dish machine from the detergent provider in the 5 gallon bucket had no soap, but a dried purple stain in the bottom, he replied, "I don't know, he (Dietary Manager) puts it in." 2) On 11/5/14 at 5:00 a.m., Dietary Employee #2 came to the facility conference room and stated, "I need to talk to you about that thing." When asked if he was referring to the 5 gal container that held the detergent used to wash the dishes for the dish machine he indicated yes and stated the soap was empty...they had no dish detergent to wash dishes. When asked if the dishes were washed without soap he replied, "Yes." c. On 11/3/14 at 4:40 p.m., the (dish machine provider) Representative arrived to check the sanitizer line on the dish machine. An Extra Service Request form from the Detergent/Dish Machine Provider provided by the administrator on 11/5/14 at 11:40 a.m. documented, " Service date: 11/03/2014 Time in: 4:43 p.m. Time out: 5:12 p.m ...Replace Sanitizer line. It was broken. " d. A (Detergent/Dishmachine Provider) statement dated 9/30/14 documented $451.67 past due on account for 6/14/14 - 8/11/14. At 5:15 p.m., the DM stated the (Detergent/Dishmachine Provider) representative said he came because "State was in the building. " On 11/5/14 at 5:20 p.m., Dietary Employee #4 stated the Dietary Manager had called the detergent/dish machine provider 3 times before surveyors entered, but he wouldn't come...he came one time and was rude stating, "I didn't ask you that" when she (Dietary Employee #4) tried to tell him about the dish machine. f. The Dishwasher Temperature/Chemical Record for 10/01/14 thru 11/4/14 was received from the Administrator on 11/5/14. The Record documented on 10/1/14 through 10/31/14 "200" in each column under wash, rinse and chemical for breakfast, lunch and dinner for a low temperature dishmachine except for the chemical for the dinner meal on 10/6/14 and 10/7/14 which there was no documentation. The Record documented on 11/1/14 through 11/4/14 "200" in each column under wash, rinse and chemical for breakfast, lunch and dinner and "200" in each column under wash, rinse and chemical on 11/5/14 for a chemical dishmachine. On 11/5/14 at 3:08 p.m., the Dietary Manager (DM) was asked why no one had initialed the Dishwasher Temperature/Chemical Record until 10/8/14, the DM stated, "That was my first day." He also stated the 'wash' and 'rinse' recorded on the form were supposed to be temperatures from the thermometers located on the bottom of the machines. "I'm in-servicing on that now." He also stated that the staff was not aware that wash/rinse was temperature. He was informed that the chemical strip did not register on 11/3/14 and the form documented 200 part per million. He was asked if the facility had used paper plates. He stated, "No." Paper plates and other paper products were observed in the closet. When asked if paper plates had been used for residents at a meal, he stated, "Not since I've been here." f. On 11/4/14 at 9:55 a.m., the Administrator provided a statement from the dish machine provider dated 9/30/14 that documented $451.67 past due on account for 6/11/14 - 9/11/14. On 11/5/14 at 11:40 a.m., the Administrator provided invoices from the facility ' s food supplier that documented the facility received a 5 gallon container of dish soap on 9/9/14, on 9/26/14, and on 10/14/14. On 11/5/14 at 3:08 p.m., the Dietary Manager stated that a 5 gallon container of dish soap would last approximately 3 weeks. g. On 11/5/14 at 4:25 p.m., the Immediate Jeopardy was removed and the scope and severity lowered to an "F", after the facility began implementation of the following Plan of Removal: 1) Immediately on 11/3/14, dietary staff removed all dishes from service. The Dietary Manager went to Sysco to pick up soap on 11/3/14., invoice # (Attachment #1). The vendor Sysco was last paid on 10/24/14 and is in good standing. All dishes were washed, rinsed and sanitized on 11/3/14 by the dietary staff. (Dish Machine Company) came to the facility on [DATE] to repair the sanitizer line (Attachment #2) to the dish machine. The vendor, (Dish Machine Company) was last paid on 11/5/14 by credit card with a credit balance of 81.44. The Dietary Manager tested the dishwasher for chemicals at 5:15 p.m. with no negative findings. On 11/3/14, Dietary Manager and staff thoroughly cleaned and sanitized the kitchen throughout the day. Dietary Manager was in-serviced by the Administrator on 11/3/14 to ensure that equipment is functioning properly with all necessary supplies. 2) All resident were assessed for signs and symptoms of infection on 11/5/14 by the DON (Director of Nursing) and ADON (Assistant Director of Nursing) and RN (Registered Nurse) Supervisor with no negative findings. 3) The Dietary Manager in-serviced dietary staff on proper procedure for "Dishwasher Sanitizing Checks" on 11/5/14 at 1:40 pm. (Dish Machine Company) Representative performed an in-service on 11/5/14 at 4:25 p.m. with Administrator, Dietary Manager and Dietary staff on how to operate the dishwasher equipment. All in-services done before going on the floor and on-going to include new employees and any employees returning from leave. 4) The Administrator/Registered Dietitian will monitor the Dietary Manager to ensure proper functioning of the dish machine and that chemicals for dish machine are readily available. Dietary Manager will monitor the dietary staff for the proper functioning of the dish machine and that chemicals for dish machine are present. 3. A Pest Elimination Service log report received 11/4/14 at 9:10 a.m. from the administrator and dated 6/4/14 documented, " Dietary areas roaches cracks & (and) crevice. " A pest Elimination Report dated 7/11/14 documented, " Dietary roach - dish room ... " A Pest Elimination Service log report dated 8/5/14 documented, " Dietary ...roach dish room ... " a. A statement from the Pest Elimination Service was received from the Administrator on 11/4/14 at 9:55 a.m. that documented, " Statement as of 9/3/2014 ...4/7/14 ...amount $47.24. 6/18/14 ...amount $532.02. 8/5/14 ...amount $518.88. Please remit $1098.14. " b. On 11/5/14 at 4:32 p.m., a Pest Control Representative #2 stated per telephone conference that the pest control company had not been out to the facility since August. They stopped coming due to the unpaid bill. c. On 11/5/14 at 4:40 p.m., the Administrator stated that she was having trouble getting the proof from the vendors of what was owed and what had been paid.

Complaint # substantiated (all or in part) in these findings. A. Based on observation, record review, and interviews, the facility failed to ensure that a soft belt restraint which was contraindicated due to agitation and combative behaviors was not used and was not applied incorrectly according to the manufacturer's guidelines for 1 (Resident #21) of 1 case mix resident with agitation and combative behaviors and physician's orders [REDACTED]. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death, for Resident #21 who was restrained with a soft belt restraint that was loose and allowed the resident's buttocks to slide forward in the seat, placing the resident at risk for chest compression and suffocation if the resident's body weight became suspended off the chair seat. The failed practice also had the potential to cause more than minimal harm for 6 residents who had physician's orders [REDACTED]. The facility was informed of the Immediate Jeopardy on 8/30/10 at 4:55 p.m. The findings are: 1. The Lap Belt/Padded Lap Belt Application Instructions provided by the Director of Nursing on 8/30/10 documented, "Contraindications: DO NOT use on a patient who is or becomes highly aggressive, combative, agitated or suicidal. Application Instructions: Position the patient as far back in the seat as possible, with the buttocks against the back of the chair. Lay the belt across the patient's thighs. Bring the ends of the connecting straps down at a 45 degree angle between the seat and the wheelchair sides....Adjust the tightness of the slide buckles...The belt must be snug, but not interfere with breathing. To check for proper fit, slide an open hand (flat) between the belt and the patient. Warning: Heed these warnings to reduce the risk of serious injury or death: There is a risk of chest compression or suffocation, if the patient's body weight is suspended off the chair seat. Monitor per facility policy to ensure that the patient cannot slide down, or fall off the chair seat and become suspended. STOP USE AT ONCE: If the patient has a tendency to slide forward or down in the device; or is able to self-release." 2. Resident #21 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 5/27/10 documented the resident was severely impaired in cognitive skills for daily decision-making, had indicators of Delirium - e.g. periods of altered perception , periods of restlessness, indicators of Anxiety e.g. repetitive questions, verbalizations and persistent anger, behavioral symptoms of wandering, was verbally abusive, had socially inappropriate/disruptive behavioral symptoms, resisted care, was able to wheel self in a wheelchair, required the use of a trunk restraint and received an antipsychotic medication 7 of the past 7 days. The Resident Assessment Protocol (RAP) Summary dated 5/28/10 documented, "She frequently becomes anxious, agitated, will resist care, be verbally abusive and socially inappropriate. She is easily annoyed and does get very agitated with staff at times. She requires the use of anxiolytics PRN (as needed) due to her agitation, anxiety and daily use of antipsychotics for her Dementia with Behavioral disturbances. She is able to wander about in wheelchair." a. A physician's orders [REDACTED]. b. A physician's orders [REDACTED]." c. A physician's orders [REDACTED]. d. The August 2010 Medication Administration Record (MAR) documented Ativan 1 mg was administered on 8/15 at 1745 for "screaming, cursing, hollering at everyone"; on 8/17 at 1210 and 8/18 at 1310 for "increased agitation, screaming out loud"; on 8/18 at 2000, 8/20 at 0830, 8/21 at 1200 and 8/22 at 1220 for "increased agitation, swearing out loud". 1) The Nurse's Note dated 8/22/10 at 3:00 p.m. documented, "Very agitated and combative." 2) The Nurse's Note dated 8/22/10 at 3:00 p.m. documented, "Onset of agitation and combative". e. A physician's orders [REDACTED]. f. The August 2010 Medication Administration Record documented Ativan 1 mg was administered on 8/23 at 1230, 8/24 at 0720, 8/25 at 1320 8/26 at 0805 (8:05 a.m.) and 8/28/10 at 8:00 p.m. for "increased agitation, swearing out loud". g. On 8/30/10 at 4:00 p.m., the resident's room door was partially closed. The resident was not visible from the hallway. The surveyor and Director of Nursing (DON) entered the room. No staff were in the room. The resident was sitting in a wheelchair. The resident's torso had slid down at an angle with the top of the wheelchair seat at the level of the resident's ears. The resident's hips were scooted forward approximately 6-8 inches away from the back of the wheelchair. The resident's thighs and part of her buttocks extended past the front edge of the wheelchair seat. The front edge of the wheelchair seat was at the level of the resident ' s coccyx. The resident's knees were straight and her legs were extended straight in front of her and did not assist with torso balancing. The DON was asked to check the restraint. The DON pulled the soft belt out away from the resident's body approximately 6 inches and stated, "It's too loose." The DON brought Certified Nursing Assistant (CNA) #12 into the room to assist with repositioning the resident in the chair. CNA #12 stated, "She starts off sitting up but eventually she scoots herself down." The CNA stated it was "not unusual" for the resident to scoot herself down. h. On 8/30/10 at 5:53 p.m., the facility submitted a plan of removal that documented the soft belt restraint had been removed from the resident. However, the facility applied the soft belt restraint on the resident the next day: 1) On 8/31/10 at 9:50 a.m., the resident was sitting in a wheelchair with a soft belt restraint in place. The resident's hips were scooted forward away from the back of the wheelchair approximately 4 inches. The soft belt was loosely applied and could be pulled out approximately 4 to 6 inches away from the resident's body. CNA #13 stated, "She scoots herself forward in the chair all the time." The CNA was asked if the resident ever slid down in the chair and she stated, "Yes". 2) On 8/31/10 at 10:00 a.m., the Physical Therapy Assistant (PTA) stated the wheelchair seat and cushion were "just regular seats" and were not designed to keep the resident from scooting forward or sliding down. He stated he had been asked to look at the resident's chair today and was planning to install a drop seat. 3. On 8/31/10 at 11:45 a.m., the Immediate Jeopardy was removed and the scope/severity lowered to an "E" when the facility implemented the following plan of removal: a. The affected resident was assessed by the DON and the soft belt was removed on 8/30/10 at 5:28 p.m. b. On 8/30/10 facility assessed resident for safety device and contacted physician and he was notified of all previous devices used for safety. The physician ordered a Pommel Cushion to prevent the resident from sliding and rising. Resident remained under supervision during meal service with Pommel Cushion in place. After meal service resident began to voice complaints of discomfort with Pommel Cushion in place. Resident was placed in recliner in her room. Resident went from recliner to bed. On 8/30/10 the physician was contacted and discussed resident's complaints of discomfort with use of Pommel Cushion. On 8/30/10 the Physician ordered the continued use of the soft belt on 8/30/10 until recommendations received by therapy. c. On 8/31/10 at 10:20 a.m., the soft belt restraint was removed and the resident was provided one-on-one supervision until a suitable solution can be obtained from IDT (Interdisciplinary Team). d. On 8/31/10 the resident was reassessed by the DON with no negative outcomes related to the use of the soft belt restraint. e. The DON identified other residents with soft belts with the potential to be affected per the Roster/Sample Matrix and/or physician order [REDACTED]. All residents with soft belts were assessed to ensure that all were applied correctly and no one else was found to be affected. f. All nursing staff shall be in-serviced by the DON/Designee starting immediately (8/30/10) on the proper application and maintenance of soft belt restraints. Nursing staff will receive this in-service before starting their next scheduled shift. All staff on vacation will be in-serviced upon return and new hires will be in-serviced during orientation. B. Based on observation, record review, and interviews, the facility failed to ensure bed alarms were consistently implemented to decrease the risk of recurrent falls for 2 of 2 (Residents #24 and #25) case mix residents with bed alarms. The facility also failed to ensure when gait belt assisted transfers were performed, support was provided to the torso and lower extremities to minimize injuries to the upper arms/shoulders or rib cage for 1 (Resident #24) of 5 (Residents #5, #17, #21, #24 and #25) case mix residents who required gait belt assistance with transfers. These failed practices had the potential to affect 13 residents who required the use of a bed alarm and 16 residents who required gait belt assistance with transfers as documented on lists provided by the Administrator on 9/2/10. The findings are: 1. Resident #24 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 6/18/10 documented the resident had severely impaired cognitive skills for daily decision-making, was non-ambulatory, totally dependent on staff for transfers and had fallen in the past 30 days and in the past 31-180 days. a. The Nurse's Note dated 6/18/10 documented, "(Resident #24) is much weaker and has had significant change since her last fall and subsequent hospitalization . She is not walking at all, leans to the left when they stand her. 7-3 shift uses 2 persons for all transfers". b. The Plan of Care dated 6/23/10 documented, "At risk for falls with injury related to poor balance, no safety awareness, lethargic at times. History of falls. Put side rails up on bed and attach bed alarm". c. On 8/30/10 at 3:10 p.m., the resident was lying in bed. The personal alarm box was on the headboard of the bed but the clip was not attached to the resident. d. On 8/31/10 at 8:20 a.m., the resident was sitting in a wheelchair in her room. CNA #14 applied a gait belt loosely around the resident's waist. CNA #14 and CNA #15 transferred the resident from the wheelchair to the bed by standing on either side of the resident and pulling up on the gait belt and under the resident's armpits. The gait belt slid up over the resident's chest/rib cage during the transfer. The resident was not weight-bearing and her feet slid along the floor. No support was provided for the lower torso which placed the entire weight of the resident on her shoulders and rib cage. 2. Resident #25 had [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 8/3/10 documented the resident had moderately impaired cognitive skills for daily decision-making, required extensive assistance with transfers and had fallen in the past 30 days. a. A physician's orders [REDACTED]. b. The Event Reporting Form dated 4/25/10 documented, "Found on floor ...The alarm was not sounding and was in the off position. . . In-service staff on checking alarms". c. The Fall Risk assessment dated [DATE] documented the resident had a score of 11 and "Total score of 10 or above represents HIGH RISK." d. The Plan of Care dated 8/3/10 documented, "At risk for falls or injury related to Huntington's. Bed alarm on bed to alert staff of unassisted transfer attempts. Check and make sure bed alarm is in working mode and attached correctly each time she is placed in bed." e. On 8/30/10 at 3:12 p.m., the resident was in bed. Approximately half of the length of the 3 foot long sensor pad was hanging out from under the mattress and was clearly visible from the doorway of the room. The alarm box was not blinking. LPN #9 was asked by the surveyor to check the alarm and he stated it was turned "off".

Complaint # is substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure the majority of medications administered through a PEG (Percutaneous Gastrostomy) tube were in liquid form to prevent obstruction of the tube for 1 (Resident #20) of 3 case mix residents (Resident's #13, #14 and #20) whose medications were administered through PEG tubes. The failed practice resulted in a pattern of harm for Resident #20 who had to undergo multiple PEG tube replacements as a result of obstruction and had the potential to cause more than minimal harm for 8 residents whose medications were administered through PEG tubes, as documented on a list received from the Director of Nursing on 8/19/10 at 5:21p.m. The findings are: Resident #20 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was comatose and had a feeding tube. a. The Nurse's Notes dated 4/16/10 at 11:00 a.m. documented, "R (resident) to (Hospital) for tube replacement." b. The APN (Advanced Practice Nurse) Note dated 4/16/10 documented, "Patient has been seen three times in March for [DEVICE] exchange and now again today. There seems to be issues with the patient getting his medications via his feeding tube. For patient convenience and comfort, as well as, to decrease his procedure encounters: 1. The majority of his medications should be in suspension form. 2. He is continuing to take [MEDICATION NAME], pharmacy states there is not a suspension alternative but that the beads can be better dissolved when mixed with an acidic juice instead of plain water. If we can address the patient's medication regimen to help eliminate as many non suspension formulations as possible, this may benefit the patient by decreasing the amount of trips to the ER (emergency room ) and [MEDICATION NAME] Radiology for procedures." c. The Nurse's Notes dated 5/3/10 at 7:00 a.m. documented, "11-7 (11:00 p.m. - 7:00 a.m. shift) Nurse states PEG tube plugged. Will send to (Hospital) for replacement in a.m. to be picked up by 9:00 a.m." c. The Nurse's Notes dated 6/9/10 at 8:00 a.m. documented, "R (Resident) tube clogged. Attempted several times to unclog. Set up for tube replacement at (Hospital) 6/10/10 at 9:30 a.m." d. The Nurse's Notes dated 6/21/10 at 4:00 p.m. documented, "R sent out from this facility to (Hospital) related to busted PEG tube." e. The Nurse's Notes dated 7/20/10 at 7:30 a.m. documented, "R to (Hospital) for tube replacement due to one side busted." f. On 8/19/10 at 4:06 p.m., the Director of Nursing stated, "The facility did not get an order or contact the physician to get the medications changed to suspension formulas." g. As of 8/19/10 at 4:00 p.m., Resident #20 was still receiving [MEDICATION NAME] Forte 1 mg (milligram) tab TID (three times daily) and Multivitamin with minerals 1 tab every day and neither were administered in a liquid or suspension form.