Every finding on record at Bolivar Medical Center LTC

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of two (2) quarters reviewed. (2nd Quarter 2025)Findings include: Record review of the facility policy titled, “Electronic Staffing Data Submission Payroll-Based Journal” with a revision date of 6/30/25, revealed, “ .Mandated to submit to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .” Record review of the “PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 2 2025 (January 1 - March 31)” revealed “Excessively Low Weekend Staffing – Triggered = Submitted Weekend Staffing data is excessively low. No RN (Registered Nurse) Hours – Triggered = Four or More Days Within the Quarter with no RN Hours. Failed to have Licensed Nursing Coverage 24 Hours/Day – Triggered = Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage.” During an interview on 7/30/2025 at 11:25 AM, the Administrator (ADM) stated that the facility had recently transitioned to a new payroll system. She explained that, unlike the previous system, the new system did not automatically transfer data from the time clock, which resulted in missing staffing data for the second quarter of 2025 PBJ submission. The ADM acknowledged that she failed to verify the accuracy of the data prior to its transfer and submission, which led to discrepancies and errors in the quarterly PBJ report.

Based on observation, staff interviews, and facility policy review the facility failed to ensure hair restraints were utilized during food preparation to prevent contamination for one (1) of two (2) kitchen tours. Findings include:Review of the facility policy SANITATION AND INFECTION CONTROL with a revision date of 1/2025, revealed that Team members will wear hair restraints regardless of the length of hair or beard at all times in the kitchen. On 7/30/2025 at 11:00 AM during the kitchen tour with the Dietary Manager (DM), an observation was made of Chef #1 preparing food in the kitchen without a hair net in place. Chef #1 was wearing a black baseball hat, and his hair was sticking out approximately 3-4 inches in length from under the hat.An interview with the DM on 7/30/25 at 11:15 AM revealed she was aware Chef #1 was required to wear a hair net and stated, Yes, he should have a hair net on and I've told him he has to wear it. During an interview with the Administrator (ADM) on 7/31/2025 at 9:45 AM, she stated that she has had to talk with Chef #1 in the past regarding the hair net and their facility policy regarding food safety.

Based on staff interview, record review, and facility policy review, the facility failed to code the Minimum Data Set (MDS) accurately for a resident with a Mental Illness for one (1) of the 22 sampled residents. Resident #19 Findings include: Review of the facility policy titled “Nursing Assessment and Interdisciplinary Care Plan,” with a revision date of 06/2023, revealed: 2. Long Term Care Facility will conduct a comprehensive, accurate, standardized reproducible assessment upon admission and at regular intervals to ensure that each resident meet his/her highest practicable level of physical, mental, and psycho-social functioning: Physical and mental functional status . Record review of Resident #19's Significant Change MDS with Assessment Reference Date (ARD) of May 16th, 2025, revealed Section A 1500, Is the resident currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? coded as ''No. Record review of Resident #19's Summary of Findings Report, from the PASRR Office, dated 2/13/24 under Mental Health revealed the individual meets criteria for having a diagnosis of mental illness as defined by PASRR. During an interview with MDS Coordinator on 7/30/2025 at 2:00 PM, she verified that the Significant Change MDS with an ARD of May 16th, 2024, Resident #19 was coded incorrectly. She agreed that the MDS should be coded correctly to ensure that the resident is receiving the correct level of care. In an interview with the Director of Nursing (DON) on 7/30/25 at 3:07 PM, she agreed that it was her expectation that the MDS would be coded correctly. A record review of the admission Record revealed Resident #19 was initially admitted by the facility on 2/14/2024 with a diagnosis of Bipolar Disorder.

Based on observations, staff and resident interviews, and record review, the facility failed to provide nail care for one (1) of 22 residents reviewed for Activities of Daily Living (ADL) care. Resident #18 Findings include: The facility does not have a policy related to nail care. An observation and interview, on 10/10/22 at 11:03 AM of Resident # 18 revealed he had long and jaggad fingernails with a brown substance underneath them on his right hand. An observation of Resident # 18 on 10/11/22 at 9:25 AM revealed the resident had long jagged fingernails with a brown substance under them on his right hand. During an interview and observation on 10/11/22 at 3:40 PM Certified Nursing Assistant # 1(CNA) confirmed that Resident #18 had long jagged fingernails with a brown substance under them and needed to be trimmed. CNA #1 revealed that she does not trim fingernails, is responsible for reporting to the nurse when the nails need to be trimmed, and she had not reported to anyone that the resident needed his nails trimmed. During an interview and observation on 10/11/22 at 3:47 PM the Director of Nursing (DON) revealed Resident #18 nails were long before she trimmed them yesterday (after the Surveyor made her observation). Record review of Resident #18's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/22 revealed in section G that Resident #18 required extensive assistance with Hygiene and section C revaled a Brief Interview for Mental Status (BIMs) of 15, indicating full cognitive ability.

Based on staff interview, resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for Activities of Daily Living (ADL)s for a dependent resident, as evidence of long, rough fingernails, for 1 (one) of 22 residents reviewed for ADL care. Resident #18 Findings include: A review of the facility policy, with an effective date of 03/2021, titled, Nursing Assessment and Interdisciplinary Care Plan under purpose; The purpose is to ensure resident's assessments will be performed by Registered Nurse and that all State and Federal regulations are implemented for MDS+. Under Long Term Care Facility; Revision of the Care plan states an evaluation of the problems, the goals and the interventions will be reviewed at the Interdisciplinary Team Conference and revised , including: Responsiveness to the interventions, Effectiveness of the interventions in resolving the resident's problem. A record review of the comprehensive care plan, with an onset date of 5/5/2017, and a revision date of 2/2/2018; reveals a problem of (Resident #18) has an ADL Self Care Performance Deficit r/t (related to) Old [CONDITION(S)](Cerebralvascular Accident) with Rt (right) sided [CONDITION(S)]; with a goal of (Resident #18) will maintain current level of function in Bed Mobility, Transfers, Eating, and Toilet Use through the review date. Interventions include: BATHING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. PERSONAL HYGIENE/ORAL CARE: (Resident #18) requires extensive assist with personal hygiene. [CNA,LPN] On 10/10/22 at 11:03 AM an interview with Resident # 18 revealed that the resident had long, jagged fingernails on both hands. The observation revealed the resident had long, jagged fingernails on both hands with a brown substance under the nails on the right hand. An observation of Resident # 18 on 10/11/22 at 9:25 AM revealed the resident had long, rough fingernails on both hands and with a brown substance under the nails on his right hand. During an interview and observation on 10/11/22 at 3:40 PM Certified Nursing Assistant (CNA) #1 confirmed that Resident # 18's nails needed to be trimmed, but that CNAs did not trim nails. CNA # 1 revealed that she was responsible for reporting to the nurse that his nails needed to be trimmed and she had not notified any nurses. During an interview and observation on 10/11/22 at 3:47 PM the Director of Nursing (DON) confirmed that Resident #18's nails were long and she trimmed them after the Surveyor made her observation. During an interview on 10/12/22 at 9:00 AM the DON confirmed that the care plan was not being followed. Record review of Resident #18's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/22 revealed a Brief Interview for Mental Status (BIMs) of 15, indicating Resident # 18 is cognitively intact.

Based on interview of staff, and record review the facility failed to prevent the diversion of narcotics due to allowing unauthorized personnel to have access to the keys to the lock box attached to the wall in one (1) of one (1) medication rooms where discontinued narcotics were stored waiting to be destroyed and were cited F761 at a D level. Facility policy review of Nursing Care Center Pharmacy Policy and Procedure Manual -2007 PharMerica Corp, page 1 of four (4) section 5.5 (five point five) under Procedures number 2 (two) revealed, controlled substances listed in schedules II, III, IV, and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. On [DATE] at 2:05 AM an interview with the Administrator (ADM) revealed prior to COVID the Pharmacy Consultant would come monthly and would destroy any discontinued medications. The Pharmacist stopped coming to the facility in April of 2020 and was reviewing resident's records virtual. The lock box that contained discontinued medications was located in the medication room with the key to the lock box on one of the nurse's medication cart key ring. The ADM was not knowledgeable of who implemented the lock box to be in the medication room or the key being kept on the nurse's medication cart key ring. The missing medications were noticed by Licensed Practical Nurse (LPN) #2 when she entered the lock box for a resident's medication and noticed the medications in the box did not look the same as the last time she had seen inside the lock box. The ADM confirmed that any of the nurses assigned to the medication carts would have a key to the medication room. The key to the lock box located in the medication room and attached to the wall was in possession of one of the medication cart key rings and that any nurse working that cart would have had access to the discontinued Narcotic box. On [DATE] at 2:20 PM an interview with Registered Nurse (RN) #2 revealed she was unaware there was a lock box on the wall for discontinued medications in the medication room until the incident occurred in November of 2020. She denies knowing of the key to the lock box being kept on the medication cart key ring. She reported the nurses were counting and reconciling the narcotic medications that were in the medication cart lock box at change of shift but were not counting the medication blister-pack cards. Record review of the facility's investigation of the unusual occurrence of missing narcotics in [DATE], dated [DATE] revealed, on [DATE] at 1:30 PM the ADM was informed by RN #3, Director of Nursing (DON) at that time, that there were narcotics missing from the facility's locked cabinet (medications on hold to be destroyed) inside of the medication room. The narcotics were discovered missing when LPN #2 had to enter the locked cabinet to check if a resident's reordered medication was inside the cabinet. The facility at that time had a process for destroying discontinued medications that included holding the medications until the Pharmacy consultant arrived monthly when the consultant and a nurse would destroy the medications. The Pharmacy consultants began working from home remotely in March of 2020 due to the pandemic and the last date the medications were destroyed was [DATE]. The facility changed Pharmacy consultants in August of 2020, and she also worked remotely from her home, due to COVID. It was determined that the medication missing from the locked box were 169 [MEDICATION(S)] pills. The facility began an investigation that included drug screens, immediately drug screens were performed for the employees on site and the other staff were called to return to the facility and were screened when they arrived. A locksmith was notified and the lock to the medication room was changed. The remaining medications from the locked box were removed and a Pharmacy Technician came to the facility and she and the medication nurse took the medications to the downstairs local hospital Pharmacy and destroyed them. The facility developed a different way to destroy discontinued narcotics as follows: when a medication on the medication cart is expired or discontinued, the medication nurse will contact the local hospital Pharmacy Department and request one of the Pharmacists to come to the facility to assist the medication nurse in destroying the medications. The facility will no longer store discontinued medication but will destroy them promptly. The ADM reported this occurrence to the Complaint Unit/Division of Health Facilities Licensure and Certification, MS State Department of Health, and the Attorney General office. Record review of an E-mail sent on Tuesday, [DATE] 2:37 PM to the ADM revealed LPN #1 revealed in her confession to the Attorney General's Office she had noticed a key on the medication cart ring that she used it to see if it would open the box, she did open the box and noticed the discontinued medications, a week later she said she used the key and took the narcotic cards for her own personal use. Record review of the investigation in an email to the ADM from the Attorney General's Office revealed the unusual occurrence of missing medications from a locked box at [NAME] Medical Center dated [DATE], revealed on [DATE], that the administrator was notified by the Inspector from the Mississippi Office of the Attorney General that during their investigation he had interviewed LPN #1. He reported that LPN #1 failed a polygraph test and that she had admitted that she had stole the narcotic cards (the [MEDICATION(S)]) from the facility. He stated that LPN #1 had provided him with a signed statement confessing to taking the narcotics from the facility for her own personal use. He also reported that he would be pressing charges against LPN #1. On [DATE] LPN #1 was terminated from [NAME] Medical center LTCF. The Director of the local hospital Pharmacy updated the Drug Enforcement Agency. Additionally, LPN #1 was reported to the Mississippi Board of Nursing.

F689 S/S D Based on observations, interviews, and record review, the facility failed to protect Resident #1 from a lift accident related to a fall resulting from use of a lift durining a transfer.Resident #1 was one 1 of 4 Residents reviewed for lifts. Finsdings include: Record review of the facility policy titled abuse policy and procedure for the long-term care with a revised date of 3/20/21 revealed under training and C. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a patient's physical or mental condition. Under causes related to physical or mental conditions revealed neglect is deliberate negligence, carelessness, or indifference to a patient's/resident's needs. Record review of the Invacare manual for the Reliant 600 under Lifting the patient Warning: when elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object and correct this problem. Under Introduction: Invacare recommends that two assistants be used for all lifting preparation and transferring procedures; however, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. Under Attaching a sling: place the straps of the sling over the hooks of the hanger bar. Under Detail B reveals the divided leg sling with the commode opening with six straps pictured. Record review of the facility policy on the Hoyer Lift with revised date of 8/2015 under potential indications for use #6 revealed requiring greater than two-person assist for transfer. An interview on 9/29/21 at 8:45 AM with the Administrator (ADM) revealed that she was made aware of the fall incident immediately and that she reported it to the Attorney General's (AGs) office and to the state within 2 hours of the incident. She revealed that she called the state at 4:10 PM on 9/13/21 and the written report was sent in on 9/16/21. She revealed that the certified nursing assistant (CNA) was interviewed and immediately suspended pending the investigation and terminated on 9/20/21. An interview on 9/29/21 at 10:00 AM with the Director of Nursing (DON) revealed that on 9/13/21 around 2:00 PM that RN #2 called for her assistance to Resident #1's room and when she arrived at the room that she saw Resident #1 was lying on the floor, on her back and her head was resting on the footrest of the wheelchair. She revealed that the lift was close to the door and the wheelchair was close to the bed. She revealed that the first thing she noticed was that the lift sling was still attached to the lift and that the two (2) hooks for the legs were dangling where they had not been hooked on the lift. She revealed that CNA #1 kept saying that she was so sorry that she did not know what happened. She revealed that the resident was assessed and placed on the bed by four people and that she had two skin tears on her right shin, one skin tear on her right shoulder and abrasion on her left side and right temple area. She revealed that the resident was alert and oriented and that her neurological check was normal and that the resident was able to move all extremities, as good as she had been able to before the fall. She revealed that she asked CNA #1 why she did not hook the last two (2) hooks and CNA #1 told her that she thought she had. She revealed that after the incident and the resident was assessed, that CNA #1 was called to the ADM office and interviewed, and CNA #1 was told that she was being suspended until the investigation was completed. She revealed that CNA #1 was very apologetic and said that she knew that she should have had another person to help her but that she thought that she could do it because the resident was wet. She revealed that CNA #1 completed her charting and then left the facility and later called in and was terminated because she did not follow the policy. She revealed that the MD was notified about the fall and that he ordered Resident #1 to be taken to radiology for x-rays and treatment orders for the skin tears. She revealed that the skin tears and abrasions were minor and that they did not require any sutures. An interview on 9/29/21 at 10:20 AM with Resident #1 with a Brief Interview for Mental Status (BIMS) score of 15 revealed that they use the lift to transfer her and that it used to be scary but now that she has done it a couple times that she is no longer scared. She was unable to recall how many staff members are present during the lift transfer and was unable to recall a fall. She revealed that this place is a good organization. An interview on 9/29/21 at 10:30 AM with Registered Nurse (RN) #1 revealed that she was in the hallway and responded to Resident #1's room due to a loud noise and when she arrived at the room, that Resident #1 was on the floor, and she asked CNA #1 what happened, and she told her that it was just an accident. She revealed Resident #1 was assessed and her neurological status was checked and that she was alert and oriented and that with the help of three other people that they placed Resident #1 on the bed. She revealed that Resident #1 did have a couple skin tears and abrasions but that they were minor and that she had no broken bones. She revealed that the sling was connected to the lift but that she could not remember if the hooks were hooked. An interview on 9/29/21 at 11:45 AM with the DON revealed that CNA #1 did have orientation and all new CNAs are placed on the floor with another CNA for a couple of shifts to be trained and this includes training on the lift. An interview on 9/29/21 at 11:55 AM with the ADM confirmed that all CNAs are placed with another CNA for several shifts to be trained and this includes the lift. A phone interview on 9/29/21 at 1:10 PM with CNA #1 revealed that her and RN #2 got Resident #1 up the morning of 9/13/21 and left the sling under the resident. She revealed that around two o'clock the resident was wet and needed changing and that she looked down the hall and did not see anyone to help her and that she just wanted to get the resident changed because she was wet, so she attempted to transfer the resident alone, and the resident began to slide and that she tried to get the wheelchair under her but could not so the resident slide to the floor. She confirmed that she did not wait for help and that she knew that she should have had two people for the transfer with the lift, but she thought she could do it without any problem and just wanted to get the wet clothes off Resident #1. She revealed that she thought she had hooked all the hooks but discovered that she did not once the resident slide to the floor. She confirmed that she knew to make certain that all the hooks were hooked before transferring but that she thought she had them hooked. She revealed that she just wanted to tell the truth and do the right thing. She confirmed that she has been a CNA for [AGE] years and she knows what to do. She confirmed that she worked with other CNAs for a couple shifts when hired and that they went over the use of the lift and that they used the lift several times during the orientating period. She revealed that after the incident that the DON and ADM talked to her and told her that they had to report the incident to the state and that she would have to go home until they completed the investigation. She revealed that she was called back in last Monday and was terminated. An interview on 9/29/21 at 1:45 PM with RN #1 revealed that they always use 2 people when transferring with the lift and that they make certain that all the hooks are hooked to the lift before lifting the resident. She revealed that all new CNAs are assigned with other CNAs for at least for 3 shifts for orientation and that includes the use of the lift. Record review of the facility Post Fall Huddle with a date and time of 1410 for Resident #1 revealed under injury revealed minor skin tears times three and abrasion times two and under recommendation revealed proper use of hoyer lift with 2 staff members per protocol. Record review of the care plan for Resident #1 revealed a care plan for at risk for falls related to unsteady gait, poor coordination, and generalized weakness and ADL selfcare performances deficit related to generalized weakness, SOB, and [CONDITION(S)] Fib with an intervention for mechanical lift times two people for all transfers. Record review of the MDS dated [DATE] on Resident #1 revealed under section C a BIMS summary score of 15 and under section G under B how resident moves between surfaces including to or from bed, chair, wheelchair, standing position marked # three for two-person physical assist. Record review of the facility CNA intervention/task for Resident #1 revealed under ADL-Transferring a #2 that is toilet use: support provided and a #3 for two-person physical assist and initials VB at 14:59 for 9/13/21. Record review of the x-ray reports on 9/13/21 for Resident #1 revealed left and right femur, bilateral pelvis, left and right tibula and fibula, right and left humerus, and left and right shoulder were all negative for dislocation and fracture and the CT of the head was with no acute intracranial abnormality. Record review of the face sheet for Resident #1 revealed an admitted [DATE] with diagnoses of weakness, [CONDITION(S)], Vertebra Compression fracture, and [CONDITION(S)] Fibrillation. Record review of the physician orders for Resident #1 revealed and order on 9/14/21 to clean abrasion to the left side, to skin tears to the right shin, and skin tear to right shoulder with normal saline, pat dry with 4 x 4 gauze, apply triple antibiotic ointment and cover with clean dry dressing daily and PRN until healed. Record review of the investigation for Resident #1 revealed the divided leg sling was used during the transfer and this sling was reviewed by therapy and determined it was appropriate for use with transfers and the Invacare manual has this sling listed as one of the slings appropriate for use with the Invacare 600 lift. Record review of the facility email from HR on 9/29/21 revealed a clock in time of 6:49 AM and clock out time of 16:39 on 9/13/21 for CNA #1. Record review of the facility September CNA schedule revealed [NAME] was listed to work on 9/13/21 for 7/3 shift. Record review of the facility corrective counseling record dated 9/20/21 and signed by CNA #1 for termination due to the employee did not follow policy and procedure and did not follow the resident's care plan requiring 2 people transfer assist using the mechanical lift. Record review of the Orientation Training Verification 2021 form dated 5/12/21 with initials VB and signature for Abuse, Neglect, Exploitation. Record review of the facility long term care daily assignment sheet for 9/13/21 for the seven to three shift revealed CNA #1 was assigned to Resident #1 and that Resident #1, #2, #4, and #5 have listed out of bed (OOB) daily-lift x 2 assists.

F656 S/S D Based on observations, interviews, and record review, the facility failed to follow the care plan for lift transfers for Resident #1 related to a fall while being transferred with the lift. Resident #1 was one 1 of 4 Residents reviewed for lift transfer care plans. Findings include: Record review of the facility policy titled Nursing Assessment and Interdisciplinary Care Plan with a revised date of 8/2016 under #2 revealed Long Term Care facility will conduct a comprehensive, accurate, standardized reproducible assessment upon admission and at regular intervals to ensure that each resident meet his/her highest practicable level of physical, mental, and psycho-social functioning. An interview on 9/29/21 at 8:45 AM with the Administrator (ADM) revealed that she was made aware of the fall incident immediately and that she reported it to the Attorney General's (AGs) office and to the state within 2 hours of the incident. She revealed that she called the state at 4:10 PM on 9/13/21 and the written report was sent in on 9/16/21. She revealed that the certified nursing assistant (CNA) was interviewed and immediately suspended pending the investigation and terminated on 9/20/21. An interview on 9/29/21 at 10:00 AM with the Director of Nursing (DON) revealed that on 9/13/21 around 2:00 PM that RN #2 called for her assistance to Resident #1's room and when she arrived at the room that she saw Resident #1 was lying on the floor, on her back and her head was resting on the footrest of the wheelchair. She revealed that the lift was close to the door and the wheelchair was close to the bed. She revealed that the first thing she noticed was that the lift sling was still attached to the lift and that the two (2) hooks for the legs were dangling where they had not been hooked on the lift. She revealed that CNA #1 kept saying that she was so sorry that she did not know what happened. She revealed that the resident was assessed and placed on the bed by four people and that she had two skin tears on her right shin, one skin tear on her right shoulder and abrasion on her left side and right temple area. She revealed that the resident was alert and oriented and that her neurological check was normal and that the resident was able to move all extremities, as good as she had been able to before the fall. She revealed that she asked CNA #1 why she did not hook the last two (2) hooks and CNA #1 told her that she thought she had. She revealed that after the incident and the resident was assessed, that CNA #1 was called to the ADM office and interviewed, and CNA #1 was told that she was being suspended until the investigation was completed. She revealed that CNA #1 was very apologetic and said that she knew that she should have had another person to help her but that she thought that she could do it because the resident was wet. She revealed that CNA #1 completed her charting and then left the facility and later called in and was terminated because she did not follow the policy. She revealed that the MD was notified about the fall and that he ordered Resident #1 to be taken to radiology for x-rays and treatment orders for the skin tears. She revealed that the skin tears and abrasions were minor and that they did not require any sutures. An interview on 9/29/21 at 10:20 AM with Resident #1 with a Brief Interview for Mental Status (BIMS) score of 15 revealed that they use the lift to transfer her and that it used to be scary but now that she has done it a couple times that she is no longer scared. She was unable to recall how many staff members are present during the lift transfer and was unable to recall a fall. She revealed that this place is a good organization. An interview on 9/29/21 at 10:30 AM with Registered Nurse (RN) #1 revealed that she was in the hallway and responded to Resident #1's room due to a loud noise and when she arrived at the room, that Resident #1 was on the floor, and she asked CNA #1 what happened, and she told her that it was just an accident. She revealed Resident #1 was assessed and her neurological status was checked and that she was alert and oriented and that with the help of three other people that they placed Resident #1 on the bed. She revealed that Resident #1 did have a couple skin tears and abrasions but that they were minor and that she had no broken bones. She revealed that the sling was connected to the lift but that she could not remember if the hooks were hooked. An interview on 9/29/21 at 11:45 AM with the DON revealed that she looked for the training on the lift for CNA #1 and she confirmed that she could not find one. She revealed that CNA #1 did have orientation and the competency for this was done. She revealed that new CNAs are placed on the floor with another CNA for a couple shifts to be trained and this includes training on the lift. An interview on 9/29/21 at 11:55 AM with the ADM confirmed that all CNAs are placed with another CNA for several shifts to be trained and this includes the lift. A phone interview on 9/29/21 at 1:10 PM with CNA #1 revealed that she and RN #2 got Resident #1 up the morning of 9/13/21 and left the sling under the resident. She revealed that around two o'clock the resident was wet and needed changing, she looked down the hall, did not see anyone to help her and that she just wanted to get the resident changed because she was wet. She attempted to transfer the resident alone, the resident began to slide and that she tried to get the wheelchair under her but could not so the resident slid to the floor. She confirmed that she did not wait for help and that she knew that she should have had two people for the transfer with the lift, but she thought she could do it without any problem and just wanted to get the wet clothes off Resident #1. She revealed that she thought she had hooked all the hooks but discovered that she did not once the resident slid to the floor. She confirmed that she knew to make certain that all the hooks were hooked before transferring but that she thought she had them hooked. She revealed that she just wanted to tell the truth and do the right thing. She confirmed that she has been a CNA for [AGE] years and she knows what to do. She confirmed that she worked with other CNAs for a couple shifts when hired and that they went over the use of the lift and that they used the lift several times during the orientating period. She revealed that after the incident that the DON and ADM talked to her and told her that they had to report the incident to the state and that she would have to go home until they completed the investigation. She revealed that she was called back in last Monday and was terminated. An interview on 9/29/21 at 1:45 PM with RN #1 revealed that they always use 2 people when transferring with the lift and that they make certain that all the hooks are hooked to the lift before lifting the resident. She revealed that all new CNAs are assigned with other CNAs for at least for 3 shifts for orientation and that includes the use of the lift. Record review of the facility Post Fall Huddle with a date of 9/13/21 and a time of 1410 for Resident #1 revealed under injury revealed minor skin tears times three and abrasion times two and under recommendation revealed proper use of hoyer lift with 2 staff members per protocol. Record review of the care plan for Resident #1 revealed a care plan for at risk for falls related to unsteady gait, poor coordination, and generalized weakness and ADL selfcare performances deficit related to generalized weakness, SOB, and [CONDITION(S)] Fib with an intervention for mechanical lift times two people for all transfers. Record review of the MDS dated [DATE] on Resident #1 revealed under section C a BIMS summary score of 15 and under section G under B how resident moves between surfaces including to or from bed, chair, wheelchair, standing position marked # three for two-person physical assist. Record review of the facility CNA intervention/task for Resident #1 revealed under ADL-Transferring a #2 that is toilet use: support provided and a #3 for two-person physical assist and initials VB at 14:59 for 9/13/21. Record review of the x-ray reports on 9/13/21 for Resident #1 revealed left and right femur, bilateral pelvis, left and right tibula and fibula, right and left humerus, and left and right shoulder were all negative for dislocation and fracture and the CT of the head was with no acute intracranial abnormality. Record review of the face sheet for Resident #1 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician orders for Resident #1 revealed and order on 9/14/21 to clean abrasion to the left side, to skin tears to the right shin, and skin tear to right shoulder with normal saline, pat dry with 4 x 4 gauze, apply triple antibiotic ointment and cover with clean dry dressing daily and PRN until healed. Record review of the investigation for Resident #1 revealed the divided leg sling was used during the transfer and this sling was reviewed by therapy and determined it was appropriate for use with transfers and the Invacare manual has this sling listed as one of the slings appropriate for use with the Invacare 600 lift. Record review of the facility email from HR on 9/29/21 revealed a clock in time of 6:49 AM and clock out time of 16:39 on 9/13/21 for CNA #1. Record review of the facility September CNA schedule revealed [NAME] was listed to work on 9/13/21 for 7/3 shift. Record review of the facility corrective counseling record dated 9/20/21 and signed by CNA #1 for termination due to the employee did not follow policy and procedure and did not follow the resident's care plan requiring 2 people transfer assist using the mechanical lift. Record review of the Orientation Training Verification 2021 form dated 5/12/21 with initials VB and signature for Abuse, Neglect, Exploitation. Record review of the facility long term care daily assignment sheet for 9/13/21 for the seven to three shift revealed CNA #1 was assigned to Resident #1 and that Resident #1, #2, #4, and #5 have listed out of bed (OOB) daily-lift x 2 assists.

Based on record review, staff interview, and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) for a resident who required a lap buddy for safety, Resident #16 and failed to code the MDS accurately for pressure ulcers for Resident #19; for two (2) of 18 assessments reviewed. Findings include: Review of the facility policy titled, Nursing Assessment and Interdisciplinary Care Plan, 2019, revealed, .Procedure: .2. Long Term Care Facility will conduct a comprehensive, accurate, standardized reproducible assessment upon admission and at regular intervals to ensure that each resident meet his/her highest practicable level of physical, mental, and psychosocial functioning. Resident #16 Record review of the MDS, with an Assessment Reference Date (ARD) of 7/24/19, revealed a Trunk restraint was marked as used daily. Record review of the Medication Review Report dated (MONTH) 3, 2019, revealed Lap Buddy and or lap tray to wheelchair for safety every shift, with a start date of 12/1/16. On 09/18/19, at 12:28 PM, during an interview with Registered Nurse #1/ MDS nurse, she stated that the lap buddy is an enabler because Resident #16 has problems with poor balance. She leans forward in her chair and she takes it off frequently. She also likes to lean forward and rest on it. She stated It kind of helps her and enables her. It was my misunderstanding that it was coded on the MDS as a restraint. It should not have been coded on the MDS as a restraint. That's an error. During an interview on 09/18/19, at 12:57 PM, the Director of Nursing (DON) revealed that the definition of a restraint is something that the resident cannot remove easily. She stated that some days she removes it, and when asked to remove the lap buddy for lunch and toileting, she does. She stated that it is not a restraint for Resident #16, but an enabler. On 09/18/19 at 02:50 PM, in an interview with Resident #16's Responsible Party, her daughter, she stated, That lap buddy is for her safety. It doesn't stop her from getting up. She takes it off all the time when she wants to. On 09/18/19 at 03:15 PM, interview with the DON confirmed, It is the policy of the facility to complete the MDS accurately to reflect the condition of the resident during the look back period. It was completed inaccurately by the MDS nurse, due to lack of knowledge. Resident #19 Record review of the Quarterly MDS with an ARD of 8/8/19, revealed the number of pressure ulcers was documented as two (2). Review of physician's orders and nurse's notes for the look back period of 8/2/19 - 8/8/19 revealed no documentation of a Stage 3 pressure ulcer in the medical record. In an interview on 09/18/19 at 4:44 PM, Registered Nurse #1(RN)/MDS nurse, she stated that the Resident #19 doesn't have a pressure ulcer on the side of the right foot plantar area at this time, it was healed in May. She stated the resident has a place on the left foot now. During an interview on 09/18/19 at 5:00 PM, the Director of Nursing (DON) confirmed that there was no documentation in the resident's medical record of a Stage 3 or Stage 4 pressure ulcer during the look back period for the Quarterly MDS with an ARD of 8/8/19. She stated RN #1 couldn't find any either.

Based on record review, staff interview, and facility policy review, the facility failed to accurately document a physician's order related to insulin dose for one (1) of 18 resident records reviewed, Resident #1. Findings include: Facility policy review revealed: It is the policy the facility to ensure safe ordering and transcribing of medication orders to enhance medication safety. All orders entered electronically by a physician or nurse must be verified by a pharmacist, prior to administration. If a pharmacist is not available to verify medication, then a second nurse must verify the order prior to administering the dose. Record review of physician's orders revealed the following phone order with an order date of 8/23/2019 - [MEDICATION NAME] Solution 100 unit/ML (milliliter)- Inject 24 ML subcutaneously before meals related to Type 1 Diabetes Mellitus without Complications. The order was taken and entered by Licensed Practical Nurse #2, and reviewed by Licensed Practical Nurse #1. The physician signed off on the order on 8/29/2019. Review of the Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse #1 on 9/18/2019 at 3:30 PM, revealed that it should have been entered as 24 units not 24 milliliters. She stated that 24 units is what has been given. She stated that it would have been deadly if she would have been given 24 milliliters of [MEDICATION NAME] insulin. Interview with Director of Nursing on 9/18/2019 at 3:40 PM, revealed that the orders are entered by the nurse that receives it, then checked and signed off by a second nurse. Phone interview with physician on 9/19/2019 at 10:45 AM, revealed the order should have been for [MEDICATION NAME] 24 units.

Based on record review, staff interview and facility policy review, the facility failed to follow Resident #26's Comprehensive Care Plan related to Percutaneous Endoscopic Gastrostomy (PEG) tube medication administration for one (1) of 12 care plans reviewed. Findings include: Review of the facility's policy titled, Nursing Assessment and Interdisciplinary Care Plan, dated 9/25/18, revealed: Resident care management shall include: Development of an overall plan of care for each resident. The plan will be developed by an interdisciplinary team to assure that the activity of care will achieve and maintain optimal resident status. Interventions: Each discipline will develop an intervention for each goal and document the necessary intervention on the care plan. Resident care plan interventions will be individualized, based on each resident's needs and medical condition. Review of the facility's policy titled, Enteral Tubes, dated 2007, revealed: 10. Medication administration and flushing of the tube after each individual medication is given is required if there are known comparability problems between medications to be mixed together. Administering the medications separately aids in avoiding interactions and clumping. B. The enteral tubing is flushed with at least five (5) milliliters (ml's) of water between medication administrations. During a medication pass observation, on 09/25/18 at 8:52 AM, Licensed Practical Nurse (LPN) #1 was observed administering medications via Resident #26's Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #1 administered ten (10) different medications to Resident #26, and failed to administer five (5) cubic centimeters (ccs) of water between each medication she administered. LPN #1 flushed Resident #26's PEG tube with 60 cc's of water before and after medications were administered. Review of Resident #26's Care Plan revealed the Focus, initiated on 03/03/18, and revised on 03/08/18, requires tube feedings related to resists eating and weight loss. The Interventions included flush tube with 60 cc's of water before and after medication, if medication is given per peg tube, administer 5 ccs of water between each med given On 09/25/18 at 4:53 PM, an interview with the Minimum Data Set Coordinator Nurse (MDS Nurse) revealed she stated the Care Plan directs staff to flush the PEG tube after each medication. The MDS Coordinator Nurse stated the Care Plan is developed to give staff guidance and direction for care. On 09/25/18 at 4:57 PM, an interview with the Director of Nursing (DON) confirmed staff did not follow the care plan as designed. Review of Resident #26's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/30/18, revealed Resident #26's Cognitive Skills for Daily Decision Making was coded a 3, which indicated severe cognitive impairment, never/rarely made decisions. The MDS further revealed Resident #26 was coded for a feeding tube, and mechanical altered diet, and received 51 % (percent) of her nutrition by the feeding tube. The MDS also revealed Resident #26 was admitted by the facility on 09/28/17.

Based on staff interview, record review, and facility policy review, the facility failed to follow pharmacy recommendations related to the use of an antipsychotic medication for anxiety ordered as needed (PRN) for one (1) of five (5) residents reviewed for unnecessary medications, for Resident #16. Findings include: Review of facility's policy titled, Unnecessary/Antipsychotic Hypnotic Drugs Informed Consent for [MEDICAL CONDITION] Medications Procedure, revised 02/2016 and copyright (YEAR), revealed: 2. The specific medical conditions which antipsychotic may be used included: k. Organic mental syndrome (including dementia with associated psychotic and/or agitated behaviors. 1. Which had quantitatively (number of episodes) and objectively (e.g. biting, kicking, scratching, etc.) documented. 2. Which are not caused by preventable reasons. 3. Which have caused the resident to present a danger to self or to others, 4. Which cause continuous crying, screaming, yelling, or pacing which cause an impairment in functional capacity. 5. Short term (seven (7) days) symptomatic treatment of [REDACTED]. 4. P.R.N. antipsychotic drugs will be used only when the resident has a specific medical condition as listed above and one of the following circumstances exits: a. The P.R.N. dose will be used to titrate the resident's total daily dose, to achieve symptom relief, to avoid side effects or effect a gradual dose reduction. b. The P.R.N. dose will be used to manage unexpected harmful behaviors that cannot be managed otherwise. (May not be used more than twice in any seven day period without an assessment of the cause for the resident's behavioral symptoms). Record review of the Pharmacy Reviews, dated 8/16/18 and 9/4/18, revealed the Pharmacist had recommended the following: Resident currently receives [MEDICATION NAME] 0.5 mg daily PRN agitation. CMS (Centers For Medicare and Medicaid Services) requirements state that PRN [MEDICAL CONDITION] medications must have a maximum duration of 14 days. Consider adding a stop date or changing to a scheduled frequency if receiving routinely. The Physician Response was to disagree, and continue as ordered to both recommendations. No rationale for continuing the medication was documented. Review of Resident #16's Medication Review Report/Physician Orders, dated (MONTH) (YEAR), revealed an order for [REDACTED]. During an interview with the Director of Nursing (DON), on 9/25/18, at 5:00 PM, she stated, We usually document why it is continued. We always bring to his attention any PRN meds. We review the patient's behaviors with him, and he will decide if it needs to be continued. The pharmacy consultant brings that to our attention. I was not aware of the 14 day regulation. She rarely ever takes it. Review of Resident #16's Medication Administration Records (MAR) revealed the following: (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) MAR indicated [REDACTED]. Review of the physician progress notes [REDACTED]. Review of Resident #16's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/01/18, revealed a Basic Interview For Mental Status (BIMS) score of 14, which indicated cognitive status was intact. Further review of the MDS revealed Resident #16 was coded for the administration of an antianxiety medication one time during the seven day observation period. The MDS revealed Resident #16 was admitted by the facility, on 07/19/18, with the included Active [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a medication error rate less than 5% as evidenced by incorrectly administering medications per Resident #26's Percutaneous Endoscopic Gastrostomy (PEG) Tube for 10 of 32 medication administration opportunities observed during the med pass. The medication error rate was 31.25%. Findings include: Review of the facility's policy titled, Enteral Tubes, dated 2007, revealed: 10. Medication administration and flushing of the tube after each individual medication is given is required if there are known comparability problems between medications to be mixed together. Administering the medications separately aids in avoiding interactions and clumping. B. The enteral tubing is flushed with at least five (5) milliliters (ml's) of water between medication administrations. During a medication pass observation, on 09/25/18 at 8:52 AM, Licensed Practical Nurse (LPN) #1 was observed administering medications via Resident #26's Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #1 administered the following crushed and liquid medications in separate containers, crushed medications were mixed with five (5) cubic centimeters (cc's) of water : [MEDICATION NAME] 200 milligrams (mg) one (1) tablet, Eliquis 2.5 mg one (1) tablet, [MEDICATION NAME] 325 mg per five (5)cc, [MEDICATION NAME] 40 mg one (1) tablet, MVI with Minerals five (5) ccs, [MEDICATION NAME] 15 mg/10 cc administered 10 ccs, [MEDICATION NAME] 25 mg one (1) tab, [MEDICATION NAME] 50 mcg one (1) tablet, Vitamin C 500 mg one (1) tablet, [MEDICATION NAME] 10/325 one (1) tab. LPN #1 administered ten (10) different medications to Resident #26 via her PEG tube, and failed to administer five (5) cubic centimeters (ccs) of water between each medication administered. LPN #1 flushed Resident #26's PEG tube with 60 ccs of water before and after the medications were administered. On 09/25/18 at 2:52 PM, an interview with LPN #1 revealed she stated she did not know she was supposed to flush between each medication. LPN #1 stated she thought she was only required to mix with five (5)ccs water and administer medications. On 09/25/18 at 4:29 PM, an interview with the Director of Nursing (DON) revealed she stated the facility had been doing skill check offs, and medication administration via peg tubes with all the staff throughout the year. The DON stated the nurse who performed the medication error had been assisting with the check offs. The DON stated the Pharmacist also checks the nurses off on administration of medication via peg tubes throughout the year. The DON stated the nurse should have administered five (5) ccs of water between each med as this is the standard of practice. The DON stated the facility had this same tag last year, and had been working hard to correct it. The DON stated, I just don't understand. A review of the facility's (YEAR) Annual Survey revealed the facility had received a citation related to medication error rate greater than five (5) percent for not flushing between medication administrations via a PEG tube. Review of Resident #26's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/30/18, revealed Resident #26's Cognitive Skills for Daily Decision Making was coded a 3, which indicated severe cognitive impairment, never/rarely made decisions. The MDS further revealed Resident #26 was coded for a feeding tube, and mechanical altered diet, and received 51 % (percent) of her nutrition by the feeding tube. The MDS also revealed Resident #26 was admitted by the facility on 09/28/17.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the Dietary Department was maintained in a clean and sanitary manner for two (2) of two (2) dietary tours. Findings include: Review of the facility's Hand and Equipment Hygiene policy, revised 10/14, revealed one tray-line worker wearing clean gloves will remove items from the hot units as needed during meal service. Review of the facility's Infection Control policy, revised 03/16, revealed the purpose is to prevent and control contamination, and spread of infection within the department. The food service director will develop and maintain clean, and sanitary work areas, and storage areas. Provide continuing preventative maintenance of equipment to meet the safety and infection control standards. All floors in the dietary department will be mopped with the approved disinfectant daily by the Environmental Services. Storage areas will be thoroughly cleaned each week, and inspected daily by the Director of Nutritional Services. Procedures for handling and serving of food shall meet the standards of all regulatory bodies. Ice machines shall have preventative maintenance on a monthly basis. Observation, and staff interview with the Registered Dietician, during the initial tour of the Dietary Department, on 07/12/17 at 10:18 AM, revealed/confirmed trash build-up on the floor under the three-compartment sink drain next to the hand-washing sink, behind the garbage can, the floor below and behind the ice machine, to the dry dish area in the dishwashing room, around the ice cream freezer, and under the warmer. The door seal of the ice machine was broken. There was dirt build-up on the wall leading from the food preparation area into the dishwasher room. The dry dish racks had food stains. The wall in the dishwashing area had exposed sheetrock with raised black/dark gray areas, and peeling paint. The ice cream freezer had black and brown food particles on the interior door edges, broken glass on one of the two sliding doors, and a heavy build-up of ice on the interior walls. There was a large build-up of dust to the four socket plug on the wall behind the ice machine. The paper towel dispenser next to the hand-washing sink was empty. Observation, and staff interview of the Dietary Department, on 07/13/17 at 10:50 AM, with the Registered Dietician, Infection Control Nurse #1, and the Quality Control/Joint Commission Coordinator #2, revealed and confirmed, Dietary Staff/Cook #2, placed her hands in her pocket three times while she was checking the temperatures of the food items on the steam table for lunch. She removed her gloves while checking the food temperatures, changed the gloves, and did not perform any hand hygiene. Dietary Staff/Cook #2, removed the food thermometer from her pocket, donned a glove on her left hand, and used her ungloved right hand to use the food thermometer to obtain temperatures on the baked pork chops, green beans, baked chicken, and low sodium, baked pork chops. There were 11 ceiling vents with a large build-up of hanging dust. Each staff confirmed the aforementioned findings, and said the Dietary Department needed a thorough cleaning, education on infection control, and cleaning of the ceiling vents. Staff interview with Dietary Staff #2, on 07/14/17 at 1:17 PM, confirmed she placed the food thermometer in her pocket, placed her hands in her pockets on three occasions when she was obtaining food temperatures from the steam table, and used her ungloved right hand to obtain steam table food temperatures. She confirmed causing several breaks in infection control.

Based on observation, staff interview, facility policy review, review of the Lippincott Manual of Nursing Practice 10th Edition, and record review, the facility failed to prevent the possible spread of infection for three (3) of three (3) resident rooms, and one (1) of three (3) wound care observations (Residents #2, #7, and Unsampled Resident D). Findings include: Review of facility's Environmental Services Standards for the Regulation of Medical Waste policy, revised 11/1989, revealed infectious medical waste shall be segregated from other waste at the point of origin in the producing facility. Containment of infectious medical waste shall be secured as to discourage access by unauthorized persons, and shall be marked with prominent warning signs on, or adjacent to, the exterior of entry doors, gates or lids. All bags used for containment and disposal of infectious medical waste shall be of a distinctive color, or display the universal symbol for infectious waste. Review of the facility's Wet to Dry Dressing Changes policy, dated 07/16, revealed equipment needs for the dressing changes includes using a blue pad or towel, and disposable non-sterile gloves. Review of the Lippincott Manual of Nursing Practice, 10th edition, dated 2010, revealed place dressing supplies on a clean, flat surface. Unsampled Resident D Observations, on 07/12/17 between 10:45 AM and 11:30 AM, revealed Unsampled Resident D's room was absent a special colored and marked bag to hold medical waste (red isolation bag). Review of the physician's orders [REDACTED]. During an interview, on 07/12/17 at 10:55 AM, Registered Nurse (RN) #5 confirmed there was no isolation bag in Unsampled Resident D's room. RN #5 confirmed infectious waste is placed in the same trashcan as regular trash. Inspection of the trashcan revealed many used isolation gowns and used gloves. RN #5 revealed the facility no longer uses the isolation bags in isolation rooms, but the infectious waste was separated from the regular trash when taken into the dirty utility room. We don't require visitors to wear isolation gowns and gloves. We just require them to wash their hands before they leave the room. During observation, on 07/13/17 at 12:45 AM, Housekeeper #1 was seen entering Unsampled Resident D's room, removed the trash that contained the isolation gowns, gloves, and a visible empty container of milk. Housekeeper #1 placed the white trash bag and its contents in the trash receptacle in her housekeeping cart. Housekeeper #1 said she puts all trash in her cart until someone comes from downstairs with a bigger bin to take it off of the floor. Housekeeper #1 revealed there was also a large black bin in the dirty utility to put trash in. Housekeeper #1 was asked if there was anything significant about the trash coming out of that room, and she could not answer. During an interview, on 07/13/17 at 2:30 PM, the Director of Nursing (DON) revealed the facility does not use red bags anymore, we treat every room like an isolation room, and just use regular trash bags, but just separate the trash as it leaves the room. During an interview, on 07/13/17 at 2:45 PM, RNs #1 and #4 (infection control nurses) first agreed with the DON in saying the facility no longer uses red bags, but then confirmed the infectious waste should be placed in a special red bag if it comes out of an isolation room During an interview, on 07/14/17 at 09:30 AM, Housekeeper #2 (Director of Plant Operations) confirmed there should be a red bag in all of the isolation rooms. We have purchased rolls and rolls of them. The housekeepers are trained during orientation what to do with trash from isolation rooms. The facility admitted Unsampled Resident D, on 04/07/14, with [DIAGNOSES REDACTED]. Resident #2: Review of the physician's orders [REDACTED]. Record review of a wound culture lab report, dated 05/28/17, revealed Resident #2's wound was infected with Methicillin Resistant Staphylococcus Aureus (MRSA). The lab contained a handwritten note that revealed the physician had been notified of the lab results, and verbally told Licensed Practical Nurse (LPN) #1 to place Resident #2 on contact isolation precautions Observations, on 07/12/17 from 10:45 AM to 11:30 AM, revealed Resident #2's room was absent a special colored and marked bag to hold medical waste (red isolation bag). During an interview, on 07/12/17 at 10:55 AM, Registered Nurse (RN) #5 confirmed there was no isolation bag in Resident #2's room. RN #5 confirmed infectious waste is placed in the same trash can as regular trash. Inspection of the trash can revealed many used isolation gowns and used gloves. The facility admitted Resident #2, on 04/04/17, with [DIAGNOSES REDACTED]. Resident #7 Review of physician's orders [REDACTED].#7 was on contact isolation every shift. Observations, on 07/12/17 from 10:45 AM to 11:30 AM, revealed Resident #7's room did not have a special colored and marked bag to hold medical waste (red isolation bag). During an interview on 07/12/17 at 10:55 AM, Registered Nurse (RN) #5 confirmed there was no isolation bag in Resident #7's room. RN #5 confirmed infectious waste is placed in the same trash can as regular trash. Inspection of the trash can revealed many used isolation gowns and used gloves. Observation of Resident #7's coccyx wound care, with Licensed Practical Nurse (LPN) #1, on 07/14/17 at 10:00 AM, revealed she placed a handful of gloves on the resident's overbed table next to the clean barrier with the dressing supplies. LPN #1 donned gloves to clean the wound with Normal Saline, washed her hands, and then donned a pair of gloves from the overbed table on three (3) occasions as she continued cleaning, drying, and packing the coccyx wound, and applying 4x4's to cover and tape the wound. Staff interview with LPN #1, on 07/14/17 at 10:10 AM, revealed she did not create a break in infection control by placing the gloves she used during Resident #7's sacral wound care on the bare overbed table. LPN #1 said she did not see the need for using a barrier for the gloves since she had wiped the overbed table with disinfectant wipes prior to the wound care. LPN #1 confirmed using several pair of gloves from the overbed table during the resident's wound care. Staff interview with the Director of Nursing (DON), on 07/14/17 at 10:15 AM, revealed LPN #1 did not need to place gloves on a barrier for Resident #7's wound care to her coccyx. Staff interview with Infection Control Nurse #1, and the Quality Control/Joint Commission Coordinator #2, on 07/14/17 at 10:25 AM, confirmed nurses should use barriers at all times for the resident's care. Each staff confirmed that gloves used during wound care should not be placed on an overbed table in order to prevent cross contamination, and additional infections to a resident with a wound. The facility admitted Resident #7, on 03/23/17, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of the Admission Assessment, dated 04/27/17 revealed Resident #7 had a staff assessment score for cognition of 3, indicating the resident had severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a medication error rate less than five (5) percent by incorrectly administering medications per Unsampled Resident A's Percutaneous Endoscopic Gastrostomy (PEG) tube for 17 of 27 medications observed during medication administration, and for two (2) of three (3) nurses observed administering medications per the PEG tube. The medication error rate was 7.4%. Findings include: Review of facility's Medication Administration Eternal Tubes policy, dated 10/07, revealed medication administration, and flushing of the tube after each individual medication is given is required if there are known compatibility problems between medications to be mixed together. A minimum of one flushing before and after giving the medications is acceptable when crushed tablets or capsule contents amount is not sufficient to clog the eternal tube. Administering the medications separately aids in avoiding interaction and clumping. The enteral tube is flushed with at least (five) 5 milliliters (ml) of water between medication administrations. Consult, crush guidelines before crushing tablets, Crush tablets and dissolve in at least five (5) ml of water or other appropriate liquid. An observation, on 07/13/17 at 8:20 AM, revealed Licensed Practical Nurse (LPN) #1 administered Unsampled Resident A's medication through her PEG tube. LPN #1 combined 12 medications in a single cup. The medications included: Aspirin 81 (milligram) mg tablet, [MEDICATION NAME] 20 mg tablet, [MEDICATION NAME] (10 grams per 15 milliliters) 15 ml., [MEDICATION NAME] 500 mg. tablet, [MEDICATION NAME] 7.5 ml. (750 milligrams), [MEDICATION NAME] 150 microgram (mcgm) tablet, [MEDICATION NAME] 100 mg. tablet, [MEDICATION NAME] 17 Grams, Potassium Chloride [MEDICATION NAME] 15 ml. (20 milliequivalents), [MEDICATION NAME] 10 ml., (150 milligrams), and Vitamin C 500 mg. tablet. LPN #1 all 12 of the medication at one time. LPN #1 flushed the PEG tube with 60 milliliters (ml) of water before, and after the cup of the crushed and combined medications were administered. An interview, on 07/13/17 at 8:30 AM, revealed LPN #1 confirmed she crushed, mixed, and dissolved all 12 of the medications in one cup, and administered all of the medications at the same time. LPN #1 said the doctor's orders said to flush with 60 milliliters of water before and after administering medications. An observation, on 07/13/17 at 7:15 PM, revealed LPN #2 administered Unsampled Resident A's medications via her PEG tube. LPN #2 poured up the following five (5) medications: [REDACTED]. capsule, Potassium Chloride [MEDICATION NAME] 15 ml. (20 millieqivalents), [MEDICATION NAME] 10 ml. (150 mg.), and Vitamin C 500 mg. tablet. LPN #2 administered the five (5) different crushed medications separately, but did not flush with five (5) ml. of water before and after each medication. LPN #2 flushed with 60 ml. of water before starting, and after giving all of the medications. An interview, on 07/14/17 at 7:20 PM, revealed LPN #2 confirmed she did not flush Unsampled Resident A's PEG tube with five (5) ml. of water before and after each medication. LPN #2 stated she flushed with 60 ml. of water before beginning, and after administering the medications. She said she knows to do so, that but just forgot. An interview, on 07/14 17 at 9:05 AM, revealed the Director of Nursing (DON) revealed medications given per a peg tube are supposed to administered separately with a five (5) ml. flush before and after each medication. The pharmacy consultant comes once a week. He does medication pass observations. They also send a nurse every three to four months, and they monitor nurses on medication pass. During a telephone interview, on 07/14/17 at 3:20 PM, the Pharmacist consultant revealed he does not do medication in-services personally, but he knows that the company he is contracted with sends people to do in-services on medication. He confirmed that each medication given per a PEG tube should be given individually, and the PEG tube should be flushed with five (5) ml. of water before and after each medication. The facility admitted Unsampled Resident A, on 12/14/12, with [DIAGNOSES REDACTED]. Unsampled Resident A was non-verbal, and had a Brief Interview for Mental Status (BIMS) score of 3, indicating Unsampled Resident A severe cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a resident's dignity for one (1) out of 13 residents observed (Unsampled Resident A). Findings include: Review of facility's Resident Rights Policy Statement, revised 10/20/12, revealed staff will show respect and care for residents in a manner that will maintain and enhance their dignity, individuality, and quality of life. License Practical Nurse (LPN) #1 was observed, on 07/13/17 at 8:20 AM, administering medications to Unsampled Resident A. LPN #1 entered Unsampled Resident A's room and told her (the resident) she was fat. LPN #1 was asked what she had said, and she replied that Unsampled Resident A had gained weight. LPN #1 confirmed she did say that the resident had gotten fat. During another interview, on 07/14/17 at 10:30 AM, LPN #1 first said she did not remember what she had said to Unsampled Resident A. She then confirmed she told UnSampled Resident A she was getting fat. LPN #1 said she only said that because she had not seen the resident in a long time. LPN #1 confirmed it was an inappropriate thing to say. During an interview, on 07/13/17 at 10:30 AM, the facility Administrator confirmed LPN #1's statement was inappropriate, and that is the total opposite of how we talk to our residents. She said she was going to look into it farther to rule in or out abuse. The facility admitted Unsampled Resident A, on 12/14/12, with [DIAGNOSES REDACTED]. Unsampled Resident A was non-verbal, and had a Brief Interview for Mental Status (BIMS) score of 3, indicating Unsampled Resident A's cognitive status was severely impaired.

Based on record review, staff interview, and facility policy review, the facility failed to follow the comprehensive care plan related to documentation of wounds, for two (2) of four (4) resident records reviewed (Residents #1 and #7). Findings include: Review of the facility's Nursing Assessment and Interdisciplinary Care Plan policy, revised 08/16, revealed the facility will conduct a comprehensive, assessment upon admission, and at regular intervals to ensure each resident meets his/her highest practical level of physical, mental, and psycho-social functioning. Each discipline will develop an intervention for each goal, and document the necessary intervention on the care plan. The resident's care plan will have individualized interventions, and be based on the resident's needs and medical condition. Resident #1 Review of Resident #1's wound care plan, with an onset date of 06/23/17, revealed a nursing intervention to document the appearance, size, and drainage; and to report worsening of, or no change to the wound in 14 days. Staff interview with Registered Nurse (RN) #3, on 07/13/17 at 6:20 PM, confirmed she failed to document weekly wound care notes which included measurements, appearance, and condition of the resident's Stage IV coccyx wound, resulting in her failure to follow the resident's wound care plan. RN#3 stated she completed the assessment and measurements weekly; however, revealed the last wound care note she completed was dated 03/28/17, as was confirmed by her Weekly Wound Note, dated 03/28/17. RN #3 said she is responsible for completing these wound care notes each week. Interview with the Director of Nursing (DON), on 07/14/17 at 8:55 AM, confirmed the staff failed to follow Resident #1's wound care plan as evidenced by not completing the Weekly Wound Notes weekly per the facility's policy. Review of the facility's Face Sheet revealed, the facility admitted the resident on 07/28/15. Resident #1's [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/06/17, revealed Resident #1 had a staff assessment score for cognition of 3, indicating the resident had severe cognitive impairment. Resident #7 Review of Resident #7's Pressure Ulcer Care Plan, with an onset date of 04/24/17, revealed a nursing intervention to assess, record, monitor the wound healing each week, and to measure the wound. Staff interview with RN #3, on 07/14/17 at 12:00 PM, confirmed she failed to follow the resident's wound care plan as evidenced by not completing weekly wound care notes which included measurements, appearance, and condition of the resident's coccyx/right buttock wound, and right heel wound. Staff interview with the Director of Nursing (DON), on 07/14/17 at 12:30 PM, confirmed she was unaware of RN/MDS Nurse #3, not having up-to date wound care documentation on this resident, and said the staff failed to provide weekly documentation on the resident's wounds per Resident #7's wound care plan. Review of the facility's face sheet revealed the facility admitted the resident on 03/23/17. Resident 7's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of the Admission Assessment, dated 04/27/17 revealed Resident #7 had a staff assessment score of 3 indicating the resident had severe cognitive impairment.

Based on observation, record review, staff interview, and facility policy review, the facility failed to revise a comprehensive plan of care related to administering medications through a Gastrostomy tube for one (1) of 14 plans of care reviewed (Unsampled Resident A). Findings include: Review of facility's Nursing Assessment and Interdisciplinary Care Plan policy, revised 08/2016, revealed a comprehensive, individualized interdisciplinary care plan will be developed as soon as possible after admission, but not later than one week after completion of the Minimal Data Set (MDS) assessment which occurs within 14 days of admission for long term care (LTC) residents. Goals will be developed to help each resident achieve his/her optimal level of physical, mental, psychosocial functioning. Physician orders [REDACTED]. Each discipline will be responsible for reviewing and revising problems, goals, and interventions on an ongoing basis. Review of facility's Medication Administration Internal Tubes policy, not dated, revealed medication administration and flushing of the tube after each individual medication is given is required if there are known compatibility problems between medications to be mixed together. A minimum of one flushing before and after giving the medications is acceptable when crushed tablets or capsule contents amount is not sufficient to clog the eternal tube. Administering the medications separately aids in avoiding interaction and clumping. The enteral tube is flushed with at least (five) 5 milliliters (ml) of water between medication administrations. Consult crush guidelines before crushing tablets, Crush tablets, and dissolve in at least five (5) ml of water or other appropriate liquid. Record review of Unsampled Resident A's plan of care, revision date 05/14/17, revealed Unsampled Resident A has a swallowing problem related to Dysphagia, and required a Percutaneous Endoscopic Gastrostomy (PEG) tube. This plan of care failed to address giving medication through the PEG tube, it only addressed the feeding and flushes. Licensed Practical Nurse (LPN) #1 was observed, on 07/13/17 at 8:20 AM, administering medication to Unsampled Resident A through her PEG tube. LPN #1 combined 12 medications in a single cup, and gave them all at one time. LPN #1 flushed with 60 milliliters of water before and after the cup of mixed medications were administered. During an interview, on 07/13/17 at 8:30 AM, LPN #1 confirmed she crushed, mixed, and dissolved all 12 of the medications in one cup, and administered all at the same time. LPN #1 said the doctor's orders said to flush with 60 milliliters of water before and after administering the medications. LPN #2 was observed, on 0713/17 at 7:15 PM, administering medications to Unsampled Resident A through her PEG tube. LPN #2 administered five (5) different crushed medications separately, but did not flush with five (5) milliliters of water before and after each medication. LPN #2 flushed with 60 milliliters of water before starting, and after giving all of the medications. During an interview, on 07/14/17 at 7:20 PM, LPN #2 confirmed she did not flush with five (5) milliliters of water before and after each medication. LPN #2 confirmed she flushed with 60 milliliters before beginning, and after administering the medications. She said she knows to do that, but just forgot. During an interview, on 07/14/17 at 3:20 PM, Registered Nurse (RN) #3 confirmed Unsampled Resident A's plan of care did not include specifics on how to administer medications through a PEG tube. RN #3 revealed the nurses know because they are taught in nursing school, and in orientation when employed at the facility. They should know to crush, give separately, and and flush with five (5) milliliters of water before and after each medication. The facility admitted Unsampled Resident A, on 12/14/12, with [DIAGNOSES REDACTED]. Unsampled Resident A was non-verbal, and had a Brief Interview for Mental Status (BIMS) score of 3, indicating Unsampled Resident A's cognitive status was severely impaired.

Based on record review, observation, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for Resident #1 related to catheter and [MEDICAL CONDITION] care; and for Resident #6 related to the use of a restraint, for two (2) of nine (9) residents' MDSs reviewed. Findings include: Review of the facility's MDS Assessment policy, dated 08/2013, stated: To produce a comprehensive, accurate, standardized and reproducible assessment of each resident's functional capacity as mandated by federal regulations for Medicare and Medicaid payment systems as well as for publicly reported Quality Measures. Resident #6 Record review of the facility's Roster Matrix on 09/27/16 at 1:00 PM, revealed Resident #6 was checked for a restraint. Review of Resident #6's Physician's Orders did not reveal an order to indicate Resident #6 had a restraint. Review of Resident #6's Quarterly MDS dated [DATE], revealed a number two (2) for trunk restraint was coded in Section P, indicating: Trunk restraint is used in chair or out of bed. Interview with Certified Nursing Assistant (CNA) #1 at 2:00 PM on 09/27/16, confirmed that she is the CNA that provides care for Resident #6, and she is not aware of any type of restraint used on the resident. Observation on 09/27/16 at 3:00 PM, revealed Resident #6 attending an activity sitting in her wheelchair, and she did not have a restraint device attached to her chair, or the trunk area of her body. Interview on 09/28/16 at 9:45 AM, with the MDS Nurse confirmed that the 08/11/16, Quarterly MDS assessment indicated that Resident #6 had a restraint while up in the chair, or out of bed. The MDS Nurse confirmed that it must have been an error on her part because the resident does not have a restraint, and stated, I don't know why I did that. I know she doesn't (have a restraint) because I push her to activity in her wheelchair sometimes. Review of the facility's Long Term Care Registration Form revealed the facility admitted Resident #6 on 07/08/13, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS with an Assessment Reference Date (ARD) of 8/11/16, revealed a Basic Interview for Mental Status (BIMS) score of seven (7), indicating severe cognitive impairment. Resident #1 Observation during Resident #1's Supra-Pubic catheter care provided by Licensed Practical Nurse (LPN) #1 on 09/28/16 at 10:20 AM, revealed Resident #1 had a Suprapubic catheter, and a [MEDICAL CONDITION]. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE], revealed Section H0300 was coded as zero (0) for urinary incontinence, which indicated Resident #1 was continent of bladder. Further review of the MDS revealed Resident #1's Section H0400 was coded as zero (0) for bowel incontinence, which indicated Resident #1 was continent of bowel. Interview on 9/28/16 at 10:00 AM, with the MDS Coordinator revealed she knew Resident #1 had a Suprapubic catheter, and a [MEDICAL CONDITION], and just failed to code it properly. The MDS Coordinator stated all residents are discussed at the Interdisciplinary Team Meeting, and the failure to code properly was an oversight on her part. Interview on 9/28/16 at 11:10 AM, with the Director of Nursing (DON) revealed the MDS Coordinator was responsible for assessing residents, completing the MDS, and ensuring it is accurate. Review of the facility's Long Term Care Registration Form revealed the facility admitted Resident #1 on 7/28/15, with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS with an ARD of 07/04/16, revealed his Daily Cognitive Skills for Daily Decision Making was coded a three (3), which indicated severe impairment.