Every finding on record at Claiborne County Senior Care

Based on observation, interviews, record reviews and facility policy review the facility failed to provide sufficient weight management for one (1) of two (2) residents with weight loss. Resident #40.Findings Include: Record review of the facility policy, Management of Residents With Nutrition Problems dated 7/24 revealed A resident identified with nutrition problems or who are at risk of inadequate nutrition/hydration shall be evaluated and monitored by the Director of Food and Nutrition Services (DFNS)/ consultant dietician (CD) to ensure appropriate and timely interventions to maintain or improve nutrition status clinical conditions demonstrates that this is not possible.On 05/13/2026 at 11:35 AM, in an interview with Certified Nursing Assistant (CNA) #5 stated Resident #40 does not eat her meals. She prefers junk food and soda. She stated resident was in the day room and did not eat her food. CNA #5 pointed at the tray on the table. Nothing was eaten off the lunch tray. She stated that is typical of the resident. She stated residents do not eat breakfast or lunch. She may eat some if it is something she likes.On 05/13/2026 at 1:37 PM, in a phone interview with the Registered Dietician (RD) stated Resident #40 only wants sweets. She stated resident weight is up and down. The RD stated that the staff was telling her that the resident eats junk food. She stated she did not think about ordering an appetite enhancer. She stated honestly, I should have ordered it. On 05/13/2026 at 5:05 PM, during an observation, Resident #40 was lying in bed. The dinner tray was sitting on the bedside table. It contained chicken pasta, steamed broccoli, and a roll. She stated I am not eating that. I do not like pasta. Resident #40 had eaten 0% of the dinner tray.On 05/14/2026 at 1:26 PM, an interview with the Director of Nursing (DON) confirmed that Resident #40 has had significant weight loss. She stated the resident had a Percutaneous Endoscopic Gastrostomy (peg) tube and had pulled it out several times. She stated it was taken out after she pulled it out several times. She stated they tried placing a border over the peg tube and she still pulled it out. She stated residents have schizophrenia and will not eat food. On 05/15/26 at 8:22 AM, in a post survey phone interview with the Medical Doctor (MD) stated that Resident #40 has never had a peg tube. He stated the Resident Representative (RR) would not agree to a peg tube. He stated they tried Megace and it did not work. He stated Resident #40 she has been hospitalized numerous times, and they cannot find anything wrong. He stated the weight loss was contributed to Dementia.Record review of the Weights and Vitals Summary with a date range of 11/1/25 through 5/31/26 revealed the following: On 12/16/2025, Resident #40's weight was documented as 140 pounds (lbs.). On 03/10/2026, the resident weighed 118 lbs. On 04/7/2026, the resident weighed 116 lbs. On 05/05/2026, the resident weighed 114 lbs. indicating significant weight loss.Record review of the RD assessment dated [DATE] revealed .Reason for Assessment; SWL (significant weight loss) x 90 and 180 days, WL (weight loss) x 30 days. interventions recommended included Boost with morning tray for 60 days . Record review of the Order Summary Report with active orders as of 5/14/26 revealed an order dated 4/30/24 NAS (No added salt) Carb (carbohydrate) Consistent diet, Mechanical Soft texture, Regular liquids consistency. and an order dated 4/30/26, Boost in the morning.Record review of the admission Record revealed an admission date of 1/11/19 with current diagnoses that included Alzheimer's early onset and Abnormal weight loss.Record review of the Minimum Data Set with an Assessment Reference Date of 4/21/26 revealed a Brief Interview for Mental Status score of 10 indicating moderate cognitive impairment.

Based on observation, interviews, record reviews and facility policy review the facility failed to provide a sanitary environment free of gnats for two (2) of four (4) days of survey. Findings Include:Record review of the facility policy Resident Environmental Quality dated 4/2025 revealed, Policy: It is the policy of this facility to be.maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .On 05/11/2026 at 2:33 PM, an observation revealed several gnats flying around in the day room on the Alzheimer's unit, while residents were watching tv. There were three (3) Certified Nursing Assistants (CNAs) in the day room with the residents.On 05/13/2026 at 12:00 PM, observed residents eating lunch in the dining room. During this time there were 2-3 gnats flying around resident's lunch trays. On 05/13/2026 at 2:20 PM, an observation of CNA #1 providing peri care for Resident # 38 revealed there were gnats flying around in the room at that time. CNA #1 stated that was her first time noticing them in the residents' room. She stated that gnats are usually in the day room.On 05/13/26 at 4:50 PM, an observation of dayroom on the Alzheimer's unit revealed several gnats circling around in the room before dinner trays arrived.On 05/13/2026 at 4:55 PM, an interview with CNA #2 confirmed that the gnats have been in the dayroom for a while.On 05/13/26 at 5:00 PM, an observation of CNA #3 with feeding Resident #25 chicken pasta. CNA #3 was holding the spoon with her right hand and swatting at the gnats with her left hand. She stated the gnats are bad in the room and that management knew about the gnats. She stated, It's been bad like this for two weeks now, I try to keep gnats away from the residents' food while assisting with feeding. CNA #3 continued to swat at gnats the entire time she was feeding the resident.On 05/13/2026 5:05 PM, an observation of Resident #40 lying in bed. The dinner tray was on the bedside table. An observation of gnats was circling around the resident's dinner tray.On 05/14/2026 at 11:42 AM in an interview, CNA #4 confirmed the gnats have been in the day room for two weeks. She stated she does not know where they come from and stated it's a lot of them when the residents eat.On 05/14/2026 at 12:31 PM, an interview with Maintenance stated the door on C hall would not close good. He stated it is fixed now. He confirmed that there has been a problem with gnats in the facility for over two weeks.On 05/14/2026 at 1:17 PM, in an interview with the acting Nursing Home Administrator (NHA) she stated she was not aware of the gnat problem. She stated they will take care of it. She stated gnats carry all types of germs and should not be in the facility.On 05/14/2026 at 1:29 PM, an interview with the Director of Nursing (DON) she confirmed she was aware of the gnats. She stated she saw them around the Alzheimer's unit's resident's food.Record reviews of the pest control invoices revealed gnats were identified in the facility on 3/16/26, 4/28/26 and 5/13/26.

Based on observation, interview, facility policy review and record review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) during Intravenous (IV) drug administration for one (1) of (1) residents reviewed for IV drug administration. Resident #58 Findings Include: Record review of the facility policy titled Enhanced Barrier Precautions dated 10/23 revealed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. On 05/13/2026 at 9:20 AM, during an observation, Registered Nurse (RN)#1 administered ceftriaxone 1 gram through an intravenous (IV) in the right arm of Resident #58. RN #1 did not don (put on) a gown prior to accessing, flushing, and subsequently administering the drug through the IV site. During an interview on 5/13/26 at 9:30 AM, RN# 1 revealed she was unaware that EBP personal protection equipment such as a gown should be worn during IV drug administration. She noted that the facility follows EBP guidelines during catheter care and Percutaneous Endoscopic Gastrostomy (peg) tube administration but not during IV site care but would if it was a central line. She agreed that an IV is a possible entry point possibly for infection into the body if the proper precautions were not followed handling it. At 12:04 PM on 5/13/26, during an interview the Director of Nursing (DON) stated the purpose of EBP was to prevent the spread of multi-drug-resistant organisms to the residents. She noted that her expectation is that staff will follow EBP guidelines appropriately and as recommended by Centers of Medicare and Medicaid Services (CMS) guidelines. She stated that signs are used throughout the facility to remind staff to wear EBP when ordered for specific residents. She stated that not properly wearing personal protective equipment (PPE) during procedures could lead to increased infection risk for residents. An interview with the infection preventionist at 2:06 PM on 5/13/26, revealed the necessity of EBP is to protect residents with indwelling medical devices such as IV's, catheters, or peg tubes from infections. She noted that if staff do not follow EBP protocol appropriately then the facility could see an increase in infections as IV sites specifically are a portal to the bloodstream. She noted that the facility was unaware that IV sites were to be included in EBP protocol but stated in-services would be initiated to address this oversight. Record review of Resident #58's admission Record revealed the resident was admitted [DATE] with diagnoses that included Urinary Tract Infection. Record review of Resident #58's Order Summary Report with active orders as of 5/13/26 revealed an order dated 5/12/26 for Ceftriaxone 1gm (gram) intravenously every 24 hours for 3 days.

Based on observation, interview, facility policy review and record review, the facility failed to ensure that a resident was free from unnecessary medications, specifically by failing to monitor and respond to clinically significant adverse effects including excessive daytime sedation associated with a concurrent regimen of five (5) sedating/psychotropic medications for one (1) of (5) sampled residents reviewed for unnecessary medication. Resident #3. Findings included: Record review of the facility policy Unnecessary Medications dated 5/24 revealed, It is the policy of this facility that unnecessary medications will not be given to the resident . During an observation on 5/11/26 at 2:10 PM, revealed the resident was asleep in bed and not easily awakened. During a follow-up observation on 5/12/26 at 3:20 PM, the resident was again found asleep in bed. On 5/13/26 at 11:38 AM, the resident was observed in the dining room falling asleep while seated upright in her wheelchair chair, with her head bobbing repeatedly while awaiting her meal tray. On 5/13/26 at 12:29 PM, during a medication administration observation, the resident was asleep in the day room. Licensed Practical Nurse (LPN) #2 had to physically pat Resident #3 on the shoulder to administer her scheduled Ativan. She fell back asleep immediately upon completion of the interaction.An interview with Certified Nursing Assistant (CNA) #6 on 5/12/26 at 3:21 PM, revealed the resident sleeps almost all day and that the night shift reports the resident sleeps most of the night as well. The most activity observed was occasional mumbling while speaking out of her head.An interview with LPN #2 on 5/13/26 at 12:31 PM, revealed the resident typically sleeps throughout the day and often becomes drowsier following the lunch time Ativan administration. LPN #2 identified five concurrent sedating medications Ativan, Restoril, Seroquel, Haloperidol, and Trazodone. LPN#2 stated she believed the resident could benefit from a possible dose decrease given the constant sleeping and absence of recent behavioral episodes.An interview with Registered Nurse (RN) #1 on 5/14/26 at 9:21 AM, confirmed the resident is drowsy at times. She noted no observed behavioral episodes in the past year. She acknowledged the resident had previously been combative and refused medications but now only occasionally yells or talks out of her head during care.An interview with the pharmacist on 5/14/26 at 10:47 AM revealed the purpose of gradual dose reductions (GDRs) is to identify the lowest effective therapeutic dose. She confirmed standard GDR reviews occur in July and January and stated that no staff members had reported unwanted side effects to her at this time.An interview with the attending physician on 5/14/26 at 10:53 AM, revealed he was aware the resident had been on Ativan, Haldol, Seroquel, Restoril, and Trazodone, and acknowledged the combination could be a little much, particularly given that the resident required awakening for scheduled Ativan administration. He further noted that Ativan was originally intended as a short-term, as-needed medication and that benzodiazepines can sometimes worsen behavioral symptoms in elderly patients. He stated the standard protocol is for nursing staff or the Director of Nursing (DON) to notify him of excessive daytime sleepiness for medication adjustment, but that no one had contacted him regarding this concern.An interview with the Director of Nurses (DON) on 5/14/26 at 11:10 AM, revealed she was aware of the resident's prior behavioral episodes (scratching herself and cursing at staff) and noted the resident had been hospitalized the previous month, after which her medications had not been reassessed since return. She acknowledged that staff could notify the physician when a resident exhibits excessive daytime sleepiness, and that unnecessary psychotropic medications can cause unwanted effects such as lethargy.Record review of Resident #3's admission Record revealed an admission date of 7/8/22 with diagnoses that included unspecified dementia.Record review of the Minimum Data Set (MDS) with an Assessment Reference date of 3/26/26 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. Record review of Resident # 3's Order Summary Report revealed orders as follows: Ativan Oral Tablet 0.5 mg (milligram) (Lorazepam) Give 1 tablet by mouth three times a day related to generalized anxiety disorder, dated3/20/24; Haloperidol Oral Tablet 0.5 mg Give 1 tablet by mouth two times a day for psychosis with an order date of 8/22/24; Restoril Oral Capsule 15 mg Give 15 mg by mouth at bedtime for insomnia with an order date of 3/7/23; Seroquel Oral Tablet 25 mg Give 25 mg by mouth in the morning related to restlessness and agitation with an order date of 8/14/24; Trazodone Oral Tablet 50 mg Give 50mg by mouth at bedtime related to unspecified dementia. Record review of Resident # 3's Medication Administration Record for the month of May 2026 revealed administration as follows: Ativan Oral Tablet 0.5 mg (milligram) (Lorazepam) Give 1 tablet by mouth three times a day related to generalized anxiety disorder, dated3/20/24 not given 05/01/2026 through 05/14/2026 08:00 p.m.; ; Haloperidol Oral Tablet 0.5 mg Give 1 tablet by mouth two times a day for psychosis with an order date of 8/22/24given 05/01/2026 through 05/14/2026 08:00 a.m. and 6:00 p.m. ; Restoril Oral Capsule 15 mg Give 15 mg by mouth at bedtime for insomnia with an order date of 3/7/23 given 05/01/2026 through 05/14/2026 08:00 p.m.; Seroquel Oral Tablet 25 mg Give 25 mg by mouth in the morning related to restlessness and agitation with an order date of 8/14/24 given 05/01/2026 through 05/14/2026 08:00 a.m.;; Trazodone Oral Tablet 50 mg Give 50mg by mouth given 05/01/2026 through 05/14/2026 08:00 p.m.;. Record review of the Pharmaceutical Consultant Report- Psychoactive Gradual Dose Reduction dated 1/28/26 revealed there was not a dose reduction on Ativan, Restoril, Seroquel, Trazadone or Haloperidol. The physician response indicated Mood and behavior stable tolerates current regiment.

Based on observation, interview, and record review, and facility policy review the facility failed to discontinue an as-needed (PRN) order for a psychotropic medication beyond the allowable fourteen (14) day period, for one (1) of five (5) medication reviews (Resident #58). Findings included: A review of the facility's policy, Medication Monitoring (Drug Regimen Review Monthly Review), undated, revealed, The facility supports pharmacy services that promote quality care including drug regimen review (DRR). DRR is defined as the systematic evaluation of drug therapy viewed within the context of resident-specific data. The consultant pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are reported to the Administrator, Director of Nursing, the attending physician, and the Medical Director, when appropriate. A record review of Resident #58's Physician Orders revealed an order dated 5/24/2024 for Haldol Decanoate Intramuscular Solution 50 MG/ML (milligrams/milliliters) to inject fifty (50) mg intramuscularly as needed for increased agitation and aggressive behavior, not to exceed 100 mg per month, and an order dated 9/11/24 for Haldol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate) to be administered once a month on the twenty-third (23rd) of each month. A record review of Resident #58's Electronic Medication Administration Record (eMAR) for May and June 2025 revealed the resident did not receive the PRN dose of Haldol. On 06/19/2025 at 11:42 AM, during a phone interview with the Nurse Practitioner (NP), they explained that they review all medications and orders. They reported the Haldol order should be discontinued after fourteen (14) days and that Haldol cannot be written as an as-needed medication for a year. On 06/19/2025 at 1:19 PM, during a phone interview with the Pharmacy Consultant, she explained that she visits the facility monthly and review orders. She stated that when an order needs to be stopped after fourteen (14) days, a note is placed in the dashboard. She stated that to continue Haldol beyond fourteen (14) days, a physician must conduct a physical evaluation and rewrite the order. On 06/19/2025 at 2:08 PM, during an interview with the Director of Nursing (DON), she explained the order should have been discontinued after fourteen (14) days. She stated that to maintain the order, a new evaluation and written order are required. She acknowledged that it is their responsibility along with the Charge Nurse to ensure this is completed and reported the oversight was due to human error. A record review of Resident #58's admission Record revealed an admission date of 12/21/2023, with diagnoses including Schizophrenia, unspecified, and Major Depressive Disorder. A record review of Resident #58's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/2025 revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicates cognitively intact.

Based on observation, interview, record review and facility policy review, the facility failed to provide peri-care in accordance with professional standards of care for two (2) of four (4) peri-care observations (Resident #9 and Resident #15). Findings included: A review of the facility's policy, Perineal Care Policy, with a revision date of 1/2010, revealed, POLICY It is the policy of this facility to provide perineal cleanliness and comfort to the resident, to prevent infection and skin irritation and to observe the resident skin condition . Resident #9 On 06/17/2025 at 2:10 PM, during an observation of peri-care for Resident #9 provided by Certified Nursing Assistant (CNA) 1 and assisted by CNA #2 revealed CNA #1 placed items on the nightstand beside the bed without a barrier in place. CNA #1 pulled out four wipes and cleaned the vaginal area front to back, pulling wipes from the pack a total of four times with soiled gloves. Resident #9 had feces in the back of her brief. CNA #1 removed gloves, sanitized hands, and proceeded to perform care in the buttocks area, again pulling wipes from the pack four times after starting care with dirty gloves. They then removed gloves, applied hand sanitizer, put on clean gloves, and applied a clean brief. Upon request by the State Agency to check for cleanliness, CNA #1 removed the brief and wiped a total of six additional times, each with visible smears of feces, until the resident was clean. On 06/17/2025 at 2:23 PM, during an interview with CNA #2, she explained that Resident #9 had smears of feces during the recheck. They stated that inadequate peri-care can lead to skin breakdown. On 06/17/2025 at 2:31 PM, during an interview with CNA #1, she confirmed that smears of feces were present during the recheck. She acknowledged that improper care could result in infection and skin breakdown. On 06/19/2025 at 1:50 PM, during an interview with the Director of Nursing (DON), She explained that CNAs are expected to follow the procedure for peri-care. She stated that improper care can lead to skin irritation and Urinary Tract Infections (UTIs). A record review of Resident #9's admission Record revealed an initial admission date of 4/26/2022 and a readmission date of 2/28/2025, with diagnoses including Acute Kidney Failure, Vascular Dementia, and Cognitive Communication Deficit. A record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/2025 revealed a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating the interview was not completed. The MDS dated [DATE], Section GG revealed the resident is dependent on toileting and hygiene. Resident #15 On 06/18/2025 at 4:29 PM, during an observation of peri-care for Resident #15 provided by CNA #3 and assisted by CNA #4 revealed CNA #3 placed a barrier on the bedside table. Both CNAs washed hands and applied clean gloves. CNA #3 removed the brief and began care. She wiped the front to back in the groin area on each side, then wiped down the center of the labia one time. She did not wipe down the labial sides again. CNA #3 then sanitized hands, applied clean gloves, and continued care. On 06/18/2025 at 5:44 PM, during an interview with CNA #4, she confirmed that CNA #3 wiped down the center of the vagina only once. They stated proper care requires wiping each labial side front to back, then down the center. She acknowledged this failure could lead to a UTI. On 06/18/2025 at 5:49 PM, during an interview with CNA #3, she explained they were nervous and forgot to wipe down the sides. She acknowledged that this could result in a UTI for Resident #15. On 06/19/2025 at 1:55 PM, during an interview with the DON, She confirmed CNA #3 should have wiped each labial side and then the middle. She stated failure to do so could cause UTIs or infection and that staff are expected to follow the procedure as trained. A record review of Resident #15's admission Record revealed an admission date of 7/8/2022, with diagnoses including Urinary Tract Infection and Alzheimer's Disease. A record review of Resident #15's MDS with an ARD of 3/26/2025 revealed a BIMS score of ninety-nine (99), indicating the interview was not completed. Section GG revealed the resident is dependent on toileting and hygiene.

Based on observation, interview, record review and facility policy review the facility failed to provide incontinent care in a manner to prevent the possibility of cross-contamination for one (1) of four (4) peri-care observations (Resident #9). Findings included: A review of the facility's policy, Infection Prevention and Control Program, with a revision date of August 2017, revealed, It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection. During an observation of peri-care on 06/17/2025 at 2:10 PM, for Resident #9 provided by Certified Nursing Assistant (CNA) #1 and assisted by CNA #2 revealed CNA #1 placed items on the nightstand beside the bed without a barrier in place. Both CNAs washed their hands and applied clean gloves. CNA #1 pulled out four wipes and cleaned the vaginal area front to back, pulling wipes from the pack a total of four times while wearing soiled gloves. Resident #9 had feces in the back of her brief. CNA #1 then removed gloves, sanitized hands, and continued care in the buttocks area, again pulling wipes from the pack four additional times after starting care with contaminated gloves. During an interview on 06/17/2025 at 2:23 PM, CNA #2, She explained that CNA #1 pulled additional wipes from the pack while still wearing dirty gloves. During an interview on 06/17/2025 at 2:31 PM, CNA #1, acknowledged that wipes should not have been pulled from the pack with soiled gloves. She confirmed a barrier was not used on the bedside table and that all needed wipes should have been removed prior to beginning care. She stated this was an infection control issue. During an interview on 06/18/2025 at 5:08 PM, Registered Nurse (RN) #1/Infection Preventionist (IP), explained that peri-care should be performed by two people: one clean and one dirty. She stated the clean person should pull out wipes for the dirty person to avoid contamination. She reported that improper peri-care can lead to infection and skin breakdown. During an interview on 06/19/2025 at 1:50 PM, the Director of Nursing (DON) stated CNAs are expected to follow established procedures for peri-care. She confirmed that Resident #9 could develop skin irritation and a urinary tract infection (UTI) due to the improper technique used. She reported that CNA #1 should have placed a barrier and removed wipes prior to beginning care. A record review of Resident #9's admission Record revealed an initial admission date of 4/26/2022 and a readmission date of 2/28/2025, with diagnoses including Acute Kidney Failure, Vascular Dementia, and Cognitive Communication Deficit. A record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/2025 revealed a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating the interview was not completed. The MDS, dated [DATE], Section GG revealed the resident is dependent on toileting and hygiene.

Based on observation, interview, record review and facility policy review, the facility failed to follow established guidelines for dating and labeling opened food items in the freezer and dry goods storage areas and failed to record food temperatures in the temperature log for breakfast during one (1) of four (4) survey days. This failure resulted in noncompliance with food safety standards and increased the risk of foodborne illness. Findings included: A review of the facility's policy, Food Storage Labeling, revised February 2015, revealed, The facility will ensure the safety and quality of food . 1 .All food items not in original package must be labeled .6.ii. Document the date the food is being stored . A review of the facility's policy, Monitoring Food Temperatures, policy #FP.8, revised February 2015, revealed .4. Storage temperatures should be recorded on the Cooked Food Storage Temperature Log . A record review of an in-service training dated 4/28/2025 revealed that topics included labeling, dating, temperature taking, and recording. On 06/16/2025 at 10:18 AM, during the initial kitchen tour with the Dietary Manager, during an observation, the following was observed: In the freezer, one (1) open, unlabeled box of egg rolls and (1) repackaged but undated bag of biscuits were discovered. In the dry goods area, there was (1) package each of opened and repackaged white cake mix, brownie mix, blueberry muffin mix, gelatin mix, and a five (5)-pack of graham cracker crusts-all without open dates. The temperature log for breakfast on 6/16/2025 did not contain recorded temperatures. The Dietary Manager acknowledged and confirmed all findings at the time of inspection. On 06/17/2025 at 10:20 AM, during a phone interview with the Registered Dietitian (RD), explained that they were disappointed with the department's condition during the inspection. The RD stated that expectations were for kitchen staff include following procedures for opening, dating, and labeling stored food items. On 06/19/2025 at 2:30 PM, during an interview the Administrator, explained the expectations for the dietary department are to follow facility policies and standard precautions regarding food safety and handling.

Based on observation, interviews and facility policy reviews the facility failed to serve the residents food in a manner that was appetizing and palpable, for one (1) of 17 residents reviewed for palatable meals. Resident #7 Findings Include: Review of the facility's policy, Food Preparation for Menu Items and Special Request, with a revised date of 10/17, revealed POLICY .Food is prepared by methods that preserve the nutritive value, flavor and appearance and meet standards for food safety . PROCEDURE: .5. A food service employee tastes all food items, including modified food items, to confirm acceptable quality . On 02/26/24 at 01:03 PM, in an interview with Resident #7, the resident stated the food is not good, as a lot of times it does not have any taste. On 02/27/24 at 11:20 AM, an observation and interview of Resident #7 eating lunch in the dining room, revealed the resident only ate baked apple slices. He stated this food is not worth eating. Resident #7 did not eat anything else on the tray. The lunch tray consisted of breaded baked fish, wild rice, broccoli, a roll, baked apple slices, water and tea. The broccoli was observed to be mushy. On 02/27/24 at 12:14 PM, the lunch meal was observed and tasted, along with the Dietary Manager (DM). The main meal broccoli was mushy and bland, and the breaded baked fish was bland. The DM confirmed that the fish was bland, and the broccoli was mushy and also bland. On 02/27/24 at 3:55 PM, in an interview with Cook #2, she revealed she did not have all the seasoning she needed to cook the fish. She confirmed the fish needed more seasoning, as it tasted bland. She also stated the broccoli could have tasted better. On 02/27/24 at 4:02 PM, in an interview the DM stated they were not out of the seasoning needed for the fish. However, Cook #1 told her she did not see the seasoning until after the fish had been cooked. The DM revealed that Cook #2 told her she had used onion and garlic powder on the fish, but the DM admitted that she could not taste any onion or garlic powder on the fish, and stated it was bland. Review of the Admission Record for Resident #7 revealed the facility initially admitted the resident on 10/28/2021 with current diagnoses that included Essential Hypertension, Type 2 Diabetes Mellitus and Heart Failure. Review of the Order Summary Report, with active orders as of 02/29/2024, for Resident #7, revealed a Physician Order, dated 11/27/2021, NAS Carb (No Added Salt Carbohydrates) Consistent diet, Regular texture, Regular liquids consistency. Review of the quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) 12/27/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based observation, interviews, record review, and policy review the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan to manage pain for one (1) of seventeen (17) sampled residents. Resident #47 Findings include: Record review of the facility policy titled, Pain Assessment/Management, revised 9/10, revealed, It is the policy of this facility to provide guidelines in the identification and treatment of residents a risk for acute and chronic pain. Each residents pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .Staff members providing direct care .will use an interdisciplinary approach observing pain symptoms in the resident and report it to the nurse. If possible, the nurse will discuss with the resident the severity and quality of pain using the pain reference scale. This will be documented on the pain assessment and a plan of care will be initiated. Thereafter pain will be assessed and recorded on the Medication Administration Record .When a resident demonstrates pain, whether verbal or written, the nurse is to administer pain med per PRN orders. Record review of the facility policy titled, Lab Monitoring and Follow-up Policy, revised 10/2019, revealed, It is the policy of this facility to obtain blood samples per physician order, monitor all resident's lab results for abnormal values. All abnormal values will be communicated to the physician in a timely manner. All critical values will be communicated to the licensed responsible caregiver (MD/NP) upon receipt of results, to ensure appropriate, timely patient care . All abnormal will be called in to the licensed responsible caregiver (MD/NP) within a timely manner but no longer than 24 hours of receiving . On 2/26/24 at 1:45 PM, during an observation and interview, Resident #47 was seated in a bedside chair in her room with her left shoe off. The resident stated that the fourth toe on her left foot was hurting. The resident had facial grimacing and furrowed brow as she described the pain in her left foot. It was noted that there was a small black scab on the toe, on the top on what appeared to be a pencil eraser size corn. However, it was noted that the entire left foot was swollen. On 2/27/24 at 8:45 AM, during an observation and interview, Resident #47 was seated in a bedside chair in her room, wearing both of her shoes. Without prompting, the resident stated that her toe was hurting very badly, while removing her left shoe and pointing to the fourth toe of her left foot. On 2/28/24 at 3:00 PM, during an interview with a family member in the room visiting Resident #47, it was revealed that the resident frequently complains of pain in her left foot. The family member stated that they had not reported it to the nursing staff because the staff already knew about it and the family member stated they assumed the staff were giving the resident something for pain. At that point, the resident spoke up and stated that she could not keep a shoe on her left foot, because it burns so badly. On 2/28/24 at 4:00 PM, during an observation and interview with Licensed Practical Nurse (LPN) #2, she was observed administering routine medications to Resident #47 in the resident's room. It was noted that the LPN did not ask the resident about pain during the interaction. LPN #2 confirmed that the resident had been assessed by the Nurse Practitioner on or around 2/12/24 for inflammation and pain related to Gout. The nurse revealed that she had not administered any medication for inflammation or pain to Resident #47 during February 2024. On 2/29/24 at 2:40 PM, an observation and interview with the Director of Nurses (DON) in the room of Resident #47 revealed that upon entering the room the resident immediately told the DON that her toe was hurting. The DON assessed the resident's left foot and when she touched the resident's toe, the resident jerked the left foot back and yelled out. Record review on 2/29/24 of the electronic health record, for Resident #47, revealed that there were no lab results for the uric acid level that was ordered by the physician on 2/13/24. Record review of the Order Summary Report, with active orders as of 2/29/2024, revealed a physician order, dated 12/7/2023, for Resident #47 to be evaluated pain per pain scale (0-10), every shift and prn. The order revealed that if pain is present, document interventions and follow up on effects and notify the physician of persistent pain unrelieved by intervention. A record review of the Medication Administration Record (MAR), dated 2/1/2024 through 2/29/24, revealed that Resident #47 was assessed for pain, using the 0-10 pain scale every shift for the month of February and each time, the nurses recorded that the resident reported 0, indicating no pain at that time. During an interview on 2/29/24 at 3:45 PM, the DON, confirmed that Resident #47 continued to exhibit signs and symptoms of a Gout flareup, including pain. She confirmed that the resident had physician orders for pain medication to be given as needed (PRN) and said that it was the nurses' responsibility to assess for pain, administer the pain medication, assess for effectiveness, and notify the resident's physician of unrelieved pain. The DON also confirmed that the resident had a physician order to obtain a laboratory test to measure the uric acid level related to Gout and that no results had been obtained or reported to the resident's physician. She stated that the results were supposed to be communicated to the physician through a telephone call by the nursing staff. During an interview on 2/29/24 at 5:10 PM, with LPN #4 confirmed that she had administered pain medication to Resident #47 at or around 3:15 PM. She stated she had assessed the resident for effectiveness of the pain medication and Resident #47 rated the pain in her left toe a 10 on a 0-10 pain scale. The nurse revealed she had not notified the resident's physician of unrelieved pain because, she has dementia. A record review of the MAR for Resident #47 revealed the only medication ordered for pain was Tylenol Extra Strength 500 mg, to be given every 6 hours as needed for pain or fever. During the month of February 2024, the only time pain medication administered was the Tylenol administered by LPN #4 on 2/29/24 at 3:18 PM. Further review of the MAR for Resident #47 revealed Resident #47 received Colchicine-Probenecid Oral Tablet 0.5-500 mg (milligrams) two times a day related to Gout for two (2) weeks during the month of February 2024. The medication was administered from 2/14/24 to 2/27/24. Record review of the Admission Record for Resident #47 revealed that the facility admitted Resident #47 on 6/16/23 and had diagnoses that included Osteoarthritis, Type 2 Diabetes, Dementia, Gout, and Osteoarthritis. Record review of the Quarterly Minimum Data Set (MDS) for Resident #47, with an Assessment Reference Date (ARD) of 12/20/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment.

Based on staff interviews, record reviews, and facility policy review the facility failed to complete a comprehensive Minimum Data Set (MDS) for two of 13 residents reviewed for comprehensive assessments, with the potential to affect 70 residents. Resident #11 and Resident #12 Record review of the facility's MDS Assessment policy dated 5/2006 revealed, It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set for by CMS (Centers for Medicare and Medicaid Services) protocol. Record review of CMS's RAI Version 3.0 Manual dated October 2019 indicated The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) . Resident #11 A record review of the Admission Record revealed the facility admitted Resident #11 on 10/16/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed Minimum Data Set (MDS) revealed a quarterly assessment with an Assessment Reference Date (ARD) of 6/18/2021. Further review of the electronic medical revealed Resident #11's comprehensive annual assessment had not been completed. Resident #12 A record review of the Admission Record revealed the facility admitted Resident #12 on 12/21/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS revealed a quarterly assessment with an ARD of 6/23/21. Further review of the electronic medical revealed Resident #12's comprehensive annual assessment had not been completed. On 10/28/21 at 11:07 AM, during an interview with the Director of Nursing (DON), she stated the reason the MDS assessments have not been completed is because the facility has experienced recent turnover in the MDS nurse position and the current MDS nurse has been in her current role for only a week. On 10/28/21 at 11:18 AM, during an interview with MDS Corporate Coordinator, Registered Nurse (RN), she stated the current MDS nurse is new. She confirmed there are MDS Assessments that are past due and states she is aware of the issue. She stated throughout the company there has been a shortage of MDS staff and they try to do assessments for Part A (Medicare Part A) residents timely. She stated, It's a mess, we know. On 10/28/21 at 1:22 PM, during a follow up interview with the MDS Corporate Coordinator, RN, she accessed Resident #11's and Resident #12's electronic MDS using the facility laptop. She confirmed the last completed MDS assessments dates were accurate for Resident #11 and Resident #12. She further stated, the next ones (next MDS assessments) are open but they are not completed. On 10/28/21 at 11:40 AM, during an interview with the Administrator, he stated that his expectations are that Part A MDS assessments have to be completed for residents and Medicaid resident assessments are not as time sensitive and they try to prioritize and work in that fashion. He stated he is aware there are some MDS assessments that are not completed timely. He said they have had turnover in the MDS nurse position.

Based on staff interviews, record reviews, and facility policy review, the facility failed to complete quarterly Minimum Data Set (MDS) Assessments for ten (10) of 13 residents reviewed for quarterly assessments, with the potential to affect 70 residents. Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 Resident #6, Resident #7, Resident #8, Resident #9, Resident #13 Record review of the facility's MDS Assessment policy dated 5/2006 revealed, It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set for by CMS (Centers for Medicare and Medicaid Services) protocol. Record review of CMS's RAI Version 3.0 Manual dated October 2019 indicated The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days . Resident #1 A record review of the Admission Record revealed the facility admitted Resident #1 on 6/7/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #1 revealed a quarterly assessment with an ARD of 5/27/21, which is more than 92 days. Resident #2 A record review of the Admission Record revealed the facility admitted Resident #2 on 8/13/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #2 revealed a comprehensive assessment with an ARD of 5/28/21, which is more than 92 days. Resident #3 A record review of the Admission Record revealed the facility admitted Resident #3 on 2/26/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #3 revealed a quarterly assessment with an ARD of 6/1/21, which is more than 92 days. Resident #4 A record review of the Admission Record revealed the facility admitted Resident #4 on 6/2/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #4 revealed a comprehensive assessment with an ARD of 6/8/21, which is more than 92 days. Resident #5 A record review of the Admission Record revealed the facility admitted Resident #5 on 5/3/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #5 revealed a quarterly assessment with an ARD of 6/2/21, which is more than 92 days. Resident #6 A record review of the Admission Record revealed the facility admitted Resident #6 on 6/18/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #6 revealed a quarterly assessment with an ARD of 6/2/21, which is more than 92 days. Resident #7 A record review of the Admission Record revealed the facility admitted Resident #7 on 2/7/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #7 revealed a quarterly assessment with an ARD of 6/9/21, which is more than 92 days. Resident #8 A record review of the Admission Record revealed the facility admitted Resident #8 on 7/19/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #8 revealed a comprehensive assessment with an ARD of 6/9/21, which is more than 92 days. Resident #9 A record review of the Admission Record revealed the facility admitted Resident #9 on 2/11/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #9 revealed a quarterly assessment with an ARD of 6/10/21, which is more than 92 days. Resident #13 A record review of the Admission Record revealed the facility admitted Resident #13 on 3/9/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the last completed MDS for Resident #13 revealed a comprehensive assessment with an ARD of 6/23/21, which is more than 92 days. On 10/28/21 at 11:07 AM, during an interview with the Director of Nursing (DON), she stated the reason the MDS assessments have not been completed is because the facility has experienced recent turnover in the MDS nurse position and the current MDS nurse has been in her current role for only a week. On 10/28/21 at 11:18 AM, during an interview with MDS Corporate Coordinator, Registered Nurse (RN), she stated the current MDS nurse is new. She confirmed there are MDS Assessments that are past due and stated she is aware of the issue. She stated throughout the company there has been a shortage of MDS staff and they try to do assessments for Part A (Medicare Part A) residents timely. She stated, It's a mess, we know. On 10/28/21 at 1:22 PM, during a follow up interview with the MDS Corporate Coordinator, RN, she accessed Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #13's electronic MDS using the facility laptop. She confirmed the last completed MDS assessments dates were accurate for those residents. She further stated, the next ones (next MDS assessments) are open but they are not completed. On 10/28/21 at 11:40 AM, during an interview with the Administrator, he stated that his expectations are that Part A MDS assessments have to be completed for residents and Medicaid resident assessments are not as time sensitive and they try to prioritize and work in that fashion. He stated he is aware there are some MDS assessments that are not completed timely. He said they have had turnover in the MDS nurse position.

Based on staff interviews and record reviews the facility failed to accurately code the Minimum Data Set (MDS) reflecting anticoagulant medications for two (2) residents of 17 sampled residents. (Resident #28 and Resident #41) A record review of the facility's policy dated 5/2006 revealed It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol. A record review of the [NAME] Drug Guide for Nurses Fifteenth Edition 2015 revealed the classification of [MEDICATION(S)] ([MEDICATION(S)]) is listed as therapeutic: antiplatelet agents and Pharmacologic: platelet aggregation inhibitors. Resident #28 Record review of Resident #28's Admission Record revealed the facility admitted the resident on 10/28/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #28's Order Summary Report dated 07/01/2021 revealed an order with an order date of 10/28/2020 for [MEDICATION(S)] 75 mg daily give one (1) tablet by mouth one time a day related to [CONDITION(S)] and [CONDITION(S)] following [CONDITION(S)] Disease. There were no anticoagulant medications listed on the Order Summary Report. Review of Resident #28's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/22/21 revealed coding in Section N as Resident #28 received anticoagulant medication for seven (7) days out of the seven (7) day look back period. Record review of Resident #28's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41 Record review of Admission Record revealed the facility admitted Resident #41 on 01/21/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an Order Summary Report for Resident #41 for the month of August 2021 revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no anticoagulant medications listed on the Order Summary Report. Record review the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/17/2021 revealed coding under Section N which indicated Resident #41 received an anticoagulant for seven (7) days of the seven (7) day look back period. Record review of Resident #41's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Facility's MDS medication reference sheet revealed a section heading of Anticoagulants (Code on MDS [N410E]) in which [MEDICATION(S)] Bisulfate is not listed in that section of the reference sheet. The reference sheet also includes a section with the heading Antiplatelet agents (do not code on MDS [N410E]) in which [MEDICATION(S)] Bisulfate is listed in that section. On 10/28/21 at 11:40 AM, during an interview with the Administrator, he stated that his expectations are that all MDS assessments should be coded correctly. He stated there has been staffing issues and turnover in the MDS nurse position. On 10/28/21 at 12:00 PM, during an interview with the MDS Corporate Coordinator, Registered Nurse (RN), she explained [MEDICATION(S)] is not an anticoagulant medication. She stated the facility has a cheat sheet (reference sheet) to assist with accurately coding medications for the MDS. She explained the MDS nurse who completed the assessments for Resident #28 and Resident #41 no longer works for the facility and they are aware of the errors the nurse had made on MDS assessments. She further explained that she has been correcting and reviewing the MDS assessments but has not had time to review and correct inaccurate coding related to medications.

Based on observation, staff interview, and facility policy review, the facility failed to account for medication reconcilement sheets for eight (8) of 51 discontinued medications, which presented the potential for medication misuse. Findings include: Review of the facility's, Storage of Discontinued Controlled Drug policy, dated 10/16, revealed: When a controlled drug is discontinued it is to be given to the DON, along with the controlled drug sign out sheet. The controlled drug is to be logged onto the Controlled Drug Locked Box Inventory Log for the DON office. An observation on 12/16/19 at 3:30 PM, in the Director of Nurses' (DON) Office, with the DON and Administrator present, revealed 8 medications in a double locked metal storage cabinet, without medication administration sheets attached. The medications included two (2) punch cards of single dose packets of pain medication ([MEDICATION NAME]), with a pharmacy filled date of 12/13/18; two (2) bottles of liquid cough medicine ([MEDICATION NAME]), one (1) of the bottles with a pharmacy filled date of 4/26/17; 2 punch cards of single dose antidiarrheal medication ([MEDICATION NAME]), with a pharmacy filled date of 4/9/19; and 2 packages of individual tubes of a combination topical pain cream (ABHR), with a pharmacy filled date of 4/1/19 and 7/3/19. During an interview, on 12/16/19 at 4:35 PM, the DON revealed she did not know why those medications did not have the sign out sheets attached. The DON further stated they would not be accepted from the medication carts without the sheets. The DON could not explain why the form was not there with the medications. An interview with the Pharmacy Consultant, on 12/17/19 at 9:35 AM, revealed she addressed controlled drug storage each visit. Their policy doesn't say how often the drugs should be removed and destroyed. The Pharmacy Consultant further stated, either the DON or the Administrator were not there together on the days of the Pharmacist visit, which prevented access to the storage box.

Based on observation, interview, and review of facility recipes, it was determined the facility failed to follow the puree recipes for fried chicken and broccoli menus. This had the potential to affect six (6) of six (6) residents receiving pureed diets. Findings include: Review of the facility's document titled, Recipe Report Pureed Fried Chicken, with a copyright date of 1999 to 2019, revealed the recipe was designed for 10 residents receiving a pureed diet. The recipe called for eight (8) pieces of chicken rolled in seasoned flour and fried. Remove the required number of portions and place in the processor bowl. Process for 30 to 45 seconds or until the mixture is smooth. Check for texture and consistency; add hot liquid, if needed, to make the consistency of pudding or mashed potatoes. Food thickener should not be needed. If liquid is added, continue the process for one (1) minute longer or until smooth Review of the facility document titled, Recipe Report for Pureed Broccoli, with a copyright date of 1999 to 2019, revealed the resident was designed for 10 residents. The recipe called for two and half (2 ½) pounds (lbs.) of frozen broccoli florets to be placed in the steamer with seasoning of margarine and salt for five (5) to 10 minutes, or until tender. Then removed the required number of portions from the amount prepared and place in the food processor bowl. Process for 30 to 45 seconds or until mixture is smooth. Check for texture and consistency; add thickener if needed, to make consistency of mashed potatoes. On 2/27/19 at 9:43 AM, observation of the pureed meal preparation for fried chicken revealed Dietary Cook (DC) #7 placed six (6) fried boneless chicken breasts in the Robot Coupe and poured a small amount (no measurement used) of whole milk in the mixer and proceeded to puree the mixture for two (2) to three (3) minutes. During this process, the Cook added a small amount of milk four (4) additional times without measurement. DC #7 was asked what consistency she was looking for in the pureed mixture. DC #7 responded she was not sure what the surveyor meant by consistency. After giving the Cook an example of consistency (i.e. pudding or mashed potatoes), the Cook responded the consistency, Should be able to fill scoop #10. When finished pureeing, the mixture had a smooth runny appearance with no shape. The Dietary Cook placed the mixture in a steel container in the warming oven. The Dietary Cook said the mixture was enough for six (6) residents. The Dietary Cook then prepared to puree the broccoli. The Dietary Cook drained water from a pot of cooked broccoli and then placed broccoli florets (without measurement) into the Robot Coupe and proceeded to puree the vegetable. The Dietary Cook, when asked how much broccoli was used, responded it was one (1) chunk. She did not know exactly how many ounces the one (1) chunk was. The Cook pureed the mixture for approximately 60 seconds and then stirred the mixture with a spatula. The Cook did not add anything else to the mixture. The mixture was pureed again for 40 seconds and then was poured into a metal container and placed in the oven. The mixture lacked the consistency of pudding or mashed potatoes. An interview was conducted with Dietary Cook #7 on 2/27/19 at 10:23 AM. DC #7 admitted that she did not add the milk to the puree fried chicken and was not aware the recipe required (called for) hot liquid to be added, not cold milk. The Cook also stated that she does not always measure the amount of food item, that she usually guesses on what the amount should be. The Dietary Cook further stated that she prepared enough for the six (6) residents on pureed diets. However, if the residents requested additional servings, that she would have to prepare more of the pureed items, causing a delay in the resident receiving their food requests in a timely manner. During an interview with the Dietary Manager (DM) on 2/27/19 at 10:40 AM, the procedure the Dietary Cook used to puree the fried chicken and broccoli was described. The DM stated the Cook should have followed the recipes to ensure the pureed items were prepared to the proper consistency, palatability, and serving size. The Cook stated the pureed items should have consistency of mashed potatoes or pudding. The DM agreed the Dietary Cook should follow the recipe for the pureed fried chicken and pureed broccoli. The DM confirmed currently there were six (6) residents in the facility on a pureed diet.

Based on observation, record review, and interview, it was determined the facility failed to administer medications according to the physician's orders for one (1) resident, Resident #30, of nine (9) residents observed during medication administration. These were two (2) nurses observed for medication administration. This resulted in a medication error rate of 33%. Findings include: On 2/27/19 at 11:02 AM, during medication administration observation, License Practical Nurse (LPN) #1 was observed to administer the following five (5) medications out of the time range to Resident #30: - Atorvastatin calcium (lipid lowering agent) 80 milligram (mg) one (1) tablet, - [MEDICATION NAME] (steroid) 40 mg one (1) tablet -[MEDICATION NAME](antibiotic) 500 mg one(1) tablet - Eliquis 5 mg (anticoagulant) one (1) tablet - [MEDICATION NAME] 50 mg one (1) tablet The medications were crushed in a separate bag and then placed in separate containers for administration via feeding tube. LPN #1 was observed checking the placement of the feed tube. LPN #1 flushed with five (5) ml of water between each medication administered. LPN#1 flushed with 30 milliliters (ml) water before and after completion of medication pass. The nurse was observed picking up the medication containers and the water container and carried them out of the resident room. LPN #1 then threw the containers into the waste disposal. A review of the resident's 2/27/19 Medication Administration Audit Report revealed the resident was to receive the following medications at 8:00 AM: - [MEDICATION NAME] Powder 3350 17 grams daily - NAME] 40 mg daily - Eliquis 5 mg one(1) tablet twice a day - Systene gel one (1) drop in both eyes twice a day - [MEDICATION NAME] 50 mg one(1) tablet twice a day - Atrovastatin Calcium 80 mg one (1) tablet daily - MagOx 400 mg one(1) tablet two (2) times a day - [MEDICATION NAME] Solution 100 mg/milliliter(ml) give 15 ml every 12 hours - Prostate Sugar Free 30 ml three (3) times a day - Vitamin C 500 mg one(1) tablet three (3) times a day - [MEDICATION NAME] 40 mg one (1) tablet daily - Tylenol with [MEDICATION NAME] #3 300-30 mg one(1) tablet daily -[MEDICATION NAME] mg one (1) capsule twice a day - An additional review of the resident's Medication Administration Audit Report revealed the resident did not receive the following six (6) medications during the 11:02 AM medication pass, which were scheduled to be given at 8:00 a.m.: - Magnesium Oxide (mineral) 400 mg one (1) tablet - [MEDICATION NAME] Solution (anti-convulsant) 100 mg/milliliter (15 ml every 12 hours) - Tylenol with [MEDICATION NAME] #3 (narcotic) 300-30 mg - [MEDICATION NAME] Powder (laxative) 17 grams - NAME] (antacid) 40 mg - [MEDICATION NAME] gel 0.4-0.3% (dry eyes) one (1) drop to both eyes - These medications were later charted as being given at 1:327 PM., four (4) hours after the 8:00 AM scheduled time. In an interview conducted on 2/27/19 at 11:02 AM., LPN #1 stated she was running late giving her medications because it had been a long time since she had administered medications to the residents. She also reported that she was having difficulty with her computer. The computer was locking her out of the system and she was unclear of why this was occurring. The Administrator was working on her computer to solve the issue. In an interview with the Director of Nursing on 2/28/19 at 4:45 PM, the DON said that all medications had been administered to Resident #30, but they had been given late according to her report from LPN #1 and her audit report. The DON said she was sorry that this had occurred. The Medical Director was unavailable for an interview regarding the late administration of this resident's medications During the Medication Administration observations, 33 medications were observed being administered with 11 total medications errors. The facility's medication error rate was 33 percent.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner. Inspection tour of the facility revealed excessive buildup of frost and ice in the facility freezer, crusty residue on the dish storage cart, and residents' water pitcher with water inside the inner container. This created the potential for the spread of food borne illness to 73 of 75 residents who received their meals prepared in the kitchen. Findings include: The initial kitchen inspection was conducted with Dietary Cook (DC) #6, on 2/25/19 at 9:30 AM, with the following concerns identified: The walk-in freezer had an outside temperature (temp) of minus one (1) degree and inside temp of minus 10 degrees, with a heavy buildup of frost and ice along the doorway of freezer, ceiling, packages of food, and around the fans in the room. Icicles were forming from the ceiling of the freezer, frost starting to form on the floor, and food frozen solid. DC #6 stated this problem has existed for several months. DC #6 stated they had the Trouble Shooter company to evaluate the problem two (2)times and explained a new strip was needed along the edge of the doorway for the door to close properly. DC #6 stated the staff must scrape the frost/ice from the doorway to allow the door to close properly. Tour of the kitchen on 2/27/19 8:45 AM, revealed the following concerns: Four (4) of eight (8) residents' water pitchers were observed with water droplets trapped inside pitcher container. Interview with Dietary Cook #6 revealed the water pitchers were supposed to be completely dry and this was not sanitary. DC #6 removed the water pitchers from the tray. A Two (2) tier cart that contained two (2) trays of dishes including 38 plates, 53 bowls, and 27 saucers for the lunch meal service, had beige crusty-type flakes on the cart and among the dishes. An interview with DC #6, during this observation, revealed the staff should ensure the cart is clean by wiping it off before putting trays of clean dishes on the cart. The walk-in freezer outside temperature showed a minus four (4) degrees and frost forming on the bottom portion of the door. There was a sign posted on the freezer door instructing the staff to be sure the door was completely closed. Frost and ice had formed on the doorway, walls, and around fans of the freezer motor; and small icicles were forming on the ceiling. The Dietary Manager (DM) had just finished scraping ice and frost from the edges of the freezer door. The DM stated the problem had existed for several weeks now. The DM stated the Maintenance Supervisor was unable to fix the problem and they had to call in an outside contractor, The Trouble Shooters, twice to address the problem. The DM thought the door needed to replace. The DM stated that the Administrator had the paper work and was addressing problem. The DM also stated the staff usually scraped the frost/ice from the doorway every other day to ensure the door closed properly. The DM acknowledged that frost was now forming on the bottom door leading to the refrigerator portion. A wall vent with heavy brown grease buildup was observed. The DM stated the maintenance department was responsible for cleaning. The DM was unable to provide cleaning log for the vent. During an interview on 2/27/19 3:30 PM, the Administrator acknowledged problems with the facility's freezer. The Administrator stated the Trouble Shooters consultants had evaluated the problems twice and identified the building's settling has caused the problems with the freezer door and the age of the freezer was a problem also. The Administrator stated the freezer door needed to be replaced as well as the refrigerator door. The Administrator provided a copy of a capital equipment request. The Administrator also stated the request had been submitted to the Corporate office and was awaiting the approval.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the staff followed policy and procedures for disinfecting glucometers before and after each resident use for two (2) of six (6) glucometers observed for cleaning. This had the potential to spread blood-borne pathogens to residents who received Acu-checks. The facility also failed to ensure that one (1) of three (3) residents, Resident #30, received wound care and dressing changes, utilizing appropriate clean technique. Findings include: Glucometers: Review of the facility policy titled, Infection Prevention and Control Program, dated 8/2017, indicated it was the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The policy documented: 8. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedure governing the cleaning and sterilization of soiled or contaminated equipment. Review of the manufacturer's undated recommendations titled, Cleaning and Disinfection Procedures documented cleaning and disinfecting the FORA GD 20 blood glucose meter. To clean the glucometer use a lint free cloth damped with soapy water or [MEDICATION NAME] (70% to 80%) to clean the outside of the blood glucose meter. To disinfect the blood glucometer, the manufacturer recommended the use of Super Sani-Cloth Germicical Wipes or Sani-Cloth Bleach Germicidal Disposables. The manufacturer's recommendations also included that it was crucial that the FORA GD20 meter was completely dry before testing a resident's blood glucose level and to follow the disinfectant product label instructions to ensure proper drying times. A review of the label for the use of the Super Sani-Cloth Germicidal Disposable Wipes revealed the following: if present, remove heavy soil loads prior to disinfecting. Unfold a clean wipe and thoroughly treat the surface. Allow surface to remain treated for [REDACTED]. Review of the facility policy titled, Glucometer Disinfection, dated 2/10/2018, indicated the purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 3. The glucometers should be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA) registered healthcare disinfectant that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] virus . 4. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions, regardless of whether they are intended for single resident or multiple resident use. 5. Procedure included: i. Retrieve two (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/ or other contaminants left on the surface of the glucometer. k. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following by wrapping the machine with the disinfecting wipe and leaving wrapped no less than two (2) full minutes. l. Discard disinfectant wipe in waste receptacle. m. Perform hand hygiene. During the medication administration pass observation on 2/27/19 at 8:05 AM, License Practical Nurse (LPN) #1 was observed cleaning/disinfecting a blood glucose meter in the following manner: LPN #1 picked up the blood glucose meter from the medication cart located on Hall C. She took one (1) wipe from a container labeled PDI Santi-Hands. Using the Santi-Hands cloth, LPN#1 wiped off the blood glucose meter on the front side and then turned it over and wiped off the back side. LPN #1 then placed the blood glucose meter in the top drawer of the medication cart on Hall C and threw away the PDI Santi-Hands cloth in the waste dispenser. LPN #1 took another PDI Santi- Hands cloth from the container on medication cart Hall C and wiped off her hands. On 2/27/19 at 11:57 AM, LPN #2 was observed cleaning and disinfection a blood glucose meter on the medication cart located on Hall A in the following manner: LPN #2 took one (1) cloth from a blue top container labeled Clorox Healthcare Bleach Germicidal Wipes. LPN#2 then took the germicidal wipe and wiped down the front side of the blood glucose meter and then turned it over and wiped down the back side. LPN #2 then took a clean paper towel and wrapped the blood glucose meter in the towel. LPN #2 then placed the wrapped blood glucose meter in the medication cart's top drawer. LPN #2 then threw the germicidal wipe in the waste dispenser and used another germicidal wipe to clean her hands. Review of the facility sanitization policy revealed that the PDI Santi Wipe were recommended for an antiseptic for handwashing to decrease bacteria on the skin. On 2/27 19 at 1:53 PM, an interview was conducted with LPN #2 at the nurse's station. LPN #2 reported she had been trained by several different nurses. LPN #2 said she was told to wipe the blood glucose meter down with a bleach wipe and then place the blood glucose meter in a paper towel. In an interview, on 2/27/19 at 1:58 PM, at the nurse's station, LPN #1 said she was taught to wipe the blood glucose meter down before putting in back in the medication cart. LPN #1 stated she did not recall any wait time for drying. An interview was conducted with RN Charge Nurse #3 (RN) at the nurses' station on 2/27/19 at 2:23 PM. RN #3 reported she did not remember the procedure for cleaning and disinfection the blood glucose meters. She stated it had been a long time since she had attended an in-service for cleaning and disinfecting blood glucose meters. An interview was conducted on 2/27/19 at 2:27 PM with LPN #4. The LPN said she would clean her glucose meter before and after using it. She said that she would let it air dry about three (3) minutes and that she used the purple Super Cloths to clean the glucose meter. LPN #4 said she had been in-serviced last year. An interview was conducted on 2/27/19 at 4:00 PM, with the Staff Development Coordinator (SDC), in her office. The SDC reported that the staff should know the procedure for cleaning and disinfection the facility blood glucose meters. She said the Director of Nursing (DON) had conducted the last in-service on 1/24/19. The SDC said she does random inspections to monitor and ensure the staff are doing the proper procedure for cleaning and disinfecting their blood glucose meters. The SDC reported she watches the nurses as they do their Acu-checks and cleaning of their blood glucose meters. The SDC said she would be doing another in-service with the nurses on the policy of cleaning and disinfecting the facility blood glucose meters. On 2/27/19 at 4:16 PM, an interview was conducted with the DON in the facility conference room. The DON said she discusses and demonstrates the proper procedure to her nurses weekly. She stated she does random discussions and does not use a sign-in sheet. The DON said she would expect them to know how to clean and disinfect their blood glucose meter. The DON said she purchased two (2)blood glucose meters for each medication cart, so they would not have to wait while the blood glucose meter dried between cleanings. She said they were shown the facility policy and procedure on how to clean and disinfect the blood glucose meters in the last in-service. The facility provided documentation of an in-service class, conducted on the 1/24/19, for the licensed staff, which included training on disinfecting the blood glucose meters. Review of the facility's attendance sheets revealed LPN #1 and LPN #2 attended this training session. Resident #30: Review of facility undated document titled, Clean Dressing Change, documented compliance guidelines for dressing changes included the following: #5. Set up a clean field on the overbed table with needed supplies wound cleansing and dressing application #6. Establish area for soiled products to be placed #7. Wash hands and put on clean gloves #8. Place a barrier cloth or pad next to the resident under the wound to protect the bed linen #9. Loosen the tape and remove existing dressing . #10. Remove gloves pulling inside out over the dressing and discard into appropriate receptacle #11. Wash hands and put on clean gloves #12. Cleanse the wound as ordered taking care not to contaminate other skin surfaces or surfaces of the wound (clean outward from the center of the wound) Pat dry with gauge. #13. Wash hands and put on clean gloves #14. Apply topical ointments or creams and dress the wound as ordered Observation on 2/25/19 at 2:29 PM, of Resident #30's wound care, revealed the following: The Wound Care Nurse had the resident position on his side. She prepared the over-bed table with two (2) plastic cups, one (1) cup contained saline soaked gauze and the other cup contained Dakin soaked gauze. The WCN removed the old undated dressing from the resident's sacral wound. The WCN discarded the old dressing in a plastic bag located at the foot of the bed. The wound was a healing stage III sacral ulcer, with pink granulating tissue, with a small dark area in the center of the wound. The WCN removed her gloves and went to wash her hands. While the nurse was washing her hands, the resident rolled onto his back. The WCN nurse returned and donned a new pair of gloves from the nightstand at the foot of the resident's bed and reposition the resident on his side. The WCN obtained a saline soaked gauze and wipe from the resident's buttock cheek to the center of the sacral ulcer, thereby contaminating the wound from other skin surfaces. The WCN discarded the used gauze and with her dirty gloves, placed a clean gauze in the resident's sacral wound. The nurse left to change her gloves and the resident again rolled onto his back contaminating the clean gauze. The WCN donned clean gloves and removed contaminated gauze from wound and then packed area with Dakin's soaked gauze. The packed wound was then covered with a silicone dressing, without the LPN changing to new gloves. The silicone dressing was not thoroughly sealed and was coming loose. The nurse degloved, washed her hands, donned new gloves, and held the dressing in place for 45 seconds, until the dressing was completely sealed. During an interview with the Director of Nursing (DON) on 2/26/19 at 3:10 PM, the dressing change observed by the WCN on 2/25/19 was described to the DON. The DON stated she couldn't understand why the nurse did not have another staff member help position the resident. The DON also stated that when cleaning a wound, the nurse should wipe in a circular motion from the clean area to dirty area. The DON also stated that it appeared the WCN had contaminated the wound a couple times during the dressing change. An interview with the WCN on 2/27/19 at 4:15 PM, revealed she was aware there should have been another staff member present to help her, but it was at the end of the shift and could not find anyone. The WCN admitted that she had made some mistakes while doing the dressing changes because she was nervous and did not expect to have anyone observe her that day doing a dressing change.

Based on observation, staff interview, record review, and facility policy review, the facility failed to discard expired medications from medication carts and floor stock supply for one (1) of 1 medication rooms and two (2) of two (2) medication carts. Findings include: Review of the Facility's Medication Storage in the Facility policy, undated, revealed outdated medications are immediately removed from stock, and disposed of according to procedures for medication disposal. Observation of the medication room floor stock and interview with Licensed Practical Nurse #5, on 03/23/17 at 4:45 PM, revealed expired floor stock medications with two (2) bottles of Bisacodyl Stimulant Laxative 5 (five) mg tablets/100 milligram (mg) tablets with an expiration date of 02/17, and one (1) bottle with an expiration date of 12/16; and one (1) bottle of Doscusate Sodium 50 mg/5 mg with an expiration date of 10/16. Observation of the medication cart for the A Hall assigned to LPN #5, revealed one (1) bottle of Omeprazole 20.6 mg caplets (cap) with an expiration date of 10/16. While checking the medication room's floor stock and the A Hall medication cart, LPN #5 confirmed the expired medications and stated she was unsure of the person responsible for checking the expiration dates of the floor stock medications. Observation of the medication cart for B Hall and C Hall, with Licensed Practical Nurse #2, on 03/23/17 at 3:05 PM, revealed/confirmed a bottle of Acetaminophen 325 mg tablets with an expiration date of 12/16; one (1) bottle of Vitamin B12 100 mg tablets with an expiration date of 01/17; one (1) bottle of Dimenhydrinate 50 gm tablets with an expiration date of 08/16; one (1) bottle of Magnesium with Calcium 64 mg tablets Enteric Coated (EC) 60 tablets/bottle with an expiration date of 10/16. There was one (1) tube of Proctosol-HC 2.5% (two point five percent) cream for an Unsampled resident, filled on 9/08/15, with an expiration date of 09/07/16. Staff interview with LPN #2, on 03/23/17 at 3:05 PM, while checking the B Hall and C Hall medication cart, confirmed there were expired medications in the medication cart. She said the 11 PM to 7 AM shift nurses were responsible for checking the expiration dates of the medication cart medications. Staff interview with the Administrator and Director of Nursing (DON), on 03/23/17 at 5:05 PM, revealed there should not be any expired medications in the medication carts or with the floor stock. The Administrator revealed the DON is responsible for checking the expiration dates of the floor stock medications, and the nurses are responsible for checking the medication carts. Staff interview with the Facility's Registered Pharmacist Consultant, on 03/23/17 at 5:25 PM, revealed his duties include checking the floor stock in the medication room and spot checking medication carts and narcotics. He said he was at the facility on 02/20/17.

Based on observations, staff interviews, record review, and the facility policy review, the facility failed to replace baseboards, electrical wall outlet covers, cracked wall paper, stained privacy curtains and ceiling tiles for three (3) of three (3) halls. Findings Include: Review of the facility's policy, Maintenance Worker Duties, 4/2015, revealed, It is the policy of this facility for the maintenance worker to follow preventative maintenance programs, inspect the building and equipment, and make any necessary repairs as needed. The maintenance department works in cooperation with the nursing department, dietary department, housekeeping, laundry, and office staff. Review of the Contract Company policy for Room Cleaning, undated, revealed during deep cleaning of rooms, stained privacy curtains were to be taken down and replaced. Deep cleaning of rooms was to be done per weekly schedule. Observation of Room #1 on initial tour 3/21/2017, around 8:50 AM, revealed a hole approximately 12 inches in length and four (4) inches in width with a warped base board below the tissue dispenser. Observation on 3/23/2017 at 11:00 AM, in room 24, revealed the wall vinyl covering with tears/cracks and a circular, brown shaped stain approximately 12 inches long by 12 inches wide on the ceiling. Observation on 3/23/2017 at 11:05 AM, in room 26, revealed a stained ceiling tile approximately 12 inches in length by 12 inches wide. Observation in Resident Room #10 on 3/23/2017 at 11:10 AM, revealed a dark brown stain on the privacy curtain between beds A and B. Observation on A Hall at 11:10 AM on 3/23/2017, on the left side of the hall near the exit door, revealed missing base boards. Observation on 3/23/2017 at 11:15 AM, in Room #16, revealed a missing electrical wall outlet cover and one (1) broken outlet cover. Observation in Room 35, on 3/23/2017 at 11:25 AM, revealed stained ceiling tiles. Also there were missing baseboards by the end of Hall B, and in the whirlpool bathing room #1. Observation in the front lobby near the nursing station on 3/23/2017 at 11:40 AM, revealed scarred wall paint. Interview on 3/23/2017 at 11:00 AM, with the Maintenance Director, revealed the torn vinyl in room 24 was a special order and there was none on hand. He further stated he was not aware of the stain on the ceiling. Interview on 3/23/2017 at 11:10 AM with the Maintenance Director revealed he had not replaced the missing baseboards because he had been busy working on air conditioner units. He further stated he would replace the missing outlet covers today and had not known about them. Interview on 3/23/2017 at 11:10 AM, with the Housekeeping Supervisor, confirmed the privacy curtain in Room 10 was stained and he would have it taken down and cleaned. Interview on 3/23/2017 at 11:40 AM, with the Maintenance Director, revealed the scarred wall paint in the lobby next to the nursing station was caused by the resident's chairs bumping the wall. He further stated he had re-painted the wall two weeks ago and he needed to put up a chair rail. Review of the maintenance logs for reporting of repairs did not mention ceiling tile stains, missing baseboards, missing/broken electrical outlet covers or stained privacy curtains.

CI MS # Based on observation, staff interview, record review and policy review, the facility failed to ensure that Resident #16's care plan for high risk for falls was implemented for one (1) of sixteen (16) sampled residents reviewed (Resident #16). This was evidenced by Resident #16 being care planned for high risk for falls. Resident #16 was tied in a chair with a sheet, in the common dayroom of the Alzheimer's Unit on 05/06/13 at 6:24 a.m. by Certified Nursing Assistant (CNA) #1. CNA #1 indicated "She wasn't gonna fall on my watch." Findings include: Resident #16 Resident #16 was admitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #16's current Plan of Care, initiated 04/26/13, addressed Resident #16's falls related to [MEDICAL CONDITION] activity. Resident #16 was at high risk for falls related to (r/t) wanders, [MEDICAL CONDITION], side effects (s/e) of medications (meds), missed chair and sat on floor. Resident #16 experienced a recent fall on 04/26/13. Resident #16 attempted to sit in a chair and missed the chair and sat on the floor, there were no injuries noted and her care plan was reviewed and revised following this incident of 04/26/13. The interventions documented, "When she attempts to sit, try to ensure that the chair is behind her. Monitor wandering on Dementia Unit." Review of Resident #16's most recent Minimum Data Set (MDS), with an Assessment Reference Date of 04/19/13, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Interview with Certified Nursing Assistant (CNA) #4 on 05/16/13 at 7:24 p.m., stated "She is a sweet lady, she wanders and walks, but walks about the Alzheimer's Unit." Interview with the Director of Nursing (DON) on 05/16/13 at 4:20 p.m., confirmed Resident #16 was an ambulatory resident. When I (the DON) ask (CNA #1) why she tied her in the chair her response to me was, "She wasn't gonna fall on my watch." Review of Resident #16's nurse's notes, dated 05/06/13 at 8:00 a.m., revealed "Reported to writer by (LPN #3) that (Resident #16) had been found tied to chair. Went to unit with (LPN #3) to check (Resident #16). Head to toe check revealed no s/s injury. She continues to ambulate in dementia unit steady gait. No s/s of discomfort." Signed (DON). Interview with Resident #16's family member on 05/17/13 at 11:30 a.m., stated, "My mama just likes to walk, she is just confused." Phone Interview with CNA #1 on 05/17/13 at 1:10 p.m., revealed CNA #1 decided she was going to tie Resident #16 in the chair with a sheet to keep her from falling. CNA #1 stated, "She sometimes falls, she wasn't gonna fall on me. I tied her about 6:20 a.m." Review of the Personnel Action Form, dated 05/06/13, revealed "Resident on unit was restrained with a sheet by (CNA #1). The (Resident #16) did not have an order for [REDACTED]." Educated (CNA #1) there was help that the (they) could have requested from the floor. She states I got everybody up and did everything I didn't need help. Informed (CNA #1) that she would be terminated. She ask for a chance to resign, this was agreed. (CNA #1) was ask by the (DON) why she sat in the chair played on the phone and read the newspaper, (CNA #1) stated, "My work was done." The reasons listed on the Personnel Action form listed were as follows: "(9).Improper conduct, (11). Violation of company rules, (12). Defective and improper work." A telephone interview on 05/17/13 at 3:40 p.m. with the Medical Director, who is also the Attending Physician for Resident #16, confirmed he was informed by the facility of the Immediate Jeopardy that was identified on 05/16/13. The Physician confirmed that he was informed of Resident # 16's [MEDICAL CONDITION] activity that occurred 05/17/13 and that Resident # 16 was admitted to the hospital for evaluation and treatment. An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 05/18/13 at 12:37 p.m. A review of the AOC revealed the following: "On May 6th at 7:05am, when entering the dementia unit, resident # 16 was noted by CNA #2 to have a sheet tied across her waist and tied in the back to a stationary chair in the dining room. CNA #2 informed LPN #3 at that time. LPN #3 came to unit and had resident # 16 released from the restraint at 7:10am. Resident # 16 was checked at that time for any injuries by LPN #3 and no injury was noted. After questioning by the DON, LPN #3 stated " she was like that when CNA #1 left at 7am. " At 8:00am, the Director of Nursing was informed by LPN #3 of situation and the DON assessed the resident and found no injuries. All resident have the potential to be affected by this deficient practice. Investigation started at 8:00am by DON and Administrator on May 6, 2013 which revealed CNA #1 had tied Resident with a sheet to chair at 6:23am. Resident #16 was in that position until released by CNA #2 at 7:10am under direction of LPN #3. Resident #16 has [DIAGNOSES REDACTED]. The facility Medical Director was informed by phone of incident May 6, 2013 at 8:30am by the DON. No new orders were given. The DON made rounds at 8:45am to assure no other resident was restrained improperly. A census of 60 revealed no further residents were restrained. The Responsible Party was notified May 6th at 2:00pm by DON through a visit to the home. The Responsible Party's phone was not working by attempts were made beginning at 8:35am up until 2:00pm when informed face to face. The Administrator and DON viewed the camera May 6th, 2013 at 10:15am. While viewing camera CNA#1 was noted sitting at a table in dining room on dementia unit, talking on her cell phone, and reading a newspaper while resident #16 was restrained directly beside her. CNA #1 was called at 10:20am and asked to return to the facility to discuss the restraint she had placed on resident #16 without physician orders. CNA #1 returned to facility at 10:30 am and was questioned why she restrained resident #16. CNA #1 responded, "she was not going to fall on my watch." CNA #1 stated, "I unknowlkdgeable (unknowingly) restraint of resident under while working in demention (dementia) unit by myself" (Census of 10 residents on dementia unit). When CNA #1 was asked why she was on her cell phone and reading the newspaper CNA #1 stated, "all my work was done." CNA #1 did not follow the restraint policy as evidenced by her tying resident #16 to a stationary chair. CNA #1 was allowed to resign per her request. The Medical Director was informed by the DON via phone May 6th, 2013 at 3:00pm of all meeting, in-services, and interventions put into place. Medical Director remains actively involved in Quality Assurance Process and Program. Corrective action was started immediately May 6, 2013 at 8:00am. Administrator called emergency staff meeting for May 6th, 2013 at 1:00pm to discuss the Call-in Policy, Cell Phone Usage Policy, and incident involving resident #16 and CNA # 1. Discussed in detail was the use of a restraint without an order, the staffing on unit that led to this deficient practice and the use of staff cell phones while on duty. Results of meeting yielded staff rounds would be made every 2 hours and as needed on dementia unit and other areas of home by staff nurses. These rounds began May 6th, 2013 at 2:00pm and continue presently. It was determined that when a staff member 'called in', the charge nurse is to immediately notify the DON or RN #1 so coverage is obtained. These actions went into effect at 2:00pm on May 6th, 2013 and log books were placed at the nurse's station to allow nurses to document on making the facility rounds. In-service conducted by DON and RN #1 May 6th, 2013 at 8:00am and continued until completed May 8th, 2013 at 8:00pm. Staff in-service included the dietary department, housekeepers, maintenance, therapy, nurses, CNA's, social service, activity, and laundry department, and office manager. The in-service contained both handouts and verbal education. Examples of what is considered a restraint (i.e. sheets tied to chair or sheets tucked tightly into bed to prevent movement), and signs and symptoms of abuse were addressed. The Abuse and Neglect Policy and the Restraint policy were also reviewed with attending staff. The State Department of Health was notified of incident by DON on May 13th, 2013 at 10:18am via fax. The Administrator notified the Resident Council President on May 16th, 2013 at 9:30pm to request an emergency Resident Council meeting. The Mississippi State Board of Nursing was notified of the incident by the DON on May 17th, 2013 at 8:00am per hotline and message left. May 17th, 2013 at 8:30am, the Administrator and DON met with the resident council where the Immediate Jeopardy was discussed with all in attendance. They interviewed the committee for complaints of use of restraints for staff convenience. They were explained what a restraint could be, i.e. sheets being tied around a resident to prevent them from movement. They also interviewed attending residents to ask if they fear retaliation from staff if they report abuse or neglect. After explanation of what the immediate jeopardy entailed, no residents in attendance were in fear of retaliation and none were aware of or reported any misuse of restraint in facility. The resident stated, "The staff goes above and beyond". The State Attorney General's Office was notified of the incident by the Administrator on May 17th 2013 at 9:45am by computer report. A mandatory staff in-service was held on May 17th, 2013 at 10:00am by Administrator for dietary department, housekeepers, maintenance, therapy, nurses, CNAs, social service, activity, laundry department and office manager. They received training and education on Restraint Policy, Abuse and Neglect and Elder Abuse Act. Also, re-education of the use of cell phones while on duty was conducted. All cell phones are to be turned off while on duty and only used by staff on their break. The Call-In policy was reviewed and instruction given that all call-ins must be reported to DON or RN #1 so coverage is obtained. Staff was also instructed that the dementia unit is never to have less than 2 employees on duty. Finally, training was conducted to instruct staff that newspapers, magazines, or any other form of literature is never to be read by staff while on duty unless reading directly to a resident. The dietary department, housekeepers, maintenance, therapy, nurses, CNA's, social service, activity, laundry department, and office manager are trained on hire, Bi-annually and as needed on the restraint policy as well as in-serviced on Abuse and Neglect policy on hire, quarterly and as needed. Initiated May 17th, 2013 at 6:00pm, the Quality Assurance Committee is monitoring every week all call-ins to ensure there is sufficient staff. The DON, RN#1, or designee is monitoring every day to ensure that the facility has adequate staffing to meet resident needs and maintain regulatory compliance. The DON reports these results every week for review by the QA Committee. The QA Committee is monitoring and reviewing the round documentation log on dementia unit and other areas of the nursing home for compliance with policy and procedures of the facility on a weekly basis. Random rounds are also being made by the DON and Administrator to ensure the interventions put into place continue to be effective. The Facility feels the immediate jeopardy has been removed May 18th, 2013." The survey team validated the corrective actions taken by the facility as follows: A review of Resident #16's nurses' notes on 5/18/13 at 1:20 p.m., validated that Resident #16 had been assessed by the DON on 05/06/13 at 8:00 a.m. and no injuries noted. Review of an incident report on 05/18/13 at 4:20 p.m., validated that the Medical Director was informed of the incident by the DON on 05/06/13 at 8:30a.m. Review of the nurses' notes, validated that DON made rounds on 05/06/13 at 8:45 a.m. to assure that no other residents were restrained improperly. Documentation of notification of Resident #16's Responsible Party (RP) was validated by the DON and interview with RP. Interview with CNA #1, the DON and the Administrator on 05/06/13 at 10:30 a.m., was validated by review of documentation of CNA #1's personnel file. Validated by documentation review and interview with the Medical Director that the Medical Director was notified by DON of all meetings, in-services, and interventions put into place. Reviewed staff meeting agenda and sign-in sheets to validate attendance of emergency staff meetings called by Administrator to begin on 05/06/13 at 1:00 p.m. and completed 05/08/13 at 8:00 p.m. A review of the "Round Check Logs" validated that rounds are being made by nursing staff at least every two hours in the dementia unit and other areas of the home. Documentation was reviewed to validate that any "call-in" since 05/06/13 are being monitored and action taken. Information that was given to employees at in-services of 05/06/13 through 05/08/13 was reviewed for validation of in-service content. Communication with the Resident Council President on 05/17/13 at 8:30 a.m. was validated by review of documentation, review of Resident Council minutes and interview with the Resident Council President and Unsampled Resident E. A review of a written statement signed by the DON validated that the State Board of Nursing was notified 05/17/13 at 8:30 a.m. A review of a written statement signed by the Administrator validated that the Attorney General's Office was notified on 05/17/13 at 9:45 a.m. A review of the in-service agenda and sign-in sheets validated in-service held on 05/17/13 at 10:00 a.m. and interviews with staff members further validated their attendance and content of meeting. This in-service was more detailed from the in-service conducted on 05/08/13. A review of documentation by RN #1 that call-ins and a review of the rounds documentation logs validated that Quality Assurance Committee is monitoring these areas. Interview with the Office Manager on 05/18/13 at 1:15 p.m., confirmed she had received in-service training by the facility on 05/17/13 on abuse and neglect, restraint and the different types of restraints, cell phone usage and staffing. The Office Manager confirmed that the in-service was conducted by the Administrator and the Director of Nursing. Interview with Social Services Designee (SSD) on 05/18/13 at 2:00 p.m., confirmed that she had attended an in-service on 5/17/13 and she stated, "Our in-service yesterday morning included the seven (7) types of abuse and the different types of restraints; it was emphasized that this is a restraint free facility." The SSD also verbalized, "If you witness any problem or witnessed a resident having a problem, use the chain of command when reporting an incident." The SSD stated, "What I am trying to say, if you see a resident in bed with the side rails up, report to the nurse; if that resident is agitated or trying to get up, get assistance and check with the nurse." She denied witnessing any resident being restrained. A phone interview with Certified Nursing Assistant (CNA) #4 on 05/18/13 at 2:20 p.m., confirmed that she had received instruction and training on 05/17/13 that included abuse and neglect and use of cell phones would not be permitted in the facility. CNA #4 stated, "CNAs could at no time initiate any kind of restraint." CNA #4 also confirmed that the training included that a physician's orders [REDACTED]. CNA #4 stated, "You can only read at anytime if reading for or to a resident." CNA #4 confirmed that she had received prior training about Resident Rights, Restraints, and Abuse/Neglect. CNA #4 stated, "We have training every month about Resident Rights; I treat my resident as I would like to be treated, I love my residents." CNA #4 confirmed that prior to her assignment in the Alzheimer's Unit that she had received training and stated, "I went to Jackson for special training to work this unit; the facility sent me." Interview with Unsampled Resident E on 05/18/13 at 3:05 p.m., stated "The group met yesterday (05/17/13) with (Administrator) to discuss how the group could help watch out for those that can't look out for their own self." Unsampled Resident E denied ever seeing any resident tied or restrained in any way. Unsampled Resident E said, "We usually get along like a good family, no major problems." Interview with Resident Council President on 05/18/13 at 4:17 p.m., confirmed that the resident council had met and he stated, "I believe it was yesterday (05/17/13) with (Administrator) and (Director of Nurses)." He confirmed that restraining of residents was discussed and he said, "They talked about tying residents down" and verbalized that "he had not ever seen anything like that." He denied fear of any of the staff and that he felt free to go to them with any concerns. An acceptable Allegation of Compliance was received on 05/18/13 which alleged removal of Immediate Jeopardy on 05/18/13. The State Agency determined the Immediate Jeopardy was removed on 05/18/13, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F-282), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

CI MS # Based on observation, staff interview, record review and policy review, the facility failed to ensure that Resident #16 was free of a physical restraint for one (1) of sixteen (16) sampled residents reviewed (Resident #16). This was evidenced by Resident #16 being tied in a chair with a sheet, in the common dayroom of the Alzheimer's Unit on 05/06/13 at 6:24 a.m. by Certified Nursing Assistant (CNA) #1. CNA #1 was noted via video surveillance, in the common dayroom of the Alzheimer's Unit, sitting in the chair playing on the phone and reading the newspaper. Findings include: Resident #16 Resident #16 was admitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #16's most recent Minimum Data Set (MDS), with an Assessment Reference Date of 04/19/13, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Observation of Resident #16 on 05/16/13 at 7:22 p.m., revealed that she was lying in bed covered with clean linens. The bed was in a low position. Resident #16 did not speak, but did make eye contact and smiled. Interview with Certified Nursing Assistant (CNA) #4 on 05/16/13 at 7:24 p.m., confirmed Resident #16 was not a behavior problem, she required assistance with Activities of Daily Living (ADL). Resident #16 feeds herself with assistance and prompting. Resident #16 was incontinent of bowel and bladder. CNA #4 stated, "She is a sweet lady, she wanders and walks, but walks about the Alzheimer's Unit." Review of Resident #16's physician's orders [REDACTED].#16 had a physician's orders [REDACTED].#16 had an assessment for a restraint. There was no documented evidence in the medical record for Resident #16's Responsible Party having a signed consent for her to be restrained by the facility. Review of the facility's policy "Restraints" in the Dementia Manual, dated 6/02, revealed "It is the policy of this facility to have a restraint free unit when at all possible. Restrains may not be used for the convenience of the nursing staff. This includes controlling a resident's behavior with a lesser amount of effort by the facility and not the resident's best interest. Restraints are not to be used as punishment to the resident, or in any manner that could cause harm or injury to the resident. The use of a restraint will require an assessment of need, a signed consent and a physician's orders [REDACTED]. The order is to include the type of restraint to be used and the medical reason for the restraint. (It will need to be determined if a wheelchair, gerichair or recliner is being used as a restraint or enabler.) Restrained residents are to be observed every thirty (30) minutes. Restraints are to loosened at least every two (2) hours, for at least ten (10) minutes, and the resident exercised, toileted and/or repositioned." Interview with the Director of Nursing (DON) on 05/16/13 at 4:20 p.m., regarding restraints in the facility, confirmed that the facility was a restraint free facility. The DON stated, "Yes ma'am, on May 6th I had a CNA that tied a resident (Resident #16) up in a sheet one morning before she got off. I have since terminated (CNA #1)." The DON went onto explain the details of the incident of 05/06/13 are as follows: "(CNA #1) was working on the Alzheimer's Unit on 05/06/13 on 11-7 shift. There had been a call-in on the 11-7 shift. There was an LPN that floated between the Alzheimer's Unit and the floor. Once the (CNA #1) got the residents up and dressed for the day she then tied (Resident #16) to a chair in the dayroom. (Resident #16) is an ambulatory resident. When I ask (CNA #1) why she tied her in the chair her response to me was, "She wasn't gonna fall on my watch." Further interview with the DON, revealed that she and the Administrator had reviewed the video surveillance of 05/06/13. The review revealed CNA #1 tying Resident #16 in a chair with a bed sheet while talking on a cell phone. Once the Resident #16 was tied in the chair the CNA sat down at the table and read the newspaper and talked on the cell phone. The DON confirmed there was a lack of supervision and staff in the Alzheimer's Unit on 11-7 shift on 05/06/13. The facility offered to allow the survey team to view the video surveillance of 05/06/13 of the aforementioned incident. The survey team was provided a watermarked copy of video surveillance by the facility of this incident of 05/06/13. Review of the facility's statement from (LPN #3), dated 05/06/13, revealed "Upon entering dining room on dementia unit, noted resident 33B (Resident #16) sitting in a chair tied with a sheet. Immediately had CNA to untie her. PROM and AROM performed. CNA on 7-3 shift informed this writer that was sitting in that position when they arrived. Educated CNAs that residents cannot be restrained at anytime. Attempted to contact RP with no answer. Left answer on answering machine to contact facility." Signed (LPN #3). Review of Licensed Practical Nurse (LPN) #3's written statement from 05/17/13, revealed "Upon entering dementia unit noted 33B tied to chair with sheet. Immediately had CNA to untie resident and educated CNA that resident cannot be tied at anytime, that is abuse and is not tolerated. Reported this to (DON). Later that same day checked on resident and she was up ambulatory about the unit." Review of LPN #4's written statement from 05/17/13, revealed "On the morning of 5/6/13 I was assigned to the dementia hall with (CNA #1). When I left she was on the dementia unit and the only residents was Resident #14 and Unsampled Resident D. I went to the nurse's station to finish shift charting, etc. Later that day I received a call stating that (CNA #1) had been terminated for tying a resident up with a sheet. I did not witness that occurrence that night and have never seen any resident restrained in my four (4) years of employment here." Review of CNA #3's written statement from 05/18/13, revealed "I came in to work on May 06, 2013 for 7am-3pm shift. (CNA #1) told me that she had (Resident #16) tied to the chair with a sheet because she kept getting up walking and she was afraid that she would fall. She said that she worked alone that night and the nurse did not come to the unit to help her. After she told me that I went back into the dining room and I saw (Resident #16) tied up. I told (CNA #2) the other aide that worked with me that morning to look. I proceeded to untie her and (CNA #2) told me not to untie her, wait until she call the nurse. When the nurse (LPN #3) came, we explained to her what happened. She told us to untie her and that she would report the incident to (DON). Then (LPN #3) told us to never tie a resident up." Review of (CNA #2's) written statement from 05/18/13, revealed "I (CNA #2) came in on May 6, 2013 to work the unit, as I enter into the dinning (dining) room were (where) they eat (Resident #16) was tied to the chair with a sheet around her. So another CNA came in (CNA #3). So we page for the nurse to come in and look at the patients (patient) tied to the chair. And the nurse (LPN #3) took (told) us to untied (untie) the patient and she was going to report it to the DON." Review of the facility's Incident Report, dated 05/06/13 at 8:00 a.m., revealed the following: "(LPN # 3) reported that 7-3 staff (CNA #2) had found resident tied to straight chair with a sheet. (LPN #3) immediately had resident released and checked for injuries. (Resident #16) stated, "Thank you Jesus!", and starting ambulating in the hall. (LPN #3) and (DON) checked for any injuries r/t (related to) restraint. None noted. "Resident #16's Responsible Party and the attending Physician were notified of this incident on 05/06/13." Review of Resident #16's nurse's notes, dated 05/06/13 at 8:00 a.m., revealed "Reported to writer by (LPN #3) that (Resident #16) had been found tied to chair. Went to unit with (LPN #3) to check (Resident #16). Head to toe check revealed no s/s injury. She continues to ambulate in dementia unit steady gait. No s/s of discomfort." Signed (DON). Interview with Resident #16's family member on 05/17/13 at 11:30 a.m., confirmed that she have been informed by the facility of the incident on 05/06/13 of Resident #16. The family member stated, "I have never given them permission to restrain my mama. My mama just likes to walk, she is just confused." Phone Interview with CNA #1 on 05/17/13 at 1:10 p.m., revealed that she had been a CNA for two (2) years and received her training at a local Vocal-Technical High School program. CNA #1 worked the 11-7 shift on 05/06/13. CNA #1 stated, "I worked alone that night on the Alzheimer's Unit because of a staff shortage due to a call-in." CNA #1 was assigned ten (10) residents. CNA #1 stated, "I began to get the resident up and dressed for the day between 4:45 a.m. - 5:15 a.m. I had three (3) ambulatory residents. (Resident #16) was one of those ambulatory residents. " CNA #1 decided she was going to tie Resident #16 in the chair with a sheet to keep her from falling. CNA #1 stated, "She sometimes falls, she wasn't gonna fall on me. I tied her about 6:20 a.m. I have seen others do it." The surveyor questioned CNA #1 what shifts and or names of residents had she tied or restrained. CNA #1 could not provide any resident names or staff names to substantiate her statement. When ask if she had received any training on restraints CNA #1 responded, no and she did not know the different types of restraints. CNA #1 confirmed she had been trained on abuse and neglect. When ask who was in charge or who the Charge Nurse was on 05/06/13, CNA #1 responded that she did not know. Review of CNA #1's in-service training record, dated 06/01/12, revealed (CNA) #1 had received the following lecture training: Proper Use of Restraints and Different Types of Restraints. CNA #1 received a lecture/demonstration in-service training on 04/10/12 on the Seven Types of Abuse, Stress and Burn Out. Further review of the CNA #1's in-service training record revealed that she was trained on the seven (7) types of Abuse, Reporting , Stress and Burn-Out. The date of the lecture in-service was 01/03/13. Review of the Personnel Action Form, dated 05/06/13, revealed "Resident on unit was restrained with a sheet by (CNA #1). The (Resident #16) did not have an order for [REDACTED]." Educated (CNA #1) there was help that the (they) could have requested from the floor. She states I got everybody up and did everything I didn't need help. Informed (CNA #1) that she would be terminated. She ask for a chance to resign, this was agreed. (CNA #1) was ask by the (DON) why she sat in the chair played on the phone and read the newspaper, (CNA #1) stated, "My work was done." The reasons listed on the Personnel Action form listed were as follows: "(9).Improper conduct, (11). Violation of company rules, (12). Defective and improper work." Review of Resident #16's current Plan of Care that addresses Resident #16's falls related to [MEDICAL CONDITION] activity. Resident #16 experienced a recent fall on 04/26/13. Resident #16 attempted to sit in a chair and missed the chair and sat on the floor, there were no injuries noted and her care plan was reviewed and revised following this incident of 04/26/13. The interventions documented, "When she attempts to sit, try to ensure that the chair is behind her. Monitor wandering on Dementia Unit." A telephone interview on 05/17/13 at 3:40 p.m. with the Medical Director, who is also the Attending Physician for Resident #16, confirmed he was informed by the facility of the Immediate Jeopardy that was identified on 05/16/13. The Physician confirmed that he was informed of Resident # 16's [MEDICAL CONDITION] activity that occurred 05/17/13 and that Resident # 16 was admitted to the hospital for evaluation and treatment. An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 05/18/13 at 12:37 p.m. A review of the AOC revealed the following: "On May 6th at 7:05am, when entering the dementia unit, resident # 16 was noted by CNA #2 to have a sheet tied across her waist and tied in the back to a stationary chair in the dining room. CNA #2 informed LPN #3 at that time. LPN #3 came to unit and had resident # 16 released from the restraint at 7:10am. Resident # 16 was checked at that time for any injuries by LPN #3 and no injury was noted. After questioning by the DON, LPN #3 stated " she was like that when CNA #1 left at 7am. " At 8:00am, the Director of Nursing was informed by LPN #3 of situation and the DON assessed the resident and found no injuries. All resident have the potential to be affected by this deficient practice. Investigation started at 8:00am by DON and Administrator on May 6, 2013 which revealed CNA #1 had tied Resident with a sheet to chair at 6:23am. Resident #16 was in that position until released by CNA #2 at 7:10am under direction of LPN #3. Resident #16 has [DIAGNOSES REDACTED]. The facility Medical Director was informed by phone of incident May 6, 2013 at 8:30am by the DON. No new orders were given. The DON made rounds at 8:45am to assure no other resident was restrained improperly. A census of 60 revealed no further residents were restrained. The Responsible Party was notified May 6th at 2:00pm by DON through a visit to the home. The Responsible Party's phone was not working by attempts were made beginning at 8:35am up until 2:00pm when informed face to face. The Administrator and DON viewed the camera May 6th, 2013 at 10:15am. While viewing camera CNA#1 was noted sitting at a table in dining room on dementia unit, talking on her cell phone, and reading a newspaper while resident #16 was restrained directly beside her. CNA #1 was called at 10:20am and asked to return to the facility to discuss the restraint she had placed on resident #16 without physician orders. CNA #1 returned to facility at 10:30 am and was questioned why she restrained resident #16. CNA #1 responded, "she was not going to fall on my watch." CNA #1 stated, "I unknowlkdgeable (unknowingly) restraint of resident under while working in demention (dementia) unit by myself" (Census of 10 residents on dementia unit). When CNA #1 was asked why she was on her cell phone and reading the newspaper CNA #1 stated, "all my work was done." CNA #1 did not follow the restraint policy as evidenced by her tying resident #16 to a stationary chair. CNA #1 was allowed to resign per her request. The Medical Director was informed by the DON via phone May 6th, 2013 at 3:00pm of all meeting, in-services, and interventions put into place. Medical Director remains actively involved in Quality Assurance Process and Program. Corrective action was started immediately May 6, 2013 at 8:00am. Administrator called emergency staff meeting for May 6th, 2013 at 1:00pm to discuss the Call-in Policy, Cell Phone Usage Policy, and incident involving resident #16 and CNA # 1. Discussed in detail was the use of a restraint without an order, the staffing on unit that led to this deficient practice and the use of staff cell phones while on duty. Results of meeting yielded staff rounds would be made every 2 hours and as needed on dementia unit and other areas of home by staff nurses. These rounds began May 6th, 2013 at 2:00pm and continue presently. It was determined that when a staff member 'called in', the charge nurse is to immediately notify the DON or RN #1 so coverage is obtained. These actions went into effect at 2:00pm on May 6th, 2013 and log books were placed at the nurse's station to allow nurses to document on making the facility rounds. In-service conducted by DON and RN #1 May 6th, 2013 at 8:00am and continued until completed May 8th, 2013 at 8:00pm. Staff in-service included the dietary department, housekeepers, maintenance, therapy, nurses, CNA's, social service, activity, and laundry department, and office manager. The in-service contained both handouts and verbal education. Examples of what is considered a restraint (i.e. sheets tied to chair or sheets tucked tightly into bed to prevent movement), and signs and symptoms of abuse were addressed. The Abuse and Neglect Policy and the Restraint policy were also reviewed with attending staff. The State Department of Health was notified of incident by DON on May 13th, 2013 at 10:18am via fax. The Administrator notified the Resident Council President on May 16th, 2013 at 9:30pm to request an emergency Resident Council meeting. The Mississippi State Board of Nursing was notified of the incident by the DON on May 17th, 2013 at 8:00am per hotline and message left. May 17th, 2013 at 8:30am, the Administrator and DON met with the resident council where the Immediate Jeopardy was discussed with all in attendance. They interviewed the committee for complaints of use of restraints for staff convenience. They were explained what a restraint could be, i.e. sheets being tied around a resident to prevent them from movement. They also interviewed attending residents to ask if they fear retaliation from staff if they report abuse or neglect. After explanation of what the immediate jeopardy entailed, no residents in attendance were in fear of retaliation and none were aware of or reported any misuse of restraint in facility. The resident stated, "The staff goes above and beyond". The State Attorney General's Office was notified of the incident by the Administrator on May 17th 2013 at 9:45am by computer report. A mandatory staff in-service was held on May 17th, 2013 at 10:00am by Administrator for dietary department, housekeepers, maintenance, therapy, nurses, CNAs, social service, activity, laundry department and office manager. They received training and education on Restraint Policy, Abuse and Neglect and Elder Abuse Act. Also, re-education of the use of cell phones while on duty was conducted. All cell phones are to be turned off while on duty and only used by staff on their break. The Call-In policy was reviewed and instruction given that all call-ins must be reported to DON or RN #1 so coverage is obtained. Staff was also instructed that the dementia unit is never to have less than 2 employees on duty. Finally, training was conducted to instruct staff that newspapers, magazines, or any other form of literature is never to be read by staff while on duty unless reading directly to a resident. The dietary department, housekeepers, maintenance, therapy, nurses, CNA's, social service, activity, laundry department, and office manager are trained on hire, Bi-annually and as needed on the restraint policy as well as in-serviced on Abuse and Neglect policy on hire, quarterly and as needed. Initiated May 17th, 2013 at 6:00pm, the Quality Assurance Committee is monitoring every week all call-ins to ensure there is sufficient staff. The DON, RN#1, or designee is monitoring every day to ensure that the facility has adequate staffing to meet resident needs and maintain regulatory compliance. The DON reports these results every week for review by the QA Committee. The QA Committee is monitoring and reviewing the round documentation log on dementia unit and other areas of the nursing home for compliance with policy and procedures of the facility on a weekly basis. Random rounds are also being made by the DON and Administrator to ensure the interventions put into place continue to be effective. The Facility feels the immediate jeopardy has been removed May 18th, 2013." The survey team validated the corrective actions taken by the facility as follows: A review of Resident #16's nurses' notes on 5/18/13 at 1:20 p.m., validated that Resident #16 had been assessed by the DON on 05/06/13 at 8:00 a.m. and no injuries noted. Review of an incident report on 05/18/13 at 4:20 p.m., validated that the Medical Director was informed of the incident by the DON on 05/06/13 at 8:30a.m. Review of the nurses' notes, validated that DON made rounds on 05/06/13 at 8:45 a.m. to assure that no other residents were restrained improperly. Documentation of notification of Resident #16's Responsible Party (RP) was validated by the DON and interview with RP. Interview with CNA #1, the DON and the Administrator on 05/06/13 at 10:30 a.m., was validated by review of documentation of CNA #1's personnel file. Validated by documentation review and interview with the Medical Director that the Medical Director was notified by DON of all meetings, in-services, and interventions put into place. Reviewed staff meeting agenda and sign-in sheets to validate attendance of emergency staff meetings called by Administrator to begin on 05/06/13 at 1:00 p.m. and completed 05/08/13 at 8:00 p.m. A review of the "Round Check Logs" validated that rounds are being made by nursing staff at least every two hours in the dementia unit and other areas of the home. Documentation was reviewed to validate that any "call-in" since 05/06/13 are being monitored and action taken. Information that was given to employees at in-services of 05/06/13 through 05/08/13 was reviewed for validation of in-service content. Communication with the Resident Council President on 05/17/13 at 8:30 a.m. was validated by review of documentation, review of Resident Council minutes and interview with the Resident Council President and Unsampled Resident E. A review of a written statement signed by the DON validated that the State Board of Nursing was notified 05/17/13 at 8:30 a.m. A review of a written statement signed by the Administrator validated that the Attorney General's Office was notified on 05/17/13 at 9:45 a.m. A review of the in-service agenda and sign-in sheets validated in-service held on 05/17/13 at 10:00 a.m. and interviews with staff members further validated their attendance and content of meeting. This in-service was more detailed from the in-service conducted on 05/08/13. A review of documentation by RN #1 that call-ins and a review of the rounds documentation logs validated that Quality Assurance Committee is monitoring these areas. Interview with the Office Manager on 05/18/13 at 1:15 p.m., confirmed she had received in-service training by the facility on 05/17/13 on abuse and neglect, restraint and the different types of restraints, cell phone usage and staffing. The Office Manager confirmed that the in-service was conducted by the Administrator and the Director of Nursing. Interview with Social Services Designee (SSD) on 05/18/13 at 2:00 p.m., confirmed that she had attended an in-service on 5/17/13 and she stated, "Our in-service yesterday morning included the seven (7) types of abuse and the different types of restraints; it was emphasized that this is a restraint free facility." The SSD also verbalized, "If you witness any problem or witnessed a resident having a problem, use the chain of command when reporting an incident." The SSD stated, "What I am trying to say, if you see a resident in bed with the side rails up, report to the nurse; if that resident is agitated or trying to get up, get assistance and check with the nurse." She denied witnessing any resident being restrained. A phone interview with Certified Nursing Assistant (CNA) #4 on 05/18/13 at 2:20 p.m., confirmed that she had received instruction and training on 05/17/13 that included abuse and neglect and use of cell phones would not be permitted in the facility. CNA #4 stated, "CNAs could at no time initiate any kind of restraint." CNA # 4 also confirmed that the training included that a physician's orders [REDACTED]. CNA # 4 stated, "You can only read at anytime if reading for or to a resident." CNA # 4 confirmed that she had received prior training about Resident Rights, Restraints, and Abuse/Neglect. CNA #4 stated, "We have training every month about Resident Rights; I treat my resident as I would like to be treated, I love my residents." CNA # 4 confirmed that prior to her assignment in the Alzheimer's Unit that she had received training and stated, "I went to Jackson for special training to work this unit; the facility sent me." Interview with Unsampled Resident E on 05/18/13 at 3:05 p.m., stated "The group met yesterday (05/17/13) with (Administrator) to discuss how the group could help watch out for those that can't look out for their own self." Unsampled Resident E denied ever seeing any resident tied or restrained in any way. Unsampled Resident E said, "We usually get along like a good family, no major problems." Interview with Resident Council President on 05/18/13 at 4:17 p.m., confirmed that the resident council had met and he stated, "I believe it was yesterday (05/17/13) with (Administrator) and (Director of Nurses)." He confirmed that restraining of residents was discussed and he said, "They talked about tying residents down" and verbalized that "he had not ever seen anything like that." He denied fear of any of the staff and that he felt free to go to them with any concerns. An acceptable Allegation of Compliance was received on 05/18/13 which alleged removal of Immediate Jeopardy on 05/18/13. The State Agency determined the Immediate Jeopardy was removed on 05/18/13, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practice (F-221), while the facility monitors the effectiveness of systemic changes and quality assurance activities.