Every finding on record at Corpus Christi Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for respiratory care.The facility failed to ensure Resident #1's pressurized air with oxygen was physically on Resident #1, as well as was turned on at the machine on 08/17/2026.This deficient practice placed residents who received respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.The findings included:Record review of Resident #1's face sheet, dated 08/17/2026, revealed a [AGE] year-old female with an original admission date of 05/18/2021, and a current admission date of 04/24/2025. Pertinent diagnoses included Tracheostomy Status (an artificial opening into the trachea, or windpipe, which assisted with breathing) and Quadriplegia (a symptom or pattern of paralysis, the inability to make voluntary muscle movements, from the neck down).Record review of Resident #1's Annual MDS assessment, dated 06/02/2026, revealed no BIMS was conducted as Resident #1 was in a persistent vegetative state. The MDS assessment also revealed Resident #1 received oxygen therapy and tracheostomy care. Record review of Resident #1's active physician order summary, reviewed 08/17/2026, revealed an order, started 06/19/2026, for Trach humidification with air compressor (pressurized air provided for air flow and humidification for a tracheostomy) at 30 PSI with continuous Oxygen at 3 liters per minute via concentrator (a medical device which delivers concentrated oxygen to a patient) as needed for - May remove for ADL's - Oxygen to remain greater than 92%, related to chronic Respiratory Failure (long-term inability of the lungs to maintain healthy oxygen or carbon dioxide levels). Despite the physician's order showing the oxygen was continuous, it also revealed as needed, and may remove for ADLs. Record review of Resident #1's care plan, initiated 06/14/2021 and revised 01/13/2026, revealed a care plan focus for oxygen therapy related to ineffective gas exchange (failure of oxygen to properly move in and out of the lungs and blood). Interventions included trach humidification with air compressor at 30 PSI with continuous oxygen at 3 liters per minute.Record review of Resident #1's August 2026 Medication Administration Record, reviewed 08/17/2026, Revealed Resident #1's oxygen level was monitored twice per day and as needed. An observation on 08/17/2026 at 9:37 AM revealed Resident #1's oxygen was connected to the pressurized air tubing, which was connected to Resident #1's trach collar, but both the oxygen concentrator and the pressurized air machine were turned off, and the trach collar was hanging, unclasped, off the side of Resident #1's neck. There was no one in the room with Resident #1 upon entrance because the family had been waiting in the hall for housekeeping to clean the room. In an interview on 08/17/2026 at 9:40 AM, Resident #1's family stated Resident #1 always wore oxygen, and he was not sure why the trach collar was hanging off of her neck or why the oxygen was not turned on. He stated he thought the nurse was coming back to change it, but she had not come back in to change it. In an interview on 08/17/2026 at 9:40 AM, the DON stated Resident #1 did not need continuous oxygen because her oxygen levels were always good, and she was not sure why the order specified continuous oxygen, but she planned to clarify the order and have it changed. She stated Resident #1's oxygen saturation (oxygen levels) were checked every shift and as needed. She stated she was not sure why the pressurized air was not on or why the trach collar was hanging off the side of Resident #1's neck and not clasped over the trach or turned on. She stated the nurse was the person responsible for attaching the trach collar and turning the air on, but they are able to remove it when performing ADLs with Resident #1. In an interview on 08/17/2026 at 5:10 PM, LVN-A stated Resident #1 always had 3 liters of oxygen continuously with her pressurized air. She stated it was continuous, but per the physician's order, sometimes they turned it off and removed it for Resident #1's ADLs. She stated she was not sure why Resident #1's oxygen and air had been turned off, or why her trach collar was hanging off the side of her neck with oxygen and air tubing connected to it, but she knew Resident #1's family had been educated previously to not remove or turn off Resident #1's oxygen because she needed it. She stated Resident #1's oxygen levels were checked each shift and as needed. An Oxygen Administration Policy was requested from the DON on 08/17/2026 at 9:45 AM, but the DON stated the facility did not have a specific Oxygen Administration policy. Record review of the facility's Medication Administration policy, dated 10/01/2019, revealed 2. Administration: A. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulation to administer medications. B. Medications are administered in accordance with written orders of the prescriber. F. Medications are administered without unnecessary interruptions.

Based on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for one of eight (Resident #30) observed for medication errors.1. The facility failed to ensure MA C administered Resident #30's blood pressure altering medication on 07/08/26, 07/25/26, and 07/26/26 when there were no hold parameters per the physician's order.2. The facility failed to ensure MA A administered Resident #30's blood pressure altering medication on 07/31/26 and 08/01/26 when there were no hold parameters per the physician's order.3. The facility failed to ensure MA C did not administer Resident #30's blood pressure altering medication on 07/08/26, 07/09/26, and 07/12/26 when her pulse was not within the required parameters for administration per the physician's order.These failures could place residents who receive blood pressure altering medications at an increased risk for complications such as increased or decreased blood pressure, increased or decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization.The findings included:Record review of Resident #30's admission record on 08/03/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included essential hypertension (high blood pressure), paroxysmal atrial fibrillation (an irregular, often fast heartbeat that starts and stops on its own), occlusion and stenosis of cerebral arteries (blockage of arteries in the brain), cerebral infarction (stroke; damage to brain tissue due to a blockage or bleeding of an artery in the brain), hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness to one side of the body due to a stroke), presence of aortocoronary bypass graft (surgery that uses a healthy artery from another part of the body to bypass occluded or narrowed arteries in the heart to restore blood flow to the heart muscle), and diabetes mellitus (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke).Record review of Resident #30's quarterly MDS assessment reflected a BIMS score of 12 which indicated she had moderate cognitive impairment.Record review of Resident #30's care plan dated 09/19/19 reflected the focus of coronary artery disease related to atrial fibrillation and hypertension. The goal was she would remain free from signs and symptoms of complications of cardiac problems and the interventions included give all cardiac medications as ordered by the physician; initiated on 09/24/24. Record review of Resident #30's order summary report on 08/02/26 reflected the following orders:Lisinopril Tablet 20mg. Give 1 tablet by mouth one time a day related to essential (primary) hypertension. No hold parameters. Ordered on 12/23/25.Metoprolol Tartrate Tablet 25mg. Give 0.5 tablet by mouth two times a day related to essential (primary) hypertension. Give 1/2 tablet to = 12.5mg. Hold when BP less than 90/60 and hold for heart rate is less than 60. Ordered on 06/07/26.Record review of Resident #30's July and August 2026 MARs reflected the following:On 07/08/26, 6:00 am, MA C documented BP: 99/64 and 4=BS/VS Outside of Parameters for Admin for Lisinopril when there were no hold parameters per the physician's order.On 07/08/26, 6:00 pm, MA C documented BP: 146/66, P: 51 and a checkmark which indicated she administered Metoprolol when the pulse was below the parameters for administration per the physician's order.On 07/09/26, 6:00 am, MA C documented BP: 137/65, P: 50 and a checkmark which indicated she administered Metoprolol when the pulse was below the parameters for administration per the physician's order.On 07/12/26, 6:00 am, MA C documented BP: 124/65, P: 50 and a checkmark which indicated she administered Metoprolol when the pulse was below the parameters for administration per the physician's order.On 07/25/26, 6:00 am, MA C documented BP: 108/58 and 4=BS/VS Outside of Parameters for Admin for Lisinopril when there were no hold parameters per the physician's order.On 07/26/26, 6:00 am, MA C documented BP: 114/55 and 4=BS/VS Outside of Parameters for Admin for Lisinopril when there were no hold parameters per the physician's order .On 07/31/26, 6:00 am, MA A documented BP: 116/53 and 5=Hold/See progress notes for Lisinopril when there were no hold parameters per the physician's order.On 08/01/26, 6:00 am, MA A documented BP: 145/65 and 5=Hold/See progress notes for Lisinopril when there were no hold parameters per the physician's order.Record review of Resident #30's progress notes reflected the following:There was not a progress note on 07/08/26 by MA C in reference to Resident #30's 6:00am Lisinopril or her 6:00 pm Metoprolol.There was not a progress note on 07/09/26 by MA C in reference to Resident #30's 6:00 am Metoprolol.There was not a progress note on 07/12/26 by MA C in reference to Resident #30's 6:00 am Metoprolol.There was not a progress note on 07/25/26 by MA C in reference to Resident #30's 6:00 am Lisinopril.There was not a progress note on 07/26/26 by MA C in reference to Resident #30's 6:00 am Lisinopril.Effective Date: 07/31/2026 07:01 am. Type: Orders - Administration Note. Note Text: Lisinopril Tablet 20mg. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (110) no hold parameters. MA A documented, bp below parameters. Effective Date: 08/01/2026 07:34 am. Type: Orders - Administration Note. Note Text: Lisinopril Tablet 20mg. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (110) no hold parameters. MA A documented, pulse below parameters 55. In an interview on 08/04/26 at 3:50 pm, MA C stated she thought the parameters for Lisinopril were the same as for Metoprolol. She stated she always asked the nurse about giving the resident her Lisinopril if the resident's blood pressure or pulse were low. She stated she talked to the nurse every time she held Resident #30's blood pressure altering medications. MA C also stated she checked with the nurse on the days that she gave Metoprolol when Resident #30's pulse was below 60. MA C stated it was important to give medications as ordered so the resident did not have complications from her atrial fibrillation or blood pressure. She stated in-services on medication administration were done often and the last one was about a month or two ago. In an interview on 08/04/26 at 4:15 pm, MA A stated she did hold Resident #30's Lisinopril on 07/31/26 due to her blood pressure being low and on 08/01/26 because her pulse was low and if she was not mistaken, the resident was not feeling good. She stated she talked to the nurse about it but did not document it. She stated the Lisinopril should have been given because there were no hold parameters. MA A stated if a medication was held that was not supposed to be, it could cause her blood pressure to go up and cause a stroke or strain on her heart. If it was given with BP low could cause hypotension and possibly hospitalization. She stated in-services on medication administration were yearly with skills check-offs and renewals and were also as needed. She stated the last one was last month. In an interview on 08/04/26 at 4:26 pm, the DON stated medication administration check offs were done annually, in-services were done as needed and the last one was a couple of months ago. She stated it was not appropriate for the MAs to hold the Lisinopril when there were no hold parameters. She stated if the MA notified the nurse, then they should have documented it and the nurse should have documented that the physician was notified, also. She stated it was important to document things because if it was not documented, it did not happen. She stated it was important to give the Lisinopril because it protects the kidneys as well as controls the blood pressure. The DON stated f blood pressure altering medications were not given, it could cause the blood pressure to go up and could cause a stroke. She stated if a medication was given when it was outside of parameters it could cause the pulse or BP to drop lower and cause hospitalization and even death. Record review of the facility's medication administration policy dated 10/01/19 reflected in part: Policy Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.Procedure1. PreparationD. 10 Rights of Medication Administration 9. Right Assessment/ Response - Medications like blood pressure medications always warrant a quick blood pressure check before giving a blood pressure medication. Nurses must be aware of parameters for administration specific to a medication. If a medication requires a specific assessment for administration, these need to be done as specified.2. AdministrationB. Medications are administered in accordance with written orders of the prescriber. Record review of the facility's medication administration policy dated 10/24/22 reflected in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so m this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines:8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review, the facility failed to ensure each resident was provided and received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for palatable food. 1. The facility failed to provide meal services in a manner to ensure palatable food served was appetizing to residents. 2. The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #3, #124, #102, #38, # 9, and other anonymous residents made during the resident council meeting who complained the food served did not taste good. 3. The facility failed to provide each resident with properly prepared foods that have had the most nutritional value. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included:Observation of Resident #3 and interview with CNA G on 08/02/2026 at 12:37 pm revealed Resident #3 was non-interviewable and did not rouse when calling her name. Her regular diet lunch tray was being delivered by CNA G. Resident #3's meal ticket identified the meal tray as mechanical soft, regular diet, thin fluids/liquids. CNA G said Resident #3 did not speak and was not on hospice. She said Resident #3's family member came to visit but not often. Resident #3 had tea and water on her tray. CNA G prepared to assist with feeding Resident #3. Resident #3 could open her mouth, take a bite of food from a spoon, chew, and swallow without choking. She did not open her eyes or seem to communicate other than opening her mouth appropriately. CNA G said this was the resident's baseline. In an interview with Resident #124 on 08/02/2026 at 3:40 pm, she said the food was horrible, bland, mushy, and overcooked. She said she had never been offered an alternate tray and did not know there was an alternative menu. She said she was on a renal diet (a diet that helps damaged kidneys function better. It requires limitations of certain minerals such as salt, phosphorus (found in dark sodas, dairy, and processed meats), and potassium). In an interview with Resident #102 on 08/02/2026 at 4:19 pm, she said the food was horrible. She said the food was bland and mushy. She said her family members tried the food and would not eat it. She said she ordered food to be delivered daily because of it. She said she had never been offered an alternate menu. She said sandwiches were better than the food, but she always had to ask for them. She said she resorted to ordering out because it was easier and tasted better than any food she received from the kitchen. In an interview with Resident #38 on 08/03/2026 at 8:56 am, she said the food at the facility was not good. She said the eggs were powdered and watery. She said the food was sometimes not warm and had no taste at all most of the time. She said the food was always soft. In an interview with Resident #9 on 08/03/2026 at 9:23 am, he said the biscuits this morning were so hard he could not eat them. He said he did not get jelly or oatmeal, which he ordered. He said he could not stand white gravy because it had milk in it. He said he had to send back his trays almost daily, but he was getting tired of sandwiches. He said he had to fight to get double portions and finally got them, but did not get his double portions half the time. He said sometimes the food was inedible. He said he could not stand the smell of spices because it made him nauseated. He said he got noodles and he could smell the spices as soon as his tray came through the door. He said he did not like the spicy stuff. He said he kept snacks in his room so he could get enough to eat since he did not eat much from the kitchen. During a confidential interview with 5 anonymous residents on 08/03/26 beginning at 11:00 am, residents stated meals were always late, the food was bland, and they did not like the options. Observation of the kitchen and interview with the RD on 08/03/26 at 11:11 am, the RD said she was new to the facility and was beginning work with the DM, who was also new to the facility. She said she was unaware of the food problems. Observation and interview with the DM, RD, and ADM on 08/03/26 at 12:00 pm revealed regular, pureed, and mechanical soft test trays were provided. The state survey team, DM, RD, and ADM sampled the test trays. The DM said the pureed squash had an odd flavor and was spicy. The ADM said the regular chicken fried steak was hard around the edges. The RD said the mechanical diet lacked flavor. The survey team tasted the same test trays and had the same experiences of the DM, RD, and ADM. In an interview with the RD and DM on 08/03/26 at 12:20 pm, the RD said she saw all new admits for nutrition needs. The DM said the kitchen was a mess and she was trying to clean it up. She said she had worked at the facility for a week. The RD said she worked at the facility for a month.Record review of the weekly menu reflected the food that had been served during the survey. An alternate menu and an all time menu were posted in the dining area.

Based on observations, interviews, and record review, the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for residents reviewed for food preferences and food allergies and the accommodation of resident's meal choices for residents that dine in the dining room or their room. -The facility failed to display an alternate/substitute meal menu to accommodate residents' vision and access in the dining room on 06/03/2025 through 6/06/2025. The facility failed to provide preferred food served to Residents #3, #124, #102, #38, # 9, and other anonymous residents made during the resident council meeting who complained the food served did not taste good, or they were allergic to it. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included:Observation of Resident #3 and interview with CNA G on 08/02/2026 at 12:37 pm revealed Resident #3 was non-interviewable and did not rouse when calling her name. Her regular diet lunch tray was being delivered by CNA G. Resident #3's preference ticket identified the meal tray as mechanical soft, regular diet, thin fluids/liquids. CNA G said Resident #3 did not speak and was not on hospice. She said Resident #3's family member came to visit but not often, and wrote the note taped to the wall regarding Resident #3's preferences. The note reflected, She likes coffee and cranberry juice at meals. Please give if you can. *coffee=milk + 2 sweet & low. Resident #3 had tea and water on her tray. CNA G prepared to assist with feeding Resident #3. Resident #3 could open her mouth, take a bite of food from a spoon, chew, and swallow without choking. She did not open her eyes or seem to communicate other than opening her mouth appropriately. CNA G said this was the resident's baseline. In an interview with Resident #38 on 08/03/2026 at 8:56 am, she said the food at the facility was not good. She said the eggs were powdered and watery. She said she liked her eggs fried. In an interview with Resident #9 on 08/03/2026 at 9:23 am, he said he got milk on his tray and was lactose intolerant. He said he could not stand white gravy because it had milk in it. He said he could not stand the smell of spices because it made him nauseated. He said he got noodles and he could smell the spices as soon as his tray came through the door. He said he did not like the spicy stuff. He said he kept snacks in his room so he could get enough to eat since he did not eat much from the kitchen. During a confidential interview with 5 anonymous residents on 08/03/26 beginning at 11:00 am, residents stated meals were always late, the food was bland, and they did not like the options. Another resident said she received a peanut butter sandwich on her tray 2 different times, and she had a peanut allergy. She said one time it was in the morning and then again last night. Observation of the kitchen and interview with the RD on 08/03/26 at 11:11 am, the RD said she was new to the facility and was beginning work with the DM, who was also new to the facility. She said she was unaware of the food and preference problems. Preference cards for Residents #3, #124, #102, #38, and #9 were requested at this time. Resident #124's preference card was not received. A policy for preferences was requested but not received. Record review of Resident #3's preference card revealed beverages of milk, orange juice, and iced tea. There was no cranberry juice or coffee with sweetener listed for any meal. Record review of Resident #102's preference card revealed mechanical soft, regular diet, thin fluids. Under notes reflected Likes sandwiches; chicken or tuna salad, ham and cheese. Record review of Resident #38's preference card revealed regular texture, regular diet, thin fluids, large protein portions. Record review of Resident #9's preference card revealed regular texture, reduced concentrated sweets, thin fluids, double portions. Allergies: Dairy, Milk. Observation and interview with the DM, RD, and ADM on 08/03/26 at 12:00 pm revealed regular, pureed, and mechanical soft test trays were provided. The state survey team, DM, RD, and ADM sampled the test trays. The DM said the pureed squash had an odd flavor and was spicy. The ADM said the regular chicken fried steak was hard around the edges. The RD said the mechanical diet lacked flavor. The survey team tasted the same test trays and had the same experiences of the DM, RD, and ADM. In an interview with the RD and DM on 08/03/26 at 12:20 pm, they said they were unaware of Resident #3's preferences written on a sign on the wall of her room. The RD said she saw all new admits for nutrition needs. The DM said she placed the nutrition needs from the RD onto the resident's preference cards. The DM said the kitchen was a mess and she was trying to clean it up, which included preference cards. She said she had worked at the facility for a week. The RD said she worked at the facility for a month. Record review of the weekly menu reflected the food that had been served during the survey. An alternate menu and an all time menu were posted in the dining area.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.1.The facility failed to maintain, clean, and properly store 2 of 2 juice guns. 2.The facility failed to label and date beverages in the refrigerator.3.The facility failed to remove dented holding pans from service.4.The facility failed to properly maintain and document the low-temp dishwasher chemical sanitation logs.5.The facility failed to keep prep tables clean and free of scissors.6.The facility failed to calibrate and use thermometers correctly for food holding temperatures.These failures could place residents who received meals and/or snacks from the kitchen at risk for food contamination and foodborne illness.Findings included:Initial observation tour of the kitchen on 08/02/26 at 10:10 am revealed 2 of 2 juice guns had a black/red substance in the inner nozzles. One of them did not have a holster to rest in and was hanging from the machine over the side of the table they were on. In the refrigerator, there was a bin holding four sippy cups with what appeared to be milk and four juice glasses with a yellow-orange liquid that had settled in the bottoms, and two of the glasses were on their side. Neither the bin nor the sippy cups and glasses were labeled with identifiers of substance, a name, or dated with a preparation date or use-by date. There was a sticky spill on the prep table near the can opener. On a clean rack, there were 6 of 6 medium-sized food-holding pans with creased dents in the corners. The low-temp dishwashing machine sanitization logs had the same PPM numbers (100) written in the spaces for May, June, and July 2026. A chem strip test was performed by the DW, but it did not register the PPM. Another was done, and it did not register the PPM. Return visit and observation of the kitchen on 08/03/26 at 11:13 pm revealed both juice guns were hanging off the table. There was an unlabeled pair of scissors on one of the prep tables. The six thermometers used to temp the food before serving were in a glass of cool water without ice near the service area. Each thermometer displayed a different temperature that ranged from 30 degrees F to 130 degrees F. On a clean rack, five of five small food-holding pans had creased dents in the corners. The low-temp dishwasher chem strip did not register the PPM but was written in the logbook as 100 for August 1st, 2nd, and 3rd, 2026. In an interview with the DM on 08/02/26 at 10:24 am, she said she was moved from a sister facility to take over the kitchen and had worked at the facility for one week. She said the kitchen was an overwhelming disaster when she got there. She said the juice guns should have been cleaned according to the cleaning schedule. She said she would have to order a holster for the one that was hanging from the machine. She said she did not know why creased dents in the food-holding pans were hazardous. She said all food items should be labeled and dated in the refrigerators, storeroom, and freezers. She said she thought the kitchen staff knew how to document on the dishwasher sanitizer log or at least tell her when things did not seem right. In an interview with the DW on 08/02/26 at 10:50 am, she said she did not test the PPM nor log it when she came to work. She said she did not know who logged the PPM, but she was not responsible for it. She said she did not say anything to the DM about the test strips. She said the test strips should turn a shade of purple when sanitizer was detected. In an interview with the RD on 08/03/26 at 11:15 am, she said she noticed items in the refrigerator were not dated or labeled. She said she noticed the sticky spill on the prep table near the can opener. She said she was pretty sure the scissors on the other prep table should not have been there due to cross-contamination, and they were not kitchen scissors. She said the thermometers in the glass of cool water had not been calibrated if all the temperatures were different. She said she would ensure a proper cleaning schedule was implemented in the kitchen. She said in-services were needed for kitchen workers to ensure they understood their roles and to keep residents healthy. She said the holding temps documented in the logbook could not have been accurate due to the thermometers not being calibrated and having such a range of different temperatures when sitting in the same water; they should have had the same temperature displayed. The RD said the instructions for calibrating thermometers were right on the wall above where the thermometers were in the glass of water and pointed to the printed instruction page of how to calibrate thermometers. In an interview and observation with the [NAME] and the RD on 08/03/26 at 11:27 am, the [NAME] said she knew how to calibrate thermometers and had just got them out of the box before she used them and they were brand new. She said she did not calibrate the thermometers after she got them out of the box or before she initially temped the food. She said she had not noticed the temperatures on the thermometers were all different. She retrieved another glass, filled it with ice and water and placed the thermometers in it. After several minutes, she said, See? They're going down (in temperature). The Cook, the RD, and this state surveyor observed that none of the thermometers reached zero during calibration. To calibrate the thermometers, the [NAME] said she did not know the plastic handles attached to each thermometer were also the wrench used to turn the dial for calibration. The cook tried to turn the dials by grabbing the stem and trying to turn the dials not knowing the stem was taking the temperature of her hand. The [NAME] said she did not know the plastic wrench/handle had to be clicked into place in order to work. The [NAME] was unaware the instructions for calibrating thermometers were three feet away from her on the wall and within eyesight. The [NAME] proceeded to re-temp the food in the holding pans on the steam table. She could not say why the temperatures in the logbook did not match the temperatures she took with the calibrated thermometers. The RD explained it to the Cook. The [NAME] did not understand as evidenced by her frustration of having to re-warm some of the food and saying, I'll just do what ya'll tell me. The [NAME] was able to state what the proper temperatures of the food should be. Record review of the 18-item Monday through Sunday Daily Cleaning Schedules dated 01/26/26 through 07/21/26 revealed multiple days, weeks, and months were missing. 01/26/26-02/01/26 was filled in. There was no schedule from 02/02/26-02/15/26. The next schedule was dated 02/16-22/26. There were no cleaning schedules until 03/02/26-03/15/26, then 03/23-03/29/26. The next dated cleaning schedule was 04/06/26-04/12/26, then 04/27/26-05/03/26, but 04/30/26-05/03/26 were blank. 05/04/25-05/10/26 was complete. The next dated cleaning schedule was 07/08/26-07/19/26. The month of June was missing. The next dated cleaning schedule was 07/08/26-07/14/26, but the days were marked out of sequence: 08, 14, 15, 16, 17, 18, 19. The next schedule was dated Monday 07/08/26, then 07/14/26-07/19/26. 07/08/26 was a Wednesday. 07/15/26-07/21/26 was missing 4 days out of 7 and showed Monday, 07/15/26, when 07/15/26 was a Wednesday. There were no schedules for August 2026. There were no separate weekly or monthly cleaning schedules per facility policy. Record review of the Daily Dish machine Temperature and Sanitizer logs dated 01/01/26 through 07/31/26 revealed temperatures and sanitation were done three times a day. All times in January were marked at 100 PPM. In February, the PPM was marked at 100 with the exception of the first 4 breakfast and lunch days (02/01/26-02/04/26) and the last 4 lunch days (02/27-02/28), which were marked at 200. All times in March, the PPM was marked at 200 with the exception of the last 4 breakfast days marked at 100 and the 26th, 27th, and 28th marked at 100. April, May, June, and July were all marked at 100 PPM with the exception of 07/28th and 29th, which were blank yet initialed as having been done. Record review of the facility policy dated 10/01/18 titled, Cleaning Schedules under Policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. Under Procedure: 1. The Nutrition & Foodservice Manager will develop a cleaning schedule for daily, weekly and monthly cleaning. Sample forms for daily cleaning, weekly cleaning and monthly cleaning follow this policy. 2. Cleaning tasks will be assigned to positions and included in the job descriptions. 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The Nutrition & Foodservice Manager or designee will verify that the tasks were completed as assigned. Record of the facility policy revised 06/01/19 titled, Food Storage under Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes andRecord review of the HACCP (Hazard Analysis Critical Control Point) guidelines. 2. Refrigerators: d. Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the facility policy dated 10/01/18, titled General Kitchen Sanitation under Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of the FDA (Food and Drug Administration) Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: (I) employees are properly maintaining the temperatures of time/temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures. Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A) Multiuse food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints. 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (C) Equipment food-contact surfaces and utensils shall be cleaned throughout the day at least every 4 hours.

Based on observation, interview, and record review, it was determined the facility failed to maintain all kitchen equipment in safe operating condition for 1 of 1 main kitchen reviewed for safe operating equipment. 1.The facility failed to maintain the vent hood by using caulk on the inside seams.2The facility failed to maintain the gasket on the door of a refrigerator.3.The facility failed to maintain the low-temp dishwasher sanitation component.These failures could cause food-borne illness from the equipment not being maintained and/or cleaned effectively.Findings included:Initial observation tour of the kitchen on 08/02/26 at 10:10 am revealed the vent hood had a thick layer of a cracked and peeling whitish substance resembling caulk spread over the seams on the inside top and sides directly over food on the stove. The gasket on the refrigerator door fell nearly completely off onto the ground when the door was opened. The low-temp dishwashing machine log had the same PPM numbers (100) written in the spaces for May, June, July, and August 2026. A chem strip test was performed by the DW, but it did not register PPM. Another was done, and it did not register the PPM. In an interview with the DM on 08/02/26 at 10:24 am, she said she was moved from a sister facility to take over the kitchen and had worked at the facility for one week. She said she did not know what or why there was caulking inside the vent hood. She said the low-temp dishwasher had been serviced on 07/27/26. She said there might be something wrong with the chem strips because they were not registering PPM. She said she called the company to check it out. She said she told the MS about the refrigerator door gasket last Wednesday, 07/29/26, and he fixed it Friday, 07/31/26. She said the MS took care of that.In an interview with the DW on 08/02/26 at 10:50 am, she said she did not test the PPM nor log it when she came to work. She said she did not know who logged the PPM, but she was not responsible for it.Record review of the facility policy dated 10/01/18 titled, Manual Cleaning and Sanitizing of Utensils and Portable Equipment under Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards.Record review of the FDA (Food and Drug Administration) Food Code 2022 Ch.4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Record review of the NFPA (National Fire Protection Association) 96 requirement for hood construction and sealing: Seams and joints: All seams, joints, and penetrations must have liquid-tight continuous external welds at the hood's lower perimeter to prevent grease-laden vapors from entering the hood or bypassing the system. Practical implications for caulking: Sealing joints and penetrations: If the hood or ductwork has non-welded joints, gaskets, or penetrations, caulking or sealing compound must be applied to create a continuous liquid-tight seal. Fire-rated materials: The caulking compound must be fire-rated and compatible with stainless steel or other hood materials to avoid degradation or grease buildup. Maintenance: Over time, caulking can crack or degrade; NFPA 96 requires regular cleaning and inspection, so seals should be maintained or replaced as part of the cleaning schedule. Summary While NFPA 96 doesn't use the term caulking, it requires liquid-tight, noncombustible seals at all hood joints, penetrations, and connections. In practice, this means using fire-rated caulking or gaskets where [NAME] is not possible, ensuring no grease-laden vapor can bypass the system.

Based on observation, record review, and interview, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, for one (Resident #69) of six residents that were observed for a safe, comfortable, homelike environment. The facility failed to ensure Resident #69's bed remained in safe and operable condition. Resident #69 remained in a wheelchair for approximately five hours while awaiting a replacement bed. This failure could place the residents at risk of decreased quality of life and comfort.The findings include: Record review of Resident #69's face sheet dated 08/03/26 reflected an [AGE] year-old-female with an original admission date of 09/08/25. Diagnoses include Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), high blood pressure, chronic kidney disease, restlessness and agitation. Record review of Resident #69's quarterly MDS dated [DATE] reflected a mental status of short-term and long-term memory problems, is rarely understood, and decision making is severely impaired. Resident #69 is dependent (helper does all of the effort. Resident does none of the effort to complete the activity or requires the assistance of two or more helpers to complete the activity) on staff for toileting, eating, showering, dressing, oral hygiene and personal hygiene. Resident #69 was always incontinent of bowel and bladder. Resident #69 was at risk for developing pressure ulcers/injuries and was utilizing a pressure reducing device for bed only. Resident #69 utilized a wheelchair for mobility. Record review of Resident #69's care plan initiated on 09/17/25 reflected bowel incontinence. Interventions included to check on Resident #69 every two hours and assist with toileting as needed. Provide peri care after each incontinent episode, and staff to check every 15-minute interval to assess if Resident #69 had a bowel movement. During an observation on 08/02/26 at 11:11 a.m., after being alerted by a family member, Resident #69's bed was observed leaning downward on the left side from the headboard to the floor. Resident #69 was in her wheelchair in the common room area. During an interview on 08/02/26 at 11:12 a.m., a family member stated she came to visit Resident #69 after reviewing the resident's in-room camera and realized, the resident's brief had not been changed since early that morning. The family member stated she did not want Resident #69 up in the wheelchair without being changed for such an extended period of time. The family member stated that during a visit the previous night, Resident #69's bed was not broken. The family member expressed concern that if she had not come to the facility, Resident #69's bed would have remained broken and the resident's brief would not have been changed. During an interview on 08/02/26 at 11:23am. LVN D stated she was notified by CNA E and CNA F between approximately 6:30 a.m. or 7:00 a.m. that morning that Resident #69's bed was not functioning. LVN D stated she contacted Resident #69's hospice answering service to notify them of the situation but did not receive a response. LVN D stated she had not notified the MD because she did not have his phone number. LVN D stated she had not notified any other manager or supervisor regarding the broken bed. LVN D stated Resident #69 remained in her wheelchair throughout the morning because her bed was inoperable because she was occupied caring for another resident who was actively passing away and did not have the opportunity to address the situation further. LVN D stated she did not know if Resident #69's brief was changed or if she was checked on. During an observation on 08/02/26 at 11:36 a.m., the MD removed Resident #69's inoperable bed from the room and replaced it with a functioning bed. In an interview on 08/02/26 at 12:21 p.m., CNA E stated between approximately 6:30 a.m. and 7:00 a.m. that morning, she went in to change Resident #69's brief and discovered Resident #69's bed was broken and immediately reported the issue to LVN D. CNA E stated Resident #69 was transferred to her wheelchair and remained there throughout that morning. CNA E stated she believed she had to wait until the bed was replaced before returning Resident #69 to bed and was unaware of any alternative procedures to follow. CNA E did not state whether she checked on Resident #69 during the five hours, but did state Resident #69's brief was not changed. During an interview on 08/03/26 at 2:52 p.m., the MD stated that the response to a broken bed depends on whether the bed belongs to the facility or hospice. The MD stated that if the bed was facility owned, staff are expected to submit a maintenance request thought TELS (a maintenance and service requests system that informs technicians of work orders that can be tracked and monitored). The MD stated that if the bed belonged to a hospice entity and the malfunction affects resident care, staff should replace the bed with an available facility bed while hospice can repair or replace its equipment. The MD stated that no one notified him of the issue with Resident #69's bed. The MD stated he first became aware of the broken bed after arriving at the facility at approximately 10:00 a.m. on 08/02/26 for an unrelated maintenance issue. The MD stated that all staff had access to his telephone number, which was posted throughout the facility. During an interview on 08/04/26 at 8:37 a.m., the DON stated the facility aways had a manager available, and staff are expected to notify the manager when issues arise that affect resident care. The DON stated that when Resident #69's bed became inoperable, staff should have either replaced the bed immediately or utilized an available bed or room. The DON stated she was unaware Resident #69's bed was broken and she was at the facility since 7:30 a.m. on 08/02/26 that morning. The DON stated staff have been in-serviced numerous times to notify management whenever they were unsure about how to handle a situation or had questions. The DON stated the facility would provide additional education regarding broken equipment, the chain of notification, and staff responsibilities when resident care may be affected. Record review of the facility's admission packet for resident rights revealed: Statement of Resident Rights You have the right to: (1) all care necessary for you to have the highest possible level of health; (2) safe, decent and clean conditions (4) be treated with courtesy, consideration, and respect

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #69) of six residents reviewed for quality of care. The facility failed to ensure Resident #69 received necessary incontinent care and assessment of toileting needs while the resident remained seated in a wheelchair for approximately five hours after Resident #69's bed became inoperable on 08/02/26. This failure could place residents at risk for discomfort, impaired skin integrity, infection, and diminished quality of life. The findings include: Record review of Resident #69's face sheet dated 08/03/26 reflected an [AGE] year-old-female with an original admission date of 09/08/25. Diagnoses include Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), high blood pressure, chronic kidney disease, restlessness and agitation. Record review of Resident #69's quarterly MDS dated [DATE] reflected a mental status of short-term and long-term memory problems, is rarely understood, and decision making is severely impaired. Resident #69 is dependent (helper does all of the effort. Resident does none of the effort to complete the activity or requires the assistance of two or more helpers to complete the activity) on staff for toileting, eating, showering, dressing, oral hygiene and personal hygiene. Resident #69 was always incontinent of bowel and bladder. Resident #69 was at risk for developing pressure ulcers/injuries and was utilizing a pressure reducing device for bed. Record review of Resident #69's care plan initiated on 09/17/25 reflected bowel incontinence. Interventions included to check on Resident #69 every two hours and assist with toileting as needed. Provide peri care after each incontinent episode, and staff to check every 15-minute interval to assess if Resident #69 had a bowel movement. During an observation on 08/02/26 at 11:11 a.m., after being alerted by a family member, Resident #69's bed was observed leaning downward on the left side from the headboard to the floor. During an interview on 08/02/26 at 11:23am. LVN D stated she was notified by CNA E and CNA F between approximately 6:30 a.m. or 7:00 a.m. that morning that Resident #69's bed was not functioning. LVN D stated Resident #69 received incontinent care at that time and was then placed in her wheelchair because the bed was inoperable. LVN D stated she contacted Resident #69's hospice answering service to notify them of the situation. LVN D stated she was unaware Resident #69 had not received incontinent care throughout the morning because she was occupied with another resident who was actively passing away. LVN D stated that if Resident #69 did not receive timely incontinent care, it could result in skin irritation and possible skin breakdown. During an observation on 08/02/26 at 11:36 a.m., the MD removed Resident #69's inoperable bed from the room and replaced it with a functioning bed. During an observation on 08/02/26 at 11:45 a.m., Resident #69 was transferred from her wheelchair to the replacement bed using a Hoyer lift. Staff then provided incontinent care. Upon removal of Resident #69's brief, the brief was observed to be heavily soiled with urine and feces extending from front to back. There was not skin redness or skin irritation noted. In an interview on 08/02/26 at 12:21 p.m., CNA E stated the last time Resident #69's brief was changed was between approximately 6:30 a.m. and 7:00 a.m. that morning. CNA E stated she discovered Resident #69's bed was broken and immediately reported the issue to LVN D. CNA E stated that, to her knowledge, Resident #69's brief had not been changed again since that morning. CNA E stated she was unable to provide incontinent care because Resident #69 could not be safely positioned in the broken bed. CNA E stated she believed she had to wait until the bed was replaced before providing care and was unaware of any alternative procedures to follow. CNA E stated that if Resident #69 remained in a soiled brief for an extended period of time, it could result in skin breakdown. In an interview on 08/02/26 at 12:27 p.m., CNA F stated the last time Resident #69's brief was changed was between approximately 6:30 a.m. and 7:00 a.m. that morning. CNA F stated she had not provided incontinent care to Resident #69 since the bed was broken. CNA F stated if Resident #69 remained in a soiled brief for an extended period of time, it could result in skin breakdown. During an interview on 08/04/26 at 8:37 a.m., the DON stated the facility aways had a manager available, and staff were expected to notify the manager when issues arise that affect resident care. The DON stated that when Resident #69's bed became inoperable, staff should have either replaced the bed immediately or utilized an available bed or room to provide incontinent care. The DON stated she was unaware Resident #69's bed was broken. The DON further stated that if Resident #69 remained in a soiled brief for appropriately five hours, it could lead to skin irritation and skin breakdown. Record review of the facility's Perineal Care policy dated 10/24/22 reflected: Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Record review of the facility's admission packet for resident rights revealed: Statement of Resident Rights You have the right to: (1) all care necessary for you to have the highest possible level of health; (2) safe, decent and clean conditions (4) be treated with courtesy, consideration, and respect

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of six (Resident #112) residents reviewed for urinary catheter care.1. The facility failed to ensure Resident #112's urinary catheter bag was not touching the floor on 08/02/26.This failure could place residents at risk of infections. The findings included:Record review of Resident #112's admission record on 08/03/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with most recent admission on [DATE]. His diagnoses included anemia (low levels of healthy red blood cells to carry oxygen in the body), cognitive communication deficit(difficulty with communication), benign prostatic hyperplasia with lower urinary tract symptoms (a common, non-cancerous enlargement of the prostate gland in older men that compresses the urethra, causing lower urinary tract symptoms like weak stream, frequency, urgency, and nocturia), obstructive and reflux uropathy (urine flow is blocked and causes urine to back up into the kidneys causing kidney damage), and unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently). Record review of Resident #112's Medicare 5-day MDS assessment dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment.Record review of Resident #112's order summary report on 08/03/26 reflected the following order: Monitor that collection bag is off the floor and hung below bladder level every shift- start date 06/29/2026 at 10:00 pm.Record review of Resident #112's care plan dated 09/19/25 reflected he had an indwelling catheter due to BPH (benign prostatic hypertrophy- enlarged prostate gland), obstructive and reflux uropathy, and bladder mass. The goal was he would remain free from catheter-related trauma through review date and interventions included urinary catheter care every shift and PRN and monitor that collection bag is off the floor and hung below bladder level, initiated on 01/28/26 and revised on 05/11/26. During an observation on 08/02/2026 at 4:13 pm, Resident #112's urinary catheter bag was hung from the side of his bed and was touching the floor. In an interview on 08/02/2026 at 4:17 pm, MA A stated the catheter should not be kinked to allow for free flow of the urine, and the bag should always be below the bladder but not on the floor because of infection control. She stated if the bag was on the floor, it could be stepped on and cause trauma. She stated in-services on catheter care were at least once a year and as needed and the last one was a month or two ago with skills checkoffs. In an interview on 08/02/2026 at 4:25 pm, CNA B stated she last checked on Resident #112 around 1:00 pm and she did not notice his urinary catheter collection bag on the floor. She stated his catheter bag was not supposed to be on the floor. CNA B stated it could cause an infection if it was on the floor. She stated in-services were monthly and as needed and the last one was last month.In an interview on 08/04/26 at 9:00 am, the DON stated the catheter bag should be kept off the floor for infection control. She stated if it was on the floor, it could open and cause urine to get on the floor or cause cross contamination from touching the bag then touching him. Resident #112 did have a history of UTIs due to his medical history, and she asked if it could be discontinued or changed to a suprapubic catheter and was told by the NP that he was not a candidate for either one. She stated staff was in-serviced on cath care once a month and as needed and the last one was a couple of months ago. In an interview on 08/04/26 at 10:21 am, the IP stated it was not acceptable to have a urinary catheter bag on the floor or touching the floor. She stated in her in-services, she educated if anything touched it floor, it was automatically contaminated. She stated they had already started utilizing basins earlier this year due to resident beds having to be low to the ground and the urinary catheter bags touching the floor because of the distance between the bed rail and the floor. She stated it was important to keep it off the floor to avoid contamination. She stated contamination could cause infection and hospitalization. The IP stated in-services on urinary catheter care were done every January and as needed and the last one was 08/02/26. The one before that was a couple of months ago. A policy on urinary catheter care was requested from the facility on 08/02/26, 08/03/26, and 08/04/26 from the DON and the Adm, however they stated they did not have one. The policy the facility provided was only for urinary catheter insertion.

Based on observation, interview and record review revealed; based on a resident's comprehensive assessment, the facility must ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 Residents (Resident #120) whose records were reviewed for weight loss. The facility failed to follow the physician's orders/Care Plan for weekly and admission weights. This deficient practice could affect residents at risk for losing weight and result in unplanned weight loss and a decline in the resident's overall health. Findings included:Record review of Resident #120's face sheet dated 07/28/26 revealed a [AGE] year-old female with an admission date of 07/28/26. Diagnoses included COPD (Chronic Obstructive Pulmonary Disease) (a long-term lung disease that makes it hard to breathe. It damages the airways and air sacs in the lungs, trapping air inside and making it hard to get enough fresh oxygen. The tubes that carry air get swollen and blocked by thick mucus. The tiny balloon-like sacs that move oxygen into the bloodstream lose their stretch and break down), unspecified psychosis (a loss of contact with reality), diarrhea, depression, anxiety disorder, anemia (a health condition where the blood does not have enough healthy red blood cells to carry oxygen from the lungs to the rest of the body, meaning the organs and tissues do not get enough oxygen), diabetes, dementia, late onset Alzheimer's, high blood pressure, GERD (Gastroesophageal Reflux Disease is when stomach acid flows backward in the food pipe, also known as acid reflux or heartburn), muscle wasting, and dependence on wheelchair. Record review of Resident #120's admission MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. She was admitted from home and had a urinary tract infection. She used a manual wheelchair and could self-propel. She was continent of bladder and bowel. Section GG (Functional abilities), height, weight, nutritional approaches (diet), and high-risk drugs were not documented. Record review of Resident #120's care plan dated 07/29/26 revealed Resident #120 had a nutritional problem related to diet restrictions, diabetes, and impaired cognition. Her diet was listed as regular, mechanical soft texture, regular liquids consistency. Date initiated 08/03/26. The goal was: The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition, and consuming at least (75)% of at least (3) meals daily through review date.Date Initiated: 08/03/2026. Interventions included: Monitor weight as ordered. Date Initiated: 08/03/2026. Obtain height and weight on admission. Date Initiated: 08/03/2026. Record review of Resident #120's physician orders revealed Weigh weekly x 4 weeks, then monthly and PRN Active 07/28/2026. Weight and height on admission. Active 07/29/2026. Record review of Resident #120's weights and heights documentation revealed no weight or height documented as of 08/04/26. Observation and interview with Resident #120 on 08/03/26 at 8:43 am revealed a frail female in a wheelchair. She was self-propelling near the dining room. She was dressed in clean clothes, and her hair was combed. She did not have any teeth. She said she liked the facility and was getting used to it because she had only been there a week. She said the staff were nice. She said she had not been weighed. In an interview with the DON on 08/04/2026 at 8:51 am, she said, We have Resident #120's height and weight-it's on paper. She said she was going to enter it in the computer on Sunday 08/02/26, but y'all (the surveyors) were here. She said they had 24-48 hours to place admission orders. She said all nurses were responsible for admission orders and she followed up on them. She said neither she nor any nurse followed through with documenting Resident #120's height or weight in the electronic health record. She said she did not know where the paper was that had Resident #120's height and weight written on it, or who might have written it or when. She said there was no way to monitor Resident #120's weight loss if there was no baseline weight and, in this case, no follow-up weight because Resident #120 had been at the facility for a week and the orders said upon admission and weekly. She said this could affect Resident #120 by not getting appropriate treatment and they would not be treated as they should be. The facility policies for admission orders and weighing residents were requested at this time but not received.

Based on observation, interview, and record review, it was revealed that 1 of 1 grease traps reviewed for proper containment was not maintained in a sanitary condition to prevent the harborage of feeding pests. The facility failed to ensure an outside barrel-type grease trap was properly sealed with a lock ring and properly fitting lid. This failure could place residents at risk of contracting disease by attracting pests and disease-carrying rodents. Findings included:Initial observation tour of the kitchen on 08/02/26 at 10:10 am revealed the oil barrel by the dumpsters did not have a seal ring to keep it closed, and the lid did not fit the barrel.In an interview with the MS on 08/02/26 at 10:30 am, he said he did not know the oil barrel required properly fitting lids with a ring lock. He said he did not know there was a risk to residents for not keeping the oil barrel lid secured, which could attract rodents, vermin, and insects. He said he would have the oil barrel replaced.In an interview with the ADM on 08/04/26 at 5:00 pm, she said she was unaware the oil barrel needed a properly sealing lid. She said the risk to residents, leaving an oil barrel lid unsecured, was the potential for rodents to accumulate. Record review of the facility's policy revised on 06/01/19 titled, Garbage Receptacles revealed under Policy: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Outdoor receptacles: Outdoor storage surfaces for refuse shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside.Record review of the FDA (Food and Drug Administration) Food Code 2022 Ch.4, 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602

Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one (Resident #1) of five residents reviewed for meal percentage logs.The facility failed to document the meal percentages in Resident #1's electronic health record on 02/28/2026, 03/17/2026, and 03/23/2026 as per the facility's Medical Record documentation Policy. This failure could jeopardize residents from receiving adequate nutrition and assessment which could compromise the residents' specific dietary needs. Record review of Resident #1's admission record dated 03/28/2026 revealed Resident #1 was initially admitted on [DATE]. Resident #1 was admitted with multiple diagnoses including Alzheimer's disease (cognition disease), dementia (memory deficit), muscle wasting and atrophy (wasting), not elsewhere classified, other lack of coordination, and need for assistance with personal care. Record review of Resident #1's Significant Change MDS dated [DATE] revealed Resident #1 had a BIMS score of 1- indicating severe cognitive impairment. Resident #1 was coded for mechanically altered diet and was not coded for weight loss or gain for the last 6 months. Resident #1 was coded for needing partial/moderate assistance with ADLs. Record review of Resident #1's care plan date initiated 03/26/2026 revealed The family of [Resident #1] requests that he does not get up for meals. [Resident #1] will maintain highest practicable level of function and nutritional intake. Monitor and document meal intake and tolerance. Report changes in condition (e.g., increased coughing, decreased intake, fatigue). Notify physician and interdisciplinary team of any concerns or decline. Record review of Resident #1's meal percentage log dated 02/28/2026, 03/17/2026, and 03/23/2026 revealed no documentation for meal percentages eaten. During an interview on 03/30/2026 at 1:28pm-2:31PM with CNA A, CNA C, and CNA F, all stated they have assisted Resident #1 to eat. While referencing date 02/28 CNA A stated she assisted Resident #1 to eat for his meals, CNA C stated she assisted Resident #1 to eat his meals on 03/17/2026, and CNA F stated she has assisted Resident #1 to eat on 03/23/2026. All three CNAs stated that due to the heaviness of the hall and the demanding needs of the residents on the 100 hallways, they had forgotten to document the meal percentages during their shift. All three CNAs verbalized the recent facility education regarding documentation and stated documenting the meal percentages were important as it could negatively impact Resident #1's well-being. All three CNAs stated they were more diligent with documenting Resident #1's meal percentages and furthermore the facility has incorporated a paper log binder on 03/26/2026, for Resident #1, that they were also to document meal percentages. All three CNAs reiterated that they did assist Resident #1 to eat on 02/28/2026, 03/17/2026, and 03/23/2026 but forgot to document the meal percentages. During an interview on 03/30/2026 at 3:08pm Dietician, stated Resident #1's current BMI 27.9 and WNL for Resident #1's age and weight range. The Dietician stated she was not concerned for Resident #1's nutritional status and was not concerned that Resident #1 was not receiving his meals. The Dietician stated there has been no compromising concern for Resident #1's weight or muscle waste, and furthermore reiterated Resident #1's nutrition was satisfactory. During an interview on 03/30/2026 at 4:26pm the DON stated, she implemented a binder for Resident #1 that was specific to his meal percentages and care. The DON stated she has commenced an clinical staff in-service on 03/25/2026 regarding documentation in the electronic health record. The DON stated it was the facility's expectation to all clinical staff when providing any form of care, including meal eating assistance, to document the care in the resident's electronic health record. The DON stated since 03/25/2026 the facility has additionally incorporated at the end of every nurse's shift; the nurses were expected to review and ensure the documentation has been completed by the CNAs. Additionally, the DON stated she was also assisting as a third reviewer to ensure the documentation was completed daily. The DON stated the lack of documentation did not negatively affect Resident #1, but had the circumstances been different, Resident #1's nutritional status and well-being of could have been negatively affected. The DON stated the incident regarding Resident #1's meal percentages was an isolated to just Resident #1. Record review of the facility's Documentation in Medical Record policy date implemented 10/24/2022 revealed, B. Documentation shall be accurate, relevant and complete, containing sufficient details about the residents' care and/or responses to care.

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk for needs and accommodation being unmet.Record review of a face sheet dated 11/05/2025 indicated Resident #1 was a [AGE] year-old who was last admitted on [DATE] with multiple diagnoses to include Chronic Obstructive Pulmonary Disease (a long term lung condition that makes it hard to breathe), Memory Deficit, Cerebral Infarction (blood flow to part of the brain was or is blocked, leading to brain cell damage or death), Dysphagia (difficulty swallowing), Cognitive Communication Deficit, Altered Mental Status, and Vascular Dementia (a condition that causes memory, thinking, and reasoning problems due to reduced or blocked blood flow to the brain. Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 13 which indicated normal cognitive function. The MDS indicated Resident #1 was able to understand others and to make her needs known verbally. The MDS also indicated Resident #1 needed supervision and/or partial assistance with toileting hygiene, showering, upper and lower body dressing and personal hygiene. Record review of Resident #1's care plan, undated revealed, Resident #1 at a high risk for falls with an intervention to ensure the resident's call light within reach of the resident to use for assistance as needed. Resident #1's care plan also revealed The resident needs prompt response to all requests for assistance. On 11/5/2025 at 2:15 pm, during an observation of Resident #1 in her room, Resident #1 was in her bed with the door open calling out into the hallway with call light on the bedside table outside of the reach of Resident #1. Resident #1 attempted to use call light but used the bed remote instead because Resident #1 could not find the call light within her reach. On 11/5/2025 at 2:20 pm, during an interview with LVN A, she stated she is unaware Resident #1 could not reach the call light, and the call light should have been left where Resident #1 could reach the call light. LVN A stated she is unsure how long Resident #1 was without her call light. LVN A stated she checked on Resident #1 after lunch and Resident #1 had her call light within her reach at that time. On 11/5/2025 at 2:40 pm, during an interview with the DON, she stated it was not acceptable for residents to not be able to reach the call light. The DON stated she had just walked down Resident #1's hall at 2:10 pm and Resident #1 was not calling out for assistance at that time. The DON stated she will be doing staff education, check offs for call light placement, and 1:1 education with staff last assisting this resident. The DON stated it is protocol for residents to have their call light in reach. The DON stated Resident #1's result of not having the call light within reach could mean her needs may not have been met. On 11/6/2025 at 1:50 pm, during an interview with CNA B, she stated she did care for Resident #1 on 11/5/2025 and did assist the resident to bed. CNA B stated the call light was placed next to Resident #1 about 1:20 pm and she wasn't aware of anyone else moving the call light. CNA B stated she was in-serviced on call light placement today by the DON. On 11/6/2025 at 2:00 pm, during a follow-up interview with the DON, she stated staff were in-serviced regarding call lights always being in reach of all residents and the call light policy, 100% rounding performed to ensure all call lights were in reach of all residents yesterday evening, and there was an audit of 40% of the rooms with call lights this morning. The DON stated all residents had their call lights within reach. Record review of facility policy titled Call Lights: Accessibility and Timely Response and dated 10/13/2022 included verbiage The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interviews and record review, the facility failed to maintain clinical records that were complete and accurately documented in accordance with accepted professional standards and practices for 4 (100 hall glucometer, 200 hall glucometer, 300 hall glucometer, and 400 hall glucometer) of 8 glucometers (device used to measure the amount of glucose in a resident's blood) reviewed for pharmacy services. 1. The facility failed to ensure the 2 glucometers in the 200-hall nurse cart and 2 glucometers in the 400-hall nurse cart were tested for accuracy and recorded in the glucometer logbook on 06/01/25, 06/02/25 and 06/03/25. 2. The facility failed to ensure the 2 glucometers in the 100-hall nurse cart and 2 glucometers in the 300-hall nurse cart were tested for accuracy and recorded in the glucometer logbook on 06/03/25. These failures could place residents at risk of receiving either too much insulin or not enough. The findings included: Record review of the glucometer logbook on 06/04/25 at 12:47 PM revealed the test results for the 2 glucometers in the 100-hall nurse cart were not recorded on 06/03/25. The test results for the 200-hall nurse cart were not recorded on 06/01/25, 06/02/25, and 06/03/25. The test results for the 300-hall nurse cart were not recorded on 06/03/25. The test results for the 400-hall nurse cart were not recorded on 06/01/25, 06/02/25, and 06/03/25. In an interview with ADON A on 06/05/25 at 1:46 PM, ADON A stated she worked from 6:00 AM to 2:00 PM on 06/01/25. ADON A stated she checked the glucometer logbook when she arrived at the beginning of her shift and noticed none of the log had been filled out for 06/01/25. ADON A stated it was the night shift nurses' responsibility to test the glucometers and record the results in the logbook. ADON A stated she tested all 8 of the glucometers on 06/01/25, but she forgot to record all the results in the logbook. ADON A stated the glucometers were supposed to be tested for accuracy every day. ADON A stated it was important to ensure the glucometers were working appropriately for the safety of the residents. ADON A stated if a glucometer was not accurate it could lead to a resident getting too much insulin causing hypoglycemia (low blood sugar characterized by blood glucose levels dropping below 70 mg/dL). In an interview with RN C on 06/05/25 at 1:58 PM, RN C stated the glucometers were supposed to be tested daily. RN C stated the night shift nurses tested the glucometers and recorded the results in the logbook. RN C stated if the glucometer was not accurate a resident may get too little or too much insulin. In an interview with LVN D on 06/05/25 at 2:19 PM, LVN D stated she worked the night shift at the facility. LVN D stated it was the night shift nurses' responsibility to test the glucometers daily and record the results in the logbook. LVN D stated they typically had two nurses working the night shift. LVN D stated she worked at the facility from 10:00 PM on 05/31/25 to 6:00 AM on 06/01/25. LVN D stated during that shift she forgot to test the glucometers in the nurse's carts. LVN D stated the glucometers were tested daily to ensure the residents did not receive too much or too little insulin. In an interview with the DON on 06/05/25 at 2:36 PM, the DON stated it was important to ensure the glucometers were accurate so residents received the correct dose of insulin. The DON stated incorrect doses of insulin could cause hypoglycemia symptoms such as lethargy, profuse sweating, disorientation, and in severe cases even death. The DON stated she had been DON at the facility for approximately one year. The DON stated the glucometers were tested and the results recorded in the glucometer logbook every day since she had been employed at the facility. The DON stated it was the night shift nurses' responsibility to test the glucometers daily and record the results in the logbook. The DON stated she was not aware of any written facility policy that stated the glucometers were to be tested daily. The DON stated the manufacture's guidelines for the glucometers they used at the facility stated they only needed to be tested on ce per week. The DON stated she required the nursing staff tested the glucometers every day as a precaution and because of her previous nurse training and experience. This state surveyor requested a facility policy from the DON on 06/05/25 at 2:36 PM dictating how often to test the glucometers but none was provided.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #39) out of 5 residents reviewed for care plans. The facility failed to review or revise Resident #39's care plan after a significant change in condition when Resident #39's code status changed from full code to DNR on [DATE]. This failure could place resident at risk for receiving inadequate care and services. Findings included: Record review of Resident #39's face sheet dated [DATE] revealed a [AGE] year-old male with an original admission date of [DATE] and a current admission date of [DATE]. Diagnoses included Chronic Kidney Disease - Stage 3 (a condition in which the kidneys are damaged and cannot filter blood properly), Type 2 Diabetes (a chronic condition which occurs when the body cannot use insulin effectively, leading to high blood sugar levels), Obstructive and Reflux Uropathy Unspecified (occurs when urine flow is blocked), Benign Prostatic Hyperplasia (a condition caused by an enlarged prostate which can cause urinary problems), and Acute Kidney Failure (sudden loss of kidney function). Record review of Resident #39's care plan initiated [DATE] and revised on [DATE] revealed Resident #39 was a full code (if a person's heart stopped beating and/or if they stopped breathing, all resuscitation procedures would be provided). Interventions for this care plan included initiate CPR and call 911, as well as mark chart and all pertinent documents with full code. Record review of Resident #39's physician orders revised [DATE] revealed an order for DNR. Further review of the physician orders revised [DATE] revealed an order to admit resident to hospice. Record review of Resident #39's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, moderately impaired cognition. Record review of Resident #39's progress note dated [DATE] revealed resident returned to facility from hospital and would be a DNR and placed on hospice. Record review of Resident #39's Out of Hospital Do Not Resuscitate Order dated [DATE] revealed resident's signature for DNR. In an interview on [DATE] at 5:47 PM with the DON she stated Resident #39's care plan should have been updated with the proper code status on [DATE] when it changed from full code to DNR. She stated the MDS nurse was the one responsible for updating the care plans when there had been a change in condition. She stated the care plan not having the proper code status could have caused confusion on what the nurses or staff should have done in a code situation. She also stated the nurses or staff could have accidently performed CPR on Resident #39 when they were not supposed to. In an interview on [DATE] at 5:53 PM with the MDS nurse she stated she was the one responsible for updating the comprehensive care plans, so it would have been her job to update Resident #39's care plan. She stated she was unsure of how it got missed, but she was still new and learning at the time. She also stated if nurses had only viewed the care plan and not known about the DNR order, they may have inadvertently performed CPR on Resident #39 when he was a DNR. Record review of the facility's Comprehensive Care Plans policy, implemented [DATE], revealed Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. F. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated.

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for wound care. The facility failed to ensure the wound care nurse knew the proper technique for cleansing the venous stasis ulcer during wound care in order to prevent cross-contamination and infection. The deficient practice and failure could place residents at risk for cross contamination, infection, and improper wound healing. Findings included: Record review of Resident #1's face sheet, dated 05/05/25, revealed a [AGE] year-old-male with an original admission date of 05/02/24. Diagnoses included Peripheral Vascular Disease(a disorder of the blood vessels outside the heart which affects circulation), Hemiplegia (severe or complete unilateral loss of strength or paralysis), and Hemiparesis (weakness in one leg, arm or side of face), Type 2 Diabetes With Other Skin Ulcer (a chronic condition which occurs when the body cannot use insulin effectively), Chronic Venous Hypertension With Ulcer (characterized by increased pressure in the veins, often resulting from venous insufficiency). Record review of Resident #1's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, intact cognition. MDS also revealed the presence of a venous and/or arterial ulcer. Record review of Resident #1's physician orders with a start date of 06/03/25 revealed an order for wound care to left medial lower leg which included to cleanse wound with wound cleanser. Record review of Resident #1's care plan initiated 05/02/24 and revised 04/25/24 revealed venous stasis ulcers of the bilateral lower legs with a goal to have no signs or symptoms of infection through review with a target date of 08/18/2025. In an observation on 06/04/25 at 11:05 AM the wound care nurse was observed cleansing Resident #1's wound with a folded gauze soaked in wound cleanser. She was observed scrubbing the center of the wound in an up and down motion, then moving to the outside of the wound with an up and down motion, and then she proceeded to go back to the center of the wound with an up and down motion. She was observed doing this process for approximately 1-2 minutes. She continued to use the same dirty, blood-soaked gauze to clean the outside and center of the wound many times. In an interview on 06/04/25 at 11:41 AM with the wound care nurse, she stated she was supposed to be using a scrubbing technique while cleansing Resident #1's wound, which was why she kept going back and forth over the wound from clean to dirty to clean. She stated she realized she should have scrubbed from inner to outer, clean to dirty, then discarded the blood-soaked gauze, and not continued to start the process over with the same blood-soaked gauze. She stated this could have caused cross-contamination of the wound, introduced bacteria, and placed the resident at risk for infection. In an interview on 06/04/25 at 11:49 AM with ADON-B, he stated when cleansing the wound the wound care nurse should have cleansed from the inner part of the wound to the outer area of the wound, which was from clean to dirty, then disposed of the dirty gauze, and started the process over with a clean gauze if the wound still needed to be cleansed. He stated going in and out of the wound over and over creates cross-contamination and could have introduced bacteria and caused an infection. Also, you would not have continued to cleanse the wound with the gauze once it became blood-soaked, dirty, and contaminated. In an interview on 06/04/25 at 4:48 PM with the DON, she stated wound care should have been performed from the inner part of the wound to the outer area of the wound, which was from the cleanest area to the dirtiest area, then disposed of the dirty, bloody gauze. She also stated going in and out of the wound could have created cross-contamination and introduced bacteria into the wound, which could have caused Resident #1 an infection. Record review of the facility's Infection Prevention and Control Program, implemented 05/13/23, revealed This facility has established and maintains 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 infections as per accepted national standards and guidelines.

Based on observation, interviews, and record reviews, the facility failed to ensure that one (Residents #17) of one resident with an indwelling urinary catheter reviewed received the appropriate treatment and services to prevent Urinary Tract Infection (UTI's): The facility failed to ensure Resident #17 ' s urinary drainage tubing and catheter drainage bag were kept from touching and resting on the floor. This failure could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTI's. The findings included: Record review of Resident #17's Face Sheet dated 06/03/25 documented an 82- year-old female admitted [DATE] and re-admitted [DATE] with the diagnoses of: Urine tract infection, Acute Pyelonephritis (kidney infection an illness in one or both kidney organs), and Hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine). Record review of Resident #17's MDS dated [DATE] documented: -Bed mobility: Substantial/maximal assistance - Helper does More Than Half the effort. A helper lifts or holds trunk or limbs and provides less than half the effort. -Toilet use: Totally dependent on assistance -Personal hygiene: Substantial/maximal assistance -Helper does More Than Half the effort. Record review of Resident #17's care plan dated 12/16/20 revised on 05/06/25 documented a urinary catheter, indwelling. Care Plan Goal: - The resident has bladder incontinence related to inability to control bladder. Interventions: - Incontinent check several times a shift and as required for incontinence. - Wash, rinse, and dry the perineum. - Change clothing as needed after incontinence episodes. - The resident uses disposable briefs. Change prn. - Clean peri-area with each incontinence episode. Record review of Resident #17 progress notes dated 06/03/25 indicated Catheter/ Foley care provided by staff and toileting program and assistive devices such as pads and or briefs provided. During an observation of Resident #17's catheter drainage bag on 06/03/25 at 10:12 AM revealed the catheter drainage bag hung from the lower bed frame on the right side of the bed and the tubing and catheter drainage bag rested on the floor. During an observation and interview on 06/03/25 at 10:40 AM, LVN E went into Resident #17's room to observe the foley catheter bag and tubing touching the ground. She stated, it [The Foley catheter bag and tubing] should not be touching the ground. while lifting the bed a little to get the drainage bag and tubing off the floor. LVN E stated it was important that the tubing and drainage bag should not touch the floor to prevent risk of infection. LVN E stated the catheter bag should be hung below the bladder to prevent back flow to the bladder. LVN E said she received infection control in-service approximately 1 week ago. During an interview with the ADON on 06/03/25 at 10:55 AM, he stated the catheter drainage bag should be hung on the bed frame below the bladder to prevent cross contamination from touching the dirty floor and with a privacy bag over it for resident ' s dignity. The ADON stated each of these scenarios can cause an infection to the resident. The ADON said all staff were to ensure that these measures were in place every time staff conducted their daily and shift rounds. The ADON stated the last infection control in-service was 1 week ago. Record review of the facility Incontinent Care skills checklist dated 05/13/23 documented Ensure the drainage bag is maintained below the level of the bladder at all times and does not rest on bed and kept off the floor According to the DON on 06/04/20245 and 5:43 PM, she said the facility did not have a Catheter Care/Maintenance policy and procedure but followed the Incontinent Care skills checklist.

Based on interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 9 of 12 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) reviewed for pharmacy services. 1) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 02/28/25 for Resident #2. 2) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 03/04/25 for Resident #3. 3) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 03/04/25 for Resident #4. 4) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 01/13/25 for Resident #5. 5) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 02/09/25 for Resident #6. 6) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 10-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 03/15/25 for Resident #7. 7) The facility failed to ensure ADON D disposed of one tablet of Hydrocodone-APAP 5-325 mg by properly including a witness signature on the narcotic sheet when destroyed on 01/13/25 for Resident #8. 8) The facility failed to ensure ADON D disposed of Tramadol 50 mg (pain medication) by properly including a witness signature on the narcotic sheet when destroyed on 01/13/25 for Resident #9. 9) The facility failed to ensure ADON D disposed of Acetaminophen-Codeine 300-30 mg (pain medication) by properly including a witness signature on the narcotic sheet when destroyed on 12/18/24 for Resident #10. These failures could place residents at risk for or lead to drug diversion. Findings included: 1. Record review of Resident #2's face sheet dated 04/10/25 revealed a [AGE] year-old male with an initial admitted [DATE] and current admitted [DATE]. Record review of Resident #2's order summary revealed an active order for Hydrocodone-APAP 10-325 mg initiated on 12/15/22. Record review of Resident #2's narcotic sheet for Hydrocodone-APAP 10-325 mg revealed 1 tablet was destroyed without a witness present on 03/04/25. 2. Record review of Resident #3's face sheet dated 04/10/25 revealed a [AGE] year-old female with an initial admitted [DATE] and current admitted [DATE]. Record review of Resident #3's order summary revealed an active order for Hydrocodone-APAP 10-325 mg initiated on 03/14/25. Record review of Resident #3's narcotic sheet for Hydrocodone-APAP 10-325 mg revealed 1 tablet was destroyed without a witness present on 03/04/25. 3. Record review of Resident #4's face sheet dated 04/10/25 revealed an [AGE] year-old male with an admitted [DATE]. Record review of Resident #4's order summary revealed a discontinued order for Hydrocodone-APAP 10-325 mg initiated on 02/20/25. Record review of Resident #4's narcotic sheet for Hydrocodone-APAP 10-325 mg revealed 1 tablet was destroyed without a witness present on 03/04/25. 4. Record review of Resident #5's face sheet dated 04/10/25 revealed a [AGE] year-old male with an initial admitted [DATE] and current admitted [DATE]. Record review of Resident #5's order summary revealed a discontinued order for Hydrocodone-APAP 10-325 mg initiated on 01/05/25. Record review of Resident #5's narcotic sheet for Hydrocodone-APAP 10-325 mg revealed 1 tablet was destroyed without a witness present on 01/13/25. 5. Record review of Resident #6's face sheet dated 04/10/25 revealed a [AGE] year-old male with an initial admitted [DATE] and current admitted [DATE]. Record review of Resident #6's order summary revealed an active order for Hydrocodone-APAP 10-325 mg initiated on 12/06/24. Record review of Resident #6's narcotic sheet for Hydrocodone-APAP 10-325 mg revealed 1 tablet was destroyed without a witness present on 02/09/25. 6. Record review of Resident #7's face sheet dated 04/10/25 revealed a [AGE] year-old male with an initial admitted [DATE] and current admitted [DATE]. Record review of Resident #7's order summary revealed an active order for Hydrocodone-APAP 10-325 mg initiated on 07/03/24. Record review of Resident #7's narcotic sheet for Hydrocodone-APAP 10-325 mg revealed 1 tablet was destroyed without a witness present on 03/15/25. 7. Record review of Resident #8's face sheet dated 04/10/25 revealed a [AGE] year-old female with an admitted [DATE]. Record review of Resident #8's order summary revealed an active order for Hydrocodone-APAP 5-325 mg initiated on 10/20/22. Record review of Resident #8's narcotic sheet for Hydrocodone-APAP 5-325 mg revealed 1 tablet was destroyed without a witness present on 01/13/25. 8. Record review of Resident #9's face sheet dated 04/10/25 revealed a [AGE] year-old male with an admitted [DATE]. Record review of Resident #9's order summary revealed an active order for Tramadol 50 mg initiated on 06/06/24. Record review of Resident #9's narcotic sheet for Tramadol 50 mg revealed 1 tablet was destroyed without a witness present on 01/13/25. 9. Record review of Resident #10's face sheet dated 04/10/25 revealed a [AGE] year-old female with an initial admitted [DATE] and current admitted [DATE]. Record review of Resident #10's order summary revealed a discontinued order for Acetaminophen-Codeine 300-30 mg initiated on 09/20/23. Record review of Resident #10's narcotic sheet for Acetaminophen-Codeine 300-30 mg revealed 1 tablet was destroyed without a witness present on 12/18/24. Record review of the provider investigation summary dated 03/24/25 revealed the following: [ADON D] admitted to disposing of the medications as per protocol but did so without a witness. He denies taking any medication for himself from the facility [ADON E] also confirmed that several times she did cosign of a disposed medication where the other ADON had signed without personally witnessing the act This incident has been reported to HHSC due to its nature and per reporting guidelines however, the facility believes the alleged incident is unconfirmed Both ADON's will be terminated for failure to follow company policy and procedures. In an interview with ADON E at 2:27 PM on 04/08/25, ADON E stated she never destroyed any narcotics without a witness present. ADON E stated in her review of the narcotic books, she saw a lot of signatures by ADON D destroying narcotics without an accompanying witness signature. ADON E stated she informed the DON about these incidents of not following proper procedure. In an interview with LVN B at 3:21 PM on 04/08/25, LVN B stated she had never seen anyone destroy a controlled medication without a witness. LVN B stated she always got a witness to sign the narcotic book if she had to destroy a narcotic to ensure there were no suspicions of drug diversion. In an interview with ADON D at 4:54 PM on 04/08/25, ADON D stated the ADONs were given an instruction by the DON to audit the narcotics on the resident halls. ADON D stated he never destroyed any controlled medications without a witness present. ADON D stated he marked the narcotics for destruction, and then came back with a witness anytime he destroyed one. In an interview with LVN C at 8:47 AM on 04/09/25, LVN C stated she always got a witness to sign the narcotic sheet anytime she had to destroy a narcotic. LVN C stated she had destroyed narcotics twice since she had been at the facility since December 2024, and both times she had a witness sign the book with her. In an interview with LVN A at 10:12 AM on 04/09/25, LVN A stated she had never seen any nurse destroy a controlled medication without a witness. LVN A stated it was important to have a witness when a nurse destroyed a narcotic because narcotics were often abused and preventing drug diversion was important. In an interview with the DON at 11:38 AM on 04/09/25, the DON stated there were several medications that ADON D destroyed without a witness to sign. The DON stated she told the ADONs sometime in November or December of 2024 to go through the medication carts and find blister packs that were damaged and destroy the potentially damaged medications. The DON stated ADON D found medications with damaged blister packs but destroyed the medications without a witness. The DON stated it was important to have a witness sign off on drug destruction to ensure nobody was diverting any controlled medications. Record review of the facility's policy titled Documentation of Controlled Substances dated 10/01/19 revealed the following: When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed by two licensed nurses employed by the facility, and the disposal is documented in the controlled substances record on the line representing that dose. The same process applies to disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances waster for any reason.

Based on interviews and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to record any documentation showing any care plan meeting involving Resident #1 or their RP occurred during her stay at the facility from her admitted on 05/29/24 through her discharge date of [DATE]. This failure could place residents at risk for inadequate care, accidents, and injuries. The findings included: Record review of Resident #1's face sheet dated 04/10/25 revealed an [AGE] year-old female with an initial admitted [DATE] and discharge date of [DATE]. Pertinent diagnoses included unspecified dementia (loss of cognitive function that interferes with daily life in which the cause was unidentified). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 (moderate cognitive impairment). Record review of Resident #1's care plan was initiated on 05/29/24 with the next review date set for 03/26/25. Resident #1's comprehensive care plan had been developed with interventions made in the care plan throughout her stay at the facility. Record review of Resident #1's care plan history revealed no documentation that any care plan meetings occurred with the resident or RP. In an interview with the RP for Resident #1 on 04/07/25 at 4:20 PM, the RP stated they only had one care plan meeting during the seven months Resident #1 was at the facility. The RP stated they did not have quarterly care plan meetings. In an interview with the DON at 11:28 AM on 04/10/25, the DON stated it was standard procedure to invite resident RP's to care plan meetings. The DON stated they would hold care plan meetings even if the RP did not show up based on the status of the resident. The DON stated the RP did show up to the first care plan meeting with Resident #1, but she could not remember the exact date. The DON stated the care plan meetings with Resident #1 should have been documented, along with notes from the meetings. The DON stated care plan meetings happened quarterly, after a change of condition, within 72 hours of a transition, and as needed. The DON stated there was no documentation of any care plan meetings with Resident #1. The DON stated the CMS nurse should have recorded the meetings. The DON stated it was important to document care plan meetings so they could reference them in the future to measure changes in a resident's behavior, progression, or regression of their conditions. In an interview with the LMSW at 12:11 PM on 04/10/25, the LMSW stated typically the CMS Nurse documented care plan meetings. The LMSW stated the CMS Nurse would document who attended the meetings and what was discussed. The LMSW stated she was present at all care plan meetings. The LMSW stated care plan meetings occurred quarterly, with a change of condition, or as needed. The LMSW stated she did not find any documentation of care plan meetings with Resident #1. The LMSW stated she only remembered taking part in onea care plan meeting with Resident #1 around September of 2024 . The LMSW stated it was important to have care plan meetings to discuss concerns with the resident and RP to ensure everybody was on the same page. In an interview with the CMS Nurse at 12:24 PM on 04/10/25, the CMS Nurse stated she could not find any documentation related to any care plan meetings with Resident #1. The CMS Nurse stated she should have documented the details of the quarterly care plan meetings for Resident #1. The CMS nurse stated she remembered participating in a care plan meeting with Resident #1 around September of 2024. The CMS Nurse stated it was important to document the details of care plans meetings so they could look back and reference them to notice any changes in the resident. Record review of the facility policy titled Care Plan Revisions Upon Status Change implemented on 10/24/22 revealed the following: b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes.

Based on observation, interview, and record review the facility failed 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 infections for 4 of 5 residents (Residents #1, #2, #3 and #4) reviewed for infection control practices. 1. The facility failed to ensure the ICP, ADON, DON, staff nurses and CNAs knew the proper placement of PPE carts. 2. The facility failed to ensure PPE carts were posted outside of the EBP rooms of Residents #1, #2, #3 and #4. These failures could place residents at risk of cross contamination and/or infection. Findings include: 1. Record review of Resident #1's face sheet, dated 03/20/25, revealed an [AGE] year-old-female with an original admitted [DATE] and a current admitted [DATE]. Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS of 02, which indicated severely impaired cognition. The MDS also revealed Resident #1 had a urinary tract infection, urinary incontinence, and indwelling catheter. Record review of Resident #1's care plan, initiated 03/04/25, revealed a care plan for UTI with ESBL with interventions to maintain contact isolation and ensure to use appropriate PPE when providing care. Record review of Resident #1's physician orders, with a start date of 03/06/25, revealed an order for contact isolation for diagnosis of UTI with ESBL. During an observation on 03/19/25 at 8:36 AM of Resident #1's door and room, there was an EBP sign posted, but there was no EBP - PPE cart posted on the outside of Resident #1's room. Upon further inspection, it was noted there was an EBP - PPE cart located on the inside of the room with the middle drawer of the cart left open. 2. Record review of Resident #2's face sheet, dated 09/29/24, revealed an [AGE] year-old-male with an original admitted [DATE] and a current admitted [DATE]. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS of 12, which indicated moderately impaired cognition. The MDS also revealed Resident #2 had an indwelling catheter. Record review of Resident #2's care plan, initiated 03/20/25, revealed a care plan for EBP due to wounds and indwelling device. Record review of Resident #2's physician orders, with a start date of 02/12/25, revealed an order to change Foley catheter as needed. It also revealed an order with a start date of 02/26/25 for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk for MDR (residents with wounds or indwelling medical devices). During an observation on 03/19/25 at 8:36 AM of Resident #2's door and room revealed an EBP sign on the resident's door, but no EBP - PPE cart outside or inside Resident #2's room. 3. Record review of Resident #3's face sheet, dated 03/20/25, revealed a [AGE] year-old-male with an original admitted [DATE] and a current admitted [DATE]. Record review of Resident #3's annual MDS, dated [DATE], revealed a BIMS of 13, which indicated intact cognition. The MDS also revealed Resident #3 had a feeding tube. Record review of Resident #3's care plan, initiated 01/04/24, revealed a care plan for a feeding tube, as well as a care plan initiated on 05/02/24 for EBP due to G-tube. Record review of Resident #3's physician orders, with a start date of 11/20/24, revealed an order for enteral feeds via G-tube. It also revealed an order with a start date of 05/01/24 for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk for MDR (residents with wounds or indwelling medical devices). During an observation on 03/19/25 at 8:39 AM of Resident #3's door and room revealed an EBP sign on the resident's door, but no EBP - PPE cart outside or inside Resident #3's room. 4. Record review of Resident #4's face sheet, dated 03/20/25, revealed a [AGE] year-old-male with an original admitted [DATE] and a current admitted [DATE]. Record review of Resident #4's care plan, initiated 03/20/25, revealed a care plan for EBP due to dialysis. Record review of Resident #4's physician orders, with a start date of 10/02/24, revealed an order for dialysis on Monday, Wednesday and Friday. During an observation on 03/19/25 at 8:41 AM of Resident #4's door and room revealed an EBP sign on the resident's door, but no EBP - PPE cart outside or inside Resident #4's room. In an interview with CNA-A on 3/19/25 at 1:00 PM, she stated she could tell who was on precautions because usually there was a box outside the door or inside the door and a sign on the door, but they did use the centrally located green PPE carts if there was not a PPE cart by the resident's room. She stated PPE was to keep from transferring the infection from one resident to another, and it was a lot easier to remember what PPE to put on when there was a PPE cart at the door to be able to get the supplies from. She stated she has not personally placed the PPE carts at or in residents' rooms, but she believed it was the person from central supply who put the carts out. She stated she was in-serviced on putting on the gown and gloves prior to going into the room to give care. In an interview with LVN-B on 3/19/25 at 1:15 PM, she stated you could tell by the sign on the door who was on EBP and contact precautions. There should also be a box outside the room which contained the PPE supplies which were needed for the precautions that the resident was on. She stated she did not notice there were no carts outside the rooms before today, and PPE carts should not be located inside the residents' rooms because they would be considered contaminated and create cross-contamination when the cart itself or the supplies had to come back out of the resident's room. In an interview with the ICP - ADON on 3/19/25 at 2:00 PM, he stated PPE carts should have been placed outside the room, but he was told by the facility's corporate office that with EBP you did not have to enter the room with PPE unless you were providing direct contact with the resident, so it was okay to store the PPE in a central location to the hall for all the EBP rooms. He stated with contact precautions you must put on the PPE prior to entering the room, and there was some confusion with whether to place the PPE carts inside or outside the contact isolation rooms. He stated that since the contact PPE carts were being placed inside the contact isolation rooms, they would have to be emptied, all the products inside of the cart disposed of, and the cart cleaned and sanitized before it could come out and be utilized for any other room. He stated it was mostly the CNAs and LVNs who had been placing the EBP and Contact precaution signs and PPE carts, and the staff were in-serviced and educated on the correct way to do it, but they continued to do it wrong. He also stated improper use of PPE, or not wearing any PPE, could cause cross-contamination and an increase of infections in the facility. In an interview with the DON on 3/19/25 at 4:20 PM, she stated there was a locally centralized cart that was utilized for EBP - PPE, and someone from the corporate office was the one who taught them to keep PPE in a central location. She stated they were told not to have PPE carts in the hall outside the rooms, which was why there was a centrally located cart for EBP-PPE, and that was also why the PPE carts for the contact isolation rooms were being placed inside the rooms. She stated if staff did not have access to or know the appropriate PPE to utilize, cross-contamination could occur, and infections could be passed and spread. The DON stated the ADONs and floor nurses were responsible for placing the PPE carts. Record review of CDC: Long-Term Care Facilities: Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 04/02/24, revealed the use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves); For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that required the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room. Website reviewed on 03/19/25 at 4:35 PM: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html Record review of Enhanced Barrier Precautions policy dated 04/05/24 revealed 2) Initiation of Enhanced Barrier Precautions: b. an order for enhanced barrier precautions would be obtained for residents with any of the following: wounds, indwelling medical devices, infection, and/or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. 3) Implementation of Enhanced Barrier Precautions: a. make gowns and gloves available immediately near or outside of the resident's room.

Based on observations, interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #3) of11 residents reviewed for pharmacy services, in that:. LVN C failed to accurately reconcile Resident #3's heart medications of: Hydralazine 50mg Q8hr, Metoprolol 50mg Q12hr, Isosorbide dinitrate 20mg daily, or Nifedipine 20mg Q8hr was not acquired and administered from 11/16/2023-11/24/2023 (8days). Resident #3 was admitted to the hospital from dialysis with diagnoses including NSTEMI type 2 (heart attack), Atrial fibrillation. The noncompliance was identified as PNC. The IJ began on 11/16/23 and ended on 11/28/23. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents who receive blood pressure/heart medications at an increased risk for complications such as decreased blood pressure, decrease pulse, an exacerbation of symptoms and disease process, and potential hospitalization . Findings include: Record review of Resident #3's face sheet dated 01/05/2024 documented an [AGE] year-old female with a diagnosis of hyperlipidemia (high cholesterol), hypertension (high blood pressure), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), atrial fibrillation (irregular heart rhythm), chronic kidney disease (kidney damage), transient ischemic attack (stroke, mini stroke) and cerebral infarction (stroke). Record review of Resident #3's MDS dated [DATE] documented Resident #3's BIMS score of 12/15 indicating moderate cognitive impairment, as well as coded Resident #3 with atrial fibrillation or other dysrhythmias (abnormality in the rhythm in the activity of the brain or the heart), coronary artery disease (damange or disease in the heart's major blood vessels), hypertension (high blood pressure), and renal insufficiency/renal failure or end-stage renal disease. Record review of Resident #3's care plan date initiated on 08/02/2023 documented, Resident #3 has HAD transient ischemic attacks (TIA)(stroke) r/t Atrial fibrillation. Goal: Resident #3 will be free from s/sx of complications r/t TIA through the review date. Interventions: Address resident by name, introduce self and explain what you are going to do with each interaction. Educate resident/family/caregivers about the importance of seeking medical consultation to determine cause of TIA even though the symptoms resolve in order to prevent potential problems such as major stroke. Monitor for and document any s/sx of ineffective cerebral perfusion: Altered mental status, Dysphasia (inability to produce or understand spoken language), pupil changes, abnormal speech patterns or aphasia, weakness or paralysis of an extremity, behavioral changes, any changes in motor responses. Record review of Resident #3's care plan date initiated on 08/02/2023 documented, Resident #3 has altered cardiovascular status r/t Hypertension, CAD, AFIB. Goal: Resident #3 will be free from complications of cardiac problems through the review date. Assess for chest pain every (specify). Enforce the need to call for assistance is pain. Assess for shortness of breath and cyanosis (bluish or grayish color of skin, nails, lips or around the eyes) every (specify) Medications as ordered by MD for Hypertension and AFIB. Monitor/document/report PRN any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight. Monitor/document/report PRN any s/sx of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in capillary refill, color/warmth of extremities. Record review of Resident #3's hospital discharge medication reconciliation list dated 11/16/2023 at 3:24PM, [hospital] discharged Resident #3 with a finalized Discharge Medication list that documented to continue Hydralazine 50mg Q8hr, Metoprolol tartrate 50mg Q12hr, Isosorbide dinitrate 20mg daily and Nifedipine 20mg Q8hr Record review of Resident #3's physician orders documented: From 11/16/2023-11/24/2023, none of the listed medications were reordered. -Isosorbide Dinitrate 20mg tablet PO for heart failure state date: 11/07/2023 d/c date:11/15/2023 -Nifedipine ER 30mg tablet PO Daily state date: 11/13/2023 d/c date: 11/15/2023 -Metoprolol tartrate 50mg tablet Q12hr for hypertension start date: 11/06/2023 d/c date: 11/15/2023. -Hydralazine HCL 50mg tablet PO Q8hr for hypertension start date: 11/07/2023 d/c date: 11/15/2023. Record review of Resident #3's blood pressure on: 11/16/2023 No blood pressure reading available. 11/17/2023 at 12:47AM: 160/81, 7:17PM: 180/75 11/18/2023 at 1:56AM 173/80, 12:37PM:172/85, 7:53PM 169/84 11/19/2023 at 2:02AM:155/80, 1:42PM 150/78 Record review of Resident #3's progress note dated 11/23/2023 at 9:14PM, LVN C documented patient complained of chest pain she was given one sublingual tablet of nitroglycerin that was effective. Record review of Resident #3's progress note dated 11/24/2023 at 7:55PM, LVN D documented received call from dialysis sending resident to [hospital] emergency room diagnosis atrial fibrillation. Called RP made aware and DON. Record review of Resident #3's progress note dated 11/28/2023, ADON B documented notified by case manager at hospital that resident's family member had concerns over whether BP meds were given while resident was in facility, conducted a review of admission orders and determined medication reconciliation had inconsistencies. Medication reconciliation completed with inconsistencies. Record review of Resident #3's [hospital] discharge report on 11/24/2023 Resident #3 was admitted to [hospital] for NSTEMI type 2 (heart attack), Atrial fibrillation (irregular often rapid heart rate), encephalopathy (a brain disease that alters the brain's function), severe hyperkalemia (high potassium level), normocytic anemia (codition in which blood does not have enough red blood cells). Resident #3 was discharged from [hospital] on 11/30/2023. During an observation and interview on 01/05/2024 at 2:01PM, Resident #3 was ambulating within her room. Resident #3 stated she was preparing to leave for her appointment to a dialysis center. Resident #3 stated she recalled while she was at her dialysis session on 11/24/2023, she began to feel a pain in her chest, and notified the staff at the dialysis center. Resident #3 stated the pain she felt was not unusual and felt like the chest pains she usually got. Resident #3 stated she recalled being hospitalized on [DATE] for heart issues but does not recall the specifics of her hospitalization . Resident #3 stated she felt fine and did not verbalize any concerns. During an interview on 01/06/2024 at 12:29PM the NP stated she was not made aware by the nursing facility of Resident #3's lack of cardiac medications during the period of 11/16/2023-11/24/2023 but was notified by the facility later of Resident #3's hospitalization on [DATE]. The NP stated the medication reconciliation process when a resident is being admitted is for the receiving facility staff member to notify either the NP, Doctor, or on-call physician, and verify which orders to continue. The NP stated she could not recall going over medication reconciliation for Resident #3 but did recall Resident #3 had a history of cardiac issues. The NP stated she oversees many residents and relies on staff personnel to advocate on a resident's behalf. The NP stated Metoprolol is used for blood pressure and atrial fibrillation, and without proper management could affect a resident's well-being detrimentally, especially if the resident does not receive proper management which would include medication administration. The NP stated she does not recall reconciling medication for Resident #3 upon her admittance into the nursing facility on 11/16/2023 and stated she would expect the nursing facility to do their due diligence and ensure and advocate for the well-being of all residents within their care. The NP stated the usual process for medication reconciliation is during the admission/readmission process nurses will call either her, the Doctor, or on-call physician, and review all hospital orders and whilst on the phone the medical professional will verbalize to either continue/discontinue the nursing facility or hospital orders. The NP stated she was under the impression that either the DON or ADONs would follow up on orders however was not fully knowledgeable of the process of order follow ups. The NP stated the process for acquiring orders is identical to medication reconciliation, the nurses will call either her, the Doctor, or on-call physician and advocate/request orders. The NP stated during the period of 11/16/2023-11/24/2023 she was not contacted for new or continuing orders regarding cardiac medications for Resident #3. The NP stated this instance regarding Resident #3's lack of cardiac medication management/administration may have been her oversight during medication reconciliation on Resident #3's readmittance on 11/16/2023, but stated her expectation is for the facility to follow up and ensure accuracy/advocacy for each resident and stated this was overlooked by the facility. The NP stated Resident #3's hospitalization on [DATE] could potentially have been caused by Resident #3 not receiving her cardiac medications for 8 days and stated Resident #3 could have exhibited signs of uncontrolled atrial fibrillation like chest pains, or palpitation as well as signs of high blood pressure which would be indicative within vital sign results. The NP stated atrial fibrillation could potentially have led to blood clots which would negatively affect any resident's health. During an interview on 01/06/2024 at 12:53PM, LVN C (Charge Nurse) stated she had worked with Resident #3 consistently prior to 11/16/2023. LVN C stated she cared for Resident #3 during the period of 11/16/202311/24/2023 and recalled some of Resident #3 diagnosis history. LVN C stated she was the admitting nurse for Resident #3 on 11/16/2023. LVN C stated she recalled receiving the hospital's medication reconciliation list for Resident #3 and does recall notifying an on-call physician of Resident #3's arrival into the facility on [DATE]. LVN C stated on 11/16/2023, while speaking to the unknown on-call physician, she advocated for the on-call physician to continue Resident #3's Nitroglycerin sublingual tablet due to Resident #3's history of chest pain. LVN C stated she failed to advocate for a continuation of Resident #3's additional cardiac medication admission orders due to her not seeing page 2 of Resident #3's hospital's discharge medication reconciliation form dated 11/16/2023. LVN C stated she takes some responsibility for the mistake, however to her knowledge, no other shift (day/evening/night) from 11/16/2023-11/24/2023, made any inquiry to advocate for Resident #3's medications. LVN C stated Resident #3 went without her cardiac medications for 8 days. LVN C stated she should have been more diligent while going through the hospital medication reconciliation list, however stated it is not just her fault, but the fault of the facility for not doing double checks. LVN C stated when she held an ADON position previously within the facility, she would perform double checks for all admitting/readmitting resident. LVN C stated double checks are when once the admitting nurse uploads the physician's orders upon any admission/readmission, she would follow up the following day to ensure accuracy and verification of all orders. LVN C stated since she withdrew herself from the ADON position, no one has maintained the continuation of the order accuracy/verification process. LVN C stated she does not want to throw anyone under the bus but felt the facility also failed Resident #3 due to not double-checking orders, and stated had the facility double checked orders, the medication error would have been caught. LVN C stated Metoprolol is important for management of blood pressure and used to increase the strength and contractility of the heart's beat, as well as assist with rhythmic abnormalities like atrial fibrillation, and is a very important to the well-being of Resident #3. LVN C stated Hydralazine also assists with the management of blood pressure and is a very important medication because Resident #3 has a history of high blood pressure. LVN C stated if Resident #3's blood pressure was not managed Resident #3 could potentially have a stroke and worst-case scenario could be fatal. LVN C stated collectively as a care team, should have ensured all of Resident #3's medications orders were accurate and active, as well as taken the time to update oneself on the Resident #3's hospitalization as well as advocate for residents in general when a nurse notices irregularities in physician orders. LVN C stated she did not recall noticing any irregularities on Resident 3's orders, but wishes she was more diligent during the admitting medication reconciliation process and stated Resident #3's hospitalization potentially could have been avoided. LVN C stated a sign of uncontrolled atrial fibrillation could be chest pain and recalled on 11/23/2023 notifying the on-call physician of Resident #3's complaint of chest pain, but does not recall who she spoke to, however does recall the physician instructed her to maintain a three pill protocol (administer 1 nitroglycerin pill, assess after 5 minutes, if chest pain persists, administer another nitroglycerin pill, wait assess after 5minutes, if chest pain persists, administer 1 more nitroglycerin pill, after the third pill send out to EMS) state after she administered Resident #3's first nitroglycerin tablet, Resident #3 verbalized no additional concerns for chest pain. LVN C stated she was in-serviced on medication reconciliation, medication error/transcription error process, notification to medical director for verification/clarification of medications upon admission/readmission, as well as correctly verbalized her directive to ensure any admission/readmission of any resident is secondly notified to the ADONs. During an interview on 01/06/2024 at 1:54PM, LVN D stated she had been taking care of Resident #3 for at least a year. LVN D stated the process when admitting/readmitting a resident is to perform a head-to-toe assessment, vital signs, verify medications with the doctor and ask if they want to continue medications, as well as interact and learn as much history from the resident. LVN D stated she recalled Resident #3 began dialysis recently, as well as had a history of hypertension, early dementia, and diabetes. LVN D stated she recalled Resident #3 had cardiac issues as well as a history of stroke or heart attack and recalled Resident #3's heart was not in good condition. LVN D stated a generalized statement that during Resident #3's several hospitalization s, the hospitals would administer many medications and stated the hospitals did not think about the long-term effects for Resident #3. LVN D stated she theorized that even if Resident #3 was given the cardiac medications during the 8-day period between 11/16/2023-11/24/2023, the outcome of hospitalization , would have been the same due to Resident #3's cardiac issues. LVN D stated chest pain could have been indicative of cardiac issues. LVN D stated the process of medication reconciliation is for the admitting nurse to verify with the doctor/NP which orders they want for each resident. LVN D stated the process to attain orders is the same as medication reconciliation, the nurse will call the Doctor/NP to acquire orders. LVN D stated she wished and should have advocated for Resident #3 cardiac medications. LVN D stated she did not call Doctor or NP for cardiac medication orders for Resident #3 during those 8 days because she believed all medication reconciliation orders for Resident #3 had been taken care of and did not think much about it because she believed all orders had been taken care of. LVN D stated she felt terrible that the lack of advocacy for Resident #3 results in Resident #3's hospitalization . LVN D stated everyone at the facility was at fault for not advocating for Resident #3, and stated this medication error could have been caught, and should have been caught, but was not. LVN D stated this failure could have jeopardized the well-being and health of Resident #3. LVN D stated she attended multiple in-services on 11/28/2023 and 11/29/2023, and correctly verbalized the process for medication reconciliation/ medication error/transcriptions, as well as verbalized her directive to notify ADONs as part of a double check, of all admission/readmissions of residents to ensure accuracy of all physician orders. During an interview on 01/08/2024 at 10:47AM, ADON A stated the admission/readmission process is for the admitting nurse to verify orders with doctor and confirm what orders the physician wants to maintain or implement. ADON A stated during the admitting/readmitting verification process the nurse will ensure accuracy of specific order parameters and should be diligent and thorough when reviewing the medication reconciliation with MD. ADON A stated prior to Resident #3's 11/16/2023 medication reconciliation incident, she was unaware of ADONs tasked to check/verify medication reconciliation admission/readmission orders. ADON A stated she does not recall being notified of any medication irregularities regarding Resident #3 during 11/16/2023-11/24/2023. ADON A stated the expectation of the facility is for all nurses to do their due diligence and double check all orders especially when confirming hospital orders with physicians. ADON A stated on 11/16/2023, LVN C may have reviewed Resident #3's medication reconciliation with physician quickly which could have led to LVN C overlooking page 2 on Resident #3's hospital's 11/16/2023 medication reconciliation form. ADON A stated LVN C should have taken her time and thoroughly reviewed each page with the MD, which could have potentially eliminated Resident #3's 11/24/2023 hospitalization . ADON A stated if Resident #3's atrial fibrillation was uncontrolled, Resident #3's well-being could have jeopardized, due to the lack of rhythmic medication management, which potentially could have been fatal. ADON A stated similarly, if Resident #3's blood pressure was high and uncontrolled by medication management, the well-being of Resident #3 could have been negatively impacted. ADON A stated she attended several in-services on 11/28/2023 and 11/29/2023 and verbalized the correct procedures of her role to thoroughly verify all physician orders upon admission/readmission within a 24hr period. During an interview on 01/08/2024 at 11:15AM, MA A stated he knew Resident #3 well. MA A stated he recalled Resident #3 had taken scheduled oral cardiac medications prior to 11/16/2023. MA A stated one thing that he recognized on 11/17/2023 was that Resident #3's blood pressure medications were not on Resident #3's MAR and recalled inquiring to LVN C about Resident #3's cardiac medications. MA A stated LVN C stated Resident #3 was newly on dialysis and that would assist with Resident #3's blood pressure issue but gave no definitive answer if Resident #3 would resume/begin with any blood pressure medications, and believed LVN C would follow up on MA A's concern. MA A stated from work experience he did not believe dialysis would solely fix the problem for Resident #3's blood pressure but was confident that LVN C would advocate for Resident #3. MA A stated he still took Resident #3's blood pressure vital signs during 11/17/2023-11/24/2023. MA A stated the following day on 11/18/2023, he notified RN A about Resident #3's high blood pressure readings, and that RN A stated she would give Resident #3 Clonidine PRN. MA A stated he asked/notified RN A about his concern, that Resident #3 did not have her previous blood pressure medications on the MAR but was not given a definitive answer on how to proceed. MA A stated he notified LVN D of Resident #3's blood pressure reading on 11/19/2023 but again was not given a definitive answer. MA A stated he felt within those 3 days LVN C, LVN D, and RN A did not hear/act upon his concern. MA A stated he continued to take Resident #3's blood pressure even though Resident #3 was not receiving blood pressure medications, as his attempt to advocate for Resident #3. MA A stated he took pride in his work because resident lives are in staff's hands. MA A stated when speaking to the three nurses he did not feel heard, and that staff cannot pick and choose what parts of care to do and not do. MA A stated he did not believe the facility neglected Resident #3. MA A stated he attended in-services on 11/28/2023 and 11/29/2023, and correctly verbalized the procedures of notifying licensed nurse, charge nurse, ADON, or DON with any concerns or discrepancies regarding medications. During an interview on 01/08/2024 at 11:53AM, RN A stated on 11/17/2023, during the day shift, she reviewed Resident #3 hospitalization record dated 11/16/2023, as well as reviewed Resident #3's medication reconciliation form also dated 11/16/2023. RN A stated on 11/17/2023, she noticed several discrepancies regarding Resident #3's blood pressure medications while she was comparing Resident #3's facility chart to the hospital medication reconciliation form. RN A stated she noticed that Resident #3's blood pressure medications were not active in the Resident #3's MAR. RN A stated once she realized the discrepancies, she took the concern to ADONs. RN A stated the ADONs told her that the medications would have to be reviewed and confirmed by the admitting nurse and MD. RN A stated originally, she assumed the ADONs would verify and solve the issue, and stated she did not want to call and clarify/bother the admitting nurse. RN A stated she could have called the MD and wishes she did now. RN A stated she was knowledgeable of the process to attain physician orders, but did not attempt to contact the MD, NP, or on-call physician because she believed the ADONs would take care of Resident #3's blood pressure medication issue. RN A stated she should have advocated for continuation of cardiac medications for Resident #3 and wishes she did. RN A stated Resident #3 was under her care on 11/17/2023 and 11/18/2023 but was never notified of any staff regarding blood pressure abnormalities for Resident #3. RN A stated if high blood pressure is not managed properly, high blood pressure could lead to heart attack, stroke, as well as if high blood pressure is uncontrolled, it could have affected Resident #3 in a negative way, and worst-case scenario be fatal. RN A stated she attended several in-services on 11/28/2023 and 11/29/2023, and correctly verbalized the procedures regarding medication error/transcription error, medication reconciliation and order entries for admission/readmission, clarification of medication and for any concerns or discrepancies of medication and must notify DON and immediately call the MD in charge of resident to clarify. RN A stated within the in-services on 11/28/2023 and 11/29/2023, she was directed to notify ADONs of any admission/readmissions and the ADONs are tasked to follow up and verify. During an interview on 01/08/2024 at 1:13PM, the interim DON stated she has been positioned at the facility for the past three weeks and was not present during the incident regarding Resident #3's failed medication reconciliation post hospitalization of 11/16/2023. The interim DON stated she did familiarize herself with the 11/28/2023 in-service regarding medication reconciliation and stated the facility's expectation for medication reconciliation process, is that ADONs are to verify reconciled medications and ensure accuracy during daily clinical morning meetings. During the daily morning clinical meetings, the managerial team will review all new admission/readmissions that happened 24 hours prior. The interim DON stated blood pressure medications are important to the well-being of any resident experiencing high blood pressure. The interim DON stated if blood pressure is not managed properly, blood pressure can increase and lead to stroke. The interim DON stated in worst-case scenario blood pressure can lead to stroke, which can then be fatal. The interim stated she was briefed about the incident regarding Resident #3 and was told that the clinical nursing staff did not realize that Resident #3 was without cardiac medications. The interim DON stated it is the expectation that post the initial medication reconciliation, ADONs are verifying orders 24hr after admission/readmissions to ensure accuracy and verification of all physician orders. The interim DON stated the nursing staff (day/evening/night shift) during the 8-day period of 11/16/2023-11/24/2023, should have reviewed Resident #3's chart/orders/hospitalization record to familiarize themselves with the most updated plan of care, and in doing so may have uncovered the medication discrepancy which potentially could have kept Resident #3 from being hospitalized . The interim DON stated had the nursing staff realized the medication discrepancy, they should have advocated for cardiac medications for Resident #3. Prior to entrance on 01/04/2024, the facility conducted the following training: Record review of the facility's 11/28/2023 Inservice: Medication Error/Transcription Error: All Medication errors identified must notify MD, DON immediately. Record review of the facility's 11/28/2023 Inservice: Notification to MD/ verification/clarification of Meds upon admit/re-admit: Return from ER med and document upon any admission/readmit all medications and orders to be verified by Dr. if NP on call Dr. and correctly entered into PCC Nurses to document on any D/C or readmit time where admit/d/c to and notify DON. Record review of the facility's 11/28/2023 Inservice: Medication reconciliation and order entry for admission/readmission from ER. Nurses to ensure all medications and orders upon admit/readmit have been checked with Doctor/FNP/On-call Drs. And correctly entered into PCC. Record review of the facility's 11/29/2023 Inservice Clarification of medications: For any concerns or discrepancies of medications, licensed nurse must notify DON and immediately call the MD in charge of resident to clarify. Record review of the facility's 11/29/2023 Inservice: Medication Review (orders): 1. Review resident orders or admission/readmission/ER (emergency room ) visits during the morning clinical meeting to ensure orders are transcribed correctly. 2. New orders will be reviewed in the morning clinical meeting by the DON to ensure orders are written correctly. Observation of medication pass beginning on 01/08/2024 at 9:34AM of Resident's #4 and #5 revealed no identified concerns. Record review of the facility's Medication Reconciliation policy and procedure dated 04/10/2023 revealed, this facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent. 4. Admission process b. Compare orders to hospital records, etc. Obtain clarification order as needed. c. Transcribe orders in accordance with procedures for admission orders. e. Verify medications received match the medication orders.

Based on interview, and record review, the facility failed to ensure for 1 of 11 residents (Resident #3) was admitted with physician order for their care reviewed for admission orders, in that. LVN C failed to accurately reconcile Resident #3's hospital instructions to resume medications with the physician for her prescribed heart medication of: Hydralazine 50mg Q8hr, Metoprolol 50mg Q12hr, Isosorbide dinitrate 20mg daily, or Nifedipine 20mg Q8hr from 11/16/2023-11/24/2023 (8days). The noncompliance was identified as PNC. The IJ began on 11/16/23 and ended on 11/28/23. The facility had corrected the noncompliance before the survey began. This failure could have jeopardized the well-being of Resident #3 as well as could have led to the demise of Resident #3. Findings include: Record review of Resident #3's face sheet dated 01/05/2024 documented an [AGE] year-old female with a diagnosis of hyperlipidemia (high cholesterol), hypertension (high blood pressure), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), atrial fibrillation (irregular heart rhythm), chronic kidney disease (kidney damage), transient ischemic attack and cerebral infarction (stroke). Record review of Resident #3's MDS dated [DATE] documented Resident #3's BIMS score of 12/15 moderate cognitive impairment, as well as coded Resident #3 with atrial fibrillation or other dysrhythmias, coronary artery disease, hypertension, and renal insufficiency/renal failure or end-stage renal disease. Record review of Resident #3's care plan date initiated on 08/02/2023 documented, Resident #3 has HAD transient ischemic attacks (TIA)(stroke) r/t Atrial fibrillation. Goal: Resident #3 will be free from s/sx of complications r/t TIA through the review date. Interventions: Address resident by name, introduce self and explain what you are going to do with each interaction. Educate resident/family/caregivers about the importance of seeking medical consultation to determine cause of TIA even though the symptoms resolve in order to prevent potential problems such as major stroke. Monitor for and document any s/sx of ineffective cerebral perfusion: Altered mental status, Dysphasia, pupil changes, abnormal speech patterns or aphasia, weakness or paralysis of an extremity, behavioral changes, any changes in motor responses. Record review of Resident #3's care plan date initiated on 08/02/2023 documented, Resident #3 has altered cardiovascular status r/t Hypertension, CAD, AFIB. Goal: Resident #3 will be free from complications of cardiac problems through the review date. Assess for chest pain every (specify). Enforce the need to call for assistance is pain. Assess for shortness of breath and cyanosis (bluish or grayish color of skin, nails, lips or around the eyes) every (specify) Medications as ordered by MD for Hypertension and AFIB. Monitor/document/report PRN any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight. Monitor/document/report PRN any s/sx of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in capillary refill, color/warmth of extremities. Record review of Resident #3's hospital discharge medication reconciliation list dated 11/16/2023 at 3:24PM, [hospital] discharged Resident #3 with a finalized Discharge Medication list that documented to continue Hydralazine 50mg Q8hr, Metoprolol tartrate 50mg Q12hr, Isosorbide dinitrate 20mg daily and Nifedipine 20mg Q8hr Record review of Resident #3's physician orders documented: From 11/16/2023-11/24/2023, none of the listed medications were reordered. -Isosorbide Dinitrate 20mg tablet PO for heart failure state date: 11/07/2023 d/c date:11/15/2023 -Nifedipine ER 30mg tablet PO Daily state date: 11/13/2023 d/c date: 11/15/2023 -Metoprolol tartrate 50mg tablet Q12hr for hypertension start date: 11/06/2023 d/c date: 11/15/2023. -Hydralazine HCL 50mg tablet PO Q8hr for hypertension start date: 11/07/2023 d/c date: 11/15/2023. Record review of Resident #3's blood pressure on: 11/16/2023 No blood pressure reading available. 11/17/2023 at 12:47AM: 160/81, 7:17PM: 180/75 11/18/2023 at 1:56AM 173/80, 12:37PM:172/85, 7:53PM 169/84 11/19/2023 at 2:02AM:155/80, 1:42PM 150/78 Record review of Resident #3's progress note dated 11/23/2023 at 9:14PM, LVN C documented patient complained of chest pain she was given one sublingual tablet of nitroglycerin (used to treat chest pain) that was effective. Record review of Resident #3's progress note dated 11/24/2023 at 7:55PM, LVN D documented received call from dialysis sending resident to [hospital] emergency room diagnosis atrial fibrillation. Called RP made aware and DON. Record review of Resident #3's progress note dated 11/28/2023, ADON B documented notified by case manager at hospital that resident's family member had concerns over whether BP meds were given while resident was in facility, conducted a review of admission orders and determined medication reconciliation had inconsistencies. Medication reconciliation completed with inconsistencies. Record review of Resident #3's [hospital] discharge report on 11/24/2023 Resident #3 was admitted to [hospital] for NSTEMI type 2 (heart attack), Atrial fibrillation (irregular often rapid heart rate), encephalopathy (a brain disease that alters the brain's function), severe hyperkalemia (high potassium level), normocytic anemia (codition in which blood does not have enough red blood cells). Resident #3 was discharged from [hospital] on 11/30/2023. During an observation and interview on 01/05/2024 at 2:01PM, Resident #3 was ambulating within her room. Resident #3 stated she was preparing to leave for her appointment to a dialysis center. Resident #3 stated she recalled while she was at her dialysis session on 11/24/2023, she began to feel a pain in her chest, and notified the staff at the dialysis center. Resident #3 stated the pain she felt was not unusual and felt like the chest pains she usually got. Resident #3 stated she recalled being hospitalized on [DATE] for heart issues but does not recall the specifics of her hospitalization . Resident #3 stated she felt fine and did not verbalize any concerns. During an interview on 01/06/2024 at 12:29PM the NP stated she was not made aware by the nursing facility of Resident #3's lack of cardiac medications during the period of 11/16/2023-11/24/2023 but was notified by the facility later of Resident #3's hospitalization on [DATE]. The NP stated the medication reconciliation process when a resident is being admitted is for the receiving facility staff member to notify either the NP, Doctor, or on-call physician, and verify which orders to continue. The NP stated she could not recall going over medication reconciliation for Resident #3 but did recall Resident #3 had a history of cardiac issues. The NP stated she oversees many residents and relies on staff personnel to advocate on a resident's behalf. The NP stated Metoprolol is used for blood pressure and atrial fibrillation, and without proper management could affect a resident's well-being detrimentally, especially if the resident does not receive proper management which would include medication administration. The NP stated she does not recall reconciling medication for Resident #3 upon her admittance into the nursing facility on 11/16/2023 and stated she would expect the nursing facility to do their due diligence and ensure and advocate for the well-being of all residents within their care. The NP stated the usual process for medication reconciliation is during the admission/readmission process nurses will call either her, the Doctor, or on-call physician, and review all hospital orders and whilst on the phone the medical professional will verbalize to either continue/discontinue the nursing facility or hospital orders. The NP stated she was under the impression that either the DON or ADONs would follow up on orders however was not fully knowledgeable of the process of order follow ups. The NP stated the process for acquiring orders is identical to medication reconciliation, the nurses will call either her, the Doctor, or on-call physician and advocate/request orders. The NP stated during the period of 11/16/2023-11/24/2023 she was not contacted for new or continuing orders regarding cardiac medications for Resident #3. The NP stated this instance regarding Resident #3's lack of cardiac medication management/administration may have been her oversight during medication reconciliation on Resident #3's readmittance on 11/16/2023, but stated her expectation is for the facility to follow up and ensure accuracy/advocacy for each resident and stated this was overlooked by the facility. The NP stated Resident #3's hospitalization on [DATE] could potentially have been caused by Resident #3 not receiving her cardiac medications for 8 days and stated Resident #3 could have exhibited signs of uncontrolled atrial fibrillation like chest pains, or palpitation as well as signs of high blood pressure which would be indicative within vital sign results. The NP stated atrial fibrillation could potentially have led to blood clots which would negatively affect any resident's health. During an interview on 01/06/2024 at 12:53PM, LVN C (Charge Nurse) stated she has worked with Resident #3 consistently prior to 11/16/2023. LVN C stated she cared for Resident #3 during the period of 11/16/202311/24/2023 and recalled some of Resident #3 diagnosis history. LVN C stated she was the admitting nurse for Resident #3 on 11/16/2023. LVN C stated she recalled receiving the hospital's medication reconciliation list for Resident #3 and does recall notifying an on-call physician of Resident #3's arrival into the facility on [DATE]. LVN C stated on 11/16/2023, while speaking to the unknown on-call physician, she advocated for the on-call physician to continue Resident #3's Nitroglycerin sublingual tablet due to Resident #3's history of chest pain. LVN C stated she failed to advocate for a continuation of Resident #3's additional cardiac medication admission orders due to her not seeing page 2 of Resident #3's hospital's discharge medication reconciliation form dated 11/16/2023. LVN C stated she takes some responsibility for the mistake, however to her knowledge, no other shift (day/evening/night) from 11/16/2023-11/24/2023, made any inquiry to advocate for Resident #3's medications. LVN C stated Resident #3 went without her cardiac medications for 8 days. LVN C stated she should have been more diligent while going through the hospital medication reconciliation list, however stated it is not just her fault, but the fault of the facility for not doing double checks. LVN C stated when she held an ADON position previously within the facility, she would perform double checks for all admitting/readmitting resident. LVN C stated double checks are when once the admitting nurse uploads the physician's orders upon any admission/readmission, she would follow up the following day to ensure accuracy and verification of all orders. LVN C stated since she withdrew herself from the ADON position, no one has maintained the continuation of the order accuracy/verification process. LVN C stated she does not want to throw anyone under the bus but felt the facility also failed Resident #3 due to not double-checking orders, and stated had the facility double checked orders, the medication error would have been caught. LVN C stated Metoprolol is important for management of blood pressure and used to increase the strength and contractility of the heart's beat, as well as assist with rhythmic abnormalities like atrial fibrillation, and is a very important to the well-being of Resident #3. LVN C stated Hydralazine also assists with the management of blood pressure and is a very important medication because Resident #3 has a history of high blood pressure. LVN C stated if Resident #3's blood pressure was not managed Resident #3 could potentially have a stroke and worst-case scenario could be fatal. LVN C stated collectively as a care team, should have ensured all of Resident #3's medications orders were accurate and active, as well as taken the time to update oneself on the Resident #3's hospitalization as well as advocate for residents in general when a nurse notices irregularities in physician orders. LVN C stated she did not recall noticing any irregularities on Resident 3's orders, but wishes she was more diligent during the admitting medication reconciliation process and stated Resident #3's hospitalization potentially could have been avoided. LVN C stated a sign of uncontrolled atrial fibrillation could be chest pain and recalled on 11/23/2023 notifying the on-call physician of Resident #3's complaint of chest pain, but does not recall who she spoke to, however does recall the physician instructed her to maintain a three pill protocol (administer 1 nitroglycerin pill, assess after 5 minutes, if chest pain persists, administer another nitroglycerin pill, wait assess after 5minutes, if chest pain persists, administer 1 more nitroglycerin pill, after the third pill send out to EMS) state after she administered Resident #3's first nitroglycerin tablet, Resident #3 verbalized no additional concerns for chest pain. LVN C stated she was in-serviced on medication reconciliation, medication error/transcription error process, notification to medical director for verification/clarification of medications upon admission/readmission, as well as correctly verbalized her directive to ensure any admission/readmission of any resident is secondly notified to the ADONs. During an interview on 01/06/2024 at 1:54PM, LVN D stated she has been taking care of Resident #3 for at least a year. LVN D stated the process when admitting/readmitting a resident is to perform a head-to-toe assessment, vital signs, verify medications with the doctor and ask if they want to continue medications, as well as interact and learn as much history from the resident. LVN D stated she recalled Resident #3 began dialysis recently, as well as had a history of hypertension, early dementia, and diabetes. LVN D stated she recalled Resident #3 had cardiac issues as well as a history of stroke or heart attack and recalled Resident #3's heart was not in good condition. LVN D stated a generalized statement that during Resident #3's several hospitalization s, the hospitals would administration many medications and stated the hospitals did not think about the long-term effects for Resident #3. LVN D stated she theorized that even if Resident #3 was given the cardiac medications during the 8-day period between 11/16/2023-11/24/2023, the outcome of hospitalization , would have been the same due to Resident #3's cardiac issues. LVN D stated chest pain could have been indicative of cardiac issues. LVN D stated the process of medication reconciliation is for the admitting nurse to verify with the doctor/NP which orders they want for each resident. LVN D stated the process to attain orders is the same as medication reconciliation, the nurse will call the Doctor/NP to acquire orders. LVN D stated she wished and should have advocated for Resident #3 cardiac medications. LVN D stated she did not call Doctor or NP for cardiac medication orders for Resident #3 during those 8 days because she believed all medication reconciliation orders for Resident #3 had been taken care of and did not think much about it because she believed all orders had been taken care of. LVN D stated she felt terrible that the lack of advocacy for Resident #3 results in Resident #3's hospitalization . LVN D stated everyone at the facility was at fault for not advocating for Resident #3, and stated this medication error could have been caught, and should have been caught, but was not. LVN D stated this failure could have jeopardized the well-being and health of Resident #3. LVN D stated she attended multiple in-services on 11/28/2023 and 11/29/2023, and correctly verbalized the process for medication reconciliation/ medication error/transcriptions, as well as verbalized her directive to notify ADONs as part of a double check, of all admission/readmissions of residents to ensure accuracy of all physician orders. During an interview on 01/08/2024 at 10:47AM, ADON A stated the admission/readmission process is for the admitting nurse to verify orders with doctor and confirm what orders the physician wants to maintain or implement. ADON A stated during the admitting/readmitting verification process the nurse will ensure accuracy of specific order parameters and should be diligent and thorough when reviewing the medication reconciliation with MD. ADON A stated prior to Resident #3's 11/16/2023 medication reconciliation incident, she was unaware of ADONs tasked to check/verify medication reconciliation admission/readmission orders. ADON A stated she does not recall being notified of any medication irregularities regarding Resident #3 during 11/16/2023-11/24/2023. ADON A stated the expectation of the facility is for all nurses to do their due diligence and double check all orders especially when confirming hospital orders with physicians. ADON A stated on 11/16/2023, LVN C may have reviewed Resident #3's medication reconciliation with physician quickly which could have led to LVN C overlooking page 2 on Resident #3's hospital's 11/16/2023 medication reconciliation form. ADON A stated LVN C should have taken her time and thoroughly reviewed each page with the MD, which could have potentially eliminated Resident #3's 11/24/2023 hospitalization . ADON A stated if Resident #3's atrial fibrillation was uncontrolled, Resident #3's well-being could have jeopardized, due to the lack of rhythmic medication management, which potentially could have been fatal. ADON A stated similarly, if Resident #3's blood pressure was high and uncontrolled by medication management, the well-being of Resident #3 could have been negatively impacted. ADON A stated she attended several in-services on 11/28/2023 and 11/29/2023 and verbalized the correct procedures of her role to thoroughly verify all physician orders upon admission/readmission within a 24hr period. During an interview on 01/08/2024 at 11:15AM, MA A stated he knew Resident #3 well. MA A stated he recalled Resident #3 had taken scheduled oral cardiac medications prior to 11/16/2023. MA A stated one thing that he recognized on 11/17/2023 was that Resident #3's blood pressure medications were not on Resident #3's MAR and recalled inquiring to LVN C about Resident #3's cardiac medications. MA A stated LVN C stated Resident #3 was newly on dialysis and that would assist with Resident #3's blood pressure issue but gave no definitive answer if Resident #3 would resume/begin with any blood pressure medications, and believed LVN C would follow up on MA A's concern. MA A stated from work experience did not believe dialysis would solely fix the problem for Resident #3's blood pressure but was confident that LVN C would advocate for Resident #3. MA A stated he still took Resident #3's blood pressure vital signs during 11/17/2023-11/24/2023. MA A stated the following day on 11/18/2023, he notified RN A about Resident #3's high blood pressure readings, and that RN A stated she would give Resident #3 Clonidine PRN. MA A stated he asked/notified RN A about his concern, that Resident #3 did not have her previous blood pressure medications on the MAR but was not given a definitive answer on how to proceed. MA A stated he notified LVN D of Resident #3's blood pressure reading on 11/19/2023 but again was not given a definitive answer. MA A stated he felt within those 3 days LVN C, LVN D, and RN A did not hear/act upon his concern. MA A stated he continued to take Resident #3's blood pressure even though Resident #3 was not receiving blood pressure medications, as his attempt to advocate for Resident #3. MA A stated he takes pride in his work because resident lives are in staff's hands. MA A stated when speaking to the three nurses he did not feel heard, and that staff cannot pick and choose what parts of care to do and not do. MA A stated he did not believe the facility neglected Resident #3. MA A stated he attended in-services on 11/28/2023 and 11/29/2023, and correctly verbalized the procedures of notifying licensed nurse, charge nurse, ADON, or DON with any concerns or discrepancies regarding medications. During an interview on 01/08/2024 at 11:53AM, RN A stated on 11/17/2023, during the day shift, she reviewed Resident #3 hospitalization record dated 11/16/2023, as well as reviewed Resident #3's medication reconciliation form also dated 11/16/2023. RN A stated on 11/17/2023, she noticed several discrepancies regarding Resident #3's blood pressure medications while she was comparing Resident #3's facility chart to the hospital medication reconciliation form. RN A stated she noticed that Resident #3's blood pressure medications were not active in the Resident #3's MAR. RN A stated once she realized the discrepancies, she took the concern to ADONs. RN A stated the ADONs told her that the medications would have to be reviewed and confirmed by the admitting nurse and MD. RN A stated originally, she assumed the ADONs would verify and solve the issue, and stated she did not want to call and clarify/bother the admitting nurse. RN A stated she could have called the MD and wishes she did now. RN A stated she was knowledgeable of the process to attain physician orders, but did not attempt to contact the MD, NP, or on-call physician because she believed the ADONs would take care of Resident #3's blood pressure medication issue. RN A stated she should have advocated for continuation of cardiac medications for Resident #3 and wishes she did. RN A stated Resident #3 was under her care on 11/17/2023 and 11/18/2023 but was never notified of any staff regarding blood pressure abnormalities for Resident #3. RN A stated if high blood pressure is not managed properly, high blood pressure could lead to heart attack, stroke, as well as if high blood pressure is uncontrolled, it could have affected Resident #3 in a negative way, and worst-case scenario be fatal. RN A stated she attended several in-services on 11/28/2023 and 11/29/2023, and correctly verbalized the procedures regarding medication error/transcription error, medication reconciliation and order entries for admission/readmission, clarification of medication and for any concerns or discrepancies of medication and must notify DON and immediately call the MD in charge of resident to clarify. RN A stated within the in-services on 11/28/2023 and 11/29/2023, she was directed to notify ADONs of any admission/readmissions and the ADONs are tasked to follow up and verify. During an interview on 01/08/2024 at 1:13PM, the interim DON stated she has been positioned at the facility for the past three weeks and was not present during the incident regarding Resident #3's failed medication reconciliation post hospitalization of 11/16/2023. The interim DON stated she did familiar herself with the 11/28/2023 in-service regarding medication reconciliation and stated the facility's expectation for medication reconciliation process, is that ADONs are to verify reconciled medications and ensure accuracy during daily clinical morning meetings. During the daily morning clinical meetings, the managerial team will review all new admission/readmissions that happened 24 hours prior. The interim DON stated blood pressure medications are important to the well-being of any resident experiencing high blood pressure. The interim DON stated if blood pressure is not managed properly, blood pressure can increase and lead to stroke. The interim DON stated in worst-case scenario blood pressure can lead to stroke, which can then be fatal. The interim stated she was briefed about the incident regarding Resident #3 and was told that the clinical nursing staff did not realize that Resident #3 was without cardiac medications. The interim DON stated it is the expectation that post the initial medication reconciliation, ADONs are verifying orders 24hr after admission/readmissions to ensure accuracy and verification of all physician orders. The interim DON stated the nursing staff (day/evening/night shift) during the 8-day period of 11/16/2023-11/24/2023, should have reviewed Resident #3's chart/orders/hospitalization record to familiarize themselves with the most updated plan of care, and in doing so may have uncovered the medication discrepancy which potentially could have kept Resident #3 from being hospitalized . The interim DON stated had the nursing staff realized the medication discrepancy, they should have advocated for cardiac medications for Resident #3. Prior to entrance on 01/04/2024, the facility conducted the following training: Record review of the facility's 11/28/2023 Inservice: Medication Error/Transcription Error: All Medication errors identified must notify MD, DON immediately. Record review of the facility's 11/28/2023 Inservice: Notification to MD/ verification/clarification of Meds upon admit/re-admit: Return from ER med and document upon any admission/readmit all medications and orders to be verified by Dr. if NP on call Dr. and correctly entered into PCC Nurses to document on any D/C or readmit time where admit/d/c to and notify DON. Record review of the facility's 11/28/2023 Inservice: Medication reconciliation and order entry for admission/readmission from ER. Nurses to ensure all medications and orders upon admit/readmit have been checked with Doctor/FNP/On-call Drs. And correctly entered into PCC. Record review of the facility's 11/29/2023 Inservice Clarification of medications: For any concerns or discrepancies of medications, licensed nurse must notify DON and immediately call the MD in charge of resident to clarify. Record review of the facility's 11/29/2023 Inservice: Medication Review (orders): 1. Review resident orders or admission/readmission/ER (emergency room ) visits during the morning clinical meeting to ensure orders are transcribed correctly. 2. New orders will be reviewed in the morning clinical meeting by the DON to ensure orders are written correctly. Observation of medication pass beginning on 01/08/2024 at 9:34AM of Resident's #4 and #5 revealed no identified concerns. Record review of the facility's Medication Reconciliation policy and procedure dated 04/10/2023 revealed, this facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent. 4. Admission process b. Compare orders to hospital records, etc. Obtain clarification order as needed. c. Transcribe orders in accordance with procedures for admission orders. e. Verify medications received match the medication orders.

Based on observation, record review and interview, the facility failed to implement policies and procedures that prohibit and prevent neglect for three Residents (R#3, R#2 and R#1) out of 15 residents reviewed for dehydration. The facility was aware R#3 was at risk for dehydration but did not monitor or encourage R#3's fluid intake. R#3 had recently returned from the hospital with the [DIAGNOSES REDACTED]. The facility failed to provide R#2 with any Gastrostomy feeding or water for seven hours. R#2 Dietary Progress Note dated 11/29/16 revealed: Vital 1.5@ 70ml/hr x24 hour. Flush with H20 150mlq 4hrs . 2520kcal (formula) + 160kcal (Juven) .900ml (flushes)= 2500ml R #1's feeding supplement (Nepro) was not increased to 45 centimeters (cc) an hour and Juven (nutritional supplement) was not administered as ordered by the Physician. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 11-30-16. The IJ was removed on 12-02-16, however, the facility remained out of compliance at a severity of actual harm with a scope assessed as a pattern. These failures could affect 67 residents identified with hydration issues. The findings were: The facility's training information, undated defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. R#3 R#3's Face Sheet dated 05/04/15 indicated R#3 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Face Sheet indicated R#3 was [AGE] years old. R#3's Admission Minimum Data Set ((MDS) dated [DATE] indicated R#3 had clear speech, was understood and could understand others. Her vision was severely impaired. R#3 required extensive assistance for bed mobility, transfers, dressing and toileting by two or more staff assistance. According to the MDS, R#3 required supervision (oversight, encouragement or cueing for eating. R#3's Care Plan with problem onset date of 03/13/14 indicated R#3 was at risk for dehydration due to her fluctuation cognition causing her to be unaware to drink adequate amounts of fluids. R#3 also has a history of dehydration. Goal &Target Date indicated R#3 would drink 5-6 cups of fluid daily for the next 90 days, target date-12/25/16; R#3 would drink 7-8 cups of water 5 days a week within the next 90 days, target date-12/25/16. Approaches listed were: Monitor R#3's electrolytes; Monitor for changes in R#3's symptoms that may indicate worsening of condition and notify the physician; Hydration Assessment Quarterly and as needed and Bowel and Bladder Assessment Quarterly and as needed. Another Care Plan with the problem onset date of 03/21/14 indicated R#3 had severely impaired visual functioning. No vision or sees only light, colors or shapes due to her [DIAGNOSES REDACTED]. The Care Plan indicated R#3 was at risk for falls and injury due to decreased vision. One approach listed was that R#3 would be assisted with eating, dressing and grooming as needed. Hospital History and Physical admitted , 10/31/16 indicated R#3 became very lethargic and had been brought to the emergency room , noted to have acute kidney failure. The Assessment indicated R#3 had Acute Kidney Injury, [MEDICAL CONDITION], high potassium and Hypotensive shock due to dehydration. Progress Note written by Nurse Practitionar (NP) Q dated 11/10/16 indicated the NP had seen R#3 for a follow-up on this date after being discharged from the hospital for acute kidney injury, [MEDICAL CONDITION] and hypotensive shock due to dehydration. Departmental Notes dated 11/14/16 at 7:26 p.m. indicated R#3 was prescribed an antibiotic for a urinary tract infection [MEDICAL CONDITION]. Admission Quarterly Hydration assessment dated [DATE] indicated R#3 was on a Diuretic and a laxative, putting her at risk for dehydration. R#3 was observed during initial tour on 11/28/16 at approximately 8:25 a.m. Registered Nurse (RN) L who accompanied the surveyor stated R#3 was alert and interviewable and was able to feed herself. RN L added R#3 was almost blind and preferred to stay in bed. RN L also stated R#3 had been on hospice, but was no longer on hospice. R#3 asked for ice. R#3 was observed sleeping at 12:46 p.m. A salad with ham, milk, apple juice and house shake (supplement) sat on her tray, next to her bed. Observation showed the tray and drinks remained untouched at 2:20 p.m. R#3 was observed sleeping. On 11/28/16 at 3:55 p.m., the surveyor asked RN L if R#3 would be getting help with her meal, since it was still untouched. At this time, a certified nurse aide (CNA) attempted to give R#3 the salad. R#3 asked the CNA if there was wilted lettuce and let the CNA know that she could go ahead and throw it in the trash. R#3 did ask for juice and the CNA told R#3 there was juice on the tray. R#3 did not drink the juice and the CNA did not help R#3 drink the juice. On 11/29/16 at 8:28 a.m., R#3 was observed in her room. The breakfast tray was in front of her. R#3 stated her breakfast was not good. The surveyor observed a gnat flying around her scrambled eggs and there was milk and water spilled in the eggs. R#3 had cranberry juice, water and a house shake also. R#3 stated the staff did not know how to fix boiled eggs and that they brought her the same foods. R#3 stated her patience was getting very low. R#3 stated she had the staff put ice in her glass and that she had to tell the staff to bring her ice because they wouldn't remember. There was a large mug half filled with ice. R#3 stated she liked the ice to melt. R#3 stated no one helped her eat and that she helped herself. CNA P stated on 11/29/16 at 10:45 a.m. that she documented on the computer the percentage of food the residents ate, but did not document if the residents were consuming the supplements provided. On 11/29/16 at 11:55 a.m., R#3 stated she did need someone to help her eat and she would be very glad if someone helped her. On 11/29/16 at 12:35 p.m., R#3's lunch tray was on her side table. R#3 was asleep. The resident had a vanilla house shake, apple juice, water plus some of the cranberry juice from her breakfast. R#3 was sleeping at 2:05 p.m. Her lunch tray was still by her bedside. R#3's mug was half filled with melted ice, the apple juice, house shake were not yet touched. R#3cranberry juice from breakfast was still sitting there also. On 11/29/16 at 2:45 p.m., R#3 was awake. R#3 stated she told staff not to wake her and that staff had gone to warm up her food. On 11/29/16 at 4:50 p.m., R#3 was sleeping. R#3's lunch tray was on her side table. The three steak fingers, french fries, vegetables, vanilla house shake, apple juice, cranberry juice and the mug that was half filled with ice was still there. R#3 stated on 11/30/16 at 8:43 a.m. that she would feel around her plate to find her food. R#3 had scrambled eggs and a slice of bacon. R#3 had cranberry juice and was drinking small sips of the juice. R#3 stated the CNAs did not encourage her to drink and added she did not think the CNAs were very interested in what she drank or didn't drink. R#3 added, these are young people. The Director of Nurses (DON) reported on 11/30/16 at 9:00 a.m. that staff was not documenting the amounts of fluids R#3 was drinking. The DON added there was not a physician's orders [REDACTED].#3. The DON stated she would need to talk to the MDS nurse to find out why the MDS nurse had written on R#3's care plan the number of cups per day R#3 would drink and how she came up with the number of cups. Licensed Vocational Nurse (LVN) D (MDS nurse) reported on 11/30/16 at 9:23 a.m. that she would need to ask the CNAs if they were able to input, into the computer, the fluid intake on R#3. LVN D stated the cups listed on the Care Plan was a goal, but she was not sure if fluids consumed were recorded anywhere. LVN D stated she was not sure if R#3 was on fluid restrictions. R#2 R#2 undated Face Sheet revealed a [AGE] year old male admitted to this Facility on10/25/16 with the [DIAGNOSES REDACTED]. R#2's MDS Admission Assessment and Care Screening dated 11/01/16 revealed R#2 had no speech; Severely impaired rarely ever made decisions, total dependence on staff on eating, locomotion, personal hygiene, bathing and toilet use. R#2 is a two-person physical assist in transferring, ROM (range of motion) 1. Impairment on one side upper extremity and impairment on one side lower extremity. R#2's MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Nutritional status, Feeding tubes, Dehydration/Fluid maintenance, Pressure Ulcers. R#2 Care Plan's (no date) revealed: -R#2 has a feeding self-care deficit d/t (due to) his [DIAGNOSES REDACTED].-flush tube feeding as ordered per md, Gastrostomy site care as ordered per MD. R#2 is at risk for dysfunction GI .Encourage adequate fluid and food intake daily , give feedings/flushes via [DEVICE] per MD orders. R#2 is at risk .has DTI to right calcareous, right ®t lateral ankle, abscess (boil) to right top buttock, abscess to left buttock, abscess to mid left buttock. R#2 is at risk for unstable blood glucose level d/t his [DIAGNOSES REDACTED]. R#2's risk for dehydration-signs or symptoms for dehydration- care plan-not available R#2's nutritional risk care plan- not available According to the American Medical Directors Association, www.amda.com, retrieved on 12/09/16 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, .Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored .The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration . R#2's Physicians order dated 10/25/16 revealed Vital AF 1.5 calorie at 70ml/h (milliliters per hour)via stationary pump Dx: Nurtrition. 2) Flush feeding with 100ml of H20 (water) q 4 hours 3) flush feeding tube with 50ml H20 before and after administration of feedings and meds , If residual is greater than 60ml, hold feeding and contact MD . R#2's Dietary Consult Initial assessment dated [DATE] revealed: - 10/24 [MEDICATION NAME] 2.6 Normal (3.4 to 5.5g/dl) - Current enteral nutrition meeting estimated needs calculated for wound healing .increase flushes to 150ml H20 q 4 hours. R#2's Weekly Weights 10/25/16 (142.0), 11/02/16 (139.6), 11/08/16 (138.6), 11/14/16 (141.10), 11/22/16 (140.0). R#2's Physicians orders for the month of November 2016 revealed: Levimer (long-[MEDICATION NAME] basal insulin) - Administer 24 units SQ Q HS start date 11/16/16. R#2's Emergency Provider Report dated11/21/16 from Hospital AA revealed: -6:20 p.m. History and Physical -Chief complaint: blood in urine, Onset- days. -Indwelling foley -sent here for Hematuria (blood in urine) duration-for three days. No Anticoagulants ((blood thinners). -PROGRESS-Cont. Will treat Urinary infection, needs Urology f/u (follow -up) Chronic [MEDICAL CONDITION]. -Activity Restrictions or Additional Instruction from Hospital AA included- Force fluids, see the urologist this week, [MEDICATION NAME] (Antibiotic used to treat UTI) 100mg . -R#2 Laboratory Test results dated 11/21/16 from Hospital AA revealed: -Blood Chemistry: -Glucose 127 H (High) Normal range 65-99 -BUN 26 H(NAME)range 6-20 The Blood Chemistry dated 11/21/16 indicated R#2 had the potential to be dehydrated. Observation on 11/28/16 at 9:15 a.m., during initial tour R#2 in bed. [DEVICE] (GT) Feeding Vital 1.5 commercial prefilled formula bottle hanging with 700ml in bag dated 11/28/16 at 5:00 a.m. Observation on 11/28/16 at 12:10 p.m.;GT feeding not attached to R#2; feeding pump off. Observation on 11/28/16 at 12:55 p.m., GT feeding not attached to R#2; feeding pump off. Observation on 11/28/16 at 2:15 p.m., GT feeding not attached to R#2.and feeding pump off. Observation on 11/28/16 at 2:40 p.m., CNAs showering R#2; GT feeding tube clamped. Observation on 11/28/16 at 4:15 p.m., revealed R#2 in bed, awake, facial grimacing noted; Feeding pump off and not attached to patient. Surveyor checked formula bottle and it appeared to be at approximately 675ml/ out of 900ml left in the formula bottle. Interview on 11/28/16 at 4:20 p.m., with LVN S stated he didn't know the GT feeding was off; LVN S stated there is usually 900ml in the formula bottle and there is approximately 650ml left. LVN S stated the morning nurse reported there were no issues with R#2 today so the GT feeding should be infusing. R#2 Dietary Progress Note dated 11/29/16 revealed: Vital 1.5@ 70ml/hr x24 hour. Flush with H20 150mlq 4hrs . 2520kcal (formula) + 160kcal (Juven) .900ml (flushes)= 2500ml fluid. REC (Recommendation) : Vital 1.5 @ 70ml x22hrs. to provide 2310 kcal, 103g protein, 1178 ml fluid total Kcal+ 2400 ml fluid. Interview on 11/29/16 at 11:00 a.m., with Dietician concerning R#2 revealed, He needed the continuous infusion, but (they) want me to recommend less hours for down time; but he still needs all those calories. Dietician stated she made new recommendations for feeding to run from 24 hours to 22 hours. Phone Interview with R#2's (familymember) on 11/29/16 at 11:30.a.m. revealed she worked full-time and doesn't get to spend a lot of time with R#2 at facility. Family member stated R#2 was admitted to the Facility for Physical Therapy and Speech Therapy. Family Member stated that R#2 had been in the hospital last week for blood in urine; the emergency room doctor told me that (R#2) had a Urinary Infection and was dehydrated. Family Member stated she wanted R#2 to get better, so she could take him home. R #1 Record review of R #1's Face Sheet dated 09/09/16 revealed a [AGE] year old female admitted to the facility on [DATE]. R #1's [DIAGNOSES REDACTED]. Record review of R #1's quarterly MDS assessment dated [DATE] revealed she was moderately impaired for decisions making, had unclear speech with slurred or mumbled words. R #1 had a catheter for urine (tube inserted into the bladder) and was always incontinent of bowel and had a feeding tube for nutrition. Record review of R #1's Physician orders [REDACTED]. 11/14/16 Increase Nepro (feeding supplement) to 45 cubic centimeters (cc) hour. 11/14/16 Juven one packet twice a day. Record review of R #1's Care Plan dated 09/30/16 revealed: Problem: R #1 receives all nutritional value via [DEVICE]. Goal: There will not be any sign or symptoms of aspiration pneumonia within the next 90 days. Approaches: Will administer tube feedings and flushes as per physician orders. Problem: R #1 is at risk for dehydration. Goal: Will not experience any symptoms of dehydration. Approaches: [DEVICE] flushes as ordered per Physician. Problem: R #1 is NPO (nothing by mouth) R #1 received all nutritional value via [DEVICE]. Goal: Resident will show a stable weight within the next 90 days. Approaches: Monitor monthly weights. Will administer tube feedings and flushes as per Physician orders. Observation on 11/28/16 at 11:50 a.m. accompanied by Licensed Vocational Nurse (LVN) M revealed R #1 in bed awake. R #1's eyes were open and she made eye contact when spoken to but R #1 did not answer when spoken to. R #1 had a feeding tube ([DEVICE]) with a supplement running at 40 cc an hour. R #1 had a Foley catheter in a privacy bag with a scant amount (less than 20 cc) of carmel color urine in the bag. Surveyor observed Licensed Vocational Nurse (LVN) D administer R #1's 9:00 a.m. scheduled medications at 9:40 a.m. on 11-29-16. Surveyor noted R #1's feeding was at 40cc an hour. The surveyor noted the dietary supplement Juven was not administered as ordered. LVN D stated the Juven supplement was not in stock at the time of administration. LVN D stated R #1's Nepro was ordered to run at 40 cc an hour. In an interview on 11/30/16 at 3:00 p.m. the Assistant Director of Nursing (ADON) stated the Physician orders [REDACTED]. The ADON stated they had a system for taking off orders and she could not explain how that order was missed. The facility's policy, HYDRATION PROGRAM GUIDELINES, undated indicated that the facility would have a process in place to identify residents at risk for dehydration and would ensure that each resident would receive sufficient fluids and assistance, based on the resident's individual needs when drinking beverages. The Administrator and DON were notified at 5:40 p.m. on 11-30-16 that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was approved at 5:20 p.m. on 12-01-16. The plan included: 1. Licensed nurses performed 100% audit of residents to determine their risk for dehydration. 2. Residents who were determined at risk for dehydration were care planned with the goals and approaches to assist the residents in maintaining their hydration level or enteral feeding requirements as established by the Dietician and the Physician. 3. The Regional Nurse Consultant re-educated the DON and the Administrator on the action plan for hydration. The DON re-educated nursing staff on the need to offer hydration opportunities for the residents throughout the day. The CNAs were instructed not to turn off any feeding tubes to do activities of daily living (ADLs). The charge nurse would be required to turn off the feeding tube and removing the tubing. Upon completion of the ADLs, the charge nurse would be responsible to ensure the feeding pump was on as ordered by the physician. The DON/Designee would be responsible for monitoring. 4. The hydration and snack carts would be passed on each hall by the Restorative Aides on the morning and afternoon shifts and by the CNAs on the night shift. The charge nurses were responsible for ensuring hydration and snack carts were passed. The DON/Designee and/or the Dietary Manager would be responsible for monitoring. 5. The DON/Designee would communicate with the CNAs the residents who were at highest risk of dehydration and those needed to be encouraged to consume fluids. The communication would be done by updating the electronic kiosk (computer) the CNAs used to document ADL care. The update would ask the CNAs how many cups of fluid the resident consumed during their shift. The nurse would be notified if the resident did not consume the recommended amount. The charge nurses would monitor the documentation from the kiosk for completed care and the DON/Designee would be responsible for monitoring. On 12-02-16, surveyors verified the Plan of Removal by conducting review of training for nursing staff on all three shifts and resident assessments. Interviews were conducted with nursing staff on two shifts to determine the level of understanding of newly implemented policies and procedures. All nursing staff interviewed were aware of the newly implemented policies and procedures. Observations were made of individual residents identified in the Plan of Removal. The Administrator was informed at 4:20 p.m. on 12-02-16 that the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility's CMS Form-802 indicated there were 67 residents with hydration issues.

Based on observation, record review and interview, the facility failed to implement written policies and procedures that prohibit and prevent neglect for three Residents (R#3, R#2 and R#1) out of 15 residents reviewed for dehydration. The facility was aware R#3 was at risk for dehydration but did not monitor or encourage R#3's fluid intake. R#3 had recently returned from the hospital with the [DIAGNOSES REDACTED]. The facility failed to provide R#2 with any Gastrostomy feeding or water for seven hours. R#2 Dietary Progress Note dated 11/29/16 revealed: Vital 1.5@ 70ml/hr x24 hour. Flush with H20 150mlq 4hrs . 2520kcal (formula) + 160kcal (Juven) .900ml (flushes)= 2500ml R #1's feeding supplement (Nepro) was not increased to 45 centimeters (cc) an hour and Juven (nutritional supplement) was not administered as ordered by the Physician. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 11-30-16. The IJ was removed on 12-02-16, however, the facility remained out of compliance at a severity of actual harm with a scope assessed as a pattern. These failures could affect 67 residents identified with hydration issues. The findings were: The facility's training information, undated defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. R#3 R#3's Face Sheet dated 05/04/15 indicated R#3 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Face Sheet indicated R#3 was [AGE] years old. R#3's Admission Minimum Data Set ((MDS) dated [DATE] indicated R#3 had clear speech, was understood and could understand others. Her vision was severely impaired. R#3 required extensive assistance for bed mobility, transfers, dressing and toileting by two or more staff assistance. According to the MDS, R#3 required supervision (oversight, encouragement or cueing for eating. R#3's Care Plan with problem onset date of 03/13/14 indicated R#3 was at risk for dehydration due to her fluctuation cognition causing her to be unaware to drink adequate amounts of fluids. R#3 also has a history of dehydration. Goal &Target Date indicated R#3 would drink 5-6 cups of fluid daily for the next 90 days, target date-12/25/16; R#3 would drink 7-8 cups of water 5 days a week within the next 90 days, target date-12/25/16. Approaches listed were: Monitor R#3's electrolytes; Monitor for changes in R#3's symptoms that may indicate worsening of condition and notify the physician; Hydration Assessment Quarterly and as needed and Bowel and Bladder Assessment Quarterly and as needed. Another Care Plan with the problem onset date of 03/21/14 indicated R#3 had severely impaired visual functioning. No vision or sees only light, colors or shapes due to her [DIAGNOSES REDACTED]. The Care Plan indicated R#3 was at risk for falls and injury due to decreased vision. One approach listed was that R#3 would be assisted with eating, dressing and grooming as needed. Hospital History and Physical admitted , 10/31/16 indicated R#3 became very lethargic and had been brought to the emergency room , noted to have acute kidney failure. The Assessment indicated R#3 had Acute Kidney Injury, [MEDICAL CONDITION], high potassium and Hypotensive shock due to dehydration. Progress Note written by Nurse Practitionar (NP) Q dated 11/10/16 indicated the NP had seen R#3 for a follow-up on this date after being discharged from the hospital for acute kidney injury, [MEDICAL CONDITION] and hypotensive shock due to dehydration. Departmental Notes dated 11/14/16 at 7:26 p.m. indicated R#3 was prescribed an antibiotic for a urinary tract infection [MEDICAL CONDITION]. Admission Quarterly Hydration assessment dated [DATE] indicated R#3 was on a Diuretic and a laxative, putting her at risk for dehydration. R#3 was observed during initial tour on 11/28/16 at approximately 8:25 a.m. Registered Nurse (RN) L who accompanied the surveyor stated R#3 was alert and interviewable and was able to feed herself. RN L added R#3 was almost blind and preferred to stay in bed. RN L also stated R#3 had been on hospice, but was no longer on hospice. R#3 asked for ice. R#3 was observed sleeping at 12:46 p.m. A salad with ham, milk, apple juice and house shake (supplement) sat on her tray, next to her bed. Observation showed the tray and drinks remained untouched at 2:20 p.m. R#3 was observed sleeping. On 11/28/16 at 3:55 p.m., the surveyor asked RN L if R#3 would be getting help with her meal, since it was still untouched. At this time, a certified nurse aide (CNA) attempted to give R#3 the salad. R#3 asked the CNA if there was wilted lettuce and let the CNA know that she could go ahead and throw it in the trash. R#3 did ask for juice and the CNA told R#3 there was juice on the tray. R#3 did not drink the juice and the CNA did not help R#3 drink the juice. On 11/29/16 at 8:28 a.m., R#3 was observed in her room. The breakfast tray was in front of her. R#3 stated her breakfast was not good. The surveyor observed a gnat flying around her scrambled eggs and there was milk and water spilled in the eggs. R#3 had cranberry juice, water and a house shake also. R#3 stated the staff did not know how to fix boiled eggs and that they brought her the same foods. R#3 stated her patience was getting very low. R#3 stated she had the staff put ice in her glass and that she had to tell the staff to bring her ice because they wouldn't remember. There was a large mug half filled with ice. R#3 stated she liked the ice to melt. R#3 stated no one helped her eat and that she helped herself. CNA P stated on 11/29/16 at 10:45 a.m. that she documented on the computer the percentage of food the residents ate, but did not document if the residents were consuming the supplements provided. On 11/29/16 at 11:55 a.m., R#3 stated she did need someone to help her eat and she would be very glad if someone helped her. On 11/29/16 at 12:35 p.m., R#3's lunch tray was on her side table. R#3 was asleep. The resident had a vanilla house shake, apple juice, water plus some of the cranberry juice from her breakfast. R#3 was sleeping at 2:05 p.m. Her lunch tray was still by her bedside. R#3's mug was half filled with melted ice, the apple juice, house shake were not yet touched. R#3cranberry juice from breakfast was still sitting there also. On 11/29/16 at 2:45 p.m., R#3 was awake. R#3 stated she told staff not to wake her and that staff had gone to warm up her food. On 11/29/16 at 4:50 p.m., R#3 was sleeping. R#3's lunch tray was on her side table. The three steak fingers, french fries, vegetables, vanilla house shake, apple juice, cranberry juice and the mug that was half filled with ice was still there. R#3 stated on 11/30/16 at 8:43 a.m. that she would feel around her plate to find her food. R#3 had scrambled eggs and a slice of bacon. R#3 had cranberry juice and was drinking small sips of the juice. R#3 stated the CNAs did not encourage her to drink and added she did not think the CNAs were very interested in what she drank or didn't drink. R#3 added, these are young people. The Director of Nurses (DON) reported on 11/30/16 at 9:00 a.m. that staff was not documenting the amounts of fluids R#3 was drinking. The DON added there was not a physician's orders [REDACTED].#3. The DON stated she would need to talk to the MDS nurse to find out why the MDS nurse had written on R#3's care plan the number of cups per day R#3 would drink and how she came up with the number of cups. Licensed Vocational Nurse (LVN) D (MDS nurse) reported on 11/30/16 at 9:23 a.m. that she would need to ask the CNAs if they were able to input, into the computer, the fluid intake on R#3. LVN D stated the cups listed on the Care Plan was a goal, but she was not sure if fluids consumed were recorded anywhere. LVN D stated she was not sure if R#3 was on fluid restrictions. R#2 R#2 undated Face Sheet revealed a [AGE] year old male admitted to this Facility on10/25/16 with the [DIAGNOSES REDACTED]. R#2's MDS Admission Assessment and Care Screening dated 11/01/16 revealed R#2 had no speech; Severely impaired rarely ever made decisions, total dependence on staff on eating, locomotion, personal hygiene, bathing and toilet use. R#2 is a two-person physical assist in transferring, ROM (range of motion) 1. Impairment on one side upper extremity and impairment on one side lower extremity. R#2's MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Nutritional status, Feeding tubes, Dehydration/Fluid maintenance, Pressure Ulcers. R#2 Care Plan's (no date) revealed: -R#2 has a feeding self-care deficit d/t (due to) his [DIAGNOSES REDACTED].-flush tube feeding as ordered per md, Gastrostomy site care as ordered per MD. R#2 is at risk for dysfunction GI .Encourage adequate fluid and food intake daily , give feedings/flushes via [DEVICE] per MD orders. R#2 is at risk .has DTI to right calcareous, right ®t lateral ankle, abscess (boil) to right top buttock, abscess to left buttock, abscess to mid left buttock. R#2 is at risk for unstable blood glucose level d/t his [DIAGNOSES REDACTED]. R#2's risk for dehydration-signs or symptoms for dehydration- care plan-not available R#2's nutritional risk care plan- not available According to the American Medical Directors Association, www.amda.com, retrieved on 12/09/16 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, .Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored .The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration . R#2's Physicians order dated 10/25/16 revealed Vital AF 1.5 calorie at 70ml/h (milliliters per hour)via stationary pump Dx: Nurtrition. 2) Flush feeding with 100ml of H20 (water) q 4 hours 3) flush feeding tube with 50ml H20 before and after administration of feedings and meds , If residual is greater than 60ml, hold feeding and contact MD . R#2's Dietary Consult Initial assessment dated [DATE] revealed: - 10/24 [MEDICATION NAME] 2.6 Normal (3.4 to 5.5g/dl) - Current enteral nutrition meeting estimated needs calculated for wound healing .increase flushes to 150ml H20 q 4 hours. R#2's Weekly Weights 10/25/16 (142.0), 11/02/16 (139.6), 11/08/16 (138.6), 11/14/16 (141.10), 11/22/16 (140.0). R#2's Physicians orders for the month of November 2016 revealed: Levimer (long-[MEDICATION NAME] basal insulin) - Administer 24 units SQ Q HS start date 11/16/16. R#2's Emergency Provider Report dated11/21/16 from Hospital AA revealed: -6:20 p.m. History and Physical -Chief complaint: blood in urine, Onset- days. -Indwelling foley -sent here for Hematuria (blood in urine) duration-for three days. No Anticoagulants ((blood thinners). -PROGRESS-Cont. Will treat Urinary infection, needs Urology f/u (follow -up) Chronic [MEDICAL CONDITION]. -Activity Restrictions or Additional Instruction from Hospital AA included- Force fluids, see the urologist this week, [MEDICATION NAME] (Antibiotic used to treat UTI) 100mg . -R#2 Laboratory Test results dated 11/21/16 from Hospital AA revealed: -Blood Chemistry: -Glucose 127 H (High) Normal range 65-99 -BUN 26 H(NAME)range 6-20 The Blood Chemistry dated 11/21/16 indicated R#2 had the potential to be dehydrated. Observation on 11/28/16 at 9:15 a.m., during initial tour R#2 in bed. [DEVICE] (GT) Feeding Vital 1.5 commercial prefilled formula bottle hanging with 700ml in bag dated 11/28/16 at 5:00 a.m. Observation on 11/28/16 at 12:10 p.m.;GT feeding not attached to R#2; feeding pump off. Observation on 11/28/16 at 12:55 p.m., GT feeding not attached to R#2; feeding pump off. Observation on 11/28/16 at 2:15 p.m., GT feeding not attached to R#2.and feeding pump off. Observation on 11/28/16 at 2:40 p.m., CNAs showering R#2; GT feeding tube clamped. Observation on 11/28/16 at 4:15 p.m., revealed R#2 in bed, awake, facial grimacing noted; Feeding pump off and not attached to patient. Surveyor checked formula bottle and it appeared to be at approximately 675ml/ out of 900ml left in the formula bottle. Interview on 11/28/16 at 4:20 p.m., with LVN S stated he didn't know the GT feeding was off; LVN S stated there is usually 900ml in the formula bottle and there is approximately 650ml left. LVN S stated the morning nurse reported there were no issues with R#2 today so the GT feeding should be infusing. R#2 Dietary Progress Note dated 11/29/16 revealed: Vital 1.5@ 70ml/hr x24 hour. Flush with H20 150mlq 4hrs . 2520kcal (formula) + 160kcal (Juven) .900ml (flushes)= 2500ml fluid. REC (Recommendation) : Vital 1.5 @ 70ml x22hrs. to provide 2310 kcal, 103g protein, 1178 ml fluid total Kcal+ 2400 ml fluid. Interview on 11/29/16 at 11:00 a.m., with Dietician concerning R#2 revealed, He needed the continuous infusion, but (they) want me to recommend less hours for down time; but he still needs all those calories . Dietician stated she made new recommendations for feeding to run from 24 hours to 22 hours. Phone Interview with R#2's (familymember) on 11/29/16 at 11:30.a.m. revealed she worked full-time and doesn't get to spend a lot of time with R#2 at facility. Family member stated R#2 was admitted to the Facility for Physical Therapy and Speech Therapy. Family Member stated that R#2 had been in the hospital last week for blood in urine; the emergency room doctor told me that (R#2) had a Urinary Infection and was dehydrated. Family Member stated she wanted R#2 to get better, so she could take him home. R #1 Record review of R #1's Face Sheet dated 09/09/16 revealed a [AGE] year old female admitted to the facility on [DATE]. R #1's [DIAGNOSES REDACTED]. Record review of R #1's quarterly MDS assessment dated [DATE] revealed she was moderately impaired for decisions making, had unclear speech with slurred or mumbled words. R #1 had a catheter for urine (tube inserted into the bladder) and was always incontinent of bowel and had a feeding tube for nutrition. Record review of R #1's Physician orders [REDACTED]. 11/14/16 Increase Nepro (feeding supplement) to 45 cubic centimeters (cc) hour. 11/14/16 Juven one packet twice a day. Record review of R #1's Care Plan dated 09/30/16 revealed: Problem: R #1 receives all nutritional value via [DEVICE]. Goal: There will not be any sign or symptoms of aspiration pneumonia within the next 90 days. Approaches: Will administer tube feedings and flushes as per physician orders. Problem: R #1 is at risk for dehydration. Goal: Will not experience any symptoms of dehydration. Approaches: [DEVICE] flushes as ordered per Physician. Problem: R #1 is NPO (nothing by mouth) R #1 received all nutritional value via [DEVICE]. Goal: Resident will show a stable weight within the next 90 days. Approaches: Monitor monthly weights. Will administer tube feedings and flushes as per Physician orders. Observation on 11/28/16 at 11:50 a.m. accompanied by Licensed Vocational Nurse (LVN) M revealed R #1 in bed awake. R #1's eyes were open and she made eye contact when spoken to but R #1 did not answer when spoken to. R #1 had a feeding tube ([DEVICE]) with a supplement running at 40 cc an hour. R #1 had a Foley catheter in a privacy bag with a scant amount (less than 20 cc) of carmel color urine in the bag. Surveyor observed Licensed Vocational Nurse (LVN) D administer R #1's 9:00 a.m. scheduled medications at 9:40 a.m. on 11-29-16. Surveyor noted R #1's feeding was at 40cc an hour. The surveyor noted the dietary supplement Juven was not administered as ordered. LVN D stated the Juven supplement was not in stock at the time of administration. LVN D stated R #1's Nepro was ordered to run at 40 cc an hour. In an interview on 11/30/16 at 3:00 p.m. the Assistant Director of Nursing (ADON) stated the Physician orders [REDACTED]. The ADON stated they had a system for taking off orders and she could not explain how that order was missed. The facility's policy, HYDRATION PROGRAM GUIDELINES, undated indicated that the facility would have a process in place to identify residents at risk for dehydration and would ensure that each resident would receive sufficient fluids and assistance, based on the resident's individual needs when drinking beverages. The Administrator and DON were notified at 5:40 p.m. on 11-30-16 that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was approved at 5:20 p.m. on 12-01-16. The plan included: 1. Licensed nurses performed 100% audit of residents to determine their risk for dehydration. 2. Residents who were determined at risk for dehydration were care planned with the goals and approaches to assist the residents in maintaining their hydration level or enteral feeding requirements as established by the Dietician and the Physician. 3. The Regional Nurse Consultant re-educated the DON and the Administrator on the action plan for hydration. The DON re-educated nursing staff on the need to offer hydration opportunities for the residents throughout the day. The CNAs were instructed not to turn off any feeding tubes to do activities of daily living (ADLs). The charge nurse would be required to turn off the feeding tube and removing the tubing. Upon completion of the ADLs, the charge nurse would be responsible to ensure the feeding pump was on as ordered by the physician. The DON/Designee would be responsible for monitoring. 4. The hydration and snack carts would be passed on each hall by the Restorative Aides on the morning and afternoon shifts and by the CNAs on the night shift. The charge nurses were responsible for ensuring hydration and snack carts were passed. The DON/Designee and/or the Dietary Manager would be responsible for monitoring. 5. The DON/Designee would communicate with the CNAs the residents who were at highest risk of dehydration and those needed to be encouraged to consume fluids. The communication would be done by updating the electronic kiosk (computer) the CNAs used to document ADL care. The update would ask the CNAs how many cups of fluid the resident consumed during their shift. The nurse would be notified if the resident did not consume the recommended amount. The charge nurses would monitor the documentation from the kiosk for completed care and the DON/Designee would be responsible for monitoring. On 12-02-16, surveyors verified the Plan of Removal by conducting review of training for nursing staff on all three shifts and resident assessments. Interviews were conducted with nursing staff on two shifts to determine the level of understanding of newly implemented policies and procedures. All nursing staff interviewed were aware of the newly implemented policies and procedures. Observations were made of individual residents identified in the Plan of Removal. The Administrator was informed at 4:20 p.m. on 12-02-16 that the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility's CMS Form-802 indicated there were 67 residents with hydration issues.

Based on observation, record review and interview, the facility failed to provide evidence of sufficient fluid intake to maintain proper hydration for three Residents (R#3, R#2 and R#1) out of 15 residents reviewed for dehydration. The facility was aware R#3 was at risk for dehydration but did not monitor or encourage R#3's fluid intake. R#3 had recently returned from the hospital with the [DIAGNOSES REDACTED]. The facility failed to provide R#2 with any Gastrostomy feeding or water for seven hours. R#2 Dietary Progress Note dated 11/29/16 revealed: Vital 1.5@ 70ml/hr x24 hour. Flush with H20 150mlq 4hrs . 2520kcal (formula) + 160kcal (Juven) .900ml (flushes)= 2500ml R #1's feeding supplement (Nepro) was not increased to 45 centimeters (cc) an hour and Juven (nutritional supplement) was not administered as ordered by the Physician. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 11-30-16. The IJ was removed on 12-02-16, however, the facility remained out of compliance at a severity of actual harm with a scope assessed as a pattern. These failures could affect 67 residents identified with hydration issues. The findings were: R#3 R#3's Face Sheet dated 05/04/15 indicated R#3 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Face Sheet indicated R#3 was [AGE] years old. R#3's Admission Minimum Data Set ((MDS) dated [DATE] indicated R#3 had clear speech, was understood and could understand others. Her vision was severely impaired. R#3 required extensive assistance for bed mobility, transfers, dressing and toileting by two or more staff assistance. According to the MDS, R#3 required supervision (oversight, encouragement or cueing for eating. R#3's Care Plan with problem onset date of 03/13/14 indicated R#3 was at risk for dehydration due to her fluctuation cognition causing her to be unaware to drink adequate amounts of fluids. R#3 also has a history of dehydration. Goal &Target Date indicated R#3 would drink 5-6 cups of fluid daily for the next 90 days, target date-12/25/16; R#3 would drink 7-8 cups of water 5 days a week within the next 90 days, target date-12/25/16. Approaches listed were: Monitor R#3's electrolytes; Monitor for changes in R#3's symptoms that may indicate worsening of condition and notify the physician; Hydration Assessment Quarterly and as needed and Bowel and Bladder Assessment Quarterly and as needed. Another Care Plan with the problem onset date of 03/21/14 indicated R#3 had severely impaired visual functioning. No vision or sees only light, colors or shapes due to her [DIAGNOSES REDACTED]. The Care Plan indicated R#3 was at risk for falls and injury due to decreased vision. One approach listed was that R#3 would be assisted with eating, dressing and grooming as needed. Hospital History and Physical admitted , 10/31/16 indicated R#3 became very lethargic and had been brought to the emergency room , noted to have acute kidney failure. The Assessment indicated R#3 had Acute Kidney Injury, [MEDICAL CONDITION], high potassium and Hypotensive shock due to dehydration. Progress Note written by Nurse Practitionar (NP) Q dated 11/10/16 indicated the NP had seen R#3 for a follow-up on this date after being discharged from the hospital for acute kidney injury, [MEDICAL CONDITION] and hypotensive shock due to dehydration. Departmental Notes dated 11/14/16 at 7:26 p.m. indicated R#3 was prescribed an antibiotic for a urinary tract infection [MEDICAL CONDITION]. Admission Quarterly Hydration assessment dated [DATE] indicated R#3 was on a Diuretic and a laxative, putting her at risk for dehydration. R#3 was observed during initial tour on 11/28/16 at approximately 8:25 a.m. Registered Nurse (RN) L who accompanied the surveyor stated R#3 was alert and interviewable and was able to feed herself. RN L added R#3 was almost blind and preferred to stay in bed. RN L also stated R#3 had been on hospice, but was no longer on hospice. R#3 asked for ice. R#3 was observed sleeping at 12:46 p.m. A salad with ham, milk, apple juice and house shake (supplement) sat on her tray, next to her bed. Observation showed the tray and drinks remained untouched at 2:20 p.m. R#3 was observed sleeping. On 11/28/16 at 3:55 p.m., the surveyor asked RN L if R#3 would be getting help with her meal, since it was still untouched. At this time, a certified nurse aide (CNA) attempted to give R#3 the salad. R#3 asked the CNA if there was wilted lettuce and let the CNA know that she could go ahead and throw it in the trash. R#3 did ask for juice and the CNA told R#3 there was juice on the tray. R#3 did not drink the juice and the CNA did not help R#3 drink the juice. On 11/29/16 at 8:28 a.m., R#3 was observed in her room. The breakfast tray was in front of her. R#3 stated her breakfast was not good. The surveyor observed a gnat flying around her scrambled eggs and there was milk and water spilled in the eggs. R#3 had cranberry juice, water and a house shake also. R#3 stated the staff did not know how to fix boiled eggs and that they brought her the same foods. R#3 stated her patience was getting very low. R#3 stated she had the staff put ice in her glass and that she had to tell the staff to bring her ice because they wouldn't remember. There was a large mug half filled with ice. R#3 stated she liked the ice to melt. R#3 stated no one helped her eat and that she helped herself. CNA P stated on 11/29/16 at 10:45 a.m. that she documented on the computer the percentage of food the residents ate, but did not document if the residents were consuming the supplements provided. On 11/29/16 at 11:55 a.m., R#3 stated she did need someone to help her eat and she would be very glad if someone helped her. On 11/29/16 at 12:35 p.m., R#3's lunch tray was on her side table. R#3 was asleep. The resident had a vanilla house shake, apple juice, water plus some of the cranberry juice from her breakfast. R#3 was sleeping at 2:05 p.m. Her lunch tray was still by her bedside. R#3's mug was half filled with melted ice, the apple juice, house shake were not yet touched. R#3cranberry juice from breakfast was still sitting there also. On 11/29/16 at 2:45 p.m., R#3 was awake. R#3 stated she told staff not to wake her and that staff had gone to warm up her food. On 11/29/16 at 4:50 p.m., R#3 was sleeping. R#3's lunch tray was on her side table. The three steak fingers, french fries, vegetables, vanilla house shake, apple juice, cranberry juice and the mug that was half filled with ice was still there. R#3 stated on 11/30/16 at 8:43 a.m. that she would feel around her plate to find her food. R#3 had scrambled eggs and a slice of bacon. R#3 had cranberry juice and was drinking small sips of the juice. R#3 stated the CNAs did not encourage her to drink and added she did not think the CNAs were very interested in what she drank or didn't drink. R#3 added, these are young people. The Director of Nurses (DON) reported on 11/30/16 at 9:00 a.m. that staff was not documenting the amounts of fluids R#3 was drinking. The DON added there was not a physician's orders [REDACTED].#3. The DON stated she would need to talk to the MDS nurse to find out why the MDS nurse had written on R#3's care plan the number of cups per day R#3 would drink and how she came up with the number of cups. Licensed Vocational Nurse (LVN) D (MDS nurse) reported on 11/30/16 at 9:23 a.m. that she would need to ask the CNAs if they were able to input, into the computer, the fluid intake on R#3. LVN D stated the cups listed on the Care Plan was a goal, but she was not sure if fluids consumed were recorded anywhere. LVN D stated she was not sure if R#3 was on fluid restrictions. R#2 R#2 undated Face Sheet revealed a [AGE] year old male admitted to this Facility on10/25/16 with the [DIAGNOSES REDACTED]. R#2's MDS Admission Assessment and Care Screening dated 11/01/16 revealed R#2 had no speech; Severely impaired rarely ever made decisions, total dependence on staff on eating, locomotion, personal hygiene, bathing and toilet use. R#2 is a two-person physical assist in transferring, ROM (range of motion) 1. Impairment on one side upper extremity and impairment on one side lower extremity. R#2's MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision included Nutritional status, Feeding tubes, Dehydration/Fluid maintenance, Pressure Ulcers. R#2 Care Plan's (no date) revealed: -R#2 has a feeding self-care deficit d/t (due to) his [DIAGNOSES REDACTED].-flush tube feeding as ordered per md, Gastrostomy site care as ordered per MD. R#2 is at risk for dysfunction GI .Encourage adequate fluid and food intake daily , give feedings/flushes via [DEVICE] per MD orders. R#2 is at risk .has DTI to right calcareous, right ®t lateral ankle, abscess (boil) to right top buttock, abscess to left buttock, abscess to mid left buttock. R#2 is at risk for unstable blood glucose level d/t his [DIAGNOSES REDACTED]. R#2's risk for dehydration-signs or symptoms for dehydration- care plan-not available R#2's nutritional risk care plan- not available According to the American Medical Directors Association, www.amda.com, retrieved on 12/09/16 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, .Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored .The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration . R#2's Physicians order dated 10/25/16 revealed Vital AF 1.5 calorie at 70ml/h (milliliters per hour)via stationary pump Dx: Nurtrition. 2) Flush feeding with 100ml of H20 (water) q 4 hours 3) flush feeding tube with 50ml H20 before and after administration of feedings and meds , If residual is greater than 60ml, hold feeding and contact MD . R#2's Dietary Consult Initial assessment dated [DATE] revealed: - 10/24 [MEDICATION NAME] 2.6 Normal (3.4 to 5.5g/dl) - Current enteral nutrition meeting estimated needs calculated for wound healing .increase flushes to 150ml H20 q 4 hours. R#2's Weekly Weights 10/25/16 (142.0), 11/02/16 (139.6), 11/08/16 (138.6), 11/14/16 (141.10), 11/22/16 (140.0). R#2's Physicians orders for the month of November 2016 revealed: Levimer (long-[MEDICATION NAME] basal insulin) - Administer 24 units SQ Q HS start date 11/16/16. R#2's Emergency Provider Report dated11/21/16 from Hospital AA revealed: -6:20 p.m. History and Physical -Chief complaint: blood in urine, Onset- days. -Indwelling foley -sent here for Hematuria (blood in urine) duration-for three days. No Anticoagulants ((blood thinners). -PROGRESS-Cont. Will treat Urinary infection, needs Urology f/u (follow -up) Chronic [MEDICAL CONDITION]. -Activity Restrictions or Additional Instruction from Hospital AA included- Force fluids, see the urologist this week, [MEDICATION NAME] (Antibiotic used to treat UTI) 100mg . -R#2 Laboratory Test results dated 11/21/16 from Hospital AA revealed: -Blood Chemistry: -Glucose 127 H (High) Normal range 65-99 -BUN 26 H(NAME)range 6-20 The Blood Chemistry dated 11/21/16 indicated R#2 had the potential to be dehydrated. Observation on 11/28/16 at 9:15 a.m., during initial tour R#2 in bed. [DEVICE] (GT) Feeding Vital 1.5 commercial prefilled formula bottle hanging with 700ml in bag dated 11/28/16 at 5:00 a.m. Observation on 11/28/16 at 12:10 p.m.;GT feeding not attached to R#2; feeding pump off. Observation on 11/28/16 at 12:55 p.m., GT feeding not attached to R#2; feeding pump off. Observation on 11/28/16 at 2:15 p.m., GT feeding not attached to R#2.and feeding pump off. Observation on 11/28/16 at 2:40 p.m., CNAs showering R#2; GT feeding tube clamped. Observation on 11/28/16 at 4:15 p.m., revealed R#2 in bed, awake, facial grimacing noted; Feeding pump off and not attached to patient. Surveyor checked formula bottle and it appeared to be at approximately 675ml/ out of 900ml left in the formula bottle. Interview on 11/28/16 at 4:20 p.m., with LVN S stated he didn't know the GT feeding was off; LVN S stated there is usually 900ml in the formula bottle and there is approximately 650ml left. LVN S stated the morning nurse reported there were no issues with R#2 today so the GT feeding should be infusing. R#2 Dietary Progress Note dated 11/29/16 revealed: Vital 1.5@ 70ml/hr x24 hour. Flush with H20 150mlq 4hrs . 2520kcal (formula) + 160kcal (Juven) .900ml (flushes)= 2500ml fluid. REC (Recommendation) : Vital 1.5 @ 70ml x22hrs. to provide 2310 kcal, 103g protein, 1178 ml fluid total Kcal+ 2400 ml fluid . Interview on 11/29/16 at 11:00 a.m., with Dietician concerning R#2 revealed, He needed the continuous infusion, but (they) want me to recommend less hours for down time; but he still needs all those calories . Dietician stated she made new recommendations for feeding to run from 24 hours to 22 hours. Phone Interview with R#2's (familymember) on 11/29/16 at 11:30.a.m. revealed she worked full-time and doesn't get to spend a lot of time with R#2 at facility. Family member stated R#2 was admitted to the Facility for Physical Therapy and Speech Therapy. Family Member stated that R#2 had been in the hospital last week for blood in urine; the emergency room doctor told me that (R#2) had a Urinary Infection and was dehydrated. Family Member stated she wanted R#2 to get better, so she could take him home. R #1 Record review of R #1's Face Sheet dated 09/09/16 revealed a [AGE] year old female admitted to the facility on [DATE]. R #1's [DIAGNOSES REDACTED]. Record review of R #1's quarterly MDS assessment dated [DATE] revealed she was moderately impaired for decisions making, had unclear speech with slurred or mumbled words. R #1 had a catheter for urine (tube inserted into the bladder) and was always incontinent of bowel and had a feeding tube for nutrition. Record review of R #1's Physician orders [REDACTED]. 11/14/16 Increase Nepro (feeding supplement) to 45 cubic centimeters (cc) hour. 11/14/16 Juven one packet mix with 6 ounces of water twice a day. Record review of R #1's Care Plan dated 09/30/16 revealed: Problem: R #1 receives all nutritional value via [DEVICE]. Goal: There will not be any sign or symptoms of aspiration pneumonia within the next 90 days. Approaches: Will administer tube feedings and flushes as per physician orders. Problem: R #1 is at risk for dehydration. Goal: Will not experience any symptoms of dehydration. Approaches: [DEVICE] flushes as ordered per Physician. Problem: R #1 is NPO (nothing by mouth) R #1 received all nutritional value via [DEVICE]. Goal: Resident will show a stable weight within the next 90 days. Approaches: Monitor monthly weights. Will administer tube feedings and flushes as per Physician orders. Observation on 11/28/16 at 11:50 a.m. accompanied by Licensed Vocational Nurse (LVN) M revealed R #1 in bed awake. R #1's eyes were open and she made eye contact when spoken to but R #1 did not answer when spoken to. R #1 had a feeding tube ([DEVICE]) with a supplement running at 40 cc an hour. R #1 had a catheter in a privacy bag with a scant amount (less than 20 cc) of carmel color urine in the bag. Surveyor observed Licensed Vocational Nurse (LVN) D administer R #1's 9:00 a.m. scheduled medications at 9:40 a.m. on 11-29-16. Surveyor noted R #1's feeding was at 40cc an hour. The surveyor noted the dietary supplement Juven mixed with 6 ounces of water was not administered as ordered. LVN D stated the Juven supplement was not in stock at the time of administration. LVN D stated R #1's Nepro was ordered to run at 40 cc an hour. In an interview on 11/30/16 at 3:00 p.m. the Assistant Director of Nursing (ADON) stated the Physician orders [REDACTED]. The ADON stated they had a system for taking off orders and she could not explain how that order was missed. The facility's policy, HYDRATION PROGRAM GUIDELINES, undated indicated that the facility would have a process in place to identify residents at risk for dehydration and would ensure that each resident would receive sufficient fluids and assistance, based on the resident's individual needs when drinking beverages. The Administrator and DON were notified at 5:40 p.m. on 11-30-16 that an Immediate Jeopardy situation was identified. Interviews conducted on 12/02/16 between 1:50 p.m. and 3:00 p.m. with a multiple of nursing staff members from various shifts revealed they were aware of the appropriate actions to ensure residents with proper hydration. The facility's Plan of Removal was approved at 5:20 p.m. on 12-01-16. The plan included: 1. Licensed nurses performed 100% audit of residents to determine their risk for dehydration. 2. Residents who were determined at risk for dehydration were care planned with the goals and approaches to assist the residents in maintaining their hydration level or enteral feeding requirements as established by the Dietician and the Physician. 3. The Regional Nurse Consultant re-educated the DON and the Administrator on the action plan for hydration. The DON re-educated nursing staff on the need to offer hydration opportunities for the residents throughout the day. The CNAs were instructed not to turn off any feeding tubes to do activities of daily living (ADLs). The charge nurse would be required to turn off the feeding tube and removing the tubing. Upon completion of the ADLs, the charge nurse would be responsible to ensure the feeding pump was on as ordered by the physician. The DON/Designee would be responsible for monitoring. 4. The hydration and snack carts would be passed on each hall by the Restorative Aides on the morning and afternoon shifts and by the CNAs on the night shift. The charge nurses were responsible for ensuring hydration and snack carts were passed. The DON/Designee and/or the Dietary Manager would be responsible for monitoring. 5. The DON/Designee would communicate with the CNAs the residents who were at highest risk of dehydration and those needed to be encouraged to consume fluids. The communication would be done by updating the electronic kiosk (computer) the CNAs used to document ADL care. The update would ask the CNAs how many cups of fluid the resident consumed during their shift. The nurse would be notified if the resident did not consume the recommended amount. The charge nurses would monitor the documentation from the kiosk for completed care and the DON/Designee would be responsible for monitoring. On 12-02-16, surveyors verified the Plan of Removal by conducting review of training for nursing staff on all three shifts and resident assessments. Interviews were conducted with nursing staff on two shifts to determine the level of understanding of newly implemented policies and procedures. All nursing staff interviewed were aware of the newly implemented policies and procedures. Observations were made of individual residents identified in the Plan of Removal. The Administrator was informed at 4:20 p.m. on 12-02-16 that the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility's CMS Form-802 indicated there were 67 residents with hydration issues.

Based on interview and record review the facility failed to immediately consult with the resident's Physician when there was a significant change in the resident's physical or psychosocial status for one Resident (R #1) of seven residents reviewed for moderate to severe pain. R #1's Pain Physician was not consulted when R #1 reported her pain symptoms were not being managed by the [MEDICATION NAME] prescribed 09/24/15. This failure could affect 54 residents on a pain management program by placing them at risk for unassessed pain, untreated pain, decline in function for activities of daily living, isolation and delay in treatment. The findings were: R #1 Record review of R #1's Face Sheet dated 10/14/15 revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record Review of R #1's Consolidated Physician order [REDACTED].#1 had a Peripherally Inserted Central Catheter (PICC) line for infusing medication intravenously (through a vein.) The PICC line was to be flushed before and after each medication dose with 10 milliliters (ml) of normal saline. R #1 had an indwelling urinary catheter (Foley catheter) to drain urine from her bladder that was to be changed monthly. R #1 had a stage four pressure sore (full thickness tissue loss due to localized pressure over a boney area that exposed bone, tendon or muscle) on her left foot. R #1 was being seen by a wound care physician and the facility wound care nurse was performing treatments. R #1's Physician ordered pain and anti-spasm medications included the following: -[MEDICATION NAME] 100 micrograms (mcg) per hour skin patch to be replace every 48 hours (Narcotic pain reliever) with the physician ordered start date of 06/16/15. -[MEDICATION NAME] 10-325 milligram (mg), one tablet by mouth every four hours as needed for pain (Narcotic pain reliever) with the physician ordered start date of 10/14/14. -[MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain (Narcotic pain reliever) with the physician ordered start date of 09/24/15. -[MEDICATION NAME] 50 mg, one tablet by mouth every four hours as needed for pain (Narcotic-like pain reliever) with the physician ordered start date of 08/05/14. -[MEDICATION NAME] 4 mg, two tablets by mouth four times per day as need for muscle spasms (Anti-spasm medication) with the physician ordered start date of 08/05/14. Record review of R #1's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #1 understood others with clear comprehension and was able to make herself understood and did not exhibit any behavioral symptoms. R #1 required extensive assistance from at least one staff person for bed mobility, dressing, toilet use and personal hygiene. R #1 was not scored for transfer or locomotion as those activities did not occur. R #1's pain interview revealed she rated the intensity of her pain at nine out of 10 with zero being no pain at all and 10 being the worst pain. R #1's pain interview described the frequency of her pain as almost constantly. Record review of R #1's care plan signed 8/21/15 revealed R #1's acceptable pain was a three on a pain scale of zero to 10. R #1 was to have her pain level reevaluated after each dose of pain medication was received; to include assessments regarding onset, location, frequency, duration and description of pain. R #1 was to have pain medication administered per physician orders. The care plan did not list non-pharmacological interventions for pain relief (ways to ease pain other than medication.) Goals with a target date of 11/21/15 included the following: -R #1 will verbalize full relief of pain by 11/21/15. -R #1 will verbalize that pain is decreased to goal of three or less by 11/21/15. -R #1 will ask appropriate people to receive pain medication within the next 90 days by 11/21/15. R #1's care plan listed her as bedfast all or most of the time and assigned the approach of active and passive range of motion during Activities of Daily Living (ADLs) daily to the role of the CNAs. Licensed nurses were to perform weekly skin assessments on R #1 and monitor her for skin breakdown and contractures with the goal that R #1 will show minimal or no ill effects of being bed bound with the target date of 11/21/15. R #1's care plan with a quarterly review date of 01/15/15 and the target date of 04/06/15 revealed the same goals as the care plan dated 08/21/15 with the target date of 11/21/15. Record review of R #1's three most recent Pain Assessment - Admission and Quarterly assessments dated 04/03/15, 07/13/15 and 08/13/15 all revealed that R #1 reported she was in severe pain . almost constantly that she rated at an intensity of nine of 10 and caused her [MEDICAL CONDITION] or affected her ability to sleep. Each of these facility pain assessments listed R #1's non-verbal expressions of pain to include muscle rigidity and depression. The 07/13/15 and 08/13/15 assessments included facial grimacing. Each of these facility pain assessments answered the final section What is the conclusion of the assessment with no intervention was necessary. Reassess quarterly or with onset of pain. Observation on 10/14/15 at 3:00 p.m. revealed R #1 sitting up in bed leaning on her right side. Surveyor observed R #1 had a Peripherally Inserted Central Catheter (PICC) line in her upper left arm used to for intravenous (through the vein) medication and fluid therapy. Surveyor observed R #1's lower extremities did not extend past her hips toward the end of the bed under the sheet. Surveyor observed R #1's skin tone was pale, her forehead was furrowed and she displayed facial grimacing. Surveyor observed R #1's eyes were open and she was alert. Surveyor observed R #1 use the remote control to adjust the TV volume. Surveyor observed R #1 had spasms of her lower extremities while she sat up in bed. In an interview conducted on 10/14/15 at 3:00 p.m., R #1 stated the she had asked facility staff to change the PICC line dressing on her left arm for the past week. R #1 stated that the last time staff changed the PICC line dressing to her left arms was in September 2015. R #1 stated nursing said they would be back to change the PICC line dressing when she showed them the edges were rolling up and nursing staff did not change the PICC line dressing. R#1 stated that she did not want to give the names of the nursing staff that she asked to change her PICC line dressing. R #1 stated that she was in a lot of pain and felt the facility staff did not give her enough medication to control her pain. R #1 stated she wanted to change her primary physician because she had been in the facility for over a year and only saw her physician three times since admission. R #1 stated she told nurses she wanted to change physicians and the nurses would respond that they would let administration know. R #1 stated that she never heard back from any staff about her request change physician. R #1 stated that she was in constant pain that she rated as nine of 10 when her pain medication stopped working and eight of 10 after she took her pain medication. R #1 stated she wanted to change her pain control physician that she started seeing in September 2015. R #1 stated that last time she was transferred out of bed was on 09/24/15 when she went by ambulance to see a pain control physician. R #1 stated that the pain control physician gave her a prescription for the pain medication [MEDICATION NAME] and it did not effectively control her pain. R #1 stated she had contractures of her left leg that caused it to uncontrollably draw up and her left foot wrapped underneath her right thigh. R #1 stated she had a pressure sore on her left ankle that was being treated by a wound care physician and the facility wound care nurse. R #1 stated that with her contractures and muscle spasms in her lower extremities and abdomen she was unable to be in any other position without making her pain worse. R #1 stated that she asked nursing staff for pain medication and at times had to wait a long time. R #1 stated that in the past she used her phone to call the nurse station for pain medication because she waited so long in severe pain. R #1 stated that staff told her not to call the nurse station and for her to wait for the assigned nurse to bring her pain medication. R #1 stated I used to stand up for myself. Now I just wait for someone to come back. R #1 stated that she would like to be able to get into her chair and go out of her room but she did not because her pain level was too high to sit in her chair. R #1 stated that her family came to visit her last Sunday, 10/11/15, and she asked them to leave because I was in so much pain and I didn't want them to see me cry. According to U.S. Department of Health & Human Services Pain: You Can Get Help information retrieved 10/28/15 from https://www.nia.nih.gov/health/publication/pain, Often, you have to stick with a treatment plan before you get relief. It ' s important to stay on a schedule. Sometimes this is called 'staying ahead' or 'keeping on top' of your pain. As your pain lessens, you can likely become more active and will see your mood lift and sleep improve . In addition to drugs, there are a variety of complementary and alternative approaches that may provide relief . It may take both medicine and other treatments to feel better . Most people don ' t have to live with pain. There are pain treatments. While not all pain can be cured, most pain can be managed. Record review of R #1's controlled substance record revealed her pain control physician prescribed the [MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain on 09/24/15. The control substance record from the date the prescription was ordered revealed the medication had been administered to R #1 by facility nursing staff on 09/25/15, 10/03/15, 10/09/15 and 10/11/15. Record review of R #1's Skilled Nursing MAR for October 2015 revealed the medication [MEDICATION NAME] was ordered every 4 hours as needed for pain. Documentation on R #1's Skilled Nursing Mar for October 2015 revealed R #1 was not administered [MEDICATION NAME] by facility nursing staff in October 2015. Record review of R #1's Departmental Notes revealed R #1 complained to nursing staff of unresolved pain and nursing staff did not administer [MEDICATION NAME] 10-325mg on 10/02/15, 10/07/15 and 10/14/15. Record review of R #1's [MEDICATION NAME] ([MEDICATION NAME]/APAP) narcotic count for prescription (RX) dated 09/20/15 through 10/15/15 revealed the time of day facility staff administered [MEDICATION NAME] to R #1 on 10/02/15, 10/07/15 and 10/14/15. The results were combined as follow: -On 10/02/15 at 3:09 a.m. R #1 continues to complain of pain in body. Request [MEDICATION NAME] and Xanaflex with fair results. The free text documentation by nursing staff did not define fair results. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/02/15 at 2:00 a.m., 7:20 a.m., 4:00 p.m., and 8:00 p.m. -On 10/07/15 at 6:49 a.m. R #1 complains of pain to bilateral lower extremities. As needed pain med given. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/07/15 at 2:00 a.m., 11:30 a.m., 5:00 p.m. and 10:30 p.m. -On 10/14/15 at 5:19 a.m. R #1 continues to complain about frequent pain. Requests [MEDICATION NAME], Xanaflex and [MEDICATION NAME]. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1four times on 10/14/15 at 3:30 a.m., 9:20 a.m., 2:45 p.m. and 8:00 p.m. No entries were made to Departmental Notes on the following dates: 10/01/15, 10/05/15, 10/0815, 10/10/15 and 10/12/15. In an interview conducted 10/14/15 at 4:45 p.m., the Director of Nursing (DON) stated if R #1 was voicing the need for additional pain control she should be given [MEDICATION NAME]. Record review of R #1's Skilled Nursing MAR for [MEDICATION NAME] 10-325 mg in conjunction with record review of R #1's controlled substance administration log revealed R #1 received 66 doses of [MEDICATION NAME] from 10/01/15 to 10/14/15. Facility staff documented 23 follow-up assessments after R #1 was administered [MEDICATION NAME] from 10/01/15 to 10/14/15. Of those 23 assessments, eight follow-up assessments included R #1's pain level number that ranged from four of 10 to seven of 10 after administration of the [MEDICATION NAME]. The facility staff did not document follow-up pain assessments after they administered 43 of the 66 doses of [MEDICATION NAME] to R #1 from 10/01/15 to 10/14/15. In an interview on 10/15/15 at 11:45 a.m., R #1 stated that when facility staff asked her about her follow-up pain level, she had never reported a pain level number less than eight of 10. In an interview on 10/15/15 at 12:00 p.m., LVN F stated that he last gave R #1 a [MEDICATION NAME] for her pain that she rated nine of 10 on 10/15/15 at approximately 7:20 a.m. LVN F stated that the follow-up pain level given to him by R #1 an hour later was five of 10. In an interview on 10/15/15 at 12:02 p.m., R #1 stated that she did not verbalize a follow-up number on her pain level after the 7:20 a.m. dose of [MEDICATION NAME] on 10/15/15 as They don't always ask. In an interview on 10/15/15 at 12:20 p.m., Certified Nurse Aid (CNA) H stated that R #1 complained of pain and sometimes she has to wait a long time to get pain medicine from the nurse. CNA H stated R #1 Cries in pain. CNA H did not want to give names of employees or dates of occurrences. CNA H stated that she had never been instructed by licensed nursing staff or administration regarding non-pharmacological ways to relieve a resident's pain. In an interview on 10/15/15 at 1:50 p.m., CNA C stated R #1 complained of pain when she was transferred to her wheelchair by mechanical lift. CNA C stated R #1 used to take a bath in the whirlpool and but now she only takes a bed bath. CNA C stated R #1 was less contracted when she took a bath in the whirlpool. In an interview on 10/15/15 at 3:20 p.m., CNA I stated that R #1 is Always hurting and calls a lot for pain medication. CNA I stated she had never been instructed by licensed nursing staff or administration on non-pharmacological ways to relieve a resident's pain. CNA I stated that R #1 takes a bed bath and refuses to transfer to her wheelchair. In an interview on 10/15/15 at 4:15 p.m., the Activity Director (AD) stated that R #1 stopped going on outings to the store and out to eat at restaurants in August of 2015. The AD stated that she did not know if R #1 stopped participating in outings because of pain. The AD stated she did not ask R #1 about her pain. In an interview on 10/15/15 at 4:00 p.m., in response to surveyor questions, the DON stated that the facility Medical Director had not been contacted about R #1's unresolved pain. The DON also stated that she did not know if R #1's primary care physician or pain control physician had been contacted by facility staff about her complaints of unresolved pain. Record review throughout R #1's medical record revealed no documentation from R #1's pain control physician in progress notes nor any correspondence from facility staff to R #1's pain control physician from 09/24/15 through 10/15/15. In an interview on 10/15/15 at 4:45 p.m., Registered Nurse (RN) L stated that the facility had no documentation of progress notes or facility communication with R #1's pain management physician regarding R #1's pain level and response to treatment. After facility attempts to contact R #1's pain control physician on 10/15/15, attempts were made to interview R #1's pain control physician by telephone on 10/15/15 at 11:00 a.m. and 3:00 p.m. Messages left by the surveyor were not returned from R #1's pain control physician by the time of exit from the facility on 10/15/15 at 5:00 p.m. Record review of the facility Pain Assessment policy and procedure dated July 2015 revealed the purpose of the pain procedure was to assess the resident's pain level and provide optimal comfort through a pain control plan which was mutually established with the resident, family and members of the health care team. General guidelines included the following: -A comprehensive pain assessment should be completed as part of the initial nursing assessment with development of a pain management program as indicated. -The comprehensive pain assessment should be reviewed quarterly and with a significant change in status. -Continuing assessment of the pain management program should occur daily and should focus on the effectiveness of the program and the comfort level of the resident. -Pain should be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident should occur. Steps in the facility Pain Assessment procedure included: -Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. -Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. -Determine appropriate type of pain medication as ordered by the physician. -Medicate the resident as the physician ordered. -Do follow-up assessment after administration of medication. -Evaluate effectiveness of non-pharmacologic interventions. -If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician and obtain an order. -Document results in resident's clinical record. The facility's centers for Medicare and Medicad Services form CMS-672 dated 10/13/15 revealed 54 residents who were on a pain management program.

Based on observation, interview and record review, the facility failed to implement their policy and procedure that prohibits neglect for three Residents (R #1, R #2 and R #3) out of seven sampled residents reviewed for neglect. -The facility did not provide R #1 with an effective pain management program to allow her to participate in out of room activities, social events or visits with family due to her unresolved pain. -The facility did not administer pain medication to R #1 as ordered by her physician to manage her unresolved pain. -The facility did not assess and document the effectiveness of pain medication administered to R #1 per facility policy. -The facility did not follow-up on physician recommended [MEDICATION NAME] procedure to treat R #1's painful lower extremity contractures and spasms. -Staff did not change R #1's Peripherally Inserted Central Catheter dressing weekly for two weeks although staff documented the Peripherally Inserted Central Catheter dressing change as completed for two weeks in a row. -Staff assessed R #1's Peripherally Inserted Central Catheter and infused medications through R #1's Peripherally Inserted Central Catheter without documenting the Peripherally Inserted Central Catheter dressing needed to be changed. -The facility did not place the call buttons within reach of R #2 or R #3 to allow them to call staff for assistance. These failures placed two residents who received intravenous therapy, 54 residents who were on a pain management program and 89 residents who were in bed or a chair most of the time.in the facility at increased risk for neglect The findings were: R #1 Record review of R #1's Face Sheet dated 10/14/15 revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record Review of R #1's Consolidated Physician order [REDACTED].#1 had a Peripherally Inserted Central Catheter (PICC) line for infusing medication intravenously (through a vein.) The PICC line was to be flushed before and after each medication dose with 10 milliliters (ml) of normal saline. R #1 had an indwelling urinary catheter (Foley catheter) to drain urine from her bladder that was to be changed monthly. R #1 had a stage four pressure sore (full thickness tissue loss due to localized pressure over a boney area that exposed bone, tendon or muscle) on her left foot. R #1 was being seen by a wound care physician and the facility wound care nurse was performing treatments. R #1's Physician ordered pain and anti-spasm medications included the following: -[MEDICATION NAME] 100 micrograms (mcg) per hour skin patch to be replace every 48 hours (Narcotic pain reliever) with the physician ordered start date of 06/16/15. -[MEDICATION NAME] 10-325 milligram (mg), one tablet by mouth every four hours as needed for pain (Narcotic pain reliever) with the physician ordered start date of 10/14/14. -[MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain (Narcotic pain reliever) with the physician ordered start date of 09/24/15. -[MEDICATION NAME] 50 mg, one tablet by mouth every four hours as needed for pain (Narcotic-like pain reliever) with the physician ordered start date of 08/05/14. -[MEDICATION NAME] 4 mg, two tablets by mouth four times per day as need for muscle spasms (Anti-spasm medication) with the physician ordered start date of 08/05/14. Record review of R #1's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #1 understood others with clear comprehension and was able to make herself understood and did not exhibit any behavioral symptoms. R #1 required extensive assistance from at least one staff person for bed mobility, dressing, toilet use and personal hygiene. R #1 was not scored for transfer or locomotion as those activities did not occur. R #1's pain interview revealed she rated the intensity of her pain at nine out of 10 with zero being no pain at all and 10 being the worst pain. R #1's pain interview described the frequency of her pain as almost constantly. Record review of R #1's care plan signed 8/21/15 revealed R #1's acceptable pain was a three on a pain scale of zero to 10. R #1 was to have her pain level reevaluated after each dose of pain medication was received; to include assessments regarding onset, location, frequency, duration and description of pain. R #1 was to have pain medication administered per physician orders. The care plan did not list non-pharmacological interventions for pain relief (ways to ease pain other than medication.) Goals with a target date of 11/21/15 included the following: -R #1 will verbalize full relief of pain by 11/21/15. -R #1 will verbalize that pain is decreased to goal of three or less by 11/21/15. -R #1 will ask appropriate people to receive pain medication within the next 90 days by 11/21/15. R #1's care plan listed her as bedfast all or most of the time and assigned the approach of active and passive range of motion during Activities of Daily Living (ADLs) daily to the role of the CNAs. Licensed nurses were to perform weekly skin assessments on R #1 and monitor her for skin breakdown and contractures with the goal that R #1 will show minimal or no ill effects of being bed bound with the target date of 11/21/15. R #1's care plan with a quarterly review date of 01/15/15 and the target date of 04/06/15 revealed the same goals as the care plan dated 08/21/15 with the target date of 11/21/15. Record review of R #1's three most recent Pain Assessment - Admission and Quarterly assessments dated 04/03/15, 07/13/15 and 08/13/15 all revealed that R #1 reported she was in severe pain . almost constantly that she rated at an intensity of nine of 10 and caused her [MEDICAL CONDITION] or affected her ability to sleep. Each of these facility pain assessments listed R #1's non-verbal expressions of pain to include muscle rigidity and depression. The 07/13/15 and 08/13/15 assessments included facial grimacing. Each of these facility pain assessments answered the final section What is the conclusion of the assessment with no intervention was necessary. Reassess quarterly or with onset of pain. Observation on 10/14/15 at 3:00 p.m. revealed R #1 sitting up in bed leaning on her right side. Surveyor observed R #1 had a Peripherally Inserted Central Catheter (PICC) line in her upper left arm used to for intravenous (through the vein) medication and fluid therapy. R #1's PICC line dressing was dated 09/25/15 as the most recent dressing change. The Surveyor observed that the edges of R #1's PICC line dressing were loose and rolled up on her skin. Surveyor observed R #1's lower extremities did not extend past her hips toward the end of the bed under the sheet. Surveyor observed R #1's skin tone was pale, her forehead was furrowed and she displayed facial grimacing. Surveyor observed R #1's eyes were open and she was alert. Surveyor observed R #1 use the remote control to adjust the TV volume. Surveyor observed R #1 had spasms of her lower extremities while she sat up in bed. In an interview conducted on 10/14/15 at 3:00 p.m., R #1 stated the she had asked facility staff to change the PICC line dressing on her left arm for the past week. R #1 stated that the last time staff changed the PICC line dressing to her left arms was in September 2015. R #1 stated nursing said they would be back to change the PICC line dressing when she showed them the edges were rolling up and nursing staff did not change the PICC line dressing. R#1 stated that she did not want to give the names of the nursing staff that she asked to change her PICC line dressing. R #1 stated that she was in a lot of pain and felt the facility staff did not give her enough medication to control her pain. R #1 stated she wanted to change her primary physician because she had been in the facility for over a year and only saw her physician three times since admission. R #1 stated she told nurses she wanted to change physicians and the nurses would respond that they would let administration know. R #1 stated that she never heard back from any staff about her request change physician. R #1 stated that she was in constant pain that she rated as nine of 10 when her pain medication stopped working and eight of 10 after she took her pain medication. R #1 stated she wanted to change her pain control physician that she started seeing in September 2015. R #1 stated that last time she was transferred out of bed was on 09/24/15 when she went by ambulance to see a pain control physician. R #1 stated that the pain control physician gave her a prescription for the pain medication [MEDICATION NAME] and it did not effectively control her pain. R #1 stated she had contractures of her left leg that caused it to uncontrollably draw up and her left foot wrapped underneath her right thigh. R #1 stated she had a pressure sore on her left ankle that was being treated by a wound care physician and the facility wound care nurse. R #1 stated that with her contractures and muscle spasms in her lower extremities and abdomen she was unable to be in any other position without making her pain worse. R #1 stated that she asked nursing staff for pain medication and at times had to wait a long time. R #1 stated that in the past she used her phone to call the nurse station for pain medication because she waited so long in severe pain. R #1 stated that staff told her not to call the nurse station and for her to wait for the assigned nurse to bring her pain medication. R #1 stated I used to stand up for myself. Now I just wait for someone to come back. R #1 stated that she would like to be able to get into her chair and go out of her room but she did not because her pain level was too high to sit in her chair. R #1 stated that her family came to visit her last Sunday, 10/11/15, and she asked them to leave because I was in so much pain and I didn't want them to see me cry. According to U.S. Department of Health & Human Services Pain: You Can Get Help information retrieved 10/28/15 from https://www.nia.nih.gov/health/publication/pain, Often, you have to stick with a treatment plan before you get relief. It ' s important to stay on a schedule. Sometimes this is called 'staying ahead' or 'keeping on top' of your pain. As your pain lessens, you can likely become more active and will see your mood lift and sleep improve . In addition to drugs, there are a variety of complementary and alternative approaches that may provide relief . It may take both medicine and other treatments to feel better . Most people don ' t have to live with pain. There are pain treatments. While not all pain can be cured, most pain can be managed. Record review of R #1's controlled substance record revealed her pain control physician prescribed the [MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain on 09/24/15. The control substance record from the date the prescription was ordered revealed the medication had been administered to R #1 by facility nursing staff on 09/25/15, 10/03/15, 10/09/15 and 10/11/15. Record review of R #1's Skilled Nursing MAR for October 2015 revealed the medication [MEDICATION NAME] was ordered every 4 hours as needed for pain. Documentation on R #1's Skilled Nursing Mar for October 2015 revealed R #1 was not administered [MEDICATION NAME] by facility nursing staff in October 2015. Record review of R #1's Departmental Notes revealed R #1 complained to nursing staff of unresolved pain and nursing staff did not administer [MEDICATION NAME] 10-325mg on 10/02/15, 10/07/15 and 10/14/15. Record review of R #1's [MEDICATION NAME] ([MEDICATION NAME]/APAP) narcotic count for prescription (RX) dated 09/20/15 through 10/15/15 revealed the time of day facility staff administered [MEDICATION NAME] to R #1 on 10/02/15, 10/07/15 and 10/14/15. The results were combined as follow: -On 10/02/15 at 3:09 a.m. R #1 continues to complain of pain in body. Request [MEDICATION NAME] and Xanaflex with fair results. The free text documentation by nursing staff did not define fair results. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/02/15 at 2:00 a.m., 7:20 a.m., 4:00 p.m., and 8:00 p.m. -On 10/07/15 at 6:49 a.m. R #1 complains of pain to bilateral lower extremities. As needed pain med given. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/07/15 at 2:00 a.m., 11:30 a.m., 5:00 p.m. and 10:30 p.m. -On 10/14/15 at 5:19 a.m. R #1 continues to complain about frequent pain. Requests [MEDICATION NAME], Xanaflex and [MEDICATION NAME]. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1four times on 10/14/15 at 3:30 a.m., 9:20 a.m., 2:45 p.m. and 8:00 p.m. No entries were made to Departmental Notes on the following dates: 10/01/15, 10/05/15, 10/0815, 10/10/15 and 10/12/15. In an interview conducted 10/14/15 at 4:45 p.m., the Director of Nursing (DON) stated if R #1 was voicing the need for additional pain control she should be given [MEDICATION NAME]. Record review of Departmental Notes entry dated 09/15/15 at 4:07 p.m. revealed wound assessment notes documented by charge nurse Licensed Vocational Nurse (LVN) J stating R #1's wound care physician recommended another physician to do [MEDICATION NAME] (injectable medication to temporarily paralyze nerves and relax muscles) procedure for release (of R #1's) contracture. Record review of Departmental Notes entry dated 09/22/15 at 2:51 p.m. revealed Notes documented by charge nurse LVN J stating R #1's orders were refaxed to Physician K for consult of [MEDICATION NAME] for contracture release .(confirmed with office staff that) all orders received. Awaiting call back for appointment if accepted. Record review of Departmental Notes entry dated 09/23/15 at 11:22 p.m. revealed Notes documented by charge nurse LVN J stating Called Physician K office regarding paperwork for [MEDICATION NAME] for (R #1's) contracture release. (Physician K) has not yet read it and will get back .with outcome per (Physician K office staff.) Record review of Departmental Notes entry dated 10/06/15 at 3:53 p.m. revealed Notes documented by charge Nurse LVN J stating that R #1 requested an update on the [MEDICATION NAME] referral. Spoke with (Physician K office staff who) stated it's on his desk and will review it after hours. Will inform the facilty of outcome. Resident made aware and will (follow up) tomorrow on the status No further entries were made in Departmental Notes regarding [MEDICATION NAME] therapy for R #1. In an interview on 10/15/15 at 3:40 p.m., LVN J stated A referral has been made to Physician K regarding Release of R #1's contracture but that the facility had not been notified if Physician K had accepted R #1 for treatment. According to the National Institutes of Health Management of [DIAGNOSES REDACTED] After Spinal Cord Injury: Current Techniques and Future Directions information retrieved 10/20/15 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 42/, [DIAGNOSES REDACTED] that leads to spasms, pain, and contractures is a debilitating secondary complication of Spinal Cord Injury (SCI.) Identification of potential mechanisms and their significance to the pathophysiology of [DIAGNOSES REDACTED] is critical for the design of rehabilitation programs. Record review of R #1's Skilled Nursing MAR for [MEDICATION NAME] 10-325 mg in conjunction with record review of R #1's controlled substance administration log revealed R #1 received 66 doses of [MEDICATION NAME] from 10/01/15 to 10/14/15. Facility staff documented 23 follow-up assessments after R #1 was administered [MEDICATION NAME] from 10/01/15 to 10/14/15. Of those 23 assessments, eight follow-up assessments included R #1's pain level number that ranged from four of 10 to seven of 10 after administration of the [MEDICATION NAME]. The facility staff did not document follow-up pain assessments after they administered 43 of the 66 doses of [MEDICATION NAME] to R #1 from 10/01/15 to 10/14/15. In an interview on 10/15/15 at 11:45 a.m., R #1 stated that when facility staff asked her about her follow-up pain level, she had never reported a pain level number less than eight of 10. In an interview on 10/15/15 at 12:00 p.m., LVN F stated that he last gave R #1 a [MEDICATION NAME] for her pain that she rated nine of 10 on 10/15/15 at approximately 7:20 a.m. LVN F stated that the follow-up pain level given to him by R #1 an hour later was five of 10. In an interview on 10/15/15 at 12:02 p.m., R #1 stated that she did not verbalize a follow-up number on her pain level after the 7:20 a.m. dose of [MEDICATION NAME] on 10/15/15 as They don't always ask. In an interview on 10/15/15 at 12:20 p.m., Certified Nurse Aid (CNA) H stated that R #1 complained of pain and sometimes she has to wait a long time to get pain medicine from the nurse. CNA H stated R #1 Cries in pain. CNA H did not want to give names of employees or dates of occurrences. CNA H stated that she had never been instructed by licensed nursing staff or administration regarding non-pharmacological ways to relieve a resident's pain. In an interview on 10/15/15 at 1:50 p.m., CNA C stated R #1 complained of pain when she was transferred to her wheelchair by mechanical lift. CNA C stated R #1 used to take a bath in the whirlpool and but now she only takes a bed bath. CNA C stated R #1 was less contracted when she took a bath in the whirlpool. In an interview on 10/15/15 at 3:20 p.m., CNA I stated that R #1 is Always hurting and calls a lot for pain medication. CNA I stated she had never been instructed by licensed nursing staff or administration on non-pharmacological ways to relieve a resident's pain. CNA I stated that R #1 takes a bed bath and refuses to transfer to her wheelchair. In an interview on 10/15/15 at 4:15 p.m., the Activity Director (AD) stated that R #1 stopped going on outings to the store and out to eat at restaurants in August of 2015. The AD stated that she did not know if R #1 stopped participating in outings because of pain. The AD stated she did not ask R #1 about her pain. In an interview on 10/15/15 at 4:00 p.m., in response to surveyor questions, the DON stated that the facility Medical Director had not been contacted about R #1's unresolved pain. The DON also stated that she did not know if R #1's primary care physician or pain control physician had been contacted by facility staff about her complaints of unresolved pain. Record review throughout R #1's medical record revealed no documentation from R #1's pain control physician in progress notes nor any correspondence from facility staff to R #1's pain control physician from 09/24/15 through 10/15/15. In an interview on 10/15/15 at 4:45 p.m., Registered Nurse (RN) L stated that the facility had no documentation of progress notes or facility communication with R #1's pain management physician regarding R #1's pain level and response to treatment. After facility attempts to contact R #1's pain control physician on 10/15/15, attempts were made to interview R #1's pain control physician by telephone on 10/15/15 at 11:00 a.m. and 3:00 p.m. Messages left by the surveyor were not returned from R #1's pain control physician by the time of exit from the facility on 10/15/15 at 5:00 p.m. Record review of R #1's Skilled Nursing Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Observation on 10/14/15 at 4:25 p.m. revealed LVN E at R #1's bedside changing her PICC line dressing. In an interview conducted on 10/14/15 at 4:30 p.m., LVN E stated that he did not remember the date of the dressing he removed from R #1's PICC line to apply the new dressing and that he threw the old dressing in the trash. Observation and Interview on 10/14/15 at 4:30 p.m. revealed LVN E retrieved the removed dressing from R #1's trash after he changed her PICC line dressing. LVN E stated that the date on the removed dressing was 09/25/15. Record review of the facility Skilled Nursing MAR for October 2015 revealed nursing staff documented on all three shifts from 10/02/15 through 10/14/15 that R #1's PICC line was flushed and assessed for redness, tenderness, bleeding, [MEDICAL CONDITION] and pain every shift. Record review of Departmental Notes for R #1 dated 10/02/14 through 10/13/15 revealed no documentation about the date on R #1's PICC line dressing being 09/25/15. In an interview conducted on 10/14/15 at 4:25 p.m., the Director of Nursing (DON) stated facility policy and her expectation was that PICC line dressings were to be changed weekly and as needed and that documentation on the MAR indicated [REDACTED] According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Peripherally Inserted Central Catheter Use, page 565 A PICC dressing should be changed at least every 7days .Replace (the) dressing if it becomes damp, loosened, or visibly soiled. According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Peripherally Inserted Central Catheter Use, page 571 If the (PICC) dressing becomes damp, loose, or soiled, change it immediately. Maintaining a clean, dry and occlusive dressing is important to protect the catheter insertion site and reduce the risk for infection. Record review of the facility Employee counseling Report dated 10/14/15 revealed LVN G was given an unpaid, written suspension for Falsification of record as LVN G singed on R #1's Skilled Nursing MAR indicated [REDACTED]. The Employee counseling Report was signed by the DON and LVN G 10/14/15. Record review of the facility Pain Assessment policy and procedure dated July 2015 revealed the purpose of the pain procedure was to assess the resident's pain level and provide optimal comfort through a pain control plan which was mutually established with the resident, family and members of the health care team. General guidelines included the following: -A comprehensive pain assessment should be completed as part of the initial nursing assessment with development of a pain management program as indicated. -The comprehensive pain assessment should be reviewed quarterly and with a significant change in status. -Continuing assessment of the pain management program should occur daily and should focus on the effectiveness of the program and the comfort level of the resident. -Pain should be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident should occur. Steps in the facility Pain Assessment procedure included: -Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. -Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. -Determine appropriate type of pain medication as ordered by the physician. -Medicate the resident as the physician ordered. -Do follow-up assessment after administration of medication. -Evaluate effectiveness of non-pharmacologic interventions. -If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician and obtain an order. -Document results in resident's clinical record. R #2 Record review of R #2's Face Sheet dated 10/14/15 revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record Review of R # 2's Consolidated Physician order [REDACTED].#2 was to have one quarter side rails (side rails for upper body) up times two (both sides) to aid in bed mobility due to muscle disuse and atrophy secondary to right femur (thigh bone) and right sided [MEDICAL CONDITION] (BKA). Record review of R #2's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #2 usually understood others and missed some part or intent of the message but comprehended most conversation,, was understood by others and had behavioral symptoms of [MEDICAL CONDITION] (when a person loses contact with reality.) R #2 required extensive assistance from at least two staff persons for bed mobility, transfer, toileting, dressing and bathing. R #2 required extensive assistance from at least one staff person for eating and personal hygiene. R #2 was totally dependent on one staff member for assistance with locomotion in her wheelchair. Record review of R #2's care plan dated received 10/14/15 revealed R #2 was at risk for injury and had a high susceptibility of falls for problem onset date 05/30/15. Approaches identified in R #2's care plan included the following: -Facility staff was to ensure R #2's call light was in her reach at all times when she was in her room or bathroom. -Facility staff was to remind and encourage R #2 to call for assistance as needed and staff was to praise R #2 when she did call for assistance. -Facility staff was to answer R #2's call light promptly. -Facility staff was to keep R #2's side rails up times two when she was in bed per physician's orders [REDACTED]. Record review of R #2's post fall care plan dated 09/08/15 revealed facility staff were to ensure R #2's call light was within reach as R #2 sustained a fall 09/08/15. Record review of R #2's restraint review dated 09/29/15 revealed R #2 continued to need one quarter side rails up times two to aide in her repositioning and bed mobility. Observation on 10/14/15 at 10:50 a.m. revealed R #2 lying in bed on her right side low in bed wearing a hospital gown. R #2's right side bed rail was raised up and her left side bedrail was low and out of R #2's reach. R #2's call light was tied to the bottom of the left bedrail, rested on the floor and was not within her reach. R #2's incontinence brief was visible as her blanket was on the floor and her gown was open in the back and her brief, gown and bed under pad were observed to be wet at the level of R #2's hips and perineal (peri) area. The smell of urine was detected in R #2's room. In an interview conducted on 10/14/15 at 11:20 a.m., CNA A stated R #2's call light should have been clipped on her pillow or sheet so she could reach it. CNA A stated that on 10/14/15 the first time she was in R #2's room was at 10:55 a.m. and she did not know if any other staff attended to R #2 since shift change at 6:00 a.m. In an interview conducted on 10/14/15 at 11:25 a.m. CNA B stated that if R #2 could not reach her call bell to request assistance she could call out our names. In an interview conducted on 10/14/15 at 11:45 a.m., Hospitality Aid (HA) D stated the last time she noticed facility staff in R #2's room was at 7:00 a.m. when R #2 received wound care. In an interview conducted on 10/14/15 at 2:00 p.m., the Director of Nursing (DON) stated staff was to ensure call bells were within reach of residents at all times. R #3 Record review of R #3's Face Sheet dated 11/19/14 revealed a [AGE] year old female with admitted on [DATE] and included the [DIAGNOSES REDACTED]. Record Review of R # 3's Consolidated Physician order [REDACTED]. Record review of R #3's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #3 usually understood others and missed some part or intent of the message but comprehended most conversation, was understood by others and had verbal behaviors directed toward others one to three times per week. R #3 required extensive assistance from at least two staff persons for bed mobility and toileting. R #3 required extensive assistance from at least one staff person for transfer, dressing, bathing and personal hygiene. R #3 was totally dependent on one staff member for assistance with locomotion in her wheelchair. Observation on 10/15/15 at 1:30 p.m. revealed R #3 sitting up in bed yelling Help a minimum of three times over five minutes from her bed that could be heard in the hallway. R #3's call bell was tied to the right bedrail hanging down the side of the bed with a pillow over the call bell cord. In an interview conducted on 10/15/15 at 1:30 p.m., R #3 stated that she needed help with her lunch tray and she could not reach her call bell because her arthritis made it difficult for her to move around in bed. R #3 stated it happens a lot that she was not able to find her call bell and facility staff tell me not to scream and it makes me feel bad. R #3 stated Sometimes I scream and sometimes I just wait for someone to come. Sometimes my roommate presses her button for me. Observation on 10/15/15 at 1:35 p.m., CNA C came in R #3's room and removed her lunch tray. CNA C did not move R #3's call bell to a position where she could reach it before leaving her room. In an interview conducted on 10/15/15 at 1:50 p.m., CNA C stated another CNA left R #3's call bell in the wrong place and that it should have been clipped to the pillow or sheet in reach of R #3. Record review of the facility Answering the Call Light policy and procedure dated 07/2015 stated the following: -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. -Some residents may not be able to use their call light. Be sure you check these residents frequently. Record review of the Facility Abuse Prohibition Policy and Procedure dated June 2015revealed The facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. The facility's centers for Medicare and Medicaid Services form CMS-672 dated 10/13/15 revealed two residents received intravenous therapy, 54 residents were on a pain management program and 89 residents were in bed or a chair most of the time.

Based on observation, record review and interview, the facility failed to implement their written policy and procedures to prohibit neglect for three Residents (R #1, R #2 and R #3) out of seven sampled residents reviewed for neglect. -The facility did not provide R #1 with an effective pain management program to allow her to participate in out of room activities, social events or visits with family due to her unresolved pain. -The facility did not administer pain medication to R #1 as ordered by her physician to manage her unresolved pain. -The facility did not assess and document the effectiveness of pain medication administered to R #1 per facility policy. -The facility did not follow-up on physician recommended [MEDICATION NAME] procedure to treat R #1's painful lower extremity contractures and spasms. -Staff did not change R #1's Peripherally Inserted Central Catheter dressing weekly for two weeks although staff documented the Peripherally Inserted Central Catheter dressing change as completed for two weeks in a row. -Staff assessed R #1's Peripherally Inserted Central Catheter and infused medications through R #1's Peripherally Inserted Central Catheter without documenting the Peripherally Inserted Central Catheter dressing needed to be changed. -The facility did not place the call buttons within reach of R #2 or R #3 to allow them to call staff for assistance. These failures placed two residents who received intravenous therapy, 54 residents who were on a pain management program and 89 residents who were in bed or a chair most of the time.in the facility at increased risk for neglect. The findings were: Record review of the Facility Abuse Prohibition Policy and Procedure dated June 2015revealed The facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. R #1 Record review of R #1's Face Sheet dated 10/14/15 revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record Review of R #1's Consolidated Physician order [REDACTED].#1 had a Peripherally Inserted Central Catheter (PICC) line for infusing medication intravenously (through a vein.) The PICC line was to be flushed before and after each medication dose with 10 milliliters (ml) of normal saline. R #1 had an indwelling urinary catheter (Foley catheter) to drain urine from her bladder that was to be changed monthly. R #1 had a stage four pressure sore (full thickness tissue loss due to localized pressure over a boney area that exposed bone, tendon or muscle) on her left foot. R #1 was being seen by a wound care physician and the facility wound care nurse was performing treatments. R #1's Physician ordered pain and anti-spasm medications included the following: -[MEDICATION NAME] 100 micrograms (mcg) per hour skin patch to be replace every 48 hours (Narcotic pain reliever) with the physician ordered start date of 06/16/15. -[MEDICATION NAME] 10-325 milligram (mg), one tablet by mouth every four hours as needed for pain (Narcotic pain reliever) with the physician ordered start date of 10/14/14. -[MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain (Narcotic pain reliever) with the physician ordered start date of 09/24/15. -[MEDICATION NAME] 50 mg, one tablet by mouth every four hours as needed for pain (Narcotic-like pain reliever) with the physician ordered start date of 08/05/14. -[MEDICATION NAME] 4 mg, two tablets by mouth four times per day as need for muscle spasms (Anti-spasm medication) with the physician ordered start date of 08/05/14. Record review of R #1's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #1 understood others with clear comprehension and was able to make herself understood and did not exhibit any behavioral symptoms. R #1 required extensive assistance from at least one staff person for bed mobility, dressing, toilet use and personal hygiene. R #1 was not scored for transfer or locomotion as those activities did not occur. R #1's pain interview revealed she rated the intensity of her pain at nine out of 10 with zero being no pain at all and 10 being the worst pain. R #1's pain interview described the frequency of her pain as almost constantly. Record review of R #1's care plan signed 8/21/15 revealed R #1's acceptable pain was a three on a pain scale of zero to 10. R #1 was to have her pain level reevaluated after each dose of pain medication was received; to include assessments regarding onset, location, frequency, duration and description of pain. R #1 was to have pain medication administered per physician orders. The care plan did not list non-pharmacological interventions for pain relief (ways to ease pain other than medication.) Goals with a target date of 11/21/15 included the following: -R #1 will verbalize full relief of pain by 11/21/15. -R #1 will verbalize that pain is decreased to goal of three or less by 11/21/15. -R #1 will ask appropriate people to receive pain medication within the next 90 days by 11/21/15. R #1's care plan listed her as bedfast all or most of the time and assigned the approach of active and passive range of motion during Activities of Daily Living (ADLs) daily to the role of the CNAs. Licensed nurses were to perform weekly skin assessments on R #1 and monitor her for skin breakdown and contractures with the goal that R #1 will show minimal or no ill effects of being bed bound with the target date of 11/21/15. R #1's care plan with a quarterly review date of 01/15/15 and the target date of 04/06/15 revealed the same goals as the care plan dated 08/21/15 with the target date of 11/21/15. Record review of R #1's three most recent Pain Assessment - Admission and Quarterly assessments dated 04/03/15, 07/13/15 and 08/13/15 all revealed that R #1 reported she was in severe pain . almost constantly that she rated at an intensity of nine of 10 and caused her [MEDICAL CONDITION] or affected her ability to sleep. Each of these facility pain assessments listed R #1's non-verbal expressions of pain to include muscle rigidity and depression. The 07/13/15 and 08/13/15 assessments included facial grimacing. Each of these facility pain assessments answered the final section What is the conclusion of the assessment with no intervention was necessary. Reassess quarterly or with onset of pain. Observation on 10/14/15 at 3:00 p.m. revealed R #1 sitting up in bed leaning on her right side. Surveyor observed R #1 had a Peripherally Inserted Central Catheter (PICC) line in her upper left arm used to for intravenous (through the vein) medication and fluid therapy. R #1's PICC line dressing was dated 09/25/15 as the most recent dressing change. The Surveyor observed that the edges of R #1's PICC line dressing were loose and rolled up on her skin. Surveyor observed R #1's lower extremities did not extend past her hips toward the end of the bed under the sheet. Surveyor observed R #1's skin tone was pale, her forehead was furrowed and she displayed facial grimacing. Surveyor observed R #1's eyes were open and she was alert. Surveyor observed R #1 use the remote control to adjust the TV volume. Surveyor observed R #1 had spasms of her lower extremities while she sat up in bed. In an interview conducted on 10/14/15 at 3:00 p.m., R #1 stated the she had asked facility staff to change the PICC line dressing on her left arm for the past week. R #1 stated that the last time staff changed the PICC line dressing to her left arms was in September 2015. R #1 stated nursing said they would be back to change the PICC line dressing when she showed them the edges were rolling up and nursing staff did not change the PICC line dressing. R#1 stated that she did not want to give the names of the nursing staff that she asked to change her PICC line dressing. R #1 stated that she was in a lot of pain and felt the facility staff did not give her enough medication to control her pain. R #1 stated she wanted to change her primary physician because she had been in the facility for over a year and only saw her physician three times since admission. R #1 stated she told nurses she wanted to change physicians and the nurses would respond that they would let administration know. R #1 stated that she never heard back from any staff about her request change physician. R #1 stated that she was in constant pain that she rated as nine of 10 when her pain medication stopped working and eight of 10 after she took her pain medication. R #1 stated she wanted to change her pain control physician that she started seeing in September 2015. R #1 stated that last time she was transferred out of bed was on 09/24/15 when she went by ambulance to see a pain control physician. R #1 stated that the pain control physician gave her a prescription for the pain medication [MEDICATION NAME] and it did not effectively control her pain. R #1 stated she had contractures of her left leg that caused it to uncontrollably draw up and her left foot wrapped underneath her right thigh. R #1 stated she had a pressure sore on her left ankle that was being treated by a wound care physician and the facility wound care nurse. R #1 stated that with her contractures and muscle spasms in her lower extremities and abdomen she was unable to be in any other position without making her pain worse. R #1 stated that she asked nursing staff for pain medication and at times had to wait a long time. R #1 stated that in the past she used her phone to call the nurse station for pain medication because she waited so long in severe pain. R #1 stated that staff told her not to call the nurse station and for her to wait for the assigned nurse to bring her pain medication. R #1 stated I used to stand up for myself. Now I just wait for someone to come back. R #1 stated that she would like to be able to get into her chair and go out of her room but she did not because her pain level was too high to sit in her chair. R #1 stated that her family came to visit her last Sunday, 10/11/15, and she asked them to leave because I was in so much pain and I didn't want them to see me cry. According to U.S. Department of Health & Human Services Pain: You Can Get Help information retrieved 10/28/15 from https://www.nia.nih.gov/health/publication/pain, Often, you have to stick with a treatment plan before you get relief. It ' s important to stay on a schedule. Sometimes this is called 'staying ahead' or 'keeping on top' of your pain. As your pain lessens, you can likely become more active and will see your mood lift and sleep improve . In addition to drugs, there are a variety of complementary and alternative approaches that may provide relief . It may take both medicine and other treatments to feel better . Most people don ' t have to live with pain. There are pain treatments. While not all pain can be cured, most pain can be managed. Record review of R #1's controlled substance record revealed her pain control physician prescribed the [MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain on 09/24/15. The control substance record from the date the prescription was ordered revealed the medication had been administered to R #1 by facility nursing staff on 09/25/15, 10/03/15, 10/09/15 and 10/11/15. Record review of R #1's Skilled Nursing MAR for October 2015 revealed the medication [MEDICATION NAME] was ordered every 4 hours as needed for pain. Documentation on R #1's Skilled Nursing Mar for October 2015 revealed R #1 was not administered [MEDICATION NAME] by facility nursing staff in October 2015. Record review of R #1's Departmental Notes revealed R #1 complained to nursing staff of unresolved pain and nursing staff did not administer [MEDICATION NAME] 10-325mg on 10/02/15, 10/07/15 and 10/14/15. Record review of R #1's [MEDICATION NAME] ([MEDICATION NAME]/APAP) narcotic count for prescription (RX) dated 09/20/15 through 10/15/15 revealed the time of day facility staff administered [MEDICATION NAME] to R #1 on 10/02/15, 10/07/15 and 10/14/15. The results were combined as follow: -On 10/02/15 at 3:09 a.m. R #1 continues to complain of pain in body. Request [MEDICATION NAME] and Xanaflex with fair results. The free text documentation by nursing staff did not define fair results. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/02/15 at 2:00 a.m., 7:20 a.m., 4:00 p.m., and 8:00 p.m. -On 10/07/15 at 6:49 a.m. R #1 complains of pain to bilateral lower extremities. As needed pain med given. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/07/15 at 2:00 a.m., 11:30 a.m., 5:00 p.m. and 10:30 p.m. -On 10/14/15 at 5:19 a.m. R #1 continues to complain about frequent pain. Requests [MEDICATION NAME], Xanaflex and [MEDICATION NAME]. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1four times on 10/14/15 at 3:30 a.m., 9:20 a.m., 2:45 p.m. and 8:00 p.m. No entries were made to Departmental Notes on the following dates: 10/01/15, 10/05/15, 10/0815, 10/10/15 and 10/12/15. In an interview conducted 10/14/15 at 4:45 p.m., the Director of Nursing (DON) stated if R #1 was voicing the need for additional pain control she should be given [MEDICATION NAME]. Record review of Departmental Notes entry dated 09/15/15 at 4:07 p.m. revealed wound assessment notes documented by charge nurse Licensed Vocational Nurse (LVN) J stating R #1's wound care physician recommended another physician to do [MEDICATION NAME] (injectable medication to temporarily paralyze nerves and relax muscles) procedure for release (of R #1's) contracture. Record review of Departmental Notes entry dated 09/22/15 at 2:51 p.m. revealed Notes documented by charge nurse LVN J stating R #1's orders were refaxed to Physician K for consult of [MEDICATION NAME] for contracture release .(confirmed with office staff that) all orders received. Awaiting call back for appointment if accepted. Record review of Departmental Notes entry dated 09/23/15 at 11:22 p.m. revealed Notes documented by charge nurse LVN J stating Called Physician K office regarding paperwork for [MEDICATION NAME] for (R #1's) contracture release. (Physician K) has not yet read it and will get back .with outcome per (Physician K office staff.) Record review of Departmental Notes entry dated 10/06/15 at 3:53 p.m. revealed Notes documented by charge Nurse LVN J stating that R #1 requested an update on the [MEDICATION NAME] referral. Spoke with (Physician K office staff who) stated it's on his desk and will review it after hours. Will inform the facilty of outcome. Resident made aware and will (follow up) tomorrow on the status No further entries were made in Departmental Notes regarding [MEDICATION NAME] therapy for R #1. In an interview on 10/15/15 at 3:40 p.m., LVN J stated A referral has been made to Physician K regarding Release of R #1's contracture but that the facility had not been notified if Physician K had accepted R #1 for treatment. According to the National Institutes of Health Management of [DIAGNOSES REDACTED] After Spinal Cord Injury: Current Techniques and Future Directions information retrieved 10/20/15 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 42/, [DIAGNOSES REDACTED] that leads to spasms, pain, and contractures is a debilitating secondary complication of Spinal Cord Injury (SCI.) Identification of potential mechanisms and their significance to the pathophysiology of [DIAGNOSES REDACTED] is critical for the design of rehabilitation programs. Record review of R #1's Skilled Nursing MAR for [MEDICATION NAME] 10-325 mg in conjunction with record review of R #1's controlled substance administration log revealed R #1 received 66 doses of [MEDICATION NAME] from 10/01/15 to 10/14/15. Facility staff documented 23 follow-up assessments after R #1 was administered [MEDICATION NAME] from 10/01/15 to 10/14/15. Of those 23 assessments, eight follow-up assessments included R #1's pain level number that ranged from four of 10 to seven of 10 after administration of the [MEDICATION NAME]. The facility staff did not document follow-up pain assessments after they administered 43 of the 66 doses of [MEDICATION NAME] to R #1 from 10/01/15 to 10/14/15. In an interview on 10/15/15 at 11:45 a.m., R #1 stated that when facility staff asked her about her follow-up pain level, she had never reported a pain level number less than eight of 10. In an interview on 10/15/15 at 12:00 p.m., LVN F stated that he last gave R #1 a [MEDICATION NAME] for her pain that she rated nine of 10 on 10/15/15 at approximately 7:20 a.m. LVN F stated that the follow-up pain level given to him by R #1 an hour later was five of 10. In an interview on 10/15/15 at 12:02 p.m., R #1 stated that she did not verbalize a follow-up number on her pain level after the 7:20 a.m. dose of [MEDICATION NAME] on 10/15/15 as They don't always ask. In an interview on 10/15/15 at 12:20 p.m., Certified Nurse Aid (CNA) H stated that R #1 complained of pain and sometimes she has to wait a long time to get pain medicine from the nurse. CNA H stated R #1 Cries in pain. CNA H did not want to give names of employees or dates of occurrences. CNA H stated that she had never been instructed by licensed nursing staff or administration regarding non-pharmacological ways to relieve a resident's pain. In an interview on 10/15/15 at 1:50 p.m., CNA C stated R #1 complained of pain when she was transferred to her wheelchair by mechanical lift. CNA C stated R #1 used to take a bath in the whirlpool and but now she only takes a bed bath. CNA C stated R #1 was less contracted when she took a bath in the whirlpool. In an interview on 10/15/15 at 3:20 p.m., CNA I stated that R #1 is Always hurting and calls a lot for pain medication. CNA I stated she had never been instructed by licensed nursing staff or administration on non-pharmacological ways to relieve a resident's pain. CNA I stated that R #1 takes a bed bath and refuses to transfer to her wheelchair. In an interview on 10/15/15 at 4:15 p.m., the Activity Director (AD) stated that R #1 stopped going on outings to the store and out to eat at restaurants in August of 2015. The AD stated that she did not know if R #1 stopped participating in outings because of pain. The AD stated she did not ask R #1 about her pain. In an interview on 10/15/15 at 4:00 p.m., in response to surveyor questions, the DON stated that the facility Medical Director had not been contacted about R #1's unresolved pain. The DON also stated that she did not know if R #1's primary care physician or pain control physician had been contacted by facility staff about her complaints of unresolved pain. Record review throughout R #1's medical record revealed no documentation from R #1's pain control physician in progress notes nor any correspondence from facility staff to R #1's pain control physician from 09/24/15 through 10/15/15. In an interview on 10/15/15 at 4:45 p.m., Registered Nurse (RN) L stated that the facility had no documentation of progress notes or facility communication with R #1's pain management physician regarding R #1's pain level and response to treatment. After facility attempts to contact R #1's pain control physician on 10/15/15, attempts were made to interview R #1's pain control physician by telephone on 10/15/15 at 11:00 a.m. and 3:00 p.m. Messages left by the surveyor were not returned from R #1's pain control physician by the time of exit from the facility on 10/15/15 at 5:00 p.m. Record review of R #1's Skilled Nursing Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Observation on 10/14/15 at 4:25 p.m. revealed LVN E at R #1's bedside changing her PICC line dressing. In an interview conducted on 10/14/15 at 4:30 p.m., LVN E stated that he did not remember the date of the dressing he removed from R #1's PICC line to apply the new dressing and that he threw the old dressing in the trash. Observation and Interview on 10/14/15 at 4:30 p.m. revealed LVN E retrieved the removed dressing from R #1's trash after he changed her PICC line dressing. LVN E stated that the date on the removed dressing was 09/25/15. Record review of the facility Skilled Nursing MAR for October 2015 revealed nursing staff documented on all three shifts from 10/02/15 through 10/14/15 that R #1's PICC line was flushed and assessed for redness, tenderness, bleeding, [MEDICAL CONDITION] and pain every shift. Record review of Departmental Notes for R #1 dated 10/02/14 through 10/13/15 revealed no documentation about the date on R #1's PICC line dressing being 09/25/15. In an interview conducted on 10/14/15 at 4:25 p.m., the Director of Nursing (DON) stated facility policy and her expectation was that PICC line dressings were to be changed weekly and as needed and that documentation on the MAR indicated [REDACTED] According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Peripherally Inserted Central Catheter Use, page 565 A PICC dressing should be changed at least every 7days .Replace (the) dressing if it becomes damp, loosened, or visibly soiled. According to Lippincott's Nursing Procedures 2013 Sixth Edition, entitled Peripherally Inserted Central Catheter Use, page 571 If the (PICC) dressing becomes damp, loose, or soiled, change it immediately. Maintaining a clean, dry and occlusive dressing is important to protect the catheter insertion site and reduce the risk for infection. Record review of the facility Employee counseling Report dated 10/14/15 revealed LVN G was given an unpaid, written suspension for Falsification of record as LVN G singed on R #1's Skilled Nursing MAR indicated [REDACTED]. The Employee counseling Report was signed by the DON and LVN G 10/14/15. Record review of the facility Pain Assessment policy and procedure dated July 2015 revealed the purpose of the pain procedure was to assess the resident's pain level and provide optimal comfort through a pain control plan which was mutually established with the resident, family and members of the health care team. General guidelines included the following: -A comprehensive pain assessment should be completed as part of the initial nursing assessment with development of a pain management program as indicated. -The comprehensive pain assessment should be reviewed quarterly and with a significant change in status. -Continuing assessment of the pain management program should occur daily and should focus on the effectiveness of the program and the comfort level of the resident. -Pain should be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident should occur. Steps in the facility Pain Assessment procedure included: -Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. -Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. -Determine appropriate type of pain medication as ordered by the physician. -Medicate the resident as the physician ordered. -Do follow-up assessment after administration of medication. -Evaluate effectiveness of non-pharmacologic interventions. -If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician and obtain an order. -Document results in resident's clinical record. R #2 Record review of the facility Answering the Call Light policy and procedure dated 07/2015 stated the following: -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. -Some residents may not be able to use their call light. Be sure you check these residents frequently. Record review of R #2's Face Sheet dated 10/14/15 revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record Review of R # 2's Consolidated Physician order [REDACTED].#2 was to have one quarter side rails (side rails for upper body) up times two (both sides) to aid in bed mobility due to muscle disuse and atrophy secondary to right femur (thigh bone) and right sided [MEDICAL CONDITION] (BKA). Record review of R #2's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #2 usually understood others and missed some part or intent of the message but comprehended most conversation,, was understood by others and had behavioral symptoms of [MEDICAL CONDITION] (when a person loses contact with reality.) R #2 required extensive assistance from at least two staff persons for bed mobility, transfer, toileting, dressing and bathing. R #2 required extensive assistance from at least one staff person for eating and personal hygiene. R #2 was totally dependent on one staff member for assistance with locomotion in her wheelchair. Record review of R #2's care plan dated received 10/14/15 revealed R #2 was at risk for injury and had a high susceptibility of falls for problem onset date 05/30/15. Approaches identified in R #2's care plan included the following: -Facility staff was to ensure R #2's call light was in her reach at all times when she was in her room or bathroom. -Facility staff was to remind and encourage R #2 to call for assistance as needed and staff was to praise R #2 when she did call for assistance. -Facility staff was to answer R #2's call light promptly. -Facility staff was to keep R #2's side rails up times two when she was in bed per physician's orders [REDACTED]. Record review of R #2's post fall care plan dated 09/08/15 revealed facility staff were to ensure R #2's call light was within reach as R #2 sustained a fall 09/08/15. Record review of R #2's restraint review dated 09/29/15 revealed R #2 continued to need one quarter side rails up times two to aide in her repositioning and bed mobility. Observation on 10/14/15 at 10:50 a.m. revealed R #2 lying in bed on her right side low in bed wearing a hospital gown. R #2's right side bed rail was raised up and her left side bedrail was low and out of R #2's reach. R #2's call light was tied to the bottom of the left bedrail, rested on the floor and was not within her reach. R #2's incontinence brief was visible as her blanket was on the floor and her gown was open in the back and her brief, gown and bed under pad were observed to be wet at the level of R #2's hips and perineal (peri) area. The smell of urine was detected in R #2's room. In an interview conducted on 10/14/15 at 11:20 a.m., CNA A stated R #2's call light should have been clipped on her pillow or sheet so she could reach it. CNA A stated that on 10/14/15 the first time she was in R #2's room was at 10:55 a.m. and she did not know if any other staff attended to R #2 since shift change at 6:00 a.m. In an interview conducted on 10/14/15 at 11:25 a.m. CNA B stated that if R #2 could not reach her call bell to request assistance she could call out our names. In an interview conducted on 10/14/15 at 11:45 a.m., Hospitality Aid (HA) D stated the last time she noticed facility staff in R #2's room was at 7:00 a.m. when R #2 received wound care. In an interview conducted on 10/14/15 at 2:00 p.m., the Director of Nursing (DON) stated staff was to ensure call bells were within reach of residents at all times. R #3 Record review of R #3's Face Sheet dated 11/19/14 revealed a [AGE] year old female with admitted on [DATE] and included the [DIAGNOSES REDACTED]. Record Review of R # 3's Consolidated Physician order [REDACTED]. Record review of R #3's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #3 usually understood others and missed some part or intent of the message but comprehended most conversation, was understood by others and had verbal behaviors directed toward others one to three times per week. R #3 required extensive assistance from at least two staff persons for bed mobility and toileting. R #3 required extensive assistance from at least one staff person for transfer, dressing, bathing and personal hygiene. R #3 was totally dependent on one staff member for assistance with locomotion in her wheelchair. Observation on 10/15/15 at 1:30 p.m. revealed R #3 sitting up in bed yelling Help a minimum of three times over five minutes from her bed that could be heard in the hallway. R #3's call bell was tied to the right bedrail hanging down the side of the bed with a pillow over the call bell cord. In an interview conducted on 10/15/15 at 1:30 p.m., R #3 stated that she needed help with her lunch tray and she could not reach her call bell because her arthritis made it difficult for her to move around in bed. R #3 stated it happens a lot that she was not able to find her call bell and facility staff tell me not to scream and it makes me feel bad. R #3 stated Sometimes I scream and sometimes I just wait for someone to come. Sometimes my roommate presses her button for me. Observation on 10/15/15 at 1:35 p.m., CNA C came in R #3's room and removed her lunch tray. CNA C did not move R #3's call bell to a position where she could reach it before leaving her room. In an interview conducted on 10/15/15 at 1:50 p.m., CNA C stated another CNA left R #3's call bell in the wrong place and that it should have been clipped to the pillow or sheet in reach of R #3. The facility's centers for Medicare and Medicaid Services form CMS-672 dated 10/13/15 revealed two residents received intravenous therapy, 54 residents were on a pain management program and 89 residents were in bed or a chair most of the time.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with the comprehensive assessment and plan of care for one Resident (R #1) of seven residents reviewed for moderate to severe pain. -The facility did not provide R #1 with an effective pain management program to allow her to participate in out of room activities, social events or visits with family due to her unresolved pain. -The facility did not administer pain medication to R #1 as ordered by her physician to manage her unresolved pain. -The facility did not follow-up on physician recommended [MEDICATION NAME] procedure to treat R #1's painful lower extremity contractures and spasms. These failures could affect 54 residents on a pain management program by placing them at risk for unassessed pain, untreated pain, a decline in function for activities of daily living, isolation and delay in treatment. The findings were: R #1 Record review of R #1's Face Sheet dated 10/14/15 revealed a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record Review of R #1's Consolidated Physician order [REDACTED].#1 had a Peripherally Inserted Central Catheter (PICC) line for infusing medication intravenously (through a vein.) The PICC line was to be flushed before and after each medication dose with 10 milliliters (ml) of normal saline. R #1 had an indwelling urinary catheter (Foley catheter) to drain urine from her bladder that was to be changed monthly. R #1 had a stage four pressure sore (full thickness tissue loss due to localized pressure over a boney area that exposed bone, tendon or muscle) on her left foot. R #1 was being seen by a wound care physician and the facility wound care nurse was performing treatments. R #1's Physician ordered pain and anti-spasm medications included the following: -[MEDICATION NAME] 100 micrograms (mcg) per hour skin patch to be replace every 48 hours (Narcotic pain reliever) with the physician ordered start date of 06/16/15. -[MEDICATION NAME] 10-325 milligram (mg), one tablet by mouth every four hours as needed for pain (Narcotic pain reliever) with the physician ordered start date of 10/14/14. -[MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain (Narcotic pain reliever) with the physician ordered start date of 09/24/15. -[MEDICATION NAME] 50 mg, one tablet by mouth every four hours as needed for pain (Narcotic-like pain reliever) with the physician ordered start date of 08/05/14. -[MEDICATION NAME] 4 mg, two tablets by mouth four times per day as need for muscle spasms (Anti-spasm medication) with the physician ordered start date of 08/05/14. Record review of R #1's Quarterly Minimum Data Sheet ((MDS) dated [DATE] revealed R #1 understood others with clear comprehension and was able to make herself understood and did not exhibit any behavioral symptoms. R #1 required extensive assistance from at least one staff person for bed mobility, dressing, toilet use and personal hygiene. R #1 was not scored for transfer or locomotion as those activities did not occur. R #1's pain interview revealed she rated the intensity of her pain at nine out of 10 with zero being no pain at all and 10 being the worst pain. R #1's pain interview described the frequency of her pain as almost constantly. Record review of R #1's care plan signed 8/21/15 revealed R #1's acceptable pain was a three on a pain scale of zero to 10. R #1 was to have her pain level reevaluated after each dose of pain medication was received; to include assessments regarding onset, location, frequency, duration and description of pain. R #1 was to have pain medication administered per physician orders. The care plan did not list non-pharmacological interventions for pain relief (ways to ease pain other than medication.) Goals with a target date of 11/21/15 included the following: -R #1 will verbalize full relief of pain by 11/21/15. -R #1 will verbalize that pain is decreased to goal of three or less by 11/21/15. -R #1 will ask appropriate people to receive pain medication within the next 90 days by 11/21/15. R #1's care plan listed her as bedfast all or most of the time and assigned the approach of active and passive range of motion during Activities of Daily Living (ADLs) daily to the role of the CNAs. Licensed nurses were to perform weekly skin assessments on R #1 and monitor her for skin breakdown and contractures with the goal that R #1 will show minimal or no ill effects of being bed bound with the target date of 11/21/15. R #1's care plan with a quarterly review date of 01/15/15 and the target date of 04/06/15 revealed the same goals as the care plan dated 08/21/15 with the target date of 11/21/15. Record review of R #1's three most recent Pain Assessment - Admission and Quarterly assessments dated 04/03/15, 07/13/15 and 08/13/15 all revealed that R #1 reported she was in severe pain . almost constantly that she rated at an intensity of nine of 10 and caused her [MEDICAL CONDITION] or affected her ability to sleep. Each of these facility pain assessments listed R #1's non-verbal expressions of pain to include muscle rigidity and depression. The 07/13/15 and 08/13/15 assessments included facial grimacing. Each of these facility pain assessments answered the final section What is the conclusion of the assessment with no intervention was necessary. Reassess quarterly or with onset of pain. Observation on 10/14/15 at 3:00 p.m. revealed R #1 sitting up in bed leaning on her right side. Surveyor observed R #1's lower extremities did not extend past her hips toward the end of the bed under the sheet. Surveyor observed R #1's skin tone was pale, her forehead was furrowed and she displayed facial grimacing. Surveyor observed R #1's eyes were open and she was alert. Surveyor observed R #1 use the remote control to adjust the TV volume. Surveyor observed R #1 had spasms of her lower extremities while she sat up in bed. In an interview conducted on 10/14/15 at 3:00 p.m., R #1 stated that she was in a lot of pain and felt the facility staff did not give her enough medication to control her pain. R #1 stated she wanted to change her primary physician because she had been in the facility for over a year and only saw her physician three times since admission. R #1 stated she told nurses she wanted to change physicians and the nurses would respond that they would let administration know. R #1 stated that she never heard back from any staff about her request change physician. R #1 stated that she was in constant pain that she rated as nine of 10 when her pain medication stopped working and eight of 10 after she took her pain medication. R #1 stated she wanted to change her pain control physician that she started seeing in September 2015. R #1 stated that last time she was transferred out of bed was on 09/24/15 when she went by ambulance to see a pain control physician. R #1 stated that the pain control physician gave her a pain medication prescription for the pain medication [MEDICATION NAME] that did not effectively control her pain. R #1 stated she had contractures of her left leg that caused it to uncontrollably draw up and her left foot wrapped underneath her right thigh. R #1 stated she had a pressure sore on her left foot that was being treated by a wound care physician and the facility wound care nurse. R #1 stated that with her contractures and muscle spasms in her lower extremities and abdomen she was unable to be in any other position without making her pain worse. R #1 stated she asked nursing staff for pain medication and at times had to wait a long time. R #1 stated that in the past she used her phone to call the nurse's station for pain medication because she waited so long in severe pain. R #1 stated that staff told her not to call the nurse's station and for her to wait for the assigned nurse to bring her pain medication. R #1 stated I used to stand up for myself. Now I just wait for someone to come back. R #1 stated that she would like to be able to get into her wheel chair and go out of her room but she did not because her pain level was too high to sit in her chair. R #1 stated that her family came to visit her last Sunday, 10/11/15, and she asked them to leave because I was in so much pain and I didn't want them to see me cry. According to U.S. Department of Health & Human Services Pain: You Can Get Help information retrieved 10/28/15 from https://www.nia.nih.gov/health/publication/pain, Often, you have to stick with a treatment plan before you get relief. It ' s important to stay on a schedule. Sometimes this is called 'staying ahead' or 'keeping on top' of your pain. As your pain lessens, you can likely become more active and will see your mood lift and sleep improve . In addition to drugs, there are a variety of complementary and alternative approaches that may provide relief . It may take both medicine and other treatments to feel better . Most people don ' t have to live with pain. There are pain treatments. While not all pain can be cured, most pain can be managed. Record review of R #1's controlled substance record revealed her pain control physician prescribed the [MEDICATION NAME] 10-325 mg, one tablet by mouth every two days as needed for pain on 09/24/15. The control substance record from the date the prescription was ordered revealed the medication had been administered to R #1 by facility nursing staff on 09/25/15, 10/03/15, 10/09/15 and 10/11/15. Record review of R #1's Skilled Nursing MAR for October 2015 revealed the medication [MEDICATION NAME] was ordered every 4 hours as needed for pain. Documentation on R #1's Skilled Nursing Mar for October 2015 revealed R #1 was not administered [MEDICATION NAME] by facility nursing staff in October 2015. Record review of R #1's Departmental Notes revealed R #1 complained to nursing staff of unresolved pain and nursing staff did not administer [MEDICATION NAME] 10-325mg on 10/02/15, 10/07/15 and 10/14/15. Record review of R #1's [MEDICATION NAME] ([MEDICATION NAME]/APAP) narcotic count for prescription (RX) dated 09/20/15 through 10/15/15 revealed the time of day facility staff administered [MEDICATION NAME] to R #1 on 10/02/15, 10/07/15 and 10/14/15. The results were combined as follow: -On 10/02/15 at 3:09 a.m. R #1 continues to complain of pain in body. Request [MEDICATION NAME] and Xanaflex with fair results. The free text documentation by nursing staff did not define fair results. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/02/15 at 2:00 a.m., 7:20 a.m., 4:00 p.m., and 8:00 p.m. -On 10/07/15 at 6:49 a.m. R #1 complains of pain to bilateral lower extremities. As needed pain med given. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1 four times on 10/07/15 at 2:00 a.m., 11:30 a.m., 5:00 p.m. and 10:30 p.m. -On 10/14/15 at 5:19 a.m. R #1 continues to complain about frequent pain. Requests [MEDICATION NAME], Xanaflex and [MEDICATION NAME]. The free text documentation by facility nursing staff did not describe the effectiveness of pain medications administered to R #1. Facility staff administered [MEDICATION NAME] to R #1four times on 10/14/15 at 3:30 a.m., 9:20 a.m., 2:45 p.m. and 8:00 p.m. No entries were made to Departmental Notes on the following dates: 10/01/15, 10/05/15, 10/0815, 10/10/15 and 10/12/15. In an interview conducted 10/14/15 at 4:45 p.m., the Director of Nursing (DON) stated if R #1 was voicing the need for additional pain control she should be given [MEDICATION NAME]. Record review of Departmental Notes entry dated 09/15/15 at 4:07 p.m. revealed wound assessment notes documented by charge nurse Licensed Vocational Nurse (LVN) J stating R #1's wound care physician recommended another physician to do [MEDICATION NAME] (injectable medication to temporarily paralyze nerves and relax muscles) procedure for release (of R #1's) contracture. Record review of Departmental Notes entry dated 09/22/15 at 2:51 p.m. revealed Notes documented by charge nurse LVN J stating R #1's orders were refaxed to Physician K for consult of [MEDICATION NAME] for contracture release .(confirmed with office staff that) all orders received. Awaiting call back for appointment if accepted. Record review of Departmental Notes entry dated 09/23/15 at 11:22 p.m. revealed Notes documented by charge nurse LVN J stating Called Physician K office regarding paperwork for [MEDICATION NAME] for (R #1's) contracture release. (Physician K) has not yet read it and will get back .with outcome per (Physician K office staff.) Record review of Departmental Notes entry dated 10/06/15 at 3:53 p.m. revealed Notes documented by charge Nurse LVN J stating that R #1 requested an update on the [MEDICATION NAME] referral. Spoke with (Physician K office staff who) stated it's on his desk and will review it after hours. Will inform the facility of outcome. Resident made aware and will (follow up) tomorrow on the status No further entries were made in Departmental Notes regarding [MEDICATION NAME] therapy for R #1. In an interview on 10/15/15 at 3:40 p.m., LVN J stated A referral has been made to Physician K regarding Release of R #1's contracture but that the facility had not been notified if Physician K had accepted R #1 for treatment. According to the National Institutes of Health Management of [DIAGNOSES REDACTED] After Spinal Cord Injury: Current Techniques and Future Directions information retrieved 10/20/15 from <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 42/>, [DIAGNOSES REDACTED] that leads to spasms, pain, and contractures is a debilitating secondary complication of Spinal Cord Injury (SCI.) Identification of potential mechanisms and their significance to the pathophysiology of [DIAGNOSES REDACTED] is critical for the design of rehabilitation programs. Record review of R #1's Skilled Nursing MAR for [MEDICATION NAME] 10-325 mg in conjunction with record review of R #1's controlled substance administration log revealed R #1 received 66 doses of [MEDICATION NAME] from 10/01/15 to 10/14/15. Facility staff documented 23 follow-up assessments after R #1 was administered [MEDICATION NAME] from 10/01/15 to 10/14/15. Of those 23 assessments, eight follow-up assessments included R #1's pain level number that ranged from four of 10 to seven of 10 after administration of the [MEDICATION NAME]. The facility staff did not document follow-up pain assessments after they administered 43 of the 66 doses of [MEDICATION NAME] to R #1 from 10/01/15 to 10/14/15. In an interview on 10/15/15 at 11:45 a.m., R #1 stated that when facility staff asked her about her follow-up pain level, she had never reported a pain level number less than eight of 10. In an interview on 10/15/15 at 12:00 p.m., LVN F stated that he last gave R #1 a [MEDICATION NAME] for her pain that she rated nine of 10 on 10/15/15 at approximately 7:20 a.m. LVN F stated that the follow-up pain level given to him by R #1 an hour later was five of 10. In an interview on 10/15/15 at 12:02 p.m., R #1 stated that she did not verbalize a follow-up number on her pain level after the 7:20 a.m. dose of [MEDICATION NAME] on 10/15/15 as They don't always ask. In an interview on 10/15/15 at 12:20 p.m., Certified Nurse Aid (CNA) H stated that R #1 complained of pain and sometimes she has to wait a long time to get pain medicine from the nurse. CNA H stated R #1 Cries in pain. CNA H stated that she had never been instructed by licensed nursing staff or administration regarding non-pharmacological ways to relieve a resident's pain. In an interview on 10/15/15 at 1:50 p.m., CNA C stated R #1 complained of pain when she was transferred to her wheelchair by mechanical lift. CNA C stated R #1 used to take a bath in the whirlpool and but now she only takes a bed bath. CNA C stated R #1 was less contracted when she took a bath in the whirlpool. In an interview on 10/15/15 at 3:20 p.m., CNA I stated that R #1 is Always hurting and calls a lot for pain medication. CNA I stated she had never been instructed by licensed nursing staff or administration on non-pharmacological ways to relieve a resident's pain. CNA I stated that R #1 takes a bed bath and refuses to transfer to her wheelchair. In an interview on 10/15/15 at 4:15 p.m., the Activity Director (AD) stated that R #1 stopped going on outings to the store and out to eat at restaurants in August of 2015. The AD stated that she did not know if R #1 stopped participating in outings because of pain. The AD stated she did not ask R #1 about her pain. In an interview on 10/15/15 at 4:00 p.m., in response to surveyor questions, the DON stated that the facility Medical Director had not been contacted about R #1's unresolved pain. The DON also stated that she did not know if R #1's primary care physician or pain control physician had been contacted by facility staff about her complaints of unresolved pain. Record review throughout R #1's medical record revealed no documentation from R #1's pain control physician in progress notes nor any correspondence from facility staff to R #1's pain control physician from 09/24/15 through 10/15/15. In an interview on 10/15/15 at 4:45 p.m., Registered Nurse (RN) L stated that the facility had no documentation of progress notes or facility communication with R #1's pain management physician regarding R #1's pain level and response to treatment. After facility attempts to contact R #1's pain control physician on 10/15/15, attempts were made to interview R #1's pain control physician by telephone on 10/15/15 at 11:00 a.m. and 3:00 p.m. Messages left by the surveyor were not returned from R #1's pain control physician by the time of exit from the facility on 10/15/15 at 5:00 p.m. Record review of the facility Pain Assessment policy and procedure dated July 2015 revealed the purpose of the pain procedure was to assess the resident's pain level and provide optimal comfort through a pain control plan which was mutually established with the resident, family and members of the health care team. General guidelines included the following: -A comprehensive pain assessment should be completed as part of the initial nursing assessment with development of a pain management program as indicated. -The comprehensive pain assessment should be reviewed quarterly and with a significant change in status. -Continuing assessment of the pain management program should occur daily and should focus on the effectiveness of the program and the comfort level of the resident. -Pain should be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident should occur. Steps in the facility Pain Assessment procedure included: -Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. -Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. -Determine appropriate type of pain medication as ordered by the physician. -Medicate the resident as the physician ordered. -Do follow-up assessment after administration of medication. -Evaluate effectiveness of non-pharmacologic interventions. -If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician and obtain an order. -Document results in resident's clinical record. The facility's centers for Medicare and Medicaid Services form CMS-672 dated 10/13/15 revealed 54 residents who were on a pain management program.

Based on observation, interview, and record review, the facility failed to implement their policy and procedures that prohibit neglect for two Residents (R #4 and R #9) of 37 Residents reviewed for neglect. -R #4 had a necrotic open wound to her right heel and was sent to the hospital on [DATE] with large maggots in the open wound, placing R #4 at risk for infection and death. -Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. -The facility failed to ensure staff knew how to assess residents who had wounds and failed to ensure staff knew all interventions to help protect 15 residents with wounds from contracting maggots. This failure resulted in identification of an Immediate Jeopardy (IJ) on 10/16/13 at 6:40 p.m. While the IJ was removed on 10/16/13, the facility remained out of compliance for actual harm at a scope of pattern due to all active staff were still being in-serviced on assessing residents at risk of contracting maggots, all interventions to help protect residents with wounds from contracting maggots and the facility was still monitoring the Plan of Removal. Non IJ: -The facility was aware that R #9 was at risk of developing pressure ulcers. -The facility did not put effective interventions into place to prevent R #9 from developing pressure ulcers. -R #9's heels were lying flat on the bed. -The facility was not aware that R #9 had developed a facility acquired avoidable deep tissue injury to her left heel until surveyor intervention on 10/16/13. Failure to put effective interventions into place and ensure staff knew how to assess and intervene to protect 15 other residents with wounds from potentially developing an infection and/or death from maggots, and to protect R #9 from potential harm, affected R #4 and R #9 by possibly denying them care and services to avoid physical harm and/or death and could place 15 residents with wounds and 32 residents requiring assistance with positioning at risk for harm and lack of services. Findings were: R #4 R #4's Face Sheet dated 10/16/13 revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's "Wound Assessment Worksheet" dated 06/19/13 revealed R #4 was admitted to the facility with an unstageable, eschar (dark colored dead tissue) covered wound to her right heel. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #4 had a moderately impaired cognition (decisions poor; cues supervision required); was totally dependent on staff for bed mobility, locomotion, dressing, toileting and personal hygiene; required extensive assistance with transfers; was incontinent of bowel and bladder. R #4's physician progress notes [REDACTED]. R #4's Nurses Notes dated 10/15/13 at 11:00 a.m. revealed: "As this nurse was removing (dressing) to (right) heel noted maggots fall out of wound. The area (where the) wound edge was detached were the maggots come-out. Notified (Director of Nurses). Called (physician). (Resident) to be sent to (hospital)..." The Nurses Note was signed by Licensed Vocational Nurse (LVN) "M." R #4's "Rapid Triage" document from Hospital "AA" dated 10/15/13 revealed: "...(R #4) sent from (the facility) with (complaints of) maggots in (right) heel infection ...(R #4) presents with (wound to right heel) and 100 maggots noted to be crawling out of margins of wound ..." R #4's History and Physical from Hospital "AA" dated 10/15/13 revealed: "...Utilize [MEDICATION NAME] cream (medication used to eradicate maggots) to kill the maggots and to consult with (orthopedics) who will then potentially take her to surgery for [REDACTED]. R #4's right heel wound culture from Hospital "AA" dated 10/15/13 revealed the infection providencia stuartii. According to http://emedicine.medscape.com/article/ 1-overview, "...Providencia species are found in multiple animal reservoirs, including flies ...(and) also found commonly in soil, water, and sewage ... " On 10/16/13 at 11:30 a.m., Medical Doctor (MD) "BB" from Hospital "AA" stated that R #4 would "possibly need surgical amputation of her right foot" due to the maggot infestation. On 10/16/13 at 12:00 p.m., MD "CC" from Hospital "AA" stated that the maggots present to R #4's right heel wound "had to have been there for at least three weeks" because "fat maggots were present which meant they were mature." MD "CC" stated, "Untreated maggots are aggressive. There is a 50/50 chance that (R #4) will lose her limb or foot due to the maggot infestation." MD "CC" stated that R #4 could develop an infection due to the maggot infestation, which could result in death. MD "CC" stated, "The maggots are (currently) coming out from under the eschar. There are thousands." According to the U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/ on 10/23/13 "...A lack of adequate medical and (nursing) care of the elderly ..., especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation ...(i) ...Upon hatching, the larvae begin feeding, causing an extensive destruction of tissue ...and pockets may be eaten out beneath the skin ...An infested person may die from tissue destruction ..." According to Texas A&M Agrilife Extension, https://insects.tamu.edu/fieldguide/cimg239.html, the most common types of maggots to infest human wounds "...develop... from egg to adult...in 16 to 35 days, depending on temperature and environmental conditions..." On 10/16/13 at 2:00 p.m., the Administrator stated that on 10/15/13, after the maggots were found on R #4's right heel wound and R #4 was sent to the hospital, the facility put the following interventions into place: -R #4's room was cleaned. -The facility's exterminator was contacted and would be in the facility on 10/17/13 as "precautionary measures." -R #4's roommate was assessed for transfer of the maggots. -A 100% assessment was completed on residents with skin or wound impairment and would continue for 72 hours. -An inservice was conducted with staff and the treatment nurse on infection control. -The facility contacted an outside entomologist for further direction. Review of the facility's Inservices dated 10/15/13 and 10/16/13 related to R #4's maggot infestation revealed staff were not inserviced on how maggots were transmitted into wounds, signs and symptoms, and preventative measures to ensure other residents did not contract maggots. Review of the facility's Skin/Wound Assessments of 15 residents with skin or wound impairments dated 10/15/13 revealed the following assessment for each resident: Dressing changed, wound assessed, clean, dry and intact. The assessments did not indicate if those residents were free from maggots and/or include descriptions of the wounds. On 10/16/13 at 2:15 p.m., Treatment Nurse, Licensed Vocational Nurse (LVN) "M", stated that she could not describe what each wound looked like for the residents' wounds she had assessed on 10/15/13. Review of the facility's undated "(R #4's) Timeline" of events revealed: "It is our understanding that the wound was closed from the hospital dismissal and subsequent readmission...to discharge from our facility..." R #4's "Wound Assessment Worksheets", signed by Treatment Nurse, Licensed Vocational Nurse (LVN) "M", revealed the following dates when R #4's wound to her right heel was not intact due to drainage. Dates marked with an "M" represent maceration (the softening and breaking down of the skin resulting from prolonged exposure to moisture): -06/20/13; M -06/25/13 -07/02/13 -07/09/13; M -07/16/13; M -07/23/13; M -07/30/13; M -08/06/13; M with odor -08/13/13; M -08/20/13; had odor -08/27/13; M with odor -09/03/13; had odor -09/09/13; had odor -09/16/13; M with odor; "eschar had detached." -10/07/13 -10/14/13; M with odor; "wound edges detaching." R #4's Physician order [REDACTED]. as needed. On 10/16/13 at 2:45 p.m., LVN "M" stated that R #4's wound to her right heel had been "closed" since R #4's admission to the facility except for 09/16/13 and 10/14/13, so therefore the maggots "couldn't have happened here." LVN "M" stated that there were no maggots present to R #4's right heel wound on 10/14/13. Surveyor asked LVN "M" how a closed wound could have drainage. LVN "M" replied, "Sometimes (R #4) refused [MEDICAL TREATMENT]. The drainage had to go somewhere." LVN "M" stated that she had changed R #4's dressing to her right heel "every day" and was not aware if R #4's dressing had not been changed as ordered. Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. The open area had moist grey colored dead tissue present. The edge of the wound had open areas under the skin at the base of the wound. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. The photograph indicated that the condition of R #4's right heel wound had the potential to have developed before 10/15/13. R #4's Treatment MAR for the month of October 2013 revealed staff documented by initialing that R #4 received wound care daily as ordered by the physician. On 10/16/13 at 6:40 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 6:40 p.m. of the IJ due to the above failures. On 10/16/13 at 11:00 p.m., the facility's second Plan of Removal was accepted and contained the following: "Issues: 1. Facility failed to put pest control interventions in place to prevent fly infestation. 2. Facility failed to adequately train nursing staff to identify potential maggot infestations in wounds and residents at risk for infestation. Interventions Issue #1: 1. Pest Control company had been notified and will treat the facility for flies on 10/16/13. The Pest Control company will complete the Emergent Pest Control Log with the date and time of their interventions. Pest control will come within 72 hours post initial visit and then weekly for four weeks (or as needed). Findings will be monitored by the QA (Quality Assurance) committee and reviewed and revised as needed. Maintenance, or their designee, will monitor log daily. Administrator or his designee will monitor the log daily for two weeks and then weekly thereafter. This will be presented to the QA meeting for review and evaluation. 2. Facility staff, to include nursing, maintenance, administration, dietary, housekeeping, laundry and therapy services, will be in-serviced on prompt reporting of pest control issues and will document any pest control issues identified on the designated log. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 3. Maintenance will monitor the designated log to identify pest control issues, and will contact the pest control company as indicated. Interventions Issue #2: 1. Quality Assurance Nurse Consultant will educate the Director of Nurses and wound care nurse on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take up identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such. 2. Quality Assurance Nurse Consultant and/or DON will in-service nursing staff on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take upon identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such and prompt reporting of skin changes. 3. Quality Assurance Nurse Consultant and/or DON will in-service Administration, nursing staff, dietary, housekeeping, laundry, therapy services and maintenance on identification of maggots and/or larvae and the process for reporting such to administration. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 4. A 100% skin audit has been completed by nurse management on 10/16/13 to identify all residents at risk of maggot infestation to open wounds. No other residents were found to have signs or symptoms of maggots present in the wounds. Notations will be made in the clinical record to record these assessments and findings. Monitoring: 1. Management staff will monitor for pests during rounds. 2. Administrator will monitor the designated log for pest control issues to verify that appropriate interventions have been put into place to address such issues. 3. The facility Medical Director has been notified of the immediate jeopardy and interventions that have been put into place. 4. The facility QA committee will be responsible for monitoring the plan of removal and making revisions as indicated." On 10/16/13 at 7:45 p.m., the facility conducted an inservice which included the following information: "...ID (identification) of flies, what to do and who to report to...Maggots...what to look for and how to report and steps to follow...Infection Control..." 30 staff members attended the training. Review of the facility's undated "(R #4's) Timeline" of events revealed: "...Understanding the stage of development of larvae (non-pupa) and that the wound being closed since readmission to our facility, it would rightly assumed that the introduction of the larvae did occur at our facility." On 10/16/13 at 11:20 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. On 10/22/13 at 5:00 p.m., in response to surveyor's question regarding how the IJ came about, the Administrator stated, "There was a possibility that the eggs were laid somewhere else. When it was discovered, we sent (R #4) out, reported it to the state, put actions into place to address it to the best of our ability as was possible." On 10/22/13 at 5:20 p.m., in response to surveyor's question regarding how the IJ came about, DON stated, "If you look at the timeline, there were gaps in the timeline. The larvae were not visible prior to the discovery. There weren't signs of larvae activity." The DON also stated he knew that the nursing staff had knowledge of appropriate wound assessments prior to R #4's incident on 10/15/13 because the nursing staff had performed "simulated air-return demonstrations" of appropriate dressing change techniques, without physically performing the task. Through observations, interviews and record reviews, the survey team determined that Pest Control treated the facility for flies on 10/16/13, wound assessments were accurate, in-servicing was initiated, and staff followed the pest control monitoring that was documented in the facility's Plan of Removal were implemented. Non IJ: R #9 The facility's "treatment of [REDACTED]. A number of contributing or confounding factors are also associated with pressure ulcers;...Suspected deep tissue injury-depth unknown (:) Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear...Avoid positioning the resident on a pressure ulcer. Use positioning devices to raise a pressure ulcer off the support surface..." R #9's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old female admitted on [DATE] and the [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE] revealed R #9: had a severely impaired cognition (never/rarely made decisions); was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene and bathing; was always incontinent of bowel and bladder; was at risk of developing a pressure ulcer; did not have a pressure ulcer; had a pressure reducing device for her bed. R #9's Care Plans dated 09/04/13 revealed: -"...(R #9) is on Turtle Program (due to) fragile skin. Has a prevalence for discolorations and skin tears...Staff will reposition resident every 2 hours while in bed..." -"...(R #9) requires total assist times two with bed mobility...due to muscle disuse...Air mattress as indicated..." R #9's Braden Scale dated 09/04/13 revealed a score of 14. A total score of 13 to 14 represented a moderate risk of developing pressure ulcers. Observation on 10/16/13 at 4:05 p.m. with LVN "M" revealed R #9 lying in bed with both heels flat against the mattress. After assessing R #9's heels, LVN "M" stated that R #9 had a deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (friction of skin against an object)) to her left heel. LVN "M" stated that she was not aware of R #9's deep tissue injury and that R #9's heels "should be elevated" to prevent pressure to R #9's heels. R #9's "Pressure Ulcer Prevention Protocol" dated 10/16/13 revealed: "Resident admitted to the facility free of pressure sores but identified at risk on the Braden Scale with a score of 14 or below will be placed on aggressive prevention interventions. The following checklist is to be completed at admission by the assisting nurse to select appropriate interventions and ensure compliance..." The following sections were documented as interventions: -"Specialty bed-air fluid; low air loss therapy." -"Prevalon boots." Observation on 10/17/13 at 1:50 p.m. revealed R #9 lying in bed with both heels flat against the mattress. R #9 was not lying on a specialty bed. R #9's "Clinically Unavoidable Skin Condition" document dated 10/17/13 and signed by R #9's Physician, MD "Q", on 10/18/13 revealed: "Skin conditions for the resident identified below has been determined to be clinically unavoidable due to the indicated circumstances:..." Handwritten in the "Type of Wound...Other" section was "suspected deep tissue injury." R #9's "physician progress notes [REDACTED].#9) multiple, severe comorbidities and general debility, as well as her current anti-[MEDICAL CONDITION] regimen, the patient is likely to develop...skin breakdown with no trauma or excessive pressure to the area. Her newest area of discoloration on the (left) ankle is most likely spontaneous bruising but is being classified as a possible (deep tissue injury) at this time." On 10/22/13 at 9:25 a.m., CNA "O" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 12:00 p.m., CNA "R" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 12:10 p.m., CNA "S" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 2:00 p.m., ADON "B" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 5:20 p.m., the DON stated residents who were at risk of developing pressure ulcers should have "pillows under the feet" and/or "Prevalon" boots to relieve pressure to the heels. The Texas Administrative Code Title 40, Part 1, Chapter 19, Subchapter B, Rule 19.01, states: "...(81) Neglect-The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness..." The facility's "Facility Abuse Prohibition Policy and Procedure" dated 03/2012 revealed: "...This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing regulations as required by law...Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. As a general overall policy, the facility will use reasonable efforts, through operational policies, so that...neglect...does not occur and that steps are taken to reduce the potential for such forms of abuse...The facility will use reasonable efforts to develop systems to identify events, occurences, patterns and trends that constitute or may be a precursor to...neglect...to help minimize the threat or occurrence of abuse...The facility will use reasonable efforts during the investigative process...to minimize harm to residents..." The facility's undated "Resident Rights Under Texas Law" revealed: "You, the resident, do not give up any rights when you enter a nursing facility...Any violation of these rights is against the law...You have a right: 1. to all care necessary for you to have the highest possible level of health..." The facility's Wound List dated 10/16/13 revealed 15 residents with wounds. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 10/15/13 revealed 32 residents required assistance with positioning. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to nursing assessments, wound care, and pressure ulcers. As of exit on 10/24/13 at 4:35 p.m., the facility provided no further information.

Based on observation, interview, and record review, the facility failed to implement their written policy and procedures that prohibit neglect for two Residents (R #4 and R #9) of 37 Residents reviewed for neglect. -R #4 had a necrotic open wound to her right heel and was sent to the hospital on [DATE] with large maggots in the open wound, placing R #4 at risk for infection and death. -Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. -The facility failed to ensure staff knew how to assess residents who had wounds and failed to ensure staff knew all interventions to help protect 15 residents with wounds from contracting maggots. This failure resulted in identification of an Immediate Jeopardy (IJ) on 10/16/13 at 6:40 p.m. While the IJ was removed on 10/16/13, the facility remained out of compliance for actual harm at a scope of pattern due to all active staff were still being in-serviced on assessing residents at risk of contracting maggots, all interventions to help protect residents with wounds from contracting maggots and the facility was still monitoring the Plan of Removal. Non IJ: -The facility was aware that R #9 was at risk of developing pressure ulcers. -The facility did not put effective interventions into place to prevent R #9 from developing pressure ulcers. -R #9's heels were lying flat on the bed. -The facility was not aware that R #9 had developed a facility acquired avoidable deep tissue injury to her left heel until surveyor intervention on 10/16/13. Failure to put effective interventions into place and ensure staff knew how to assess and intervene to protect 15 other residents with wounds from potentially developing an infection and/or death from maggots, and to protect R #9 from potential harm, affected R #4 and R #9 by possibly denying them care and services to avoid physical harm and/or death and could place 15 residents with wounds, 32 residents requiring assistance with positioning at risk for harm and lack of services. Findings were: The Texas Administrative Code Title 40, Part 1, Chapter 19, Subchapter B, Rule 19.01, states: "...(81) Neglect-The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness..." The facility's "Facility Abuse Prohibition Policy and Procedure" dated 03/2012 revealed: "...This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing regulations as required by law...Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. As a general overall policy, the facility will use reasonable efforts, through operational policies, so that...neglect...does not occur and that steps are taken to reduce the potential for such forms of abuse...The facility will use reasonable efforts to develop systems to identify events, occurences, patterns and trends that constitute or may be a precursor to...neglect...to help minimize the threat or occurrence of abuse...The facility will use reasonable efforts during the investigative process...to minimize harm to residents..." The facility's undated "Resident Rights Under Texas Law" revealed: "You, the resident, do not give up any rights when you enter a nursing facility...Any violation of these rights is against the law...You have a right: 1. to all care necessary for you to have the highest possible level of health..." R #4 R #4's Face Sheet dated 10/16/13 revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's "Wound Assessment Worksheet" dated 06/19/13 revealed R #4 was admitted to the facility with an unstageable, eschar (dark colored dead tissue) covered wound to her right heel. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #4 had a moderately impaired cognition (decisions poor; cues supervision required); was totally dependent on staff for bed mobility, locomotion, dressing, toileting and personal hygiene; required extensive assistance with transfers; was incontinent of bowel and bladder. R #4's physician progress notes [REDACTED]. R #4's Nurses Notes dated 10/15/13 at 11:00 a.m. revealed: "As this nurse was removing (dressing) to (right) heel noted maggots fall out of wound. The area (where the) wound edge was detached were the maggots come-out. Notified (Director of Nurses). Called (physician). (Resident) to be sent to (hospital)..." The Nurses Note was signed by Licensed Vocational Nurse (LVN) "M." R #4's "Rapid Triage" document from Hospital "AA" dated 10/15/13 revealed: "...(R #4) sent from (the facility) with (complaints of) maggots in (right) heel infection ...(R #4) presents with (wound to right heel) and 100 maggots noted to be crawling out of margins of wound ..." R #4's History and Physical from Hospital "AA" dated 10/15/13 revealed: "...Utilize [MEDICATION NAME] cream (medication used to eradicate maggots) to kill the maggots and to consult with (orthopedics) who will then potentially take her to surgery for [REDACTED]. R #4's right heel wound culture from Hospital "AA" dated 10/15/13 revealed the infection providencia stuartii. According to http://emedicine.medscape.com/article/ 1-overview, "...Providencia species are found in multiple animal reservoirs, including flies ...(and) also found commonly in soil, water, and sewage ... " On 10/16/13 at 11:30 a.m., Medical Doctor (MD) "BB" from Hospital "AA" stated that R #4 would "possibly need surgical amputation of her right foot" due to the maggot infestation. On 10/16/13 at 12:00 p.m., MD "CC" from Hospital "AA" stated that the maggots present to R #4's right heel wound "had to have been there for at least three weeks" because "fat maggots were present which meant they were mature." MD "CC" stated, "Untreated maggots are aggressive. There is a 50/50 chance that (R #4) will lose her limb or foot due to the maggot infestation." MD "CC" stated that R #4 could develop an infection due to the maggot infestation, which could result in death. MD "CC" stated, "The maggots are (currently) coming out from under the eschar. There are thousands." According to the U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/ on 10/23/13 "...A lack of adequate medical and (nursing) care of the elderly ..., especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation ...(i) ...Upon hatching, the larvae begin feeding, causing an extensive destruction of tissue ...and pockets may be eaten out beneath the skin ...An infested person may die from tissue destruction ..." According to Texas A&M Agrilife Extension, https://insects.tamu.edu/fieldguide/cimg239.html, the most common types of maggots to infest human wounds "...develop... from egg to adult...in 16 to 35 days, depending on temperature and environmental conditions..." On 10/16/13 at 2:00 p.m., the Administrator stated that on 10/15/13, after the maggots were found on R #4's right heel wound and R #4 was sent to the hospital, the facility put the following interventions into place: -R #4's room was cleaned. -The facility's exterminator was contacted and would be in the facility on 10/17/13 as "precautionary measures." -R #4's roommate was assessed for transfer of the maggots. -A 100% assessment was completed on residents with skin or wound impairment and would continue for 72 hours. -An inservice was conducted with staff and the treatment nurse on infection control. -The facility contacted an outside entomologist for further direction. Review of the facility's Inservices dated 10/15/13 and 10/16/13 related to R #4's maggot infestation revealed staff were not inserviced on how maggots were transmitted into wounds, signs and symptoms, and preventative measures to ensure other residents did not contract maggots. Review of the facility's Skin/Wound Assessments of 15 residents with skin or wound impairments dated 10/15/13 revealed the following assessment for each resident: Dressing changed, wound assessed, clean, dry and intact. The assessments did not indicate if those residents were free from maggots and/or include descriptions of the wounds. On 10/16/13 at 2:15 p.m., Treatment Nurse, Licensed Vocational Nurse (LVN) "M", stated that she could not describe what each wound looked like for the residents' wounds she had assessed on 10/15/13. Review of the facility's undated "(R #4's) Timeline" of events revealed: "It is our understanding that the wound was closed from the hospital dismissal and subsequent readmission...to discharge from our facility..." R #4's "Wound Assessment Worksheets", signed by Treatment Nurse, Licensed Vocational Nurse (LVN) "M", revealed the following dates when R #4's wound to her right heel was not intact due to drainage. Dates marked with an "M" represent maceration (the softening and breaking down of the skin resulting from prolonged exposure to moisture): -06/20/13; M -06/25/13 -07/02/13 -07/09/13; M -07/16/13; M -07/23/13; M -07/30/13; M -08/06/13; M with odor -08/13/13; M -08/20/13; had odor -08/27/13; M with odor -09/03/13; had odor -09/09/13; had odor -09/16/13; M with odor; "eschar had detached." -10/07/13 -10/14/13; M with odor; "wound edges detaching." R #4's Physician order [REDACTED]. as needed. On 10/16/13 at 2:45 p.m., LVN "M" stated that R #4's wound to her right heel had been "closed" since R #4's admission to the facility except for 09/16/13 and 10/14/13, so therefore the maggots "couldn't have happened here." LVN "M" stated that there were no maggots present to R #4's right heel wound on 10/14/13. Surveyor asked LVN "M" how a closed wound could have drainage. LVN "M" replied, "Sometimes (R #4) refused [MEDICAL TREATMENT]. The drainage had to go somewhere." LVN "M" stated that she had changed R #4's dressing to her right heel "every day" and was not aware if R #4's dressing had not been changed as ordered. Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. The open area had moist grey colored dead tissue present. The edge of the wound had open areas under the skin at the base of the wound. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. The photograph indicated that the condition of R #4's right heel wound had the potential to have developed before 10/15/13. R #4's Treatment MAR for the month of October 2013 revealed staff documented by initialing that R #4 received wound care daily as ordered by the physician. On 10/16/13 at 6:40 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 6:40 p.m. of the IJ due to the above failures. On 10/16/13 at 11:00 p.m., the facility's second Plan of Removal was accepted and contained the following: "Issues: 1. Facility failed to put pest control interventions in place to prevent fly infestation. 2. Facility failed to adequately train nursing staff to identify potential maggot infestations in wounds and residents at risk for infestation. Interventions Issue #1: 1. Pest Control company had been notified and will treat the facility for flies on 10/16/13. The Pest Control company will complete the Emergent Pest Control Log with the date and time of their interventions. Pest control will come within 72 hours post initial visit and then weekly for four weeks (or as needed). Findings will be monitored by the QA (Quality Assurance) committee and reviewed and revised as needed. Maintenance, or their designee, will monitor log daily. Administrator or his designee will monitor the log daily for two weeks and then weekly thereafter. This will be presented to the QA meeting for review and evaluation. 2. Facility staff, to include nursing, maintenance, administration, dietary, housekeeping, laundry and therapy services, will be in-serviced on prompt reporting of pest control issues and will document any pest control issues identified on the designated log. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 3. Maintenance will monitor the designated log to identify pest control issues, and will contact the pest control company as indicated. Interventions Issue #2: 1. Quality Assurance Nurse Consultant will educate the Director of Nurses and wound care nurse on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take up identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such. 2. Quality Assurance Nurse Consultant and/or DON will in-service nursing staff on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take upon identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such and prompt reporting of skin changes. 3. Quality Assurance Nurse Consultant and/or DON will in-service Administration, nursing staff, dietary, housekeeping, laundry, therapy services and maintenance on identification of maggots and/or larvae and the process for reporting such to administration. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 4. A 100% skin audit has been completed by nurse management on 10/16/13 to identify all residents at risk of maggot infestation to open wounds. No other residents were found to have signs or symptoms of maggots present in the wounds. Notations will be made in the clinical record to record these assessments and findings. Monitoring: 1. Management staff will monitor for pests during rounds. 2. Administrator will monitor the designated log for pest control issues to verify that appropriate interventions have been put into place to address such issues. 3. The facility Medical Director has been notified of the immediate jeopardy and interventions that have been put into place. 4. The facility QA committee will be responsible for monitoring the plan of removal and making revisions as indicated." On 10/16/13 at 7:45 p.m., the facility conducted an inservice which included the following information: "...ID (identification) of flies, what to do and who to report to...Maggots...what to look for and how to report and steps to follow...Infection Control..." 30 staff members attended the training. Review of the facility's undated "(R #4's) Timeline" of events revealed: "...Understanding the stage of development of larvae (non-pupa) and that the wound being closed since readmission to our facility, it would rightly assumed that the introduction of the larvae did occur at our facility." On 10/16/13 at 11:20 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. On 10/22/13 at 5:00 p.m., in response to surveyor's question regarding how the IJ came about, the Administrator stated, "There was a possibility that the eggs were laid somewhere else. When it was discovered, we sent (R #4) out, reported it to the state, put actions into place to address it to the best of our ability as was possible." On 10/22/13 at 5:20 p.m., in response to surveyor's question regarding how the IJ came about, DON stated, "If you look at the timeline, there were gaps in the timeline. The larvae were not visible prior to the discovery. There weren't signs of larvae activity." The DON also stated he knew that the nursing staff had knowledge of appropriate wound assessments prior to R #4's incident on 10/15/13 because the nursing staff had performed "simulated air-return demonstrations" of appropriate dressing change techniques, without physically performing the task. Through observations, interviews and record reviews, the survey team determined that Pest Control treated the facility for flies on 10/16/13, wound assessments were accurate, in-servicing was initiated, and staff followed the pest control monitoring that was documented in the facility's Plan of Removal were implemented. Non IJ: R #9 The facility's "treatment of [REDACTED]. A number of contributing or confounding factors are also associated with pressure ulcers;...Suspected deep tissue injury-depth unknown (:) Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear...Avoid positioning the resident on a pressure ulcer. Use positioning devices to raise a pressure ulcer off the support surface..." R #9's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old female admitted on [DATE] and the [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE] revealed R #9: had a severely impaired cognition (never/rarely made decisions); was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene and bathing; was always incontinent of bowel and bladder; was at risk of developing a pressure ulcer; did not have a pressure ulcer; had a pressure reducing device for her bed. R #9's Care Plans dated 09/04/13 revealed: -"...(R #9) is on Turtle Program (due to) fragile skin. Has a prevalence for discolorations and skin tears...Staff will reposition resident every 2 hours while in bed..." -"...(R #9) requires total assist times two with bed mobility...due to muscle disuse...Air mattress as indicated..." R #9's Braden Scale dated 09/04/13 revealed a score of 14. A total score of 13 to 14 represented a moderate risk of developing pressure ulcers. Observation on 10/16/13 at 4:05 p.m. with LVN "M" revealed R #9 lying in bed with both heels flat against the mattress. After assessing R #9's heels, LVN "M" stated that R #9 had a deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (friction of skin against an object)) to her left heel. LVN "M" stated that she was not aware of R #9's deep tissue injury and that R #9's heels "should be elevated" to prevent pressure to R #9's heels. R #9's "Pressure Ulcer Prevention Protocol" dated 10/16/13 revealed: "Resident admitted to the facility free of pressure sores but identified at risk on the Braden Scale with a score of 14 or below will be placed on aggressive prevention interventions. The following checklist is to be completed at admission by the assisting nurse to select appropriate interventions and ensure compliance..." The following sections were documented as interventions: -"Specialty bed-air fluid; low air loss therapy." -"Prevalon boots." Observation on 10/17/13 at 1:50 p.m. revealed R #9 lying in bed with both heels flat against the mattress. R #9 was not lying on a specialty bed. R #9's "Clinically Unavoidable Skin Condition" document dated 10/17/13 and signed by R #9's Physician, MD "Q", on 10/18/13 revealed: "Skin conditions for the resident identified below has been determined to be clinically unavoidable due to the indicated circumstances:..." Handwritten in the "Type of Wound...Other" section was "suspected deep tissue injury." R #9's "physician progress notes [REDACTED].#9) multiple, severe comorbidities and general debility, as well as her current anti-[MEDICAL CONDITION] regimen, the patient is likely to develop...skin breakdown with no trauma or excessive pressure to the area. Her newest area of discoloration on the (left) ankle is most likely spontaneous bruising but is being classified as a possible (deep tissue injury) at this time." On 10/22/13 at 9:25 a.m., CNA "O" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 12:00 p.m., CNA "R" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 12:10 p.m., CNA "S" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 2:00 p.m., ADON "B" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 5:20 p.m., the DON stated residents who were at risk of developing pressure ulcers should have "pillows under the feet" and/or "Prevalon" boots to relieve pressure to the heels. The facility's Wound List dated 10/16/13 revealed 15 residents with wounds. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 10/15/13 revealed 32 residents required assistance with positioning. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to nursing assessments, wound care, and pressure ulcers. As of exit on 10/24/13 at 4:35 p.m., the facility provided no further information.

Based on observaton, interview and record review, the facility failed to ensure services provided met professional standards of quality for one Resident (R #4) of 36 Residents reviewed for quality of care. -R #4 had a necrotic open wound to her right heel and was sent to the hospital on [DATE] with large maggots in the open wound, placing R #4 at risk for infection and death. -Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. -The facility failed to ensure staff knew how to assess residents who had wounds and failed to ensure staff knew all interventions to help protect 15 residents with wounds from contracting maggots. This failure resulted in identification of an Immediate Jeopardy (IJ) on 10/16/13 at 6:40 p.m. While the IJ was removed on 10/16/13, the facility remained out of compliance for actual harm at a scope of pattern due to all active staff were still being in-serviced on assessing residents at risk of contracting maggots, all interventions to help protect residents with wounds from contracting maggots and the facility was still monitoring the Plan of Removal. Failure to put effective interventions into place and ensure staff knew how to assess and intervene to protect R #4 and 15 other residents with wounds from potentially developing an infection and/or death from maggots could place them at risk for harm and lack of services. Findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms;...(iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status;...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;..." R #4's Face Sheet dated 10/16/13 revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's "Wound Assessment Worksheet" dated 06/19/13 revealed R #4 was admitted to the facility with an unstageable, eschar (dark colored dead tissue) covered wound to her right heel. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #4 had a moderately impaired cognition (decisions poor; cues supervision required); was totally dependent on staff for bed mobility, locomotion, dressing, toileting and personal hygiene; required extensive assistance with transfers; was incontinent of bowel and bladder. R #4's physician progress notes [REDACTED]. R #4's Nurses Notes dated 10/15/13 at 11:00 a.m. revealed: "As this nurse was removing (dressing) to (right) heel noted maggots fall out of wound. The area (where the) wound edge was detached were the maggots come-out. Notified (Director of Nurses). Called (physician). (Resident) to be sent to (hospital)..." The Nurses Note was signed by Licensed Vocational Nurse (LVN) "M." R #4's "Rapid Triage" document from Hospital "AA" dated 10/15/13 revealed: "...(R #4) sent from (the facility) with (complaints of) maggots in (right) heel infection ...(R #4) presents with (wound to right heel) and 100 maggots noted to be crawling out of margins of wound ..." R #4's History and Physical from Hospital "AA" dated 10/15/13 revealed: "...Utilize [MEDICATION NAME] cream (medication used to eradicate maggots) to kill the maggots and to consult with (orthopedics) who will then potentially take her to surgery for [REDACTED]. R #4's right heel wound culture from Hospital "AA" dated 10/15/13 revealed the infection providencia stuartii. According to http://emedicine.medscape.com/article/ 1-overview, "...Providencia species are found in multiple animal reservoirs, including flies ...(and) also found commonly in soil, water, and sewage ... " On 10/16/13 at 11:30 a.m., Medical Doctor (MD) "BB" from Hospital "AA" stated that R #4 would "possibly need surgical amputation of her right foot" due to the maggot infestation. On 10/16/13 at 12:00 p.m., MD "CC" from Hospital "AA" stated that the maggots present to R #4's right heel wound "had to have been there for at least three weeks" because "fat maggots were present which meant they were mature." MD "CC" stated, "Untreated maggots are aggressive. There is a 50/50 chance that (R #4) will lose her limb or foot due to the maggot infestation." MD "CC" stated that R #4 could develop an infection due to the maggot infestation, which could result in death. MD "CC" stated, "The maggots are (currently) coming out from under the eschar. There are thousands." According to the U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/ on 10/23/13 "...A lack of adequate medical and (nursing) care of the elderly ..., especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation ...(i) ...Upon hatching, the larvae begin feeding, causing an extensive destruction of tissue ...and pockets may be eaten out beneath the skin ...An infested person may die from tissue destruction ..." According to Texas A&M Agrilife Extension, https://insects.tamu.edu/fieldguide/cimg239.html, the most common types of maggots to infest human wounds "...develop... from egg to adult...in 16 to 35 days, depending on temperature and environmental conditions..." On 10/16/13 at 2:00 p.m., the Administrator stated that on 10/15/13, after the maggots were found on R #4's right heel wound and R #4 was sent to the hospital, the facility put the following interventions into place: -R #4's room was cleaned. -The facility's exterminator was contacted and would be in the facility on 10/17/13 as "precautionary measures." -R #4's roommate was assessed for transfer of the maggots. -A 100% assessment was completed on residents with skin or wound impairment and would continue for 72 hours. -An inservice was conducted with staff and the treatment nurse on infection control. -The facility contacted an outside entomologist for further direction. Review of the facility's Inservices dated 10/15/13 and 10/16/13 related to R #4's maggot infestation revealed staff were not inserviced on how maggots were transmitted into wounds, signs and symptoms, and preventative measures to ensure other residents did not contract maggots. Review of the facility's Skin/Wound Assessments of 15 residents with skin or wound impairments dated 10/15/13 revealed the following assessment for each resident: Dressing changed, wound assessed, clean, dry and intact. The assessments did not indicate if those residents were free from maggots and/or include descriptions of the wounds. On 10/16/13 at 2:15 p.m., Treatment Nurse, Licensed Vocational Nurse (LVN) "M", stated that she could not describe what each wound looked like for the residents' wounds she had assessed on 10/15/13. Review of the facility's undated "(R #4's) Timeline" of events revealed: "It is our understanding that the wound was closed from the hospital dismissal and subsequent readmission...to discharge from our facility..." R #4's "Wound Assessment Worksheets", signed by Treatment Nurse, Licensed Vocational Nurse (LVN) "M", revealed the following dates when R #4's wound to her right heel was not intact due to drainage. Dates marked with an "M" represent maceration (the softening and breaking down of the skin resulting from prolonged exposure to moisture): -06/20/13; M -06/25/13 -07/02/13 -07/09/13; M -07/16/13; M -07/23/13; M -07/30/13; M -08/06/13; M with odor -08/13/13; M -08/20/13; had odor -08/27/13; M with odor -09/03/13; had odor -09/09/13; had odor -09/16/13; M with odor; "eschar had detached." -10/07/13 -10/14/13; M with odor; "wound edges detaching." R #4's Physician order [REDACTED]. as needed. On 10/16/13 at 2:45 p.m., LVN "M" stated that R #4's wound to her right heel had been "closed" since R #4's admission to the facility except for 09/16/13 and 10/14/13, so therefore the maggots "couldn't have happened here." LVN "M" stated that there were no maggots present to R #4's right heel wound on 10/14/13. Surveyor asked LVN "M" how a closed wound could have drainage. LVN "M" replied, "Sometimes (R #4) refused [MEDICAL TREATMENT]. The drainage had to go somewhere." LVN "M" stated that she had changed R #4's dressing to her right heel "every day" and was not aware if R #4's dressing had not been changed as ordered. Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. The open area had moist grey colored dead tissue present. The edge of the wound had open areas under the skin at the base of the wound. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. The photograph indicated that the condition of R #4's right heel wound had the potential to have developed before 10/15/13. R #4's Treatment MAR for the month of October 2013 revealed staff documented by initialing that R #4 received wound care daily as ordered by the physician. On 10/16/13 at 6:40 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 6:40 p.m. of the IJ due to the above failures. On 10/16/13 at 11:00 p.m., the facility's second Plan of Removal was accepted and contained the following: "Issues: 1. Facility failed to put pest control interventions in place to prevent fly infestation. 2. Facility failed to adequately train nursing staff to identify potential maggot infestations in wounds and residents at risk for infestation. Interventions Issue #1: 1. Pest Control company had been notified and will treat the facility for flies on 10/16/13. The Pest Control company will complete the Emergent Pest Control Log with the date and time of their interventions. Pest control will come within 72 hours post initial visit and then weekly for four weeks (or as needed). Findings will be monitored by the QA (Quality Assurance) committee and reviewed and revised as needed. Maintenance, or their designee, will monitor log daily. Administrator or his designee will monitor the log daily for two weeks and then weekly thereafter. This will be presented to the QA meeting for review and evaluation. 2. Facility staff, to include nursing, maintenance, administration, dietary, housekeeping, laundry and therapy services, will be in-serviced on prompt reporting of pest control issues and will document any pest control issues identified on the designated log. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 3. Maintenance will monitor the designated log to identify pest control issues, and will contact the pest control company as indicated. Interventions Issue #2: 1. Quality Assurance Nurse Consultant will educate the Director of Nurses and wound care nurse on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take up identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such. 2. Quality Assurance Nurse Consultant and/or DON will in-service nursing staff on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take upon identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such and prompt reporting of skin changes. 3. Quality Assurance Nurse Consultant and/or DON will in-service Administration, nursing staff, dietary, housekeeping, laundry, therapy services and maintenance on identification of maggots and/or larvae and the process for reporting such to administration. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 4. A 100% skin audit has been completed by nurse management on 10/16/13 to identify all residents at risk of maggot infestation to open wounds. No other residents were found to have signs or symptoms of maggots present in the wounds. Notations will be made in the clinical record to record these assessments and findings. Monitoring: 1. Management staff will monitor for pests during rounds. 2. Administrator will monitor the designated log for pest control issues to verify that appropriate interventions have been put into place to address such issues. 3. The facility Medical Director has been notified of the immediate jeopardy and interventions that have been put into place. 4. The facility QA committee will be responsible for monitoring the plan of removal and making revisions as indicated." On 10/16/13 at 7:45 p.m., the facility conducted an inservice which included the following information: "...ID (identification) of flies, what to do and who to report to...Maggots...what to look for and how to report and steps to follow...Infection Control..." 30 staff members attended the training. Review of the facility's undated "(R #4's) Timeline" of events revealed: "...Understanding the stage of development of larvae (non-pupa) and that the wound being closed since readmission to our facility, it would rightly assumed that the introduction of the larvae did occur at our facility." On 10/16/13 at 11:20 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. On 10/22/13 at 5:00 p.m., in response to surveyor's question regarding how the IJ came about, the Administrator stated, "There was a possibility that the eggs were laid somewhere else. When it was discovered, we sent (R #4) out, reported it to the state, put actions into place to address it to the best of our ability as was possible." On 10/22/13 at 5:20 p.m., in response to surveyor's question regarding how the IJ came about, DON stated, "If you look at the timeline, there were gaps in the timeline. The larvae were not visible prior to the discovery. There weren't signs of larvae activity." The DON also stated he knew that the nursing staff had knowledge of appropriate wound assessments prior to R #4's incident on 10/15/13 because the nursing staff had performed "simulated air-return demonstrations" of appropriate dressing change techniques, without physically performing the task. Through observations, interviews and record reviews, the survey team determined that Pest Control treated the facility for flies on 10/16/13, wound assessments were accurate, in-servicing was initiated, and staff followed the pest control monitoring that was documented in the facility's Plan of Removal were implemented. The Texas Administrative Code Title 40, Part 1, Chapter 19, Subchapter B, Rule 19.01, states: "...(81) Neglect-The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness..." The facility's "Facility Abuse Prohibition Policy and Procedure" dated 03/2012 revealed: "...This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing regulations as required by law...Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. As a general overall policy, the facility will use reasonable efforts, through operational policies, so that...neglect...does not occur and that steps are taken to reduce the potential for such forms of abuse...The facility will use reasonable efforts to develop systems to identify events, occurences, patterns and trends that constitute or may be a precursor to...neglect...to help minimize the threat or occurrence of abuse...The facility will use reasonable efforts during the investigative process...to minimize harm to residents..." The facility's undated "Resident Rights Under Texas Law" revealed: "You, the resident, do not give up any rights when you enter a nursing facility...Any violation of these rights is against the law...You have a right: 1. to all care necessary for you to have the highest possible level of health..." The facility's Wound List dated 10/16/13 revealed 15 residents with wounds. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to professional standards. As of exit on 10/24/13 at 4:35 p.m., the facility provided no further information.

Based on observation, interview, and record review, the facility failed to ensure each resident received and provided the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one Resident (R #4) of 36 Residents reviewed for neglect. -R #4 had a necrotic open wound to her right heel and was sent to the hospital on [DATE] with large maggots in the open wound, placing R #4 at risk for infection and death. -Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. -The facility failed to ensure staff knew how to assess residents who had wounds and failed to ensure staff knew all interventions to help protect 15 residents with wounds from contracting maggots. This failure resulted in identification of an Immediate Jeopardy (IJ) on 10/16/13 at 6:40 p.m. While the IJ was removed on 10/16/13, the facility remained out of compliance for actual harm at a scope of pattern due to all active staff were still being in-serviced on assessing residents at risk of contracting maggots, all interventions to help protect residents with wounds from contracting maggots and the facility was still monitoring the Plan of Removal. Failure to put effective interventions into place and ensure staff knew how to assess and intervene to protect R #4 and 15 other residents with wounds from potentially developing an infection and/or death from maggots could place them at risk for harm and lack of services. Findings were: R #4's Face Sheet dated 10/16/13 revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's "Wound Assessment Worksheet" dated 06/19/13 revealed R #4 was admitted to the facility with an unstageable, eschar (dark colored dead tissue) covered wound to her right heel. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #4 had a moderately impaired cognition (decisions poor; cues supervision required); was totally dependent on staff for bed mobility, locomotion, dressing, toileting and personal hygiene; required extensive assistance with transfers; was incontinent of bowel and bladder. R #4's physician progress notes [REDACTED]. R #4's Nurses Notes dated 10/15/13 at 11:00 a.m. revealed: "As this nurse was removing (dressing) to (right) heel noted maggots fall out of wound. The area (where the) wound edge was detached were the maggots come-out. Notified (Director of Nurses). Called (physician). (Resident) to be sent to (hospital)..." The Nurses Note was signed by Licensed Vocational Nurse (LVN) "M." R #4's "Rapid Triage" document from Hospital "AA" dated 10/15/13 revealed: "...(R #4) sent from (the facility) with (complaints of) maggots in (right) heel infection ...(R #4) presents with (wound to right heel) and 100 maggots noted to be crawling out of margins of wound ..." R #4's History and Physical from Hospital "AA" dated 10/15/13 revealed: "...Utilize [MEDICATION NAME] cream (medication used to eradicate maggots) to kill the maggots and to consult with (orthopedics) who will then potentially take her to surgery for [REDACTED]. R #4's right heel wound culture from Hospital "AA" dated 10/15/13 revealed the infection providencia stuartii. According to http://emedicine.medscape.com/article/ 1-overview, "...Providencia species are found in multiple animal reservoirs, including flies ...(and) also found commonly in soil, water, and sewage ... " On 10/16/13 at 11:30 a.m., Medical Doctor (MD) "BB" from Hospital "AA" stated that R #4 would "possibly need surgical amputation of her right foot" due to the maggot infestation. On 10/16/13 at 12:00 p.m., MD "CC" from Hospital "AA" stated that the maggots present to R #4's right heel wound "had to have been there for at least three weeks" because "fat maggots were present which meant they were mature." MD "CC" stated, "Untreated maggots are aggressive. There is a 50/50 chance that (R #4) will lose her limb or foot due to the maggot infestation." MD "CC" stated that R #4 could develop an infection due to the maggot infestation, which could result in death. MD "CC" stated, "The maggots are (currently) coming out from under the eschar. There are thousands." According to the U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/ on 10/23/13 "...A lack of adequate medical and (nursing) care of the elderly ..., especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation ...(i) ...Upon hatching, the larvae begin feeding, causing an extensive destruction of tissue ...and pockets may be eaten out beneath the skin ...An infested person may die from tissue destruction ..." According to Texas A&M Agrilife Extension, https://insects.tamu.edu/fieldguide/cimg239.html, the most common types of maggots to infest human wounds "...develop... from egg to adult...in 16 to 35 days, depending on temperature and environmental conditions..." On 10/16/13 at 2:00 p.m., the Administrator stated that on 10/15/13, after the maggots were found on R #4's right heel wound and R #4 was sent to the hospital, the facility put the following interventions into place: -R #4's room was cleaned. -The facility's exterminator was contacted and would be in the facility on 10/17/13 as "precautionary measures." -R #4's roommate was assessed for transfer of the maggots. -A 100% assessment was completed on residents with skin or wound impairment and would continue for 72 hours. -An inservice was conducted with staff and the treatment nurse on infection control. -The facility contacted an outside entomologist for further direction. Review of the facility's Inservices dated 10/15/13 and 10/16/13 related to R #4's maggot infestation revealed staff were not inserviced on how maggots were transmitted into wounds, signs and symptoms, and preventative measures to ensure other residents did not contract maggots. Review of the facility's Skin/Wound Assessments of 15 residents with skin or wound impairments dated 10/15/13 revealed the following assessment for each resident: Dressing changed, wound assessed, clean, dry and intact. The assessments did not indicate if those residents were free from maggots and/or include descriptions of the wounds. On 10/16/13 at 2:15 p.m., Treatment Nurse, Licensed Vocational Nurse (LVN) "M", stated that she could not describe what each wound looked like for the residents' wounds she had assessed on 10/15/13. Review of the facility's undated "(R #4's) Timeline" of events revealed: "It is our understanding that the wound was closed from the hospital dismissal and subsequent readmission...to discharge from our facility..." R #4's "Wound Assessment Worksheets", signed by Treatment Nurse, Licensed Vocational Nurse (LVN) "M", revealed the following dates when R #4's wound to her right heel was not intact due to drainage. Dates marked with an "M" represent maceration (the softening and breaking down of the skin resulting from prolonged exposure to moisture): -06/20/13; M -06/25/13 -07/02/13 -07/09/13; M -07/16/13; M -07/23/13; M -07/30/13; M -08/06/13; M with odor -08/13/13; M -08/20/13; had odor -08/27/13; M with odor -09/03/13; had odor -09/09/13; had odor -09/16/13; M with odor; "eschar had detached." -10/07/13 -10/14/13; M with odor; "wound edges detaching." R #4's Physician order [REDACTED]. as needed. On 10/16/13 at 2:45 p.m., LVN "M" stated that R #4's wound to her right heel had been "closed" since R #4's admission to the facility except for 09/16/13 and 10/14/13, so therefore the maggots "couldn't have happened here." LVN "M" stated that there were no maggots present to R #4's right heel wound on 10/14/13. Surveyor asked LVN "M" how a closed wound could have drainage. LVN "M" replied, "Sometimes (R #4) refused [MEDICAL TREATMENT]. The drainage had to go somewhere." LVN "M" stated that she had changed R #4's dressing to her right heel "every day" and was not aware if R #4's dressing had not been changed as ordered. Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. The open area had moist grey colored dead tissue present. The edge of the wound had open areas under the skin at the base of the wound. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. The photograph indicated that the condition of R #4's right heel wound had the potential to have developed before 10/15/13. R #4's Treatment MAR for the month of October 2013 revealed staff documented by initialing that R #4 received wound care daily as ordered by the physician. On 10/16/13 at 6:40 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 6:40 p.m. of the IJ due to the above failures. On 10/16/13 at 11:00 p.m., the facility's second Plan of Removal was accepted and contained the following: "Issues: 1. Facility failed to put pest control interventions in place to prevent fly infestation. 2. Facility failed to adequately train nursing staff to identify potential maggot infestations in wounds and residents at risk for infestation. Interventions Issue #1: 1. Pest Control company had been notified and will treat the facility for flies on 10/16/13. The Pest Control company will complete the Emergent Pest Control Log with the date and time of their interventions. Pest control will come within 72 hours post initial visit and then weekly for four weeks (or as needed). Findings will be monitored by the QA (Quality Assurance) committee and reviewed and revised as needed. Maintenance, or their designee, will monitor log daily. Administrator or his designee will monitor the log daily for two weeks and then weekly thereafter. This will be presented to the QA meeting for review and evaluation. 2. Facility staff, to include nursing, maintenance, administration, dietary, housekeeping, laundry and therapy services, will be in-serviced on prompt reporting of pest control issues and will document any pest control issues identified on the designated log. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 3. Maintenance will monitor the designated log to identify pest control issues, and will contact the pest control company as indicated. Interventions Issue #2: 1. Quality Assurance Nurse Consultant will educate the Director of Nurses and wound care nurse on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take up identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such. 2. Quality Assurance Nurse Consultant and/or DON will in-service nursing staff on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take upon identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such and prompt reporting of skin changes. 3. Quality Assurance Nurse Consultant and/or DON will in-service Administration, nursing staff, dietary, housekeeping, laundry, therapy services and maintenance on identification of maggots and/or larvae and the process for reporting such to administration. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 4. A 100% skin audit has been completed by nurse management on 10/16/13 to identify all residents at risk of maggot infestation to open wounds. No other residents were found to have signs or symptoms of maggots present in the wounds. Notations will be made in the clinical record to record these assessments and findings. Monitoring: 1. Management staff will monitor for pests during rounds. 2. Administrator will monitor the designated log for pest control issues to verify that appropriate interventions have been put into place to address such issues. 3. The facility Medical Director has been notified of the immediate jeopardy and interventions that have been put into place. 4. The facility QA committee will be responsible for monitoring the plan of removal and making revisions as indicated." On 10/16/13 at 7:45 p.m., the facility conducted an inservice which included the following information: "...ID (identification) of flies, what to do and who to report to...Maggots...what to look for and how to report and steps to follow...Infection Control..." 30 staff members attended the training. Review of the facility's undated "(R #4's) Timeline" of events revealed: "...Understanding the stage of development of larvae (non-pupa) and that the wound being closed since readmission to our facility, it would rightly assumed that the introduction of the larvae did occur at our facility." On 10/16/13 at 11:20 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. On 10/22/13 at 5:00 p.m., in response to surveyor's question regarding how the IJ came about, the Administrator stated, "There was a possibility that the eggs were laid somewhere else. When it was discovered, we sent (R #4) out, reported it to the state, put actions into place to address it to the best of our ability as was possible." On 10/22/13 at 5:20 p.m., in response to surveyor's question regarding how the IJ came about, DON stated, "If you look at the timeline, there were gaps in the timeline. The larvae were not visible prior to the discovery. There weren't signs of larvae activity." The DON also stated he knew that the nursing staff had knowledge of appropriate wound assessments prior to R #4's incident on 10/15/13 because the nursing staff had performed "simulated air-return demonstrations" of appropriate dressing change techniques, without physically performing the task. Through observations, interviews and record reviews, the survey team determined that Pest Control treated the facility for flies on 10/16/13, wound assessments were accurate, in-servicing was initiated, and staff followed the pest control monitoring that was documented in the facility's Plan of Removal were implemented. The Texas Administrative Code Title 40, Part 1, Chapter 19, Subchapter B, Rule 19.01, states: "...(81) Neglect-The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness..." The facility's "Facility Abuse Prohibition Policy and Procedure" dated 03/2012 revealed: "...This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing regulations as required by law...Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. As a general overall policy, the facility will use reasonable efforts, through operational policies, so that...neglect...does not occur and that steps are taken to reduce the potential for such forms of abuse...The facility will use reasonable efforts to develop systems to identify events, occurences, patterns and trends that constitute or may be a precursor to...neglect...to help minimize the threat or occurrence of abuse...The facility will use reasonable efforts during the investigative process...to minimize harm to residents..." The facility's undated "Resident Rights Under Texas Law" revealed: "You, the resident, do not give up any rights when you enter a nursing facility...Any violation of these rights is against the law...You have a right: 1. to all care necessary for you to have the highest possible level of health..." The facility's Wound List dated 10/16/13 revealed 15 residents with wounds. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to nurse assessments and wound care. As of exit on 10/24/13 at 4:35 p.m., the facility provided no further information.

Based on interview and record review, the Administrator and Director of Nurses failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for one Resident (R #4) of 36 Residents whose care was reviewed. The Administrator and Director of Nurses (DON) did not ensure the facility's policies and procedures were implemented for the prohibition of neglect when R #4 was sent to the hospital with maggots in her right heel wound. The DON did not evaluate Licensed Vocational Nurse (LVN) "M"'s assessment skills for possible neglect when: -LVN "M" reported that R #4's wound to her right heel was closed before 10/14/13 and without maggots present, which contradicted the facility's and Hospital "AA"'s documentation. -LVN "M" assisted with and performed incomplete assessments for 15 residents who were at risk of contracting maggots. The DON was not aware of the facility's policies and procedures to ensure residents received quality care. The Administrator did not ensure that the DON knew the facilities policies and procedures to ensure residents received quality care. This failure resulted in identification of an Immediate Jeopardy (IJ) on 10/16/13 at 6:40 p.m. While the IJ was removed on 10/16/13, the facility remained out of compliance for potential for more than minimal harm at a scope of pattern due to all active staff were still being in-serviced on assessing residents at risk of contracting maggots, all interventions to help protect residents with wounds from contracting maggots and the facility was still monitoring the Plan of Removal. These failures could place 15 residents with wounds at risk of contracting maggots which could result in infection and/or death. Findings were: R #4's Face Sheet dated 10/16/13 revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's "Wound Assessment Worksheet" dated 06/19/13 revealed R #4 was admitted to the facility with an unstageable, eschar (dark colored dead tissue) covered wound to her right heel. R #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #4 had a moderately impaired cognition (decisions poor; cues supervision required); was totally dependent on staff for bed mobility, locomotion, dressing, toileting and personal hygiene; required extensive assistance with transfers; was incontinent of bowel and bladder. R #4's physician progress notes [REDACTED]. R #4's Nurses Notes dated 10/15/13 at 11:00 a.m. revealed: "As this nurse was removing (dressing) to (right) heel noted maggots fall out of wound. The area (where the) wound edge was detached were the maggots come-out. Notified (Director of Nurses). Called (physician). (Resident) to be sent to (hospital)..." The Nurses Note was signed by Licensed Vocational Nurse (LVN) "M." R #4's "Rapid Triage" document from Hospital "AA" dated 10/15/13 revealed: "...(R #4) sent from (the facility) with (complaints of) maggots in (right) heel infection ...(R #4) presents with (wound to right heel) and 100 maggots noted to be crawling out of margins of wound ..." R #4's History and Physical from Hospital "AA" dated 10/15/13 revealed: "...Utilize [MEDICATION NAME] cream (medication used to eradicate maggots) to kill the maggots and to consult with (orthopedics) who will then potentially take her to surgery for [REDACTED]. R #4's right heel wound culture from Hospital "AA" dated 10/15/13 revealed the infection providencia stuartii. According to http://emedicine.medscape.com/article/ 1-overview, "...Providencia species are found in multiple animal reservoirs, including flies ...(and) also found commonly in soil, water, and sewage ... " On 10/16/13 at 11:30 a.m., Medical Doctor (MD) "BB" from Hospital "AA" stated that R #4 would "possibly need surgical amputation of her right foot" due to the maggot infestation. On 10/16/13 at 12:00 p.m., MD "CC" from Hospital "AA" stated that the maggots present to R #4's right heel wound "had to have been there for at least three weeks" because "fat maggots were present which meant they were mature." MD "CC" stated, "Untreated maggots are aggressive. There is a 50/50 chance that (R #4) will lose her limb or foot due to the maggot infestation." MD "CC" stated that R #4 could develop an infection due to the maggot infestation, which could result in death. MD "CC" stated, "The maggots are (currently) coming out from under the eschar. There are thousands." According to the U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/ on 10/23/13 "...A lack of adequate medical and (nursing) care of the elderly ..., especially those with the inability to discourage flies from depositing eggs or larvae, also makes humans prone to wound infestation ...(i) ...Upon hatching, the larvae begin feeding, causing an extensive destruction of tissue ...and pockets may be eaten out beneath the skin ...An infested person may die from tissue destruction ..." According to Texas A&M Agrilife Extension, https://insects.tamu.edu/fieldguide/cimg239.html, the most common types of maggots to infest human wounds "...develop... from egg to adult...in 16 to 35 days, depending on temperature and environmental conditions..." On 10/16/13 at 2:00 p.m., the Administrator stated that on 10/15/13, after the maggots were found on R #4's right heel wound and R #4 was sent to the hospital, the facility put the following interventions into place: -R #4's room was cleaned. -The facility's exterminator was contacted and would be in the facility on 10/17/13 as "precautionary measures." -R #4's roommate was assessed for transfer of the maggots. -A 100% assessment was completed on residents with skin or wound impairment and would continue for 72 hours. -An inservice was conducted with staff and the treatment nurse on infection control. -The facility contacted an outside entomologist for further direction. Review of the facility's Inservices dated 10/15/13 and 10/16/13 related to R #4's maggot infestation revealed staff were not inserviced on how maggots were transmitted into wounds, signs and symptoms, and preventative measures to ensure other residents did not contract maggots. Review of the facility's Skin/Wound Assessments of 15 residents with skin or wound impairments dated 10/15/13 revealed the following assessment for each resident: Dressing changed, wound assessed, clean, dry and intact. The assessments did not indicate if those residents were free from maggots and/or include descriptions of the wounds. On 10/16/13 at 2:15 p.m., Treatment Nurse, Licensed Vocational Nurse (LVN) "M", stated that she could not describe what each wound looked like for the residents' wounds she had assessed on 10/15/13. Review of the facility's undated "(R #4's) Timeline" of events revealed: "It is our understanding that the wound was closed from the hospital dismissal and subsequent readmission...to discharge from our facility..." R #4's "Wound Assessment Worksheets", signed by Treatment Nurse, Licensed Vocational Nurse (LVN) "M", revealed the following dates when R #4's wound to her right heel was not intact due to drainage. Dates marked with an "M" represent maceration (the softening and breaking down of the skin resulting from prolonged exposure to moisture): -06/20/13; M -06/25/13 -07/02/13 -07/09/13; M -07/16/13; M -07/23/13; M -07/30/13; M -08/06/13; M with odor -08/13/13; M -08/20/13; had odor -08/27/13; M with odor -09/03/13; had odor -09/09/13; had odor -09/16/13; M with odor; "eschar had detached." -10/07/13 -10/14/13; M with odor; "wound edges detaching." R #4's Physician order [REDACTED]. as needed. On 10/16/13 at 2:45 p.m., LVN "M" stated that R #4's wound to her right heel had been "closed" since R #4's admission to the facility except for 09/16/13 and 10/14/13, so therefore the maggots "couldn't have happened here." LVN "M" stated that there were no maggots present to R #4's right heel wound on 10/14/13. Surveyor asked LVN "M" how a closed wound could have drainage. LVN "M" replied, "Sometimes (R #4) refused [MEDICAL TREATMENT]. The drainage had to go somewhere." LVN "M" stated that she had changed R #4's dressing to her right heel "every day" and was not aware if R #4's dressing had not been changed as ordered. Hospital "AA"'s documented photographs of R #4's right heel wound dated 10/15/13 revealed an open area approximately one half inch wide and two inches long. The open area had moist grey colored dead tissue present. The edge of the wound had open areas under the skin at the base of the wound. There were an undetermined amount of large maggots approximately one half inch long burrowed in the open area and were crawling out from in and under the unattached edge. The photograph indicated that the condition of R #4's right heel wound had the potential to have developed before 10/15/13. R #4's Treatment MAR for the month of October 2013 revealed staff documented by initialing that R #4 received wound care daily as ordered by the physician. On 10/16/13 at 6:40 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 6:40 p.m. of the IJ due to the above failures. On 10/16/13 at 11:00 p.m., the facility's second Plan of Removal was accepted and contained the following: "Issues: 1. Facility failed to put pest control interventions in place to prevent fly infestation. 2. Facility failed to adequately train nursing staff to identify potential maggot infestations in wounds and residents at risk for infestation. Interventions Issue #1: 1. Pest Control company had been notified and will treat the facility for flies on 10/16/13. The Pest Control company will complete the Emergent Pest Control Log with the date and time of their interventions. Pest control will come within 72 hours post initial visit and then weekly for four weeks (or as needed). Findings will be monitored by the QA (Quality Assurance) committee and reviewed and revised as needed. Maintenance, or their designee, will monitor log daily. Administrator or his designee will monitor the log daily for two weeks and then weekly thereafter. This will be presented to the QA meeting for review and evaluation. 2. Facility staff, to include nursing, maintenance, administration, dietary, housekeeping, laundry and therapy services, will be in-serviced on prompt reporting of pest control issues and will document any pest control issues identified on the designated log. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 3. Maintenance will monitor the designated log to identify pest control issues, and will contact the pest control company as indicated. Interventions Issue #2: 1. Quality Assurance Nurse Consultant will educate the Director of Nurses and wound care nurse on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take up identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such. 2. Quality Assurance Nurse Consultant and/or DON will in-service nursing staff on identification of signs and symptoms of possible maggot infestations in wounds (to include how maggots appear during the larvae stages and actions to take upon identification) and identifying residents at risk for infestation. Additional education will be conducted on the appropriate documentation of such and prompt reporting of skin changes. 3. Quality Assurance Nurse Consultant and/or DON will in-service Administration, nursing staff, dietary, housekeeping, laundry, therapy services and maintenance on identification of maggots and/or larvae and the process for reporting such to administration. As of 10/16/13 20% of the staff has been in-serviced on the reporting of pest control issues to include flies and larvae. The remainder of staff will be in-serviced by end of day on 10/17/13. After 10/17/13 staff members who have not been in-serviced will not be allowed to report to duty until they have received the in-service training. 4. A 100% skin audit has been completed by nurse management on 10/16/13 to identify all residents at risk of maggot infestation to open wounds. No other residents were found to have signs or symptoms of maggots present in the wounds. Notations will be made in the clinical record to record these assessments and findings. Monitoring: 1. Management staff will monitor for pests during rounds. 2. Administrator will monitor the designated log for pest control issues to verify that appropriate interventions have been put into place to address such issues. 3. The facility Medical Director has been notified of the immediate jeopardy and interventions that have been put into place. 4. The facility QA committee will be responsible for monitoring the plan of removal and making revisions as indicated." On 10/16/13 at 7:45 p.m., the facility conducted an inservice which included the following information: "...ID (identification) of flies, what to do and who to report to...Maggots...what to look for and how to report and steps to follow...Infection Control..." 30 staff members attended the training. Review of the facility's undated "(R #4's) Timeline" of events revealed: "...Understanding the stage of development of larvae (non-pupa) and that the wound being closed since readmission to our facility, it would rightly assumed that the introduction of the larvae did occur at our facility." On 10/16/13 at 11:20 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. On 10/22/13 at 5:00 p.m., in response to surveyor's question regarding how the IJ came about, the Administrator stated, "There was a possibility that the eggs were laid somewhere else. When it was discovered, we sent (R #4) out, reported it to the state, put actions into place to address it to the best of our ability as was possible." On 10/22/13 at 5:20 p.m., in response to surveyor's question regarding how the IJ came about, DON stated, "If you look at the timeline, there were gaps in the timeline. The larvae were not visible prior to the discovery. There weren't signs of larvae activity." The DON stated he knew that the nursing staff had knowledge of appropriate wound assessments prior to R #4's incident on 10/15/13 because the nursing staff had performed "simulated air-return demonstrations" of appropriate dressing change techniques, without physically performing the task. The DON stated that he was not aware of the facility's policies and procedures. Through observations, interviews and record reviews, the survey team determined that Pest Control treated the facility for flies on 10/16/13, wound assessments were accurate, in-servicing was initiated, and staff followed the pest control monitoring that was documented in the facility's Plan of Removal were implemented. The facility's "Job Description for Administrator" dated 10/2009 revealed: "The Administrator is responsible for planning, organizing, staffing, directing, coordinating...residents and equipment in a manner that the purpose of the facility shall be established and maintained in accordance with established policies...List of Specific Job Descriptions...9. Supervise all department heads..." The facility's "Job Description for Director of Nursing" dated 06/2013 revealed: "The Director of Nursing will verify the provision of quality care that promotes the highest practicable physical, mental and psychological well-being of each resident...The Director of Nursing shall know the policies and procedures of the facility..." The Texas Administrative Code Title 40, Part 1, Chapter 19, Subchapter B, Rule 19.01, states: "...(81) Neglect-The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness..." The facility's "Facility Abuse Prohibition Policy and Procedure" dated 03/2012 revealed: "...This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing regulations as required by law...Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. As a general overall policy, the facility will use reasonable efforts, through operational policies, so that...neglect...does not occur and that steps are taken to reduce the potential for such forms of abuse...The facility will use reasonable efforts to develop systems to identify events, occurences, patterns and trends that constitute or may be a precursor to...neglect...to help minimize the threat or occurrence of abuse...The facility will use reasonable efforts during the investigative process...to minimize harm to residents..." The facility's undated "Resident Rights Under Texas Law" revealed: "You, the resident, do not give up any rights when you enter a nursing facility...Any violation of these rights is against the law...You have a right: 1. to all care necessary for you to have the highest possible level of health..." The facility's Wound List dated 10/16/13 revealed 15 residents with wounds. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to administration. As of exit on 10/24/13 at 4:35 p.m., the facility provided no further information.

Based on observation, interview, and record review the facility failed to ensure that a resident having pressure sores receives the necessary treatment and services to prevent the development of one avoidable pressure ulcer for one Resident (R #9) of 15 Residents reviewed for pressure ulcers. -The facility was aware that R #9 was at risk of developing pressure ulcers. -The facility did not put effective interventions into place to prevent R #9 from developing pressure ulcers. -R #9's heels were lying flat on the bed. -The facility was not aware that R #9 had developed a deep tissue injury to her left heel until surveyor intervention. These failures could put 32 residents requiring assistance with positioning at risk of developing pressure ulcers or impaired healing of current ulcers. Findings were: R #9's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old admitted on [DATE] and the [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R #9: had a severely impaired cognition (never/rarely made decisions); was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene and bathing; was always incontinent of bowel and bladder; was at risk of developing a pressure ulcer; did not have a pressure ulcer; had a pressure reducing device for her bed. R #9's Care Plans dated 09/04/13 revealed: -"...(R #9) is on Turtle Program (due to) fragile skin. Has a prevelance for discolorations and skin tears...Staff will reposition resident every 2 hours while in bed..." -"...(R #9} requires total assist times two with bed mobility...due to muscle disuse and atrophy...Air mattress as indicated..." R #9's Braden Scale dated 09/04/13 revealed a score of 14. A total score of 13 to 14 represented a moderate risk of developing pressure ulcers. Observation on 10/16/13 at 4:05 p.m. with Licensed Vocational Nurse (LVN) "M" revealed R #9 lying in bed with both heels flat against the mattress. After assessing R #9's heels, LVN "M" stated R #9 had a deep tissue injury (purple or or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) to her left heel. LVN "M" stated she was not aware of R #9's deep tissue injury and R #9's heels "should be elevated" to prevent pressure to R #9's heels. R #9's "Clinically Unavoidable Skin Condition" document dated 10/17/13 and signed by R #9's physician, MD "Q", on 10/18/13 revealed: "Skin conditions for the resident identified below has been determined to be clinically unavoidable due to the indicated circumstances:..." Handwritten in the "Type of Wound...Other" section was suspected deep tissue injury. R #9's "physician progress notes [REDACTED].#9) multiple, severe comorbidities and general debility, as well as her current anti-[MEDICAL CONDITION] regimen, the patient is likely to develop...skin breakdown with no trauma or excessive pressure to the area. Her newest area of discoloration on the (left) ankle is most likely spontaneous bruising but is being classified as a possible (deep tissue injury) at this time." R #9's "Pressure Ulcer Prevention Protocol" dated 10/16/13 revealed: "Resident admitted to the facility free of pressure sores but identified at risk on the Braden Scale with a score of 14 or below will be placed on aggressive prevention interventions. The following checklist is to be completed at admission by the assisting nurse to select appropriate interventions and ensure compliance..." The following sections were documented as interventions: -"Specialty bed-air fluid; low air loss therapy." -"Prevalon boots." Observation on 10/17/13 at 1:50 p.m. revealed R #9 lying in bed with both heels flat against the mattress. R #9 was not lying on a specialty bed. On 10/22/13 at 9:25 a.m, Certified Nurse Aide (CNA) "O" stated it was the facility's policy to "float" residents' heels using pillows to elevate the residents' heels off of the bed to prevent pressure ulcers. On 10/22/13 at 12:00 p.m., CNA "R" stated that it was the facility's policy to "float" residents' heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 12:10 p.m., CNA "S" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 2:00 p.m., ADON "B" stated that it was the facility's policy to "float" resident's heels using pillows to elevate the resident's heels off of the bed to prevent pressure ulcers. On 10/22/13 at 5:20 p.m., the Director of Nurses (DON) stated residents who were at risk of developing pressure ulcers should have "pillows under the feet" and/or "Prevalon" boots to relieve pressure to the heels. The facility's "treatment of [REDACTED]. A number of contributing or confounding factors are also associated with pressure ulcers;...Suspected deep tissue injury-depth unknown (:) Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear...Avoid positioning the resident on a pressure ulcer. Use positioning devices to raise a pressure ulcer off the support surface..." The facility's "Facility Abuse Prohibition Policy and Procedure" dated 03/2012 revealed: "...This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing regulations as required by law...Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. As a general overall policy, the facility will use reasonable efforts, through operational policies, so that...neglect...does not occur and that steps are taken to reduce the potential for such forms of abuse...The facility will use reasonable efforts to develop systems to identify events, occurances, patterns and trends that constitute or may be a precursor to...neglect...to help minimize the threat or occurrence of abuse...The facility will use reasonable efforts during the investigative process...to minimize harm to residents..." The facility's undated "Resident Rights Under Texas Law" revealed: "You, the resident, do not give up any rights when you enter a nursing facility...Any violation of these rights is against the law...You have a right: 1. to all care necessary for you to have the highest possible level of health..." The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 10/15/13 revealed 32 residents required assistance with positioning. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to pressure ulcers. As of exit on 10/24/13 at 4:35 p.m., the facility provided no further information.

Based on interview and record review, the facility failed to provide residents the right to refuse treatment for one of 14 Residents (R #2) reviewed for resident rights. The facility failed to allow R #2 to refuse medications by staff and the nurse practitioner working for R #2's psychiatrist by injecting the antipsychotic medication [MEDICATION NAME] 2.5 mg (milligrams) after R #2 refused them and when symptoms were absent, and failed to put effective interventions in place when the facility recognized R #2's rights were violated. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The DON (Director of Nurses) was aware the resident refused the antipsychotic injection, yet instructed Licensed Vocational Nurse (LVN) "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to respect R #2's right to refuse treatment could place six residents in the facility at risk for violation of their rights. Findings were: Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding resident rights. No additional information was provided.

Based on interview and record review, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms for one of six Residents (R #2) reviewed for restraints. The facility failed to protect R #2 from physical restraints by staff and the nurse practitioner working for R #2's psychiatrist by holding down R #2 and against R #2's will to administer an antipsychotic medication. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The DON (Director of Nurses) was aware the resident refused the antipsychotic injection, yet instructed Licensed Vocational Nurse (LVN) "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to protect R #2 from physical restraints by holding down R #2 while administering a medication when R #2 refused could place six residents receiving intramuscular injections at risk for psychological harm. Findings were: Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding physical restraints. No additional information was provided.

Based on interview and record review, the facility failed to ensure residents were free from chemical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms for one of six Residents (R #2) reviewed for restraints. The facility failed to protect R #2 from chemical restraints by staff and the nurse practitioner working for R #2's psychiatrist by administering an antipsychotic injection when R #2 had not exhibited behaviors and after R #2 refused the injection. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The DON (Director of Nurses) was aware the resident refused the antipsychotic injection, yet instructed Licensed Vocational Nurse (LVN) "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to protect R #2 from chemical restraints by holding down R #2 while administering a medication when R #2 refused could place six residents receiving intramuscular injections at risk for life threatening side effects and psychological harm. Findings were: Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding chemical restraints. No additional information was provided.

Based on interview and record review, the facility failed to ensure a resident was free from physical and mental abuse for one of 14 Residents (R #2) reviewed for abuse. The facility failed to protect R #2 from abuse by staff and the nurse practitioner working for R #2's psychiatrist by holding down R #2 and administering an antipsychotic injection when the resident refused. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The DON (Director of Nurses) was aware the resident refused the antipsychotic injection, yet instructed Licensed Vocational Nurse (LVN) "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to protect R #2 from abuse by holding down R #2 while administering a medication when R #2 refused could place six residents receiving intramuscular injections at risk for psychological harm. Findings were: Review of the facility's Abuse Prohibition Policy and Procedure dated March 2012 revealed:..."This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home residents...If the alleged perpetrator is an employee of the facility, the immediate or ranking supervisor will place the employee on suspension pending investigation. The immediate or ranking supervisor will obtain a written statement from the employee regarding his/her actions at the time in question. The employee will then be removed from the facility...For verified allegations of abuse...corrective action shall be taken and documented immediately. Any employee will be subject to disciplinary action, including immediate termination, if the complaint is substantiated by the facility...Substantiated complaints against nurse aides for acts of resident abuse...will be reported to the State Nurse Aide Registry...Substantiated complaints against licensed nurses for acts of resident abuse...will be reported to the State Board of Nurse Examiners..." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding abuse. No additional information was provided.

Based on interview and record review the facility failed to follow and implement its abuse and neglect policy and procedures for protection and investigation of abuse for one of 14 Residents (R #2) reviewed for abuse. The facility failed to protect R #2 from abuse by staff and the nurse practitioner working for R #2's psychiatrist by holding down R #2 and administering an antipsychotic injection when the resident refused and continued to allow the staff to provide care for R #2. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The DON (Director of Nurses) was aware the resident refused the antipsychotic injection, yet instructed Licensed Vocational Nurse (LVN) "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to protect R #2 from abuse by holding down R #2 while administering a medication when R #2 refused could place six residents receiving intramuscular injections at risk for psychological harm. Findings were: Review of the facility's Abuse Prohibition Policy and Procedure dated March 2012 revealed:..."This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home residents...If the alleged perpetrator is an employee of the facility, the immediate or ranking supervisor will place the employee on suspension pending investigation. The immediate or ranking supervisor will obtain a written statement from the employee regarding his/her actions at the time in question. The employee will then be removed from the facility...For verified allegations of abuse...corrective action shall be taken and documented immediately. Any employee will be subject to disciplinary action, including immediate termination, if the complaint is substantiated by the facility...Substantiated complaints against nurse aides for acts of resident abuse...will be reported to the State Nurse Aide Registry...Substantiated complaints against licensed nurses for acts of resident abuse...will be reported to the State Board of Nurse Examiners..." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding abuse. No additional information was provided.

Based on interview and record review, the facility failed to implement their written policy and procedures that prohibit abuse for one of 14 Residents (R #2) reviewed for abuse. The facility failed to protect R #2 from abuse by staff and the nurse practitioner working for R #2's psychiatrist by holding down R #2 and administering an antipsychotic injection when the resident refused and continued to allow the staff to provide care for R #2. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The DON (Director of Nurses) was aware the resident refused the antipsychotic injection, yet instructed Licensed Vocational Nurse (LVN) "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to protect R #2 from abuse by holding down R #2 while administering a medication when R #2 refused could place six residents receiving intramuscular injections at risk for psychological harm. Findings were: Review of the facility's Abuse Prohibition Policy and Procedure dated March 2012 revealed:..."This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home residents...If the alleged perpetrator is an employee of the facility, the immediate or ranking supervisor will place the employee on suspension pending investigation. The immediate or ranking supervisor will obtain a written statement from the employee regarding his/her actions at the time in question. The employee will then be removed from the facility...For verified allegations of abuse...corrective action shall be taken and documented immediately. Any employee will be subject to disciplinary action, including immediate termination, if the complaint is substantiated by the facility...Substantiated complaints against nurse aides for acts of resident abuse...will be reported to the State Nurse Aide Registry...Substantiated complaints against licensed nurses for acts of resident abuse...will be reported to the State Board of Nurse Examiners..." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding abuse. No additional information was provided.

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 14 Residents (R #2) reviewed for provision of care. The facility failed to protect R #2 from abuse by staff and the nurse practitioner working for R #2's psychiatrist by holding down R #2 and administering an antipsychotic injection when the resident refused and continued to allow the staff to provide care for R #2. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The DON (Director of Nurses) was aware the resident refused the antipsychotic injection, yet instructed Licensed Vocational Nurse (LVN) "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to provide services that met professional standards affected R #2 by causing mental anguish and could place six residents receiving intramuscular injections at risk for psychological harm. Findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 states: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others;...(R) Be responsible for one's own continuing competence in nursing practice and individual professional growth." The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.12 states: "The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to:...Causing or permitting physical, emotional or verbal abuse or injury or neglect to the client or the public." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding professional standards. No additional information was provided.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for one of 14 Residents (R #2) reviewed for abuse, physical restraints, chemical restraints and resident rights. The Administrator failed to: 1) Put preventative measures in place when he became aware that R #2 was at risk of abuse, use of restraints and violation of resident rights. 2) Monitor the Director Of Nurses (DON) to ensure she followed the facility's abuse, resident rights and restraint policies. The DON was aware that R #2 was at risk of abuse, resident rights violations and the use of restraints and failed to put preventative measures in place to protect R #2. The DON instructed Licensed Vocational Nurse (LVN) "C" and "J" to administer an antipsychotic injection to R #2, after R #2 had refused the injection. 3) Monitor the DON to ensure that the nursing staff were monitored regarding abuse, resident rights and restraints. The DON failed to: 1) Put preventative measures in place when she became aware that R #2 was at risk of abuse, use of restraints and violation of resident rights. 2) Protect R #2 from abuse, use of restraints and violation of resident rights when the DON instructed LVN "C" and "J" to administer an antipsychotic injection to R #2, after R #2 had refused the injection. 3) Monitor the nursing staff regarding abuse, restraints and resident rights. -The resident refused the administration of the antipsychotic injection because she did not like the side effects. -The resident had not exhibited violent or aggressive behaviors. -The Administrator and DON was aware that R #2 was at risk of abuse, use of restraints and violation of resident rights. -The DON was aware the resident refused the antipsychotic injection, yet instructed LVN "C" and LVN "J" to administer the injection. -LVN "C" told R #2 incontinent care was being provided, then injected her with an antipsychotic medication after the resident refused the injection. -Certified Nurse Aide (CNA) "F" held down the resident's hands while the nurse practitioner working for R #2's psychiatrist (NP "E") administered the antipsychotic injection. -The facility was aware the resident had the right to refuse treatment. -R #2 suffered mental anguish as a result. These failures resulted in an Immediate Jeopardy (IJ) on 11/30/12. While the IJ was removed on 12/01/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still implementing the Plan of Removal. Failure to protect R #2 from abuse, restraints and resident rights by holding down R #2 while administering a medication and when R #2 refused could place six residents receiving intramuscular injections at risk for psychological harm. Findings were: Review of R #2's Clinical Record revealed there were no records to indicate R #2 was adjudicated incompetent or that R #2 had a Power of Attorney. On 11/30/12 at 2:30 p.m. at a specialized facility, R #2 stated she did not want to be given "shots", that it would "make me mad to hold me down" and that it had happened "a long time ago." R #2 stated she had the right to refuse medications "because of the after effects." Review of R #2's Face Sheet dated 11/20/12 revealed an [AGE] year old female with an admission date of [DATE] and the following Diagnoses: [REDACTED]., [MEDICAL CONDITION], Depression and Unspecified [MEDICAL CONDITION] ([MEDICAL CONDITION], hallucinations). Review of R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 had clear speech-distinct intelligible words; made self understood; comprehended most conversation; had inattention and disorganized thinking; had minimal depression; had no behavioral symptoms directed toward others; had no hallucinations or [MEDICAL CONDITION]; had not rejected care; required limited assistance with bed mobility, transfers and dressing; was incontinent of bowel and bladder. Review of R #2's Mood State Care Plan dated 10/12/12 and 11/16/12 revealed: "Resistant to daily care (refuses medications)...Explain to resident the benefit of receiving medications...Explain potential hazards of refusal of medications...Honor res. (residents) right to refuse medications..." Review of R #2's Physician order [REDACTED]. According to the 25th Edition, Mosby's 2012 Nursing Drug Reference, page 861, regarding the medication [MEDICATION NAME] (antipsychotic):..."Uses: [MEDICAL CONDITIONS] in [MEDICAL CONDITION] disorder; Unlabeled uses: Dementia related to [MEDICAL CONDITION] effects:...pseudoparkinsonism (Parkinson-like symptoms),[MEDICAL CONDITION] (life threatening) heart failure, sudden death (geriatric patients, IM (intramuscular))...fatal pneumonia (geriatric patients, IM)...Black Box Warning: Dementia...Precautions:...geriatric patients..." Review of R #2's Nurses Notes dated 11/10/12 revealed: " (12:45 p.m. (PCP (personal care physician)) called facility and stated if resident started exhibiting s/s (signs or symptoms) of agitation to give injection, but not to administer if she wasn't...(7:05 p.m.) Contacted (NP "E") and she said without behaviors, she wouldn't give order to give [MEDICATION NAME] IM for (medication) refusal." Review of R #2's [MEDICAL CONDITION] Drug Monitoring Sheet (PDMS) dated November 2012 revealed "Monitor for harmful, disruptive behavior"; documentation on the PDMS revealed R #2 had no harmful or disruptive behaviors exhibited for the month of November, 2012. Review of R #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of R #2's Nurses Notes dated 10/06/12 through 11/20/12 revealed R #2 had not exibited behaviors that were harmful or disruptive to herself or to others, and had not exhibited symptoms related to the medications that R #2 had refused on 11/05/12 through 11/19/12. Review of R #2's Psychiatric Progress note by NP "E" dated 11/11/12 revealed: "(R #2) is refusing her medications and is progressively getting more psychotic. (R #2) presented detached and participated with limitations in the interview....(R #2) had been compliant with medications. She requires assistance from others to meet ADLs (dressing, bathing, grooming). Anger and impulses are unchanged. Appetite is unchanged. She describes no side effects and none are in evidence." Review of R #2's Nurses Notes dated 11/13/12 revealed an entry by LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personnaly. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for MD and notified (Family Member (FM) "A"). Will monitor..." On 11/29/12 at 4:10 p.m., the DON stated that FM "A" "insisted" that R #2 be administered [MEDICATION NAME] injections for refusing medications. The DON stated the facility believed it was against R #2's rights to be given a medication when the resident refused. The DON stated that PCP stated not to administer [MEDICATION NAME] to R #2 unless symptoms were present. The DON stated she had told nursing staff to administer [MEDICATION NAME] injections to R #2. On 11/29/12 at 4:20 p.m., LVN "B" stated it was against R #2's rights to "hold her down forcibly to give a shot when there were no behaviors." LVN "B" stated she contacted the DON on 11/10/12 and told her (DON) that "I was not comfortable giving a shot even with an order without a behavior." LVN "B" stated that R #2 had not had any agitation or harmful behaviors since admission to the facility (07/13/12). On 11/29/12 at 5:05 p.m., LVN "J" stated that on 11/14/12, the DON called LVN "J" to request that she give R #2 a [MEDICATION NAME] injection. LVN "J" stated R #2 did not refuse the injection and did not display agitation or other behaviors prior to the injection. On 11/30/12 at 6:10 p.m., the Administrator stated that he was notified by RN "G" on 11/15/12 that facility staff were administering an injection to R #2 after R #2 refused the injection. The Administrator stated he was aware that R #2 had been "physically restrained" by CNA "F" so that NP "E" could administer the injection to R #2. The Administrator stated it was against facility policy to physically restrain a resident to administer a medication when the resident did not exhibit harmful behaviors. The Administrator stated it was a form of "abuse" and "against resident rights" to do so. The Administrator stated that as a result of the facility investigation, it was determined that facility staff had "abused, restrained and violated R #2's rights" by administering an injection when the resident refused. The Administrator stated the facility took action by inservicing all nursing staff regarding Abuse, Resident Rights, and Restraints. The Administrator stated the facility took no other action against the employees involved as a result of the investigation findings and that he did not feel the facility was at fault for the incidents that occurred to R #2. On 12/03/12 at 12:40 p.m., the DON stated that she had instructed nursing staff to administer [MEDICATION NAME] injections to R #2 but that the staff had misunderstood her meaning. The DON stated, "Nurses are responsible for the care and protection for the resident. It is the nurses' responsibility." The DON stated that she and the Administrator were responsible for the staff to know "what is right or wrong." On 12/03/12 at 1:45 p.m., CNA "F" stated that on (11/13/12) the "Doctor" (NP "E") for R #2 came into the facility. CNA "F" stated (NP "E") asked her to hold down R #2's hands while she (NP "E") administered an injection. CNA "F" stated she held down R #2's hands, which were positioned on her chest. CNA "F" stated R #2 said "No" when (NP "E") attempted to administer the injection into R #2's thigh. CNA "F" stated she did not feel that holding down R #2's hands was a problem because R #2 "did not fight me." On 12/04/12 at 3:20 p.m., LVN "C" stated that on 11/12/12, FM "A" "demanded" she administer a [MEDICATION NAME] injection to R #2. LVN "C" stated she approached the DON regarding FM "A's" request and that the DON "kept saying over and over to give it." LVN "C" stated she felt "intimidated" and "felt uncomfortable administering the injection" to R #2. LVN "C" stated R #2 said "No" before LVN "C" administered the injection. On 12/06/12 at 11:00 a.m., CNA "I" stated on 11/12/12, LVN "C" administered an injection to R #2, after R #2 had refused. CNA "I" stated that R #2 exhibited no agitation or change in behaviors prior to receiving the injection. On 12/06/12 at 12:50 p.m., NP "E" stated she assessed R #2 on 11/11/12 as a new patient and that R #2 exhibited "failure to thrive" behaviors which included refusing medications, refusing care and guarded behavior. NP "E" stated she had instructed the facility to notify her if R #2 continued to refuse medications and if the staff were uncomfortable administering a [MEDICATION NAME] injection, that she would give the injection to R #2. NP "E" stated that on 11/13/12, staff notified her that R #2 had refused medications. NP "E" stated she entered the facility, drew up the ordered [MEDICATION NAME] into a syringe, and asked a staff person to assist her in turning R #2 so she could inject the medication. NP "E" stated she felt R #2 needed the injection because "failure to thrive was an emergency." NP "E" stated R #2 had not exhibited any other behaviors than what she had observed on 11/11/12 (refusing medications, refusing care, and guarded behavior). NP "E" stated R #2 had told her "No" when NP "E" explained that she was going to administer an injection. NP "E" stated, "I don't read the Ombudsman Act" when asked about resident rights. (The Federal Nursing Home Reform Act or "Ombudsman Act" that was enacted in 1987, creating a set of national minimum set of standards of care and rights for people living in certified nursing facilities.) Review of the facility's Investigation Report dated 11/16/12, submitted by the Administrator, regarding R #2 revealed the following: 1.) 11/10/12: At approximately 11:00 a.m., FM "A" asked LVN "B" if R #2 had received her medications for the day. LVN "B" responded that R #2 had refused medications for the past five days. FM "A" told LVN "B", "You come with me now and you are going to give her her injection. I'm going to watch you draw it up and give it to her." LVN "B" told FM "A" that R #2 was not agitated and that she could not administer the medication because R #2 did not exhibit any behaviors. At approximately 11:30 a.m., LVN "B" called NP "D" (nurse practitioner for R #2's PCP) at the request of FM "A" regarding the administration of the [MEDICATION NAME] injection. LVN "B" also "called our Administrator. (FM "A") spoke with him on the phone." At approximately 11:50 a.m., NP "D" called LVN "B" and told her, "We are unable to give a medication to a resident simply because a family member directs us to do so..." At approximately 12:00 p.m., FM "A" asked LVN "B" to "go see her mother because she was now agitated." LVN "B" assessed R #2 and "exhibited no signs or symptoms of agitation." LVN "P" assessed R #2 as "she seems calm to me." FM "A" asked LVN "B" and LVN "P" for their "full name and license number" and said "You don't know who you are (expletive) with. You can go now." At approximately 12:45 p.m., PCP called LVN "B" and stated that "she would not give and order to give the injection for refusal of medication since the resident was not displaying any behaviors." At approximately 7:00 p.m., the DON called LVN "B" and "asked if I could contact (NP "E") to determine what she wanted to do about the situation with (R #2)." At approximately 7:05 p.m., LVN "B" contacted NP "E". NP "E" said "she wouldn't give an order for [REDACTED]. 2.) 11/12/12: FM "A" "insisted" to "LVN "C" that "R #2 needed the injection." LVN "C" consulted with the DON, telling her that she (LVN "C") felt "uncomfortable" giving the injection to R #2 because R #2 had refused medications. The DON instructed LVN "C" to administer the [MEDICATION NAME] injection to R #2, and then to notify FM "A" after the injection was given. When LVN "C" attempted to administer the [MEDICATION NAME] injection to R #2, R #2 stated "No" and became "aggressive and combative" and "kicking and hitting us." LVN "C" "realized R #2 was soaked in urine" and needed her brief changed. LVN "C" was assisted by CNA "I" to change R #2's brief. After R #2's brief was "pulled down", LVN "C" injected R #2 with the [MEDICATION NAME] injection in the outer thigh. LVN "C" then called FM "A" and told her that the injection was administered but that R #2 "was combative and didn't want it." The DON contacted LVN "C" and "asked if I had given the injection. I explained everything that happened and again told her (DON) I was uncomfortable giving the shot. (DON) said it was OK..." and "But I listened to my superior nurse's instructions and voiced my concern and followed what she told me to do." 3.) 11/13/12: LVN "D": "(8:30 a.m.) (R #2) refused (medications). Notified (NP "E"). Asked to try again. (R #2) refused [MEDICATION NAME] (injection) IM...Notified (NP "E"). (NP "E") stated to save (injection) and she will come and give (injection) personally. Will reassess at a later time. 9:35 a.m. (NP "E") administered [MEDICATION NAME] (injection) IM in (right) thigh. Will continue to monitor. (2:20 p.m.) The 6-2 CNA notified me that (NP "E") asked her to hold (R #2) for IM injection. When (NP "E") was giving IM injection (R #2) moved and resulted in two scratches to the right thigh, left (communication) form for (Medical Doctor) and notified (FM "A"). Will monitor..." 4.) 11/13/12: In a written statement, CNA "F" revealed the following: " (NP "E") request that I assist her in giving (R #2's) injection. She requests that I hold resident hands when (NP "E") attempted to give injection resident moved and (NP "E") left two scratches on her with needle." 5.) 11/14/12: The DON contacted LVN "J" and asked LVN "J" "if I could administer ...PRN [MEDICATION NAME] 2.5 mg IM (due to) (R #2) refusing (oral medications)." At 7:00 p.m. with FM "A" present, LVN "J" administered a [MEDICATION NAME] injection to R #2 for refusing medications. R #2 did not refuse the injection. 6.) 11/15/12: The ADON (Assistant Director of Nurses) contacted Registered Nurse (RN) "G" regarding "the Charge Nurses were concerned because they had an order to give a [MEDICATION NAME] injection to a resident when she (R #2) refused medications. The resident was not combative and was not a danger to herself or other residents. She (R #2) did not want the injection and the only way the nurses could administer it was to forcibly hold resident down. I instructed (ADON) to advise the Charge Nurses that residents have the right to refuse medications. It would be considered physical abuse to hold the resident down and give the injection. I advised them to follow policy...Spoke with (Administrator) and advised him of the situation..." 7.) 11/15/12: The Administrator "received a phone call from (RN "G"}...Nurses were advised that administering medications against resident's will was a violation of her rights and would be considered a form of abuse; initial investigation started and incident reported to DADS (Department of Aging and Disability Services) within 24 hours;...nurses inserviced on policy and procedure regarding medication refusal, resident's rights, chemical restraints and abuse." 8.) 11/15/12: At 9:15 p.m., RN "G" inserviced the DON on the following subject: "Residents have the right to refuse medications and or treatments. Physically forcing medication upon a resident would be considered abuse and possibly a chemical restraint." The inservice was signed by the DON on 11/19/12. 9.) 11/16/12: All staff were inserviced by the DON, Administrator and ADON on the following subject: "...Under no circumstances force meds (medications); always report abuse;...it is never OK to violate resident rights." 10.) 11/17/12: Corporate Medical Director (CMD) notified the facility of the following:..."She (R #2) is not (being) a danger to herself or others. She is only refusing noncritical medications. To force her (against) her will to accept an IM medication that offers no benefit except chemical (restraint) violates (OBRA) 87 and could be considered assault. Many doctors would see this as malpractice." 11.) 11/20/12: All nursing staff were inserviced on Resident Rights, Physical Abuse, Chemical Restraints, Refusal of Medications. (End of Investigation Report.) On 11/30/12 at 6:10 p.m., an IJ was identifed and the Administrator was informed of the IJ at 6:10 p.m. On 12/01/12 at 11:00 a.m., the Chief Operating Officer (COO) stated the facility had determined that R #2 had been abused by facility staff. The facility submitted a third plan of removal and was accepted on 12/01/12. The following plan of action to remove the IJ was submitted by the facility on 12/01/12 at 1:10 p.m: "1. Issues: -Facility used a chemical restraint for one resident with dementia as per physician's orders [REDACTED]. -Facility used a physical restraint to administer [MEDICAL CONDITION] medications for one resident against their wishes thus violating this resident's rights. -Facility failed to provide services that meet professional standards and administration. 2. Interventions Issue #1: Chemical Restraints -The Licensed nurses, medication aides and certified nursing working on the 2 p.m.-10 p.m. shifts and the 10 p.m.-6 a.m. shift on 11/30/12 were immediately in-serviced regarding resident rights, medication administration and chemical restraints. -The Licensed nurses, medication aides and certified nursing aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were in-serviced regarding resident rights, medication administration and chemical restraints. -All staff will be in-serviced on resident rights, medication administration and chemical restraints before they will be allowed to work at the facility. -All physician orders [REDACTED]. -Eight cognitive residents were interviewed on 11/30/12 to determine if any other resident was affected by the alleged deficient practice. -Additional in-service on 12/03/12 for licensed nurses, medication aides and certified nursing aides on resident rights and medication administration. -In-service initiated on 11/30/12 with nurses on accurate behavior monitoring for residents receiving psychoactive medications. PRN usage of antipsychotic medications to control behaviors is an unapproved usage and is considered a chemical restraint. -In-service will be scheduled with Consultant Pharmacist to instruct nurses and medication aides on the appropriate usage of antipsychotic medications. -11/16/12-Outside source was notified that facility would not allow the administration of medications against residents will. -Nurses, medication aides and certified nurse aides in-serviced to not allow outside sources to administer medications to residents against their will. -The Nurse Practitioner identified as administering the [MEDICATION NAME] injection to the resident will not be allowed to see residents in the facility until she signs an agreement stating that she will not administer medications to facility residents against their will. 3. Intervention Issue #2: Physical Restraint to Administer Medication: -The Licensed nurses, medication aides and certified nurse aides working on the 2 p.m.-10 p.m. shifts and on the 10 p.m.-6 a.m. shift on 11/30/12 were immediately inserviced on resident's right not to be physically restrained and how physically restraining (such as holding a resident down to admnister an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -The Licensed nurses, medication aides and certified nurse aides working on the 6 a.m.-2 p.m. shift on 12/01/12 were inserviced on the resident's right not to be physically restrained and how physically restraining (such as holding a resident down to administer an injectable medication) a resident to administer medications is physical abuse and violates the residents rights. -All nurses, medication aides and certified nurse aides will be in-serviced on residents rights, medication administration and physical restraints before they will be allowed to work at the facility. Examples of physical restraining would be actually holding a resident down to give an injectable medication. 4. Intervention Issue #3: Provide Services that Meet Professional Standards and Administration: -The Director of Nursing received individual in-servicing on residents rights, chemical restraints and professional standards regarding medication administration on 11/15/12 and 11/19/12. -The Director of Nursing was suspended without pay as a disciplinary action on 11/30/12 regarding her direction to her licensed staff and unethical behavior. -The individuals identified as administering or assisting in the administration of [MEDICATION NAME] injection to the identifed resident will receive written disciplinary action regarding the unethical behavior of holding a resident down to administer her medications before they will be allowed to return to work. -Eight interviews were conducted with cognitive residents on 11/30/12 to verify medications have been administered without violating their rights. No resident reports were received indicating any violation of resident rights. -Interviews will continue to be conducted on 12/01/12 by Social Services with the remaining cognitive residents to verify medications have been administered without violating their rights. Social Services will report to the Administrator any report from a resident who verbalizes issues with medication administration. Appropriate action will occur and an investigation will be conducted. 5. Monitoring: -Charge Nurses will contact the Director of Nurses and /or designee when receiving orders for psychoactive medications to verify appropriate diagnosis. -New telephone orders for psychoactive medications and newly admitted resident's charts will be reviewed by the Director of Nurses and the Nurse Managers in their daily mini quality assurance meeting. -Consultant Pharmacist will review the medication regimens of each resident monthly. He will verify usage of antipsychotic medications is appropriate and does not constitute a chemical restraint. 6. Prevention: -Facility will continue to encourage staff to report any instances of violation of residents rights and /or unethical behavior through regular staff in-servicing. -Administrative staff will monitor for instances of violation of residents rights and/or unethical behavior by performing daily rounds of the facility." On 12/01/12, interviews and observations on the 6:00 a.m. to 2:00 p.m. shift with nursing staff revealed the facility had inserviced them on resident rights, physically and chemically restraining residents, abuse, and outside resources administering medications; resident rights were not violated and staff did not hold down residents to administer medications. Through observation, interviews and record review, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 12/01/12 at 1:10 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. On 12/03/12 during continued monitoring of the implementation of the Plan of Removal, it was determined that staff had continued to be be inserviced. LVN "C", CNA"F" and the DON stated they had been disciplined with a written reprimand for "unethical behavior." The DON also stated she had been suspended on 11/30/12 and returned to work on 12/02/12. On 12/03/12 at 11:40 a.m., the Administrator stated, "Everybody has their own reason for following orders, their own reason for doing things. I do not condone what they (staff) did. It was wrong." Review of the facility's Abuse Prohibition Policy and Procedure dated March 2012 revealed:..."This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home residents...If the alleged perpetrator is an employee of the facility, the immediate or ranking supervisor will place the employee on suspension pending investigation. The immediate or ranking supervisor will obtain a written statement from the employee regarding his/her actions at the time in question. The employee will then be removed from the facility...For verified allegations of abuse...corrective action shall be taken and documented immediately. Any employee will be subject to disciplinary action, including immediate termination, if the complaint is substantiated by the facility...Substantiated complaints against nurse aides for acts of resident abuse...will be reported to the State Nurse Aide Registry...Substantiated complaints against licensed nurses for acts of resident abuse...will be reported to the State Board of Nurse Examiners..." Review of the facility's Resident Bill of Rights dated June 2012 revealed:..."The Resident will be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the Resident's medical symptoms...An elderly individual may not be physically or chemically restrained unless the restraint: is necessary in an emergency to protect the elderly individual or others from injury after the individual harms or threatens to harm himself or another;...An elderly individual shall be given the right to refuse treatment..." Review of the facility's Antipsychotic Injectable List dated 11/29/12 revealed six residents received antipsychotic injections. On 12/06/12 at 6:45 p.m. during the exit conference, the DON and Admnistrator were given the opportunity to provide additional information regarding administration. No additional information was provided.

Based on observation, interview, and record review, the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers for one of four sampled residents (SR #2) observed for care. Certified Nurse Assistants did not report SR #2's changes in skin condition to facility's licensed nurses. SR #2 was admitted to the facility on [DATE] without pressure ulcers. On 02/10/11 SR #2 was identified with two Stage 2 pressure ulcers. Failure to prevent the development of pressure ulcers could affect 67 residents in the facility who were incontinent of bowel and bladder. Findings were: On 02/10/11 at 10:28 a.m., incontinent care was observed provided to SR #2 by Certified Nurse Assistants (CNA) "A" and "B". When SR #2 was positioned to lay on the left side, two small shallow skin sores with pink-red bases and scant clear drainage were observed on the upper right and left buttocks, one on each side. SR #2 was facing CNA "B". CNA "A" was standing behind SR #2 and could see the [MEDICAL CONDITION]. When asked about the [MEDICAL CONDITION], CNA "A" said that she usually worked on another unit and was not familiar with SR #2. CNA "A" stated that she was not sure if the nurses knew about SR #2's [MEDICAL CONDITION] and that she would report the finding to the unit charge nurse. Upon completing SR #2's pericare, CNA "A" and "B" left the resident's room and walked down the hallway to a utility room in order to dispose of soiled linens. CNA "B" said that she would take the soiled linen bin to empty and CNA "A" was called by another staff member to assist with another task. Review of SR #2's Face Sheet, dated 12/10/10 revealed SR #2's admitting [DIAGNOSES REDACTED]. The Face Sheet showed boxes before the following conditions that could be present on admission: "Catheter present, Contractures, Restraint Orders, or Pressure Sores (other than Stage I)"; all the boxes were left blank. Review of SR #2's "Informed Results of Resident's Refusal of Treatment/Medication Diet" dated 12/22/10 was written in response to SR #2 "refusing showers, all ADLs (Activities of Daily Living--transfers, ambulation, dressing, eating, and hygiene/bathing), therapy"; refusal of care could result in "weakness, debility, infection -- possibly leading to death". It was signed on 12/27/10 by SR #2 and the resident's Family Nurse Practitioner. There was no documentation that the resident was counseled that over time refusal of care could result in increased risk of pressure ulcer development. Review of SR #2's "Braden Scale - For Predicting Pressure Sore Risk" was completed on 12/11/10 and showed an assigned score of 21. The Braden Scale is a list of 6 risk factors for developing pressure ulcers; a score is assigned to each factor as to its presence and severity. A total score of less than or equal to 12 indicated a high risk for developing pressure ulcers; a total score of 13-14 indicated a moderate risk; and a total score of 15-16 for people under [AGE] years of age or 15-18 if over the age of [AGE] years indicated a low risk. SR #2, age [AGE] years, was assessed as being low risk for developing pressure ulcers. The Braden Scale for SR #2 had not been assessed since the initial evaluation of 12/11/10. Interview with Assistant Director of Nursing (ADON) "F" on 02/09/11 at 3:26 p.m., revealed that SR #2 alternated between a state of being alert to being confused, required assistance with activities of daily living, was incontinent of bowel and bladder, and was not compliant with medications and diet. ADON "F" described SR #2 as requiring heavy care but was not bedfast and used a wheelchair for mobility. ADON "F" stated that SR #2's dementia was worsening. Interview on 02/10/11 at 10:47 a.m., with the facility Wound Care Nurse, Registed Nurse (RN) "E", revealed that SR #2 was receiving no wound treatments. RN "E" stated that the last Weekly Skin Assessment she performed on SR #2 was on 02/04/11 and was remarkable for the presence of "redness" in the perineal area (anterior genital). RN "E" said there were no pressure ulcers to SR #2's back or buttocks on 02/04/11. RN "E" said that SR #2 had not been noted to have pressure ulcers since being in the facility. Observation on 02/10/11 at 11:02 a.m., of RN "E" performing a skin assessment on SR #2 revealed that when RN "E" inspected the two [MEDICAL CONDITION] one on the upper right buttock and one on the upper left buttock, she said, "those are two Stage 2s" (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough). When asked what type of [MEDICAL CONDITION] were noted on SR #2's buttocks, RN "E" stated "pressure sores" ([MEDICAL CONDITION] caused by unrelieved pressure that results in damage to the underlying tissue). RN "E" said that she would notify SR #2's Responsible Party and consult with SR #2's Physician for treatment orders. RN "E" stated that she would measure the pressure sores when she initiated treatment. Interview on 02/11/11 at 8:15 a.m., with the facility Nurse Educator revealed that CNAs were taught to report alterations in skin integrity to the unit Charge Nurse as soon as they were noted. Training included review of videos depicting pressure sores from Stage 1 to Stage 4. Training also included review of pressure sore preventive measures such as re-positioning residents every two hours and providing incontinent care at least every two hours. The Nurse Educator stated that CNAs were trained to provide these measures during all hours of the day and night. Interview on 02/11/11 at 9:18 a.m., with CNA "D" revealed that she had worked from 10:00 p.m. on 02/09/11 to 6:00 a.m. on 02/10/11. Incontinent care was first provided to SR #2 at approximately 10:30 p.m. on 02/09/11, and "open areas" were noted on his buttocks; CNA "D" said that they were "Stage 2". CNA "D" said that she did not report the presence of the [MEDICAL CONDITION] on SR #2's buttocks to the unit Charge Nurse because she assumed that the nurse "already knew about them" (the Stage 2 [MEDICAL CONDITION]). When asked how often SR #2 was provided with incontinent care and re-positioned, CNA "D" replied "every two hours". When asked if SR #2 had ever declined or refused care, CNA "D" answered, "No. I don't know about during the day but he has never refused care at night". CNA "D" stated that she last provided pericare to SR #2 at approximately 5:30 a.m. on 02/10/11. Interview on 02/11/11 at 10:00 a.m., with CNA "A" revealed that she had worked from 6:00 a.m. to 2:00 p.m. on 02/10/11. She said that she had taken care of SR #2 approximately four times since his admission to the facility. She stated that SR #2 has occasionally refused showers, that there were days that he could perform some activites of daily living and other days that he could not. CNA "A" stated that she and CNA "B" had seen SR #2 at approximately 7:30 to 8:00 a.m. on 02/10/11 and that he did not require pericare and a change of incontinent brief at that time. Open [MEDICAL CONDITION] on the buttocks were not noted until 10:30 a.m. on 02/10/11. Interview on 02/11/11 at 10:00 a.m., with CNA "C" revealed that she had worked from 6:00 a.m. to 2:00 p.m. on 02/10/11. CNA "C" reported providing incontinent care to SR #2 with CNA "B" after breakfast on 02/10/11 and that SR #2 had urinated but had no bowel movement. When questioned regarding the time that incontinent care was provided to SR #2, CNA "C" was uncertain if care had been in the morning or afternoon. She said that she did not remember "anything from the morning." Interview on 02/11/11 at 10:15 a.m., with CNA "B" revealed that she had worked from 6:00 a.m. to 2:00 p.m. on 02/10/11. CNA "B" said that she and CNA "A" had provided incontinent care to SR #2 at around 7:00 to 7:30 a.m. on 02/10/11; she stated that SR #2 had a small bowel movement and that she had not noticed [MEDICAL CONDITION] on the resident's buttocks as she was standing with the resident facing her and could not see skin areas on the buttocks. When asked if care was rushed, CNA "B" said that it was not. But that she and CNA "A", had to help other residents to the dining room for breakfast. When asked for the time that she first became aware of [MEDICAL CONDITION] being present on SR #2's buttocks, CNA "B" said that it was at 10:30 a.m. on 02/10/11. Interview on 02/11/11 at 10:35 a.m. with RN "E" revealed that there were currently 14 residents in the facility being treated for [REDACTED]. Surveyor asked RN "E" for measurements of the pressure sores identified on SR #2's buttocks. RN "E" provided two "E-Z Graph Wound Assessment Worksheets". Review of SR #2's two "E-Z Graph Wound Assessment Worksheets" dated 02/10/11 revealed the following: 1) A Stage 2 partial-thickness wound to the right buttock measuring 1.7 centimeters (cm) in length by 1.4 cm in width by <0.1 cm in depth. The wound was newly acquired, pressure in origin and date of occurrence was 02/10/11. The wound had a red base with a scant amount of serous (light brown, thin, clear) drainage and was [DIAGNOSES REDACTED]tous (red) around the border. 2) A Stage 2 partial-thickness wound to the left buttock measuring 1.3 cm in length by 1.3 cm in width by <0.1 sm in depth. The wound was newly acquired, pressure in origin and date of occurrence was 02/10/11. The wound had a red base with a scant amount of serous drainage and was [DIAGNOSES REDACTED]tous around the border. Review of SR #2's "Skin - Acute Care Plan" revealed plans started on 02/10/11 to treat a Stage 2 Pressure ulcer to the Right upper buttock and another Stage 2 Pressure ulcer to the Left upper buttock that were related to decreased mobility and incontinence. Review of SR #2's physician's orders [REDACTED]. Cleanse Stage II to Rt buttock with NS or WC. Pat dry with 4x4, apply [MEDICATION NAME] every 3 days and PRN. An entry to the SR #2's "Nurses Notes" dated 2/10/11 at 12:30 p.m., revealed "Stage II to Rt and Lt buttock" and detailed the treatment plan to include dressing changes every three days and as needed, turn and re-position every two hours, and incontinent care as needed. Review of the facility's policy "Prevention of Pressure Ulcers" (Skin Care rev. 08/10) revealed that staff actions in providing care to residents should include the following: 1) "For a person in bed: change position at least every two hours" 2) "For a person in a chair: change position at least every two hours" 3) For residents who are incontinent of bowel/bladder, "Clean skin as soon as soiled." According to the CMS form 672 dated 02/09/2011, provided by the facility, there were 67 residents who were occasionally or frequently incontinent of bowel and bladder. There were 15 residents who were bedfast all or most of the time and 58 who were in chair all or most of the time. At the exit conference on 02/11/11 at 11:10 a.m., the facility was given the opportunity to provide additional information. None was given.