Every finding on record at Courtyard Manor Nurse Care Center & Assisted Liv

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: multiple spots of build up debris and a red sticky substance on the covering of the ice machine;uncovered and expired food items stored in the refrigerator; andexposed hair and facial hair.This deficient practice had the potential to affect the 75 residents who consumed food from the kitchen.Findings:On 01/05/2026, a review of the facility's policy titled, Food Receiving and Storage, with a last reviewed date of 07/29/2025, revealed in part. Refrigerated/Frozen Storage 1. All food stored in the refrigerator or freezer are covered, labeled and dated ( use by date).On 01/05/2026, a review of the facility's policy titled, Refrigerator and Freezer, with a last reviewed date of 07/29/2025, revealed in part.Food Preparation Area.5.Hair nets and beard restraints are to be worn while in food preparation areas. On 01/05/2026 at 8:31 a.m., a tour of the facility's kitchen was conducted with S1DM1 (Dietary Manager 1), who stated herself and S2DM2 (Dietary Manager 2) were responsible for the day to day management of the kitchen.On 01/05/2026 at 8:38 a.m., an observation of the ice machine was conducted with S1DM1 and revealed the covering of the ice machine had multiple spots of build up debris and a red sticky substance. S1DM1 confirmed the covering of the ice machine should have been cleaned and was not.On 01/05/2026 at 8:45 a.m., an observation of the refrigerator was conducted with S1DM1 and revealed a container of thickened water with no screw top covering attached. Further observation of the refrigerator revealed a container of thickened orange juice with an opened date of 12/03/2025. S1DM1 confirmed the thickened water should have had a screw top covering, and the thickened orange juice was expired and should have been removed from the refrigerator and discarded. On 01/05/2026 at 12:10 p.m., S4DW (Dishwasher) was observed in the kitchen with his hair and facial hair exposed and was not wearing a hair net or a beard restraint.On 01/05/2026 at 12:12 p.m., S2DM2 confirmed that S4DW should have been wearing a hair net and a beard restraint and was not.On 01/05/2026 at 2:18 p.m., S5Maint (Maintenance) was observed in the kitchen with his hair and facial hair exposed and not wearing a hair net or a beard restraint.On 01/05/2026 at 2:29 p.m., S2DM2 confirmed that S5Maint should have been wearing a hair net and a beard restraint and was not.

Based on observations, record review, and interviews, the facility failed to ensure that a resident's physician was immediately notified of a change in the resident's skin condition for 1 (#17) resident out 2 (#17, #77) residents investigated for pressure ulcers. Findings:Review of the facility's policy titled Change in a Resident's Condition or Status with a review date of 07/29/2025, read as follows: 1. The nurse will notify the resident's attending physician or physician on call when there has been a: i. specific instruction to notify the physician of changes in the resident's condition. Review of Resident #17's medical record revealed an admission date of 10/08/2024 with diagnoses that included cerebral infarction, prediabetes, and vascular dementia. On 01/05/2026 at 9:59 a.m., an observation was made of Resident #17 with an uncovered, open abrasion on her left facial cheek. On 01/06/2026 at 3:20 p.m., a second observation was made of Resident #17 who remained to have the uncovered, open abrasion on her left facial cheek. Review of Resident #17's medical record revealed there was no evidence that the physician had been notified. On 01/06/2026 at 3:30 p.m., a concurrent observation and interview was conducted with S4LPN (Licensed Practical Nurse) of Resident #17. S4LPN observed the uncovered open abrasion to Resident #17's left facial cheek and stated that she had not noted it when she observed her Resident #17 throughout the day and further confirmed that this was a change in the resident's condition; therefore, the physician should be notified to obtain treatment orders. S4LPN then reviewed Resident #17's medical record and confirmed there was no evidence the physician had been notified of the resident's change in skin condition.On 01/07/2026 at 10:25 a.m., a third observation was made of Resident #17 with the uncovered open abrasion on her left facial cheek. On 01/07/2026 at 3:50 p.m., a concurrent observation, record review and interview was conducted with S5DON (Director of Nursing) of Resident #17. S5DON observed the open abrasion on Resident #17's left facial cheek and confirmed this was a change in the resident's condition that warranted a physician's notification and should have been done by S4LPN when she learned about it on 01/06/2026. S5DON then reviewed Resident #17's medical record and further confirmed there was no evidence of a physician notification.

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Pre-admission Screening and Resident Review) evaluation and determination for 1 (#33) of 3 residents investigated for PASARR. A review of Resident #33's record revealed an admission date of 08/15/2024 with diagnoses that included in part, dementia in other diseases classified elsewhere, unspecified severity, with agitation and unspecified psychosis not due to a substance or known physiological condition. Further review revealed she was diagnosed with major depressive disorder on 10/07/2024. A review of Resident #33's Level I Pre-admission Screening and Resident Review dated 07/11/2024 was conducted. Review of Section III, 1. revealed in part, an empty box next to the diagnosis of major depressive disorder. A review of the Resident #33's document Medicaid Program, Notice of Medical Certification dated 07/30/2024 revealed that a Level II decision was not required. On 01/07/2026 at 2:36 p.m., an interview and review of Resident #33's record was conducted with S3ADM (Administrator). S3ADM confirmed that Resident #33 received a qualifying diagnosis after her admission date and after the last PASSAR was completed on 07/11/2024. She further confirmed the facility should have resubmitted for a Level II PASARR evaluation and determination to include the new diagnosis of major depressive disorder and had not.

Based on record review and interview, the facility failed to ensure a resident identified with a mental disorder had an accurately completed PASARR (Pre-admission Screening and Resident Review) on admission for 1 (Resident #57) of 3 residents investigated for PASARR.Resident #57 was admitted to the facility on [DATE] with diagnoses that included in part, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, depression, and generalized anxiety disorder. A review of Resident #57's PASARR dated 02/24/2025 was conducted. Review of Section III, 1., revealed in part, an empty box next to Other Psychotic Disorder. A review of Resident #57's document Medicaid Program, Notice of Medical Certification dated 02/28/2025 revealed in part that a Level II decision was not required. On 01/07/2026 at 2:30 p.m., an interview and review of Resident #57's record was conducted with S3ADM (Administrator). S3ADM stated that the PASARR dated on 02/24/25 was completed by another facility prior to admit and was the most current PASARR for the resident. S3ADM confirmed that Resident #57 had a diagnosis on admit of unspecified psychosis not due to a substance or known physiological condition, and confirmed that the box next to Other Psychotic Disorder should have been checked on the PASARR. She further confirmed the PASARR dated for 02/24/2025 had not been accurately completed to include this diagnosis upon Resident #57's admission to the facility.

Based on observation, record review, and interview, the facility failed to implement the comprehensive person-centered care plan and a physician order for a concave mattress for 1 (Resident #76) of 27 sampled residents.Review of Resident #76's record revealed the resident was admitted to the facility on [DATE] with diagnoses that include in part, anxiety disorder, unspecified dementia, psychotic disorder with delusions, Alzheimer's Disease, and bipolar disorder. A review of Resident #76's Order Summary Report revealed a physician order dated 10/14/2024 for Concave mattress every shift. A review of Resident #76''s Care Plan Report revealed in part: Focus: I am at risk for falls related to impaired mobility, generalized weakness and multiple medication use. Interventions: Maintain concave mattress to my bed.On 01/06/2026 at 2:12 p.m., an observation was made of Resident #76's empty bed. The mattress looked flat and not concave.On 01/07/2026 at 8:40 a.m., an observation was made of Resident #76's empty bed. The mattress looked flat and not concave.On 01/07/2026 at 1:56 p.m., an observation was made with S6CNA (Certified Nursing Assistant) of Resident #76's empty bed. S6CNA confirmed that Resident #76's mattress was a regular mattress and not a concave mattress.On 01/07/2026 at 2:00 p.m., a review of Resident #76's record, interview, and observation of Resident #76's empty bed was made with S5DON (Director of Nursing). S5DON confirmed that Resident 76's mattress was not a concave mattress. She confirmed that Resident #76 should have a concave mattress according to the physician orders and the comprehensive care plan.

Based on observations, interviews and record reviews, the facility failed to ensure that nursing staff possessed competencies and skill sets necessary to provide nursing services to meet the residents' needs safely, and attain or maintain the highest practicable physical well-being for 1(#12) of 00 sampled residents as evidenced by nursing staff failing to properly maintain and record output from a Jackson Pratt (JP) drain for Resident #12. Findings: On 10/30/2024, a review of the facility's assessment with no revision date, read in part Before any new diagnoses is accepted into the facility the facility ensures the staff is competent of taking care of the resident. If a new diagnosis occurs then the facility would seek education and resources to ensure that the facility is able to care for the resident and new diagnoses, through this process. Further review revealed a review of clinical competencies within the clinical department is done on hire, annually and as needed based on need to ensure new protocols and procedures are performed adequately. Review of Resident #12's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Unspecified Site of Female Breast, Aphasia, Contracture of Muscle, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Contracture Left and Right Hand, and Alzheimer's Disease. Review of Resident #12's Treatment Administration Record (TAR) dated October 2024 read in part monitor JP drain to right breast surgical incision site, for placement, color and drainage amount in milliliters. Review of Resident #12's discharge summary from a local hospital titled Drain Instructions and dated 10/17/2024, read in part instructions for emptying the drain- squeeze the container making it flat and close it. Keeping the container flat, helps to remove drainage from under the skin. Record the date, time, and the amount of drainage on the bottom of the sheet. Empty the container three times a day-morning, noon, and night. On 10/28/2021 at 2:21 p.m., a Review of Resident #12's physician's orders dated October 2024 prior to the facility staff changing the order read in part record JP drain output and record. Review of Resident #12's care plan dated 10/17/2024, read in part .right breast mastectomy due to breast cancer - follow post-operative orders as ordered by physician, monitor and record drainage from JP drain as ordered, monitor incision site of s/s (signs/symptoms)of infection, and bring to follow up appointment. On 10/28/2024 at 2:21p.m., an observation of Resident #12's JP drain revealed an uncompressed bulb with light red colored fluid in the drain. An immediate observation and interview was conducted with S3ADON (Assistant Director of Nursing) who stated that S5LPN (Licensed Practical Nurse) should have emptied the drain. S3ADON confirmed that the drain bulb should have been compressed. S3ADON emptied the JP drain and discarded 75 ml (Milliliters) of drainage which compressed the bulb. Further observation revealed an additional 65 ml was emptied from the JP drain immediately. S3ADON confirmed that S5LPN should have been monitoring the JP drainage every shift and as needed. On 10/28/2024 at 2:30 p.m., S2DON (Director of Nursing) entered the resident's room and presented the recorded output for the JP drain since its insertion on 10/17/2024. A review of the document revealed on 10/19/2024, 10/20/2024, 10/21/2024, and 10/25/2024, staff had failed to record output on the 6 a.m. to 6 p.m. shift. 10/29/2024 at 1:29 p.m., an interview was conducted with S7LPN who stated when the resident returned to the facility on [DATE] she had two forms for recording output in her discharge packet. One was to complete and return to physician office at the time of follow up. The other form was for care of the JP drain, and to empty 3 times daily and record amount and color. S7LPN stated drainage was recorded every shift and not three times daily. On 10/29/2024 at 4:00 p.m., an interview was conducted with S7LPN who stated that S12LPN worked with Resident #12 on 10/19/2024 and 10/20/2024 and S5LPN worked with the resident on 10/21/2024. S13LPN worked with her on 10/25/2024. Review of the staff skills checklist with S7LPN, revealed no evidence staff were trained or had knowledge of the care and maintenance of a JP drain. On 10/30/2024 at 8:28 a.m., an interview was conducted with S7LPN who stated the S2DON should have completed an in-service training on the care of the JP drain. On 10/30/24 at 11:00 a.m., an interview was conducted with S2DON who confirmed she did not complete an in-service on the care and maintenance of the JP drain with staff. On 10/30/2024 at 4:05 p.m., a follow up observation of Resident #12's JP drain was conducted. The JP drain was observed not compressed. An observation and interview was immediately conducted with S7LPN confirmed the bulb was not compressed. S6LPN was called into the resident's room by S7LPN, and when asked if she had compressed the bulb of the drain after emptying the drain, S6LPN did not have a response. S7LPN confirmed that the JP bulb was to remain compressed.

Based on record reviews, observations and interviews, the facility failed to ensure reasonable accommodation of resident's needs for 1 (#12) out of 29 sampled residents as evidenced by Resident #12's easy touch call light device outside of her reach. Findings: On 10/30/2024, a review of the facility's policy titled Call System, Residents with no revision date, read in part residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Review of Resident #12's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hemiplegia and Hemiparesis, Non-traumatic Intracranial Hemorrhage Affecting Left Non-dominant Side, Contracture Left and Right hand, and Right Mastectomy. Review of Resident #12's October 2024 physician's orders revealed an order dated 11/15/2023 which read in part .ensure flat soft touch call bell is within reach at all times, every shift. Review of Resident #12's comprehensive care plan, dated 11/15/2023, revealed in part, resident bilateral hand contractures. I had a flat soft touch call bell that I was able to use accurately. Intervention - ensure the flat soft touch call bell is within my reach at all time. On 10/28/2024 at 9:49 a.m., an observation was made of Resident #12's call bell position The soft touch call bell was located on the right side of the resident near her hip. When the resident was asked if she was able to reach her call bell, she stated she did not know where it was. The surveyor pointed to the call bell and the resident stated she was unable to reach it. On 10/29/2024 at 7:45 a.m., a second observation was made of Resident #12's call bell position. The resident's soft touch call bell was hanging on the bed rail, and not within the resident's reach. On 10/29/2024 at 7:48 a.m., an observation and interview was conducted with S1ADM (Administrator) who stated the call bell should have been clamped to the resident's sheet to ensure the resident was able to reach and use the call bell. She stated staff should have ensured the resident was able to reach and press the call bell prior to leaving the room.

Based on record review and interviews, the facility failed to notify a resident's representative when a resident had a significant change in condition for 1 (#18) resident out of 29 sampled residents. Findings: A review of the facility's policy titled, Change in a Resident's Condition or Status with a last reviewed date of 03/15/2024, read in part, . Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status; 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status. Review of Resident #18's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Cerebral Infarction, Aphasia, and Alzheimer's disease. Review of Resident #18's progress notes revealed a note dated 10/11/2024 by S15LPN (Licensed Practical Nurse) that read in part, Resident started throwing up a lot in his bed. No morning medications administered. Review of Resident #18's progress notes revealed a note dated 10/17/2024 by S15LPN that read in part, Resident vomited twice on yesterday so medications were held. Review of Resident #18's progress notes revealed a note dated 10/22/2024 by S15LPN that read in part, Resident throwing up again this morning. Holding medications. Review of Resident #18's progress notes revealed a note dated 10/23/2024 by S15LPN that read in part, Resident has thrown up three times this week. He has been unable to keep his food and medications down. He was weak afterwards and didn't put up a fight . On 10/30/2024 at 10:27 a.m., a phone interview was conducted with S15LPN. S15LPN stated she did not recall notifying Resident #18's responsible party of his episodes of vomiting during the month of October 2024. S15LPN confirmed that she should have notified the responsible party of Resident #18's change in condition. On 10/30/2024 at 2:27 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that Resident #18's episodes of vomiting that occurred on 10/11/2024, 10/17/2024, 10/22/2024 and 10/23/2024 were considered a change in condition. She confirmed that the S15LPN had not notified the responsible party after each episode of vomiting and should have done so.

Based on observations, record reviews and interviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 1 (#12) of 29 sampled residents as evidenced by staff failing to turn Resident #12 every two hours. Findings: Review of the resident's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Unspecified Site of Female Breast, Aphasia, Contracture of Muscle, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Contracture Left and Right Hand, and Alzheimer's Disease. Review of the resident's current physician's orders revealed an order dated 04/29/2023 which read, Turn every two hours every shift. Review of the resident's MAR (Medication Administration Record) for October 2024 read in part .turn every two hours every shift. Review of the resident's care plan dated 03/07/2024 read in part .at risk for impaired skin integrity related to incontinence, and immobility. Intervention - encourage/assist with turning and reposition every two hours. On 10/28/2024 at 9:00 a.m., an observation was made of Resident #12 in her room. The resident was lying on her back with a pillow under her head, and her bilateral above the knee amputation stumps were elevated on a cushion. On 10/28/2024 at 12:00 p.m., a follow up observation was made of Resident #12's room, which revealed the resident was lying on her back with one pillow under her head, and both stumps elevated on a cushion. Further observation revealed no other positional cushions or pillows on the resident's side of the room. On 10/29/2024 at 7:37 a.m., another observation was made of Resident #12 in her room which revealed the resident was lying on her back, with one pillow under her head, and bilateral stumps elevated on a cushion. Further observations were conducted at 8:20 a.m., 11:32 a.m., 1:29 p.m., and 4:00 p.m. The resident was in the same position for all observations. On 10/30/2024 at 8:25 a.m., an interview was conducted with S9CNA (Certified Nursing Assistant), S11TX (Treatment Nurse), S3ADON (Assistant Director of Nursing). S11TX stated that Resident #12 was on a turn schedule, and was supposed to be turned every two hours. S3ADON confirmed that staff should have had positioning cushions or extra pillows to assist with the repositioning of the resident and did not. On 10/30/2024 at 11:05 a.m., an interview was conducted with S6LPN (Licensed Practical Nurse) who confirmed that staff had not been repositioning Resident #12 every two hours as per physician orders and comprehensive care plan.

Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#57) of 3 (#12, #47 and #57) residents reviewed for ADLs. Findings: Review of Resident #57's clinical record revealed he was admitted to the facility on [DATE] with the following diagnoses, in part, Hemiplegia and Hemiparesis following other non traumatic intracranial hemorrhage affecting left non-dominant side, Contracture to left and right hand, and Contracture to left and right leg. Review of the Minimum Data Set (MDS) dated [DATE] read in part .Brief Interview for Mental Status (BIMS) score was 9, which indicated he had moderate cognitive impairment. Review of the resident's care plan dated 08/27/2024 read in part At risk for bowel and bladder incontinence related to immobility, Benign Prostatic Hyperplasia (BPH), Overactive bladder. I am incontinent of bowel and bladder, and I require total assistance with perineal care. Incontinent checks every two hours with perineal care. I require assistance with activities of daily living for a history related to Cerebrovascular accident with left hemiparesis, immobility, bowel and bladder incontinence, and bilateral upper and lower extremity contractures. Perineal care provided per staff every two hours and as needed. On 10/28/2024 at 9:09 a.m., an observation and interview was conducted with Resident #57. He stated staff got him up this morning at 5 a.m. and they had not performed perineal care on him since 5 a.m. Resident #57 stated that when the staff gets him up in the mornings, no one comes back put him in bed until after lunch and that is when they usually perform perineal care again. On 10/28/2024 at 11:05 a.m., an observation and follow-up interview was conducted with the resident. He stated that staff had not perform perineal care on him since put him in his geri (geriatric) chair. Resident #57 was observed with a strong urine and feces odor. On 10/28/2024 at 12:26 p.m., Resident #57 was observed in the dining room being assisted with his meal by S10CNA (Certified Nursing Assistant). During the lunch meal, the resident still had a strong urine and feces odor. On 10/28/2024 at 12:56 p.m., S10CNA and S11TX (Treatment Nurse) was observed assisting Resident #57 back to bed. Further observation revealed the resident was soiled with a large amount of urine and feces. S10CNA confirmed she had not performed perineal care prior to the resident going to the dining room. On 10/28/24 at 1:08 p.m., Resident #57 stated, in the presence of S10CNA, this was the second time he received perineal care since he was put in his geri chair at 5 a.m. S10CNA confirmed that the night shift put the resident in his geri chair around 5 a.m., or 6 a.m. S10CNA also confirmed that the resident should have received perineal care prior to bringing him to the dining room and every two hours, as needed.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents (#46) investigated for respiratory care out of a finalized sample of 29 residents by failing to label and properly store Resident #46's CPAP (continuous positive airway pressure) mask. Findings: Resident #46 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Cerebral Infarction, Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypercapnia, Sleep Apnea and Morbid (Severe) Obesity. Review of Resident #46's physician orders revealed an order initiated on 01/26/2024 that read Change CPAP humidifier chamber and full mask with head gear every 6 months and prn (as needed.) Review of Resident #46's care plan revealed in part . I am at risk for respiratory complications r/t (related to) chronic respiratory failure, sleep apnea and obesity. I require O2 (oxygen) therapy and I use a CPAP during sleep to assist with breathing. Interventions: CPAP as ordered; follow directions to keep it clean. On 10/28/2024 at 12:26 p.m., an observation and interview was conducted with S3ADON (Assistant Director of Nursing) of Resident #46's CPAP mask. Resident #46's CPAP mask was observed to be unlabeled and stored in an unlabeled plastic bag. S3ADON confirmed that the mask or storage bag should have been labeled with the date it was changed and was not.

Based on observations and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 83. Findings: On 10/29/2024 at 10:15 a.m., an observation of the daily posted staffing information revealed a date of 10/28/2024. On 10/29/2024 at 10:16 a.m., an observation of the daily posted staffing information and an interview was conducted with S14WC (Ward Clerk). She stated that she was responsible for posting the staffing information on a daily basis. S14WC confirmed the date of 10/28/2024 on the posting and stated that they have always posted the staffing information for the previous day. On 10/29/2024 at 10:50 a.m., an interview was conducted with S1ADM (Administrator). She confirmed that the staffing information posted was from the previous day (10/28/2024). She stated the information had always been posted with the prior, and not the current date.

Based on observations, interviews, and record review, the facility failed to honor and accommodate food preferences for 2 (#17 and #23) out of 6 (#17, #23, #26, #49, #72, and #379) residents reviewed for dining. This deficient practice had the potential to affect 78 residents who consumed meals from the kitchen. Resident #17 Review of Resident #17's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Type 2 Diabetes Mellitus and Muscle Wasting and Atrophy. Review of Resident #17's most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 8, indicating his cognition was moderately impaired. Review of Resident #17's meal ticket, read in part, . meal note: No [NAME] Leafy foods. On 10/29/2024 at 12:40 p.m. and observation and interview was conducted with Resident #17. Resident #17 was observed to have iceberg lettuce on his meal tray. Resident #17 stated that he did not like lettuce and he had removed the lettuce from his hamburger. On 10/29/2024 at 12:40 p.m., an observation of Resident #17's meal tray was conducted with S4DM (Dietary Manager). S4DM confirmed that iceberg lettuce was served on Resident #17's meal tray. On 10/30/2024 at 10:39 a.m., an observation and interview was conducted with S4DM (Dietary Manager). S4DM confirmed that Resident #17's meal ticket stated that the resident's preference included no green leafy foods. S4DM confirmed that iceberg lettuce should not have been served on Resident #17's meal tray on 10/29/2024. 47540 Resident #23 Review of Resident #23's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Type II Diabetes Mellitus, Hyperlipidemia, and Age-Related Osteoporosis. Review of Resident #23's most recent State Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating her cognition was severely impaired. Section G: Functional Status read in part, Eating was coded as 1 (supervision-oversight, encouragement or cueing). Review of Resident #23's comprehensive plan of care, read in part, I am at risk for complications/injury r/t (related to) Osteoporosis with interventions . dated 08/14/2023; encourage intake of dairy products . enriched with calcium and vitamin D . Review of Resident #23's meal ticket, read in part, . meal note: milk with lunch meal. On 10/28/2024 at 12:13 p.m., Resident #23 was observed consuming her lunch meal. Her meal tray did not have milk on it. The resident stated, I would like some milk with my lunch, but they never bring any milk with lunch. On 10/28/2024 at 12:16 p.m., an observation and interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN confirmed that Resident #23's meal ticket stated that the resident's preference was to receive milk with all lunch meals and she had not. On 10/30/2024 at 10:31 a.m., an interview and a review of Resident #23's meal ticket was conducted with S4DM (Dietary Manager) who confirmed that Resident #23 should receive milk with all lunch meals.

Based on record review and interview, the facility failed to maintain a system of accounting of each resident's personal funds entrusted to the facility on the resident's behalf by failing to provide quarterly statements for 1 (# 49) of 1 resident investigated for personal funds out of a finalized sample of 41 residents. Findings: A review of the facility's policy titled Resident Trust Fund, read in part .Policy Interpretation and Implementation. Should a resident decide to deposit into a resident trust fund it should consist of the items below .4. Quarterly statements reflecting the interest earned and balance of the account are to be mailed to all residents and or responsible party. Resident #49 was admitted to the facility on [DATE]. The resident had a BIMS (Brief Interview of Mental Status) score of 14, indicating that her cognition was intact. On 09/26/2023 at 8:00 a.m., an interview was conducted with Resident #49. The resident stated that she should have $38.00 left over after her bills were paid each month but she never received a statement from the facility. On 09/26/2023 at 8:32 a.m., an interview was conducted with S4BOM (Business Office Manager). S4BOM stated that Resident #49's daughter was her (RP) Responsible Party, and that the facility had been sending the quarterly statements to the resident's RP. On 09/26/2023 at 7:00 p.m., a phone interview was conducted with Resident #49's RP. She stated that she received one statement of Resident #49's funds from the facility a long time ago. Resident #49's RP further stated that the only statement she had received for the year of 2023 was given to her when she went to the facility to visit her mother this evening. On 09/27/2023 at 8:50 a.m., an interview was conducted with S4BOM. S4BOM was asked for receipts that quarterly statements had been sent to Resident #49 and/or the resident's RP for the year of 2023. She stated she was unable to provide the requested information and confirmed that she provided the resident's RP with a statement on yesterday 09/26/2023 when the RP visited the facility. S4BOM explained the statement was provided after the facility learned that Resident #49 voiced concerns to the survey team of not receiving statements.

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 (#1, #18) of 4 (#1, #18, #53, #62) residents investigated for PASARR in a final sample of 41 residents. Resident #1 A review of Resident #1's record revealed an admitted [DATE]. Further review revealed he was diagnosed with Schizophrenia on 06/04/2015. A review of the Resident #1's current physician's orders September 2023 revealed he had been prescribed the antipsychotic medication Seroquel 25mg (milligrams) related to the diagnosis of Schizophrenia. Further review of Resident #1's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 06/22/2010. No PASARR Level II was noted in Resident #1's record. On 09/27/2023 at 10:50 a.m., an interview conducted with S5SSD (Social Service Director), who stated that when a resident is diagnosed with a new mental disorder, the facility sends a determination letter to the appropriate state-designated authority, to determine if a Level II PASARR should be conducted. S5SSD confirmed that the facility failed to notify the appropriate state-designated authority when Resident #1 was diagnosed with Schizophrenia on 06/04/2015, and that they should have. 47123 Resident #18 A review of Resident #18's record revealed an admitted [DATE] with diagnoses including Major Depressive Disorder, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Psychotic Disturbance, and Mood Disturbance. Further review of Resident #18's record revealed a Level I PASARR dated 08/07/2018. No evidence that a Level II PASARR request had been submitted to the appropriate state-designated authority by the facility was noted in the resident's record. On 9/27/2023 at 09:16 a.m., an interview was conducted with S5SSD. She confirmed that Resident #18 had diagnoses including Major Depressive Disorder, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Psychotic Disturbance, and Mood Disturbance upon admit on 8/10/2018. S5SSD confirmed that the facility failed to ensure that a request for a Level II PASARR determination was submitted to the appropriate state-designated authority and that the request should have been submitted upon the resident's admission with those diagnoses.

Based on observation, record review and interview, the facility failed to ensure the resident's comprehensive plan of care was implemented for 2 (#6 and #49) residents out of 41 sampled residents as evidenced by: 1. Failing to follow the physician's standing orders to address a blood sugar reading of 44 for Resident #6 and 2. Failing to ensure Resident #49 received a renal diet. Findings: Resident #6 Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Atherosclerotic Heart Disease, Diabetes, and Hypertension. Review of the resident's care plan revealed the resident was at risk for unstable blood glucose related to Diabetes. The care plan included an intervention for diabetic medication as ordered by physician. Review of the resident's physician's standing orders revealed in part: For CBG (Capillary Blood Glucose) results in the range of 0-64 Give 4 ounce orange juice or glucose gel 24 g (grams) and repeat CBG in 15 minutes. CBG below 64 and patient unable to swallow or unresponsive, give Glucagon 1 mg (milligram) IM (Intramuscular) stat and notify MD (Medical Doctor). Review of the resident's Nurses Note dated 04/11/2023 at 19:23 (7:23 p.m.) revealed: Alerted by CNA (Certified Nursing Assistant) that resident was lethargic. Upon entering the patient room noticed that the resident was not being herself and she had a wet cough. Checked blood sugar, CBG (Capillary Blood Glucose) was 44. Attempted to get resident to drink orange juice with no success. There was no evidence the nurse attempted to administer Glucagon 1 mg IM. On 09/26/2023 at 2:45 p.m., an interview was conducted with S8LPN (Licensed Practical Nurse). He stated on 4/11/2023 when the resident had a change in mental status and was lethargic, he checked the resident's blood sugar. S8LPN stated the resident's blood sugar result was 44 and that he attempted to give the resident some orange juice with sugar but she could not drink it. S8LPN stated that he did not attempt to administer Glucagon. On 09/26/2023 at 2:50 p.m., an interview was conducted with S4NP (Nurse Practitioner). He stated if the resident's blood sugar was 44, the nurse should have followed the physician's standing orders. S4NP stated if the resident was lethargic and unable to drink the orange juice, then the standing orders for Glucagon 1 mg IM should have been administered for blood sugar result of 44. 47965 Resident #49 Resident #49 was admitted to the facility on [DATE] with diagnoses in part: Acute Kidney Failure, Morbid Obesity, and Diabetes Mellitus. A review of Resident #49's Physician's orders revealed an order written on 06/07/2023 for a Renal Dialysis diet, Regular Texture, Thin Consistency, extra gravy. A review of a dietary note written on 08/17/2023 at 11:03 a.m. stated .resident is on same renal diet. On 09/26/2023 at 8:40 a.m., an observation was made of Resident #49 in her room. The resident's unfinished breakfast of white toast, grits, scrambled eggs and a glass of orange juice was on her over bed table. A review of the menu card on the resident's tray revealed that she should have received a renal diet. Resident #49 stated she is supposed to get apple or cranberry juices and they keep bringing her orange juice. On 09/26/2023 at 12:32 p.m., an interview was conducted with S6DM (Dietary Manager). S6DM stated that S11DA (Dietary Aide) placed the food on the resident's tray this morning and she should not have had orange juice because she is on renal diet. On 09/26/2023 at 12:36 p.m., an interview was conducted with S11DA. S11DA confirmed that he placed orange juice on the resident's breakfast tray and should not have because the resident is on a special diet.

Based on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure that dietary staff utilize the appropriate hair covering when not covering a beard with a beard restraint to prevent hair from contacting food. This deficiency had the potential to affect the entire census of 79 residents, who consumed food that was prepared in the kitchen. Findings: A review of the facility's Policy and Procedure titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices was conducted. The policy included, in part: Policy Statement: Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent spread of foodborne illnesses. Hair Nets: 15 Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. On 09/25/2023 at 09:43 a.m., an observation was conducted of S10DA (Dietary Aide) working in the kitchen as food was being prepared for the lunch meal. S10DA was observed with no beard restraint covering on his beard. S6DM was present during this observation. On 09/25/2023, between 11:00 a.m. and 12:00 p.m., multiple observations were conducted of S10DA as he worked in and around the food service line area. He was observed handling the trays that held food and drink as he prepared the carts that held lunch trays for delivery to residents. No beard restraint was noted on S10DA's face. S6DM was present during these observations. On 09/26/2023 at 10:45 a.m., an observation was conducted of S10DA handling the trays that held food and drink as he prepared a food cart for the residents' lunch trays. No beard restraint was noted on S10DA's face. S6DM was present during this observation. On 09/26/2023 at 09:30 a.m., an interview was conducted with S6DM. She confirmed that S10DA should have worn a beard restraint over his beard and had failed to do so while working in the kitchen and food service area on 09/25/2023 and 09/26/2023. On 09/26/2023 at 09:35 a.m., an interview was conducted with S1ADM. She confirmed that S10DA should have been wearing a beard restraint over his beard while he was in kitchen and/or food service area.

Based on policy review, record review, and interview, the facility failed to ensure each resident's plan of care and clinical record accurately reflected their advanced directives for 1 (#65) out of 41 sampled residents. This deficient practice had the potential to affect the entire census of 79 residents. Findings: A review of the facility's policy titled Advance Directives read, in part .If the resident has an Advance directive .4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive . Resident #65 was admitted to the facility on [DATE] with diagnoses including: Acute Respiratory Failure with Hypoxia, Benign Prostatic Hyperplasia, and Acute Lymphoblastic Leukemia. A review of Resident #65's care plan revealed he had an Advanced Directive with a DNR (Do Not Resuscitate) status. A review of Resident # 65's record revealed an Advanced Directive with no circled beside DNR and no also circled beside CPR (Cardio Pulmonary Resuscitation). On [DATE] at 12:20 p.m., an interview was conducted with S5SSD (Social Service Director). S5SSD confirmed that no was circled for DNR status and stated that yes should have been circled.

Based on record review and interview, the facility failed to ensure the nurse informed each resident's RP (Responsible Party) of a significant change in condition as evidenced by: 1. Failing to notify Resident #6's RP when the resident was transferred to the hospital and; 2. Failing to notify Resident #69's RP when the resident had an unwitnessed fall for 2 (#6, #69) out of 41 sampled residents. Findings: 1. Resident #6. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Atherosclerotic Heart Disease, Diabetes, and Hypertension. Review of the resident's Nurses Note dated 04/11/2023 at 19:23 (7:23 p.m.) revealed: Alerted by CNA (Certified Nursing Assistant) that resident was lethargic. Upon entering the patient room noticed that the resident was not being herself and she had a wet cough. Checked blood sugar, CBG (Capillary Blood Glucose) was 44. Attempted to get resident to drink orange juice with no success. Ambulance and S7NP (Nurse Practitioner) contacted. There was no evidence the resident's RP was notified. On 09/26/2023 at 11:05 a.m., an interview was conducted with S8LPN (Licensed Practical Nurse). He confirmed that there was no evidence in the clinical records the resident's responsible party was notified of the resident's change of condition and transfer to the hospital. 2. Resident #69. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Senile Degeneration of Brain, Major Depressive Disorder, Anxiety Disorder, Bipolar Disorder, and Schizoaffective Disorder. Review of the resident's quarterly MDS (Minimum Data Set) dated 07/20/2023 revealed the resident's BIMS (Brief Interview Mental Status) score was 5 which indicated the resident was severely impaired for cognition. Review of the resident's nurse's note dated 09/05/2023 at 19:40 (7:40 p.m.) revealed: Late entry: CNA (Certified Nursing Assistant) made writer aware that resident was on side of her bed praying on her knees and now would like something for pain. Writer then went to assess patient and ask what's hurting. Resident states her knees hurts, rating 8 out of 10 and would like something for pain . Resident also stated that she had an unwitnessed fall . There was no evidence the RP (Responsible Party) was notified. On 09/26/2023 at 4:15 pm, a telephone interview was conducted with S2DON (Director of Nursing). S2DON stated on 09/05/2023, the resident was found on the floor on hands and knees. S2DON stated the incident was not witnessed. S2DON confirmed the nurse did not notify the RP of the incident.

Based on observations, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#39, and #65) of 2 (#39 and #65) residents reviewed for respiratory care in a final sample of 41 residents. The facility failed to ensure: 1. Respiratory equipment was properly stored when not in use 2. Resident #65 received oxygen as ordered by the physician. Findings: Review of the facility's policy titled, Oxygen Administration read in part .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Caring for equipment 1. Oxygen tubing must be changed weekly for residents utilizing oxygen. 2. Humidifier bottles must be changed weekly for residents utilizing oxygen. 3. Oxygen tubing must be kept in a bag while not in use. 1. Resident # 39 Review of Resident #39's record revealed she was admitted to the facility on [DATE] with diagnoses including Shortness of Breath, Acute Respiratory Failure, and Unspecified with Hypoxia or Hypercapnia. Review of Resident #39's current physician's orders read in part, Change humidifier every three days. Review of Resident #39's care plan read in part, The resident has risk for altered respiratory status or decline in oxygen saturation especially during exertion. Interventions: Change o2 (oxygen) tubing and clean o2 filter every Saturday. Change o2 humidifier q (every) 3 days and prn (as needed). On 09/25/2023 at 9:49 a.m., Resident #39's nasal cannula was visualized, not in use and on the floor of the resident's room. On 09/26/2023 at 11:39 a.m., Resident # 39's nasal cannula was visualized draped over the oxygen concentrator, not in use, open to air, and not in a bag. The resident's nasal cannula was dated 09/09/2023 and the humidifier bottle was labeled 09/14/2023. On 09/26/2023 at 11:44 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse). She confirmed Resident #39's nasal cannula was not in use and not stored in a bag. She also confirmed the resident's nasal cannula was dated 09/09/2023 and the humidifier bottle was dated 09/14/2023. S9LPN stated the resident's nasal cannula was supposed to be changed out every Saturday and the humidifier was supposed to be changed out every 3 days. She confirmed they were not changed per the resident's care plan orders. 47965 2. Resident #65 Review of the facility's policy titled, Oxygen Administration read in part .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #65 was admitted to the facility on [DATE] with diagnoses in part: Acute Respiratory Failure with Hypoxia, and Acute Lymphoblastic Leukemia Not Having achieved Remission. A review of the Physician's Orders revealed an order written on 08/21/2023 at 16:00 (4:00 p.m.) for O2 (oxygen) at 3L (Liters) NC (Nasal Cannula). On 09/25/2023 at 9:00 a.m., an observation was made of Resident #65 in his room. The resident was lying in his bed and receiving o2 via nasal cannula at a set rate of 2.5L as observed on the o2 concentrator. On 09/25/2023 at 2:47 p.m., a second observation was made of Resident #65 in his room. The resident was lying in his bed and receiving o2 via nasal cannula at a set rate of 2.5L from the o2 concentrator. On 09/25/2023 at 4:20 p.m., an interview was conducted with S9LPN (Licensed Practical Nurse). S9LPN checked the resident's orders on her computer and confirmed that Resident #65 was ordered to receive 3L o2 via nasal cannula. On 09/25/2023at 4:23 p.m., an observation of Resident #65's room was conducted with S9LPN, who confirmed the O2 setting on the resident's oxygen concentrator was at a set rate of 2.5L and stated it should have been set at 3L as the physician ordered.

Based on record review and interview, the facility failed to ensure all residents received all care and treatment in accordance with professional standards of practice as evidenced by the nurse failing to perform a blood glucose checks for 1 (#3) out of 3 (#1, #3, #4) residents getting CBG (Capillary Blood Glucose) checks. The deficient practice resulted in an actual harm for Resident #3, who has a diagnosis of diabetes, on 1/2/2023 at 6:00 a.m., when the facility's surveillance camera on the resident's hall revealed S2LPN (Licensed Practical Nurse) did not check the blood glucose level that AM and documented a level of 137. Resident #3 had a blood glucose level of 656 per lab work drawn on 1/2/2023 at 4:29 a.m. Resident #3 was transferred to the emergency roiagnom on [DATE] at 10:00 a.m. after the resident's daughter voiced concerns about the resident not eating, complaints of sore throat and losing weight. The resident's blood work was drawn in the emergency room and the blood glucose result was 646. The resident's admitting diagnosis to the hospital included Hyperosmolar Hyperglycemic State (HHS). The resident did not return to the facility after being sent to the emergency room . The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Resident #3. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Alzheimer's Disease, Major Depressive Disorder, Aphasia, Dysphagia, Diabetes, Chronic Kidney Disease, and Unspecified Protein Calorie Malnutrition. Review of the resident's physician's orders with start date 1/19/2022 revealed an order for Novolin R solution (Insulin Regular Human) inject as per sliding scale subcutaneously one time a day related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease before breakfast. If 0-60 = 0 give 4 oz (ounce) of OJ (orange juice) recheck CBG in 15 minutes; 61-150 = 0 do nothing; 151-200 = 2 Units; 201-250 = 3 Units; 251-300 = 5 Units; 301-350 = 7 Units; 351-400 = 10 Units; Call MD/NP (Medical Doctor/Nurse Practitioner) if over 400 for further directions, subcutaneously one time a day related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease before breakfast. Review of the resident's MAR (Medication Administration Record) for December 2022 revealed that S2LPN checked the resident's blood glucose level on 12/26/2022 at 6:00 a.m. to 1/2/2023 at 6:00 a.m. and documented the resident's results as 137 for all 8 days. Review of the resident's nurse note dated 1/2/2023 at 10:00 a.m. revealed, Resident being sent to (hospital emergency room ) at this time per family request . Resident transported to hospital per stretcher via ambulance . Further review of the nurse's note revealed that there was no documentation of the resident's condition at the time of transfer to the hospital. Review of the resident's emergency room notes dated 1/2/2023 at 10:53 a.m. revealed, [AGE] year old female past medical history of Alzheimer's, Diabetes, Hypertension, Hypothyroidism presents for encephalopathy and somnolence. Per daughter the patient is normally very interactive, apparently she had COVID 2 to 3 weeks ago, returned back to the nursing home and over the past 2 to 3 days has had progressively more generalized weakness and today she is not speaking or interacting which is very abnormal for the patient . Per EMS (Emergency Medical Services) . Patient was Hyperglycemic with CBG (Capillary Blood Glucose) 560 and heart rate was slightly elevated 105 . Patient is minimally interactive on exam unable to obtain a history from the patient. Patient presents from nursing home with somnolence . found to be mildly acidotic . primary diagnosis is HHS (Hyperosmolar Hyperglycemic State) . Patient was given fluids and insulin in the emergency department .Medically appropriate to be admitted to hospitalist team for further management. Review of the facility's Incident/Accident log revealed that on 1/9/2023 a medication error occurred with the resident. The comments on the report read, Nurse documented that resident's blood glucose level was 137 x 6 days and resident had labs drawn on 1/2/2023 @ (at) 0429 (4:29 am) and blood glucose was 656. @ 0600 (6:00 am) on 1/2/2023, nurse charted that blood glucose was 137, resident's family member called and stated that her mother's blood glucose at the hospital was 780. Camera reviewed and nurse did not check the blood glucose level that AM and documented that she did. On 1/9/2023 family member notified nursing facility of the blood glucose and stated that she was not happy because this could have been prevented . Review of the facility's Medication Deviation Report dated 1/9/2023 revealed that the resident was scheduled a blood glucose on 1/2/2023 at 6:00 am. Nurse charted blood glucose result of 137. The resident's physician's order was blood glucose every am before breakfast with sliding scale. The resident was sent out to emergency room and outcome of deviation was Hyperglycemia. The investigative findings revealed that the resident's family called the facility on 1/9/2023 to inform that lab work showed 656 at 4:29 a.m. and the blood glucose at 6:00 a.m. 137 and then at hospital had 780 blood glucose on 1/2/23. On 2/20/2023 at 12:50 p.m, an interview was conducted with S2LPN. She stated that she worked the 6p-6a shift. S2LPN stated the resident appeared to be fine during the shift she worked on 1/2/2023. S2LPN stated that routine labs were drawn at 4:00 am, which included the blood glucose level. S2LPN stated that she was off duty when the resident's lab results came in. S2LPN stated she checked the resident's blood glucose level with the blood glucose machine between 4:45 a.m. and 5:45 a.m. in the morning and that the resident's blood glucose results was 137. S2LPN was asked about the blood glucose results on the dates 12/26/2022 to 1/2/2023 when she worked. She stated that she documented the results that she saw on the blood glucose machine and on those dates the results were 137. S2LPN stated that she did not know about the resident being admitted to the hospital until later. S2LPN stated that S1DON (Director of Nurses) spoke to her concerning the blood glucose results and she stated that she told him the same thing and that 137 was the result that she saw on the machine. On 2/20/2023 at 2:40 p.m., an interview was conducted with S1DON. He stated that on 1/9/2023, the resident's daughter had brought to his attention that the resident's blood glucose that was drawn on 1/2/2023 at 4:49 a.m. was 656 and that the nurse at the facility told her the blood glucose was 137. S1DON stated that was when he checked to see what the nurse had documented. S1DON stated that S2LPN had documented 137 for the resident's blood glucose results for 8 days from 12/26/2022 to 1/2/2023. He stated that it did not look right, so he went and checked video footage to see if the nurse had actually went in the room and performed the blood glucose check. S1DON stated he viewed camera footage from 4:45 a.m. to 6:30 a.m. on 1/2/2023 and S2LPN was by the resident's room door. He did not see the nurse go in the resident's room with the blood glucose machine. Instead, she walked away with the blood glucose machine. S1DON stated that he spoke to S2LPN and she told him that she did check the resident's blood glucose levels on those dates. S1DON stated that the nurse later called him back and told him that on the morning of 1/2/2023 that she had not checked the resident's blood glucose levels that morning. On 2/20/2023 at 4:11 p.m., the nurse was observed conducting blood glucose testing on resident #4. The nurse was observed to conduct the test appropriately and document the result accurately on the MAR (Medication Administration Record). On 2/20/2023 at 3:20 p.m., S1DON provided documentation of in-service training for the nursing staff. The training included instructions on blood glucose checks and that blood glucose results must be completed and charted appropriately. S1DON stated that he physically observed the nursing staff perform the resident's blood glucose weekly to ensure the blood glucose were being done and documented accurately. On 2/20/2023 at 4:20 pm, an interview was conducted with S4LPN. She stated that the staff was in-serviced on performing blood glucose checks and documenting the blood glucose results. On 2/22/2023 at 8:50 am, an interview was conducted with S5LPN. S5LPN stated that she was in-serviced on blood glucose checks a month ago and that S1DON and Assistant Director of Nurses (ADON) observed her perform the blood glucose checks. The facility has implemented the following actions to correct the deficient practice: Quality Assurance Action Plan: POC (plan of correction)- CBGs In order to ensure that the deficient practice does not reoccur for any and all other residents in the facility, the Director of Nursing and or facility designee will in-service the nursing staff on following the policy and procedure on blood glucose monitoring to ensure that all residents who are on scheduled blood glucose checks are consistent and are accurately transcribed with the physician order. A review will be conducted to ensure that monitoring of blood glucose levels are occurring in the facility. The blood glucose monitoring in-service was conducted on 1/10/2023. Reviewed the weekly monitoring logs that were provided by S1DON. A review was conducted on all residents with scheduled blood glucose checks to ensure no discrepancies re-occurred within the facility. The resident was transferred to a higher level of care for hyperglycemia monitoring but did not have an adverse event. No other residents were affected. The Director of Nursing and or Facility Designee will perform weekly random quality measure checks on residents who have scheduled blood glucose checks to ensure consistency with blood glucose are present and documented accurately in the residents' EMR (Electronic Medical Record). The Director of Nursing or Facility Designee will monitor for 90 days and will re-evaluate POC to determine if the compliance is met or revision needs to be conducted. Date of compliance is 2/1/2023. The policy and procedure has been updated for blood glucose to reflect changes to prevent adverse events from re-occurring. The nurse in question was agency and was terminated/Do not return to facility and removed from schedule permanently. Blood glucose control log was updated to reflect hi and low numbers for control test. Any staff member observed to not be in compliance with the practice is subject to further disciplinary action including possible termination. S2LPN was an agency nurse and was terminated from the facility. The staffing agency was informed that S2LPN was a DNR (Do Not Return).

Based on record review, observations and interviews, the facility failed ensure each resident received adequate supervision and assistance to prevent accidents for one (#1) of five sampled residents (#1-#5) and one (RR #1) random sampled resident observed for transfers. This deficient practice resulted in an Actual Harm for Resident #1 on 4-24-2019 when a CNA attempted to transfer the resident from the whirlpool stretcher to the bed by herself. During the transfer, the resident who required two person assistance, fell to the floor and sustained injuries to the scalp. The resident was transferred to a local hospital and diagnosed with [REDACTED]. FINDINGS: A review of the Policy/Procedure titled Whirlpool Stretcher Transfers submitted by the facility read in part: Purpose: .to help ensure an injury free transfer of a resident while using the stretcher. General Guidelines: . should be used with a two person assist while in actual transfer of the resident .Whirlpool stretcher is to be locked at the time of actual transfer. Resident #1. A review of Resident #1's clinical record revealed an admitted [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the quarterly Resident Minimum Data Set ((MDS) dated [DATE] revealed resident #1 had a BIMS (Brief Interview for Mental Status) of 3 indicative of severe cognitive impairment. Continued review of the MDS form revealed the resident required total assistance for all activities of daily living (ADL'S) with transfer: two person physical assist and mobility, dressing, eating, personal hygiene requiring total dependency x 1 person physical assist. A review of the Nurses Notes revealed the following entry which read in part as followed: 4-24-19 at 1333pm--Summoned to resident's room per whirlpool aide. Upon arrival, noted resident lying on the floor between bed and whirlpool stretcher. Resident assessed .noted raised hematoma approximately 3.8 x3.0cm and a posterior scalp laceration approximately 2.5 x 0.3 cm. Resident responsive to stimuli .hips in proper alignment. Assisted back to bed x 2 MD (medical doctor) notified .transferred to hospital via ambulance. A review of the hospital emergency room Record dated 4-24-19 revealed discharge [DIAGNOSES REDACTED]. A review of Resident #1's current plan of care initiated on 1-4-16 and current as of survey date, revealed resident plan for Activities of Daily Living (ADL'S) which reads in part : Transfers: resident requires total assistance for transfers with 2 person physical assist. Resident requires lifter and Geri-chair for locomotion. On 5-21-19 at 10:00am, Resident #1 was observed lying in bed on her right side, dressed for the day, and appeared to be sleeping. There was no evidence of odors in the room. An attempt to interview Resident #1 was unsuccessful as she would only open her eyes to verbal stimuli and close them again. A review of the bath log revealed that Resident #1 had been bathed on 5-20-19 and was not due for a whirlpool. An interview was conducted with S3 CNA, Whirlpool on 5-21-19 at 10:00am. During this interview, S3CNA confirmed she was one of the aides working during the incident with Resident #1 on 4-24-19. S3CNA stated that when Resident #1's whirlpool bath was completed, she and S4CNA transferred the resident back to her room via the whirlpool stretcher. When they got in front of the resident's room, a door alarm went off so S4CNA left to see about the issue. In the meantime, she pushed the whirlpool stretcher with Resident #1 into her room and positioned the stretcher to the left side of her bed. S3CNA verified the position of Resident #1 at that time as lying on her right side facing the wall of her room. S3CNA stated she then pushed the stretcher slightly over the bed and began to undo the 2 straps that held the resident securely in the stretcher. S3CNA stated she removed the strap from the upper torso of the resident and then went to the foot of the stretcher and removed the strap securing the lower portion of the torso. S3CNA stated that when she was removing the strap from the lower part of the resident's body, the resident suddenly moved toward the wall and the resident fell off the stretcher onto the floor. S3CNA stated she attempted to stop the resident from falling but was not able to. Resident #1 fell to the floor between the wall and the stretcher/resident bed hitting her head and sustaining a laceration as well. After the nurses checked out the resident, we then lifted her and put her into her bed. The nurse then went to call the doctor and resident #1 was sent to the hospital. S3CNA was questioned further during this interview in regards to the procedure for transferring a resident with the whirlpool stretcher. S3CNA stated that after the bath is completed, 2 people are to transfer the resident down the hall and into their room. The stretcher is then positioned on the side of their bed. S3CNA was then asked if it was proper procedure to move the resident into her room by herself, position the resident over bed and to remove the straps in preparation for physical transfer of resident without assistance at which time she stated No, but I have been doing this for 7 years and worked by myself for a long time so I just started doing it. S3CNA was asked if she should have waited for the other CNA to return to complete the transfer of Resident #1 and she stated Yes. During this same interview, S3CNA was asked if she had locked the bed and the whirlpool stretcher prior to transfer and she stated no. An interview was conducted with S4CNA, Whirlpool who confirmed she was also on duty on 4-24-19 at the time of the incident with Resident #1. S4CNA confirmed that she and S4CNA were transferring Resident #1 to her room from whirlpool. When they got to the resident's room, a door alarm went off so she left to go and check on another resident. S4CNA stated she was not in the room at the time of the incident. During this interview, S4CNA stated that they are to have 2 people for transfer of residents per whirlpool stretcher and transferring them back to their beds. An interview with S5LPN (Licensed Practical Nurse) CNA Supervisor was conducted on 5-21-19 at 10:45am. During this interview, S5CNA Supervisor confirmed that when a resident is transferred from whirlpool via whirlpool stretcher, there are to be 2 staff members to perform the transfer. S5CNA Supervisor verified that there were 2 staff members performing the transfer of Resident #1 on 4-24-19 but one of the CNA's left before the transfer was completed to answer an alarm regarding another resident. S5CNA Supervisor confirmed that S3CNA should have waited for the other CNA to return before attempting to transfer the resident.

Based on observation, record review, and interview, the Facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers, and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (#5) of 5 (#1-#5) sampled residents investigated for Quality of Care and Treatment. This deficient practice resulted in actual harm for resident #5 when a Stage 3 pressure ulcer was identified on 1/8/18 to the right calf area under the right knee immobilizer. The facility did not remove the resident's right knee immobilizer once a day as recommended by the Orthopedic Clinic Note dated 12/7/17 to evaluate for any skin breakdown. Findings: Review of Resident #5's record revealed the resident was a [AGE] year old female with the following Diagnoses: [REDACTED]. Record review of Resident #5's MDS (Minimum Data Set) dated 9/19/17 revealed the resident's cognition was severely impaired, was at risk for pressure ulcer development, non-ambulatory, and required extensive assistance of staff for ADLs (Activities of Daily Living). A review of Resident #5' ER (emergency room ) visit on 11/19/17 revealed the resident was diagnosed with [REDACTED]. The resident was discharged on the same day with instructions to use a right knee immobilizer to protect the right tibia and right fibula fractures, to be given pain medication as needed, to have extra lifting assistance, to follow-up with her primary care physician and to call the orthopedist's office to schedule a follow-up orthopedic reevaluation. Record review of Resident #5's care plan revealed on 11/19/17, the resident was care planned for Increased Pain, Fracture Right Leg and the interventions included in part: Right Knee Immobilizer in place; Observe for signs and symptoms of skin breakdown. Record review Resident #5's Orthopedic Clinic Note dated 12/7/17 revealed the Assessment/Plan was for the resident to remain non-weight bearing to the right lower extremity, to continue a knee immobilizer, he discussed appropriate skin care, her knee immobilizer was to be removed at least once a day to evaluate for any skin breakdown. Review of the Facility's Splints and Braces policy revealed in part: -Upon assessment of splint/brace, nurse will check braces and splints for proper circulation and/or [MEDICAL CONDITION], or breaks in skin integrity. Review of Resident #5's MAR (Medication Administration Record) and TAR (Treatment Administration Record) from December 2017 through January 7, 2018 failed to reveal documentation that the right knee immobilizer was checked for placement, that they observed for signs and symptoms of skin breakdown, Review of Resident #5's nurse's notes failed to reveal documentation that the right knee immobilizer was checked for placement or that they observed for signs and symptoms of skin breakdown. There were no Nurse's notes from 12-5-17 to 1-8-18. Record review of Resident #5's Weekly Body Audits from 12/4/17-1/4/18 revealed that Resident #5 did not have any skin breakdown to her right lower extremity. Record review of a Wound Assessment Record dated 1/8/18 and completed by S2Treatment Nurse and S3RN. S3RN identified a Stage 3 pressure ulcer to the right calf measuring 1.5cm (centimeters) X 1cm X 0.2cm. The wound bed was noted to have [MEDICATION NAME] tissue and slough (dead tissue). The wound had no exudate (fluid) at the time of assessment. An observation and interview was made during an assessment of the pressure ulcer to the resident's right lower calf on 1/10/18 at 10:00 a.m. with S2Treatment Nurse and S4NP, a wound care specialist. S4NP stated that this was the first time he was going to assess the wound. Before S4NP assessed the wound, S2Treatment Nurse removed a gauze pad that was taped to the inner part at the end of the immobilizer. A patch of raised, rough fibers was noted under the gauze pad where the pressure ulcer was located. S2Treatment Nurse stated that this was probably the cause of the wound. S4NP assessed the wound and reported the following wound measurements: 1.5cm X 0.6cm X UTD (unable to determine) depth. He stated that the pressure ulcer was Unstageable at that time. S4NP stated that the wound bed was 90% slough and 10% granulation (new connective tissue) with a small amount of serosanguineous (watery fluid containing blood) drainage. He stated that he scraped and pressed against the wound bed to see if there were any pockets and stated that there were none. S4NP ordered to apply Santyl ([MEDICATION NAME] ointment) (every day) to the wound, remove the immobilizer twice a day, and to administer pain medication as needed. During an interview on 1/10/18 at 11:30 a.m. with S2Treatment Nurse, she stated that if a resident was at high risk for pressure ulcer development, she performed an assessment, but not a thorough assessment, and documented the bare minimum. She stated that each nurse was assigned to perform a body audit on a specific resident once a week, so that every resident received a weekly assessment. She stated that if a resident had a brace, splint, or immobilizer in place, the protocol was to obtain a doctor's order for frequency of the brace removal. She stated that the nurses were to sign off on the TAR to indicate the device was removed and that the skin was assessed every shift. S2Treatment Nurse reviewed Resident #5's December 2017 MAR and TAR and confirmed that there was no documentation that the skin under the right leg immobilizer was assessed for any signs of skin breakdown. She stated that she did not know if there was a physician's order to remove the immobilizer and performs skin checks. She reviewed the 12/7/17 Assessment/Plan written by the resident's orthopedic doctor to remove the immobilizer and assess the skin for any breakdown. She confirmed that the order was not carried out. She then stated that there was a big miscommunication amongst staff and that this was why the order was never placed on Resident #5's MAR or TAR. She stated she realized this when the Stage 3 pressure ulcer was identified on 1/8/18. She stated that she then called S4NP to obtain a treatment order for the pressure ulcer identified on 1/8/18. She stated she also applied skin remedy lotion to the resident's legs per physician's orders every Monday through Friday. She stated that she just rubbed the lotion on the lower extremities but didn't do a full skin assessment of the resident's extremities when she applied the lotion. She stated that if the nurses had been doing comprehensive assessments of the resident's skin under the right leg immobilizer, then this wound would not have been discovered at a Stage 3. She stated that Stage 3 pressure ulcers do not develop overnight. During an interview on 1/10/18 at 12:12 p.m. with S5LPN, she stated that she cared for Resident #5 on the day shifts. She stated that the resident had the right leg immobilizer placed at the end of November 2017. She stated that there was no physician's order to remove the immobilizer and perform skin checks. She stated that even though there was no physician's order to remove the brace, she used her nursing judgment and unstrapped the top of the brace to observe the skin under the brace, but stated that she didn't completely remove the brace. She stated that she looked at the top and sides of the calf, but not underneath the calf. She stated that during her shifts she did not apply the skin remedy lotion to the resident's extremities because the treatment nurse applied the lotion during these shifts. She stated that she never documented anywhere that she removed the brace or performed an assessment of the resident's skin. S5LPN stated that she was not aware that the resident had a pressure ulcer until today (1/10/18). During an interview on 1/10/18 at 1:51 p.m. with S1DON, she confirmed that she could not find the Orthopedist's Recommendations/Orders for December 2017 to remove Resident #5's right knee immobilizer once a day and perform skin checks to observe for skin breakdown. S1DON reviewed the nurse's notes and body audits and confirmed there was no documentation that the nurses removed the immobilizer or performed skin checks. She confirmed that the nurses' lack of assessments led to the development of a Stage 3 pressure ulcer. She confirmed the Orthopedist's Recommendations/Orders were not implemented and the nurses' were not following the resident's plan of care.

Based on interview, record review, and observations. the provider failed to ensure that the facility was administered in a manner that enabled the use of resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident by administration's failure to: Immediate Jeopardy Situation: The facility failed to ensure all alleged violations involving abuse of residents are identified, reported, thoroughly investigated, and the resident was protected; and the facility failed to implement policies and procedures for screening, protection, identification, and reporting of abuse as evidences by: 1. Staff not immediately reporting to the administrator of the facility and other officials in accordance with state law (Resident # 5,16, 19) 2. Staff not thoroughly investigating alleged abuse. (Resident # 5, 16) 3. Staff not ensuring the protection of the resident from further potential abuse when the abuse was identified and while the investigation was in progress. (Resident #5, 16, 19) 4. Administration not ensuring the implementation of policies and procedures for screening, protection, identification, and reporting of abuse. (Resident #5, 16, 19) For 3 (#5, 16,19) of 3 (#5, 16, 19) residents reviewed for abuse out of a total sample of 39 Residents. Resident #5: The immediate jeopardy situation began on 1/25/13 at______ (the facility failed to identify the time this occurred) when Resident #5 reported being afraid and humiliated while receiving care from 2CNAs assigned to whirlpool, the provider failed to protect the resident from further potential abuse, and staff failed to report the incident to administration, and administration failed to ensure staff knowledge of and staff identification of abuse, or investigate the incident as an alleged abuse. Resident #16: The immediate jeopardy situation began on 8/23/12 at 10:00 p.m. when S3CNA. S4CNA and S9CNA staff failed to report alleged abuse, the resident was not protected from further potential abuse, administration failed to thoroughly investigate all parties involved (S6CNA), and Resident #16 remains in the care of the alleged perpetrator (S6CNA). An immediate jeopardy was called on 2/1/13 at 11:50 a.m. The immediate jeopardy was removed on 2/1/13 at 4:30 p.m. after the facility presented a plan of removal to address the removal of the staff alleged in the abuse allegations, ensured there were no outstanding grievances or complaints against the staff accused of abuse, in-serviced staff and S8, CNA supervisor, initiated reports to the state, initiated further investigation and monitoring, and ensured criminal background checks were completed. While the immediate jeopardy was removed on 2/1/13, the facility remained out of compliance at Level 2 for Resident # 5, 16, 19. Findings: Immediate Jeopardy Situation: Resident #5: Review of Resident #5 ' s MDS (Minimum Data Set), completed prior to the alleged incident of 1-25-13, had a reference date of 12-3-12. This MDS revealed that Resident #5 ' s BIMS (Brief Interview of Mental Status) score = 15, cognition intact. Further review of the MDS revealed that Resident #5 was totally dependent 1 person physical assist for bathing. Resident #5 was a [AGE] year old with [DIAGNOSES REDACTED]. During an interview with Resident #5 on 1/29/13 at 2:30 p.m., he answered " yes " when asked if he had ever been treated roughly by staff, or had staff ever spoken rudely to him. He indicated the whirlpool staff, S21 CNA and S22 CNA, were rough and rude to him. He stated he was afraid and felt humiliated. He stated he told the CNA supervisor who must have spoken to them because S22 CNA came and confronted him about the allegation. He stated he didn't understand S22 CNA' s word, and S22 CNA to him he was " trifling. " Review of the grievance logs from November and December of 2012 and January of 2013 revealed no grievance having been filed by Resident #5 or his family. During an interview with S8 CNA Supervisor on 1/31/13 at 11:00 a.m., she stated that she had written a grievance/complaint form on Resident #5. Review of a grievance report dated 1/25/13 (no time indicated), revealed Resident #5 " asked one of the CNA to call me. I went to his room to see what he needed. He told me that the two whirlpool CNA ' s are very ugly and rough to him. He said (they) always talk to him ugly and he doesn't ' want to go to whirlpool with them anymore. " Further documentation on the grievance report indicated Facility Follow-up 1/28/13 (no time) which read, " I had a meeting with S21 CNA (and) S22 CNA and they replied, they never be ugly or rough with the resident. S22 CNA replied she has not whirlpool Resident #5 for two months because he refuses to go to whirlpool. S21CNA replied, she only tills him he needs to go to whirlpool in a nice way ....I CNA Supervisor will be monitoring the whirlpools. " During a review of the grievance/complaint form with S8 CNA Supervisor and S1 Administrator on 1/31/13 at 11:00 a.m., S8 CNA Supervisor stated she had not addressed the grievance with the administrator yet, but had followed up on the grievance with the whirlpool staff and the resident. S8 CNA Supervisor stated she counseled S21CNA and S22 CNA. Record review did not reveal an investigation of Resident #5 ' s allegation of abuse. Furthermore, the employee records did not reveal suspension or disciplinary actions against S21 CNA or for S22 CNA to date. There was no documented evidence that either CNA was suspended by S8 CNA Supervisor pending an investigation. During an interview with S1 Administrator on 1/31/13 at 1:00 p.m., she verified that an OTIS report should have been filed with the state, and that no investigation had been initiated to investigate Resident #5 ' s allegation of abuse. She stated S21 CNA and S22 CNA were still on the current work schedule and had not been suspended. She stated she, " only found out about the incident today, " meaning 1/31/13, when surveyor addressed the incident with her. Resident #16: Resident #16: Review of Resident #16's MDS (Minimum Data Set), completed prior to the alleged incident of 8/23/12, had a reference date of 7/14/2012. This MDS revealed Resident #16's BIMS (Brief Interview of Mental Status) score = 3, severely impaired. Further review of the MDS revealed Resident #16 required total dependence/one person assist for toilet use (meaning full staff performance), and she required extensive/one person assist for personal hygiene (meaning resident involved in activity, staff provide weight-bearing support). Resident #16 was a [AGE] year old with [DIAGNOSES REDACTED]. On 1/30/13 at 10:50 a.m., surveyor received a list of residents in which the facility had filed reports with the state. Resident #16 was one of the residents identified. Review of the facility's report of the alleged incident for Resident #16 revealed that the incident occurred 8/23/12 at 10:00 p.m. Resident #16 resided in the facility's locked unit at the time of the alleged incident. The facility's client incident report revealed on 8/27/12 at 10:00 a.m., S3CNA and S4CNA reported to administration that they witnessed S5CNA physically and verbally abuse Resident #16 on 8/23/12 at 10:00 p.m. The report read S9CNA also claimed to have witnessed S5CNA slapping Resident #16. The statement revealed S5CNA and S6CNA were assigned to work on the Alzheimer's Unit on 8/23/12 at the time of the incident. The report revealed that an investigation began on 8/27/12 at 10:00 a.m. Review of the statements of the CNAs revealed the following: S4CNA's report dated 8/26/12 revealed on ....8/23/12 (time unknown)...."I heard the nurse paging for someone to assist (Resident #16) resident's room. After time passed by the nurse paged again. I left off my hall to go and assist ....When I walked through the double door, I met S3CNA going to check (Resident #16)....we walked in the room and Resident #16 had BM (bowel movement) all over the floor. We turned off the call light and told Resident #16 stay put we were going to get her aide. we walked off the unit and found S6CNA walking around the nurse's station. We told S6CNA that Resident #16 needed assistance....S6CNA and S5CNA...went assist Resident #16......I went to see if S6CNA needed help. As I got to the room, S6CNA was walking out going to use the restroom. S5,CNA was in the room getting ready to push Resident #16 into the restroom. S9CNA walked in to see if her assistance was needed..... (There was no statement in the report given by S9CNA)......S5CNA started telling Resident #16 she was a 'big nasty b****'.....she then told her she ought be ashamed of herself and that 'she was too big to be s***ing' on herself. She then used the back of her hand and hit Resident #16 repeatedly on her left cheek telling her she was a big stanky h**...I walked out of the room and S9,CNA followed behind me." The report then read, "S9CNA, S3CNA, and I (S4CNA) walked onto (another) hall and talked amongst ourselves trying to figure out who we could have reported the incident to since the nurses on duty were fairly new. I (S4CNA) took it amongst myself to wait until Monday after the meeting so I could speak to the right person. I went check my residents and made rounds and went back on the unit to see if they were done cleaning up. Before I walked through the doors I could hear Resident #16 screaming to stop spraying hot water in her face. S6CNA was holding the shower head and S5CNA grabbed it and sprayed Resident #16 again. I walked out the room and stayed on my hall the rest of the night." S3CNA's written statement dated 8/23/12 revealed the following: "This happen Thursday August 23, 2012... I was training to work the back of the unit by S18CNA (There was no statement in the report given by S18CNA).....I was speaking with...this girl I know name S4CNA ...she also worked here and we heard someone ...they kept call and I saw the room light on. So we walk in (Resident #16 room) and saw BM from the bed to the bathroom. We look in the bathroom and saw Resident #16 sit on the toilet....I told her to stay their so I can go get some help. we left S18CNA watching the unit until we go fine S6CNA...so I told S6CNA and her and S5CNA walk in Resident#16 room...I walk in behind her and I had to walk out because my stomach had been hurting all night and when I smell BM I got sick and had to vomit so I left out and went vomit in another bathroom.. I when back in (Resident #16 room) start help clean up the BM and I heard S5CNA, S6CNA calling Resident #16 names likes 'nasty [***] ' 'stupid [***] '... so me and S4CNA and S9CNA walk out the room....I heard them call her names but I didn't see nothing cause I was feeling so sick I keep walking out the room." S6CNA's written statement (no date) revealed the following: "....I ' m writing this statement regarding Resident #16....S5CNA and I was coming back from break ...I was clocking back in and S3CNA came walking down the hall telling us that Resident #16 had BM everywhere all over her ...I asked S5CNA if she would come help me and she said yes....when we entered the room Resident #16 was sitting on her bed full of BM I then went to the clean linen and went get towels to bathe her and a gown to put on me ...by then S5CNA had got her out her bed and went bring her to the bathroom and we put her in the shower and we both showered her we had to also wash her hair....after we finished S5CNA took Resident #16 out the shower and dressed her ...I was in the bathroom cleaning up." S5CNA's written statement dated 8/27/12 revealed the following: "when me and S6CNA was getting off our break the S3CNA told S6CNA that Resident #16 had BM all over the floor so S6CNA asked me too help her so I said yes...when we got in there me and S6CNA put Resident #16 in the shower and wash her off and dressed her...S3CNA was also helping us...S4CNA came in there and look and left out." Review of the facility policy and procedure for abuse prevention and prohibition revealed, "all employees will have criminal background checks....Resident abuse must be reported immediately to the Director of Nursing and Administration....The facility Administrator or Director of Nursing will thoroughly investigate alleged violations....and document appropriate action....implement steps to prevent further potential abuse....staff will immediately remove the resident from any alleged perpetrator...when an employee is the alleged perpetrator of abuse, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution or disciplinary action against the employee...the facility employee or agent who becomes aware of abuse....shall immediately report the matter to the facility Administrator and Director of Nursing. Further review of the facility's investigation revealed that S5CNA was suspended and later terminated, but there was no documented evidence to support that an investigation into the actions of S6CNA (alleged by S4CNA and S3CNA) had been investigated to date. In addition, there was no documented evidence that the facility obtained statements from S9CNA or from S18CNA who were also mentioned in statements given by S4CNA and S3CNA. During an interview with the S1, Administrator on 1/30/13 at 12:00 and again on 2/4/13 at 8:50 a.m., she confirmed the CNAs did not report the incident until 8/27/12 at 10:00 a.m., that no staff members ensured that the resident was protected from further potential abuse from S5CNA from 8/23/12 at 10:00 p.m. until 8/27/12 at 10:00 a.m. when the incident was reported, and that there was no documentation to support that S6CNA was ever suspended pending an investigation or that an investigation of S6CNA had occurred to date. S1Administrator confirmed that S6CNA was still employed and still worked with Resident #16. S1 Administrator could not confirm that there was a statement obtained from S9CNA. Resident #19: Resident #19: Review of the facility investigation of an alleged abuse which occurred on 8/9/12 at 9:50 p.m. revealed Resident #19 ' s daughter called S19 LPN to report alleged abuse occurring to her mother. Resident #19's daughter reported that S13CNA emotionally and physically abused her mother on 8/9/12 at 9:50 p.m. An investigation was initiated on 8/10/12 at 10:00 a.m. after the resident's daughter called social services to report the incident. S16CNA witnessed the incident and reported "no one done anything" in her statement. The facility initiated an investigation on 8/9/12 at 10:00 a.m. Further review of the time sheets for S13CNA revealed she left work at 10:19 p.m. on 8/9/12 and did not return until 8/14/12 after the investigation was complete and administration unsubstantiated the allegation. Review of the employee records for S13CNA and S16CNA revealed no criminal background check on file for their current period of employment. S13, CNA was employeed with another provider and was not rescreened by the current provider, and S16CNA quit and then returned to work and the provider did not repeat her criminal background check. Further review of the nurse's notes attached to the investigation revealed S19LPN failed to immediately report the allegation to administrations.

Based on observation, record review, and staff interview, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law, and that all alleged violations are thoroughly investigated, and prevent further potential abuse while the investigation is in progress by failing to: 1. Ensure staff identification of suspected abuse (#5, 16) 2. Ensure all alleged violations involving abuse of residents are reported immediately to the administrator of the facility and other officials in accordance with state law (Residents # 5, 16, 19). 3. Ensure that all alleged abuse violations are thoroughly investigated. (Residents # 5, 16) 4. Ensure the protection of the residents from further potential abuse until an investigation is initiated and while the investigation is in progress. (Resident #5, 16). This deficient practice was identified for 3 (#5, 16,19) of 3 (#5, 16, 19) residents reviewed for abuse out of a total sample of 39. The immediate jeopardy is as follows: Resident #5: The immediate jeopardy situation began on 1/25/13 at______ (the facility failed to identify the time this occurred) when Resident #5 reported being afraid and humiliated while receiving care from S21 CNA and S22 CNA assigned to whirlpool; when the provider failed to protect the resident from further potential abuse; when staff failed to report the incident to administration; when administration failed to ensure staff knowledge of and staff identification of abuse; and when administration failed to investigate the incident as an alleged abuse. Resident #16: The immediate jeopardy situation began on 8/23/12 at 10:00 p.m. when S3CNA, S4CNA, and S9CNA staff failed to immediately report alleged abuse, resident was not protected from further potential abuse, administration failed to thoroughly investigate all parties involved, and Resident #16 remains in the care of one of the alleged perpetrators. An immediate jeopardy was called on 2/1/13 at 11:50 a.m. The immediate jeopardy was removed on 2/1/13 at 4:30 p.m. after the facility presented a plan of removal to address the removal of the staff alleged in the abuse allegations, ensured there were no outstanding grievances or complaints against the staff accused of abuse, in-serviced staff and S8, CNA supervisor, initiated reports to the state, initiated further investigation and monitoring, and ensured criminal background checks were completed. While the immediate jeopardy was removed on 2/1/13, the facility remained out of compliance at Level 2 for Resident # 5, 16, 19. Findings: Resident #5: Review of Resident #5 ' s MDS (Minimum Data Set), completed prior to the alleged incident of 1-25-13, had a reference date of 12-3-12. This MDS revealed that Resident #5 ' s BIMS (Brief Interview of Mental Status) score = 15, cognition intact. Further review of the MDS revealed that Resident #5 was totally dependent 1 person physical assist for bathing. Resident #5 was a [AGE] year old with [DIAGNOSES REDACTED]. During an interview with Resident #5 on 1/29/13 at 2:30 p.m., he answered " yes " when asked if he had ever been treated roughly by staff, or had staff ever spoken rudely to him. He indicated the whirlpool staff, S21 CNA and S22 CNA, were rough and rude to him. He stated he was afraid and felt humiliated. He stated he told the CNA supervisor who must have spoken to them because S22 CNA came and confronted him about the allegation. He stated he didn't understand S22 CNA' s word, and S22 CNA told him he was " trifling. " Review of the grievance logs from November and December of 2012 and January of 2013 revealed no grievance having been filed by Resident #5 or his family. During an interview with S8 CNA Supervisor on 1/31/13 at 11:00 a.m., she stated that she had written a grievance/complaint form on Resident #5. Review of a grievance report dated 1/25/13 (no time indicated), revealed Resident #5 " asked one of the CNA to call me. I went to his room to see what he needed. He told me that the two whirlpool CNA ' s are very ugly and rough to him. He said (they) always talk to him ugly and he doesn't want to go to whirlpool with them anymore. " Further documentation on the grievance report indicated Facility Follow-up 1/28/13 (no time) which read, " I had a meeting with S21 CNA (and) S22 CNA and they replied, they never be ugly or rough with the resident. S22 CNA replied she has not whirlpool Resident #5 for two months because he refuses to go to whirlpool. S21CNA replied, she only tells him he needs to go to whirlpool in a nice way ....I CNA Supervisor will be monitoring the whirlpools. " During a review of the grievance/complaint form with S8 CNA Supervisor and S1 Administrator on 1/31/13 at 11:00 a.m., S8 CNA Supervisor stated she had not addressed the grievance with the administrator yet, but had followed up on the grievance with the whirlpool staff and the resident. S8 CNA Supervisor stated she counseled S21CNA and S22 CNA. Record review did not reveal an investigation of Resident #5 ' s allegation of abuse. Furthermore, the employee records did not reveal suspension or disciplinary actions against S21 CNA or for S22 CNA to date. There was no documented evidence that either CNA was suspended by S8 CNA Supervisor pending an investigation. During an interview with S1 Administrator on 1/31/13 at 1:00 p.m., she verified that an OTIS report should have been filed with the state, and that no investigation had been initiated to investigate Resident #5 ' s allegation of abuse. She stated S21 CNA and S22 CNA were still on the current work schedule and had not been suspended. She stated she, " only found out about the incident today, " meaning 1/31/13, when surveyor addressed the incident with her. Resident #16: Review of Resident #16's MDS (Minimum Data Set), completed prior to the alleged incident of 8/23/12, had a reference date of 7/14/2012. This MDS revealed Resident #16's BIMS (Brief Interview of Mental Status) score = 3, severely impaired. Further review of the MDS revealed Resident #16 required total dependence/one person assist for toilet use (meaning full staff performance), and she required extensive/one person assist for personal hygiene (meaning resident involved in activity, staff provide weight-bearing support). Resident #16 was a [AGE] year old with [DIAGNOSES REDACTED]. On 1/30/13 at 10:50 a.m., surveyor received a list of residents for whom the facility had filed reports with the state. Resident #16 was one of the residents identified. Review of the facility's report of the alleged incident for Resident #16 revealed that the incident occurred 8/23/12 at 10:00 p.m. Resident #16 resided in the facility's locked unit at the time of the alleged incident. The facility's client incident report revealed on 8/27/12 at 10:00 a.m., S3CNA and S4CNA reported to administration that they witnessed S5CNA physically and verbally abuse Resident #16 on 8/23/12 at 10:00 p.m. The report read S9CNA also claimed to have witnessed S5CNA slapping Resident #16. The statement revealed S5CNA and S6CNA were assigned to work on the Alzheimer's Unit on 8/23/12 at the time of the incident. The report revealed that an investigation began on 8/27/12 at 10:00 a.m. Review of the statements of the CNAs revealed the following: S4CNA's report dated 8/26/12 revealed on ....8/23/12 (time unknown)...."I heard the nurse paging for someone to assist (Resident #16) resident's room. After time passed by the nurse paged again. I left off my hall to go and assist ....When I walked through the double door, I met S3CNA going to check (Resident #16)....we walked in the room and Resident #16 had BM (bowel movement) all over the floor. We turned off the call light and told Resident #16 stay put we were going to get her aide. we walked off the unit and found S6CNA walking around the nurse's station. We told S6CNA that Resident #16 needed assistance....S6CNA and S5CNA...went assist Resident #16......I went to see if S6CNA needed help. As I got to the room, S6CNA was walking out going to use the restroom. S5,CNA was in the room getting ready to push Resident #16 into the restroom. S9CNA walked in to see if her assistance was needed..... (There was no statement in the report given by S9CNA)......S5CNA started telling Resident #16 she was a 'big nasty b****'.....she then told her she ought be ashamed of herself and that 'she was too big to be s***ing' on herself. She then used the back of her hand and hit Resident #16 repeatedly on her left cheek telling her she was a big stanky h**...I walked out of the room and S9,CNA followed behind me." The report then read, "S9CNA, S3CNA, and I (S4CNA) walked onto (another) hall and talked amongst ourselves trying to figure out who we could have reported the incident to since the nurses on duty were fairly new. I (S4CNA) took it amongst myself to wait until Monday after the meeting so I could speak to the right person. I went check my residents and made rounds and went back on the unit to see if they were done cleaning up. Before I walked through the doors I could hear Resident #16 screaming to stop spraying hot water in her face. S6CNA was holding the shower head and S5CNA grabbed it and sprayed Resident #16 again. I walked out the room and stayed on my hall the rest of the night." S3CNA's written statement dated 8/23/12 revealed the following: "This happen Thursday August 23, 2012... I was training to work the back of the unit by S18CNA (There was no statement in the report given by S18CNA).....I was speaking with...this girl I know name S4CNA ...she also worked here and we heard someone ...they kept call and I saw the room light on. So we walk in (Resident #16 room) and saw BM from the bed to the bathroom. We look in the bathroom and saw Resident #16 sit on the toilet....I told her to stay their so I can go get some help. we left S18CNA watching the unit until we go fine S6CNA...so I told S6CNA and her and S5CNA walk in Resident#16 room...I walk in behind her and I had to walk out because my stomach had been hurting all night and when I smell BM I got sick and had to vomit so I left out and went vomit in another bathroom.. I when back in (Resident #16 room) start help clean up the BM and I heard S5CNA, S6CNA calling Resident #16 names likes 'nasty [***] ' 'stupid [***] '... so me and S4CNA and S9CNA walk out the room....I heard them call her names but I didn't see nothing cause I was feeling so sick I keep walking out the room." S6CNA's written statement (no date) revealed the following: "....I ' m writing this statement regarding Resident #16....S5CNA and I was coming back from break ...I was clocking back in and S3CNA came walking down the hall telling us that Resident #16 had BM everywhere all over her ...I asked S5CNA if she would come help me and she said yes....when we entered the room Resident #16 was sitting on her bed full of BM I then went to the clean linen and went get towels to bathe her and a gown to put on me ...by then S5CNA had got her out her bed and went bring her to the bathroom and we put her in the shower and we both showered her we had to also wash her hair....after we finished S5CNA took Resident #16 out the shower and dressed her ...I was in the bathroom cleaning up." S5CNA's written statement dated 8/27/12 revealed the following: "when me and S6CNA was getting off our break the S3CNA told S6CNA that Resident #16 had BM all over the floor so S6CNA asked me too help her so I said yes...when we got in there me and S6CNA put Resident #16 in the shower and wash her off and dressed her...S3CNA was also helping us...S4CNA came in there and look and left out." Review of the facility policy and procedure for abuse prevention and prohibition revealed, "all employees will have criminal background checks....Resident abuse must be reported immediately to the Director of Nursing and Administration....The facility Administrator or Director of Nursing will thoroughly investigate alleged violations....and document appropriate action....implement steps to prevent further potential abuse....staff will immediately remove the resident from any alleged perpetrator...when an employee is the alleged perpetrator of abuse, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution or disciplinary action against the employee...the facility employee or agent who becomes aware of abuse....shall immediately report the matter to the facility Administrator and Director of Nursing. Further review of the facility's investigation revealed that S5CNA was suspended and later terminated, but there was no documented evidence to support that an investigation into the actions of S6CNA (alleged by S4CNA and S3CNA) had been investigated to date. In addition, there was no documented evidence that the facility obtained statements from S9CNA or from S18CNA who were also mentioned in statements given by S4CNA and S3CNA. During an interview with the S1, Administrator on 1/30/13 at 12:00 and again on 2/4/13 at 8:50 a.m., she confirmed the CNAs did not report the incident until 8/27/12 at 10:00 a.m., that no staff members ensured that the resident was protected from further potential abuse from S5CNA from 8/23/12 at 10:00 p.m. until 8/27/12 at 10:00 a.m. when the incident was reported, and that there was no documentation to support that S6CNA was ever suspended pending an investigation or that an investigation of S6CNA had occurred to date. S1Administrator confirmed that S6CNA was still employed and still worked with Resident #16. S1 Administrator could not confirm that there was a statement obtained from S9CNA. Resident #19: Resident #19: Review of the facility investigation of an alleged abuse which occurred on 8/9/12 at 9:50 p.m. revealed Resident #19 ' s daughter called S19 LPN to report alleged abuse occurring to her mother. Resident #19's daughter reported that S13CNA emotionally and physically abused her mother on 8/9/12 at 9:50 p.m. An investigation was initiated on 8/10/12 at 10:00 a.m. after the resident's daughter called social services to report the incident. S16CNA witnessed the incident and reported "no one done anything" in her statement. The facility initiated an investigation on 8/9/12 at 10:00 a.m. Further review of the time sheets for S13CNA revealed she left work at 10:19 p.m. on 8/9/12 and did not return until 8/14/12 after the investigation was complete and administration unsubstantiated the allegation. Review of the employee records for S13CNA and S16CNA revealed no criminal background check on file for their current period of employment. S13, CNA was employeed with another provider and was not rescreened by the current provider, and S16CNA quit and then returned to work and the provider did not repeat her criminal background check. Further review of the nurse's notes attached to the investigation revealed S19LPN failed to immediately report the allegation to administrations.

Based on observation, record review, and staff interview, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents by failing to implement policy and procedure to: 1. Ensure screening of employees (Resident #19) 2. Ensure protection of a resident immediately and during an investigation (Resident #5,16) 3. Ensure staff identification and reporting of suspected abuse (Resident #'s 5, 16, 19) 4. Ensure a thorough investigation of allegations of abuse (Resident #5, 16) This deficient practice was identified for 3 (#5, 16,19) of 3 (#5, 16, 19) residents reviewed for abuse out of a total sample of 39. The immediate jeopardy is as follows: Resident #5: The immediate jeopardy situation began on 1/25/13 at______ (the facility failed to identify the time this occurred) when Resident #5 reported being afraid and humiliated while receiving care from 2CNAs assigned to whirlpool, the provider failed to protect the resident from further potential abuse, and staff failed to report the incident to administration, and administration failed to ensure staff knowledge of and staff identification of abuse, or investigate the incident as an alleged abuse. Resident #16: The immediate jeopardy situation began on 8/23/12 at 10:00 p.m. when S3CNA, S4CNA, and S9CNA staff failed to immediately report alleged abuse, resident was not protected from further potential abuse, administration failed to thoroughly investigate all parties involved, and Resident #16 remains in the care of one of the alleged perpetrators. An immediate jeopardy situation was called on 2/1/13 at 11:50 a.m. The immediate jeopardy was removed on 2/1/13 at 4:30 p.m. after the facility presented a plan of removal to address the removal of the staff alleged in the abuse allegations, ensured there were no outstanding grievances or complaints against the staff accused of abuse, in-serviced staff and S8, CNA supervisor, initiated reports to the state, initiated further investigation and monitoring, and ensured criminal background checks were completed. While the immediate jeopardy was removed on 2/1/13, the facility remained out of compliance at Level 2 for Resident # 5, 16, 19. Findings: Resident #5: Review of Resident #5 ' s MDS (Minimum Data Set), completed prior to the alleged incident of 1-25-13, had a reference date of 12-3-12. This MDS revealed that Resident #5 ' s BIMS (Brief Interview of Mental Status) score = 15, cognition intact. Further review of the MDS revealed that Resident #5 was totally dependent 1 person physical assist for bathing. Resident #5 was a [AGE] year old with [DIAGNOSES REDACTED]. During an interview with Resident #5 on 1/29/13 at 2:30 p.m., he answered " yes " when asked if he had ever been treated roughly by staff, or had staff ever spoken rudely to him. He indicated the whirlpool staff, S21 CNA and S22 CNA, were rough and rude to him. He stated he was afraid and felt humiliated. He stated he told the CNA supervisor who must have spoken to them because S22 CNA came and confronted him about the allegation. He stated he didn't understand S22 CNA' s word, and S22 CNA to him he was " trifling. " Review of the grievance logs from November and December of 2012 and January of 2013 revealed no grievance having been filed by Resident #5 or his family. During an interview with S8 CNA Supervisor on 1/31/13 at 11:00 a.m., she stated that she had written a grievance/complaint form on Resident #5. Review of a grievance report dated 1/25/13 (no time indicated), revealed Resident #5 " asked one of the CNA to call me. I went to his room to see what he needed. He told me that the two whirlpool CNA ' s are very ugly and rough to him. He said (they) always talk to him ugly and he doesn't ' want to go to whirlpool with them anymore. " Further documentation on the grievance report indicated Facility Follow-up 1/28/13 (no time) which read, " I had a meeting with S21 CNA (and) S22 CNA and they replied, they never be ugly or rough with the resident. S22 CNA replied she has not whirlpool Resident #5 for two months because he refuses to go to whirlpool. S21CNA replied, she only tills him he needs to go to whirlpool in a nice way ....I CNA Supervisor will be monitoring the whirlpools. " During a review of the grievance/complaint form with S8 CNA Supervisor and S1 Administrator on 1/31/13 at 11:00 a.m., S8 CNA Supervisor stated she had not addressed the grievance with the administrator yet, but had followed up on the grievance with the whirlpool staff and the resident. S8 CNA Supervisor stated she counseled S21CNA and S22 CNA. Record review did not reveal an investigation of Resident #5 ' s allegation of abuse. Furthermore, the employee records did not reveal suspension or disciplinary actions against S21 CNA or for S22 CNA to date. There was no documented evidence that either CNA was suspended by S8 CNA Supervisor pending an investigation. During an interview with S1 Administrator on 1/31/13 at 1:00 p.m., she verified that an OTIS report should have been filed with the state, and that no investigation had been initiated to investigate Resident #5 ' s allegation of abuse. She stated S21 CNA and S22 CNA were still on the current work schedule and had not been suspended. She stated she, " only found out about the incident today, " meaning 1/31/13, when surveyor addressed the incident with her. Resident #16: Review of Resident #16's MDS (Minimum Data Set), completed prior to the alleged incident of 8/23/12, had a reference date of 7/14/2012. This MDS revealed Resident #16's BIMS (Brief Interview of Mental Status) score = 3, severely impaired. Further review of the MDS revealed Resident #16 required total dependence/one person assist for toilet use (meaning full staff performance), and she required extensive/one person assist for personal hygiene (meaning resident involved in activity, staff provide weight-bearing support). Resident #16 was a [AGE] year old with [DIAGNOSES REDACTED]. On 1/30/13 at 10:50 a.m., surveyor received a list of residents in which the facility had filed reports with the state. Resident #16 was one of the residents identified. Review of the facility's report of the alleged incident for Resident #16 revealed that the incident occurred 8/23/12 at 10:00 p.m. Resident #16 resided in the facility's locked unit at the time of the alleged incident. The facility's client incident report revealed on 8/27/12 at 10:00 a.m., S3CNA and S4CNA reported to administration that they witnessed S5CNA physically and verbally abuse Resident #16 on 8/23/12 at 10:00 p.m. The report read S9CNA also claimed to have witnessed S5CNA slapping Resident #16. The statement revealed S5CNA and S6CNA were assigned to work on the Alzheimer's Unit on 8/23/12 at the time of the incident. The report revealed that an investigation began on 8/27/12 at 10:00 a.m. Review of the statements of the CNAs revealed the following: S4CNA's report dated 8/26/12 revealed on ....8/23/12 (time unknown)...."I heard the nurse paging for someone to assist (Resident #16) resident's room. After time passed by the nurse paged again. I left off my hall to go and assist ....When I walked through the double door, I met S3CNA going to check (Resident #16)....we walked in the room and Resident #16 had BM (bowel movement) all over the floor. We turned off the call light and told Resident #16 stay put we were going to get her aide. we walked off the unit and found S6CNA walking around the nurse's station. We told S6CNA that Resident #16 needed assistance....S6CNA and S5CNA...went assist Resident #16......I went to see if S6CNA needed help. As I got to the room, S6CNA was walking out going to use the restroom. S5,CNA was in the room getting ready to push Resident #16 into the restroom. S9CNA walked in to see if her assistance was needed..... (There was no statement in the report given by S9CNA)......S5CNA started telling Resident #16 she was a 'big nasty b****'.....she then told her she ought be ashamed of herself and that 'she was too big to be s***ing' on herself. She then used the back of her hand and hit Resident #16 repeatedly on her left cheek telling her she was a big stanky h**...I walked out of the room and S9,CNA followed behind me." The report then read, "S9CNA, S3CNA, and I (S4CNA) walked onto (another) hall and talked amongst ourselves trying to figure out who we could have reported the incident to since the nurses on duty were fairly new. I (S4CNA) took it amongst myself to wait until Monday after the meeting so I could speak to the right person. I went check my residents and made rounds and went back on the unit to see if they were done cleaning up. Before I walked through the doors I could hear Resident #16 screaming to stop spraying hot water in her face. S6CNA was holding the shower head and S5CNA grabbed it and sprayed Resident #16 again. I walked out the room and stayed on my hall the rest of the night." S3CNA's written statement dated 8/23/12 revealed the following: "This happen Thursday August 23, 2012... I was training to work the back of the unit by S18CNA (There was no statement in the report given by S18CNA).....I was speaking with...this girl I know name S4CNA ...she also worked here and we heard someone ...they kept call and I saw the room light on. So we walk in (Resident #16 room) and saw BM from the bed to the bathroom. We look in the bathroom and saw Resident #16 sit on the toilet....I told her to stay their so I can go get some help. we left S18CNA watching the unit until we go fine S6CNA...so I told S6CNA and her and S5CNA walk in Resident#16 room...I walk in behind her and I had to walk out because my stomach had been hurting all night and when I smell BM I got sick and had to vomit so I left out and went vomit in another bathroom.. I when back in (Resident #16 room) start help clean up the BM and I heard S5CNA, S6CNA calling Resident #16 names likes 'nasty [***] ' 'stupid [***] '... so me and S4CNA and S9CNA walk out the room....I heard them call her names but I didn't see nothing cause I was feeling so sick I keep walking out the room." S6CNA's written statement (no date) revealed the following: "....I ' m writing this statement regarding Resident #16....S5CNA and I was coming back from break ...I was clocking back in and S3CNA came walking down the hall telling us that Resident #16 had BM everywhere all over her ...I asked S5CNA if she would come help me and she said yes....when we entered the room Resident #16 was sitting on her bed full of BM I then went to the clean linen and went get towels to bathe her and a gown to put on me ...by then S5CNA had got her out her bed and went bring her to the bathroom and we put her in the shower and we both showered her we had to also wash her hair....after we finished S5CNA took Resident #16 out the shower and dressed her ...I was in the bathroom cleaning up." S5CNA's written statement dated 8/27/12 revealed the following: "when me and S6CNA was getting off our break the S3CNA told S6CNA that Resident #16 had BM all over the floor so S6CNA asked me too help her so I said yes...when we got in there me and S6CNA put Resident #16 in the shower and wash her off and dressed her...S3CNA was also helping us...S4CNA came in there and look and left out." Review of the facility policy and procedure for abuse prevention and prohibition revealed, "all employees will have criminal background checks....Resident abuse must be reported immediately to the Director of Nursing and Administration....The facility Administrator or Director of Nursing will thoroughly investigate alleged violations....and document appropriate action....implement steps to prevent further potential abuse....staff will immediately remove the resident from any alleged perpetrator...when an employee is the alleged perpetrator of abuse, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution or disciplinary action against the employee...the facility employee or agent who becomes aware of abuse....shall immediately report the matter to the facility Administrator and Director of Nursing. Further review of the facility's investigation revealed that S5CNA was suspended and later terminated, but there was no documented evidence to support that an investigation into the actions of S6CNA (alleged by S4CNA and S3CNA) had been investigated to date. In addition, there was no documented evidence that the facility obtained statements from S9CNA or from S18CNA who were also mentioned in statements given by S4CNA and S3CNA. During an interview with the S1, Administrator on 1/30/13 at 12:00 and again on 2/4/13 at 8:50 a.m., she confirmed the CNAs did not report the incident until 8/27/12 at 10:00 a.m., that no staff members ensured that the resident was protected from further potential abuse from S5CNA from 8/23/12 at 10:00 p.m. until 8/27/12 at 10:00 a.m. when the incident was reported, and that there was no documentation to support that S6CNA was ever suspended pending an investigation or that an investigation of S6CNA had occurred to date. S1Administrator confirmed that S6CNA was still employed and still worked with Resident #16. S1 Administrator could not confirm that there was a statement obtained from S9CNA. Resident #19: Review of the facility investigation of an alleged abuse which occurred on 8/9/12 at 9:50 p.m. revealed Resident #19 ' s daughter called S19 LPN to report alleged abuse occurring to her mother. Resident #19's daughter reported that S13CNA emotionally and physically abused her mother on 8/9/12 at 9:50 p.m. An investigation was initiated on 8/10/12 at 10:00 a.m. after the resident's daughter called social services to report the incident. S16CNA witnessed the incident and reported "no one done anything" in her statement. The facility initiated an investigation on 8/9/12 at 10:00 a.m. Further review of the time sheets for S13CNA revealed she left work at 10:19 p.m. on 8/9/12 and did not return until 8/14/12 after the investigation was complete and administration unsubstantiated the allegation. Review of the employee records for S13CNA and S16CNA revealed no criminal background check on file for their current period of employment. S13, CNA was employeed with another provider and was not rescreened by the current provider, and S16CNA quit and then returned to work and the provider did not repeat her criminal background check. Review of facility policy and procedure for screening employees revealed "all employees will have criminal background checks..." Further review of the nurse's notes attached to the investigation revealed S19LPN failed to immediately report the allegation to administrations.

Based on observation, record review and interview, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and administering of drugs for 3 (#1, #3, #6) of 7 (#1, #2,#3, #4, #5, #6, #7) sampled residents. This deficient practice has the potential to affect all 84 residents residing in the facility. The facility failed to: 1. Ensure the DON accurately reconciled the July 2012 physician's orders and the July, 2012 MAR and identify errors in transcription before the resident received the wrong dose of a medication. (#1); 2. Ensure the night nurse accurately reconciled the July 2012 physician's orders and the July 2012 MAR and identified errors in transcription before the resident received the wrong dose of a medication (#1); 3. Ensure nurses followed the 5 rights for safe medication administration when administering medications (#1, #3, #6); 4. Ensure medication was dispensed from the pharmacy as ordered by the physician (#6); 6. Have a system in place to daily reconcile physician's orders for new medications or changes, to ensure the changes were reflected on the MAR (#3). The administrator and S1DON were notified of the immediate jeopardy at 4:30 pm on 7/19/12. On 6/4/12, the physician ordered the anti-thyroid drug Propylthiouracil 150 mg by mouth every 4 hours (900 mg per day) for resident #1. On 06/24/2012, S4 Pharmacist incorrectly transcribed resident #1's prescribed dose of Propylthiouracil onto the July 2012 physician ' s monthly orders and onto the July 2012 MAR. Instead of transcribing the ordered dose of 150 mg. by mouth every 4 hours, the pharmacist transcribed 50 mg by mouth every 4 hours (300 mg per day). The Resident was in Immediate Jeopardy on 6/29/12 when the DON reconciled the June 2012 and July 2012 monthly physician ' s orders and MARs and failed to identify the transcription error. On 6/30/12, the night nurse failed to identify the transcription error on the July 2012 physician ' s orders and the July 2012 MAR. The nursing staff administered the Propylthiouracil 150 mg by mouth every 4 hours from 7/1/12 to 7/18/12 (106 doses), but documented they were administering Propylthiouracil 50 mg by mouth every 4 hours. The nurses failed to recognize the MAR documented 50 mg every 4 hours and the medication blister package documented 150 mg every 4 hours. Nurses administered 106 doses from 7/1/12 through 7/18/12 without identifying the error. Surveyors discovered the transcription errors on 7/18/12. Resident #3 was placed in Immediate Jeopardy when the nursing staff failed to administer the correct dose of Levothyroxine 0.050 mg by mouth daily on 6/5/12 at 6 am. On 6/4/12, the Physician increased Resident #3's dose of Levothyroxine 0.025 mg dose to Levothyroxine 0.050 mg. The physician's order was not transcribed onto Resident #3's Medication Administration Record (MAR) on 6/4/12. The immediate Jeopardy continued from 6/5/12 to 6/25/12 and was not lifted for Resident #3 until she was transferred to the hospital on [DATE] and did not return to the facility. The facility was unaware of Resident #3's medication errors until the errors were discovered by the survey team. Resident #6 was placed in Immediate Jeopardy when the nursing staff failed to administer the correct dose of Megace 400 mg to Resident #6 on 6/29 at 6 am. The Immediate Jeopardy continued until 6/30/12, at which time the resident was hospitalized . The Immediate Jeopardy began again on 7/17/12 when Resident #6 was administered the incorrect dose of Megace 400 mg until 7/20/12 at 8:18 am when the discrepancy was reported by the surveyor and the Megace was discontinued by the Physician on 7/20/12 at 2:00 pm. Resident #6 was also placed in Immediate Jeopardy on 7/20/12 at 8:18 am when S5, LPN administered Mucinex 400 mg and the Physician's order and Medication Administration read Mucinex 600 mg. The Immediate Jeopardy continued until the Physician's order was clarified on 7/20/12 at 2 pm and the dosage was changed to 400 mg. The facility's Plan of Removal was accepted on 7/23/12 at 3:50 pm. At that time, all nursing staff was in-serviced on the policies and procedures for accurate medication administration, the 6 rights of medication administration, and medication deviation reporting. The nursing staff checked all resident's Physician Orders against the previous month's Physician Orders along with any additional new Physician Orders, nursing staff checked all resident's Physician Orders against their Medication Administration Records and the actual medications in the medication carts. The facility provided a plan to ensure that the nursing staff was provided with oversight and monitoring to prevent the deficient practices from reoccurring. This deficient practice continues as a level 2 for all residents residing in the facility who receive medications. Findings: Resident #1 A review of Resident #1's clinical record revealed she is a [AGE] year old female with [DIAGNOSES REDACTED]. Resident #1 was readmitted to this facility on 6/4/12. Resident #1's Physician's Orders dated 6/4/12 for 6/1/12 through 6/30/12 revealed a handwritten order for Propylthiouracil 150 mg by mouth every 4 hours. Propylthiouracil is an oral medication used to manage hyperthyroidism which is due to an overactive thyroid gland. It is an anti-thyroid drug. Further review of Resident #1's June Physician's Orders revealed an order which read: Draw TSH on 6/25/12 and call MD with results per signed order/S10MD/noted S12LPN. Also noted was an order dated 6/5/12 which read: TSH every 6 months per verbal order/S11MD/noted S12LPN. Resident #1's June MAR (Medication Administration Record) read: Propylthiouracil 150 mg by mouth every 4 hours. Resident #1's July Physician Orders dated 7/1/12 through 7/31/12 read: Propylthiouracil 50 mg 1 cap PO Q 4 hours for Hyperthyroidism. Resident #1's July Physician's Orders were signed by S11MD on 7/1/12. "Complete Entries Checked" was signed by S1DON on 6/29/12. The record review of Resident #1's clinical record failed to reveal an order to decrease the dosage of Propylthiouracil from 150 mg po q 4 hrs to 50 mg po q 4 hrs, other than S11MD signing the typed July Physician's Orders on 7/1/12. A review of Resident #1's current MAR for 7/1/12 through 7/31/12 read: Propylthiouracil 50 mg tab 1 cap PO Q4H for Hyperthyroidism. The nurses' initials were noted as administering this medication 6 times per day from 7/1/12 through 7/17/12 and 4 times on 7/18/12 (a total of 106 times as of 7/18/12 at 1:30 pm). During an interview on 7/18/12 at 1:33 pm, S2ADON was asked what dosage of Propylthiouracil Resident #1 was receiving. Upon reviewing Resident #1's July Physician's Orders and July MAR, S2ADON revealed Resident #1 should be receiving Propylthiouracil 50 mg by mouth every 4 hours. When asked what dosage of Propylthiouracil the resident had received in June 2012, she again reviewed the clinical record and stated Propylthiouracil 150 mg by mouth every 4 hours. S2ADON confirmed there was no written or verbal physician's order decreasing Resident #1's dose of Propylthiouracil. S2ADON revealed that possibly the pharmacist had typed the wrong dose onto the July Physician's Orders and MAR when he performed Resident #1's monthly Drug Regimen Review at the end of June, but the error should have been identified when either she or S1DON reconciled the Physician's Orders from June 2012 to July 2012 for accuracy. S2ADON confirmed S1DON had signed Resident #1's July 2012 Physician's Orders, indicating all medication entries were correct. S2ADON reviewed Resident #1's current drug card for Propylthiouracil (filled 6/28/12 with 5 refills) and verified Resident #1 was currently receiving three 50 mg tablets (150 mg) by mouth every 4 hours, but the nurses were documenting they were administering one 50 mg tablet by mouth every 4 hours. S2ADON revealed all nurses should be comparing the medication labels on the drug cards to the MARs to ensure they were administering the right dose and confirmed the nursing staff administering this medication to Resident #1 had 106 opportunities to identify this medication error, but the error was not discovered until the surveyor brought it to the facility ' s attention. S2ADON confirmed lab work to monitor Resident #1's thyroid level was not due to be drawn until December 2012, so she could have potentially received this high dose of Propylthiouracil (900 mg per day) and all documentation in her clinical record indicated she was receiving 300 mg per day. An interview with S3LPN was conducted on 7/18/12 at 1:44 pm. S3LPN reviewed Resident #1's current MAR for July 2012 and Resident #1's Propylthiouracil drug card. She confirmed she was initialing Resident # 's MAR indicating she was administering Propylthiouracil 50 mg one capsule by mouth every 4 hours, but was actually administering Propylthiouracil 50 mg three tablets by mouth every 4 hours for a total of 150 mg per dose. S3LPN revealed she read the drug name, dosage, and route on the drug card during medication administration and did not reconcile or compare the drug card to the MAR. When asked if she ever reconciled the resident's previous month' s MAR or Physician's Order to the current MAR, she replied no. The night nurse who worked the last day of the month was supposed to compare the new MAR to the old MAR before placing it in the Medication Administration Record binder and should have noticed the discrepancy in Resident #1's dose of Propylthiouracil. S3LPN confirmed she failed multiple times in the month of July 2012 to reconcile the dose on Resident #1's MAR with the actual dose printed on her medication blister pack and the dose being administered to Resident #1. S3LPN confirmed this was a medication error. Resident #1's Drug Regimen Review form dated 6/24/12 read: No recommendations at this time. This form was signed by S4 Pharmacist. During an interview on 7/18/12 at 1:50 pm, S1 DON confirmed she had signed Resident #1's Physician's Orders for July 2012 verifying she had reconciled the resident's July Physician's Orders with her June Physician's Orders and there were no discrepancies between the June 2012 orders and the July 2012 orders. S1DON stated her signature on 6/29/12 indicated Resident #1's medications on the July Physician's Orders were the right drug, right dosage, right route, and right time. S1 DON then reviewed Resident #1's June Physician's Orders and MAR and confirmed Resident #1 was prescribed Propylthiouracil 150 mg by mouth every 4 hours. S1 DON then reviewed Resident #1's July Physician's Orders and MAR and stated Resident #1's dosage of Propylthiouracil must have been decreased to 50 mg by mouth every 4 hours. S1 DON stated the resident had not been on Propylthiouracil prior to her hospitalization in May 2012 and this was a new order since her return to the facility on [DATE]. S1DON revealed she was not familiar with the drug Propylthiouracil, did not know what it was given for, and did not know what dosage it was available in. S1DON reviewed Resident #1's clinical record and confirmed there was no physician's order to decrease the dosage of Propylthiouracil from 150 mg by mouth every 4 hours to 50 mg by mouth every 4 hours. S1DON confirmed she should have noticed the discrepancy in the dose on the July Physician's Orders and MAR and obtained clarification, but she had not identified there was a problem. She further stated she had reconciled the Physician's Orders for accuracy the last week of June when S2ADON and S7 Administrator were out, leaving her by herself and she "had just missed it." S1DON reviewed a copy of Resident #1's current drug card for Propylthiouracil and stated Resident #1 had been receiving the dose that was ordered on [DATE]- 150 mg every 4 hours; therefore, she considered this to be "more of a documentation problem, not a true medication error." S1DON revealed S4 Pharmacist must have typed the wrong dose of Propylthiouracil when he transcribed Resident #1's July Physician's Orders and MAR. S1DON revealed the error was missed by her during her month to month medication reconciliation on 6/29/12, by the night nurse that worked 6/30/12 who was supposed to compare Resident #1's June MAR with her July MAR for accuracy, and by all nurses who administered each dose of Propylthiouracil given to Resident #1 in July 2012. During a phone interview on 7/18/12 at 2:30 pm, S4 Pharmacist verified he had reviewed Resident #1's medications on 6/24/12 and had no concerns or recommendations with any of her medications at that time. S4 Pharmacist verified Resident #1's June Physician's Orders were handwritten due to her return to the facility in June following a hospitalization . S4 Pharmacist revealed he used the June handwritten orders and typed Resident #1's July 2012 Physician Orders and MAR. He stated that according to his documentation, Resident #1 was prescribed Propylthiouracil 50 mg by mouth every 4 hours with lab work due in December 2012 and he made no recommendations regarding this dose because 300 mg per day was an appropriate daily dose of that drug. When asked if he had noticed Resident #1 was actually prescribed and was receiving Propylthiouracil 150 mg by mouth every 4 hours since 6/4/12, S4 Pharmacist replied "no. I thought she was receiving a total of 300 mg per day, not 900 mg per day. If I had noticed she was receiving 900 mg of Propylthiouracil daily, I would have recommended the nursing staff get clarification of the dose from the physician and for follow-up lab work to be considered prior to December 2012." S4 Pharmacist confirmed he must have made an error when he typed the dosage of this drug, but his transcription error should have been identified when the nursing staff reconciled Resident #1's July Physician ' s Orders with her handwritten June Physician's Orders. After S4 Pharmacist reviewed literature regarding Propylthiouracil, he revealed the recommended dose for the drug was 150 mg to 300 mg daily for geriatric residents, but a resident may receive up to 200 mg every 4 to 6 hours until full control was achieved. S4 Pharmacist again stated if he had realized Resident #1 was receiving 900 mg of Propylthiouracil, he would have "felt more comfortable getting clarification from the physician." When asked if this error would have been identified when he performed his next Drug Regimen Review at the end of this month, he confirmed it probably would not have been identified by him because he did not routinely compare the drug cards with the prescriber's orders and would have not had any reason to look at the original June 2012 order. S4 Pharmacist confirmed the nursing staff administering Propylthiouracil 150 mg by mouth every 4 hours should have identified the discrepancy before the first dose was given in July, but had given 106 doses of the drug without comparing the dose being administered with the dose on the medication administration record. Resident #1's Nurses' Notes dated 6/25/12, timed 11:00 am read: S13RNP followed up on TSH. Resident already on PTU (Propylthiouracil) at this time. This entry was signed by S1DON. During an interview on 7/18/12 at 2:50 pm, S1DON confirmed Resident #1's physician order, which read: Draw TSH on 6/25/12 and call MD (Medical Doctor) with results, had been ordered by S10MD but he had not been notified of the results. S1 DON confirmed the lab results dated 6/25/12 was signed by S13RNP, who had a contractual agreement with S11MD, not S10MD. S1DON confirmed the physician ordering the lab test should have been notified of the lab results. On 7/18/12 at 3:55 pm, S1DON confirmed there was a break in the facility's system regarding medication administration because S4 Pharmacist did not accurately reconcile Resident #1's medications, which resulted in her dosage of a medication being transcribed incorrectly on the resident's Physician's Orders and Medication Administration Record. This error was not identified by S1DON or the night nurse on 6/30/12. S1 DON revealed each nurse administering a dose of the medication in the month of July 2012 failed 106 times to identify the error because the nurses should be ensuring the dose on the Medication Administration Record was the same dose being administered. On 7/19/12 at 2:55 pm, Resident #1's July 2012 Physician's Orders were reviewed with S1 DON. S1DON verified she changed the dosage of Propylthiouracil on the July 2012 Physician's Orders to 3 tabs after the surveyor discovered the "medication deviation" and did not initial or date the change. S1DON confirmed she had not received clarification from Resident #1's physician regarding the dosage of Propylthiouracil when she put a slash mark through the "1" and wrote a "3" its place and thought she was rectifying the situation or " righting the wrong " . S1DON stated she had not notified Resident #1's physician of the medication error because it was documentation error, not an actual medication error. S1DON stated "the resident received the right dose of the medication. We simply documented the wrong dose." S1DON confirmed S11MD had signed Resident #1's Physician Orders for July 2012 on 7/1/12, which was the order for Propylthiouracil 50 mg tablets 1 cap by mouth every 4 hours, making it the valid dose since 7/1/12. A review of the facility's Policy and Procedure titled Physician Order Reconciliation revealed: Policy- Newly printed Physician Order Sheets shall be reconciled with Current Physician Order Sheets before they are implemented on the chart to ensure all new and existing orders are properly carried forward for the safety and welfare of the resident. Procedure- 3. Any discrepancy between the current and newly printed orders shall be verified with current physician orders documented in resident chart. 7. The newly printed physician orders will replace current physician order at 12 Midnight on predesignated date and become the current physician orders. During an interview on 7/23/12 at 12:20 pm, S7 Administrator confirmed there were several breaks in the facility's current system leading to the medication errors discovered by the survey team. S7 Administrator confirmed the medication errors were not noticed and there were many opportunities for the facility to identify there was a problem prior to the survey team discovering the deficient practice. She stated she was under the impression that S1DON and S2ADON were performing random medication passes, but there may not be documentation. S7 Administrator confirmed the medication errors were not noticed and there were many opportunities for the facility to identify there was a problem prior to the survey team discovering the deficient practice. An interview was conducted with S1DON on 7/23/12 at 3:50 pm. S1DON stated she had not performed supervision of the nursing staff at medication pass since this was assigned to S2ADON. S1DON stated she had no documentation of the supervision of medication pass prior to the employment of S2ADON. An interview was conducted with S2 ADON on 7/23/12 at 3:55 pm who stated that her date of hire was April, 2012 and she had not yet performed supervision of any medication pass. She further stated she was not aware that it was her duty to perform supervision of the nursing staff performing medication administration and that she assumed that it was the duty of the pharmacist. A review of the facility's Director of Nursing Job Description dated 4/1/08 revealed the following: the Director of Nursing, to supervise the day-to-day activities performed by LPN ' s, conduct periodic reviews of medical records, nursing care plans and nursing related reports to ensure proper delivery and documentation of services, monitors compliance with standards of care by observation, verbal reports and written documentation, monitors the implementation of primarily clinical practice standards, through direct observation and interactions with nursing staff and collaborates with other staff and Physician to meet the medication needs of the residents. Resident #3 A review of Resident #3's Physician's Monthly Progress Notes dated 6/4/12 revealed her Levothyroxine (thyroid medication) dose was 0.025 mg and would be increased to 0.050 mg by mouth daily. A review of Resident #3's June 2012 Physician's orders revealed a new order on 6/4/12 to increase the Levothyroxine dose to 0.050 mg by mouth daily. A review of Resident #3's Medication Administration Record for June, 2012 revealed that Resident #3 received Levothyroxine 0.025 mg by mouth daily on 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25/ 2012 (21 doses). Resident #3 was transferred out to the hospital per her husband ' s request and Physician ' s orders on 6/25/12 and did not return to the facility. An interview was conducted with S1 DON on 7/17/12 at 3:55 pm who confirmed that there was a Physician ' s order to increase Resident #3's Levothyroxine from 0.025 mg to 0.050 mg on 6/4/12. S1, DON stated that the MAR revealed that Resident #3 received 0.025 mg of Levothyroxine from 6/4/12 through 6/24/12, and this would have been considered a medication error. An additional interview was conducted with S1 DON on 7/19/12 at 4:20 pm and she stated that Resident #3's Physician and responsible party should have been informed of any medication errors and a Medication Deviation Form should have been completed by whichever nurse identified the problem. S1DON also stated that she should have been made aware of any medication deviations as well. She stated that the Physician was not notified of the error in Resident #3's medication because the resident was discharged on [DATE] to another facility and she was not aware of the medication deviation until 7/17/12. A copy of a Medication Deviation Report for Resident #3 dated 7/19/12 was provided by S1DON on 7/19/12 at 3:00 pm. A review of the document revealed that the Physician and the Family were not notified as the facility indicated that it was, "not necessary resident received correct dose." An interview was conducted with S1 DON at that time and she stated that the facility would notify both parties. An additional copy of the Medication Deviation Report for Resident #3 was provided by S1DON on 7/21/12 at 9:00 am and it revealed that the Nurse Practitioner was notified on 7/19/12 at 3:00 pm and that the responsible party was notified on 7/20/12 at 5 pm. Further review of the Medication Deviation Report dated 7/19/12 revealed that the name of the person reporting the deviation was the state surveyor and the type of deviation checked off was the wrong dosage. A review of the report also revealed that the nursing staff was in serviced on the 5 rights of Medication administration and the importance of comparing medications and medication cards to the MARs. A review of the in service training for nursing staff revealed that this training was conducted on 7/19/12 at 6:30 pm through 7/20/12 at 7:00 pm. A review of the facility's policy titled Medications.Administering (Licensed Staff) dated 5/26/12 provided by the facility revealed that the procedure for administering medications included reviewing the 5 rights of medication administration during the preparation and administration of medications. Further review revealed that the 5 rights were the right medication, right dosage, right resident, right time and right route. A review of the Medication Administration form (not dated) revealed that the nurses must adhere to the six rights of medication administration: 1.The right medication, 2.The right dose, 3.The right client, 4.The right route, 5. The right time and 6.Proper Documentation. Further review revealed the medication label should be read three times before administering the medication and again after the administration. A review of the facility's policy for filling out medication deviation reports revealed that staff must identify what type of error occurred and that the family and the Physician must be notified. A review of the facility's policy titled Physician Order Reconciliation revealed that one procedure to ensure the reconciliation of new Physician ' s orders was #5.) Nurse shall inform the nurses of the following shift of any pertinent change made to resident physician orders. Resident #6 A review of Resident #6's clinical record revealed that she was a [AGE] year old female admitted to the facility on [DATE]. A review of her accumulative [DIAGNOSES REDACTED]. Resident #6 was hospitalized from [DATE] through 7/16/12 with Bronchiectasis, Chest Pain, Pneumonia and Malnutrition. A review of Resident #6's July, 2012 Physician's orders revealed orders for Mucinex 600 mg tablets 1 by mouth twice a day and for Megace suspension (appetite stimulant) 400 mg/30 ml to administer 30 ml by mouth twice a day. Further review revealed that the initial Physician's order for Megace suspension 400 mg/30 ml was dated 6/28/12 and that it was to be administered for 1 month. Resident #6 was hospitalized [DATE] through July 16, 2012 and the Physician ' s orders were continued upon readmit for the Megace 400 mg/30 ml to administer 30 ml by mouth twice a day as well as the Mucinex 600 mg tablets 1 by mouth twice a day. A review of Resident #6's MAR for June and July, 2012 revealed an order for [REDACTED]. Resident #6 was administered Megace 400 mg/30 ml 30 ml twice a day on 6/29, 6/30, 7/17, 7/18, 7/19 and once in the morning on 7/20/12. Resident #6 was administered 11 doses of 1200 mg of Megace suspension by mouth during this timeframe. An observation was made on 7/20/12 at 8:18 am of S5 LPN dispensing and administering Mucinex 400 mg from a stock bottle to Resident #6. S5 LPN also administered Megace 30 ml out of a bottle labeled 40 mg/ml. Resident #6's Medication Administration Record (MAR) for July 20,2012 at 8 am revealed that S5 LPN documented that she administered Mucinex 600 mg and Megace suspension 30 ml of 400 mg/30 ml. An observation of the bottle of Megace filled 6/30/12 revealed the strength of 40 mg/1 ml oral suspension and the label read to give 10 ml (400mg) po bid for 30 days. Resident #6 was administered 30 ml of the Megace suspension which would be a 1200 mg dose. An interview was conducted with S5 LPN on 7/20/12 at 8:20 am who confirmed that she administered 400 mg of Mucinex and 30 ml of the Megace suspension with a bottle labeled Megace 40 mg/1ml. S5 LPN stated that the Resident #6 ' s MAR read Mucinex 600 mg and that she administered 400 mg and that this would be considered a medication error. S5, LPN also confirmed that the strength on the bottle of Megace at 40 mg/1ml did not match the MAR which read Megace 400 mg/30 ml administer 30 ml and that this would be considered a medication error. She stated that she did not check the dosages of Mucinex and Megace on the MAR and the bottles prior to and after administering the medications. An interview was conducted with S1DON on 7/20/12 at 11:15 am who confirmed that Resident #6 received 400 mg of the Mucinex on 7/20/12 at 8 am, that she should have received 600 mg of the Mucinex and that this would indicate a medication error. She also confirmed the Resident #6 had received doses of 30 ml of Megace at 40mg/1ml which would be a total of 1200 mg for the dates of 6/29, 6/30, 7/17, 7/18, 7/19 and 7/20 for a total of 11 doses. S1 DON stated that the staff should have called for clarification since the bottle of Megace labeled 40 mg/ml did not match the MAR which was Megace 400 mg/30 ml. S1 DON stated that she transcribed the Physician ' s orders for the Megace from the June 2012 MAR to the July 2012 MAR but was not aware that the Megace was only available in the 40 mg/ml strength. S1 DON stated that she was not aware of the discrepancy. An additional interview was conducted with S1, DON on 7/20/12 at 11:55 am who stated that the pharmacist that filled the script should have picked up on the deviation in the Physician's order for Megace when he filled the medication. She confirmed that the bottle was labeled 400mg/ml to administer 10 ml when the Physician's order provided to him was to administer 30 ml of 400 mg/30ml strength. An interview was conducted with S6 Pharmacist on 7/23/12 at 10:36 am who confirmed that he recalled filling the prescription for Resident #6 ' s Megace 400 mg/30 ml to administer 30 ml. S6 Pharmacist stated that he just looked at milligrams for the dosage and changed the label to read Megace 40 mg/1ml since this was the only dose of suspension available. S6 Pharmacist stated that he was going too fast when he filled the order and should have notified the Physician to clarify the order and/or obtain a new order at that point. S6 Pharmacist also stated that he should have notified the facility's nursing staff in order to alert them of the bottle being labeled 40 mg/1ml and that this would indicate a 400 mg dose. A record review of the Pharmacy Services Agreement dated 2/1/11 revealed that one of the responsibilities of the pharmacist was to provide services to (c) label all medication in accordance with local, state and federal laws, rules and regulations and (h) to provide drug information and consultation to the facility ' s licensed professional staff regarding such drugs. An interview was conducted with S2, ADON on 7/23/12 at 2:20 pm who stated that the facility's current system of checks and balances for medication administration in place would not have prevented the medication errors for this resident.

Based on observation, interview and record reviews, the Pharmacist failed to identify irregularities and report irregularities to the Director of Nursing and the attending Physician for 2 (#1, #6) of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled resident by failing to thoroughly evaluate the medication regimen of residents to prevent, identify, and report medication errors or other irregularities. The facility failed to ensure the pharmacist: 1. thoroughly evaluated Resident #1's drug regimen by failing to identify the prescribed dose of the resident's anti-thyroid medication and to prevent medication errors by transcribing the wrong dose of the anti-thyroid medication on the resident's Physician's Orders and MAR (#1); 2. developed an effective quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of a medication (#1); 3. reported an irregularity to the prescribing physician and the director of nursing for clarification of an order prior to dispensing the medication (#6). This deficient practice has the potential to affect all residents prescribed medications residing in the facility. The census as of 7/17/12 was 84 residents residing in the facility. The administrator and S1DON were notified of the immediate jeopardy at 4:30 pm on 7/19/12. On 6/4/12, the physician ordered the anti-thyroid drug Propylthiouracil 150 mg by mouth every 4 hours (900 mg per day) for resident #1. On 06/24/2012, S4 Pharmacist incorrectly transcribed resident #1's prescribed dose of Propylthiouracil onto the July 2012 physician's monthly orders and onto the July 2012 MAR. Instead of transcribing the ordered dose of 150 mg by mouth every 4 hours, the pharmacist transcribed 50 mg by mouth every 4 hours (300 mg per day). The Resident was in Immediate Jeopardy on 6/29/12 when the DON reconciled the June 2012 and July 2012 monthly physician's orders and MARs and failed to identify the transcription error. On 6/30/12, the night nurse failed to identify the transcription error on the July 2012 physician's orders and the July 2012 MAR. The nursing staff administered the Propylthiouracil 150 mg by mouth every 4 hours from 7/1/12 to 7/18/12 (106 doses), but documented they were administering Propylthiouracil 50 mg by mouth every 4 hours. The nurses failed to recognize the MAR documented 50 mg every 4 hours and the medication blister package documented 150 mg every 4 hours. Nurses administered 106 doses from 7/1/12 through 7/18/12 without identifying the error. Surveyors discovered the transcription errors on 7/18/12. Resident #6 was placed in Immediate Jeopardy when the nursing staff failed to administer the correct dose of Megace 400 mg to Resident #6 on 6/29 at 6 am. The Immediate Jeopardy continued until 6/30/12, at which time the resident was hospitalized . The Immediate Jeopardy began again on 7/17/12 when Resident #6 was administered the incorrect dose of Megace 400 mg until 7/20/12 at 8:18 am when the discrepancy was reported by the surveyor and the Megace was discontinued by the Physician on 7/20/12 at 2:00 pm. Resident #6 was also placed in Immediate Jeopardy on 7/20/12 at 8:18 am when S5, LPN administered Mucinex 400 mg and the Physician's order and Medication Administration read Mucinex 600 mg. The Immediate Jeopardy continued until the Physician's order was clarified on 7/20/12 at 2 pm and the dosage was changed to 400 mg. The facility's Plan of Removal was accepted on 7/23/12 at 3:50 pm. At that time, all nursing staff was in-serviced on the policies and procedures for accurate medication administration, the 6 rights of medication administration, and medication deviation reporting. The nursing staff checked all resident's Physician Orders against the previous month's Physician Orders along with any additional new Physician Orders, nursing staff checked all resident's Physician Orders against their Medication Administration Records and the actual medications in the medication carts. The facility provided a plan to ensure that the nursing staff was provided with oversight and monitoring to prevent the deficient practices from reoccurring. This deficient practice continues as a level 2 for all residents residing in the facility who receive medications. Findings: According to the current Consultant Pharmacist Contract between the facility and S4 Pharmacist signed 3/31/11, the Consultant Pharmacist provides consultant pharmacist services, including but not limited to the following: a. Reviewing the medication regimen of each resident at least monthly, utilizing federally-mandated standards of care in addition to other applicable standards, and documenting the review and findings in the resident ' s medical record; b. Communicating to the responsible physician potential or actual problems detected relating to mediation therapy orders. Reviewing medication administration records (MARs) and physician orders at least monthly to assure proper documentation of medication orders and administration of medication to residents; d. Assessing the performance of the nursing staff in medication administration through the process of medication pass observation, as requested by nursing and administration, and as necessary; f. Assisting the administrator and Pharmaceutical Services Subcommittee in setting standards and developing, implementing, and monitoring policies and procedures for the safe and effective distribution, control, and use of medications and related equipment and services in the facility; g. Reconciling and Printing Monthly Computerized Physician Orders and Administration Records. Resident #1 A review of Resident #1's clinical record revealed she is a [AGE] year old female with [DIAGNOSES REDACTED]. Resident #1 was readmitted to this facility on 6/4/12. Resident #1's Physician's Orders dated 6/4/12 for 6/1/12 through 6/30/12 revealed a handwritten order for Propylthiouracil 150 mg by mouth every 4 hours. Propylthiouracil is an oral medication used to manage hyperthyroidism which is due to an overactive thyroid gland. It is an anti-thyroid drug. Further review of Resident #1's June Physician's Orders revealed an order which read: Draw TSH on 6/25/12 and call MD with results per signed order/S10MD/noted S12LPN. Also noted was an order dated 6/5/12 which read: TSH every 6 months per verbal order/S11MD/noted S12LPN. Resident #1's June MAR (Medication Administration Record) read: Propylthiouracil 150 mg by mouth every 4 hours. Resident #1's July Physician Orders dated 7/1/12 through 7/31/12 read: Propylthiouracil 50 mg 1 cap PO Q 4 hours for Hyperthyroidism. Resident #1's July Physician's Orders were signed by S11MD on 7/1/12. "Complete Entries Checked" was signed by S1DON on 6/29/12. The record review of Resident #1's clinical record failed to reveal an order to decrease the dosage of Propylthiouracil from 150 mg po q 4 hrs to 50 mg po q 4 hrs, other than S11MD signing the typed July Physician's Orders on 7/1/12. A review of Resident #1's current MAR for 7/1/12 through 7/31/12 read: Propylthiouracil 50 mg tab 1 cap PO Q 4 H for Hyperthyroidism. The nurses' initials were noted as administering this medication 6 times per day from 7/1/12 through 7/17/12 and 4 times on 7/18/12 (a total of 106 times as of 7/18/12 at 1:30 pm). During an interview on 7/18/12 at 1:33 pm, S2ADON was asked what dosage of Propylthiouracil Resident #1 was receiving. Upon reviewing Resident #1's July Physician's Orders and July MAR, S2ADON revealed Resident #1 should be receiving Propylthiouracil 50 mg by mouth every 4 hours. When asked what dosage of Propylthiouracil the resident had received in June 2012, she again reviewed the clinical record and stated Propylthiouracil 150 mg by mouth every 4 hours. S2ADON confirmed there was no written or verbal physician's order decreasing Resident #1's dose of Propylthiouracil. S2ADON revealed that possibly the pharmacist had typed the wrong dose onto the July Physician's Orders and MAR when he performed Resident #1's monthly Drug Regimen Review at the end of June, but the error should have been identified when either she or S1DON reconciled the Physician's Orders from June 2012 to July 2012 for accuracy. S2ADON confirmed S1DON had signed Resident #1's July 2012 Physician's Orders, indicating all medication entries were correct, but S1DON did not identify the discrepancy in the dose of Propylthiouracil. S2ADON reviewed Resident #1's current drug card for Propylthiouracil (filled 6/28/12 with 5 refills) and verified Resident #1 was currently receiving three 50 mg tablets (150 mg) by mouth every 4 hours, but the nurses were documenting they were administering one 50 mg tablet by mouth every 4 hours. S2ADON revealed all nurses should be comparing the medication labels on the drug cards to the MARs to ensure they were administering the right dose and confirmed the nursing staff administering this medication to Resident #1 had 106 opportunities to identify this medication error, but the error was not discovered until the surveyor brought it to the facility ' s attention. S2ADON confirmed lab work to monitor Resident #1's thyroid level was not due to be drawn until December 2012, so she could have potentially received this high dose of Propylthiouracil (900 mg per day) and all documentation in her clinical record indicated she was receiving 300 mg per day. An interview with S3LPN was conducted on 7/18/12 at 1:44 pm. S3LPN reviewed Resident #1's current MAR for July 2012 and Resident #1's Propylthiouracil drug card. She confirmed she was initialing Resident # 's MAR indicating she was administering Propylthiouracil 50 mg one capsule by mouth every 4 hours, but was actually administering Propylthiouracil 50 mg three tablets by mouth every 4 hours for a total of 150 mg per dose. S3LPN revealed she read the drug name, dosage, and route on the drug card during medication administration and did not reconcile or compare the drug card to the MAR. S3LPN confirmed she failed multiple times in the month of July 2012 to reconcile the dose on Resident #1's MAR with the actual dose printed on her medication blister pack and the dose being administered to Resident #1. S3LPN confirmed this was a medication error. Resident #1's Drug Regimen Review form dated 6/24/12 read: No recommendations at this time. This form was signed by S4 Pharmacist. During an interview on 7/18/12 at 1:50 pm, S1 DON confirmed she had signed Resident #1's Physician's Orders for July 2012 verifying she had reconciled the resident's July Physician's Orders with her June Physician's Orders and there were no discrepancies between the June 2012 orders and the July 2012 orders. S1DON stated her signature on 6/29/12 indicated Resident #1's medications on the July Physician's Orders were the right drug, right dosage, right route, and right time. S1 DON then reviewed Resident #1's June Physician's Orders and MAR and confirmed Resident #1 was prescribed Propylthiouracil 150 mg by mouth every 4 hours. S1 DON then reviewed Resident #1's July Physician's Orders and MAR and stated Resident #1's dosage of Propylthiouracil must have been decreased to 50 mg by mouth every 4 hours. S1 DON stated the resident had not been on Propylthiouracil prior to her hospitalization in May 2012 and this was a new order since her return to the facility on [DATE]. S1DON revealed she was not familiar with the drug Propylthiouracil, did not know what it was given for, and did not know what dosage it was available in. S1DON reviewed Resident #1's clinical record and confirmed there was no physician's order to decrease the dosage of Propylthiouracil from 150 mg by mouth every 4 hours to 50 mg by mouth every 4 hours. S1DON confirmed she should have noticed the discrepancy in the dose on the July Physician's Orders and MAR and obtained clarification, but she had not identified there was a problem. S1DON revealed S4 Pharmacist must have typed the wrong dose of Propylthiouracil when he transcribed Resident #1's July Physician's Orders and MAR. S1DON revealed the error was missed by her during her month to month medication reconciliation on 6/29/12, by the night nurse that worked 6/30/12 who was supposed to compare Resident #1's June MAR with her July MAR for accuracy, and by all nurses who administered each dose of Propylthiouracil given to Resident #1 in July 2012. During a phone interview on 7/18/12 at 2:30 pm, S4 Pharmacist verified he had reviewed Resident #1's medications on 6/24/12 and had no concerns or recommendations with any of her medications at that time. S4 Pharmacist verified Resident #1's June Physician's Orders were handwritten due to her return to the facility in June following a hospitalization . S4 Pharmacist revealed he used the June handwritten orders and typed Resident #1's July 2012 Physician Orders and MAR. He stated that according to his documentation, Resident #1 was prescribed Propylthiouracil 50 mg by mouth every 4 hours with lab work due in December 2012 and he made no recommendations regarding this dose because 300 mg per day was an appropriate daily dose of that drug. When asked if he had noticed Resident #1 was actually prescribed and was receiving Propylthiouracil 150 mg by mouth every 4 hours since 6/4/12, S4 Pharmacist replied "no. I thought she was receiving a total of 300 mg per day, not 900 mg per day. If I had noticed she was receiving 900 mg of Propylthiouracil daily, I would have recommended the nursing staff get clarification of the dose from the physician and for follow-up lab work to be considered prior to December 2012." S4 Pharmacist confirmed he must have made an error when he typed the dosage of this drug, but his transcription error should have been identified when the nursing staff reconciled Resident #1's July Physician ' s Orders with her handwritten June Physician's Orders. After S4 Pharmacist reviewed literature regarding Propylthiouracil, he revealed the recommended dose for the drug was 150 mg to 300 mg daily for geriatric residents, but a resident may receive up to 200 mg every 4 to 6 hours until full control was achieved. S4 Pharmacist again stated if he had realized Resident #1 was receiving 900 mg of Propylthiouracil, he would have "felt more comfortable getting clarification from the physician." When asked if this error would have been identified when he performed his next Drug Regimen Review at the end of this month, he confirmed it probably would not have been identified by him because he did not routinely compare the drug cards with the prescriber's orders and would have not had any reason to look at the original June 2012 order. S4 Pharmacist confirmed the nursing staff administering Propylthiouracil 150 mg by mouth every 4 hours should have identified the discrepancy before the first dose was given in July, but had given 106 doses of the drug without comparing the dose being administered with the dose on the medication administration record. On 7/18/12 at 3:55 pm, S1DON confirmed there was a break in the facility's system regarding medication administration because S4 Pharmacist did not accurately reconcile Resident #1's medications, which resulted in her dosage of a medication being transcribed incorrectly on the resident's Physician's Orders and Medication Administration Record. This error was not identified by S1DON or the night nurse on 6/30/12. S1 DON revealed each nurse administering a dose of the medication in the month of July 2012 failed 106 times to identify the error because the nurses should be ensuring the dose on the Medication Administration Record was the same dose being administered. Resident #6 A review of Resident #6's clinical record revealed that she was a [AGE] year old female admitted to the facility on [DATE]. A review of her accumulative [DIAGNOSES REDACTED]. Resident #6 was hospitalized from [DATE] through 7/16/12 with Bronchiectasis, Chest Pain, Pneumonia and Malnutrition. A review of Resident #6's July, 2012 Physician's orders revealed orders for Mucinex 600 mg tablets 1 by mouth twice a day and for Megace suspension (appetite stimulant) 400 mg/30 ml to administer 30 ml by mouth twice a day. Further review revealed that the initial Physician's order for Megace suspension 400 mg/30 ml was dated 6/28/12 and that it was to be administered for 1 month. Resident #6 was hospitalized [DATE] through July 16, 2012 and the Physician ' s orders were continued upon readmit for the Megace 400 mg/30 ml to administer 30 ml by mouth twice a day as well as the Mucinex 600 mg tablets 1 by mouth twice a day. A review of Resident #6's MAR for June and July, 2012 revealed an order for [REDACTED]. Resident #6 was administered Megace 400 mg/30 ml 30 ml twice a day on 6/29, 6/30, 7/17, 7/18, 7/19 and once in the morning on 7/20/12. Resident #6 was administered 11 doses of 1200 mg of Megace suspension by mouth during this timeframe. An observation was made on 7/20/12 at 8:18 am of S5 LPN dispensing and administering Mucinex 400 mg from a stock bottle to Resident #6. S5 LPN also administered Megace 30 ml out of a bottle labeled 40 mg/ml. Resident #6's Medication Administration Record (MAR) for July 20,2012 at 8 am revealed that S5 LPN documented that she administered Mucinex 600 mg and Megace suspension 30 ml of 400 mg/30 ml. An observation of the bottle of Megace filled 6/30/12 revealed the strength of 40 mg/1 ml oral suspension and the label read to give 10 ml (400 mg) po bid for 30 days. Resident #6 was administered 30 ml of the Megace suspension which would be a 1200 mg dose. An interview was conducted with S5 LPN on 7/20/12 at 8:20 am who confirmed that she administered 400 mg of Mucinex and 30 ml of the Megace suspension with a bottle labeled Megace 40 mg/1ml. S5 LPN stated that the Resident #6's MAR read Mucinex 600 mg and that she administered 400 mg and that this would be considered a medication error. S5, LPN also confirmed that the strength on the bottle of Megace at 40 mg/1ml did not match the MAR which read Megace 400 mg/30 ml administer 30 ml and that this would be considered a medication error. She stated that she did not check the dosages of Mucinex and Megace on the MAR and the bottles prior to and after administering the medications. An interview was conducted with S1DON on 7/20/12 at 11:15 am who confirmed that Resident #6 received 400 mg of the Mucinex on 7/20/12 at 8 am, that she should have received 600 mg of the Mucinex and that this would indicate a medication error. She also confirmed the Resident #6 had received doses of 30 ml of Megace at 40mg/1ml which would be a total of 1200 mg for the dates of 6/29, 6/30, 7/17, 7/18, 7/19 and 7/20 for a total of 11 doses. S1 DON stated that the staff should have called for clarification since the bottle of Megace labeled 40 mg/ml did not match the MAR which was Megace 400 mg/30 ml. S1 DON stated that she transcribed the Physician ' s orders for the Megace from the June 2012 MAR to the July 2012 MAR but was not aware that the Megace was only available in the 40 mg/ml strength. S1 DON stated that she was not aware of the discrepancy. An additional interview was conducted with S1DON on 7/20/12 at 11:55 am who stated that the pharmacist that filled the script should have picked up on the deviation in the Physician's order for Megace when he filled the medication. She confirmed that the bottle was labeled 400mg/ml to administer 10 ml when the Physician's order provided to him was to administer 30 ml of 400 mg/30ml strength. An interview was conducted with S6 Pharmacist on 7/23/12 at 10:36 am who confirmed that he recalled filling the prescription for Resident #6's Megace 400 mg/30 ml to administer 30 ml. S6 Pharmacist stated that he just looked at milligrams for the dosage and changed the label to read Megace 40 mg/1ml since this was the only dose of suspension available. S6 Pharmacist stated that he was going too fast when he filled the order and should have notified the Physician to clarify the order and/or obtain a new order at that point. S6 Pharmacist also stated that he should have notified the facility's nursing staff in order to alert them of the bottle being labeled 40 mg/1ml and that this would indicate a 400 mg dose. A record review of the Pharmacy Services Agreement dated 2/1/11 revealed that one of the responsibilities of the pharmacist was to provide services to (c) label all medication in accordance with local, state and federal laws, rules and regulations and (h) to provide drug information and consultation to the facility ' s licensed professional staff regarding such drugs. An interview was conducted with S2, ADON on 7/23/12 at 2:20 pm who stated that the facility's current system of checks and balances for medication administration in place would not have prevented the medication errors for this resident.

Based on observation, record review, and staff interview, the facility failed to ensure assistive devices were provided to each resident to prevent avoidable accidents by failing to properly and securely seatbelt Resident #3 during transportation in the facility van on 8/25/11 at 4:20 PM. When the driver " hit the brakes " , Resident #3 fell out of her wheelchair and sustained a broken left leg. After Resident #3 fell out of her wheelchair and sustained a broken leg, Van Driver S4, failed to call an ambulance, instead drove with Resident #3 crying on the floor of the van unsecured back to the hospital. The Immediate Jeopardy Situation began on 8/25/11 at 4:20 PM, when Van Driver S4 failed to properly secure Resident #3 with a seatbelt for transportation, and continued while she was driven unsecured on the floor of the van until 8/25/11 at 5:22 PM, when she was returned to the hospital. The Administrator S1 was informed of the Immediate Jeopardy situation on 9/23/11 at 2:15 PM. This deficient practice remains at the actual harm level for Resident #3 and due to the failure of Administration to investigate this incident after becoming aware of the potential neglect of safety measures during transportation, this deficient practice has the potential to effect all residents' who are transported by the facility van in wheelchairs at a potential for more than minimal harm level. (#3) Findings: Resident #3: Resident #3 was a [AGE] year old female with [DIAGNOSES REDACTED]. According to Resident #3's MDS (Minimum Date Set) dated 9/5/11, she had a BIMS (Brief Interview for Mental Status) score of 14, indicating she was cognitively intact. A review of Resident #3's hospital Discharge Summary dated 8/29/11 read: This is a [AGE] year old black female who had been discharged and was on her way home when the van driver had to stop short to avoid a car, which caused the patient to be thrown from the wheelchair onto the floor of the van. The patient sustained a left tibia and fibula fracture, which was evaluated in the emergency room and the patient was admitted . The patient was seen in consultation with orthopedics. She underwent operative repair of a comminuted left distal tibia fibula fracture .... On 9/21/11 at 10:10 AM, Resident #3 revealed that Van Driver S4 only secured the front of her wheelchair when the accident happened on 8/25/11. " He did not put a seatbelt on me. He was driving way too fast and following too closely to the back of the other cars. He had to slam on his brakes, and I went flying out of the wheelchair. " On 9/21/11 at 1:20 PM, RN DON S2 was asked for the investigation of Resident #3 ' s accident in the facility ' s van on 8/25/11. She stated there was no investigation. This question was restated to confirm there was no investigation, and she stated "nope", and looked away. On 9/21/11 at 1:22 PM, Administrator S1 was asked if there was an investigation of the accident in the van involving Resident #3 on 8/25/11 and she stated there was not one. "It falls under the auto insurance." She revealed she could provide a copy of the van drivers statement. She revealed Van Driver S4 called the facility when the incident happened and "we told him to leave her (Resident #3) where she was and drive straight back to the hospital. He was closer to the hospital than here." Van Driver #4 ' s statement regarding Resident #3's accident on 8/25/11 read: A verbal conversation was held with Van Driver S4, transportation driver for .....(nursing home), regarding the accident that occurred with Resident #3 on her ride back from .... (hospital). Van Driver S4 reports - I picked up Resident #3 at .....(hospital) and was going to pick up ....(another resident) at .... Office. I turned on to ...... street, I was in the right hand lane, the car in front of me was driving at a regular rate and I was following, but not too close, because I knew I wasn't supposed to, the car hit their brakes, like they didn't realize they were at the street they wanted to turn on, she did not have her turn lights on. I hit my brakes and Resident #3 slid out of the wheelchair. I pulled to the side of the road to check on her, she was laying on her right side and the seatbelt had come undone. At first she reported she wasn ' t in pain, then began complaining of leg pain. He did not attempt to move her, called the facility for instruction, then drove her back to ....(hospital). When he got to the emergency room , there were people to help get her out of the van; two men, a woman and the security guard. He unlocked the back wheels and had a man unlock the front wheels so they could get to Resident #3. He did not assist with moving her out of the van. They got a back board, placed it under her and slid her out onto a gurney. He did report seeing a cut on her left ankle and an abrasion on her left knee. He reports on the ride to the hospital she was crying softly, and did complain of leg pain. But was not complaining of severe pain. On 9/21/11 at 3:36 PM, an interview was conducted with Van Driver S4. He revealed Resident #3 was in the back part of the van and she came forward out of the chair onto the floor of the van. The seatbelt must have come undone, it is right there by her elbow, and " I don ' t know if that is what happened, she just came flying forward. " He revealed he called the facility, and they told him to go to the hospital. He confirmed he left Resident #3 on the floor of the van unsecured when he drove her back to the hospital. On 9/22/11 at 11:30 AM, Administrator S1 was asked if they had brought the facility ' s van to the dealership or a mechanic to make sure the seatbelt locking device was working properly and would not unlock with another resident, and she stated no. She was asked if there was a weight limit for the seatbelt, and she stated she did not know. Administrator S1 was asked if the wheelchair used for Resident #3 during the accident on 8/25/11 had a seatbelt and could it accommodate her weight, and she stated she did not know which wheelchair had been used. She stated she did not think it was the transport chair for the van because she did not think the resident could fit in that chair. Administrator S1 was asked if they had looked at where the seatbelt locking device was in correlation to a resident's elbow to determine if it could easily be unlocked by accident, and she revealed they had not. She was asked if she knew where Resident #3's wheelchair had been located during the accident, and she stated she did not know. On 9/22/11 at 1:55 PM, Resident #3 was asked how she felt about the accident on 8/25/11, and she indicated it made her feel bad, "I was so excited to be getting home and then when I flew out of the wheelchair it was terrible. I was lying on the floor and I was so scared, I could see there was something wrong with my leg (Resident #3 began crying at this point in the conversation)." She indicated that she could no longer walk, but before the accident, she had been able to walk, "not very far, but I could walk to the bathroom and to the soda machine, but now I have to wear diapers and can't go to the bathroom anymore. They bath me on the 6 to 10 shift, and when they bath me, they put me to bed and I can't get up. It is just terrible." A review of Resident #3's MDS with a reentry date of 3/30/11 revealed she needed supervision and set up help only (1/1) for bed mobility, transfer, walk in room, walk in corridor, and toilet use. After the accident, Resident #3's reentry MDS dated [DATE] revealed walk in room and walk in corridor did not occur (8/8), bed mobility was limited assist one person physical assist (2/2), toilet use and transfer was total dependence with two person physical assist (4/3). On 9/23/11 at 11:00 AM, an observation of Resident #3 in the facility's transportation van returning from a doctor's appointment was made with Administrator S1 and Van Driver S4. Resident #3 stated there was no seatbelt on her when she fell out of the wheelchair and broke her leg. At that time, Administrator S1 asked Resident #3 why she did not tell the Van Driver she did not have her seatbelt on, and Resident #3 stated because she had a bunch of discharge papers in her hands from the hospital and the van was a new van that she was not familiar with. Resident #3 indicated the chair was only hooked in the front, he (van driver) had not hooked the back of the wheelchair. She had not been in her own wheelchair, but had been in an old blue wheelchair, it did not have a seatbelt on it, and the wheels were bent in. She stated her own chair had a seatbelt. She remembers lying on the floor of the van looking at everything. She could see there was something wrong with her ankle, she saw the bent wheels of the wheelchair, and she saw only the front two hooks were attached to the wheelchair holding it in place. Van Driver S4 confirmed Resident #3 was in the back part of the van for the accident on 8/25/11, and the wheelchair Resident #3 was observed in was not the wheelchair she had been in the day of the accident. The seatbelt was locked underneath the arm of the wheelchair Resident #3 was observed in and her elbow would not be able to reach it and accidentally unlock it. The facility was unable to find/produce the wheelchair Resident #3 had used the day of the accident. On 9/23/11 at 4:10 PM, an interview was conducted with Van Driver S4. He stated on 8/25/11 he heard the seatbelt click and tugged on it to make sure it was secure. "It was a mistake that happened," whether she hit the lock with her elbow, he did not know. He stated he was not sure how it happened, he heard the resident scream and then she was on the floor. He called the facility to see what to do and spoke to one of the nurses and "they told me to leave her there and driver her back to the hospital, so that is what I did." There was no evidence the facility investigated, evaluated and analyzed this accident/incident to identify potential neglect, risks and/or hazards regarding seatbelt use after Resident #3's incident on 8/25/11 which resulted in a broken leg, so as to implement interventions to prevent future occurrence. Also, Administration failed to identify the instructions given to Van Driver S4 to transport Resident #3 unsecured on the van floor as neglect to provide a seatbelt necessary to avoid further physical harm, so as to prevent future occurrence. Based on record review and interview the facility failed to ensure that each resident environment remains as free from accident hazards as possible and receives adequate supervision to prevent accidents by failing to 1) implement interventions to reduce hazards and risks, increase supervision, and monitor for effectiveness and modifying interventions to prevent accidents this resulted in a potential for more than minimal harm for 1 out of 5 residents who sustained falls (Resident #2), and 2) ensure accident hazards including exposed sharp metal on smoke area table, loose bricks in areas along side walks in the front courtyard area and back courtyard area, metal umbrella stands screwed to the ground, water hoses across courtyard, long 2 X 4 boards across sidewalks on back courtyard and uneven sidewalks in the back courtyard were identified and removed or repaired placing all residents capable of walking outside at risk. Findings. 1) Resident 2. This is an [AGE] year old resident who was admitted to the facility on [DATE] after a slip and fall with fracture of her left femoral head. Other [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that this resident has no recall and disorganized thinking. Review of resident 2's Fall Risk Assessment Form revealed that on 7/18/11, 8/6/11, and 8/12/11 the assessment's total score was 19 with 10 or above representing "High Risk". Review of the nurses notes dated 8/5/2011 revealed that "Res. was heard yelling from room "Help". Resident was found on her bottom on the floor between bed and chair, stated "I was trying to get into my bed" this nurse advised resident to always call for assistance to get into or out of bed, res. verbalizes understanding. No c/o pain or discomfort, no bruises, skin tears or lacerations." Review of resident 2's care plan dated 7/22/2011 revealed that this resident was at risk for injury. Approaches for this identified concern are as follows; check resident every two hours and as needed for optimum safety and care, keep her personal items in reach, remind her to use call bell when assistance needed, avoid clutter and harmful obstacles in room and hallways, inform staff due to her cognitive loss she might get up unassisted. The care plan was updated to reflect the fall on 8/5/11. Check resident every two hours and offer assistance and observe for resident attempting to transfer self were added to the care plan approaches. There was no change from the initial care plan approaches. Nurses notes dated 8/12/11 reads, "Resident found on floor on buttocks near recliner between w/c (wheelchair) and bed in her room. Able to MAE (Move All Extremities) without difficulty c/o (complains of) mid and lower back pain. Assisted up from floor per staff x (times) 2 to w/c. No bruising or skin tears noted at this time. Resident denies hitting her head." Review of resident 2's care plan dated 7/22/2011 revealed that the care plan was updated to reflect the fall on 8/12/11 but the approaches were not updated. Instruct staff resident gets up unassisted often, to check and offer assistance to avoid injury was the updated approach. An interview was conducted on 9/21/11 at 3:00 PM with S1, MDS Coordinator. During this interview, S1, MDS Coordinator confirmed that no new interventions were added to resident 2's care plan. 2) On 9/21/11 at 10:10 AM, an observation was made of the resident and guest outside smoking area. There was a wrought iron table that had the metal edging coming off which exposed the sharp edges of the metal grate table top. While inspecting the table, Resident #3 stated that one day she had come outside to smoke and had gotten a little too close to the table edge. She caught her stomach on the broken part (described above) and this reopened a sore she had on her stomach. The metal edging was not secured to the table and when the resident was demonstrating what happened, she was able to take her finger and move the edge of the metal and lifting it easily away from the table. This left the sharp edges of the metal grate exposed and the corners of the metal edge were slightly sharp. On 9/22/11 at 10:50 AM, a tour of the facility was conducted with Administrator S1. On the back courtyard outside of the main dining room, a small section of the uneven courtyard had been replaced. There were still uneven sections of sidewalk, divots in the sidewalk, and bricks loose at different spots throughout the courtyard which was confirmed by Administrator S1. There was a large hole down to some type of piping beside a new sidewalk that was approximately 3 foot deep. This hole was covered with single layered wooden pallets and surrounded by orange plastic netting. On 9/23/11 at 2:35 PM, another observation was made by two surveyors outside on the courtyard and around the enclosed area sidewalk ending in the smoke area. The following accident hazards were noted: loose bricks all around the building on the edges of the sidewalks, five metal umbrella stands which were screwed into the courtyard patio floors, three of which had jagged metal edges in the center, one had a pole in the middle that was waist high with a jagged metal edge, and one had a piece of the pole approximately 1 inch out of the center of the stand. The sidewalks were very uneven, some with divots approximately 6 inches wide and 1/4 to 3/4 inches deep. There were loose 2 X 4 boards lying on the sidewalk, a garden hose lying out on the walkway, a 5 gallon bucket with old water with algae growing in it which had a tall metal pole sticking out of it, and a deep hole along the new sidewalk outside the back dining room door with exposed plumbing covered with single layered wooden pallets surrounded by approximately 2 foot tall orange netting held in place by rebar approximately the same height.

Based on observation, record review, and staff interview, the facility failed to ensure that the resident environment remained free of accident hazards to prevent accidents and failed to ensure each resident received adequate supervision to prevent accidents by failing to: 1. provide adequate staff to supervise wandering Resident #1 on [DATE] which resulted in the resident walking out of the building at 03:15 A.M. without being seen by staff members, being found on the ground, and sustaining a fractured left hip for 1 of 1 sampled residents (#1), 2. ensure exit doors alarm to alert staff when wandering residents exit the facility. 3. ensure staff knew each time a resident exited through the exit doors as the exit doors automatically shut and lock after exiting, which could lock confused wandering residents outside , 4. correct the identified accident hazard risk of uneven sidewalks in the courtyard , and 5. failed to assess/identify possible contributing factors such as behaviors/medication changes. UTI that could have led to Resident #1's elopement. The facility failed to provide adequate supervision of wandering Resident #1 on [DATE] at 03:15 AM, and failed to provide adequate staffing which allowed the Resident to walk out of the building without being seen. The exit doors in the general population areas had no alarm to alert staff when Resident #1 was leaving the building, and the exit door would have automatically locked the Resident outside. The Resident was found at 5:45 AM, which was 2 ,[DATE] hours after leaving her room, lying on the extremely uneven sidewalk in the courtyard. These failures resulted in Resident #1 sustaining a fractured hip. Also, the facility failed to thoroughly investigate the [DATE] incident to identify root causes including staffing concerns, that they still had wandering residents residing in the general population who could potentially leave via the exit doors that had no alarms to alert staff if they leave and would lock them outside in potentially extreme weather, or correcting the identified uneven sidewalk accident hazard which placed wandering Residents #2, #3, #4 and #5 at risk of harm. Findings: Resident #1 was an [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #1's Care Plan with a goal date of [DATE] revealed the following problems: Wandering - (no date of onset but had a goal date of [DATE] crossed out and was continued to [DATE]) resident gets up unassisted and a goal of free from wandering outside of facility - optimum safety with approaches of 1. check resident every 2 hours and as needed for optimum safety and care, 2. inform staff resident gets up unassisted, 3. observe for underlying causes such as incontinence, thirst, pain for resident getting up, 4. keep bed at lowest level with soft mats on floor; At risk for falls, injury due to decreased mobility and cognition with onset date of [DATE] with a goal of Resident #1 will have no injury related to falls every day and approaches of 1. remind Resident #1 not to stand without assist. Place self release belt on while up in chair, 2. side rails up X2 while in bed which was discontinued on [DATE], 3. answer call light promptly, 4. Monitor frequently for safety and needs, 5. added on [DATE] lowest position while in bed, 6. added [DATE] soft mats to floor, 7. added [DATE] observe for resident getting up unassisted, assist her as needed. A review of Resident #1's nurses notes revealed on [DATE] at 10:00 PM, Resident #1 was restless after the CNA had placed her in bed for the night. She was awake and alert getting out of bed ambulating ad lib (freely) (into the hallway). At 10:30 PM, she was assisted back to bed. On [DATE] at 3:45 AM, Resident #1 was still restless and ambulated from her room up hallway to front of nurses station. At 4:00 AM, she was up again sitting on the sofa. On [DATE] at 2:00 PM, Resident #1 walked from her room to the front lobby. She was assisted back to bed and the staff nurse was notified by the LPN on duty that the resident was ambulating. There was no documented evidence the staff observed/assessed Resident #1 for underlying causes or increased checking/monitoring of resident as needed for optimum safety and care as per her care plan approaches. Further review of Resident #1's nurses notes revealed on [DATE] at 4:15 AM, the CNA reported to the nurse that the resident was not in her bed during rounds. Staff made checks of all rooms and grounds and were unable to find Resident #1. At 5:00 AM, S2 DON, S1 Administrator, and the Police department were notified of Resident #1's elopement and the staff's inability to find her. At 5:30 AM S1 Administrator and S2 DON arrived at the facility and staff continued to look for Resident #1. 5:45 AM, Resident #1 was located in the courtyard area of the facility lying on her left side on the ground. 6:00 AM, responsible party was notified and Resident #1 was placed on the locked unit. 6:10 AM ambulance service was called. 6:26 AM, Resident #1 sent to emergency room . A review of Resident #1's hospital record and hospital discharge summary revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. The summary read: This is an [AGE] year old white female who is admitted . Cardiology consult was obtained as well as an orthopedic consult. The patient underwent hip surgery on [DATE]....She did have a urinary tract infection which was treated with some antibiotics. She began to have some diarrhea which tested positive for clostridium difficile. She was started on Flagyl. The patient's condition slowly began to deteriorate however, she became fairly unresponsive. ..Hospice accepted the patient on [DATE].... Resident expired on [DATE]. On [DATE] at 10:45 AM, an interview was conducted with S1 Administrator. She stated that the facility always has a nurse and an aide assigned exclusively for the locked unit. At that time, observed Resident #1's room she lived in on [DATE] with S1 Administrator. It was located just outside of the locked unit doors and the front nurses station. S1 Administrator explained on the night shift, one CNA would be on the locked unit and the LPN would be scheduled to care for the Residents' on the locked unit, outside of the locked unit, which was also considered A hall, and half of C hall. S1 Administrator revealed after reviewing the security tapes, they saw Resident #1 leave her room at 3:15 AM on [DATE] and walked down hall B. The next camera did not show her, so they assumed she walked out of the B hall door to the courtyard where she was found lying on the ground. At that time, this surveyor and S1 Administrator walked the path Resident #1 took, and walked out of the B hall exit door to the courtyard. No alarm sounded when the door was opened and the door automatically shut and locked behind us. We were locked outside at that time. S1 Administrator confirmed that all of the doors to the courtyard automatically shut and locked, and there was no alarm or anything to alert staff when a resident walked outside to the courtyard where they would be locked outside even in extreme weather conditions. The only door with an alarm was located on the locked unit. She stated that they were in a bad neighborhood and previously had someone jump the back fence and run through the building with the police chasing them, so they always keep them locked. They are required to have doors that egress to the outside, so residents would always be able to walk outside, but would then be locked outside. All of the courtyard doors were checked and were noted to be the same. The only doors that were unlocked from the outside during the day were the front door and the designated smoking area door. While walking on the sidewalk in the courtyard to where the staff found Resident #1 lying on the ground, the sidewalk was noted to be extremely uneven. One of the surveyors tripped more than one time on this sidewalk while making this observation. The S1 Administrator confirmed that the sidewalks were very uneven and an accident risk. She confirmed that the sidewalks had been like that for a long time. S1 Administrator indicated that the sidewalks were uneven because of the big tree roots. Accident Hazard risks identified during this observation included a potential for wandering residents to exit into the courtyard through doors with no alarms to alert staff and become locked outside in potentially extreme weather conditions, and the uneven sidewalks which could lead to falls. On [DATE] at 11:19 AM, an interview was conducted with LPN S3. When she arrived at work at 7:00 PM, Resident #1 would normally be on the locked unit. She indicated Resident #1 was very confused, was combative at times, and would attempt to ambulate occasionally. LPN S3 stated she had been assigned the locked unit, A hall and the right side of C hall, which was half of the admitted residents, on the night of [DATE]. She made rounds every 2 hours and the aides would round every 2 hours. Normally, there were 5 CNAs working at night, but there were only 4 working on the night of [DATE]. LPN S3 indicated the 2 CNAs working with her assigned residents were CNA S5 and CNA S6. The CNAs had separate assignments, but they had decided to work together that night. This meant they go into the residents' rooms together and work side by side in the rooms. LPN S3 stated that CNA S6 usually worked on B hall and was not familiar with the residents on the locked unit. She felt that was the reason the CNAs had buddied up and were working together. LPN S3 explained that since the CNAs were working in tandem, when they were on C hall or the front part of A hall, then no staff was monitoring the locked unit. Also, when they were both working on the locked unit, then no one was on the front of A hall where Resident #1's room was located. The CNAs were making 4:00 AM rounds, when they found Resident #1 was not in her room. LPN S3 stated she did not feel there had been enough staff working on the night of [DATE], if there had been enough staff, then they would have seen Resident #1 get up. LPN S3 stated the last time she had seen Resident #1 in her room was at approximately 2:00 AM or 2:30 AM. She revealed she had been in another resident's room on C hall at approximately 3:00 AM or 3:30 AM and remained in the room for approximately 25 minutes. She revealed that the early morning hours were very busy. That was when rounds were being performed and she would get her 4:00 AM medications ready. When the CNAs notified her Resident #1 was missing, they performed a room to room check. She confirmed there were no alarms on the exit doors to alert staff when the resident walked outside. She then called the S2 DON and the police. She and the S2 DON found the resident outside lying on the ground. She revealed that the facility did not ask her for a witness statement or anything regarding the incident, but she assumed they did an investigation. On [DATE] at 1:15 PM, S2 DON revealed Resident #1 was not reassessed after the [DATE], [DATE], and [DATE] walking without assistance behaviors because she had not had a fall and had not tried to walk out a door. She stated they do not do an assessment because residents wander with no destination, there is no policy to address that. They have several residents in the general population that wander. Resident #1 would be placed on the locked unit during the day for low stimulation and socialization. She used to be housed on the locked unit, but was moved into the general population, so that was the environment she was used to. She only came off of the locked unit for naps and at night to sleep. S2 DON revealed she had not known the 2 CNAs had been working together instead of the way they were scheduled to work the night of [DATE]. She confirmed this would leave the locked unit unattended when they were working together outside of the unit. She revealed that on the night of [DATE], they had an aide call in, and CNA S6 normally worked on B hall, but was pulled to the locked unit due to the call in. S2 DON stated when she got to the facility on [DATE] at approximately 5:30 AM, she began looking for Resident #1 and at approximately 5:45 AM, decided to walk the perimeter of the facility and found the resident lying on the ground on the back courtyard. The resident told her she was going to New York, she was always very confused. Resident #1 was assessed, she was stood up and had some pain, so the ambulance was called and she was sent to the emergency room . They then watched the security tapes, and by process of elimination, they determined Resident #1 walked out the exit door on the B hallway. She stated that they discovered Resident #1 missing at 4:00 AM and did not find her until 5:45 AM. A review of the policy and procedure for secure wing residents read: Any one of the following conditions qualifies a resident for the secure wing: When secure wing is needed to prevent elopement due to wandering, ...constant supervision related to mental confusion, and a quiet environment with a constant schedule. Residents may be removed from the secure wing if the following conditions are met: Resident no longer has wandering tendencies, resident has become chair/bed bound and is no longer an elopement risk, and Resident no longer needs quiet environment to keep from becoming agitated. On [DATE] at 2:00 PM, S4 LPN MDS Coordinator confirmed there was no documented date of when the problem of wandering/resident gets up unassisted was added to Resident #1's care plan. After reviewing her notes, she had an incident document where Resident #1 got up unassisted on [DATE], and she felt it was added at least before June of 2010. She revealed that the CNAs would occasionally walk Resident #1 to the vending machine to get a drink so she was capable of walking. S4 LPN MDS Coordinator revealed in her [DATE] notes Resident #1 had not had problems without side rails, her physician had increased her medication Risperdal (antipsychotic) and added Remeron (antidepressant) on [DATE]. After reviewing Resident #1's nurses notes dated [DATE] - [DATE], S4 LPN MDS Coordinator did not know if she had been assessed for the changes in her behavior, and stated "I wonder if she had a UTI?" She stated she did not remember if it was routine for staff to assist Resident #1 to walk, she just remembered one particular aide that would walk her to the vending machine, she had also seen the staff walking her to the bathroom. She was not a very good walker, but she could walk. S4 LPN MDS Coordinator stated when they saw Resident #1 walking by herself, it was a panic thing and the staff would run to assist her. She indicated that Resident #1 was brought to the locked unit during the day for extra assistance and optimal care. Resident #1 was a little disruptive at times and for decreased stimulation. At that time, the S2 DON stated Resident #1 would fight when she was stimulated, she would grab out at other residents and sing yanky doodle dandy. S4 LPN MDS Coordinator revealed Resident #1 liked to curse, and she always tried to pick up things off of the floor that were not there. She came off of the locked unit for naps and went to some parties in the B hall dinning room. According to Lippincott's nursing drug guide Remeron had adverse effects listed which included disorientation, delusions, anxiety, nervousness, restlessness, agitation and insomnia. Also, Lippincott's nursing drug guide listed insomnia, anxiety, agitation, aggression as some of the adverse effects of Risperdal. Risperdal had a black box warning which read: Do not use drug to treat geriatric patients with dementia. On [DATE] at 4:45 PM, S1 Administrator and S2DON confirmed on the night of [DATE], they were short staffed one aide. The S2 DON explained to the S1 Administrator about the aides working in tandem and confirmed that would leave the locked unit with no staff while they worked outside of the unit together, and when they were working on the locked unit, the residents' outside of the locked unit, where Resident #1's room was located, would be left unattended. The S2 DON explained that since it had been CNA S6, she probably threatened the other CNA and LPN, if she had to work alone, she would leave and they would have been working with only 3 aides. S1 Administrator was asked why Resident #1 was brought to the locked unit all day, but did not reside or sleep on the locked unit. S1 Administrator stated Resident #1 was moved off of the locked unit, because they had other residents that needed the locked unit more than she had. She had not been walking and had not tried to leave the building, so they did not feel she was an elopement risk. Resident #1 was put on the locked unit during the day, because that was where she had been housed previously, and that was where she was comfortable and had friends, or as much as she was capable of having relationships with other peers. She was also socially inappropriate and the lower stimulation on the locked unit was better for her. S2 DON stated again that the facility had not reassessed Resident #1 after she walked around in the middle of the night on [DATE] - [DATE], and during the day on [DATE], because the residents' have a right to walk around, she never tried to go outside, and that they are not going to tie them down. She stated they have several Residents that are wanderers in the general population and "that is ok. They do not try to go outside". S2 DON named Residents #2, #3, #4 and #5 that were also wanderers in the general population. S1 Administrator confirmed Residents #2, #3, #4 and #5 were current wanderers housed in the general population. S1 Administrator and S2 DON stated their investigation of the [DATE] incident included watching the security videos, where they saw Resident #1 walking down the hall. When they no longer saw her on the video, they assumed that was where she exited the building and assumed she fell on the sidewalk. They confirmed they had not gotten witness statements from the staff working, the staff just verbally reported what had happened. They confirmed they had not known about the 2 CNAs working together. They just thought it was an elopement, an accident - a fall. They confirmed they did not report the incident to the State Survey Agency. There was no further investigation. The policy and procedure for missing residents and/or elopements read: ...3. Do a completed search of the buildings interior. Look in every room, bathroom and in enclosed courtyard areas. During the initial ,[DATE] minutes, cover the entire exterior of the facility. This should include both searches by care and foot. Interview staff and determine who last saw the resident and what they were wearing. assign two staff members to exit the front of the building, one to go to the left and one to go to the right, to circle the circumference of the building. ...8. Contact the State Survey Agency. Call or fax a report within 24 ours of the incident and prepare a complete report at the completion of the incident. ...Quality Assurance for the prevention of missing residents. 1. Should a resident attempt an elopement, a review of their individualized care plan shall be triggered for possible changes in care practices or safety precautions for that resident. 2. Should an elopement occur, the facility's QA team will meet to review policies and procedures to evaluate if all systems are working as they should, or whether there are any gaps that should be addressed , or areas that can be improved. ...

Based on record review and staff interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, by failing to ensure Resident #35, with poor trunk control and poor safety awareness, had a shower chair with a properly fitting safety belt and by failing to increase supervision after Physical Therapy Staff educated the Nurses and CNAs regarding watching Resident #35 closely for attempting to get up by herself resulting in Resident #35 falling out of her shower chair on 2/25/11 and sustaining a fractured femur for 1 of 3 residents reviewed for falls. (#35) Findings: 1. Resident #35: Resident #35 has [DIAGNOSES REDACTED]. admitted on [DATE] A review of Resident #35's Nurses Progress notes dated 2/25/11 at 07:15 AM revealed that CNA S19 reported to the nurse that the resident had fallen on the floor in the shower. Upon entering the room, Resident #35 was noted to be on floor in shower lying on her right side with her left leg tucked under her other leg. Resident was able to move extremity with normal limits. She complained of pain to her left leg and right arm. Swelling was noted to her left leg (thigh) area. Bruising was also noted. Pain medication was administered. At 9:00 AM Resident #35's physician was aware of incident. A new order was noted for an X-ray to her right arm and left hip and knee. At 1:10 PM, results the of x-rays were received which read: Impression left knee acute fracture of distal femoral shaft overlapping of major fragments. At 1:45 PM, Resident #35 was on route to the hospital. Resident #35's Care Plan revealed a problem of at risk for injury dated 1/17/11 with a target date of 4/17/11. Approaches included use proper technique when transferring or turning resident, and use two to three CNAs as needed. A fall was added on 2/25 with an approach of remind staff to use 2 CNAs as needed when up in shower chair. Resident #35's admission Minimum Data Set ((MDS) dated [DATE] revealed the resident needed total assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Also the resident required two plus persons physical assist for transfers and toilet use. Her height and weight were listed as 5 foot 5 inches tall and 231 pounds. According to Resident #35's Care area assessment dated [DATE], section falls read Resident is totally dependent for her ADL's due to her general weakness and depletion. She has had not recent falls. She is obese and requires two assistance for some of her care and her transfers. Also, the section Functional/Rehabilitation Potential read resident had been hospitalized for [REDACTED]. She requires two to three CNAs for transfers and mobility due to her weakness and obesity. Resident was ambulating with a walker prior to her hospitalization . She requires total assistance with her dressing, bathing and personal hygiene. She has weakness to her extremities and complains of discomfort. On 3/2/11 at 09:15 AM, a telephone interview was conducted with CNA S19. She was asked what happened with Resident #35's fall of 2/25/11. She stated that morning she took the resident for a shower. After the shower, the resident kept asking her to get up and as she was backing her out of the shower the resident leaned forward in the chair. The CNA asked her to lean back and she kept leaning forward like she was trying to pick up something and just rolled out of the chair. CNA S19 stated she tried her best to catch the resident but could not. "We usually use one person in the shower, but lately she has been thinking she can get up." For about a week, Resident #35 would say in the mornings that she had been getting up and going to the bathroom by herself. CNA S19 would tell Resident #35 that she did not walk and maybe she dreamed it, but would reinforce that she could not get up by herself. She indicated that the staff used a lifter to put her in the shower chair. There have been occasion that she does not want to use the lifter and that the resident states she can get up, but they reinforce that they have to use the lifter for her and their safety. CNA S19 revealed that there was another CNA that helped put the resident in her shower chair, but the CNA would shower her alone. "There is not enough room for more than one in the bathroom." She stated she showered the resident and everything went "ok." "Then just when backing up, the resident wanted to stand." CNA S19 was asked if the facility had informed her they would be doing anything differently for Resident #35 when she returned from the hospital regarding CNA assistance in the shower and she stated no. A review of Resident #35's Physical Therapy Progress Report dated 2/24/11 read: Patient very confused and stating she could get up and ambulate. Spoke to nursing regarding to watch Patient in case Patient would try to stand up on her own. Precautions were noted as decreased safety awareness. On 3/2/11 at 9:30 AM, an interview was conducted with Physical Therapist (PT) S20. She indicated that Resident #35 was very confused and had told her son that she had been getting up and walking which was not true. She indicated it took 5 staff members to get Resident #35 up. Within the last few weeks, Resident #35 started saying she could walk or get up. PT S20 stated that Resident #35 had very poor trunk control. The resident's blanket would fall and she could not lean forward to reach for it. At that time, Physical Therapy Assistant (PTA) S 21 joined in the interview. Both the PT and PTA indicated that Resident #35 was very motivated to walk and had been telling her son that she could walk. They indicated the son had told Resident #35 when she could walk, she could move in with him. PTA S21 stated that she had talked to the staff regarding this and to watch out for her if she decided to try and get up. They indicated they did not know anything about the shower chair or how many people should be in the shower assisting. On 3/2/11 at 11:00 AM, an interview was conducted with LPN MDS Coordinator S3. She was asked about Resident #35's fall on 2/25/11 regarding the resident stating to several people that she wanted to get up. LPN MDS Coordinator S3 confirmed that Resident #35 had been saying that. She was asked about the Resident leaning forward in the shower chair and the CNA rolling her backward, and she stated that the CNA should have had the shower chair seat belt on the Resident if there was one on the shower chair. At that time, we went to Resident #35's room and observed the shower chair along with the RN DON S2. They both confirmed that the shower chair had a seat belt. The LPN MDS Coordinator S3 stated that the fall and fracture would really set Resident #35 back from the progress she had made. On 3/2/11 at 1:10 PM, a face to face interview was conducted with CNA S19. She stated that Resident #35's seatbelt had been on the chair, but she could not use it, because it did not fit around the resident. CNA S19 stated that she was unaware that PT had educated them on the resident maybe wanting to stand up. Showed her the documentation from the 2/24/11 PT note that read: spoke to CNA's and Nurses to watch patient close due to patient states she can walk and worried she will try to get up on her own. CNS S19 indicated she had not heard anything about that. She stated that if the shower chair seat belt would have fit, she would have used it. At that time, we went to Resident #35's room and CNA S19 confirmed that was the shower chair she used for the Resident, but if she would have known that PT had said to watch her close and they were worried she would try to get up on her own, she would never have put her in that chair that the seatbelt didn't fit her. A request was made several times from 3/2/11 through 3/4/11 for the manufactures recommendations for resident #35's shower chair from the Administrator. No recommendations were ever provided. On 3/2/11 at 4:45 PM, an interview was conducted with the Administrator S1. She was shown the documentation that PT had educated the staff regarding they were worried Resident #35 would attempt to get up by herself, the assessments by PT indicating the resident had poor safety awareness and poor trunk control, information from interviews with CNA S19 indicating the shower chair seatbelt did not fit the resident and that was why she did not use it or she would have, and if she would have know about the PT teachings from the day before, she would not have used that shower chair, she would have gotten the bigger one that the seat belt would fit around her. Also, that the resident broke her femur and the MDS coordinator S3 indicated this would set Resident #35 back on her progress. The Administrator S1 looked at the PT note when they educated the nurses and CNAs and checked the calendar. She stated that was a Thursday and this must have been during the meeting PT has and the information just did not get communicated to the oncoming CNA's yet because this accident happened the next morning. On 3/3/11 at 3:15 PM, and interview was conducted with LPN CNA Supervisor in training S8. She stated that when a resident is brought to the shower in a shower chair, the CNA should use the seatbelt. "That is a safety measure. If the shower chair did not fit Resident #35, the aide should have gotten a different size when she was first admitted ." Based on observation and interview the facility failed to ensure that the resident environment remained as free from accident hazards as possible to prevent accidents by: 1) failing to empty a sharps container in a communal resident whirlpool bath area that was overfilled with several blue, uncapped razors hanging over the side of the container for 1 of 2 Whirlpool bath areas in the facility (Whirlpool Bath Hall B) and 2) by failing to ensure that water temperatures were within the safe range to prevent resident burns by having temperatures of 130 F in 4 of 49 total resident rooms. (Rooms # 124, # 303, #315 and #320.) 1) An observation was made on 3/3/11 at 10:50 am of the Hall B Whirlpool room. A sharps container was observed on a shelf on the wall behind the whirlpool bath and the container was noted to be overfilled over the Fill line and several uncapped blue razers were hanging over the edge of the container. An interview was conducted at this time with S1, Administrator and S2, DON who both confirmed that the sharps container was overfilled and that the uncapped razers were hanging out of the container. S1, Administrator stated that the uncapped razers hanging out of the sharps container were a safety issue for any residents in the whirlpool room. She also confirmed that the sharps container was within a resident's reach in it's present location. 2) An observation was made on 3/3/11 at 11:00 am of Resident room #337 lavatory area with a water temperatures of 128 F. An interview was conducted wiith S17, Maintenance on 3/3/11 at 11:15 am who confirmed the temperature in the lavatory was 128 F. S17, Maintenance stated that his department performed temperature checks weekly in all resident rooms as well as whirlpool areas but that the facility had no log to document the temperature checks. S17, Maintenance stated that if there were problems with water temperatures in the facility that he would contact his supervisor or the Administrator. S,17 Maintenance placed his hand under the running water in Resident Room 337 and stated that the water was, "too hot." When questioned about how the facility calibrated their thermometers, S17, Maintenance stated that he was unsure of how this could be done. An additional interview was conducted at this time with S, 18, Maintenance who also confirmed that the water in Resident # 337 lavatory was, "too hot." Additional observations were made of temperatures in resident room lavatories as follows on Hall A on 3/3/11 at 11:30 am as follows: Room 303 - 130 F, Room 315 - 130 F and Room 320 - 130 F. S17, Maintenance and S18, Maintenance both confirmed the temperatures obtained at this time in these resident room lavatories were as documented. Both S17, Maintenace and S18, Maintenance stated that the water temperatures in all 3 room lavatories were, "too hot." An observation and interview were conducted with the S1, Administrator on 3/3/11 at 12:35 pm in Room 303 bathroom. S1, Administrator performed water temperature checks with 2 of the facility's thermometers and stated that the temperatures were 100 and 102 F. This surveyor also performed water temperature checks with the surveyor thermometer at the same time and obtained a temperature of 124 F. When questioned about how the facility calibrated their thermometers S1, Administrator stated that she was unsure of how this could be done.