Every finding on record at Desoto Healthcare Center

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure that treatment and care were provided in accordance with professional standards of practice and physician orders by not utilizing and changing a drainage sponge at the insertion site of a Percutaneous Endoscopic Gastrostomy (PEG) tube as ordered for two (2) of three (3) residents with a PEG tube. Resident #2, and Resident #9Findings Include: A typed statement on company letterhead dated 9/17/25 and signed by the Director of Nursing (DON) revealed that the facility did not have a specific policy related to the care of PEG tubes. The facility staff are to follow the physician's orders concerning PEG tubes. Resident #2 Observation of medication administration for Resident #2 on 9/16/25 at 2:29 PM with Licensed Practical Nurse (LPN) #3, revealed no drainage sponge present around the PEG tube site. During an interview on 9/16/25 at 2:29 PM with LPN #3, she confirmed there was not a drainage sponge present. Record review of Resident #2's Order Listing Report with a Revision Date of 03/26/2025, revealed an order under PEG: Clean PEG Site with Daily Wound Care (DWC) and apply new drainage sponge at bedtime . Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Gastrostomy Status and Dysphagia following Cerebral Infarction. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood. Resident #9 During an observation and interview on 9/17/25 at 10:15 AM, LPN #1 confirmed that Resident #9's PEG tube insertion site had a brown dried substance present and no drainage sponge in place. LPN #1 stated the floor nurses are responsible for providing PEG care. During an observation and interview on 9/17/25 at 10:30 AM, LPN #2 revealed that PEG sites are to be cleaned each shift. She confirmed Resident #9's PEG site had a brown dried substance present, was not clean, and did not have a drainage sponge in place. LPN #2 stated that when PEG sites are not properly cleaned, residents are at risk for infection, and that the drainage sponge is used to protect the resident's skin around the tubing. She further reported that she last cleaned the site on Thursday, 9/11/25, when she previously worked and it appeared that it had not been cleaned since then. An interview with the DON on 9/17/25 at 11:10 AM revealed that PEG sites are to be cleaned daily and documented in the Electronic Medication Administration Record (EMAR). The DON confirmed the insertion site is always to be kept clean and a drainage sponge is to be applied to prevent infection and reduce skin irritation and breakdown. Record review of Resident #9's Order Summary Report with an Order Date of 04/04/2025, revealed an order under PEG: Clean PEG Site with/DWC and apply new drainage sponge at bedtime Record review of Resident #9's admission Record revealed the resident was admitted on [DATE] with Medical Diagnoses which include Encounter for attention to Gastrostomy. Record review of Resident #9's MDS with an ARD of 7/13/25 revealed a BIMS score of 14, which indicated the resident is cognitively intact.

Based on observation, interview, record review and facility policy review the facility failed to provide nail care for residents who required assistance with Activities of Daily Living (ADLs) for 2 (two) of nineteen sampled residents. Resident #7 and Resident #48.Findings Include: Review of the facility policy Fingernail and Toenail Care with revision date of 05/02/22, revealed, All residents of (Proper Name) facilities shall receive nail care, on a regularly scheduled basis .2. Routine cleaning, inspection, and nail care, to include trimming and filing, will be provided on a regular schedule and as needed. Resident #7 An observation of Resident #7 on 9/15/25 at 2:59 PM revealed she was sitting in a Geri-chair in her room. Her left hand was contracted, with fingers turned inward toward the palm. The fingernails on her left hand were excessively long, jagged, and measured approximately three-eighths (3/8) of an inch. An observation and interview with Licensed Practical Nurse (LPN) #4 on 9/16/25 at 2:32 PM confirmed Resident #7 had long fingernails on her contracted left hand. LPN #4 stated it was the activity staff's responsibility to trim the residents' nails. She acknowledged the resident was at risk for skin issues due to the contracture and the long nails. An interview with LPN #5 on 9/16/25 at 3:18 PM revealed she worked in activities and was responsible for cutting Resident #7's fingernails every two weeks. She reported, Maybe she needs her nails cut more often, and acknowledged Resident #7's risk of skin breakdown related to her hand contracture. A record review of Resident #7's Medication Administration Record (MAR) for September 2025 revealed an order dated 10/11/23: Fingernails and toenails to be cleaned, filed, and clipped as needed every day shift every Friday, Activities to document. The order was initialed as completed on 9/12/25. A record review of Resident #7's Certified Nurse Aide Kardex indicated under Resident Care that the resident needed her nails kept short to reduce the risk of scratching or injury from picking at skin. An interview with the Director of Nursing (DON) on 9/16/25 at 4:08 PM revealed her expectation was that residents receive nail care weekly, including cleaning, trimming, and filing. She explained that nail care was the activity staff's responsibility; however, if aides observed a need while bathing residents, they should also provide the care. A record review of the admission Record revealed the facility admitted Resident #7 on 3/24/22 with medical diagnoses including Essential (Primary) Hypertension. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #7 was severely cognitively impaired. Resident #48 An observation on 09/15/25 at 11:16 AM and on 09/16/25 at 8:38 AM revealed long, jagged fingernails on Resident #48's hands bilaterally. His fingernails were approximately one-half inch long and had brown substance underneath. Resident #48 stated, My fingernails need cutting and revealed that his fingernails had not been clipped in a while. An observation also revealed a thick, crusty brownish yellow substance covering the palm of his right hand and it had a mild odor. During an observation and interview on 09/16/25 at 2:25 PM with Certified Nursing Assistant (CNA) #2 in Resident #48's room, she confirmed that he had long, dirty fingernails. She also confirmed the brownish yellow substance and mild odor in the palm of his right hand. CNA #2 revealed that long, dirty fingernails could make him sick by spreading germs and he could scratch himself, causing a skin tear. She revealed that the staff should be washing his hands at least daily and that his fingernails should be clipped and filed every week and as needed. During an observation and interview on 09/16/25 at 2:35 PM with DON, she confirmed that Resident #48 had long, jagged fingernails with brown substance underneath. She also confirmed the mild odor and the brownish, yellow substance covering the entire palm of Resident #48's hand. DON revealed that the staff should be looking at fingernails every day and should be washing hands more than one time a day. She also revealed that long dirty fingernails could cause skin tears and possible infection. DON revealed that it was her expectations for fingernails to be assessed by the CNAs during a resident's bath or shower time and if fingernails needed attention, they should provide the care. Record review of Resident #48's admission Record revealed an admission date of 08/03/23 and that he had diagnoses that included Congestive Heart Failure and Need for Assistance with Personal Care. Record review of Resident #48's Medication Review Report revealed that fingernails and toenails to be cleaned, filed and clipped as needed every day shift every Friday. Record review of Resident #48's MDS with ARD of 12/13/24 under Section GG revealed that he required substantial to maximal assistance with his personal hygiene. Record review of Resident #48's MDS with ARD of 06/13/25 under Section C, revealed a BIMS score of 03 which indicated that he had severe cognitive deficits.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement residents' care plans for Percutaneous Endoscopic Gastrostomy (PEG) site care (Resident #2 and Resident #9) and nail care for dependent residents' (Resident #7 and Resident #48) for four (4) of 19 care plans reviewed. Resident #2, #7, #9, and #48Findings Include: A review of the facility policy titled Comprehensive Plan of Care, revised 2/17/25, revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of practice . Resident #2 A review of Resident #2's Care Plan Report revealed under Focus: The resident requires tube feeding related to (r/t) LACK OF MENTAL ALERTNESS TO CHEW OR SWALLOW/INABILITY TO CHEW OR SWALLOW WITHOUT CHOKING OR ASPIRATING. The Interventions included: PEG: Clean peg site with daily wound care (w/DWC) and apply new drainage sponge at bedtime. Observation of medication administration for Resident #2 on 9/16/25 at 2:29 PM with Licensed Practical Nurse (LPN) #3, revealed no drainage sponge present around the PEG tube site. An interview with LPN #3, she confirmed there was not a drainage sponge present. Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Dysphagia following Cerebral Infarction, and Cognitive Communication Deficit. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/25 revealed, under Section C revealed, a Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely/never understood. Resident #7 A review of Resident #7's Care Plan Report revealed under Focus: The resident has an Activities of daily living (ADL) self-care deficit related to limited mobility, tremors, a diagnosis of Alzheimer's disease, and a need for assistance with all ADLs. The Interventions included: Fingernails and toenails to be cleaned, filed, and clipped as needed. During an observation on 9/15/25 at 2:59 PM, Resident #7 was observed sitting in a Geri-chair in her room. Her left hand was contracted, with fingers turned inward toward the palm. The fingernails on her left hand were excessively long, jagged, and measured approximately three-eighths (3/8) of an inch. During an observation and interview with LPN #4 on 9/16/25 at 2:32 PM, she confirmed Resident #7 had long fingernails on her contracted left hand and her care plan for nailcare was not followed. An interview with the Director of Nursing (DON) on 9/18/25 at 9:12 AM revealed the purpose of the care plan was to inform staff of the care that should be provided to residents. She explained her expectation was that staff follow the care plan developed for all the residents. A record review of the admission Record revealed the facility admitted Resident #7 on 3/24/22 with medical diagnoses including Essential (Primary) Hypertension. A record review of the MDS with an ARD of 7/16/25 revealed, under Section C, a BIMS score of 4, which indicated Resident #7 was severely cognitively impaired. Resident #9 A review of Resident #9's Care Plan Report revealed under Focus: The resident requires ENTERAL PEG feeding related to dysphagia. The Interventions included: PEG: Clean peg site w/DWC and apply new drainage sponge at bedtime. Date Initiated 4/16/25. On 9/17/25 at 10:30 AM, during an observation and interview LPN #2 revealed that PEG sites are to be cleaned each shift. She confirmed Resident #9's PEG site did not have a drainage sponge in place and the care plan was not followed. In an interview on 9/18/25 at 9:30 AM, the DON revealed that Resident #2 and Resident #9's care plans were not being followed. She confirmed that each resident's PEG site was to be cleaned and have a drainage sponge in place as ordered by the physician, and acknowledged the facility failed to ensure this was being done. Record review of Resident #9's admission Record revealed the resident was admitted on [DATE] with medical diagnoses which included Encounter for attention to Gastrostomy. Record review of Resident #9's MDS with an ARD of 7/13/25 revealed a BIMS score of 14, which indicated the resident is cognitively intact. Resident #48 Record review of Resident #48's Care Plan revealed that he had an ADL self-care performance deficit related to muscle weakness, lack of coordination, unsteadiness on feet, need for assistance with interventions that included Nail Care as Needed. An observation on 09/15/25 at 11:16 AM and on 09/16/25 at 8:38 AM revealed that Resident #48 had long, jagged fingernails on both hands. His fingernails were approximately one-half inch long and had brown substance underneath. Resident #48 stated, My fingernails need cutting and revealed that his fingernails had not been clipped in a while. An interview on 09/16/25 at 4:10 PM with MDS Nurse revealed that the purpose of the comprehensive care plan was to show what specific care they need. She revealed that the care plans were personalized for each resident and that personal hygiene including fingernail care was included in the interventions to be completed. She also agreed that since Resident #7 and Resident #48's fingernails were not cleaned or trimmed, the care plans were not followed. Record review of Resident #48's admission Record revealed an admission date of 08/03/23 and that he had diagnoses that included Congestive Heart Failure and Need for Assistance with Personal Care. Record review of Resident #48's Medication Review Report revealed that fingernails and toenails to be cleaned, filed and clipped as needed every day shift every Friday. Record review of Resident #48's MDS with ARD of 06/13/25 under Section C revealed a BIMS score of 03 which indicated that he had severe cognitive deficits.

Based on staff and resident interviews, record review and facility policy review the facility failed to protect a resident's right to be free from misappropriation of property for Resident #1 who was one (1) of three (3) sampled residents. Based on the facility's implementation of corrective actions taken on 10/11/24, this was determined to be Past Non-Compliance (PNC). Findings Include: Record review of the facility policy, Abuse, Neglect, and Exploitation with revision date of 10/10/22 revealed, Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. On 11/25/24 at 9:15 AM an interview with the Administrator (ADM) revealed that on the night shift (3-11) of 10/10/24, the Registered Nurse (RN) #1 notified the Administrator and Director of Nursing (DON) by phone that Resident #1's debit card was lost. The ADM revealed that the next morning, Social Worker (SW) talked to Resident #1, encouraged him to cancel his debit card and she assisted him with the phone call to the bank. When the SW spoke with the bank it was revealed that there had been recent charges on the resident's debit card that totaled $242.82 that was not made by the resident. The ADM confirmed that they immediately initiated an investigation and discovered that there were two clothing companies where the orders were placed. One of the clothing companies was able to give the name of the person who placed the order and the shipping address where the items would be delivered. ADM revealed that they concluded that it was an agency Certified Nursing Assistant (CNA) #1 who had used Resident #1's debit card to make the purchases and that it was her home address that matched the address where the items were to be shipped. ADM revealed that the first and only shift that the agency CNA #1 had worked at the facility was on 10/08/24, and she made those purchases using Resident #1's debit card. ADM revealed that he tried to call CNA #1 on two separate phone numbers they had on file, and was unable to reach her to obtain a statement. On 11/25/24 at 9:30 AM, an interview with Resident #1 revealed that he kept his debit card on his overbed table because he had been getting staff to use it to get him drinks and snacks out of the vending machine. He revealed that his debit card was lost one night in October. He revealed that staff looked all over for it and never found it. He stated that he didn't want his debit card turned off at first, but agreed to it the next morning and the SW came to his room and made the call to the bank for him. Resident #1 revealed that he had to verify with the bank representative the last purchases made on his debit card and found out that someone had made two transactions that totaled over two hundred dollars. Resident #1 revealed that they fired the aide who had used his debit card and he thought she had been arrested because the police came out and talked to him. Resident #1 revealed that the facility went out of their way to make things right and done way more than they should have to take care of this. On 11/25/24 at 10:00 AM, an interview with the DON, revealed that during the night shift on 10/10/24, RN #1 notified her and the ADM that they couldn't find Resident #1's debit card. She revealed that the ADM told them to report the debit card as lost or missing. She also revealed that RN #1 encouraged Resident #1 to cancel his debit card, but he declined due to the hassle. DON revealed that the next morning, SW encouraged Resident #1 to stop payment on the debit card, he agreed, and she assisted him. DON revealed that while the SW and Resident #1 were on the phone with the bank, Resident #1 had to confirm the last purchases made with the debit card and found that there were two charges that he had not made which totaled over two hundred dollars. DON revealed that the SW called the two companies and verified the name and shipping address of the person who had made the purchases and traced it to agency staff member CNA #1, who had worked on a previous night on the 3-11 shift. On 11/25/24 at 10:25 AM, an interview with SW revealed that Resident #1 told her that his debit card was lost. SW revealed that she encouraged him to cancel his debit card and request a new one. SW revealed that she assisted him with this and while on the phone with the bank, Resident #1 had to verify the last purchases he had made. SW revealed that they found out during the call to the bank, there were two other purchases on the card that he did not make which totaled over $200. She revealed that she reported this to ADM and DON, and they initiated an immediate investigation. SW revealed that she contacted the two companies from which the unapproved purchases were made, and one company verified the name and the shipping address of the person who made the purchase. She revealed that the shipping address matched the name and home address of an agency staff CNA who had worked the night before the card went missing. The SW revealed that both purchases were made on the same date and around the same time. On 11/25/24 at 2:20 PM, an interview with DON revealed that they tried to make sure they employed the best staff and that they had the right person for the job and stated, This CNA should never be allowed to work in a facility again with these vulnerable residents. She revealed that these residents had so little, and it angered her to find out that a staff member took from one of them. Record review of the facility Report to MSDH (Mississippi Department of Health) revealed under Investigation of Incident that on 10/10/24 at 9:28 PM, ADM and DON were notified by RN #1 that Resident #1's debit card was missing, they looked for it but could not find it. ADM instructed RN #1 to request that Resident #1 report the debit card missing to his bank. Resident stated, That is a hassle. The next morning (10/11/24) at approximately 9:22 AM, Resident #1 with the encouragement and assistance from the SW, contacted (Proper Name) bank to cancel his lost debit card and received notification that there were erroneous charges dated 10/09/24. These charges occurred before the debit card was lost on 10/10/24. Resident #1 with the assistance of SW contacted one of the companies where fraudulent orders were placed in order to locate the shipping address and the name of the individual placing the order. The address and name matched agency staff, CNA #1 with (Proper Name) Staffing Agency who worked on 10/08/24. This is the only shift that had been worked by this individual. She was immediately made a do not return to the facility. She has not and will not return. Record review of the typed Statement by SW, revealed that on 10/11/24, the social worker spoke with Resident #1 to confirm that his card was canceled and that a replacement card had been ordered. Resident #1 expressed the need for a phone to facilitate the cancellation process. At approximately 9:38 AM, this SW and Resident #1 contacted (Proper Name) Bank. The representative spoke with Resident #1 and requested verification of Resident #1's information which included confirming the last three transactions made. Resident #1 listed charges for a drink machine and (Proper Name) purchases but the representative indicated that these were not the most recent transactions. SW informed the representative that Resident #1's card was lost and they needed details about the transactions. The representative revealed that the latest charges included (Proper Name) for $37.40 and (Proper Name) for $205.42. Resident #1 confirmed that he had not made these purchases, his debit card was canceled and a new one ordered. The bank representative provided them with a contact number to dispute the unauthorized charges. The SW and Resident #1 contacted (Proper Name) Bank Dispute Department, provided information about the unauthorized transactions and Resident #1 was informed that he would receive a credit back to his account within ten (10) days. The representative emailed a bank statement copy to his email, detailing the date and time of the transactions. Staff members were notified of the situation. The SW and Resident #1 then reached out to (Proper Name) to obtain the name and address associated with the order. The (Proper Name) representative successfully provided the date order was placed, name on the order, and the shipping address. The information was relayed to ADM and DON. Signed by SW. Record review of the Nursing Home (Proper Name) Agency Orientation In-service Log revealed, Topic: I have been inserviced on the agency binder of my duties and responsibilities, abuse, neglect, and exploitation, emergency codes, resident's rights, infection control and prevention, HIPPA, and Lift Protocol. I understand if I have any questions, I am to ask a nursing home (proper name) employee. This orientation log was signed on 10/08/24 by agency staff CNA #1. Record review of Agency CNA's Shift Details form revealed that CNA #1 worked on 10/08/24. Her start time was 15:00 CDT (Central Daylight Time) and her End Time was 23:00 CDT (Central Daylight Time). The recorded time at the facility was 7 hours and 49 minutes. Record review of the facility Daily Route Sheet and Nursing Hours revealed that CNA #1 worked on 10/08/24 from 3:00 PM to 11:00 PM shift and that she was assigned to Resident #1. Record review of the Incident Report by the (Proper Name) Police Department dated 10/11/24 revealed that Officer (Proper Name) was dispatched to the facility to follow up on a report taken earlier that day. ADM reported that they discovered fraudulent charges to Resident #1's debit card before the card was lost. It seemed to be only a coincidence that the card was lost shortly after. ADM informed police officer that facility staff members contacted (Proper Name) to inquire about the fraudulent charges and a representative told them that the name on the order was (Proper Name) Agency CNA #1, and that it was being shipped to (Agency CNA's address). ADM informed police officer that they employed a CNA named (Proper Name) through a temp service on 10/08/24, the day before the fraudulent charges were made. ADM revealed that before this staff member worked, they obtained a copy of her driver's license, and the address matched the address that the items ordered were being shipped to. Record review of Resident #1's Account History Inquiry form revealed that transactions totaling $242.82 for (Proper Name) and (Proper Name) were made on 10/09/24 but did not process the bank until 10/10/24. This statement was verified by SW. Record review of Resident #1's Admission Record revealed an admitted [DATE]. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/30/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he was cognitively intact. The State Agency (SA) validated through interview with the Administrator and record reviews that the facility reported the incident to the State Department of Health, to Attorney General's Office, to the Local Police Department, and to the Staffing Agency (Proper Name) on 10/11/24 and they made her a Do Not Retain status. The final investigation report was submitted to the State Department of Health on 10/14/24. The SA validated through interview and record review with Administrator and DON that on 10/11/24, they conducted an immediate investigation and initiated a mandatory in-service with all staff on Abuse, Neglect, and Exploitation with special emphasis on cash and credit cards. All residents who were under the care of CNA #1 were interviewed and there were no other reports of missing items or concerns. Updated process and in-serviced staff: Anytime a resident requests that facility staff take money/debit card (as in this instance) to the vending machine (or for any other reason) to make a purchase for them the staff is not to take the money/card. The staff will notify the front office or the charge nurse and one of those individuals will handle the resident request with a witness. This in-service was given to all current staff at the time of the event and has been added to new hire orientation for all new employees (of any type) going forward. This is in addition to our more generalized abuse/neglect/misappropriation training that is done for all staff at regular intervals and all new staff at orientation. The implementation of this process was discussed with all residents at the time of the event. All potential grievances (including potential misappropriation) are reported by the facility grievance officer twice daily at the facility standup and standdown meetings. The SA validated through interview with Administrator and Social Worker that on 10/11/24, the facility reimbursed Resident #1 for $242.82, the total amount of the unauthorized debit card purchases made by CNA #1. The SA validated through record review of Reimbursement of Credit Card Charges form, revealed that Resident #1 was given a check on 10/11/24 in the amount of $242.82, for reimbursement of charges made on his personal debit card. The SA validated through interview with Administrator and record review that an Emergency QA (Quality Assurance) Committee Meeting was held on 10/11/24 regarding fraudulent charges found on Resident #1's bank account. The facility reimbursed Resident #1 of all charges, and going forward, the front office or charge nurse is to be notified if a resident needs staff to assist them to use their cash or credit/debit cards to purchase items from the vending machine or store or make on-line purchases for them. Residents are questioned in resident council regarding any potential misappropriation issues. In addition to resident council and grievance program: QA department interviewing two residents per hall weekly for four (4) weeks, then two (2) residents monthly for 2 months then one (1) resident monthly going forward through the calendar year. This process is reviewed monthly in facility QA meeting. No issues have been reported. On 11/25/24 the SA validated facility actions taken on 10/11/24 and determined this was PNC.

Based on staff interview, record review and facility policy review, the facility failed to accurately submit staffing data into the Payroll-Based Journal (PBJ) system for two (2) of 2 quarters reviewed. First and Second Quarters of 2024. Findings Include: Record review of the facility policy, Nursing Services and Sufficient Staff revised 10/12/22 revealed . Policy Explanation and Compliance Guidelines . 7. The facility is responsible for submitting timely and accurate staffing data through the CMS (Centers for Medicaid/Medicare Services) Payroll-Based Journal (PBJ) system . Record review of the PBJ (Payroll Based Journal) Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 2 2024 (January 1-March 31) revealed Excessively Low Weekend Staffing Triggered. Triggered =Submitted Weekend Staffing data is excessively low. Record review of the PBJ Staffing Data Report CASPER Report 1705D FY Quarter 1 (October 1 - December 31) revealed Excessively Low Weekend Staffing Triggered. Triggered = Submitted Weekend Staffing data is excessively low. On 07/16/24 at 9:20 AM, an interview with the Administrator (ADM) revealed he was aware they triggered excessively low weekend staffing for January through March 31, 2024, and for the last quarter, October 1 through December 31, 2023. He revealed that he was unsure why they triggered low staffing because they had more than adequate staffing. He revealed their staff ratio was usually above 3.0. The ADM revealed the Payroll Coordinator was responsible for gathering the information and putting in the data for the PBJ and submitting it. He revealed they had been trying to figure out why they triggered low weekend staffing so they could get it fixed but they couldn't find the problem. He revealed the Payroll Coordinator had contacted CMS (Centers for Medicare and Medicaid Services) and they were looking into it. The ADM revealed there seemed to be glitches in the system because they had trouble printing out the PBJ Staffing Data Report after submitting their information. On 07/16/24 at 9:30 AM, an interview with the Payroll Coordinator revealed when she realized they triggered for excessively low weekend staffing, she contacted CMS by phone, and she hadn't heard back. She revealed after she submitted the payroll information, she was not able to run the PBJ Staffing Data Report for January 1 through March 31 due to glitches in the system. The Payroll Coordinator stated she double checked everything and confirmed that the information was submitted correctly but she was afraid it would trigger again because they didn't know how to fix it or why it triggered low staffing. She stated, We have more than enough staff. She revealed she enters agency staff hours manually, but all other direct care staff hours roll over to her directly from their payroll system. The Payroll Coordinator revealed she always compares the date in their payroll system and makes sure it is correct before she submits it. Record review of the Staffing Grid for the quarters that triggered for low weekend staffing revealed staffing in the facility was sufficient.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possibility of cross contamination to food, as evidenced by failure to perform hand hygiene after picking up a soiled item off the floor during steam table temperature checks for one (1) of three (3) kitchen observations. Findings Include: Review of the facility policy titled Infection Prevention and Control with a revision date of 6/8/2023 revealed Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . During an observation of the lunch meal steam table temperature checks on 7/17/2024 at 11:58 AM, Dietary Staff #1 dropped a pen on the floor. She retrieved the pen from the floor and continued to check and record the food temperatures without washing her hands. An interview with Dietary Staff #1, on 7/17/2024 at 12:08 PM, revealed she was nervous and should have stopped and washed her hands to prevent the spread of bacteria to the food. An interview with the Administrator, on 7/17/2024 at 12:36 PM, revealed Dietary Staff #1 should have got a new pen or washed her hands after retrieving the pen from the floor to continue temperature checks. He acknowledged bacteria could cross contaminate the food.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) care was provided daily as evidenced by a resident did not receive daily oral care for one (1) of 26 residents reviewed. Resident #93. Findings Include: Record review of the facility policy Activities of Daily Living (ADL) revised 09/15/22 revealed Policy Explanation and Compliance Guidelines . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . On 07/15/24 at 10:55 AM, an interview with Resident #93 revealed she was admitted to the facility about three (3) months ago. She revealed the Certified Nursing Assistants (CNAs) gave her good baths, but she had a concern about her teeth not getting brushed. She revealed the CNAs had helped her brush her teeth a few times since she had been there and wasn't sure if they were supposed to help her with this. She stated, If I ask, they will sometimes do it, but if I don't ask, it doesn't get done. Resident #93 revealed that she brushed her teeth once or twice a day when she was at home. She revealed that she had used a wet washcloth and paper towels to clean her teeth a few times in the facility, but they didn't get her teeth clean. She revealed that she knew that poor oral care could cause tooth decay and bad breath and she would like her teeth to be brushed every day. On 7/16/24 at 9:00 AM an observation and interview with Resident #93 revealed she was sitting up in her wheelchair in her room drinking coffee. She revealed that the CNAs had not helped her brush her teeth since one day last week. She revealed that if they would get her a toothbrush and toothpaste and set up for her, she could brush her own teeth. Resident #93 revealed that she had asked staff several times to get her a toothbrush and toothpaste so she could brush her teeth and they told her that they would get someone to do it or they gave other excuses and never returned. Resident #93 stated, I guess they got busy or forgot about it. She also revealed that she had her own teeth and stated, I have good teeth but at this rate, they won't last much longer. On 7/16/24 at 9:05 AM, an observation revealed Resident #93 had poor oral hygiene as evidenced by a yellow substance between her upper and lower teeth and gum line. During an interview on 7/16/24 at 1:30 PM, with Licensed Practical Nurse (LPN) #1 in Resident #93's room confirmed the yellow substance on Resident # 93's upper and lower teeth and gum line. LPN #1 stated Her mouth looks pretty rough. LPN #1 revealed that mouth care should be done every day, she confirmed that Resident #93's teeth had not been cleaned and that she would get it taken care of now. LPN #1 revealed that failure to provide daily oral care to this resident could lead to gingivitis, loss of appetite, tooth decay, and other issues. She revealed that CNAs were responsible for completing daily personal hygiene and it included oral care. On 7/16/24 at 1:35 PM, an interview with CNA #1 revealed personal hygiene included mouth care and was supposed to be provided every day. She revealed the CNAs helped residents brush their teeth, rinsed their mouth and provided mouthwash for the residents. CNA #1 revealed she didn't get here until 8:00 AM today and assumed the night shift CNA had taken care of Resident #93. CNA #1 looked at Resident #93's teeth and confirmed that her mouth care had not been done. She revealed that failure to provide mouth care could lead to gingivitis and other problems. On 07/17/24 at 9:20 AM, an interview with the Director of Nursing (DON) revealed the CNAs were responsible for providing personal hygiene for all residents. She confirmed personal hygiene included oral care. She revealed that failing to provide oral care for Resident #93 was not healthy and agreed that it could lead to tooth decay, bad breath, and other health problems. She revealed mouth care was supposed to be done every day and as needed. The DON revealed the CNAs on night shift got some of the residents up before the day shift came in and the day shift CNAs got the rest up and stated, I hate she's fallen through the cracks. She revealed they would resolve this issue now and that she wanted all their residents taken care of. Record review of Resident #93's Admission Record revealed an admitted [DATE] with diagnoses that included Parkinson's Disease without Dyskinesia and Need for Assistance with Personal Care. Record review of Resident #93's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated that she was cognitively intact. Section GG revealed she required partial to moderate assistance with oral hygiene.

Based on observation, Resident Representative (RR) and staff interview, record review and facility policy review the facility failed to prevent the possibility of an accident as evidenced by a physician ordered medication being found in a resident's bed for one (1) of 27 sampled residents. Resident #52 Findings Include: Review of the facility policy titled, Medication Administration with a revision date of 6/8/23 revealed under Policy Explanation and Compliance Guidelines .#16. Observe the resident consumption of medication. An interview and observation on 07/15/24 at 11:22 AM, with the RR for Resident #52 revealed she was making her mother's bed and found a blue pill in the sheets. This observation revealed she was holding the blue pill. She stated she had called for the nurse. She stated this is not the first time she has found medicine in her mother's bed, but it has been a while. An observation and interview on 7/15/24 at 11:25 AM, with Licensed Practical Nurse (LPN) #3 confirmed the blue pill found in Resident #52's bed was Levothyroxine150 micrograms (mcg). An observation at this time of the resident's medication cards confirmed this pill was Levothyroxine 150 mcg. She stated that it was supposed to have been given between 5-6 AM this morning. She stated the nurse should always stay with the resident to make sure the resident has swallowed all the medications. She stated she would make the Registered Nurse (RN) supervisor aware. An interview on 7/15/24 at 11:30 AM, with RN #1 confirmed the nurse giving the medications should always stay with the resident and make sure the resident has swallowed all medications. An interview on 07/16/24 03:11 PM, with the Director of Nurses (DON) confirmed the medication nurses should always stay with the resident until they had swallowed all medications. She stated the purpose was to make sure the resident took all of their medication, and that no other resident would have access to it. An interview on 7/16/24 at 8:50 PM, with LPN #5 revealed she was Resident #52's nurse on Sunday night 7/14/24 going into Monday morning 7/15/24 and confirmed she gave the resident her medicine while she was in her wheelchair. She stated she has only worked with this resident twice but was warned by other staff members that she tends to not swallow all her medications. She stated the purpose of staying with the resident to make sure they swallow the pills is to make sure they do not get choked on the medications, or that there are no medications left that other residents could find and take. An interview on 7/16/24 at 9:04 PM, with LPN #6 revealed she was Resident #52's nurse on Saturday night 7/13/24 going into Sunday morning 7/14/24 and she gave the resident her medication while she was sitting in her wheelchair. She revealed she always stays with her resident while they take their medicines to make sure they swallow it all. She stated she had been warned about this resident not always wanting to swallow her medicines, so she was aware of that possibility, but she stayed with her. She stated that the purpose of staying with the resident while they take their medicines is because its physicians orders, they get the medicines they need and to make sure no other resident gets them. Review of Resident #52's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's disease. Review of the Care Profile for Resident #52 revealed a physician order dated 10/11/23 for Levothyroxine TAB (tablet) 150 mcg Give 1 tablet by mouth one time a day. Record review of Resident #52's July 2024, Medication Administration Record (MAR) revealed Levothyroxine 150 mcg was documented as given daily through 7/16/24.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to implement an Activities of Daily Living (ADL) care plan for one (1) of 26 residents care plans reviewed. Resident #93 Findings Included: Record review of the facility policy titled, Comprehensive Plan of Care revised 10/10/22 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Record review of Resident #93's care plan, date initiated 4/11/24 revealed Focus: The resident has an ADL self-care performance deficit .Interventions . Resident is usually extensive assistance x (times) 1 with bed mobility, toilet use, personal hygiene, and dressing . During an interview on 7/15/24 at 10:55 AM, an interview with Resident #93 revealed she had been at this facility about three (3) months. She revealed the Certified Nursing Assistants (CNAs) gave her good baths but she was concerned about her teeth. Resident #93 revealed that the staff had brushed her teeth a few times since she had been here, but they had not brushed her teeth since 1 day last week. She stated, If I ask, they will sometimes do it, but if I don't ask, it doesn't get done. Resident #93 revealed that she knew that not brushing her teeth could lead to tooth decay and bad breath and she liked her teeth brushed every day. On 07/16/24 at 9:00 AM, an observation and interview with Resident #93 revealed she was sitting up in her wheelchair in her room drinking her coffee. She revealed that if someone would get her a toothbrush and toothpaste and set them up for her, she could brush her own teeth. She revealed that she had her own teeth and stated, I have good teeth but at this rate, they won't last much longer. On 07/16/24 at 9:05 AM, an observation revealed resident's poor oral hygiene with a yellow substance between her upper and lower teeth and gum line. On 07/16/24 at 1:30 PM an interview with Licensed Practical Nurse (LPN) #1, confirmed the yellow substance on Resident #93's upper and lower teeth and gum line and confirmed that her teeth had not been cleaned. She stated, Her mouth looks pretty rough. LPN #1 revealed that mouth care should be done every day and she would get it taken care of now. LPN #1 revealed that failure to complete daily oral care could lead to gingivitis, loss of appetite, and other issues. She also revealed that mouth care was included in daily personal hygiene and documented by the CNAs. On 07/16/24 at 1:35 PM, an interview with CNA #1 revealed that personal hygiene included mouth care and was supposed to be done every day. She revealed the CNAs helped residents brush their teeth, they rinsed their mouth and provided mouthwash for the residents. CNA #1 revealed she didn't get there until 8:00 AM today and that Resident #93's mouth care had not been done. On 07/17/24 at 9:20 AM, an interview with Director of Nursing (DON) revealed the CNAs were responsible for resident oral care. She revealed that personal hygiene included oral care and was included in Resident #93's care plan. The DON revealed the purpose of the comprehensive care plans was to ensure the staff knew how to take care of each resident to meet their individualized needs. She agreed Resident #93's ADL Care Plan was not implemented when the CNAs failed to ensure that she received daily oral care. Record review of Resident #93's Admission Record revealed an admitted [DATE] with diagnoses that included Parkinson's Disease without Dyskinesia and Need for Assistance with Personal Care.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure there was a physicians order for a bolster sheet that was being used to prevent a resident from getting out of bed for one (1) of 27 residents on sample. Resident #81 Findings Include Review of the facility policy titled, Restraints with a revision date of 11/28/17 revealed . Restraint Order .orders for restraint should specify: the rationale (medical necessity) for the use of restraint, the type of restraint . An observation on 07/15/24 at 10:50 AM, revealed there was a concave mattress on Resident #81's bed and the resident was gone to dialysis. An interview on 7/16/24 at 9:00 AM, with Registered Nurse (RN) #1 revealed Resident #81 had several falls and the facility had implemented several different measures to prevent them. She stated that the residents' mind has worsened, and she thinks she can still walk sometimes, especially if she wakes up at night. She revealed they had put her bed in the lowest position and used the concave mattress, because she would forget to use her call light. An interview on 7/16/24 at 3:00 PM, with the Director of Nurses (DON) confirmed Resident #81 had several falls and they have ended up using the concave mattress and it has helped. Record review of Resident #81's physicians orders revealed there was no order for a Concave mattress or Bolster sheet. Record review of the Resident #81 care plans revealed a care plan that was initiated on 12/11/23 for Risk for Falls with interventions that included Bolster sheet to air mattress. An observation, interview and record review on 7/17/24 at 9:40 AM, with RN #1 and Licensed Practical/Quality Assurance Nurse (LPN/QA) #2 confirmed Resident #81 had a Bolster sheet on top of her air mattress and did not have an order. She stated that it appeared that it may have been implemented with the fall that occurred 6/8/24. LPN/QA #2 confirmed Resident #81 should have an order for the bolster sheet on her air mattress and that it does prevent her from getting out of bed. An interview on 7/17/24 at 10:12 AM, the DON confirmed Resident #81 did not have an order for the bolster sheet on her air mattress. She stated she was not aware they needed an order since they were using it to define the parameters of the bed. She stated the purpose of the bolster sheet is to prevent resident's from getting out of the bed. Record review of Resident #81's Admission Record revealed the resident was admitted to the facility initially on 7/12/23 with medical diagnoses that included Osteomyelitis of Vertebra.

Based on record review, staff interview, and facility policy review, the facility failed to complete a Quarterly Minimum Data Set (MDS) resident assessment within the fourteen-day time frame for two (2) of 27 sampled residents. Resident #54 and #59 Findings Include: Record review of the facility policy titled MDS Assessments with a revision date of 6/9/2023 revealed Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity using the RAI (Resident Assessment Instrument) manual. Record review of the facility's MDS 3.0 NH (Nursing Home) Final Validation Report dated 7/11/2024 revealed a warning message for Resident #54 and Resident #59's Quarterly MDS with an Assessment Reference Date (ARD) of 5/29/24 indicated, Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Record review of Resident #54 and Resident #59's Quarterly MDS with an ARD of 5/29/2024 revealed under section Z0500, Date RN (Registered Nurse) Assessment Coordinator signed assessment as complete indicated 07/11/2024. An interview with the MDS nurse on 7/17/2024 at 11:10 AM, confirmed Resident #54 and Resident #59's Quarterly MDS assessments were completed late. She revealed that she had made corrections to both assessments which caused some delay. The MDS nurse confirmed that both assessments should have been closed by 6/12/2024. She explained they follow the RAI procedure manual for guidance in completing the MDS. An interview with the Director of Nursing (DON) on 7/17/2024 at 11:21 AM, revealed her expectations were for the MDS Nurse to complete the MDS assessments within the designated time frame set forth by CMS (Centers for Medicare and Medicaid Services). Record review of the Admission Record revealed the facility admitted Resident #54 on 12/16/2022 with medical diagnosis of Alzheimer's disease. Record review of the Admission Record revealed the facility admitted Resident #59 on 8/29/2023 with medical diagnosis of Alcohol dependence with alcohol-induced persisting dementia.

Based on record review, interview and policy/procedure review, the facility failed to implement the comprehensive person-centered care plan for one (1) of 11 residents sampled, Resident #1. Certified Nurse Aide (CNA) #1, CNA # 2 and CNA #3 failed to follow the Activities of Daily Living (ADL) care plan to use a mechanical lift for Resident #1 and transferred her during the 7:00 AM to 3:00 PM shift on 12/28/23, manually transferring her twice and with the sit to stand lift once. Resident #1 began to display signs of pain on the 3:00 PM to 11:00 PM shift and was given an as needed Acetaminophen. The Nurse Practitioner (NP) ordered in-house X-rays on 12/29/23 due to continued pain. The in-house X-rays were negative for fractures, but it did note that Resident #1 was uncooperative during the X-rays. On 12/30/23, when the resident began guarding her lower right extremity, the NP ordered Resident #1 be sent to the hospital for assessment, evaluation, and X-rays. The X-rays on 12/30/23 revealed a closed nondisplaced fracture of medial condyle of right femur. Resident #1 was fitted with a right knee immobilizer and discharged back to the nursing home on 12/30/23. Based on the facility's implementation of corrective actions on 12/30/23 - 1/2/24 taken prior to survey entrance on 1/23/24, this deficient practice was determined to be Past Non-Compliance. Findings include: Review of the facility's policy Comprehensive Plan of Care revised 10/10/2022 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Record review of the ADL care plan Date Initiated 12/20/2023 Revised on 01/25/2024 revealed the Interventions: Transfer: The resident requires Total Lift with 2 staff assistance for transfers with medium sling. Date Initiated: 12/20/2023 Revision on 01/25/2024. Record review of the facility's incident report dated 01/01/2024 revealed that on 12/28/23, Resident #1 began to complain of pain in the Right Lower Extremity (RLE). She was assessed by nursing with no redness or swelling. Resident #1 was medicated with a standing order of Tylenol 650 MG for pain. On 12/29/23, Resident #1 still exhibited pain to the right knee and the Nurse Practitioner ordered a STAT X-ray to be done in the facility. This X-ray was negative for fractures. On 12/30/23, Resident #1 was still complaining of pain in the right knee. The Nurse Practitioner sent her to the emergency room for further evaluation and X-rays. The X-rays on 12/30/23 revealed a closed nondisplaced fracture of medial condyle of right femur. Resident #1 was fitted with a right knee immobilizer and discharged back to the nursing home on 12/30/23. The facility began to conducted an investigation to determine how Resident #1 fracture occurred. Based on interviews with CNA #1, CNA #2 and CNA #3 transferred Resident #1 three (3) times and admitted to not using a Total Lift for those transfers. Record review on 1/26/24 of Resident #1's Certified Nurse Aide Standard Task: ADL-Transferring, Date initiated 10/11/2023 revealed that Resident #1 requires a Total Lift X2 (times two) Assist. On 1/29/24 at 12:25 PM, in an interview with the Administrator, revealed that he was notified about Resident #1's X-ray results from the hospital by the Director of Nursing (DON) on 12/30/23. We immediately began an investigation. He stated No, the Cans did not follow the care plan. Resident #1 requires a total lift for all transfers. There were 3 Cans that admitted to providing a manual transfer and a sit to stand lift on 12/28/23. They were suspended during the investigation and terminated after the investigation completed. He stated we began in-services immediately after being notified of the fracture. We had an emergency QA (Quality Assurance) meeting. There was a lift inservice and nursing staff had to demonstrate use of each lift. We use the Total lift and sit to stand lift. The other in-services were on abuse, neglect, resident rights, following the care plans. On 1/29/24 at 3:30 PM, interview with the Administrator revealed Resident #1 should be transferred with a total lift and 2 staff members. All three knew this and had been trained on lift use and admitted knowing the resident should have been transferred with a total lift and with 2 staff members. He stated he 3 CNAs did not follow the care plan. That information is on the door of each resident's closet, the kiosk on the wall for CNAs to read the plan of care for each resident and it is on the ADL care plan. On 1/29/24 at 2:15 PM, interview with the DON she stated that during the investigation, it was revealed that Resident #1 was transferred three times on 12/28/23, twice by manual transfer and once by the sit to stand lift. She stated that Resident #1 required a total lift with the assistance of 2 staff members for transfers. Three CNAs admitted to performing or assisting with transfers on Resident #1 that were not on the residents care plan. CNAs #1 admitted to transferring Resident #1 manually twice and using the sit to stand without any assistance of another staff member once on 12/28/23. CNAs #1 was a new hire. She stated that CNAs #2 told her, during training, that Resident #1 could be transferred by either the sit to stand lift or manually even though her plan of care had to use a total lift. The DON revealed We immediately began in-servicing staff on abuse, neglect, resident rights, following the plan of care and lifts. We reviewed the plan of care of each resident that require lifts for transfers to make sure the plan of care is what their most recent lift assessment has She stated No, they did not follow the care plan for Resident #1. She revealed that each resident that requires lift use has the lift type, number of staff needed, and sling size is on the kiosk where the CNAs' get their care plan for ADL's, it is on the care plan in the medical record and it is also on the closet door of each resident. She also confirmed that the three CNAs' involved had training on lifts and following the care plan in the last 8 months. On 2/1/24 at 9:10 AM, interview with CNAs #1 revealed that she was assigned to Resident #1 on 12/28/23. She stated that when in training and orientation A CNAs (name of CNAs #2) was training me and she told me that even though Resident #1 is supposed to be a total lift with 2 people, she can transfer with help manually or use the sit to stand lift. On her first transfer on 12/28/23, from the bed to the shower chair, (name of CNAs #2) helped me do a manual transfer. We were on each side of her. The bed was lowered down to the level of the shower chair. In the shower room, I transferred her from the shower chair to her wheelchair using a sit to stand lift with (Name of CNAs #3). Before my shift was over, I transferred her by myself manually back to bed. She stated you can find the plan of care on the kiosk. That would have how to each resident is transferred. It is also on each resident's closet. It has the lift, number of staff to do the transfer and the sling size. It is in the ADL care plan too. I knew she was a total lift with 2 people, but I had been told by another CNAs that Resident #1 can manually transfer so that is what I did. She revealed Yes, I had lift training during orientation. I had care plan training during orientation also. Interview with CNAs #2 on 1/29/24 at 2:30 PM revealed, When I was training CNAs #1, we did a manual lift on Resident #1 together. We were putting her in the shower chair from her wheelchair that time. She revealed that it is on resident closet doors, the kiosk and in the ADL care plan on how each resident is transferred. Interview with CNAs #3 on 1/29/24 at 2:40 PM revealed Resident #1 was not my resident that day. I was only helping CNAs #1 with her. (Name of CNAs #1) asked me to help her put Resident #1 on the shower chair. I said to (name of CNAs #1) that Resident #1 is supposed to be on a total lift for transfers. On her closet, it said total lift. We proceeded to manually transfer Resident #1. I got on 1 side of the bed and (name of CNAs #1) got on the other side of the bed. We went 1,2,3 and put Resident #1 on the shower chair manually. No, she didn't stand on her feet. We lifted her, nothing touched the floor after that (name of CNAs #1) took Resident #1 to the shower room. Yes, how to transfer a resident is on the closet door. It is also on the ADL's care plan. Yes, I was trained on lifts. I know it takes 2 people to use a lift. Record review of Resident #1's Admission Record revealed she was admitted to the facility 1/2/2020 with diagnoses including Muscle Weakness generalized, other lack of coordination, unspecified dementia, Morbid Obesity, and Need for Assistance with Personal Care. Record review of Resident #1's MDS dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) of 03 meaning she is unable to make daily decisions for herself. Validation of Past non-compliance The State Agency (SA) validated through interviews, record review of Progress Notes, Medical Doctor orders and emergency room documentation, on 12/29/23, Resident #1 was assessed with no injuries noted after complaints of pain to her right knee. The NP ordered a STAT X-ray with no fractures noted. The resident was sent to the emergency room (ER) on 12/30/23 by the NP related to continued complaints of pain in the right knee. X-rays at the ER revealed a closed nondisplaced fracture of medial condyle of right femur. She returned to the facility on [DATE] with a knee immobilizer on her right knee. The SA validated by interviews and record review the Director of Nurses began her investigation on 12/30/23 when notified of the fracture. She obtained written statements from staff in the facility beginning on 12/28/23 when Resident #1 began complaining of pain. There were three (3) Certified Nurse Aides (CNAs) that admitted to performing 3 inappropriate transfers of Resident #1 on 12/28/23. The 3 CNAs' were suspended 12/29/23 pending investigation completion and then terminated on 1/3/24. The SA validated from record review and interviews, the Resident Representative (RR) was notified on 12/30/2023 and the State Agency (SA) was notified on 12/30/2023. The Attorney General office was notified when the CNAs' admitted to the inappropriate transfers. All CNAs' and nurses were in serviced starting 12/30/23 on following the individual care plan related to lift use, the facility policies on Lift Use, Abuse and Neglect, and Care Plans. This was validated by the SA from sampled staff being interviewed to confirm their attendance, knowledge of the training, observation of lift use and record review of the signed documents of the attendance by the staff. All nursing new hires will be in-serviced upon hire. The SA validated through interviews that all residents care plans, lift instructions, and the resident cards located on individual resident closet doors were audited to ensure correct and consistent information. Sampled residents care plans, lift instructions, resident cards located on individual resident closet doors were audited by the SA to confirm they had consistent and correct information. The SA validated through record review and interview that the facility held a Quality Assurance and Performance Improvement meeting on 1/2/24 to discuss the incident regarding 3 CNAs' failing to use the correct lift technique for Resident #1. The SA was able to validate the actions the facility took after the incident, beginning 12/30/23 and prior to SA entrance for survey on 1/23/24, involving Resident #1 and CNAs #1, CNAs #2 and CNAs #3 through record review, interviews, and observations.

Based on record review, policy/procedure review and interview, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of 11 residents sampled, Resident #1. During the 7:00 AM to 3:00 PM shift on 12/28/23, Certified Nurse Aide (CNA) #1, CNA #2 and CNA # 3 transferred Resident #1, using a manual transfer twice and the sit to stand lift once. Resident #1 began to display signs of pain on the 3:00 PM to 11:00 PM shift and was given an as needed Acetaminophen. The Nurse Practitioner (NP) ordered in-house X-rays on 12/29/23 due to continued pain. The in-house X-rays were negative for fractures, but it did note that Resident #1 was uncooperative during the X-rays. On 12/30/23, when the resident began guarding her lower right extremity, the NP ordered that Resident #1 be sent to the hospital for assessment, evaluation, and X-rays. The X-rays on 12/30/23 revealed a closed nondisplaced fracture of medial condyle of right femur. Resident #1 was fitted with a right knee immobilizer and discharged back to the nursing home on 12/30/23. Based on the facility's implementation of corrective actions on 12/30/23 - 1/2/24 taken prior to survey entrance on 1/23/24, this deficient practice was determined to be Past Non-Compliance. Findings include: Policy and procedure review of the facility's Safe Lifting Program last revised 9/22/22 revealed the Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the residents while keeping the employees safe in accordance with current standards and guidelines .Compliance Guidelines .10. Two staff members must be utilized the transferring residents with a mechanical lift .13. Staff members are expected to maintain compliance with safe handling/transfer practices .14. Resident lifting and transferring will be performed according to the resident's individual plan of care. Record review of the facility's incident report dated 01/01/2024 revealed that on 12/28/23, Resident #1 began to complain of pain in the right lower extremity (RLE). She was assessed by nursing with no redness or swelling. Resident #1 was medicated with a standing order of Tylenol 650 MG (milligrams) for pain. On 12/29/23, Resident #1 still exhibited pain to the right knee and the Nurse Practitioner ordered a STAT (immediate) X-ray to be done in the facility. This X-ray was negative for fractures. On 12/30/23, Resident #1 was still complaining of pain in the right knee. The Nurse Practitioner sent her to the emergency room for further evaluation and X-rays. The X-rays on 12/30/23 revealed a closed nondisplaced fracture of medial condyle of right femur. Resident #1 was fitted with a right knee immobilizer and discharged back to the nursing home on 12/30/23. The facility began to conduct an investigation to determine how Resident #1's fracture occurred. Based on interviews with CNA #1, CNA #2 and CNA #3 transferred Resident #1 three (3) times and admitted to not using a Total Lift for those transfers. Record review of the ED (Emergency Department) Provider Notes dated 12/30/23 revealed, .Examination XR (x-ray) knee right AP and Lateral .Impression fracture of the distal medial right femoral metaphysis likely acute .Clinical Impression: Final diagnoses: Closed non-displaced fracture of medial condyle of right femur . Record review of Resident #1's Certified Nurse Aide Standard Task: ADL-Transferring, Date initiated 10/11/2023 revealed that Resident #1 requires a Total Lift X2 (times two) Assist. Record review of a Progress Note for Lift/transfer evaluation Effective Date 12/6/23 revealed Resident is not able or partially able to assist with transfers from bed to bed. Review of the Nurse Practitioner's (NP) Progress Notes: CPT (Amended) with Date of Service (DOS) being 12/29/2023 revealed that Resident #1 was seen by the NP due to c/o acute RLE (right lower extremity) pain and no reported injuries. The NP's Plan: obtain STAT 2 view x-ray of bilateral hip/pelvis/right knee/continue Tylenol. Record review of Progress Notes dated 12/30/2023 0900 written by a Licensed Practical Nurse (LPN) revealed NP made aware of Xray results that showed no abnormality to R (right) knee. Res still continues to display s/s of increased pain. NP ordered for res (resident) to be sent to (name of hospital) ER for further eval (evaluation). RP aware. Record review of Progress Notes dated 12/30/2023 11:42 revealed transfer to (local emergency room ) for evaluation on leg and thigh pain. Record review of Progress Notes dated 12/30/2023 17:16 revealed a call from the ER reporting Resident #1 has a right distal medial femoral fracture. Resident to return to facility with knee immobilizer this evening. Record review of Progress Notes dated 12/30/2023 18:45 revealed Resident #1 returned from the hospital with a knee immobilizer observed to R knee. Interview with the Administrator on 1/29/24 at 12:25 PM, revealed he was notified about Resident #1's X-ray results from the hospital by the Director of Nursing (DON) on 12/30/23. We immediately began an investigation. Resident #1 requires a total lift for all transfers. There were 3 CNA's that admitted to doing a manual transfer and a sit to stand lift on 12/28/23. They were suspended during the investigation and terminated after the was completed. He revealed that the DON contacted the State Agency (SA) and the Attorney General's (AG) office timely. He stated, We began in-services immediately after being notified of the fracture. We had an emergency QA (Quality Assurance) meeting. There was a lift inservice and nursing staff had to demonstrate use of each lift. We use the Total lift and sit to stand lift. The other in-services were on abuse, neglect, resident rights, and following the care plans. Interview with the Administrator on 1/29/24 at 3:30 PM, regarding the fracture of Resident #1 revealed, We were unsure of how the fracture happened. It was called in to licensure in the 2-hour time frame. We began investigating the fracture by backtracking who had cared for Resident #1 prior to the fracture and trying to find when she began having pain. The AG office was notified on 1/2/24 when we knew exactly what had happened after the interview, demonstrations and written statements by the three CNAs (CNA #1, CNA #2 and CNA #3). Resident #1 should be transferred with a total life and 2 staff members. All three knew this and had been trained on lift use and admitted knowing the resident should have been transferred with a total lift and with 2 staff members. Interview with the DON on 1/29/24 at 2:15 PM, she stated that during the investigation, it was revealed that Resident #1 was transferred three times on 12/28/23 twice by manual transfer and once by sit to stand lift. She stated that Resident #1 was a total lift with the assist of 2 staff members. Three CNAs were suspended, then their employment was terminated. All three admitted to performing or assisting with transfers on Resident #1 that were not on the resident's care plan. It was noted that late on 12/28/23 that Resident #1 was displaying signs of pain. A nurse assessed her and saw no signs of redness or swelling on her body. On 12/29/23, Resident #1 was still expressing signs of pain. The Nurse Practitioner (NP) ordered X-rays to be done STAT in house. The results did not show any fractures but did note that the resident was moving during the X-rays. On 12/30/23, the NP then ordered Resident #1 to be sent to the hospital for assessment and treatment because of continued pain. The X-rays from the hospital revealed a distal medial right femoral fracture. She returned to the facility with a knee immobilizer. I began the investigation when I got the X-ray results. During the investigation, we started looking at 12/28/23, the day she began to show signs of pain. The three CNAs involved were (names of CNA #1, CNA #2 and CNA #3). CNA #1 was the CNA assigned to Resident #1 on 12/28/23. CNA #1 admitted to transferring Resident #1 manually twice and using the sit to stand lift without any assistance of another staff member once on 12/28/23. CNA #1 was a new hire. She stated that CNA #2 told her, during training, that Resident #1 could be transferred by either the sit to stand lift or manually even though her plan of care had to use a total lift. CNA #3 admitted to assisting CNA #1 with a manual transfer of Resident #1 on 12/28/23. CNA #2 admitted to assisting CNA #1with a manual transfer of Resident #1 on 12/28/23. All 3 CNA's wrote and signed statements regarding what happened with Resident #1. They were suspended. They did return to the facility to demonstrate to the Quality Assurance (QA) team what had happened with Resident #1's transfers. Once the demonstration was completed, all three were terminated. She stated, We immediately began in-servicing staff on abuse, neglect, resident rights, following the plan of care and lifts. We did a check-off for staff and in-service on lifts. They were required to demonstrate using each lift. There was an emergency QA meeting. We reviewed the plan of care of each resident that require lifts for transfers to make sure the plan of care is what their most recent lift assessment has. She revealed that each resident that requires lift use has the lift type, number of staff needed, and sling size is on the kiosk where the CNAs get their care plan for ADL's, it is on the care plan in the medical record, and it is also on the closet door of each resident. She confirmed that she notified the State Agency (SA) within 2 hours of getting the X-ray results from the hospital. She stated the Attorney General (AG) office was notified of the incident and the admissions of each CNA. She also confirmed that the three CNAs involved had training on lifts and following the care plan in the last 8 months. Interview with the Nurse Practitioner on 1/26/24 at 9:45 AM, revealed that she saw Resident #1 on 12/27/23 and there were no issues. She was notified on 12/29/23 that the resident was guarding her right leg and moaning. She ordered STAT X-rays on 12/29/23 of the pelvic area, hips and lower extremities. That set of X-rays were done in the facility and it was noted on the X-rays that the resident was moving frequently during the X-rays. She ordered the resident be sent to the hospital on 12/30/23 when the staff stated she was continuing to display symptoms of pain. I saw her on 12/29/23 for acute pain in the right lower extremity. She would not let me extend the right lower extremity. I ordered X-rays to be done in house at that time. The results were negative for fracture but did state the resident was moving during the X-rays. On 12/30/23, she was still complaining of pain in the right lower extremity, so I had her sent to the hospital for better X-rays and further assessment. (Name of DON) began an investigation when the hospital X-rays revealed a fracture of the right femur. She returned from the hospital with a knee immobilizer on the right leg the same day. Interview with CNA #1 on 2/1/24 at 9:10 AM revealed that she was assigned to Resident #1 on 12/28/23. She stated that when in training and orientation (Proper name of CNA #2) was training me and she told me that even though Resident #1 is supposed to be a total lift with 2 people, she can transfer with help manually or use the sit to stand lift. On her first transfer on 12/28/23, from the bed to the shower chair, (name of CNA #2) helped me do a manual transfer. We were on each side of her. The bed was lowered down to the level of the shower chair. In the shower room, I transferred her from the shower chair to her wheelchair using a sit to stand lift with (Proper name of CNA #3). Resident #1 never complained of pain or showed signs of pain. She went to lunch, therapy and the beauty shop that day. Before my shift was over, I transferred her by myself manually back to bed. I lowered her bed to the level of her wheelchair seat and put her on her bed. She rubbed her leg but when I changed her, there was no swelling, bruising or redness noted. I did not ask for help when I did her last transfer. I was suspended when they were doing the investigation and then terminated after the investigation was complete. You can find the plan of care on the kiosk. Those are the computers on the walls on each hall. That would have how each resident is transferred. It is also on each resident's closet. It has the lift, number of staff to do the transfer and the sling size. It is in the ADL care plan too. I knew she was a total lift with 2 people, but I had been told by another CNA that Resident #1 can manually transfer so that is what I did. She revealed, I had lift training during orientation. I had care plan training during orientation also. Interview with CNA #2 on 1/29/24 at 2:30 PM revealed No, I did not tell CNA #1 to transfer Resident #1 manually during training. I told her she has to use the lift. I was on a different hall that day. Now, when I was training CNA #1, we did a manual lift on Resident #1 together. We were putting her in the shower chair from her wheelchair that time. She was unable to recall the date. She revealed that it is on resident closet doors, the kiosk and in the ADL care plan on how each resident is transferred. Interview with CNA #3 on 1/29/24 at 2:40 PM, revealed Resident #1 was not my resident that day. I was only helping CNA #1 with her. (Name of CNA #1) asked me to help her put Resident #1 on the shower chair. I said to (name of CNA #1) that Resident #1 is supposed to be on a total lift for transfers. On her closet, it said total lift. We proceeded to manually transfer Resident #1. I got on 1 side of the bed and (name of CNA #1) got on the other side of the bed. We went 1,2,3 and put Resident #1 on the shower chair manually. No, she didn't stand on her feet. We lifted her, nothing touched the floor after that (name of CNA #1) took Resident #1 to the shower room. How to transfer a resident is on the closet door. It is also on the ADL's care plan. I was trained on lifts. I know it takes 2 people to use a lift. Record review of Resident #1's Admission Record revealed she was admitted to the facility 1/2/2020 with diagnoses including Muscle Weakness generalized, other lack of coordination, unspecified dementia, Morbid Obesity, and Need for Assistance with Personal Care. Record review of Resident #1 Minimum Data Set (MDS) dated [DATE] Section G Functional Status revealed Resident #1 required two person extensive physical assistance with transfers. Record review of Resident #1's MDS dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 03 meaning she is unable to make daily decisions for herself. Validation of Past non-compliance The State Agency (SA) validated through interviews, record review of Progress Notes, Medical Doctor orders and emergency room documentation, on 12/29/23, Resident #1 was assessed with no injuries noted after complaints of pain in her right knee. The NP ordered a STAT X-ray with no fractures noted. The resident was sent to the emergency room (ER) on 12/30/23 by the NP related to continued complaints of pain in the right knee. X-rays at the ER revealed a closed nondisplaced fracture of medial condyle of right femur. She returned to the facility on [DATE] with a knee immobilizer on her right knee. The SA validated by interviews and record review the Director of Nurses began her investigation on 12/30/23 when notified of the fracture. She obtained written statements from staff in the facility beginning on 12/28/23 when Resident #1 began complaining of pain. There were three (3) Certified Nurse Aides (CNA) that admitted to performing 3 inappropriate transfers of Resident #1 on 12/28/23. The 3 CNAs were suspended 12/29/23 pending investigation completion and then terminated on 1/3/24. The SA validated from record review and interviews, the Resident Representative (RR) was notified on 12/30/2023 and the State Agency (SA) was notified on 12/30/2023. The Attorney General office was notified when the CNA's admitted to the inappropriate transfers. All CNA's and nurses were in serviced starting 12/30/23 on following the individual care plan related to lift use, the facility policies on Lift Use, Abuse and Neglect, and Care Plans. This was validated by the SA from sampled staff being interviewed to confirm their attendance, knowledge of the training, observation of lift use and record review of the signed documents of the attendance by the staff. All nursing new hires will be in-serviced upon hire. The SA validated through interviews that all residents care plans, lift instructions, and the resident cards located on individual resident closet doors were audited to ensure correct and consistent information. Sampled residents care plans, lift instructions, resident cards located on individual resident closet doors were audited by the SA to confirm they had consistent and correct information. The SA validated through record review and interview that the facility held a Quality Assurance and Performance Improvement meeting on 1/2/24 to discuss the incident regarding 3 CNA's failing to use the correct lift technique for Resident #1. The SA was able to validate the actions the facility took after the incident, beginning 12/30/23 and prior to SA entrance for survey on 1/23/24, involving Resident #1 and CNA #1, CNA #2 and CNA #3 through record review, interviews, and observations.

Based on staff interviews, record review and policy/procedure review, the facility failed to follow their care plan for one (1) of four (4) residents sampled as evidenced by on 7/25/23, the care plan for Resident #1 for a urinary tract infection has an intervention to Monitor lab values as ordered. Resident #1 had a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) ordered on 7/25/23 to be collected in 1 week. The CBC and BMP were collected on 7/26/23 without a Medical Doctor's (MD) order. Findings include: Record review of the facility's policy/procedure for Comprehensive Care Plan revised on 10/10/2022 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified on the resident's comprehensive assessment. Record review of the Urinary Tract Infection Care Plan dated 7/25/23 revealed an approach .2. Monitor lab values as ordered . Record review of the July 2023 Physician's Telephone Orders revealed an order dated 7/25/23, ordered by the NP, .4. CBC, BMP in 1 week. Record review of the facility (Proper Name) lab work performed at the facility for July 26, 2023 revealed the name of Resident #1 with a specimen collected date of 7/26/23 and the test ordered as a CBC and BMP. There is a straight line drawn through that with ERROR written beside it. Record review of the facility's Lab Error Report revealed that the form is signed by the Nurse Practitioner (NP) and Licensed Practical Nurse (LPN) #1. The Date of report: 07/26/2023 Date . of Error 07/26/23 are the dates of the error. It reads Person discovering error: family member inquired about lab draw site. The Date and time error discovered: 07/26/23. The form revealed Brief description of error and cause (s): Resident labs were drew before the ordered date . An interview with the Director of Nurses (DON) on 8/10/23 at 9:50 AM, revealed Yes, care plan approaches should be followed. An interview on 8/10/23 at 12:20 PM, with LPN #1 revealed she is the facility Quality Assurance (QA) nurse. She stated Resident #1 had an order for lab for a CBC and BMP. The order was to draw the lab in one (1) week. It was written on 7/25/23. I don't know who wrote it on the facility (proper name) lab log sheet. The order was signed off by (name of) LPN but someone wrote it on the log sheet to be drawn on 7/26/23. Interview with the NP on 8/10/23 at 2:00 PM revealed, No, I didn't order the lab drawn on 7/26/23. I wrote an order for lab work in one week. It was for a CBC and BMP. The order was written 7/25/23. Record review of Resident #1's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included Diarrhea, Unspecified; Candidacies, Unspecified; Personal History of Urinary (tract) Infections; Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/ Unspecified Chronic Kidney Disease.; Stage 3 Chronic Kidney Disease, Stage 3 Unspecified; Vascular Dementia, Type 2 Diabetes Mellitus without Complications, Chronic Diastolic (Congestive) Heart Failure. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/23 revealed a Brief Interview for Status (BIMS) score of 6 which indicated Resident #1 was severely cognitively impaired. She requires assistance with making daily decisions.

Based on staff interviews, record review and policy/procedure review, the facility failed to follow Medical Doctors (MD) orders for one (1) of four (4) residents sampled as evidenced by on 7/25/23, the Nurse Practitioner (NP) ordered lab work for a Complete Blood Count (CBC) and Basic Metabolic Profile (BMP) in one week for Resident #1. This lab was collected on 7/26/23 without an MD order. Findings include: Record review of the facility's policy/procedure for Physician Order Review with an effective date of 1/9/2015 revealed the PURPOSE: To maintain appropriate continuity in resident care. POLICY: Every licensed nurse shall ensure that the physician's orders for each resident has been carried out as intended . Record review of the facility's policy/procedure for Diagnostic Services: Lab tests and X-ray last revised on 11/28/2017 revealed the Procedure: Quality lab tests and radiology (i.e., x-ray, M.R.I. (Magnetic Resonance Imaging)) services only are performed upon medical order from the resident's physician. On 8/10/23 at 9:50 AM, an interview with the Director of Nurses (DON) revealed The NP ordered a CBC and BMP to be drawn in one week when she ordered the Augumentin and Diflucan on 7/25/23. We contract with a company for our lab work. The lab company came the next day, 7/26/23, and drew the CBC and BMP. I don't know why the lab was drawn a week early. On 8/10/23 at 12:20 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed she is the facility Quality Assurance (QA) nurse. She stated Resident #1 had an order for lab for a CBC and BMP. The order was to draw the lab in 1 week. It was written on 7/25/23. I don't know who wrote it on the (proper name) lab log sheet. The order was signed off by (name of) LPN but someone wrote it on the log sheet to be drawn on 7/26/23. Someone also put a line through it and wrote error. They didn't initial or date when they drew the line. On 8/10/23 at 2:00 PM, an interview with the NP stated, No, I didn't order the lab drawn on 7/26/23. I wrote an order for lab work in one week. It was for a CBC and BMP. The order was written 7/25/23. Review of the MD's July 2023 orders revealed Resident #1 was diagnosed with a Urinary Tract Infection and Yeast on 7/25/23 by the NP. The orders were to 1. D/C (discontinue) Cephalexin, Colace, Miralax. 2. Augmentin 500 milligram (MG) by mouth (po) two times a day (BID) X 5 days. 3. Diflucan 200 MG po daily X 14 days. 4. CBC, BMP in 1 week. Record review of the Clinical Testing Requisition Form revealed the lab company is (proper name) Laboratory Services. The Date of Collection: 7/26/23 Time 8:15 The lab tests marked are Basic Metabolic Panel and CBC with Automated Differential. The (Proper Name) NP is the Ordering Physician and it is signed by a facility LPN. It is dated 7/25/23. Record review of the facility's Lab Error Report revealed that the form is signed by the NP and LPN #1. The Date of report: 07/26/2023 Date & Time of Error 07/26/23 are the dates of the error. It reads Person discovering error: family member inquired about lab draw site. The Date and time error discovered: 07/26/23. The form revealed Brief description of error and cause (s): Resident labs were drew before the ordered date. Record review of the (Proper Name) lab work performed at the facility for July 26, 2023, revealed the name of Resident #1 with a specimen collected date of 7/26/23 and the test ordered as a CBC and BMP. There is a straight line drawn through that with ERROR written beside it. Record review of Resident #1's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including Diarrhea, Unspecified; Candidacies, Unspecified; Personal History of Urinary (tract) Infections;.; Stage 3 Chronic Kidney Disease, Stage 3 Unspecified, Type 2 Diabetes Mellitus without Complications, Chronic Diastolic (Congestive) Heart Failure. Record Review of the Minimum Data Set (MDS) for a Quarterly assessment with an Assessment Reference Date (ARD) of 5/11/23 revealed a Brief Interview for Status (BIMS) score of 6 which indicates severe cognitive impairment.

Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide residents an opportunity to choose a dining location as evidenced by all evening and weekend meals being served in resident rooms, for one (1) of four (4) survey days. Resident #8 and Resident #15 Findings include: Review of the facility policy titled, Resident Rights with no revision date revealed under, 5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interest, assessments, and plan of care and other applicable provisions of this part. b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Resident #8 An observation on 04/16/23 at 5:45 PM, revealed no residents in the dining room for the supper meal. Meal carts were being sent out to the floor. An interview on 04/17/23 at 08:50 AM, with Resident #8 revealed we eat in our rooms on the weekends because the dining room is closed. He revealed he would much prefer to eat his meals in the dining room, but we just stay in our rooms. He revealed he was never given a choice regarding where he wanted to eat his meals. An interview on 04/17/23 at 5:05 PM, with the Administrator revealed he was not aware that any of the residents were voicing any issues about eating in their rooms. He revealed, he doesn't believe anyone was given a choice about their preference about continuing to eat their meals in their rooms on the weekends and at night and confirmed that he really didn't present it to the residents about the dining room being closed for meals on the weekend. He confirmed it should have been opened back up and we are opening it back up fully today. An interview on 04/18/23 at 09:11 AM, Certified Nurse Aide (CNA) #1 revealed she was told a while back that the residents were not to eat in the dining room on the weekend. She revealed she let the Administrator know a couple of months ago that there are some residents that would like to go to the dining room on the weekends. She revealed they like to go to the dining room to eat and socialize. A review of the Face Sheet revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that include Chronic obstructive pulmonary disease, Bipolar Disorder, and Anemia. A review of the Minimum Data Set (MDS), Section C-Cognitive Patterns, with an Assessment Reference Date (ARD) of 2/22/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates Resident #8 is cognitively intact. 47874 Resident #15 An interview on 04/16/23 at 05:25 PM, with Registered Nurse (RN) #1 revealed she was the weekend supervisor and stated that all meals were served in the residents' rooms on the weekends and stated, You know, I'm not sure why. An observation of the dining hall on 04/16/23 at 5:30 PM revealed no supper meals being served in the dining hall. An interview on 4/17/23 at 08:44 AM, with Resident #15 revealed she loved to eat in the dining room, the food was served hotter, and she stated, I would like to go to the dining room for at least one (1) meal on the weekend. Resident #15 revealed she does not know why she cannot eat in the dining room on the weekend, and they always brought her meals to the room. An interview on 4/17/23 at 02:30 PM, with Certified Nurse Aide (CNA) #2 revealed that the supper meals Monday through Friday and all meals on the weekend were served in the resident's room. She stated that the facility did not have a big staff on the weekend, and they all must work together to get the meal trays passed. She revealed that the facility just recently started serving meals in the dining room again, following the end of the Covid-19 pandemic. An interview with the Director of Nursing (DON) on 4/17/23 at 2:40 PM, revealed she has been in this position since October 2021. She stated that the residents were not eating in the dining room when she entered the DON position due to Covid-19. She revealed that the residents prefer to eat off the dining room steam table so they can choose the foods they want. When the State Agent (SA) asked if the residents had been given a choice on whether they eat their food in their room or the dining room, she revealed she had not asked them. She stated that eating in the dining room was the Administrator's decision. An interview with the Administrator (ADM) on 4/17/23 at 2:50 PM, revealed they recently resumed eating in the dining room in October 2022 due to the Covid-19 pandemic. He stated they started with breakfast and then added lunch. He revealed that the facility casually asked the residents if they would like to resume eating in the dining room, and at the time, there was not a tremendous amount of interest. He revealed he could not swear that every resident was asked about their preference regarding where they ate their meals. He revealed with things changing so much with COVID-19, we just decided that eating in the rooms was best, and when we started eating breakfast and lunch in the dining room back in October 2022, we continued to have them eat their meals in their rooms for supper and all meals on weekends. When the SA asked the Administrator what the setback for residents would be with them not having a choice of where they ate their meals and socialized, the Administrator stated, I see what you mean. When the SA inquired if residents should have a choice the Administrator stated, yea, yea. Record review of the Face Sheet revealed Resident #15 was admitted to the facility on [DATE] with medical diagnoses that included Streptococcal Infection, unspecified, Urinary Tract Infection, site not specified, and Pneumonia, unspecified organism. Record review of Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates Resident #15 is cognitively intact.

Based on observation, staff interviews, and facility policy review, the facility failed to store controlled medications in separately locked, permanently affixed compartments in locked refrigerators of medication storage rooms for two (2) of two (2) medication storage rooms observed. Findings included: Record review of facility policy titled, Controlled Drug Management, dated 10/18/22 revealed, Policy: To ensure adequate control, dispensing, and accountability of all controlled substances in conformity with state and federal regulations . Security: When not in use, the controlled substances storage area on each resident care unit must be always kept double-locked and secure . Record review of facility letterhead written by the Director of Nursing (DON) and dated 4/19/23, revealed, At this time, (Proper name of facility) does not currently have a policy stating that the locked controlled medication storage box inside of the locked refrigerator, inside of the locked medication room must be affixed. An interview with the DON and observation of the facility medication storage rooms on 4/19/23 at 8:50 AM, revealed each of the two locked medication storage rooms contained a locked refrigerator with a locked narcotic box, but the locked narcotic boxes were not permanently affixed and were removable from the refrigerators. The DON confirmed the locked boxes were in locked refrigerators in locked medication rooms, but were not permanently affixed in place and could be removed from the refrigerators. An interview with the Administrator and observation of the facility medication storage rooms on 4/19/23 at 9:20 AM, confirmed the locked narcotic boxes in the locked refrigerators of the medication rooms were not permanently affixed as required by regulations, and could have been removed.

Based on observation, staff and resident interviews, and record review, the facility failed to maintain an effective pest control against ants, as evidenced by repeated sightings of ants and numerous ant bites to a resident for one (1) of five (5) residents reviewed concerning ants in the facility. Resident #1. Findings Include: Record review of a Departmental note dated 1/2/21 at 5:25 PM revealed that Resident #1 discharged out of the COVID-19 Unit today. Record review of Departmental Notes dated 1/3/21 at 10:04 PM and signed by RN #2 revealed, During rounds, resident found covered in ants. Skin noted to be red, bumpy, with scattered areas of inflammation. Director of Nurses (DON) and Nurse Practitioner (NP) notified. N.O.(new order)Decadron 4 milligrams (MG) Intramuscular (IM) now, [MEDICATION(S)] 50MG by mouth (PO) every (Q) 8 hours (H) as needed (PRN) itching.skin was notably irritated .Resident temporarily moved to room 310A . Record review of a Departmental note dated 1/4/21 at 11:01 AM revealed, During rounds this morning resident noted to be lethargic .Resident noted with welps on several areas of body R/T (related to) ant bites received on previous shift. Resident refused breakfast and AM (morning) meds .N.O.received-Transfer to (Proper Name of Hospital) for increased lethargy/SP (status post) large amount of ant bites/recent COVID. Record review of the ED (Emergency Department) Provider Note dated 1/4/21, revealed Patient brought from nursing home .he was found in his room with answered (ants) all over him .they state they did see aunt's (ants) on him .Rash: Location: Full Body; Quality: blistering,draining and weeping .Context :Insect bite/sting . An interview, on 6/8/21 at 9:53 AM, with the Maintenance Supervisor (Maintenance Staff) #1 revealed pest control comes monthly. The staff reports any findings of ants, and he treats them with the stuff he has at the facility, and he calls the pest control company. Maintenance Staff #1 stated that he sprays the ants if he sees them and will leave bait in the room that was left with him by the pest company. He stated there are sighting books on the East and West end of the building for the staff to document ant sightings. An observation, on 6/8/21 at 1:30 PM, in Resident #1's current room, revealed an ant bait trap was located in the corner behind the door. There were no ants seen in the room. An interview on 6/8/21 at 3:35PM, with Licensed Practical Nurse (LPN) #1, revealed the pest control people do routine visits. LPN #1 stated she was not aware of any issues with ants except Resident #1. She stated that if anyone else had been bitten, it would have been reported to her. She stated that she learned about Resident #1 being bitten by ants during the morning stand up meeting. An interview on 6/8/21 at 1:30 PM, with Resident #7 revealed he had seen ants in his room. He stated ants have been sprayed three times in the past six months. He stated that he was in his room when Resident #1, who was his roommate in the A bed, was found with ants on him. He stated that he did not move out of the room because this was his home. Resident #7 stated that he has had a couple of ants in the bed with him and had gotten bitten on his leg, but he was not worried about it because he was able to kill them. He stated he tries to kill as many as he can. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/12/21 revealed a Brief Interview for Mental Status (BIMS) score of 15 for Resident #7 indicating Resident #7 was cognitively intact. An interview, on 6/8/21 at 1:52 PM, with Resident #8, revealed he had seen a few ants several months ago on the windowsill. Resident #8 resided on the same hall as Resident #1. Record review of the MDS with an ARD of 6/1/21 revealed a BIMS score of 15 for Resident #8 indicating Resident #8 was cognitively intact. An interview on 6/8/21 at 2:25 PM, with the Certified Occupational Therapy Assistant revealed she had seen ants on the 400 Hall approximately a month ago. She stated that it was only two or three and they did get sprayed. An interview, on 6/8/21 at 3:50 PM, with Certified Nursing Assistant (CNA) #1, revealed that she had seen ants in Room 205 on a plant that was on the windowsill. An interview on 6/9/21 at 11:40 AM, with Housekeeping Staff #2, revealed she had seen ants in some resident rooms, but no ants on the residents or on the bed. She stated her findings were random and she reported it to the Supervisor and Maintenance. A telephone interview, on 6/9/21 at 11:45 AM, with Registered Nurse (RN) #2 revealed she was the first person who found Resident #1 on 1/3/21 at approximately 7:50 PM. She stated that she had seen a few ants in the facility occasionally, but never that amount. She stated that Resident #1 was covered with ants and when they pulled the bed out the ants were on the wall and the side rails against the wall. RN#2 stated that she thought there might possibly have been some drink or food residue on the wall. She stated that they stripped the Resident and got all the ants off him and moved him to another room. The Nurse Practitioner and the Director of Nursing (DON) was called. RN #2 stated at that time the Resident was at his baseline mental status. An interview, on 6/9/21 at 12:15, with the Pest Control Technician, revealed he had been working there for 1 and one-half (1/2) years. He stated that he comes to the facility twice a month. He stated that ants pop up especially when it rains. He stated this brings them in. The Pest Control Technician stated he was at the facility today for his routine service call. He stated that he did see ants on the outside of the building and windowsills today. He stated that on the outside of the building he uses the granular and liquid product which is the standard barrier treatment. He stated he is only seeing small black ants, no fire ants. He stated that when called he will come and bait the room when ants have been seen. He said this is usually because food has been wasted and that draws them in. The Pest Control Technician stated he only baits rooms when called. .A telephone interview with the Director of Nursing (DON) on 6/9/21 at 4:40 PM, revealed heavy rain drives the ants into the building. She stated the pest control company puts a barrier outside to prevent this. The DON stated the investigation of the ants on Resident #1 revealed there were no food spills, and no ants were identified on the roommate's side of the room. She stated the roommate said he had not seen any ants. She stated that she even looked at disease processes for Resident #1 thinking that that might have had some cause for them to target him. She stated after the incident the room was deep cleaned and sprayed. An interview, with the Administrator on 6/10/21 at 11:20 AM, revealed the pest control company comes two times a month and will come back as needed. He stated they have had a contract since 2003. He states they do a barrier treatment for ants which covers approximately 20 to 30 feet around the building. Concerning Resident #1, the ADM confirmed that Resident #1 was removed from his room. The room was cleaned, and all the ants were gone. He stated he was not aware of any other residents receiving ant bites. The Administrator stated the pest company is supposed to be doing all they can they do. They do have more as need (PRN) visits during the rainy season. He stated that he calls and reports if there is one ant sighting and they usually come within 24 to 48 hours. He confirmed that no record is kept of PRN call back visits by the facility. The Administrator stated that he thought the pest company had done all they could, but he couldn't say for sure, and the pest control company may need to get more aggressive than their normal protocol.

Based on observation, staff interview, resident interview, record review and facility policy review, the facility failed to store the resident's oxygen cannula and tubing in a manner to prevent the possibility for infection or cross contamination for two (2) of three (3) residents reviewed for oxygen therapy, Resident #22 and #36. Findings include: Review of the facility's Oxygen Policy, dated March 1, 2004, revealed, It is the policy of this facility that oxygen will be utilized included: With specific physician's orders [REDACTED]. Document the tubing change on the MAR (Medication Administration Record) (Tubing is to be changed weekly). Care plan the oxygen usage. Store the Oxygen cannulas in a ziplock bag when not in use. Resident #22 On 2/25/2020 at 11:00 AM, during the initial tour of the facility, an observation revealed Resident #22's oxygen (O2) tubing was draped across the oxygen concentrator in the resident's room. There was no date on the tubing or humidifier bottle. Licensed Practical Nurse (LPN) #2 was called into the room and confirmed there was no date on the tubing and that it was not stored properly. LPN#2 reported the tubing should be labeled with the date it was placed and in a bag so nothing is dropping on the floor. It's normally changed every Saturday. LPN #2 stated, We don't want to cross contaminate anything, get germs or anything like that. Review of a Physician's Telephone Order, dated [DATE], revealed an order for [REDACTED]. Review of a Physician's Telephone Order, dated 2/25/2020, revealed an order to change continuous O2 to as needed (PRN) for O2 saturation (Sat) less than (<) [AGE]%. Review of the Face Sheet revealed Resident #22 was admitted by the facility, on 12/12/2019, with [DIAGNOSES REDACTED]. Resident #36 On 02/25/20 at 8:35 AM, an observation, during the initial tour, revealed Resident #36's O2 nasal cannula was draped over the O2 concentrator and there was no bag to store it in. Resident #36 was sitting at her bedside, and an interview with her at this time revealed she stated, I ain't seen a bag over there for a good minute. An observation, on 2/25/2020 at 11:30 AM, revealed Resident #36's nasal cannula was now in a ziplock bag, dated [DATE]20. Review of Resident #22's February 2020 physician's orders [REDACTED]. On, 2/25/2020 at 11:40 AM, an interview with the Respiratory Therapist (RT) regarding Resident #36's O2 cannula and tubing observed in a ziplock bag now, revealed she stated, I saw that her oxygen cannula was draped over her concentrator in her room, and they are supposed to all be bagged. So, I went to central supply and got a bag and attached it to the concentrator for her. The RT stated, I guess I just dated it for when I knew it should have been changed. They change them on the night shift on Sunday nights. An interview, on 2/26/2020 at 3:30 PM, revealed the Director of Nursing (DON), stated she had looked all through her chart, and there is no order for them to sign when they change out the oxygen tubing, and it is not on the care plan. So I guess they just know to do it. Review of Resident #36's February 2020 Medication Administration Record [REDACTED]. Review of the Face Sheet revealed Resident #36 was admitted by the facility, on 3/29/2020, with [DIAGNOSES REDACTED].

Based on record review, staff interview, resident interview and facility policy review, the facility failed to develop a Comprehensive Care Plan for Resident #22's Oxygen (O2) use, to include approaches for the storage of Resident #36's O2 cannula and tubing when not in use and implement Resident #3's need for heel boots and/or pillows to prevent new pressure areas. This concern was identified for three (3) of 24 care plans reviewed. Findings include: Review of the facility's Intermediate Care Plan Policy, not dated, revealed, It is the policy of this facility that the intermediate care plans will be done as follows: As needed in an acute situation. Completed by the floor nurse at the time the situation occurs. Resolved when the situation is stable. Added to the long term plan by the MDS (Minimum Data Set) Nurse if the situation continues when the quarterly review is due. Review of the facility's Oxygen Policy, dated 3/1/2004, revealed oxygen use should be care planned and store the O2 cannula in a zip lock bag when not in use. Resident #22 Review of Resident #22's care plans in the paper chart and electronic medical record revealed there was no care plan for oxygen developed. An observation, on 2/25/2020 at 11:00 AM, revealed Resident #22's O2 cannula and tubing was draped across the O2 concentrator in her room. Resident #22 was not in the room at this time. Review of a Physician's Telephone Order, dated [DATE], revealed an order for [REDACTED]. Review of a Physician's Telephone Order, dated 2/25/2020, revealed an order to change continuous O2 to as needed (PRN) for O2 saturation (Sat) less than (<) [AGE]%. An interview, on 2/27/2020 at 11:00 AM, with Registered Nurse (RN) #1, revealed Resident #22 had not used the O2 recently. An interview with Licensed Practical Nurse (LPN) #1/Minimum Data Set (MDS) Coordinator, on 2/27/2020, at 10:05 AM, revealed LPN#1 confirmed a care plan for Resident #22's oxygen was not developed. LPN #1 stated MDS does the majority of care plans with the assessments and updates the care plans when the assessments are due. LPN#1 stated, I could not find one in here. It should have been developed when the order was taken. The purpose of a care plan is to know how to take care of our patients, to know what we need to do to take care of their needs and what their preferences are. On 2/27/2020, at 10:15 AM, during an interview with the Respiratory Therapist (RT), revealed she had taken the order for oxygen on [DATE], and had checked and initialed the box Pt. Care Plan on the Physician's Telephone Orders. The RT stated I don't remember writing the care plan. We're supposed to update it in the hard chart and the computer when a new order is given. The purpose of a care plan is so we know the plan of care for that resident and follow the plan of care to make sure we are doing everything we can to take care of our residents. Review of the Face Sheet revealed Resident #22 was admitted by the facility, on 12/12/2019, with [DIAGNOSES REDACTED]. Resident #36 Review of Resident #36's Comprehensive Care Plan revealed the Problem/Need, dated 3/29/2018, for [MEDICAL CONDITIONS], wheezing and cough. The approaches included the use of O2 as needed (PRN) at 2 LPM (Liters per minute) per tank or concentrator and monitor effectiveness. The care plan did not address the storage of the O2 cannula and tubing when not in use. On 2/25/2020 at 8:35 AM, an observation during the initial tour, revealed Resident #36's nasal cannula was draped over the O2 concentrator and there was no bag to put it in. An interview at this time with Resident #36 revealed she stated, I ain't seen a bag over there for a good minute. On 2/27/2020 at 10:35 AM, during an interview with the Care Plan Nurse, she stated MDS does a majority of the care plan revision when they are reviewed for the MDS process. The Care Plan Nurse said the resident's care plan was just reviewed due to having an MDS, and we should have caught the fact she had no change tubing orders during the care plan review and we didn't. Resident #3 Review of Resident #3's Comprehensive Care Plan, dated 11/11/2014, revealed the Problem/Need for Pressure Ulcer risk related to (r/t) limited mobility, impaired cognition and incontinence. The Goal & Target Date: Will develop no new pressure areas thru (through) 5/19/2020. The approaches included: Heel Well boots to BLE (Bilateral Lower Extremities) at all times. If unable to keep heel well boots in place, position pillow in between resident's feet to provide pressure relief, dated 1/13/2019. Further review of the care plan revealed the Problem/Need, dated 10/15/2015, for Smart Chart - Schedule with the included approaches: Pressure relief boot in while in bed. On 2/25/2020 at 8:40 AM, an observation during the initial tour revealed Resident #3 was lying in his bed without his heel boots on. The boots were sitting in his Geri-chair in the corner. On 02/25/20 at 2:49 PM, an observation revealed Resident #3 was lying in the bed with his feet resting on the footboard. Resident #3 was laying diagonally in bed, with his head at one corner at the head of the bed and the his feet in the corner on the opposite side at the foot of the bed (catty-cornered) with his pillow in the floor. His heel boots were sitting on his Geri-chair in the corner. On, 2/26/2020 at 8:05 AM, Resident #3 was observed lying in the bed without his heel boots on and there was no pillow between his feet as care planned. On, 2/26/2020 at 2:20 PM, Resident #3 was lying in the bed without his heels boots on and there was no pillow between his feet for positioning. On, 2/26/2020 at 2:30 PM, during an interview with the Director of Nursing (DON), the DON stated, He should either have the heel boots on or the pillow between his feet. He is resistive to care sometimes. On 2/27/2020 at 10:35 AM, an interview revealed LPN #1/Care Plan Nurse, stated, MDS does a majority of the care plan revision when they are reviewed for the MDS process; however, the nurses and department heads are to update the care plan with the new orders and behavior. We just had a care plan review for him. Review of the Face Sheet revealed Resident #3 was admitted by the facility, on 8/14/2014, with [DIAGNOSES REDACTED].

Based on observation, interview, clinical record review, and facility policy review, the facility failed to ensure Resident (R) #14, one (1) of 26 sampled residents, reviewed for limited range of motion (ROM), received the appropriate services and equipment to maintain or improve ROM, including: 1. Failure to follow therapy recommendations for the use of hand splints to reduce the risk of developing bilateral hand contractures. 2. Failure to follow therapy recommendations to place R #14 on a restorative program to reduce the risk of developing contractures. The failed practices resulted in actual harm to R #14, who developed bilateral upper and lower extremity impairment in ROM, and bilateral upper and lower extremity contractures. Findings Include: A review of the facility's policy titled, Range of Motion Policy undated, indicated the facility provided ROM services, .to move the resident's joints through a full ROM as possible, to improve or maintain joint mobility, and to prevent contractures. A review of R #14's Face Sheet in the clinical record, indicated R #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 06/21/16, specified R #14's cognition was severely impaired-never or rarely made decisions. Resident #14's Brief Interview for Mental Status (BIMS) score was unable to be completed, due the resident's cognitive status. The resident required extensive assistance of one (1) to two (2) staff members for bed mobility, transfers, and activities of daily living (ADLs). The MDS specified R #14 had no ROM impairment to her upper and lower extremities. The MDS indicated no ROM services were provided and R #14 used no mobility devices. Review of the admission Interim Care Plan, undated, revealed, no contractures were indicated, and transfer and bed mobility were an assist of one (1) staff. Review of R #14's Therapy Services Screening notes, dated from 06/16/16 through 03/18/19, indicated the following: 06/16/16 - Multidisciplinary Screen notes indicated, Pt (sic) (patient) is on hospice and skilled services are not appropriate at this time. 06/20/16 - Physical Therapy Screen notes indicated, Recommend restorative screen . There was no therapy screening or recommendation documentation provided from 06/20/16 through 01/23/18. 01/23/18 - Physical Therapy Quarterly Screen notes indicated, Patient at baseline. Eval (sic) (evaluation) not warranted. 04/03/18 - Multidisciplinary Screen notes indicated, No change in function. PT (sic) (patient) not warranted at this time. Review of the annual MDS with an ARD of 05/12/18, specified ROM impairment bilaterally to the upper and lower extremities and indicated no ROM or therapy services. There was no change in R #14's cognition of severely impaired-never or rarely made decisions. R #14's BIMS was 99, which indicated the mental status interview could not be completed. The MDS specified the resident was dependent on staff for all ADLs and indicated transfer activity had not occurred during the assessment period. Review of the Care Plan Sign - In Sheet dated, 05/17/18, indicated the interdisciplinary team (Registered Nurse (RN), MDS Coordinator, Social Services (SS), Activities, Dietary, and a CNA) and family were present for the care plan meeting. There were no therapy services representatives listed. On 07/16/18 - Physical Therapy Screen notes indicated, Pt (sic) (patient) has not had any changes in functional status to warrant PT (Physical Therapy) eval (sic) (evaluation). On 10/03/18 - Occupational Therapy Quarterly Screen notes indicated, Pt (sic) (patient) at baseline. Eval (sic) (evaluation) is not recommended. On 12/19/18 - Occupational Therapy Quarterly Screen notes indicated, Pt. (sic) (patient) would benefit from hand splint to decrease risk of skin breakdown. On 12/20/18 - Multidisciplinary Screen notes indicated, Pt (sic) (patient) has not experienced a functional change in area of PT and ST (Speech Therapy). Recommendation OT (Occupational Therapy) to eval (sic) (evaluation) to address new contractures to B (sic) (bilateral) hands. On 03/15/19 - Occupational Quarterly Screen notes indicated, Pt (sic) (patient) has history of refusing therapy and she does not get out of bed . Review of R #14's clinical record, indicated no documentation that R #14 had refused therapy or had a history of [REDACTED]. On 03/18/19 - Physical Therapy Quarterly Screening notes indicated, Patient presents at baseline and will not benefit from physical therapy. There were no documented therapy screenings or recommendations between the dates of 12/20/18 through 03/15/19. A review of R #14's Care Plan problem, dated with a goal and target date of 06/28/19, indicated, the Problem; .Requires total dependence with activities of daily living (ADLs), transfers and mobility.See Care guide ADL for individual needs. There were no interventions for restorative services to offer ROM for upper and lower extremities. A review of R #14's Hospice collaborative plan of care Hospice Notes, dated from 01/03/18 through 04/01/19, indicated no restorative ROM program or services. A clinical record review of the Physician order [REDACTED].#14 had no orders for restorative or therapy services for ROM and the care plan had been reviewed and agreed upon. Observation during the initial tour on 04/01/19 at 6:30 AM, revealed R #14 was in her room in bed. Her bilateral arms were contracted inwards toward her chest and bilateral hands were fully contracted with hand rolls in place. Observations on 04/01/19 at 8:00 AM, 12:11 PM, 12:45 PM, and 2:00 PM, revealed, R #14 was in bed, with the head of the bed slightly elevated, and she was lying on her backside with her legs crossed, contracted, and feet and lower legs angled upward, not touching the bed. Her bilateral arms and hands were contracted inward toward her chest with hand rolls in place. Observation and interview on 04/02/19 at 9:08 AM, revealed R #14 was in bed with the head of the bed upright. CNA #14 stated R #14 was unable to grab or hold anything with her hands due to the contractures. R #14's position, while in bed lying on her backside, revealed an upward inverted angle of her body, not allowing her to lay flat on the bed. This body position was due to her upper and lower extremity contractures. Interview with CNA #14 on 04/02/19 at 10:30 AM, revealed R #14 was considered extensive assistance of two (2) staff members and required a lift for transfer. She stated R #14 did not get out of the bed every day. In an interview with R #14's Power of Attorney (POA) (daughter) on 04/03/19 at 9:30 AM, she stated R #14 was not admitted with contractures to bilateral upper and lower extremities. She stated R #14, to her knowledge, had never received therapy or restorative services, nor had it been discussed with the family. She stated the family would like the resident to receive any type of ROM services to help with comfort. In an interview with the Restorative Program Licensed Practical Nurse (LPN) #38 on 04/03/19 at 10:00 AM, she stated she was new to the position and did not have knowledge of what the prior Restorative Nurse had done. She stated the process for a resident to be placed on the restorative program was when therapy made weekly rounds they would refer residents to the program. She stated nursing could also refer residents who may have had a decline in ADLs. She confirmed R #14 had bilateral upper and lower extremity contractures and should have been recommended, and placed on restorative services for ROM, prior to her developing them. She stated nursing administration would be the ones to refer residents. In an interview with Director of Nursing (DON) #30, on 04/03/19 at 10:45 AM, she stated, regarding not following therapy recommendations from 06/20/16 and 12/20/18, she could not speak to that and wasn't sure what happened, but confirmed nursing had not followed up on the recommendations. She stated it was not normal for Hospice residents to be on therapy or restorative caseload, but couldn't see a reason why they could not be. She confirmed R #14 had upper and lower contractures and that they (meaning the facility) missed the opportunity to place R #14 on a restorative program for ROM, to reduce the risk of developing contractures and a decline in her ROM. The DON could not confirm the date R #14's contractures developed. In an interview with the Director of Therapy (DOT), Occupational Therapist (OT) #1, on 04/04/19 at 9:50 AM, she stated she was familiar with R #14 and confirmed R #14 had developed upper and lower extremity contractures. She stated the therapy department had screened R #14 for being at risk for contractures, and had concluded she would benefit from hand splints and a restorative ROM and positioning program, to reduce the development of contractures; however, they had not followed through to see if it was completed. The DOT could not confirm the date R #14's contractures developed. In an interview with the MDS Coordinator, Licensed Practical Nurse (LPN) #105, on 04/04/19 at 12:27 PM, she stated to her knowledge, the completed MDS assessments for R #14 were accurate. She stated she was not completely familiar with R #14. She stated Hospice services attend the care plan meetings and collaborate with the facility care plans. She stated residents who are referred to nursing restorative services were discussed in the Transmission meeting along with Interdisciplinary Team (IDT) meetings. She stated she was not sure how the facility missed R #14 for restorative services, but confirmed R #14 should have been placed on a ROM program.

Based on review of facility policy, interview and record review, the facility failed to thoroughly investigate and report to the State Agency allegations of abuse and neglect for three (3) of 47 sampled residents, Residents (R) #55, R #157, and R #158). Two (2) allegations of verbal abuse and one (1) allegation of neglect were reported to staff. On 02/04/19, R #55, a cognitively intact resident, reported to staff that CNA #143 neglected to take her to the bathroom, per her request, over a four (4) hour period, on 02/04/19, and that she feared retaliation. On 10/01/18, R #158, a cognitively intact resident, reported to staff that she was verbally abused by Licensed Practical Nurse (LPN) #142 on 09/30/18. On 01/30/19, the roommate of R #157, reported to staff that Certified Nursing Assistant (CNA) #143 verbally abused R #157. Resident #157, a cognitively intact resident, confirmed the allegation. Resident #55 was concerned about repercussions, which rose to a harm level deficiency. Findings include: The facility Abuse Policy, with an implemented date of 1/11/18, read, Policy: It is the policy of this facility that abuse will be handled as follows: The facility will: -Prevent, identify, investigate and report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property . -Protect the resident during an abuse investigation . Guidelines . 3. Prevention . The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: a. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. b. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Any instances of abuse of any residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. c. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability . 5. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response/ investigating as described below . Investigating Any report of abuse, neglect or exploitation will be investigated by Director of Nursing Services or designee. Investigation shall include but is not limited to 1. Interviewing: a. The resident involved when appropriate b. Staff members i. working in that area at the time of the incident ii. suspected of abuse, neglect, or exploitation iii. who might have knowledge of the reported complaint c. Any visitor or family member who might have knowledge of the incident 2. Documenting interviews . The facility's Grievance Log for the last six (6) months revealed two (2) allegations of verbal abuse, and one (1) allegation of neglect which had been reported to staff. Review of the three (3) grievances and interviews with staff confirmed the facility did not thoroughly investigate the allegations, protect the residents, or report them to the State Agency. Resident #55 Review of a Grievance Investigation form, dated 02/04/19 at 8:00 AM, revealed Speech Language Pathologist (SLP) #3 completed the form when R #55 reported to her she had been neglected from 3:00 AM until 7:00 AM that morning, when CNA #143 would not take her to the bathroom at her request. (This was the second incident that involved CNA #143). She also reported that the LPN came into the room and also didn't take her to the bathroom during that time. Resident #55 was concerned about retaliation. The Details of the Investigation section of the form revealed, Director of Nursing (DON) #30 documented, Spoke w/aide regarding this incident. Educated aide that residents should get up to the restroom anytime they need to go . The Corrective Action Complete section of the form, was dated 02/06/19, and was signed by DON #30. This was two (2) days after the grievance was reported to SLP #3. CNA #143 continued to work. Resident #55's admission MDS with an ARD of 02/04/19, specified the resident had a BIMS score of 15 out of 15, which indicated no cognitive impairment. R #55 did not exhibit any behavioral symptoms. R #55 required extensive assistance of one (1) staff member with most ADLs and was independent with set up assistance only with eating. R #55 was frequently incontinent of bladder and occasionally incontinent of bowel. Incidents that did not rise to harm level: Resident #158: Review of a Grievance Investigation form, dated 10/01/18 at 9:20 AM, revealed Social Worker (SW) #90 completed the form when R #158 reported to her she was verbally abused by LPN #142 on 09/30/18. R #158 stated LPN #142 came into her room and yelled, I told you I was coming back. Don't you ever call and tell someone I am not doing my job. This was due to Resident #158 had asked for her [MEDICAL CONDITION] bag to be checked on 9/30/18, around 3:30 PM, and the LPN informed the resident she would be back later. The LPN returned at 6:58 PM, over three (3) hours after the request. The Details of the Investigation section of the form revealed, Director of Nursing (DON) #30 documented, Spoke with employee regarding this and counseled with her on appropriate customer service. She will take someone with her from now on. The Corrective Action Complete section of the form, was dated 10/03/18, and was signed by DON #30. This was two (2) days after the grievance was reported to SW #90, and the LPN continued to work. Resident #158's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/18, specified the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. R #158 did not exhibit any behavioral symptoms. R #158 required extensive assistance of one (1) staff member with most activities of daily living (ADLs) and supervision of one (1) staff member with eating. R #158 had an ostomy bag. Resident #157 Review of a Grievance Investigation form, dated 01/30/19 at 8:45 AM, revealed SW #83 completed the form when R #260 reported to her that Certified Nursing Assistant (CNA) #143 was very rude to his roommate (R #157) at 4:00 AM that morning. R #260 stated, CNA #143 told R #157, You will put these dam (sic) pants on. She then walked out of the room. SW #83 asked R #157 if his roommate's statement was true. R #157 said it was true, and he did not understand why he had to change his pants, because they were not wet. The Details of the Investigation section of the form revealed, Director of Nursing (DON) #30 documented, Counseled w/(with) aide regarding incident, that this language is not acceptable at all. Verbalized understanding and stated it will not happen again. Aide was pulled from room immediately upon notification and will not go back in the room. The Corrective Action Complete section of the form, was dated 02/03/19, and was signed by DON #30. This was four (4) days after the grievance was reported to SW #83, and the CNA was allowed to continue work. Resident #157's admission MDS with an ARD of 11/14/18, specified the resident had a BIMS score of 15 out of 15, which indicated no cognitive impairment. R #157 did not exhibit any behavioral symptoms. R #157 required extensive assistance of one (1) staff member with most ADLs and was independent with set up assistance only with eating. R #157 was frequently incontinent of bowel and bladder. Review of R #260's MDS with an ARD of 01/23/19, documented a BIMS score of 13 out of 15, which indicated no cognitive impairment. R #260 did not exhibit any behavioral symptoms. During group interview on 04/03/19 at 10:00 AM, R #260 recalled the event with his old roommate, R #157. He stated, The staff member was mean to him. During an interview, on 04/03/19 at 12:40 PM, the Risk Manager was asked what the procedure was if there was an allegation of abuse or neglect. She stated that the Administrator and DON had to be notified immediately. Then, based on what they came up with, they would notify her. The Risk Manager went on to say that a full investigation would have to be conducted. First, make sure that the resident is okay and safe, the employee must leave the resident, and it should be reported to the DON and Administrator. The incident is reviewed and call the State within 24 hours. The Risk Manager was shown the three (3) allegations (for Resident #55, #157, and #158) and was asked if she had any knowledge of the incidents. She stated she had no knowledge of the incidents. She stated that the incidents were either verbal abuse or neglect. She stated that two (2) of them occurred after (MONTH) 2019, when she took over investigations, and she should have been made aware of them. During an interview on 04/03/19 at 1:00 PM, DON #30 was asked what was to happen if an allegation of abuse or neglect is made. She said that she was usually called or texted, if not in the building, and that it should be reported to the Administrator. DON #30 was asked how to proceed once it was reported to the Administrator. She stated that it was to be thoroughly investigated and then a call made to the State within 24 hours. She was asked if there was additional documentation related to the investigation of the three (3) allegations (for Residents #55, #157, and #158). She stated, there was no other documentation. She was asked if she had completed a thorough investigation based on the facility policy. She confirmed she had not thoroughly investigated the allegations because she had not considered them as verbal abuse or neglect at the time. DON #30 was asked what took place when the Administrator was made aware of the allegations. She stated, These did not go to the Administrator. When asked if that was per policy, she stated, No. During an interview on 04/03/19 at 3:00 PM, the Administrator was shown the three (3) allegations (for Residents #55, #157, and #158) and asked how they appeared to him. The Administrator stated that he thought they were abuse and neglect. He was asked if he had seen them before. He stated, No. I should have. He stated that DON #30 never showed those to him and they should have been thoroughly investigated at the time they occurred. He stated now it's too late, because those residents are no longer here.

Based on interviews, record reviews, and review of the facility's Abuse Policy, the facility failed to implement their policy and procedures to protect residents from abuse and to thoroughly investigate and report allegations of abuse and neglect to the State Agencies for three (3) of 47 sampled residents, Resident (R) #55, R #157, and R #158. Two (2) allegations of verbal abuse and one (1) allegation of neglect were reported to staff, which rose to the harm level due to the Resident #55's fear of retaliation. Resident #55, a cognitively intact resident, was neglected by Certified Nursing Assistant (CNA) #143 (second incident) on 02/04/19, when the CNA failed to assist the resident to the bathroom over a four (4) hour period. R #55 reported the neglect to staff on 02/04/19. Corrective actions were not documented until 2/6/19. Resident #55 had concerns of fear of retaliation. Resident #158, a cognitively intact resident, was verbally abused by Licensed Practical Nurse (LPN) #142 on 09/30/18, and, reported it to staff on 10/01/18. Corrective actions for staff were not documented until 10/3/18. Resident #157, a cognitively intact resident, was verbally abused by CNA #143 on 01/30/19. The resident's roommate reported the allegation to staff on 01/30/19, and the resident confirmed the allegation. Corrective actions for staff were not documented until 2/3/19. Interviews with Administrative staff confirmed the three (3) allegations were not thoroughly investigated, the staff involved in the allegations continued to work, and the allegations were not reported to the Administrator and to the appropriate State Agencies in accordance with the facility's policy. Findings include: The facility Abuse Policy, with an implemented date of 1/11/18, read, Policy: It is the policy of this facility that abuse will be handled as follows: The facility will: -Prevent, identify, investigate and report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property . -Protect the resident during an abuse investigation . Guidelines . 3. Prevention . The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: a. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. b. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Any instances of abuse of any residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. c. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability . 5. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response/ investigating as described below. 6. Protection: a. The facility will protect residents from harm during an investigation by: i. (sic) Suspending the accused employee until facility has conducted its own investigation and no evidence of abuse was found . Procedure for Response, Reporting, Investigation Allegations of Abuse/Neglect/Exploitation . When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: Response . c. Notify the Director of Nursing Services and Administrator . f. Complete an initial report on Abuse/Neglect/Exploitation form and initiate an investigation. Reporting . The complaint must be reported immediately to the Administrator, Director of Nursing, and the Nursing Supervisor on duty. Initial report should be documented on the Initial Report on Abuse/Neglect/Exploitation Form by the person making the report, reviewed by the Nursing Supervisor on duty and turned into the Director of Nursing Services. Initial Report on Abuse/Neglect/Exploitation Forms will be kept in a red folder at each nurse's station. The report should include: l. Name, address, telephone number of the person making the report. 2. Name and room number of the resident believed to be the victim of abuse, neglect, or exploitation. 3. All statements made by the resident. 4. Details of the incident to include: Observations, beliefs, date, time, place. 5. Name of all individuals believed to have knowledge of the incident. 6. Name of the individual believed to be responsible for the incident and their connection to the resident. The complaint must be reported to: The State Department of Health By phone within 24 hours of discovery, excluding Saturdays, Sundays, and Holidays In writing within 72 hours of discovery The Medicaid Fraud Control Unit (Attorney General) via AGO website Investigating Any report of abuse, neglect or exploitation will be investigated by Director of Nursing Services or designee. Investigation shall include but is not limited to 1. Interviewing: a. The resident involved when appropriate b. Staff members i. working in that area at the time of the incident ii. suspected of abuse, neglect, or exploitation iii. who might have knowledge of the reported complaint c. Any visitor or family member who might have knowledge of the incident 2. Documenting interviews . Review of the Abuse Policy indicated that the Administrator and Director of Nursing (DON) were to be contacted immediately and a thorough investigation to include interviews from residents, staff, and witnesses were to be included in the investigation. Through review of 26 grievances, two (2) grievances alleged verbal abuse (Resident #157 and #158) and one (1) grievance alleged neglect (Resident #55). Interviews were conducted with staff, which confirmed the grievances were not thoroughly investigated and reported in accordance with the facility policy. The facility policy for reporting had not been updated to include current timeline requirements for reporting to the State. Resident #55 Review of R #55's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE]. The resident was cognitively intact, with a BIMS of 15, and required extensive assistance of one (1) staff member for bed mobility, transfers, toileting, and personal hygiene. R #55 was frequently incontinent of bladder and occasionally incontinent of bowel. Review of a Grievance Investigation, dated 02/04/19 at 8:00 AM, revealed Speech Language Pathologist (SLP) #3 documented, on either 02/03/19 and 02/04/19 at 3:00 AM, R #55 called for CNA #143 because she needed to go to the bathroom. CNA #143 came by and told the resident she was making rounds and she would get her when it was her turn. CNA #143 came back at 5:28 AM, (2 ½ hours later) and asked her what she needed. R #55 told her she needed help going to the bathroom. CNA #143 told R #55 to roll over, so she could change her pad. R #55 said no, she needed help going to the bathroom. The CNA told her that the patients could not get up to go to the bathroom during the night. The resident said, Then I will take myself. CNA #143 went out of the room mad and mouthing off complaints to the nurse and said the resident was refusing to cooperate. LPN #144 then came in and asked if she said she was going to walk to the bathroom herself. The resident said No, I wouldn't do that. The resident sat on the edge of the bed, still LPN #144 nor CNA #143 helped her to the bathroom or helped her get her leg back in bed. The resident was finally able to pull her leg back into the bed to stretch out. No one helped her to the bathroom until the 7:00 AM shift came on (4 hours after the resident had requested to go to the bathroom). The resident was concerned for fear of retaliation. When the day shift came, she told the CNA, My diaper will probably drag the floor, it was so full. The resident also reported that CNA #143 said they couldn't take her to the bathroom at night until therapy said they could. The resident said this had happened every night since she came, and they come in and expected her to use the pad. The section titled Details of Investigation revealed, Spoke w/aide regarding this incident. Educated aide that residents should get up to the restroom anytime they need to go . This was signed by the DON. The DON documented the corrective actions were completed on 2/6/19, which was two (2) days after the allegation. Staff continued to work during this time. This was the second allegation against CNA #143. Interview with SW #90 on 04/03/19 at 2:11 PM, revealed she was the Grievance Officer for the facility. SW #90 was shown the grievance for R #55 and was asked how she would classify the allegation. She stated, Re-reading it now, it is neglect. She was asked if the allegation had been investigated. She stated she gave the grievance to DON #30 and she had given it back to her and told her it was worked through. She stated they had not caught this grievance in the morning meeting. During an interview with DON #30 on 04/03/19 at 1:00 PM, DON #30 was asked if she had investigated the allegation. She stated she talked with CNA #143 and told her residents should get up to the bathroom whenever they needed to. She was asked if she had done any further investigation, she stated she had not. Interview with the Administrator on 04/03/19 at 3:00 PM, revealed he had never seen the grievance for R #55. He confirmed the allegation had not been investigated and reported to himself or to the Mississippi State Department of Health. Resident #158 Review of R #158's electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE]. The resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #158 required extensive assistance of one (1) staff member for bed mobility, transfers, dressing, and toileting. The resident had a [MEDICAL CONDITION] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon.) R #158 was discharged home on[DATE]. A Grievance Investigation, documented by SW #90, dated 10/01/18 at 9:20 AM, revealed, on 09/30/18 at 3:00 PM, R #158 stated she turned on the call light. She needed a nurse to look at her bag ([MEDICAL CONDITION]) because she thought it was leaking. At 3:30 PM, Licensed Practical Nurse (LPN) #142 came in and checked her blood sugar. It was 95. LPN #142 told the resident to eat a couple more M&Ms, but, did not check the [MEDICAL CONDITION] bag. LPN #142 told her she would return later. The resident was concerned about her bag. A friend of R #158 called the facility and said that R #158 needed help. At 6:58 PM, LPN #142 returned to the room and yelled, I told you I was coming back. Don't you ever call and tell someone I am not doing my job. The section titled Details of Investigation revealed, Spoke with employee regarding this and counseled with her on appropriate customer service. She will take someone with her from now on. This was signed by DON #30. The corrective actions were documented 10/3/18, which was four (4) days after the allegation. LPN #142 continued to work during this time. On 10/10/18, no time indicated, SW #90 documented on the Additional Comments, BSW (Bachelor of Social Work) spoke w/(with) resident on 10/10/18, regarding nurse. Resident stated that at first she was a little disappointed to see the nurse back in her room . Interview with SW #90 on 04/03/19 at 2:11 PM, revealed she was the Grievance Officer for the facility. SW #90 stated when a resident had a grievance she would speak with the resident to gather the information and then she would take the grievance to the department in which the grievance was with. She stated she would follow up with the resident in a few days to see if everything had worked out to the resident's satisfaction. SW #90 was shown the grievance for R #158 and was asked how she would classify the allegation. She stated, Re-reading it now, it is abuse. She was asked if the allegation had been investigated. She stated, she gave the grievance to DON #30 and she had given it back to her and was told it was worked through. She stated they have a morning meeting, in which they discuss grievances and allegations, but she did not catch that this grievance had not been discussed. During an interview with DON #30 on 04/03/19 at 1:00 PM, DON #30 was asked if she had investigated the allegation. She stated she talked with LPN #2 about customer service and had told her to take another staff member in the room with her in the future. DON #30 stated she had not done any further investigation related to the grievance and the resident was no longer in the facility. Interview with the Administrator on 04/03/19 at 3:00 PM, revealed he had never seen the grievance for R #158. He confirmed the allegation had not been investigated and reported to himself or to the Mississippi State Department of Health. Resident #157 Review of R #157's EMR revealed the resident was admitted to the facility on [DATE], with a re-admission date of [DATE]. The resident was cognitively intact, with a BIMS of 15, and required extensive assistance of two (2) staff members for transfers, dressing, and toileting. R #157 was frequently incontinent of bowel and bladder. R #157 was discharged home on[DATE]. Review of a Grievance Investigation, documented by SW #83 on 01/30/19 at 8:45 AM, revealed, on 01/30/19 at 4:00 AM, R #260 (R #157's roommate) stated Certified Nursing Assistant (CNA) #143 was very rude to his roommate (R #157) that morning. R #157 went to the bathroom and was going back to bed when CNA #143 came into the room. CNA #143 went to R #157's closet and got a pair of pants out and threw them on the bed. R #260 stated CNA #143 told R #157, You will put these dam (sic) pants on. She then walked out of the room. SW #83 asked R #157 if his roommate's statement was true. R #157 said it was true, and he did not understand why he had to change his pants. The section titled Details of Investigation revealed, Counseled w/(with) aide regarding incident, that this language is not acceptable at all. Verbalized understanding and stated it will not happen again .signed by DON #30. The DON documented the corrective actions were completed on 2/3/19, which was four (4) days after the allegation. Staff continued to work during this time. Review of R #260's EMR revealed he was admitted to the facility on [DATE], and had a re-admission date of [DATE]. The resident was cognitively intact, with a BIMS of 13. During group interview on 04/03/19 at 10:00 AM, R #260 recalled the event with his old roommate, R #157. He stated, The staff member was mean to him. Interview with SW #90 on 04/03/19 at 2:11 PM, revealed she was the Grievance Officer for the facility. SW #90 was shown the grievance for R #157 and was asked how she would classify the allegation. She stated, Re-reading it now, it is abuse. She was asked if the allegation had been investigated. She stated she gave the grievance to DON #30 and she had given it back to her and was told it was worked through. She stated, they have a morning meeting, in which they discuss grievances and allegations, but she did not catch that this grievance had not been discussed. During an interview with DON #30 on 04/03/19 at 1:00 PM, DON #30 was asked if she had investigated the allegation. She stated she talked with CNA #143 about inappropriate language. She was asked if she had done any further investigation, she stated she had not. Interview with the Administrator on 04/03/19 at 3:00 PM, revealed he had never seen the grievance for R #157. He confirmed the allegation had not been investigated and reported to himself or to the Mississippi State Department of Health. During an interview, on 04/03/19 at 12:40 PM, the Risk Manager was asked what the procedure was if there was an allegation of abuse or neglect. She stated that the Administrator and DON had to be notified immediately. The Risk Manager went on to say that a full investigation would have to be conducted. First, make sure that the resident is okay and safe, the employee must leave the resident, and it should be reported to the DON and Administrator. She stated the incident is reviewed and call the State within 24 hours. The Risk Manager was shown the three (3) allegations (for Resident #55, Resident #157, and Resident #158), and was asked if she had any knowledge of the incidents. She stated she had no knowledge of the incidents. She stated that the incidents were either verbal abuse or neglect. She stated that two (2) of them occurred after (MONTH) 2019, when she took over investigations, and she should have been made aware of them. During an interview on 04/03/19 at 1:00 PM, DON #30 was asked what was to happen if an allegation of abuse or neglect is made. She said that she was usually called, or texted if not in the building, and that it should be reported to the Administrator. DON #30 was asked how to proceed once it was reported to the Administrator. She stated that it was to be thoroughly investigated and then a call made to the State within 24 hours. DON #30 was asked what took place when the Administrator was made aware of the allegations. DON #30 stated, These did not go to the Administrator. DON #30 was asked if that was per policy, she stated, No. During an interview on 04/03/19 at 3:00 PM, the Administrator was asked what the policy stated about reporting allegations of abuse and neglect. He stated, when they came in they were to be brought to his attention immediately. Then they were to investigate and report to the State within 24 hours. He stated that DON #30 never showed the three (3) allegations to him and they should have been thoroughly investigated at the time they occurred. He stated now it's too late. Those residents are no longer here.

Based on facility policy review, interview and record review, the facility failed to recognize and prevent abuse and neglect, and failed to immediately protect residents after allegations of abuse and neglect were reported to staff, for three (3) of 47 sampled residents, Residents (R) #55, R #157, and R #158. Two (2) allegations of verbal abuse and one (1) allegation of neglect were reported to staff, by cognitively intact residents. Certified Nursing Assistant (CNA) #143 was identified to be involved in one (1) allegation of verbal abuse on 1/30/19, and again in the allegation of neglect on 02/04/19. The neglect of Resident #55 rose to the harm level, when the resident voiced concerns about fear of retaliation. Resident #55: CNA #143 neglected to take the resident to the bathroom, per request, for four (4) hours on 02/04/19. This was reported to the staff on 02/04/19, by the resident. Director of Nursing (DON) #30 counseled the CNA and signed the section of the grievance form Corrective Action Complete on 02/06/19. (This was two (2) days after the event). CNA #143 continued to work. The resident voiced concerns about fear of retaliation for reporting the staff. Resident #158: Licensed Practical Nurse (LPN) #142 verbally abused the resident on 09/30/18, and the resident reported the abuse to staff on 10/01/18. DON #30 counseled the LPN and signed the section of the grievance form Corrective Action Complete on 10/03/18. (This was three (3) days after the alleged event). LPN #142 continued to work. Resident #157: CNA #143 verbally abused the resident on 01/30/19, which was reported to staff by the roommate on 01/30/19, and confirmed by Resident #157. DON #30 counseled the CNA and signed the section of the grievance form Corrective Action Complete on 02/03/19. (This was four (4) days after the alleged event). CNA #143 continued to work. Findings include: The facility Abuse Policy, with an implemented date of 1/11/18, reads: Policy: It is the policy of this facility that abuse will be handled as follows: The facility will: -Prevent, identify, investigate and report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property . -Protect the resident during an abuse investigation . Guidelines included: 3. Prevention . The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: a. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. b. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Any instances of abuse of any residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish, includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. c. Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability . 5. Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response/ investigating as described below. 6. Protection: a. The facility will protect residents from harm during an investigation by: i. (sic) Suspending the accused employee until facility has conducted its own investigation and no evidence of abuse was found . Procedure for Response, Reporting, Investigation Allegations of Abuse/Neglect/Exploitation . When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated: Response . c. Notify the Director of Nursing Services and Administrator . f. Complete an initial report on Abuse/Neglect/Exploitation form and initiate an investigation. Reporting . The complaint must be reported immediately to the Administrator, Director of Nursing, and the Nursing Supervisor on duty . Review of the facility's Grievance Log for the last six (6) months revealed 26 grievances that were documented. Review of each of the grievances revealed two (2) allegations of verbal abuse (for Resident #157 and Resident #158) and one (1) allegation of neglect (for Resident #55). The three (3) allegations were reviewed and discussed with the Risk Manager, DON #30, Social Worker (SW) #90 (who was also the Grievance Officer), and the Administrator. During the interviews, it was discovered that DON #30 and SW #90 did not follow the facility policy by failing to identify abuse and neglect for the three (3) residents. DON #30 counseled the employees and allowed them to continue working. The DON did not thoroughly investigate the allegations, nor did she report the abuse and neglect to the Administrator and the State Agency. Resident #55 Review of R #55's Electronic Medical Record (EMR) revealed an undated Face Sheet. The Demographics section indicated an admitted [DATE]. The [DIAGNOSES REDACTED]. Review of R #55's admission MDS with an ARD of 02/04/19, specified the resident had a BIMS score of 15 out of 15, which indicated no cognitive impairment. R #55 did not exhibit any behavioral symptoms. R #55 required extensive assistance of one (1) staff member with bed mobility, transfers, toileting and personal hygiene. R #55 was frequently incontinent of bladder and occasionally incontinent of bowel. R #55 was discharged home on[DATE]. Review of a Grievance Investigation, dated 02/04/19 at 8:00 AM, Speech Language Pathologist (SLP) #3 documented, on either 02/03/19 and 02/04/19 at 3:00 AM, R #55 called for CNA #143 because she needed to go to the bathroom. CNA #143 came by and told the resident she was making rounds and she would get her when it was her turn. CNA #143 came back at 5:28 AM, (the buzzer went off at the desk) and asked her what she needed. R #55 told her she needed help going to the bathroom. CNA #143 came in to the resident's room and told her to roll over. The resident asked why. CNA #143 said she was going to change her pad. The resident asked why she was going to change her pad. R #55 said no, she needed help going to the bathroom. The CNA told her that the patients could not get up to go to the bathroom during the night. The resident said, Then I will take myself. CNA #143 went out of the room mad and mouthing off complaints to the nurse, or whomever, and said the resident was refusing to cooperate. LPN #144 then came in and asked if she said she was going to walk to the bathroom herself. The resident said No, I wouldn't do that. The resident sat on the edge of the bed, still LPN #144 nor CNA #143 helped her to the bathroom or helped her get her leg back in bed. The resident was finally able to pull her leg back into the bed to stretch out. No one helped her to the bathroom until the 7:00 AM shift came on. The resident was concerned for fear of retaliation. When the day shift came, she told the CNA, My diaper will probably drag the floor, it was so full. The resident also said CNA #143 said they couldn't take her to the bathroom at night until therapy said they could. The resident said this had happened every night since she came, and they come in and expect her to use the pad. The section titled Details of Investigation, revealed, Spoke w/aide regarding this incident. Educated aide that residents should get up to the restroom anytime they need to go . This was signed by the DON. The DON signed the grievance form indicating the corrective actions were completed on 2/6/19, which was two (2) days after the alleged event. The CNA continued to work. On 04/03/19 at 1:15 PM, DON #30 was given the Grievance Investigation for R #55 and was asked to classify the allegation. She stated, I don't have a good answer. She looked at the policy again and stated, According to the definition, could be neglect. Resident #158 Review of R #158's EMR revealed an undated Face Sheet. The Demographics section identified an admitted [DATE]. The [DIAGNOSES REDACTED]. Resident #158's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/18, specified the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. R #158 did not exhibit any behavioral symptoms. R #158 required extensive assistance of one (1) staff member with activities of daily living (ADLs) for bed mobility, transfers, dressing, and toileting. The MDS specified R #158 had an ostomy bag. R #158 was discharged home on[DATE]. A Grievance Investigation documented by SW #90, dated 10/01/18 at 9:20 AM, revealed, on 09/30/18 at 3:00 PM, R #158 stated she turned on the call light. She needed a nurse to look at her bag ([MEDICAL CONDITION]) because she thought it was leaking. At the same time R #158 felt her blood sugar dropped. At 3:30 PM, LPN #142 came in and checked her blood sugar. It was 95. LPN #142 told the resident to eat a couple more M&Ms, but did not check the [MEDICAL CONDITION] bag. LPN #142 told the resident she would return later. The resident was concerned about her bag. A friend of R #158 called the facility and said that R #158 needed help. At 6:58 PM, LPN #142 returned to the room and yelled, I told you I was coming back. Don't you ever call and tell someone I am not doing my job. The resident stated that the DON must have texted her. The section titled Details of Investigation revealed, Spoke with employee regarding this and counseled with her on appropriate customer service. She will take someone with her from now on. This was signed by DON #30. The DON signed the corrective actions were completed on 10/3/18, this was three (3) days after the alleged event. On 10/10/18, no time indicated, SW #90 documented on the Additional Comments, of the Grievance form, BSW (Bachelor of Social Work) spoke w/(with) resident on 10/10/18, regarding nurse. Resident stated that at first she was a little disappointed to see the nurse back in her room . During an interview with DON #30 on 04/03/19 at 1:00 PM, she was asked if she could define abuse. She said she would need to look at the policy for the definition. DON #30 was given the Grievance Investigation and was asked to how should would classify R #158's allegation. She stated, it could have been disparaging for the resident and it is verbal abuse. She was asked if the Details of Investigation she had documented addressed verbal abuse and if she had spoken with the resident regarding the allegation. She replied, the counseling provided to LPN did not include the situation was verbal abuse, because she had not recognized it as such. She confirmed she had not spoken to the resident about the incident to verify the information. She failed to provide protection to other residents. Resident #157 Review of R #157's EMR revealed an undated Face Sheet under the Demographics section with an admitted [DATE], and a re-admitted [DATE]. The [DIAGNOSES REDACTED]. R #157's admission MDS with an ARD of 11/14/18, specified the resident had a BIMS score of 15 out of 15, which indicated no cognitive impairment. R #157 did not exhibit any behavioral symptoms. R #157 required extensive assistance of two (2) staff members for transfers, dressing and toileting R #157 was frequently incontinent of bowel and bladder. R #157 was discharged home on[DATE]. Review of a Grievance Investigation, documented by SW #83 on 01/30/19 at 8:45 AM, revealed, on 01/30/19 at 4:00 AM, R #260 stated CNA #143 was very rude to his roommate (R #157) that morning. R #157 went to the bathroom and was going back to bed when CNA #143 came into the room. CNA #143 went to R #157's closet and got a pair of pants out and threw them on the bed. R #260 stated CNA #143 told R #157, You will put these dam (sic) pants on. She then walked out of the room. SW #83 asked R #157 if his roommate's statement was true. R #,157 said it was true, and he did not understand why he had to change his pants. The section titled Details of Investigation revealed, Counseled w/(with) aide regarding incident, that this language is not acceptable at all. Verbalized understanding and stated it will not happen again .signed by DON #30. The DON signed the corrective actions were completed on 2/3/19, which was four (4) days after the alleged event. During interview on 04/03/19 at 1:08 PM, with DON #30, she was shown the Grievance Investigation for R #157 and was asked how she would classify the allegation. She stated, It is verbal abuse. She stated she did not counsel the aide on verbal abuse because she had not considered it to be abuse, until she read the policy and definition of abuse. The DON stated the CNA was pulled from Resident #157's room and told not to go back to that room. She confirmed she had not talked with R #157 or R #260 about the allegation to verify the situation, and she had not provided protection to residents at the time of the allegation, because she did not investigate the allegation. Review of R #260's admission MDS with an ARD of 01/23/19, specified the resident's hearing was adequate and vision was adequate but wore corrective lenses. R #260 had a BIMS score of 13 out of 15, which indicated no cognitive impairment. R #260 did not exhibit any behavioral symptoms. R #260 was a resident at the time of the survey. During group interview on 04/03/19 at 10:00 AM, R #260 recalled the event with his old roommate, R #157. He stated, The staff member was mean to him. During an interview on 04/03/19 at 2:11 PM, SW #90 stated she was also the Grievance Officer. SW #90 was asked what that entailed, and she stated that she would take the grievance by talking with the resident and then take the grievance to the department in which the grievance was with. SW #90 added, she would follow up in a few days with the resident to see if everything had been worked out to their satisfaction. SW #90 was asked what she would do if she received any allegations of abuse or neglect. She stated she would take them to the Administrator and DON. She reviewed the three (3) allegations (for R #55, R #157, and R #158) and was asked what category she thought them to fall in. SW #90 stated, Re-reading them now, they are abuse and neglect. When asked why they appear that way now, SW #90 stated that she had received the others from DON #30, and was told they were worked through. SW #90 stated that she was aware they (grievances) had not been taken to the Administrator. She stated there was a discussion of grievance and allegations usually at the morning meeting. SW #90 stated she just did not catch it, that those had not been discussed. During an interview on 04/03/19 at 3:00 PM, the Administrator was shown the three (3) Grievance Investigations and asked how they appeared to him. The Administrator stated he thought they were abuse and neglect. He was asked if had seen them before. He stated, No. I should have. He stated that DON #30 never showed those to him He stated the residents were no longer here.

Complaint Investigation (CI) MS # Based on observation, interview, record review and policy review, the facility failed to ensure that Resident #2 was properly identified prior to the administration of medications. Resident #2 received medications on [DATE] that were prescribed for Resident #1 around 9:15 a.m. and was later sent to the hospital. The facility failed to ensure that a significant medication error did not occur for Resident #2 when he received Resident #1's medications. Resident #2 expired on [DATE] with a [DIAGNOSES REDACTED]. The facility's failure to prevent Resident #2 from receiving medications that were prescribed for Resident #1 was deemed an Immediate Jeopardy (IJ) on [DATE] at 6:15 p.m. The IJ began on [DATE] and was determined to be removed on [DATE] at 3:30 p.m. The Administrator and Director of Nurses were notified of the IJ on [DATE] at 6:15 p.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 12:55 p.m. Based on the verification of the facility's corrective actions that were validated by staff interviews, observation of residents, observation of medication procedures, record review, policy/procedure review and in-service education review, the IJ was removed and the scope and severities were lowered from a "J" to a "D" which constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure that the facility's measures could be reviewed and evaluated by the Quality Assurance Committee. Findings include: Cross refer to F-224. The facility failed to ensure that Resident #2 was properly identified prior to the administration of medications. Resident #2 received medications on [DATE] that were prescribed for Resident #1 around 9:15 a.m. as well as receiving medications that were prescribed for him (Resident #2). Therefore the facility failed to ensure that a significant medication error did not occur for Resident #2. Resident #2 received the following medications in error: Omega 3 Fish oil 1000 mg (milligrams), [MEDICATION NAME] 10 mg, Aspirin 81 mg, [MEDICATION NAME] 5 mg, Tamsulosin 0.4 mg, [MEDICATION NAME] 10 mg, Metaprolol [MEDICATION NAME] 50 mg, Gabepentin 600 mg, [MEDICATION NAME] 60 mg and [MEDICATION NAME] 500 mg. Resident #2 also received the following physician ordered medications: Aspirin 325 mg (milligrams), [MEDICATION NAME] 1 tablet, [MEDICATION NAME] 1 mg, Potassium Cloride 10 meq (milliequivalents), [MEDICATION NAME] 0.4 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] ,[DATE] diskus 1 puff, [MEDICATION NAME] 7.5 mg, [MEDICATION NAME] HCT ,[DATE].5 mg, UTI Stat 30 cc (cubic centimeters) and B-12 plus 1000 mcg (micrograms). The facility provided a credible Allegation of Compliance on [DATE] at 12:55 p.m. An Allegation of Compliance was accepted on [DATE] at 3:30 p.m. The allegation noted: "An Immediate Jeopardy was called on [DATE] at 6:15pm related to a medication error for Resident # 2, who had a change in status and was transferred to the hospital on [DATE]. [DATE] 10:00 am Licensed Practical Nurse (LPN) #4 placed a call to the Physician to notify him of the medication error for Resident # 2 no new orders were received at that time. [DATE] 10:15am LPN #2 notified resident's family of medication error of Resident #2 by phone. [DATE] 12:05pm LPN #2 notified hospice of the medication error of Resident #2. [DATE] 1:00pm LPN # 2 notified the Director of Nursing (D.O.N.) of medication error of Resident #2. State Agencies were notified of the medication error of Resident#2 [DATE] at approximately 4:30pm by LPN #6. State Board of Nursing was notified of the medication error of Resident #2 on [DATE] at approximately 2 pm by the Director of Nursing. [DATE] the facility began the investigation of the medication error of Resident #2. The D.O.N., LPN #6 and LPN #7 met with LPN #1 and LPN #2 to interview them regarding the medication error of Resident #2 at approximately 8am. During this meeting LPN #1 and LPN #2 were instructed by LPN #6 and LPN #7 that residents are to be identified by picture and that medications must be administered using facility policy and the Five Rights of medication administration to include; right resident, right drug, right dose, right route and right time. LPN #1 and LPN #2 were also informed by LPN #6 and LPN #7 on [DATE] that MARs are not to be signed until medications are given. On [DATE] at approximately 2pm it was noted by LPN #6 that Resident #1 did not have a picture on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].O.N. and placed the picture from the [DATE] MAR book on the [DATE] MAR. The Order Entry Nurse (LPN #8) is to ensure that the resident's picture is placed on the MAR. LPN #8 received a written counseling from the D.O.N. on [DATE] at approximately 3pm for failure to place a picture of Resident #1 on the [DATE] MAR. The Quality Assurance committee; consisting of the Administrator , D.O.N.,LPN #6 and LPN #7 met on the afternoon of [DATE] to discuss the medication error of Resident #2, resident identification, orientation process and medication administration. The Medical Director was not present at this initial meeting; however the Administrator met with the Medical Director on [DATE] upon his arrival to the facility to discuss the information from the meeting. The Medical Director was agreeable with changes the facility had implemented. On [DATE] All RNs and LPNs on duty received an inservice on Abuse and Neglect to include ensuring resident are not abused nor neglected by the failure to follow physician's orders [REDACTED]. This in-service was given by Licensed Social Worker (LSW) #1. No RN or LPN will be allowed to work until in-serviced. The facility made changes to the "Resident Identification Policy" on [DATE] to enable new residents to be identified until a picture could be placed on the MAR. This was accomplished with implementation of the placement of armbands on all new residents until a picture is obtained. RNs and LPNs were in serviced on Resident Identification on [DATE] by LPN #5. No RN or LPN will be allowed to work until in-serviced. The facility made changes to the orientation process on [DATE] to outline Staff Development Coordinator, Orientee and Floor Nurse Responsibilities to include the process for using the five rights of medication administration and facility medication administration policy for resident identification and proper documentation during medication pass. The Nurse Skill Review Form was updated on [DATE] by the D.O.N. to include an area for documentation of education, return demonstration, re-education if needed and return demonstration. RNs and LPNs were in serviced on the Orientation Program on [DATE] by LPN #5. No RN or LPN will be allowed to work until in-serviced. RNs and LPNs were in serviced on the Five Rights of medication administration: right resident, right time, right drug, right dose, right route and the facility medication administration policy to include the process for identification of residents and documentation of medications on [DATE] by LPN #6. No RN or LPN will be allowed to work until in-serviced. On [DATE] the Social Service Assistant reviewed a list of new admissions, took pictures for any residents that did not have them, and gave them to the floor nurses. The floor nurses ensured that the pictures were placed on the MAR. On [DATE] LPN #7 Initiated Medication Administration Audits; to include resident identification, administration of the medication to the resident, appropriate documentation of medication , this medication audit will continue until all nurses have successfully passed the audit. On [DATE] The D.O.N., LPN #6 and LPN #7 checked the MARs to ensure all residents had a picture. An armband was placed on any resident who did not have a picture. On [DATE] The facility initiated the following practice: Prior to every medication administration, the nurse must identify the resident by photo or armband. If the resident does not have a photo, an armband must be applied to the resident until a photo is obtained. The licensed nurse will be responsible for documenting that this has been checked on the Resident Identification Form. RNs and LPNs were in serviced on this practice [DATE] by the D.O.N. No RN or LPN will be allowed to work until in-serviced. Verification of the Allegation of Compliance: Review of personnel action forms revealed that Licensed Practical Nurse (LPN) #1 was placed on administrative leave [DATE] pending investigation of a significant medication error and LPN #8 was counseled on [DATE] for failure to place a photo on a resident's Medication Administration Record. Review of a Quality Assurance (QA) meeting dated [DATE] revealed that the facility met and reviewed the medication error for Resident #2 and discussed ways for improving resident identification, orientation process and medication administration. Interview with the Medical Director on [DATE] at 3:00 p.m. revealed that he had been informed and agreed with the process. Review of Audits initiated [DATE] by LPN #7 revealed that random nurse's had been checked off on resident identification, medication administration and documentation. Review of an Audit dated [DATE] by the Director of Nurses, Licensed Practical Nurse (LPN) #6 and LPN #7 revealed that all Medication Administration Records were checked for photos and documentation that arm bands were placed on residents who did not have a photo. Review of in-services revealed that nurse's were educated on the following dates on the following information with signatures of the nurses on the in-service sheets: [DATE] - Abuse/Neglect-ensuring residents are not abused nor neglected by the failure to follow physician's orders [REDACTED]. [DATE] - Resident Identification Policy - changes to enable new residents to be identified by the use of an armband until a photo could be placed on the Medication Administration Record. [DATE] -Orientation Program-to outline responsibilities of the Staff Development Coordinator, Orientee and Floor Nurse to include the process for using the five rights of medication administration and facility medication policy for resident identification and proper documentation during medication pass. [DATE] -Five Rights of Medication Administration that included the right resident, right time, right drug, right dose and right route. Also included was the process for identifying residents by photo and/or arm bands. [DATE] - Practice initiated: Prior to every medication administration, the nurse must identify the resident by photo or armband. If the resident does not have a photo, an armband must be applied to the resident until a photo is obtained. The licensed nurse will be responsible for documenting that this has been checked on the Resident Identification Form. Interviews on [DATE] with licensed nurses revealed that they had been in-serviced on the above policies and procedures. Review of the [DATE]-400 hall's Medication Administration Records (MAR) on [DATE] at 4:45 p.m. revealed that all MARs had a resident's photo. There was also a Resident Identification form in the front of each MAR indicated [REDACTED]. Observations with licensed nurses who were administering medications on [DATE] beginning at 4:00 p.m. revealed that residents were identified by reviewing the photo on the MAR (Medication Administration Record) and asking the resident their names prior to medication administration. Based on the verification of the facility's corrective actions that were validated by staff interviews, observation of residents, observation of medication procedures, record review, policy/procedure review and in-service education review, the IJ was removed and the scope and severities were lowered from a "J" to a "D" which constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure that the facility's measures could be reviewed and evaluated by the Quality Assurance Committee.

Complaint Investigation (CI) MS # Based on observation, interview, record review and policy review the facility failed to ensure that standards of practice were followed for one (1) of eight (8) residents, Resident #2, as evidenced by Resident #2 receiving medications that were ordered for another resident, Resident #1. Resident #2 was not properly identified and received medications on [DATE] that were prescribed for Resident #1 and was sent to the hospital. Resident #2 expired on [DATE] with a [DIAGNOSES REDACTED]. The facility's failure to prevent Resident #2 from receiving medications that were prescribed for Resident #1 was deemed an Immediate Jeopardy (IJ) on [DATE] at 6:15 p.m. The IJ began on [DATE] and was determined to be removed on [DATE] at 3:30 p.m. The Administrator and Director of Nurses were notified of the IJ on [DATE] at 6:15 p.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 12:55 p.m. Based on the verification of the facility's corrective actions that were validated by staff interviews, observation of residents, observation of medication procedures, record review, policy/procedure review and in-service education review, and based on the "G" level deficiency cited on the [DATE] complaint investigation, the IJ was removed and the scope and severities were lowered from a "J" to a "*G*" which constitutes actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure that the facility's measures could be reviewed and evaluated by the Quality Assurance Committee. Findings include: Cross refer to F-224. The facility failed to properly identify Resident #2 prior to medication administration and failed to follow physician's orders [REDACTED].#1 and was monitored at the facility, and then sent to the hospital on [DATE]. Resident #2 expired at the hospital on [DATE] with [DIAGNOSES REDACTED]. The facility provided a credible Allegation of Compliance on [DATE] at 12:55 p.m. An Allegation of Compliance was accepted on [DATE] at 3:30 p.m. The allegation noted: "An Immediate Jeopardy was called on [DATE] at 6:15pm related to a medication error for Resident # 2, who had a change in status and was transferred to the hospital on [DATE]. [DATE] 10:00 am Licensed Practical Nurse (LPN) #4 placed a call to the Physician to notify him of the medication error for Resident # 2 no new orders were received at that time. [DATE] 10:15am LPN #2 notified resident's family of medication error of Resident #2 by phone. [DATE] 12:05pm LPN #2 notified hospice of the medication error of Resident #2. [DATE] 1:00pm LPN # 2 notified the Director of Nursing (D.O.N.) of medication error of Resident #2. State Agencies were notified of the medication error of Resident#2 [DATE] at approximately 4:30pm by LPN #6. State Board of Nursing was notified of the medication error of Resident #2 on [DATE] at approximately 2 pm by the Director of Nursing. [DATE] the facility began the investigation of the medication error of Resident #2. The D.O.N., LPN #6 and LPN #7 met with LPN #1 and LPN #2 to interview them regarding the medication error of Resident #2 at approximately 8am. During this meeting LPN #1 and LPN #2 were instructed by LPN #6 and LPN #7 that residents are to be identified by picture and that medications must be administered using facility policy and the Five Rights of medication administration to include; right resident, right drug, right dose, right route and right time. LPN #1 and LPN #2 were also informed by LPN #6 and LPN #7 on [DATE] that MARs are not to be signed until medications are given. On [DATE] at approximately 2pm it was noted by LPN #6 that Resident #1 did not have a picture on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].O.N. and placed the picture from the [DATE] MAR book on the [DATE] MAR. The Order Entry Nurse (LPN #8) is to ensure that the resident's picture is placed on the MAR. LPN #8 received a written counseling from the D.O.N. on [DATE] at approximately 3pm for failure to place a picture of Resident #1 on the [DATE] MAR. The Quality Assurance committee; consisting of the Administrator , D.O.N.,LPN #6 and LPN #7 met on the afternoon of [DATE] to discuss the medication error of Resident #2, resident identification, orientation process and medication administration. The Medical Director was not present at this initial meeting; however the Administrator met with the Medical Director on [DATE] upon his arrival to the facility to discuss the information from the meeting. The Medical Director was agreeable with changes the facility had implemented. On [DATE] All RNs and LPNs on duty received an inservice on Abuse and Neglect to include ensuring resident are not abused nor neglected by the failure to follow physician's orders [REDACTED]. This in-service was given by Licensed Social Worker (LSW) #1. No RN or LPN will be allowed to work until in-serviced. The facility made changes to the "Resident Identification Policy" on [DATE] to enable new residents to be identified until a picture could be placed on the MAR. This was accomplished with implementation of the placement of armbands on all new residents until a picture is obtained. RNs and LPNs were in serviced on Resident Identification on [DATE] by LPN #5. No RN or LPN will be allowed to work until in-serviced. The facility made changes to the orientation process on [DATE] to outline Staff Development Coordinator, Orientee and Floor Nurse Responsibilities to include the process for using the five rights of medication administration and facility medication administration policy for resident identification and proper documentation during medication pass. The Nurse Skill Review Form was updated on [DATE] by the D.O.N. to include an area for documentation of education, return demonstration, re-education if needed and return demonstration. RNs and LPNs were in serviced on the Orientation Program on [DATE] by LPN #5. No RN or LPN will be allowed to work until in-serviced. RNs and LPNs were in serviced on the Five Rights of medication administration: right resident, right time, right drug, right dose, right route and the facility medication administration policy to include the process for identification of residents and documentation of medications on [DATE] by LPN #6. No RN or LPN will be allowed to work until in-serviced. On [DATE] the Social Service Assistant reviewed a list of new admissions, took pictures for any residents that did not have them, and gave them to the floor nurses. The floor nurses ensured that the pictures were placed on the MAR. On [DATE] LPN #7 Initiated Medication Administration Audits; to include resident identification, administration of the medication to the resident, appropriate documentation of medication , this medication audit will continue until all nurses have successfully passed the audit. On [DATE] The D.O.N., LPN #6 and LPN #7 checked the MARs to ensure all residents had a picture. An armband was placed on any resident who did not have a picture. On [DATE] The facility initiated the following practice: Prior to every medication administration, the nurse must identify the resident by photo or armband. If the resident does not have a photo, an armband must be applied to the resident until a photo is obtained. The licensed nurse will be responsible for documenting that this has been checked on the Resident Identification Form. RNs and LPNs were in serviced on this practice [DATE] by the D.O.N. No RN or LPN will be allowed to work until in-serviced. Verification of the Allegation of Compliance: Review of personnel action forms revealed that Licensed Practical Nurse (LPN) #1 was placed on administrative leave [DATE] pending investigation of a significant medication error and LPN #8 was counseled on [DATE] for failure to place a photo on a resident's Medication Administration Record. Review of a Quality Assurance (QA) meeting dated [DATE] revealed that the facility met and reviewed the medication error for Resident #2 and discussed ways for improving resident identification, orientation process and medication administration. Interview with the Medical Director on [DATE] at 3:00 p.m. revealed that he had been informed and agreed with the process. Review of Audits initiated [DATE] by LPN #7 revealed that random nurse's had been checked off on resident identification, medication administration and documentation. Review of an Audit dated [DATE] by the Director of Nurses, Licensed Practical Nurse (LPN) #6 and LPN #7 revealed that all Medication Administration Records were checked for photos and documentation that arm bands were placed on residents who did not have a photo. Review of in-services revealed that nurse's were educated on the following dates on the following information with signatures of the nurses on the in-service sheets: [DATE] - Abuse/Neglect-ensuring residents are not abused nor neglected by the failure to follow physician's orders [REDACTED]. [DATE] - Resident Identification Policy - changes to enable new residents to be identified by the use of an armband until a photo could be placed on the Medication Administration Record. [DATE] -Orientation Program-to outline responsibilities of the Staff Development Coordinator, Orientee and Floor Nurse to include the process for using the five rights of medication administration and facility medication policy for resident identification and proper documentation during medication pass. [DATE] -Five Rights of Medication Administration that included the right resident, right time, right drug, right dose and right route. Also included was the process for identifying residents by photo and/or arm bands. [DATE] - Practice initiated: Prior to every medication administration, the nurse must identify the resident by photo or armband. If the resident does not have a photo, an armband must be applied to the resident until a photo is obtained. The licensed nurse will be responsible for documenting that this has been checked on the Resident Identification Form. Interviews on [DATE] with licensed nurses revealed that they had been in-serviced on the above policies and procedures. Review of the [DATE]-400 hall's Medication Administration Records (MAR) on [DATE] at 4:45 p.m. revealed that all MARs had a resident's photo. There was also a Resident Identification form in the front of each MAR indicated [REDACTED]. Observations with licensed nurses who were administering medications on [DATE] beginning at 4:00 p.m. revealed that residents were identified by reviewing the photo on the MAR (Medication Administration Record) and asking the resident their names prior to medication administration. Based on the verification of the facility's corrective actions that were validated by staff interviews, observation of residents, observation of medication procedures, record review, policy/procedure review and in-service education review, the IJ was removed and the scope and severity was lowered from a "J" to a "*G*" which constitutes actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure that the facility's measures could be reviewed and evaluated by the Quality Assurance Committee.

Complaint Investigation (CI) MS # Based on observation, interview, record review, and policy review, the facility failed to ensure that one (1) of eight (8) residents, Resident #2, was not neglected. The facility failed to ensure that Resident #2 was properly identified prior to the administration of medications. Resident #2 received medications on [DATE] that were prescribed for Resident #1 around 9:15 a.m. and was later sent to the hospital. Resident #2 expired on [DATE] with a [DIAGNOSES REDACTED]. The facility's failure to prevent Resident #2's neglect by not providing the proper identification of the resident and giving Resident #2 medications that were ordered for another resident was deemed an Immediate Jeopardy (IJ) on [DATE] at 6:15 p.m. The IJ began on [DATE] and was determined to be removed on [DATE] at 3:30 p.m. The Administrator and Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 6:15 p.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 12:55 p.m. Based on the verification of the facility's corrective actions that were validated by staff interviews, observation of residents, observation of medication procedures, record review, policy/procedure review and in-service education review, and based on the "G" level deficiency cited on the [DATE] complaint investigation, the IJ was removed and the scope and severity were lowered from a "J" to a "G" which constitutes actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure that the facility's measures could be reviewed and evaluated by the Quality Assurance Committee. Findings include: Resident #2 Record review revealed that Resident #2 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's most recent Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 4, which indicated that Resident #2's cognitive status was severely impaired. Review of the care plan, dated [DATE], revealed that Resident #2 had severe cognitive impairment and cardiac [DIAGNOSES REDACTED]. Review of a medication error report, dated [DATE], revealed Resident #2 had been given Resident #1's 9:00 a.m. medications on [DATE] at 9:15 a.m. The report documented that possible harmful effects could be low blood pressure, renal complications and decline in status. The type of medication error was documented as: Unordered medications. Review of a "Report to State-Medication Error" report sent to the state agency on [DATE] from the facility noted, "Description/Investigation of Incident: On [DATE] at approximately 9:15 a.m. (name of LPN {Licensed Practical Nurse} #1 entered room [ROOM NUMBER] to administer medications to the resident of room [ROOM NUMBER]A (name of Resident) Resident #1. LPN #1 states when she entered the room a resident was sitting in the room in the wheelchair in front of the closet on the A side of the room. LPN #1 states that she asked this resident if he was (name of Resident #1) the resident replied yes and so she administered the medications. At this point (name of Licensed Practical Nurse) LPN #2 entered the room and noted that LPN #1 giving (name of Resident #2) resident of room [ROOM NUMBER]B (Resident #2), a drink of water and had an empty medication cup in her hand. LPN #2 stated Resident #1 was in the bathroom at this time. LPN #2 asked LPN #1 if she had given the medications to Resident #2 and LPN #1 responded yes. Resident #2 had already received his 9am morning medications as well. The physician, family member for Resident #2 was notified of the medication error. The Nurse Practitioner arrived at the facility and evaluated the resident, spoke to the family at that time family elected to have Resident #2 monitored and transfer to ER (emergency room ) if blood pressure or pulse drops. Orders received to hold 5 pm and 9 pm medications and perform q (every) 1 hour vital signs. A copy of her (Nurse Practitioner's) progress note and monitoring are included. At 9:45 pm Resident #2 was noted (to) have even, unlabored, shallow respirations @ (at) a rate of 16, blood pressure ,[DATE], heart rate of 53, pale clammy skin. Physician and family were notified of status no new orders at that time. At 10:30 p.m. Vital signs noted to be: Blood pressure of ,[DATE], Heart rate 53, Respirations 15. Director of Nursing spoke with family about potential negative outcomes of residents status if no further intervention taken. Family was agreeable with transfer to ER at that time and a Routine House Order to transfer the resident to the hospital was initiated. (Name of ambulance service) arrived at 11:20 p.m. and transported the resident to (name of local hospital) emergency room . The family notified the facility that the resident expired at the hospital on [DATE] sometime before 12:30 p.m. Resident #2 received the following medications in error: Omega 3 Fish oil 1000mg, [MEDICATION NAME] 10mg, Aspirin 81 mg, [MEDICATION NAME] 5mg, Tamsulosin 0.4mg, [MEDICATION NAME] 10mg, Metaprolol [MEDICATION NAME] 50mg, Gabepentin 600mg, [MEDICATION NAME] 60mg, [MEDICATION NAME] 500mg. The following is a list of Resident #2 (#2's) ordered medications that he also received: Aspirin 325mg, [MEDICATION NAME] 1 tablet, [MEDICATION NAME] 1mg, Potassium Cloride 10meq (milliequivalents), [MEDICATION NAME] 0.4mg, [MEDICATION NAME] 50mg, [MEDICATION NAME] 100mg, [MEDICATION NAME] ,[DATE] diskus 1 puff, [MEDICATION NAME] 7.5mg, [MEDICATION NAME] HCT ,[DATE].5mg, UTI Stat 30cc (cubic centimeters), B-12 plus 1000 mcg (micrograms). Additional information: LPN (Licensed Pratical Nurse) #2 states that she does not recall LPN #1 administering any medications after this incident. LPN #1 has been off work since this incident. LPN #1 was on day 4 of orientation to the facility. LPN #2 was the nurse orienting LPN #1. Both nurses were interviewed regarding this incident ..." Review of the Neurological Checklist for Resident #2 documented hourly checks beginning on [DATE] at 10:30 a.m. revealed that at 10:30 a.m. Resident #2's blood pressure was ,[DATE] with pulse 91 and respirations 16. At 10:30 p.m. the blood pressure was ,[DATE], pulse 53 and respirations were 15. Review of a progress note by the Nurse Practitioner (NP), dated [DATE], (not timed), noted, "Asked to see pt (patient) - Pt was given his medication & (and) the medication of his roommate. (Name of physician), RP (Responsible Party), QA (Quality Assurance) Nursing Supervisor notified by nurse. Discussed with pt's (patient's) daughter and daughter-in-law elected to monitor pt and if the BP (blood pressure) or pulse (P) drops will go to ER (emergency room ). BP stable ,[DATE], P 83, Resp (Respirations) 18. On exam ... lethargic but answered to name and attempts to drink fluids. Neck supple, chest CTA (Computed Tomography [MEDICATION NAME]), CV RRR (Cardiovascular - regular rate and rhythm) - Abd (abdomen) soft BS (bowel sounds) (+) NT/ND (non tender/non distended) trace [MEDICAL CONDITION] to BLE (bilateral lower extremities). Intermittent incont. (Incontinence) [MEDICAL CONDITION], VS (vital signs) q (every) 1 hour, Hold medications at this time. Family at bedside." Review of a progress note by the Nurse Practitioner on [DATE], not timed, noted, "Pt (patient) CK (check) - VS (vital signs) stable - Daughter @ (at) bedside. Pt still sedated but arouses easily to stimuli. Has had fluids & (and) voided but goes back to sleep. Daughter still declines ER since vitals were stable." Review of a progress note by the Nurse Practitioner on [DATE] at 6:30 p.m. noted, "Checked on pt (patient) again before leaving. Daughter just left. Pt (patient) alert finished supper meal. Nurse sitting @ (at) side of bed to ck (check) VS (vital signs) BP (blood pressure)/Heart Rate stable. Resp (Respirations) good. 360 cc (cubic centimeters) fluid & pt has voided. Moving exts (extremities) well. Follows commands. VS have been stable thru (through) out the day with family @ (at) bedside. Cont (continue) q (every) 1 hour VS (vital signs) hold medications tonight." Review of handwritten physician's orders [REDACTED]. Hold the 5pm dose of [MEDICATION NAME] and [MEDICATION NAME]. Review of handwritten orders revealed an order, dated [DATE] at 2:05 p.m., for [MEDICATION NAME] 15 mg (milligram) at 5:00 p.m. and 9:00 p.m. to be held on ,[DATE], [MEDICATION NAME] 0.5 mg at 9:00 p.m. to be held on ,[DATE]. Resume meds (medications) in morning if VS (vital signs) are stable. Review of handwritten physician's orders [REDACTED]. Review of the "Hospital Transfer Form and Nurse's Note" for Resident #2, dated [DATE], revealed that Resident #2's mental status was drowsy and had a blood pressure of ,[DATE], Temperature 97.6, Pulse 53 and Blood Sugar 166. Current Status: Resident received wrong medications see attached." Review of Resident #2's physician's orders [REDACTED].#2 was ordered and received the following medications for [DATE] at 9:00 a.m.: [MEDICATION NAME] ,[DATE] Diskus one (1) puff inhalation, [MEDICATION NAME] 7.5 mg, B-12 plus 1000 mcg, [MEDICATION NAME] HCT ,[DATE].5 mg (anti-hypertensive), Aspirin 325 mg, [MEDICATION NAME] one (1) tablet, [MEDICATION NAME] l mg, Potassium Cloride 10 meq, UTI Stat 30 cc, [MEDICATION NAME] 0.4 mg, Metaprolol 50 mg (anti-hypertensive/cardiac), and [MEDICATION NAME] 100 mg (anti-depressant) that was documented by LPN #1. Resident #2 had already received [MEDICATION NAME] 7 units of insulin at 8:00 a.m. on [DATE] that was documented by LPN #1. Review of Resident #1's physician's orders [REDACTED].#1 which were given in error to Resident #2: Omega 3 Fish Oil 1000 mg, [MEDICATION NAME] 10 mg, Aspirin 81 mg (duplicate med at lower dosage), [MEDICATION NAME] 5 mg, Tamsulosin 0.4 mg (duplicate-same as [MEDICATION NAME]), [MEDICATION NAME] 10 mg, Meoprolol [MEDICATION NAME] 50 mg (duplicate anti-hypertensive/cardiac), Gabepentin 600 mg, [MEDICATION NAME] 60 mg (anti-depressant) and [MEDICATION NAME] 500 mg (anti-convulsant). Review of a "Short Service Record" from the local hospital, dated [DATE], noted, "... Date of Admission: [DATE] Date of discharge [DATE]. Discharge Status: The patient expired...History of Present Illness: This is a [AGE] year-old male resident of (name of nursing home) admitted to the hospital secondary to low blood pressure and being unresponsive. As per the family, the patient received another patient's medications. A list was sent by (name of nursing home), which included anti-hypertensive, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] and tamsulosin as well as [MEDICATION NAME]. The patient after a couple of hours, as per the family, became unresponsive and had low blood pressure and was brought to the hospital for care...On Examination on admission: Blood pressure ,[DATE]. Pulse 47. Respirations 12. Temperature 98.3...Neurologically, the patient opened his eyes, but quickly went back to sleep again...Hospital Course: The patient was admitted to the hospital secondary to [MEDICAL CONDITION] and unresponsiveness...Unfortunately, this patient expired while in the hospital...Final Diagnoses: [REDACTED]. 2. Non-ST elevation [MEDICAL CONDITION] infarction. 3. [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. 5. Diabetes mellitus, type 2. 6. Dementia." Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:20 a.m. revealed that she had worked [DATE], [DATE], [DATE] and [DATE] with LPN #2 for orientation to the floor/medication cart and that they had the same group of residents every day. LPN #1 stated that she didn't recall whether they had gone into full detail about how to identify residents that she knew there were photos on the MAR (Medication Administration Record). LPN #1 stated that some residents had a photo and some didn't but that she didn't recall exactly how many didn't have a photo. LPN #1 stated that she was aware that residents were to be identified prior to giving them medications. LPN #1 stated that Resident #1 had no photo on the MAR ([DATE]). LPN #1 stated that she had pulled and popped out Resident #2's medication with LPN #2 observing the procedure and that LPN #2 had given Resident #1 his medications. LPN #1 stated that when she prepared Resident #1's medication that LPN #2 told her to go ahead and give the medications. LPN #1 stated that Resident #2 was sitting in a wheelchair on Resident #1's side of the room and there was a man in the bathroom. LPN #1 stated that she asked the resident in the wheelchair if he was (name of Resident #1) and the resident replied "yes", so she gave him (Resident #2) the medications. LPN #1 stated that LPN #2 walked in about that time and realized that Resident #2 had received Resident #1's medications. LPN #1 stated that the error was reported to the charge nurse and an incident report was filed. LPN #1 stated that the other residents who she had given medications to that morning ([DATE]) were witnessed by LPN #2. LPN #1 stated that she had been suspended pending the investigation of the medication error. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 4:15 p.m. revealed that the procedure prior to Resident #2 getting Resident #1's medication was for the resident to be identified by the use of a photo on the MAR (Medication Administration Record) and asking the resident their name. LPN #2 stated that she had been training LPN #1 for the 4th day on the same group of residents on the same hall. LPN #2 stated that LPN #1 had been giving some of the medications and that she (LPN #2) had been giving some of the medications on [DATE]. LPN #2 stated that she had seen Resident #1 coming down the hallway and had pointed him out to LPN #1. LPN #2 stated that LPN #1 had given Resident #1 his medications the prior day ([DATE]). LPN #2 stated that she had gone into Resident #1 and #2's room and had observed LPN #1 with an empty white medication cup and Resident #2 was sitting there. LPN #2 stated that Resident #1 was in the bathroom. LPN #2 stated that LPN #1 had given Resident #2 the medications that were intended for Resident #1. LPN #2 stated that Resident #2 had a photo on his MAR but wasn't sure about Resident #1. LPN #2 stated that the Nurse Practitioner came and assessed Resident #2 and they monitored him the rest of the shift with every hour vital signs. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 12:20 p.m. revealed that she had been the charge nurse on [DATE] when LPN #1 and LPN #2 reported that Resident #2 had received Resident #1's medications at 9:15 a.m. LPN #4 stated that she got a list of both residents medications and vital signs and reported the findings to the physician. LPN #4 stated that LPN #1 had reported that Resident #2 had told her that he was Resident #1 and that she gave him the medication that was intended for Resident #1. LPN #4 stated that she had not looked at the MARs (Medication Administration Records) to see that photos were available for Resident #1 and Resident #2. LPN #4 stated that the normal procedure for identifying residents was to look at the photo on the MAR and if the resident was alert enough to ask them their name or ask another staff member. Interview with Licensed Practical Nurse (LPN) #6 on [DATE] at 1:30 p.m. revealed that she and LPN #7, who was present, had talked with LPN #1 and LPN #2 about the medication error for Resident #2 on [DATE]. LPN #6 stated that she noticed that Resident #1 had no photo on the MAR (Medication Administration Record) but that Resident #2 did have a photo. LPN #6 stated that she asked LPN #2 if showing the photo was part of the orientation process for identifying residents and was told that it was. LPN #6 stated that she got the photo of Resident #1 from the October MAR and placed it on the November MAR but did not audit the MARs at that time to see if other residents didn't have a photo. LPN #6 stated that she and LPN #7 and the DON (Director of Nurses) had checked all residents on [DATE] to ensure that they had photos or arm bands for identification. Interview with Licensed Practical Nurse (LPN) #8, Order entry nurse, on [DATE] at 9:55 a.m. revealed that she was responsible for putting orders in the computer and to get the MARs (Medication Administration Records) printed for each month. LPN #8 stated that the Social Services Assistant (SSA) would take photos of residents and give a copy to the floor nurse to put on the current MAR and a copy of the photo to herself to put on the next month's MAR. LPN #8 stated that when she checked the [DATE] MARs prior to putting them out on the floor that Resident #1 didn't have a photo and that she had not reported this to anyone. LPN #8 stated that she should have notified the DON (Director of Nurses) or the SSA. Interview with the Social Services Assistant (SSA) on [DATE] at 8:55 a.m. revealed that she took photos of residents after admission usually within a few days of admit. The SSA stated that she had been out from [DATE] - [DATE]. The SSA stated that she took photos of all of the residents who had been admitted while she was gone as well as Resident #1. The SSA stated that she had taken a photo of Resident #1 after he was admitted and didn't know what had happened to that photo. The SSA stated that she usually took two (2) photos of residents, one for LPN (Licensed Practical Nurse) #8, data entry nurse and one for the floor nurse to put on the MAR (Medication Administration Record). The SSA stated that no one took photos if she wasn't there. Interview with the Nurse Practitioner (NP) on [DATE] at 2:00 p.m. revealed that she had been notified of Resident #2 receiving Resident #2's medication ([DATE]) and had assessed Resident #2 and talked with the family. The NP stated that the medications that Resident #2 had received in error included blood pressure medications. The NP stated that LPN (Licensed Practical Nurse) #2 had reported that Resident #2 had received his 9:00 a.m. medications and that LPN #1 had given him Resident #1's medications as well. The NP stated that she had shown Resident #2's family a list of medications that had been administered in error and explained that they could be potentially fatal or that nothing could occur. The NP stated that the family elected to leave Resident #2 at the facility and orders were given to monitor vital signs every hour. The NP stated that some of the medications that Resident #2 was given were long acting and that she'd explained to the family that effects might be delayed. The NP stated that when she had left the facility that Resident #2 had improved and was doing better and was surprised to learn that he had expired the next day. Interview with the Director of Nurses (DON) on [DATE] at 5:30 p.m. revealed that she had been called by LPN (Licensed Practical Nurse) #6 and informed of the medication error for Resident #2. The DON stated that Resident #2's vital signs were stable most of the day but had to be sent to the hospital later in the evening. The DON stated that the MARs (Medication Administration Records) were checked for photos and all but two (2) were present, one (1) of which was Resident #1. The DON stated that there had been a photo of Resident #2 on the MAR. The DON stated that there were two (2) books for the MARs and were swapped out for the month and the photo for Resident #1 failed to be placed on the [DATE] MAR. The DON stated that LPN #8 was responsible for checking the photos/MARs each month. The DON stated that there had been no other incidents of residents receiving the wrong medication. The DON stated that the procedure for identifying residents for medication administration had been to look at the photo on the MAR and to ask the resident his/her name. The DON stated that during the orientation process the preceptor will use a skills check off list which included the five (5) rights of medication administration and included identifying the resident prior to medication administration or ask a staff member who knows the resident. The DON stated that now an armband will be used to identify new residents until a photo is taken. Interview with the Director of Nurses (DON) on [DATE] at 12:00 noon revealed that Resident #1 had no photo at the time that LPN (Licensed Practical Nurse) #1 was attempting to administer his medications and instead administered them to Resident #2. The DON agreed that the process of identifying residents was via photo that should have been on the MAR (Medication Administration Record), therefore contributing to the medication error. Interview with the Medical Director on [DATE] at 3:00 p.m. revealed that he had been informed of the medication error for Resident #2 and had advised the staff to monitor him. The Medical Director stated that the Nurse Practitioner assessed and handled the situation. The Medical Director stated that the Administrator had informed him of the Quality Assurance Meeting and the process of having a photo/arm band for identification purposes and agreed with their processes/in-services. Review of the facility's "Abuse, Neglect, or Exploitation" policy, dated [DATE], revealed that one of the definitions of Abuse was the willful deprivation by a caregiver of services which are necessary to maintain the mental and physical health of a vulnerable adult. The definition of neglect included the failure of a caregiver to supply for the vulnerable adult the food, clothing, supervision, or other services which a reasonably prudent person would do to maintain the vulnerable adult's mental or physical health. Review of the Orientation Schedule, not dated, revealed under the Medication Administration Section: Six Rights of Medication Administration. 1. Right Patients-Resident Identified prior to administration. 2. Right Drug - Correct medication given... " Review of the facility's "Resident Identification Policy", not dated, noted, "It is the policy that the method of identification for resident's will be as follows: Identification will be: A picture of the resident on the MAR (Medication Administration Record). Reminders -Identify resident before any medications are given -Update the pictures with changes in the resident's appearance -When in doubt---ask. A resident may be confused and answer to another name." The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 12:55 p.m. An Allegation of Compliance was accepted on [DATE] at 3:30 p.m. The allegation noted: "An Immediate Jeopardy was called on [DATE] at 6:15pm related to a medication error for Resident # 2, who had a change in status and was transferred to the hospital on [DATE]. [DATE] 10:00 am Licensed Practical Nurse (LPN) #4 placed a call to the Physician to notify him of the medication error for Resident # 2 no new orders were received at that time. [DATE] 10:15am LPN #2 notified resident's family of medication error of Resident #2 by phone. [DATE] 12:05pm LPN #2 notified hospice of the medication error of Resident #2. [DATE] 1:00pm LPN # 2 notified the Director of Nursing (D.O.N.) of medication error of Resident #2. State Agencies were notified of the medication error of Resident#2 [DATE] at approximately 4:30pm by LPN #6. State Board of Nursing was notified of the medication error of Resident #2 on [DATE] at approximately 2 pm by the Director of Nursing. [DATE] the facility began the investigation of the medication error of Resident #2. The D.O.N., LPN #6 and LPN #7 met with LPN #1 and LPN #2 to interview them regarding the medication error of Resident #2 at approximately 8am. During this meeting LPN #1 and LPN #2 were instructed by LPN #6 and LPN #7 that residents are to be identified by picture and that medications must be administered using facility policy and the Five Rights of medication administration to include; right resident, right drug, right dose, right route and right time. LPN #1 and LPN #2 were also informed by LPN #6 and LPN #7 on [DATE] that MARs are not to be signed until medications are given. On [DATE] at approximately 2pm it was noted by LPN #6 that Resident #1 did not have a picture on the Medication Administration Record ( MAR). LPN #6 notified the D.O.N. and placed the picture from the [DATE] MAR book on the [DATE] MAR. The Order Entry Nurse (LPN #8) is to ensure that the resident's picture is placed on the MAR. LPN #8 received a written counseling from the D.O.N. on [DATE] at approximately 3pm for failure to place a picture of Resident #1 on the [DATE] MAR. The Quality Assurance committee; consisting of the Administrator , D.O.N.,LPN #6 and LPN #7 met on the afternoon of [DATE] to discuss the medication error of Resident #2, resident identification, orientation process and medication administration. The Medical Director was not present at this initial meeting; however the Administrator met with the Medical Director on [DATE] upon his arrival to the facility to discuss the information from the meeting. The Medical Director was agreeable with changes the facility had implemented. On [DATE] All RNs and LPNs on duty received an inservice on Abuse and Neglect to include ensuring resident are not abused nor neglected by the failure to follow physician's orders [REDACTED]. This in-service was given by Licensed Social Worker (LSW) #1. No RN or LPN will be allowed to work until in-serviced. The facility made changes to the "Resident Identification Policy" on [DATE] to enable new residents to be identified until a picture could be placed on the MAR. This was accomplished with implementation of the placement of armbands on all new residents until a picture is obtained. RNs and LPNs were in serviced on Resident Identification on [DATE] by LPN #5. No RN or LPN will be allowed to work until in-serviced. The facility made changes to the orientation process on [DATE] to outline Staff Development Coordinator, Orientee and Floor Nurse Responsibilities to include the process for using the five rights of medication administration and facility medication administration policy for resident identification and proper documentation during medication pass. The Nurse Skill Review Form was updated on [DATE] by the D.O.N. to include an area for documentation of education, return demonstration, re-education if needed and return demonstration. RNs and LPNs were in serviced on the Orientation Program on [DATE] by LPN #5. No RN or LPN will be allowed to work until in-serviced. RNs and LPNs were in serviced on the Five Rights of medication administration: right resident, right time, right drug, right dose, right route and the facility medication administration policy to include the process for identification of residents and documentation of medications on [DATE] by LPN #6. No RN or LPN will be allowed to work until in-serviced. On [DATE] the Social Service Assistant reviewed a list of new admissions, took pictures for any residents that did not have them, and gave them to the floor nurses. The floor nurses ensured that the pictures were placed on the MAR. On [DATE] LPN #7 Initiated Medication Administration Audits; to include resident identification, administration of the medication to the resident, appropriate documentation of medication , this medication audit will continue until all nurses have successfully passed the audit. On [DATE] The D.O.N., LPN #6 and LPN #7 checked the MARs to ensure all residents had a picture. An armband was placed on any resident who did not have a picture. On [DATE] The facility initiated the following practice: Prior to every medication administration, the nurse must identify the resident by photo or armband. If the resident does not have a photo, an armband must be applied to the resident until a photo is obtained. The licensed nurse will be responsible for documenting that this has been checked on the Resident Identification Form. RNs and LPNs were in serviced on this practice [DATE] by the D.O.N. No RN or LPN will be allowed to work until in-serviced. Verification of the Allegation of Compliance: Review of personnel action forms revealed that Licensed Practical Nurse (LPN) #1 was placed on administrative leave [DATE] pending investigation of a significant medication error and LPN #8 was counseled on [DATE] for failure to place a photo on a resident's Medication Administration Record. Review of a Quality Assurance (QA) meeting dated [DATE] revealed that the facility met and reviewed the medication error for Resident #2 and discussed ways for improving resident identification, orientation process and medication administration. Interview with the Medical Director on [DATE] at 3:00 p.m. revealed that he had been informed and agreed with the process. Review of Audits initiated [DATE] by LPN #7 revealed that random nurse's had been checked off on resident identification, medication administration and documentation. Review of an Audit dated [DATE] by the Director of Nurses, Licensed Practical Nurse (LPN) #6 and LPN #7 revealed that all Medication Administration Records were checked for photos and documentation that arm bands were placed on residents who did not have a photo. Review of in-services revealed that nurse's were educated on the following dates on the following information with signatures of the nurses on the in-service sheets: [DATE] - Abuse/Neglect-ensuring residents are not abused nor neglected by the failure to follow physician's orders [REDACTED]. [DATE] - Resident Identification Policy - changes to enable new residents to be identified by the use of an armband until a photo could be placed on the Medication Administration Record. [DATE] -Orientation Program-to outline responsibilities of the Staff Development Coordinator, Orientee and Floor Nurse to include the process for using the five rights of medication administration and facility medication policy for resident identification and proper documentation during medication pass. [DATE] -Five Rights of Medication Administration that included the right resident, right time, right drug, right dose and right route. Also included was the process for identifying residents by photo and/or arm bands. [DATE] - Practice initiated: Prior to every medication administration, the nurse must identify the resident by photo or armband. If the resident does not have a photo, an armband must be applied to the resident until a photo is obtained. The licensed nurse will be responsible for documenting that this has been checked on the Resident Identification Form. Interviews on [DATE] with licensed nurses revealed that they had been in-serviced on the above policies and procedures. Review of the [DATE]-400 hall's Medication Administration Records (MAR) on [DATE] at 4:45 p.m. revealed that all MARs had a resident's photo. There was also a Resident Identification form in the front of each MAR that nurse's were to sign for verification of identifying residents prior to medication administration. Observations with licensed nurses who were administering medications on [DATE] beginning at 4:00 p.m. revealed that residents were identified by reviewing the photo on the MAR (Medication Administration Record) and asking the resident their names prior to medication administration. Based on the verification of the facility's corrective actions, the IJ was removed and the scope and severity for F-224 and F281 were lowered from a "J" to a "G" which constitutes actual harm with potential for more than minimal harm that is not Immediate Jeopardy. F-333 was lowered from a "J" to a "D" level which constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance Committee. Please note that F-224 and F281 were cited at a scope and severity of "G" on the [DATE] complaint survey; therefore, noncompliance cont

CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that written care plans were followed for one (1) of five (5) residents (Resident #5). Resident #5 had been assessed and care planned for the use of a total lift (mechanical lift) for transfers. Resident #5 was transferred from the wheelchair to the shower chair by Certified Nurse Aide (CNA) #1 without the use of a total lift and Resident #5 sustained minor injury of bruising to the right elbow. Findings include: Cross refer to F224 for the facility's failure to ensure that the care plan was followed for Resident #5 when the Certified Nurse Aide transferred Resident #5 without the use of a total lift as assessed and care planned and the resident sustained [REDACTED].

CI MS # Based on observation, interview, record review and policy review, the facility failed to thoroughly investigate and report to the state agency an allegation of possible abuse and neglect for one (1) of five (5) residents, Resident #5. Resident #5 had been transferred from the wheelchair to the shower chair by Certified Nurse Aide (CNA) #1 without the use of a total lift (mechanical lift) as assessed and care planned for the resident and Resident #5 sustained minor injury of bruising to the right elbow. Resident #5 alleged that the Certified Nurse Aide (CNA) was rough with her and transferred her inappropriately which resulted in the bruised elbow and had also used profanity by saying that anytime someone tried to help the resident that she always [***] ed at them. Resident #1's Responsible Party (RP) also alleged that the incident with transferring Resident #5 inappropriately was neglect. Findings include: Cross refer to F224 for the facility's failure to thoroughly investigate an incident of possible abuse and neglect as reported by Resident #5 and Resident #5's Responsible Party for the inappropriate transfer, roughness and profanity by Certified Nurse Aide #1.

CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of five (5) residents (Resident #5) was not neglected. Resident #5 was transferred from the wheelchair to the shower chair by Certified Nurse Aide (CNA) #1 without the use of a total lift (mechanical lift) and Resident #5 sustained a minor injury of bruising to the right elbow. Resident #5 alleged that CNA #1 was rough with her and transferred her inappropriately which resulted in the bruised elbow. Findings include: Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #5 was cognitively intact. Review of the facility ' s "Lift/Transfer Assessment Form", dated 9/17/12, revealed that Resident #5 required total assistance of one (1) person for transfers with the use of a total lift and large sling. Review of the ADL (Activity of Daily Living) Record and care plan for October 2012 revealed that Resident #5 required a total lift (Total/Electric Hoyer) with assistance of one (1) person for Lift/Transfers. Review of the care plan, dated 9/17/12, revealed that Resident #5 required assistance with ADLs (Activities of Daily Living), transfers and mobility related to multiple fracture; see ADL care plan for individual needs. An approach was to provide assistance with ADLs, transfers and mobility according to individual needs as listed on the ADL care plan. Review of the "Grievance/Complaint Form", dated 10/3/12 at 4:20 p.m., revealed Resident #5 filed a complaint that on 10/2/12 between 7:00-8:00 a.m., a CNA (later identified as CNA #1) told resident that she had to have a shower before breakfast. When the resident got to the shower room the CNA told her to get in the shower chair. Resident told the CNA that she could not put any pressure on the right leg until she went back to the doctor. The CNA went and got another CNA to help put Resident #5 in the shower chair. Resident told the CNA that all of that could have been avoided if she would have brought the shower chair to the room. When Resident #5 was transferred from the wheelchair to the shower chair the resident's right arm hit the arm of the shower chair. Resident told the CNA again that this could have been avoided and the CNA told the resident that every time someone tried to help her all that she did was [***] ed....Resident #5 stated that she never got her face washed and didn't get any body lotion. When the shower was over the CNA got two (2) other CNAs to help get the resident back in the chair. Resident #5 stated that it wasn't as hard on her because there were more people. Resident #5 stated that the CNA was rough with her and that she didn't want to see the CNA again. On the back of the grievance form documentation from the Director of Nursing (DON) dated 10/4/12 revealed that CNA #1 denied handling Resident #5 roughly in the shower, denied using profanity, and denied knowledge of Resident #5 having bumped her arm and stated that the resident had bruising. Also there was documentation that the DON had spoken to Resident #5's RP about Resident #5 having extensive bruising to arms and informed the RP of the conversation with the CNA regarding the incident and that the CNA no longer was employed. Review of the October 2012 physician's orders [REDACTED].#5 to continue non weight bearing to the right lower extremity and follow up with the orthopedic physician in five (5) weeks related to right tib (tibula) fracture. Review of the nurse's note, dated 10/2/12 at 8:00 p.m., documented that the writer (LPN #1) was assisting the nurse with skin assessment and Resident #5 stated that "When (CNA #1) took me to shower she was rough with me. When transferring me she hit my arm on shower chair and grabbed me hard and left these bruises on me." Large bruises noted to right forearm. Medical Doctor (MD) notified and Responsible Party (RP) aware. " Review of the nurse's note, dated 10/2/12 at 10:30 p.m., revealed " Resident's son was in the facility. Came to the nurse's desk. Showed this nurse (LPN #4) pictures of bruises on the resident's arm. Stating "We need to be aware of our transferring techniques. This looks like neglect to me." Was not aware of events that had taken place in shower. Will discuss (with) unit manager in the a.m. (morning). Interview and observation with Resident #5 on 10/16/12 at 1:20 p.m. revealed Resident #5 was alert and oriented to person, place and time and had an immobilizer to the right lower extremity. Resident #5 stated that staff used the lift to transfer her but one time didn't use the lift in the shower room and bumped her arm and bruised it. Resident #5 was observed to have scattered bruises to both upper and lower extremities. Resident #5 stated that she didn't think that she intentionally meant to hurt her but that the CNA (Certified Nurse Aide )in the shower that day (CNA #1) had been rough with her. Interview with Resident #5 on 10/17/12 at 4:30 p.m. revealed that Resident #5 was alert and oriented to person, place and time. Resident #5 stated that (Certified Nurse Aide #1) would not listen to her when she tried to tell her that she could not stand on her leg until she went back to the doctor. Resident #5 stated that the CNA (CNA #1) had told her that when someone went to do something for me that all she did was [***] at them. Resident #5 stated that this was the only time that she had ever gotten on to the shower chair without the use of a lift. Resident #5 stated that she had told CNA #1 that she was to use the lift and the CNA just went and got someone to help her and didn't use the lift. Resident #5 stated that she reported CNA #1's actions to the person in the cafe and one of the nurse's had looked at her arm. Resident #5 stated that she had phoned her son that afternoon and let him know what had occurred and he came to the facility later and took some pictures of the bruise on her arm. Resident #5 stated that the arm didn't really hurt but that it smarted some when hit arm on chair, just bruised. Resident #5 stated that she told my son about it, when she called him that evening. Interview and observation of Resident #5 on 10/18/12 at 10:50 a.m. revealed that Resident #5 was alert and oriented to person, place and time and was transferred from the wheelchair to the bed by Certified Nurse Aide (CNA) #2 with the use of the total lift and large sling without incident. Resident #5's right arm and elbow had a fading reddish bruise that measured approximately 6.4 centimeters (cm) x 6.4 cm. The lower wrist/arm area had some scattered reddish/yellow fading bruises approximately 1-2 cm. The left upper extremity had scattered petechial bruising noted. Resident #5 stated that the bruise on her elbow is where she had bumped the shower chair, and the bruises to wrist area were where they had grabbed her during the transfer. Resident #5 stated that she didn't hurt and that she was upset about everything to start with but was okay now. Resident #5 stated that she didn't think that CNA #1 meant any harm but that she just wouldn't listen when trying to explain that there was a right way and a wrong way to transfer and that she wasn't doing it the right way. Interview with Resident #5's Responsible Party (RP)on 10/18/12 at 12:00 noon revealed that his mother had phoned him in the afternoon after he had gone to work and said that she had had a rough day and that there had been an incident in the shower with one of the CNAs (Certified Nurse Aides). The RP stated that he informed his mother that he would come to the facility after work. The RP stated that he had come to the facility around 10:30 p.m. and had taken photos of his mother's arm where there looked to be fresh bruises. The RP stated that he talked to the nurse's on duty and showed them the photos and told them that it looked like neglect because the CNA had not transferred his mother appropriately. The RP stated that his mother had told him that she had tried to tell the CNA that she could not stand on her leg and the CNA got help from other staff and made her stand and transfer to the shower chair and his mother had bumped her arm during the transfer causing the bruise. The RP stated that Resident #5 said that the CNA had been rough with her. The RP stated that he had talked to the Director of Nurses (DON) about the incident but that she (DON) seemed to be under the belief that the bruises were old. Interview with Certified Nurse Aide (CNA) #1 on 10/17/12 at 3:45 p.m. revealed that she had only worked at the facility a short time and had been trained on abuse/neglect and to read/follow the resident's care plan prior to giving care to a resident. CNA #1 stated that she had taken Resident #5 to the shower (10/2/12). CNA #1 stated that she and CNA #4 stood the resident up on her good leg without any problems. CNA #1 stated that she was not aware that Resident #5 had bumped her arm. CNA #1 stated that she had showered Resident #5 before and had used the lift for transfers but the Physical Therapist (PT) and the resident had said that she was standing okay. CNA #1 did not recall what the PT's name was. CNA #1 agreed that the ADL (activity of daily living) care plan documented that Resident #5 was to have a lift for transfers. Interview with Certified Nurse Aide (CNA) #1 on 10/18/12 at 8:00 a.m. revealed that she had help from CNA #4 when she transferred Resident #5 in the shower and the therapy person was (name of CNA #3) who had told her that it was okay to transfer Resident #5 without the lift. CNA #1 stated that Resident #5 didn't have any bruises on her right arm or left arm at the time of transfer, that she would have reported them. Interview with the Physical Therapy Assistant (PTA) on 10/18/12 at 8:45 a.m. revealed that Resident #5 was to have no weight bearing on the right lower extremity and up until last week was only supposed to be transferred with the total lift. The PTA stated that Resident #5 was working in therapy and was beginning to be and extensive assist with two persons to stand and pivot. The PTA stated that she had not told any of the CNAs (Certified Nurse Aides) that Resident #5 could be transferred without a lift. Interview with Certified Nurse Aide (CNA) #3, Rehab Coordinator, on 10/18/12 at 8:50 a.m. revealed that she worked in therapy with Resident #5 and had not given permission to any of the CNAs to transfer the resident without the lift. CNA #3 stated that she would refer staff to the ADLs (Activity of Daily Living) for what care to provide. Interview with Certified Nurse Aide (CNA) #4 on 10/18/12 at 8:55 a.m. revealed that she had assisted CNA #1 to transfer Resident #5 from the wheelchair to the shower chair (10/2/12). CNA #4 stated that Resident #5 was able to stand on the good leg and pivot from the wheelchair to the shower chair without falling or incident. CNA #4 stated that she did recall Resident #5 saying that she bumped her arm/hand but didn't see any bruises. CNA #4 stated that she didn't hear CNA #1 say anything out of the way to Resident #5 and denied that she told Resident #5 that she [***] ed when they tried to help her. CNA #4 stated that she did not recall Resident #5 saying that she couldn't stand up. CNA #4 stated that they were supposed to review the resident's ADLs (Activity of Daily Living) daily prior to providing care. Interview with Licensed Practical Nursing (LPN) #1 on 10/17/12 at 4:15 p.m. revealed that she was doing a weekly skin assessment on Resident #5 and noticed bruises on her arm and the resident reported that she'd hit her arm on the shower chair when the Certified Nurse Aide (CNA) put her in the shower chair and had grabbed her arm. LPN #1 stated that Resident #5 reported that CNA #1 had been a little rough and that she was [***] ing too much. LPN #1 stated that Resident #5's son came in around 10:30 p.m. and was upset and said that he was going to take some photos. LPN #1 stated that Resident #5 did have a large bruise on her right arm and had scattered bruises to both arms since admission. LPN #5 stated that she and the son talked with Resident #5 who stated that CNA #1 should have taken the shower chair to her room. LPN #1 stated that she had not notified the son about the resident's bruises or complaint. Interview with Certified Nurse Aide (CNA) #5 on 10/18/12 at 9:30 a.m. revealed that she was in the cafe (10/2/12) and Resident #5 said that she'd had a rough morning. That she'd been taken to the shower by a new CNA who had told her to stand to get from the wheelchair to the shower chair. CNA #5 stated that Resident #5 stated that she had not been standing and during the transfer she'd bumped her arm. CNA #5 stated that Resident #5 showed her some bruises on her arm/wrist area that was reddish-purple. CNA #5 stated that Resident #5 reported that she was supposed to be transferred with the lift. CNA #5 stated that she did not recall Resident #5 saying that the CNA was rough or talked ugly to her. CNA #5 stated that Resident #5 didn't really complain of abuse/neglect, only that she didn't get transferred with the lift and had bumped her arm. CNA #5 stated that she informed the DON (Director of Nurses) and Administrator of the conversation within approximately 15 minutes of the resident reporting the issue. Interview with Licensed Practical Nurse (LPN) #2 on 10/18/12 at 10:20 a.m. revealed that she had received an e-mail from Resident #5's son concerning a bruise on the resident's arm related to a transfer and there were attached photos. LPN #2 stated that she had forwarded the e-mail to the Quality Assurance (QA) Nurses, DON (Director of Nurses), the Administrator and Social Worker (who's in the hospital). LPN #2 stated that she had not seen the photos herself. Interview with Licensed Practical Nurse (LPN) #3, QA Nurse, on 10/18/12 at 10:40 a.m., revealed that she had been informed by LPN #2 that Resident #5's son had made a complaint that his mother had some bruises on the arm from where a CNA had transferred her in the shower and didn't feel that the CNA had transferred his mother appropriately because the CNA had stood his mother up and she wasn't supposed to have any weight on her leg. LPN #3 stated that she reviewed Resident #5's chart, knew that she'd had some extensive bruising. LPN #3 stated that the most recent skin assessment in the chart showed scattered bruises on the resident's body. LPN #3 stated that she recalled that the son had come to the facility because his mother had called him about the complaint. LPN #3 reviewed the nurse's notes for Resident #5, dated 10/2/12, documented by LPN #1 and LPN #4 and stated that she recalled reading the note and seeing specific documentation that the son had said that this was neglect. LPN #3 stated that she asked the Social Worker to talk with Resident #5 (documented on grievance form), and the DON (Director of Nurses) was to talk with CNA #1. LPN #3 stated that once she gathered everything together that she turned the investigation over to the DON and the Administrator. Attempts to contact Licensed Practical Nurse #4 and the Social Worker at different times from on10/16/12 through 10/18/12 were unsuccessful. Interview on 10/17/12 at 3:15 p.m. with the Director of Nurses (DON) revealed that she had not seen the incident with Resident #5 as neglect/abuse and did not call the incident in to the State Agency. The DON stated that she had talked with CNA (Certified Nurse Aide) #1 who had denied talking ugly or being rough with Resident #5 and that she had gotten assistance for the transfer even though the lift was not utilized. The DON stated that she did not see where Resident #5 was to be transferred without the use of the lift on her care plan. The DON stated that she had talked with a few of the day shift workers who had denied assisting with transferring Resident #5. The DON stated that the only documentation of the investigation was on the grievance form where she had talked with the CNA and the son and the statement from CNA #5, who the resident had originally, report the complaint to. The DON stated that CNA #1 was off after the incident and was supposed to come to the facility with a written statement and never showed up. Interview on 10/18/12 at 9:12 a.m. with the Director of Nurses (DON) revealed that CNA (Certified Nurse Aide) #5 was the first person to tell her of Resident #5's complaint that staff had bruised her arm when transferring her in the shower. The DON stated that she observed Resident #5 in the cafe and she had multiple bruises at different stages on her arms at that time and the one on the elbow looked triangular and reddish in color. The DON stated that Resident #5 was in close proximity to CNA #5 and herself when CNA #5 was related the complaint to her and Resident #5 didn't add anything else at the time. The DON stated that she talked with Resident #5's son maybe on 10/4/12 and discussed the incident and the son stated that the CNA had transferred Resident #5 without the lift in the shower room and the resident had bumped her arm. The DON stated that the son did show her some photographs and had told him that was how the bruises had looked on the resident's arm the day she had observed them. The DON stated that she had informed the son that the CNA didn't follow the care plan and that she was going to terminate her. The DON stated that she did recall seeing the e-mail that Resident #5's son had sent to LPN #2 and had talked with the son about all of the information. The DON stated that she should have looked at the incident as neglect and reported it. The DON stated that she had not called the son and reported Resident #5's bruising or incident to him when she was made aware by the resident and CNA #5. Interview on 10/18/12 at 11:15 a.m. with the Administrator revealed that he had received an e-mail that was forwarded by LPN (Licensed Practical Nurse) #2 from Resident #5's son about the resident's bruise and incident in the shower. The Administrator stated that he set up a meeting for the son to come in and discuss the issue with himself and the DON (Director of Nurses). The Administrator stated that Resident #5's son had expressed that the CNA (Certified Nurse Aide) was rough with Resident #5 and asked if this was possible abuse by the staff. The Administrator stated that he thought that poor judgment had been used and had not reported the incident as abuse/neglect. The Administrator agreed that the allegation of abuse/neglect had been reported by the resident, and the resident's son, the CNA had not followed the care plan and there had not been a thorough investigation of the incident. Review of the facility's "Abuse, Neglect, or Exploitation" policy, dated 3/15/04, revealed that one of the definitions of Abuse was the willful deprivation by a caregiver of services which are necessary to maintain the mental and physical health of a vulnerable adult. The definition of neglect included the failure of a caregiver to supply for the vulnerable adult the food, clothing, supervision, or other services which a reasonably prudent person would do to maintain the vulnerable adult's mental or physical health. The policy's "Reporting" section documented that the complaint must be reported as soon as possible to the Administrator, Director of Nursing, or Social Services. The complaint must be reported to State Department of Health and the Medicaid Fraud Control Unit (Attorney General) by phone within 24 hours of discovery and in writing within 72 hours of discovery. Under the "Investigation" section there was documentation that any report of abuse, neglect, or exploitation will be investigated by Director of Nursing or designee. The investigation shall include but is not limited to: questioning the resident involved when appropriate, questioning all staff members working in the area at the time of the incident...who might have knowledge of the incident. Written statements: by all staff questioned, signed by staff member, the resident's statement, by family questioned and by visitors question. Review of the facility's "Family Notification Policy", not dated, provided by the Director of Nurses on 10/17/12 at 10:00 a.m., noted " It was the policy of the facility that the resident's responsible party would be notified....when an accident/incident involving the resident occurs.....with any allegation of abuse by a staff member involving the resident. The family should always be notified even when there is no apparent injury to the resident ... " Review of the facility's "Resident ADL Care Plan Policy", dated 6/20/12, noted, " It is the policy of this facility that the Resident ADL (Activities of Daily Living) Care Plan is considered part of the comprehensive plan of care and will be used to care plan the resident's ADL, transfer and mobility needs....The care plan is to be reviewed by the CNA prior to providing care, at the beginning of the shift and as needed to ensure proper care. The Care plan is to be reviewed by the nurse prior to providing ADL care and monthly and as needed to ensure accurate updates are made. "

CI MS # Based on observation, interview, record review and policy review, the facility failed to notify the Responsible Party of an allegation made by the resident of possible abuse and bruising of the skin for one (1) of five (5) residents reviewed (Resident #5). Resident #5 was transferred from the wheelchair to the shower chair without the use of a total lift (mechanical lift) and sustained minor injury of bruising to the right elbow. Resident #5 alleged that the Certified Nurse Aide (CNA) was rough with her and transferred her inappropriately which resulted in the bruised elbow. Findings include: Cross refer to F224 for the facility's failure to notify Resident #5's responsible party of the allegation of possible abuse, roughness and neglect for not transferring the resident per total lift as assessed and care planned and Resident #5 bumped her arm during the transfer causing a bruise to the elbow.

Based on observation, staff interview, resident interview, record review, medical director's interview, and policy review, the facility failed to appropriately assess, to adequately supervise, and to prevent the harm caused to one (1) of eight (8) reviewed for falls (Residents #2). Findings include: Resident #2 Record review revealed that Resident #2 moved into the home on 3/1/12 with [DIAGNOSES REDACTED]. Observation on 5/14/12 at 2:30 p.m. revealed that Resident #2 was seated in a wheelchair near the bed inside of a private room. Resident #2 was well groomed, oriented and interviewable. Resident #2 stated she was precise in her recall of her treatment and of the events of her hospitalization . Interview on 5/14/12 at 2:30 p.m. with Resident #2 revealed that she had been admitted to the facility for rehabilitation purposes only. Resident #2 stated that prior to admission she had fallen in her home and had fractured her left arm and had re-fractured a hip. Resident #2 stated that she was admitted to the facility from the hospital on [DATE] with a cast to her left arm/elbow and a new hip implant. Resident #2 stated that at the time of her 3/1/12 admission, she was non-weight bearing and that she was transferred from her bed to her chair via a mechanical lift and the assistance of one (1) Certified Nurse Aide (CNA). Resident #2 stated that the sling on the mechanical lift had always made her a bit nervous because it was unsteady. Resident #2 stated that one morning in April 2012 one (1) CNA came to get her to take a bath. The one (1) CNA placed the sling under her and lifted her up in the sling from the bed to transfer her to a shower chair. As the sling held her up in the air the sling became unsteady and she fell from the sling of the mechanical lift to the floor. Resident #2 stated that the CNA that was alone with her was more up-set about Resident #2's fall than Resident #2. Resident #2 stated that the pain became more and more intense and that after an x-ray and an MRI (magnetic resonance imaging) the pelvis was fractured as a result of the fall from the mechanical lift. Resident #2 stated that after the fall and fractured pelvis the facility began to use another type of a sling with the mechanical lift and two (2) CNAs for each transfer. Review of the Minimum Data Set (MDS), dated [DATE], coded a Brief Interview of Mental Status score of 15, which indicated Resident #2 was cognitive intact. Review of the Minimum Data Sets (MDS), dated [DATE]; 3/11/12; 4/5/12; 4/10/12; and 4/26/12, coded that Resident #2 was a "two (2) + persons physical assist" with all transfers and two (2) persons assist with the mechanical lift transfers. The facility did not follow the MDS resident assessment for the "two + persons physical assist" for all transfers. Review of the comprehensive care plan revealed it was documented that Resident #2 was a "two (2) + persons physical assist" with transfers. The comprehensive care plan did not document the use of a mechanical lift for Resident #2's transfers. There was no physician's order for the use of a mechanical lift for transfers of Resident #2. Record review revealed that Resident #2 had an incomplete Lift/Transfer Assessment Form, dated 3/29/12, that was signed by a Licensed Practical Nurse (LPN #2). The lift assessment noted: "Individual can safely perform 50% or greater of lift/transfer (answer) NO-Continue with assessment ...Total Lift Required Individual cannot bear weight on at least one leg. Number of Staff required for Bed Mobility 1 person assist required. Lift Required (left blank) Sling Size (left blank) Comments for PRN use (left blank) Assessment Completed By (signed by LPN#2)." Resident #2 was not appropriately assessed for the use of the mechanical lift prior to the fall with a fracture from the lift sling on 4/18/12. The use of the mechanical lift for the transfers of Resident #2 from bed to chair was not appropriately assessed prior to the fall with a fracture of 4/18/12. The care plan was not revised and was not reviewed with new interventions documented on the care plan after the fall from the mechanical lift on 4/18/12 which resulted in a fractured pelvis. Review of the nurse's notes, dated 4/18/12 at 10:00 a.m., noted: "This nurse called to the resid (resident's) room by CNA (Certified Nurse Aide). Upon entering room this nurse noticed resid (resident) lying on back on the floor under total lift. Resid (resident) was being transferred from bed to shower via total lift and slipped out as stated by CNA. Resid (resident) assisting back to bed. No visible injuries noted. C/O (complaints of) pain to the middle back area. PRN (as needed) pain med (medication) given." Review of the nurse ' s notes, dated 5/10/12, noted: "RP (Responsible Party) returned call for above order and informed this nurse that resident has a soft area approx nickel size to Right elbow. Spoke with Resident states "I noticed it when I was in therapy. It must have happened when I fell . O c/o (no complaints of) pain/discomfort to area @ (at) this time. Able to move extremity s (with) difficulty. Elbow noted c (with) some discoloration. MD (medical doctor) aware..." Review of the results of the CT (computed tomography) scan on 4/20/12 documented by the radiologist noted: "Right superior pubic ramus fracture, comminuted and new since prior study. Multilevel degenerative change in the spine." The fracture to the pubic ramus was not care planned on the comprehensive care plan of Resident #2 after the fall of 4/18/12 nor after the CT scan of 4/20/12. The nurse's Medicare notes dated 4/18/12 read: "Resident resting in bed. C/O (complaints of) pain to back in reference to the fall of this a.m. (morning). No bruising discoloration or edema noted. X-ray ordered. Will follow-up with x-ray and M.D. orders ..." The Medicare nurse's note dated "4/19/12" read: "C/O (complains of) pain in back. Medicated for pain. Noted effective. Good appetite. Pleasant attitude attends therapy. Calm and cooperative." The Medicare nurse's notes dated "4/20/12" read: "Resident alert and cooperative lying in bed resting @ (at) this time C/O (complaints of) pain PRN (as needed) med (medication) given with eff (effective) results no adverse reaction noted no signs and symptoms of distress. Dressing to adb (abdomen) clean and intact no signs or symptoms of irritation." Review of the nurse's Medicare notes documented pain was voiced by Resident #2 up until 5/12/12 with PRN (as needed) pain medications given for the voiced pain of Resident #2. The comprehensive care plan did not address the pain of Resident #2 after the fall with a fracture on 4/18/12. The comprehensive care plan was dated 4/11/12. The pain assessment for Resident #2 was dated 3/29/12. The facility failed to document the pain of Resident #2 with a revised " Pain Assessment" after the fall from the mechanical lift which resulted in a fracture on 4/18/12 and the Resident #2's continued voiced complaints of pain after the fall. Review of the manufacturer's guidelines for the "(Name of lift) noted: "Before each patient transfer, it is important for staff to inspect the (Name of lift) to make sure no parts are missing or overly worn and that all parts work correctly. If a problem is noted, the lift should not be used until repairs have been made by qualified maintenance staff. It is also required that qualified maintenance staff inspect the lift at least monthly for missing parts and excessive wear that might cause the lift to fail. A permanent record of each of these inspections and repairs made should be kept by the facility. (See Monthly (Name of lift) Inspection Checklist at the back of this manual.) It is important that qualified maintenance staff inspect all (Name of lift) monthly. Before each patient transfer, the sling must also be inspected for signs of damage, for loose and (Name of lift) missing stitching, and for tears and excessive wear that might cause it to fail. If a sling is damaged or overly worn, it must be thrown away and replaced with an undamaged sling. It is also required that a nurse or professional rehabilitation staff member inspects all Vander-Lift slings for the above types of damage at least monthly. A permanent record of each of these inspections and action taken should be kept by the facility. (See Monthly (Name of lift) SLING Checklist at the back of this manual.) It is important that a nurse or professional rehabilitation staff member inspects all (Name of lift) slings monthly. Only staff members who have been trained according to the procedures in this manual, by a manufacturer's representative or by a nurse or professional rehabilitation staff member as your facility's mechanical lift trainer, may be allowed to use the (Name of lift)." The Manufacture's Manual also read: "Before using the (Name of lift), patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer with the (Name of lift), which (Name of lift) transfer technique to use, which size sling is appropriate, and the number of staff members necessary to transfer each patient. (Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. For example, patients with unpredictable behavior due to dementia may require additional help if their behavior poses risk of injury to themselves or to staff members, patients being transported in the (Name of lift) with a VANDERSCALE outside of the patient's room.) The above information must be recorded in the patient's record and must be communicated to the staff." The record review revealed that the facility did not follow the guidelines set forth in the Manufactures Manual. The facility had not assessed and documented the appropriate sling size to be used with the mechanical lift for Resident #2, as outlined in the Manufacturer ' s Manual. The facility failed to appropriately assess the sling size of the mechanical lift for Resident #2 and failed to appropriately assess the number of staff needed to assist in the transfers of Resident #2 while in the mechanical lift. The facility's failure to appropriately devise a comprehensive care plan and to adequately assess Resident #2's sling size and the number of staff need to appropriately and effectively transfer Resident #2 caused harm to Resident #2. Resident #2 fell from the mechanical lift sling and fractured her pubic bone and caused severe pain to Resident #2 as a result of the fall on 4/18/12. Interview on 5/15/12 at 11:25 a.m. revealed that Licensed Practical Nurse (LPN) #3 stated that the facility had no mechanical lift sling size assessment prior to the fall with a fracture on 4/18/12 of Resident #2. LPN #3 stated that they changed the type of sling needed for Resident #2's transfers after the fall of 4/18/12 because the one they used the "(name of lift)" sling was not appropriate for Resident #2. LPN #3 stated that the facility changed to a four (4) point sling which is what they are now using on everybody. LPN #3 stated that the facility had only had two (2) sizes of slings for the mechanical lifts and the two (2) size slings that they currently had were sling size large and XX large. LPN #3 stated that she was one (1) of the two (2) QA (Quality Assurance) nurses for the facility and all the nursing staff CNAs (Certified Nurse Aides) and nurses were all in-serviced on the use of the new four (4) point sling to be used with the mechanical lifts for all residents. Interview on 5/15/12 at 11:30 a.m. with Licensed Practical Nurse (LPN) #4 revealed that she was the floor nurse on 4/18/12 when Resident #2 fell from the mechanical lift to the floor. LPN #4 stated that CNA (Certified Nurse Aide) #3 came and got her to come and assess Resident #2. CNA #3 told LPN #4 that Resident #2 had fallen from the mechanical lift and was on the floor. LPN #4 stated that she assisted CNA #3 to put Resident #2 back in to the bed and assessed her for injury. LPN #4 stated that Resident #2 complained of pain later on in the shift and she gave her pain medications for the pain. LPN #4 stated that prior to the fall of 4/18/12 of Resident #2 she had not had any training on the use of the mechanical lifts and no training on the size slings to use with the lifts. LPN #4 stated that after the fall of Resident #2 all nursing staff was trained on the proper use of the mechanical lifts and the new slings. Interview on 5/15/2012 at 3:55 p.m. with the Director of Nurses (DON) revealed that Resident #2 fell from the sling of the mechanical lift on 4/18/12 at 10:00 a.m. and that there was one (1) CNA (certified nurse aide) operating the lift with Resident #2 when she fell . CNA #3 was with Resident #2 operating the mechanical lift when Resident #2 fell out of the sling on to the floor. The DON stated that at that time Resident #2 only required one (1) staff to assist with transfers and only one (1) staff was to be operating the mechanical lift. The DON stated that LPN #2 was the Medicare nurse that had assessed Resident #2 for the total mechanical lift and the assessment did not provide documentation as to how many staff should assist with the transfers in the lift and the assessment did not document the size sling needed for the transfers of Resident #2. The DON stated that LPN #2 no longer worked in the facility and had been terminated from employment on 5/7/12 for walking out of the facility after she was asked to work the floor on 5/7/12. The DON stated that the facility got rid of all of the prior slings that were used when Resident #2 fell on [DATE]. The DON stated that they had begun to use a new four (4) point sling with the mechanical lifts. The DON stated that the facility had only two (2) sizes of slings of large and extra large. The DON confirmed that there were no physician's orders for the use of mechanical lifts. The DON stated that the lift/transfer assessments do not document the size sling to be used with the lifts and do not document the number of staff needed to assist with the mechanical lifts. Interview on 5/15/12 at 4:30 p.m. with Certified Nurse Aide (CNA) #3 revealed that she was operating the mechanical lift by herself on 4/18/12 when Resident #2 fell from the lift to the floor. CNA #3 stated that she went and got Licensed Practical Nurse (LPN) #4 to help her with Resident #2. CNA #3 stated that Resident #2 was on the floor and they picked her up and placed her back to bed. LPN #4 was the floor nurse for that day and she assessed Resident #2. CNA #3 stated that Resident #2 was being transferred from her bed to the shower chair when her left arm that was in a cast from a prior fracture came out of the sling and caused Resident #2 to fall from the sling to the floor. CNA #3 stated that the sling did not break and did not malfunction or become loose from the lift. The sling was intact after the fall of Resident #2. CNA #3 stated that Resident #2 was documented on the Activities of Daily Living (ADLs) sheets as a one (1) person assist with the total lift on 4/18/12. CNA #3 stated that after Resident #2 fell on [DATE] from the total lift and fractured her pubic bone that her ADLs were changed to a two (2) person physical assist with the total lift for all transfers. Interview on 5/16/12 at 11:30 a.m. with Licensed Practical Nurse (LPN) #1 revealed that at the time that the "Lift/Transfer" assessments, dated 3/9/12, were completed on Resident #2 that the facility did not measure the length and width of any residents using the total lift for transfers. LPN #1 stated that the facility had no assessments to determine the size and type of sling to use on the mechanical total lift used for the transferring of Resident #2. LPN #1 stated that the Medicare nurse (LPN #2) had assessed Resident #2 for the total mechanical lift on 3/29/12 and that she had been verbally trained on how to assess residents for lifts and transfers. LPN #1 stated that the facility had no documentation of the lift training or the lift assessment process training prior to the fall and fracture of Resident #2 on 4/18/12. Observation and interview on 5/16/12 at 2:30 p.m. for the use of the total mechanical lift with a two (2) + person physical assistance with Certified Nurse Aide (CNA) #1 and CNA #2 was observed as they used the total lift on Resident #8. CNA #1 was not aware of any documentation that she utilized to advise her as to how to use the total mechanical lift and she was not aware of any documentation that she utilized to determine what size sling to use for the total lifts. CNA #1 stated that she judged what size sling to use with the total lift by looking at the size of the resident. CNA #1 stated that the sling she was using during the demonstration on Resident #8 was a size large sling. CNA #2 was observed looking inside of the sling that Resident #8 had around him and CNA #2 stated after looking at the size sling that was being used that "no" the sling used on Resident #8 was an extra large. CNA #1 and CNA #2 were not able to recall how the sling size was to be determined for the use of the total mechanical lift. CNA #1 and CNA #2 both stated that they had never measured the length and width of the Residents to determine the size of the sling to be used on the total mechanical lift. Both CNA #1 and CNA #2 stated "No, we do not measure the residents to determine what size sling should be used. " Interview on 5/16/12 at 3:30 p.m. with Licensed Practical Nurse (LPN) #2 revealed that she no longer worked in the employment of the facility and that her last day of employment was 5/7/12. LPN #2 stated that she had not had any training on the use of the total mechanical lift and had not received any training as to how to assess Resident #2 for the size sling to be used with the total mechanical lift. LPN #2 stated that she received little to no hands on training at the facility. Interview on 5/17/12 at 9:30 a.m. with the Medical Director (MD) revealed that he was aware of Resident #2's fall with a fracture to the pubic bone on 4/18/12. The MD stated that the Quality Assurance (QA) committee meets with him at least quarterly and that each fall and each injury was assessed by the QA committee. The MD stated that he was not aware of the assessment procedures for the sling size and the use of the total mechanical lift. The MD stated that he was not aware of the Manufacturer's Guidelines documented in the manual. Review of the "Resident ADL (Activities of Daily Living) Record" dated April 2012 documented that on 4/18/12 the "Lift" was changed to a "2 CNA Total Lift: Dependent Total/Electric /Hoyer." The comprehensive care plan had not been revised and reviewed to reflect the change in the use of the total mechanical lift. The fall of Resident #2 on 4/18/12 was not documented on the comprehensive care plan. The size sling to use on Resident #2 had not been documented and assessed and the "Lift/Transfer" assessment had not been revised and reviewed since 3/29/12. Record review revealed that the facility had not adequately and appropriately assessed and care planned Resident #2 and had not properly supervised Resident #2 to avoid harm from the fall of 4/18/12 which resulted in the fracture and severe pain to the pubic bone of Resident #2. The facility's lack of assessment and lack of supervision caused the harm to Resident #2 and caused the fall with the fracture and pain to Resident #2. The facility had not appropriately assessed the size of the sling to be used on the total lift for Resident #2 as recommended in the manufacturer's guidelines. The facility should have utilized two (2) + person physical assistance for all transfers as indicated on the MDS's of Resident #2. Review of a written statement on facility letterhead signed by the Director of Nurses, dated 5/15/12, noted: "Re: (Name of Resident #2) sling and physician order. We do not have an assessment for the size of sling to use. We do not have a physician's order for the use of the Lift." Review of the home's "Lift Policy" dated 7/13/06, noted: "It is the policy of this facility that lifts will be utilized as follows: -By a licensed nurse or C.N.A. - To enable one individual to lift and move a resident safely-On residents who can not safely perform 50% or greater of lift/transfer Procedure -According to manufactures guidelines for electric sit to stand and total lifts-According to Hoyer lift policy for Hoyer lifts-According to manufactures guidelines for lift sheets Documentation -Document use of the lift to move the resident Reminders -Complete the lift/transfer assessment form to determine the type of lift to be used (sit to stand or total)-Privacy will be provided for all care rendered-Care plan the problem requiring the use of the lift-It is always advisable to have two employees when the lift is being used-The lifts should be periodically checked by maintenance in order to ensure proper function-Some residents are afraid of the lift and reassurance needs to be provided." The facility did not follow its "Lift Policy" and procedure for care planning the problem requiring the use of the lift. The facility did not follow their 'Lift Policy" for completing the Lift/transfer assessment form to determine the type of lift to be used. Review of the home's "Lift/Transfer Assessment Form Policy", dated 8/31/09, noted: "It is the policy of this facility that the lift assessment will be utilized as follows: -On all residents-At the time of admission to determine appropriate transfer method-To determine the amount of assistance required for lifting or transfers-To be updated at least quarterly in conjunction with the MDS-Updated with significant change in resident's condition-Maintained as a permanent part of the medical record." The facility did not follow its "Lift/ Transfer Assessment Form Policy" as the lift assessment was only practically completed upon admission, dated 3/29/12, and was incomplete. The assessment was not updated to reflect the MDS and was not updated upon a significant change to Resident #2 after she fell from the lift and fractured her pubic area. The pain of Resident #2 was not appropriately assessed and was not documented on the comprehensive care plan after the fall with a fracture on 4/18/12.

Based on observation, staff interview, resident interview, record review, medical director's interview, and policy review, the facility failed to appropriately assess, to adequately supervise, and to prevent the harm caused to one (1) of eight (8) reviewed for falls (Residents #2). Findings include: Resident #2 Record review revealed that Resident #2 moved into the home on 3/1/12 with [DIAGNOSES REDACTED]. Observation on 5/14/12 at 2:30 p.m. revealed that Resident #2 was seated in a wheelchair near the bed inside of a private room. Resident #2 was well groomed, oriented and interviewable. Resident #2 stated she was precise in her recall of her treatment and of the events of her hospitalization . Interview on 5/14/12 at 2:30 p.m. with Resident #2 revealed that she had been admitted to the facility for rehabilitation purposes only. Resident #2 stated that prior to admission she had fallen in her home and had fractured her left arm and had re-fractured a hip. Resident #2 stated that she was admitted to the facility from the hospital on [DATE] with a cast to her left arm/elbow and a new hip implant. Resident #2 stated that at the time of her 3/1/12 admission, she was non-weight bearing and that she was transferred from her bed to her chair via a mechanical lift and the assistance of one (1) Certified Nurse Aide (CNA). Resident #2 stated that the sling on the mechanical lift had always made her a bit nervous because it was unsteady. Resident #2 stated that one morning in April 2012 one (1) CNA came to get her to take a bath. The one (1) CNA placed the sling under her and lifted her up in the sling from the bed to transfer her to a shower chair. As the sling held her up in the air the sling became unsteady and she fell from the sling of the mechanical lift to the floor. Resident #2 stated that the CNA that was alone with her was more up-set about Resident #2's fall than Resident #2. Resident #2 stated that the pain became more and more intense and that after an x-ray and an MRI (magnetic resonance imaging) the pelvis was fractured as a result of the fall from the mechanical lift. Resident #2 stated that after the fall and fractured pelvis the facility began to use another type of a sling with the mechanical lift and two (2) CNAs for each transfer. Review of the Minimum Data Set (MDS), dated [DATE], coded a Brief Interview of Mental Status score of 15, which indicated Resident #2 was cognitive intact. Review of the Minimum Data Sets (MDS), dated [DATE]; 3/11/12; 4/5/12; 4/10/12; and 4/26/12, coded that Resident #2 was a "two (2) + persons physical assist" with all transfers and two (2) persons assist with the mechanical lift transfers. The facility did not follow the MDS resident assessment for the "two + persons physical assist" for all transfers. Review of the comprehensive care plan revealed it was documented that Resident #2 was a "two (2) + persons physical assist" with transfers. The comprehensive care plan did not document the use of a mechanical lift for Resident #2's transfers. There was no physician's order for the use of a mechanical lift for transfers of Resident #2. Record review revealed that Resident #2 had an incomplete Lift/Transfer Assessment Form, dated 3/29/12, that was signed by a Licensed Practical Nurse (LPN #2). The lift assessment noted: "Individual can safely perform 50% or greater of lift/transfer (answer) NO-Continue with assessment ...Total Lift Required Individual cannot bear weight on at least one leg. Number of Staff required for Bed Mobility 1 person assist required. Lift Required (left blank) Sling Size (left blank) Comments for PRN use (left blank) Assessment Completed By (signed by LPN#2)." Resident #2 was not appropriately assessed for the use of the mechanical lift prior to the fall with a fracture from the lift sling on 4/18/12. The use of the mechanical lift for the transfers of Resident #2 from bed to chair was not appropriately assessed prior to the fall with a fracture of 4/18/12. The care plan was not revised and was not reviewed with new interventions documented on the care plan after the fall from the mechanical lift on 4/18/12 which resulted in a fractured pelvis. Review of the nurse's notes, dated 4/18/12 at 10:00 a.m., noted: "This nurse called to the resid (resident's) room by CNA (Certified Nurse Aide). Upon entering room this nurse noticed resid (resident) lying on back on the floor under total lift. Resid (resident) was being transferred from bed to shower via total lift and slipped out as stated by CNA. Resid (resident) assisting back to bed. No visible injuries noted. C/O (complaints of) pain to the middle back area. PRN (as needed) pain med (medication) given." Review of the nurse ' s notes, dated 5/10/12, noted: "RP (Responsible Party) returned call for above order and informed this nurse that resident has a soft area approx nickel size to Right elbow. Spoke with Resident states "I noticed it when I was in therapy. It must have happened when I fell . O c/o (no complaints of) pain/discomfort to area @ (at) this time. Able to move extremity s (with) difficulty. Elbow noted c (with) some discoloration. MD (medical doctor) aware..." Review of the results of the CT (computed tomography) scan on 4/20/12 documented by the radiologist noted: "Right superior pubic ramus fracture, comminuted and new since prior study. Multilevel degenerative change in the spine." The fracture to the pubic ramus was not care planned on the comprehensive care plan of Resident #2 after the fall of 4/18/12 nor after the CT scan of 4/20/12. The nurse's Medicare notes dated 4/18/12 read: "Resident resting in bed. C/O (complaints of) pain to back in reference to the fall of this a.m. (morning). No bruising discoloration or edema noted. X-ray ordered. Will follow-up with x-ray and M.D. orders ..." The Medicare nurse's note dated "4/19/12" read: "C/O (complains of) pain in back. Medicated for pain. Noted effective. Good appetite. Pleasant attitude attends therapy. Calm and cooperative." The Medicare nurse's notes dated "4/20/12" read: "Resident alert and cooperative lying in bed resting @ (at) this time C/O (complaints of) pain PRN (as needed) med (medication) given with eff (effective) results no adverse reaction noted no signs and symptoms of distress. Dressing to adb (abdomen) clean and intact no signs or symptoms of irritation." Review of the nurse's Medicare notes documented pain was voiced by Resident #2 up until 5/12/12 with PRN (as needed) pain medications given for the voiced pain of Resident #2. The comprehensive care plan did not address the pain of Resident #2 after the fall with a fracture on 4/18/12. The comprehensive care plan was dated 4/11/12. The pain assessment for Resident #2 was dated 3/29/12. The facility failed to document the pain of Resident #2 with a revised " Pain Assessment" after the fall from the mechanical lift which resulted in a fracture on 4/18/12 and the Resident #2's continued voiced complaints of pain after the fall. Review of the manufacturer's guidelines for the "(Name of lift) noted: "Before each patient transfer, it is important for staff to inspect the (Name of lift) to make sure no parts are missing or overly worn and that all parts work correctly. If a problem is noted, the lift should not be used until repairs have been made by qualified maintenance staff. It is also required that qualified maintenance staff inspect the lift at least monthly for missing parts and excessive wear that might cause the lift to fail. A permanent record of each of these inspections and repairs made should be kept by the facility. (See Monthly (Name of lift) Inspection Checklist at the back of this manual.) It is important that qualified maintenance staff inspect all (Name of lift) monthly. Before each patient transfer, the sling must also be inspected for signs of damage, for loose and (Name of lift) missing stitching, and for tears and excessive wear that might cause it to fail. If a sling is damaged or overly worn, it must be thrown away and replaced with an undamaged sling. It is also required that a nurse or professional rehabilitation staff member inspects all Vander-Lift slings for the above types of damage at least monthly. A permanent record of each of these inspections and action taken should be kept by the facility. (See Monthly (Name of lift) SLING Checklist at the back of this manual.) It is important that a nurse or professional rehabilitation staff member inspects all (Name of lift) slings monthly. Only staff members who have been trained according to the procedures in this manual, by a manufacturer's representative or by a nurse or professional rehabilitation staff member as your facility's mechanical lift trainer, may be allowed to use the (Name of lift)." The Manufacture's Manual also read: "Before using the (Name of lift), patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer with the (Name of lift), which (Name of lift) transfer technique to use, which size sling is appropriate, and the number of staff members necessary to transfer each patient. (Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. For example, patients with unpredictable behavior due to dementia may require additional help if their behavior poses risk of injury to themselves or to staff members, patients being transported in the (Name of lift) with a VANDERSCALE outside of the patient's room.) The above information must be recorded in the patient's record and must be communicated to the staff." The record review revealed that the facility did not follow the guidelines set forth in the Manufactures Manual. The facility had not assessed and documented the appropriate sling size to be used with the mechanical lift for Resident #2, as outlined in the Manufacturer ' s Manual. The facility failed to appropriately assess the sling size of the mechanical lift for Resident #2 and failed to appropriately assess the number of staff needed to assist in the transfers of Resident #2 while in the mechanical lift. The facility's failure to appropriately devise a comprehensive care plan and to adequately assess Resident #2's sling size and the number of staff need to appropriately and effectively transfer Resident #2 caused harm to Resident #2. Resident #2 fell from the mechanical lift sling and fractured her pubic bone and caused severe pain to Resident #2 as a result of the fall on 4/18/12. Interview on 5/15/12 at 11:25 a.m. revealed that Licensed Practical Nurse (LPN) #3 stated that the facility had no mechanical lift sling size assessment prior to the fall with a fracture on 4/18/12 of Resident #2. LPN #3 stated that they changed the type of sling needed for Resident #2's transfers after the fall of 4/18/12 because the one they used the "(name of lift)" sling was not appropriate for Resident #2. LPN #3 stated that the facility changed to a four (4) point sling which is what they are now using on everybody. LPN #3 stated that the facility had only had two (2) sizes of slings for the mechanical lifts and the two (2) size slings that they currently had were sling size large and XX large. LPN #3 stated that she was one (1) of the two (2) QA (Quality Assurance) nurses for the facility and all the nursing staff CNAs (Certified Nurse Aides) and nurses were all in-serviced on the use of the new four (4) point sling to be used with the mechanical lifts for all residents. Interview on 5/15/12 at 11:30 a.m. with Licensed Practical Nurse (LPN) #4 revealed that she was the floor nurse on 4/18/12 when Resident #2 fell from the mechanical lift to the floor. LPN #4 stated that CNA (Certified Nurse Aide) #3 came and got her to come and assess Resident #2. CNA #3 told LPN #4 that Resident #2 had fallen from the mechanical lift and was on the floor. LPN #4 stated that she assisted CNA #3 to put Resident #2 back in to the bed and assessed her for injury. LPN #4 stated that Resident #2 complained of pain later on in the shift and she gave her pain medications for the pain. LPN #4 stated that prior to the fall of 4/18/12 of Resident #2 she had not had any training on the use of the mechanical lifts and no training on the size slings to use with the lifts. LPN #4 stated that after the fall of Resident #2 all nursing staff was trained on the proper use of the mechanical lifts and the new slings. Interview on 5/15/2012 at 3:55 p.m. with the Director of Nurses (DON) revealed that Resident #2 fell from the sling of the mechanical lift on 4/18/12 at 10:00 a.m. and that there was one (1) CNA (certified nurse aide) operating the lift with Resident #2 when she fell . CNA #3 was with Resident #2 operating the mechanical lift when Resident #2 fell out of the sling on to the floor. The DON stated that at that time Resident #2 only required one (1) staff to assist with transfers and only one (1) staff was to be operating the mechanical lift. The DON stated that LPN #2 was the Medicare nurse that had assessed Resident #2 for the total mechanical lift and the assessment did not provide documentation as to how many staff should assist with the transfers in the lift and the assessment did not document the size sling needed for the transfers of Resident #2. The DON stated that LPN #2 no longer worked in the facility and had been terminated from employment on 5/7/12 for walking out of the facility after she was asked to work the floor on 5/7/12. The DON stated that the facility got rid of all of the prior slings that were used when Resident #2 fell on [DATE]. The DON stated that they had begun to use a new four (4) point sling with the mechanical lifts. The DON stated that the facility had only two (2) sizes of slings of large and extra large. The DON confirmed that there were no physician's orders for the use of mechanical lifts. The DON stated that the lift/transfer assessments do not document the size sling to be used with the lifts and do not document the number of staff needed to assist with the mechanical lifts. Interview on 5/15/12 at 4:30 p.m. with Certified Nurse Aide (CNA) #3 revealed that she was operating the mechanical lift by herself on 4/18/12 when Resident #2 fell from the lift to the floor. CNA #3 stated that she went and got Licensed Practical Nurse (LPN) #4 to help her with Resident #2. CNA #3 stated that Resident #2 was on the floor and they picked her up and placed her back to bed. LPN #4 was the floor nurse for that day and she assessed Resident #2. CNA #3 stated that Resident #2 was being transferred from her bed to the shower chair when her left arm that was in a cast from a prior fracture came out of the sling and caused Resident #2 to fall from the sling to the floor. CNA #3 stated that the sling did not break and did not malfunction or become loose from the lift. The sling was intact after the fall of Resident #2. CNA #3 stated that Resident #2 was documented on the Activities of Daily Living (ADLs) sheets as a one (1) person assist with the total lift on 4/18/12. CNA #3 stated that after Resident #2 fell on [DATE] from the total lift and fractured her pubic bone that her ADLs were changed to a two (2) person physical assist with the total lift for all transfers. Interview on 5/16/12 at 11:30 a.m. with Licensed Practical Nurse (LPN) #1 revealed that at the time that the "Lift/Transfer" assessments, dated 3/9/12, were completed on Resident #2 that the facility did not measure the length and width of any residents using the total lift for transfers. LPN #1 stated that the facility had no assessments to determine the size and type of sling to use on the mechanical total lift used for the transferring of Resident #2. LPN #1 stated that the Medicare nurse (LPN #2) had assessed Resident #2 for the total mechanical lift on 3/29/12 and that she had been verbally trained on how to assess residents for lifts and transfers. LPN #1 stated that the facility had no documentation of the lift training or the lift assessment process training prior to the fall and fracture of Resident #2 on 4/18/12. Observation and interview on 5/16/12 at 2:30 p.m. for the use of the total mechanical lift with a two (2) + person physical assistance with Certified Nurse Aide (CNA) #1 and CNA #2 was observed as they used the total lift on Resident #8. CNA #1 was not aware of any documentation that she utilized to advise her as to how to use the total mechanical lift and she was not aware of any documentation that she utilized to determine what size sling to use for the total lifts. CNA #1 stated that she judged what size sling to use with the total lift by looking at the size of the resident. CNA #1 stated that the sling she was using during the demonstration on Resident #8 was a size large sling. CNA #2 was observed looking inside of the sling that Resident #8 had around him and CNA #2 stated after looking at the size sling that was being used that "no" the sling used on Resident #8 was an extra large. CNA #1 and CNA #2 were not able to recall how the sling size was to be determined for the use of the total mechanical lift. CNA #1 and CNA #2 both stated that they had never measured the length and width of the Residents to determine the size of the sling to be used on the total mechanical lift. Both CNA #1 and CNA #2 stated "No, we do not measure the residents to determine what size sling should be used. " Interview on 5/16/12 at 3:30 p.m. with Licensed Practical Nurse (LPN) #2 revealed that she no longer worked in the employment of the facility and that her last day of employment was 5/7/12. LPN #2 stated that she had not had any training on the use of the total mechanical lift and had not received any training as to how to assess Resident #2 for the size sling to be used with the total mechanical lift. LPN #2 stated that she received little to no hands on training at the facility. Interview on 5/17/12 at 9:30 a.m. with the Medical Director (MD) revealed that he was aware of Resident #2's fall with a fracture to the pubic bone on 4/18/12. The MD stated that the Quality Assurance (QA) committee meets with him at least quarterly and that each fall and each injury was assessed by the QA committee. The MD stated that he was not aware of the assessment procedures for the sling size and the use of the total mechanical lift. The MD stated that he was not aware of the Manufacturer's Guidelines documented in the manual. Review of the "Resident ADL (Activities of Daily Living) Record" dated April 2012 documented that on 4/18/12 the "Lift" was changed to a "2 CNA Total Lift: Dependent Total/Electric /Hoyer." The comprehensive care plan had not been revised and reviewed to reflect the change in the use of the total mechanical lift. The fall of Resident #2 on 4/18/12 was not documented on the comprehensive care plan. The size sling to use on Resident #2 had not been documented and assessed and the "Lift/Transfer" assessment had not been revised and reviewed since 3/29/12. Record review revealed that the facility had not adequately and appropriately assessed and care planned Resident #2 and had not properly supervised Resident #2 to avoid harm from the fall of 4/18/12 which resulted in the fracture and severe pain to the pubic bone of Resident #2. The facility's lack of assessment and lack of supervision caused the harm to Resident #2 and caused the fall with the fracture and pain to Resident #2. The facility had not appropriately assessed the size of the sling to be used on the total lift for Resident #2 as recommended in the manufacturer's guidelines. The facility should have utilized two (2) + person physical assistance for all transfers as indicated on the MDS's of Resident #2. Review of a written statement on facility letterhead signed by the Director of Nurses, dated 5/15/12, noted: "Re: (Name of Resident #2) sling and physician order. We do not have an assessment for the size of sling to use. We do not have a physician's order for the use of the Lift." Review of the home's "Lift Policy" dated 7/13/06, noted: "It is the policy of this facility that lifts will be utilized as follows: -By a licensed nurse or C.N.A. - To enable one individual to lift and move a resident safely-On residents who can not safely perform 50% or greater of lift/transfer Procedure -According to manufactures guidelines for electric sit to stand and total lifts-According to Hoyer lift policy for Hoyer lifts-According to manufactures guidelines for lift sheets Documentation -Document use of the lift to move the resident Reminders -Complete the lift/transfer assessment form to determine the type of lift to be used (sit to stand or total)-Privacy will be provided for all care rendered-Care plan the problem requiring the use of the lift-It is always advisable to have two employees when the lift is being used-The lifts should be periodically checked by maintenance in order to ensure proper function-Some residents are afraid of the lift and reassurance needs to be provided." The facility did not follow its "Lift Policy" and procedure for care planning the problem requiring the use of the lift. The facility did not follow their 'Lift Policy" for completing the Lift/transfer assessment form to determine the type of lift to be used. Review of the home's "Lift/Transfer Assessment Form Policy", dated 8/31/09, noted: "It is the policy of this facility that the lift assessment will be utilized as follows: -On all residents-At the time of admission to determine appropriate transfer method-To determine the amount of assistance required for lifting or transfers-To be updated at least quarterly in conjunction with the MDS-Updated with significant change in resident's condition-Maintained as a permanent part of the medical record." The facility did not follow its "Lift/ Transfer Assessment Form Policy" as the lift assessment was only practically completed upon admission, dated 3/29/12, and was incomplete. The assessment was not updated to reflect the MDS and was not updated upon a significant change to Resident #2 after she fell from the lift and fractured her pubic area. The pain of Resident #2 was not appropriately assessed and was not documented on the comprehensive care plan after the fall with a fracture on 4/18/12.