Every finding on record at Diversicare of Batesville

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident was free from neglect as evidenced by not ensuring the availability of a functioning total mechanical lift or alternative transfer method for one (1) of 36 residents that required the use of a total lift. (Resident #96) Findings Include: Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, effective January 2019, revealed under Purpose .To prohibit and prevent abuse, neglect .Neglect: Failure of the center, its team members .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . An interview on 06/09/25 at 1:19 PM with Resident #96 revealed that one night the previous week, she had to sit in her wheelchair from afternoon until approximately 3:00 AM because all of the lifts were not charged. She stated that eventually, an ambulance service was called, and they lifted her manually and put her back to bed. The resident reported she had peed and pooped on herself and experienced pain requiring pain medication. She stated, This is just ridiculous that all of their lifts were not working. I don't even like to get out of bed, much less stay up that long. Record review of Resident #96's lift/transfer assessment dated [DATE] documented that Resident #96 required a total mechanical lift for all transfers. Record review of Resident #96's Medication Administration Record (MAR) for the month of 6/2025 revealed the resident had one incident of reported pain on a 10/10 scale and received a PRN (as needed) pain medication and that was on 6/4/2025 at 7:38 PM. An interview on 06/10/25 at 1:24 PM with CNA #2 confirmed the total lift batteries were not working on the night of the incident with Resident #96, which was 6/4/25. She stated that some batteries had been intermittently failing and that the Administrator had been informed prior to the incident. An interview on 06/10/25 at 1:27 PM with the Administrator and Director of Nursing (DON) confirmed that no charged total lift batteries were available during parts of the 3 PM-11 PM and 11 PM-7 AM shift on Wednesday 6/4/25. The Administrator stated she had been informed on Monday 6/2/25 about battery charging issues and ordered replacements, which did not arrive until Friday. She acknowledged being notified around 8 PM on 6/4/25 that the lifts were nonfunctional, but they continued to try and get them to charge. She admitted that she eventually instructed staff to call the ambulance service and was notified that the resident was returned to bed at approximately 11:51 PM. Both the Administrator and DON agreed the resident should not have had to sit up that long in her wheelchair. A phone interview on 06/10/25 at 1:38 PM with Licensed Practical Nurse (LPN) #1 confirmed she worked the 7 PM-7 AM shift on C Hall 6/4/25 and that none of the batteries were charged at the start of her shift. She stated only one battery eventually charged and was used to put one resident back to bed, but it was depleted by the time A Hall needed it. She confirmed that EMS was called and arrived around 11 PM to assist with returning Resident #96 to bed. She acknowledged no manual backup lift was available and that being without a total lift for so long bothered her. An interview on 06/10/25 at 2:00 PM with the DON confirmed Resident #96 was totally incontinent and left in her wheelchair from approximately 2 PM until around 11 PM on 6/4/25. She stated no skin or body assessment was completed after the resident was returned to bed but acknowledged that one should have been done. She confirmed the facility did not have an alternative back up lift to replace the non-functioning battery-operated lifts. An interview on 06/10/25 at 2:30 PM with the Wound Nurse confirmed she had not been made aware of the incident and agreed a post-incident assessment should have occurred. A phone interview on 6/11/25 at 10:38 AM with CNA #3, who worked 10:30 PM-6:30 AM on 6/4/25, revealed that Resident #96 was returned to bed around 11 PM. She reported the resident was saturated with urine and had a bowel movement extending from her back to her perineal area. She stated no nurse assessed the resident's skin and expressed frustration about the lack of working equipment. An interview on 6/11/25 at 10:45 AM with the DON confirmed that Resident #96 had no documentation of incontinent care for the time she was in the wheelchair on 6/4/25, which was approximately 2 PM-11 PM. She was not aware of the resident's state of incontinence when she was finally transferred back to bed at approximately 11 PM, reported a pain score of 10/10 or the PRN pain medication given that evening and stated, That's terrible. An interview on 6/11/25 at 11:20 AM with the Registered Nurse (RN)/Lift Champion revealed she had been notified on 5/30/25 about the charging issues with the total lift batteries and had reported the issue to the Administrator, who then ordered new batteries. She confirmed that none of the lifts were functional on the night of 6/4/25 and stated, It's terrible that the resident was left that long. She stated that her job as the lift champion was to make sure the slings were not broken and admitted that she made random rounds to check the lift batteries and there were no issues on the day of 6/4/25 that she was aware of. A phone interview on 6/11/25 at 11:34 AM with CNA #4 confirmed that Resident #96 had been gotten up by therapy around 2 PM after receiving a bed bath earlier in the day. She admitted the resident was not toileted or put back to bed before the end of her shift at 3 PM. An interview on 6/11/25 at 11:40 AM with the Certified Occupational Therapy Assistant (COTA) confirmed therapy got Resident #96 up around 1-1:30 PM on 6/4/25. She was not soiled at the time, and therapy concluded around 2:30 PM. An interview on 6/11/25 at 12:45 PM with the Administrator confirmed she was unaware the resident experienced a pain score of 10/10 or that she was saturated with urine and feces on the night of 6/4/25. An observation and interview on 6/11/25 at 2:09 PM with Resident #96 and the Wound Care Nurse revealed no skin breakdown or complaints during a sacral/perineal skin assessment. Record review of Resident #96's admission Record revealed the facility admitted the resident on 9/12/24 with diagnoses including Malignant Neoplasm of the Center Portion of the Left Breast, Joint Stiffness and Pain. Record review of Resident #96's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact and in Section GG that the resident was dependent for transfers with 2-person assistance and toileting.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to promote dignity for two (2) of 35 residents in the sample. (Resident's #44 and #106) Findings include: Review of the facility policy titled, Resident Rights & Quality of Life, with an effective date of March 13, 2020, revealed, Policy: It is the policy of proper name that all patients have the right to a dignified existence, self-determination, and communication with access to services inside and outside the facility. . Resident #44 An observation on 6/9/25 at 10:35 AM revealed Resident #44 was observed licking chocolate pudding from a small Styrofoam bowl. Chocolate pudding was observed on the resident's nose, around the mouth, and drops of pudding on his shirt, top sheet, and blanket. Resident #44 stated he was trying to eat the pudding but was not given a spoon. No spoon was observed in the resident's room. An observation and interview with Certified Nurse Assistant (CNA) #5 on 6/9/25 at 10:38 AM confirmed that Resident #44 did not have a spoon to eat his pudding, and confirmed the resident had chocolate pudding on his face and bed linens from trying to eat the pudding with no utensils. CNA #5 revealed this is a dignity concern because the resident attempted to lick the pudding out of the bowl, resulting in him getting pudding on his face, clothing, and bed linens. An interview with the Infection Preventionist on 6/10/25 at 1:10 PM confirmed it would be a dignity concern and could be embarrassing to have pudding on his face and stated staff should have provided the resident with a spoon. An interview with the Director of Nursing (DON) on 6/10/25 at 1:45 PM confirmed it was a dignity concern for Resident #44 to have to lick pudding out of a cup, resulting in the resident getting pudding on his face and linens. Record review of the admission Record revealed that Resident #44 was admitted to the facility on [DATE] with a diagnosis of nontraumatic intracranial hemorrhage. Record review of Resident #44's Section C of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. Resident #106 An observation of Resident #106's room on 6/9/25 at 10:10 AM revealed a Wound VAC (Vacuum-Assisted Closure) on the bedside nightstand next to the resident's bed, half full of dark, thick serous drainage, with a foul odor noted. The drainage container was visible from the doorway of the room and was not in use. Resident was observed sleeping. During an observation and interview with Licensed Practical Nurse (LPN) #2 on 6/9/25 at 11:41 AM, she confirmed the wound VAC was sitting on Resident #106's nightstand and confirmed it was not in use. She confirmed the drainage container was half full of old, thick, drying, putrid serous drainage. She also confirmed this was a dignity concern to have the drainage visible for everyone to see. An interview with Infection Preventionist on 6/10/25 at 12:57 PM confirmed that when Resident #106's wound VAC canister containing the old serous drainage was a dignity concern related to the drainage being visible to anyone entering the room. An interview with the DON on 6/10/25 at 1:50 PM revealed she saw the serous drainage left in Resident #106's room in the wound VAC, stating, It was awful. She stated the wound VAC was used a day and then changed because the resident kept taking it off. She stated that when the order was discontinued, the wound VAC should have been removed from the room and cleaned, and the vacutainer containing the serous drainage should have been disposed of in the biohazard room in a biohazard bag. She then revealed concerns about leaving the wound vacuum in the room for days after it was discontinued, as it is a dignity concern because the drainage was not covered. Record review of the admission Record revealed that Resident #106 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and an unspecified open wound to the lower leg. Record review of Resident #106's Section C of the MDS with an ARD of 5/29/25 revealed a BIMS score of 15, indicating the resident was cognitively intact.

Based on staff interviews, record review and review of the facility's dialysis contract, the facility failed to assess and document the presence of a bruit and thrill at the dialysis access site as part of routine monitoring as ordered for one (1) of four (4) dialysis residents reviewed: Resident #86 Findings include: Review of the typed statement on facility letterhead dated 6/12/25 revealed that it is the practice of (the facility) to follow contracts with their partnered Dialysis center and provide care in accordance with CMS guidance. Review of the facility's contract Long Term Care Facility Outpatient Dialysis Services Coordination Agreement with the off-site dialysis provider (effective 1/18/17) revealed, .Long Term Care Facility participates as a residential and health care provider of services .and promotes its End-Stage Renal Disease (ESRD) Resident's rights to obtain .benefits and services appropriate to their needs . Record review of Order Summary Report for active orders as of 6/1/25, revealed, .Hemo-Dialysis: Auscultation/Palpitation of shunt site for Bruit and Thrill every (Q) shift with order date 11/14/2024. Review of Dialysis Communication Records for June revealed assessment of site for bruit/thrill on 6/3/25, 6/5/25. 6/7/25, and 6/10/25. Record review of the Medication Administration Record (MAR) for 6/1/25 - 6/10/25 revealed the order for assessment of shunt site for bruit and/or thrill of Resident #86's shunt in his left arm was not on the MAR. During an interview on 6/10/25 at 2:35 PM with the Director of Nursing (DON) regarding Resident #86, it was confirmed the order was not listed on the MAR/TAR (Treatment Administration Record ) and the only documentation for auscultation/palpitation of the shunt site for bruit and thrill was on the dialysis communication forms. She stated that the purpose of checking the shunt site is to ensure that the shunt is functioning properly and has not malfunctioned. She further verbalized that should the shunt stop working, the resident would not be able to receive dialysis and would possibly have to have his shunt replaced. Record review of the admission Record revealed that Resident #86 was admitted to the facility on [DATE] with a diagnoses End-stage Renal Disease (ESRD). Record review of Resident #86's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications on the treatment cart were locked and secured for one (1) of five (5) medication /treatment carts observed. Findings include: Review of the facility's policy titled, (Proper Name) Medication Storage, revised 4/23, states, .it is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use . During an observation on 6/9/25 at 11:29 AM, of the treatment cart on Hall A, revealed it was unlocked and unattended, with keys placed on top of the cart. Wound Nurse exited a resident's room, and the room door had been closed. During an interview with the Wound Nurse she stated, A resident could have walked by, opened up the cart, and ingested something they should not have and confirmed, I should not have left it open, and I should not have left my keys on my cart. An interview was conducted on 6/9/25 at 2:31 PM with the Director of Nursing (DON), who confirmed that the nurse should never leave the cart unlocked and should not have left her keys on top of the cart.

Based on staff interview, record review and facility policy review, the facility failed to ensure a timely evaluation by therapy services after a referral was made for one (1) of 35 sampled residents. Resident #22. Findings include: Record review of facility policy titled, Resident Screening Guidelines updated 3/14/18 revealed, screenings be completed by (Formal Name) employees . upon referral by the medical and/or nursing department of a facility . Record review of Interdisciplinary Rehabilitation Screening Form with effective date 5/23/2025, revealed, Nursing referral due to onset of decreased strength, decreased endurance, and functional decline. Occupational Therapy (OT) evaluation indicated. An interview on 6/11/25 at 1:45 PM with the Director of Nursing (DON) confirmed, nursing did make a referral on 5/23/25 for an OT evaluation, however there was no documentation of an evaluation by OT. She stated, you will have to check with therapy about that. An interview on 6/11/25 at 3:11 PM with the Director of Therapy confirmed the nursing referral date 5/23/25 was not processed timely. She stated, I'm not sure how we missed that one. She further verbalized that the person that performed their OT evaluations was out on medical leave, however they did have someone available via telehealth for evaluations and that she was evaluating Resident # 22 right now (today). When asked could this evaluation been performed via telehealth when nursing made the referral on 5/23/25, she confirmed, yes. She revealed referrals for evaluations are expected to be evaluated between 24-48 hours after they are received. She further stated that Resident # 22 was at increased risk for further decline and even increased risk for hospitalization due to the delay in the evaluation. Record review of the admission Record revealed Resident #22 was admitted on [DATE] with diagnoses including Alzheimer's Disease. Record review of Resident #22's Section C of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment.

Based on staff interviews, record review, and facility policy review, the facility failed to maintain proper infection control practices for one (1) of 35 sampled residents. (Resident #106) Findings Include Review of the facility policy titled, Policies and Practices-Infection Control, effective date November 1, 2017, revealed: Policy Statement: This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help manage the transmission of diseases . On 6/9/25 at 10:10 AM an observation of Resident #106's room revealed a Wound VAC (Vacuum-Assisted Closure) on the bedside nightstand next to the resident's bed, half full of dark, thick serous drainage, with a foul odor noted. The drainage container was visible from the doorway of the room and was not in use. On 6/9/25 at 11:41 AM during an observation and interview with Licensed Practical Nurse (LPN) #2 , she confirmed the wound VAC was sitting on Resident #106's nightstand and that it was not in use. She also confirmed the drainage container was half full of old, thick, drying putrid serous drainage and stated this was an infection control concern due to the resident being medically compromised and at increased risk of infection. Review of the May 2025 Treatment Record for Resident #106 revealed, wound care to right lower extremity to be done every three days as needed for soilage and dislodgement. Cleanse area with wound cleanser, pat dry, protect peri wound by applying no sting barrier films. Picture frame wound with transparent film dressing. Apply black foam to wound bed only, cover with transparent dressing. Cut quarter size hole in dressing, connect to port. Set at 125 mmHg (millimeters of mercury) one time a day every Wednesday and Friday related to open wound with an order date of 5/28/25 and a discontinue date of 5/30/25. On 6/10/25 at 12:57 PM an interview with the Infection Preventionist confirmed that the wound VAC device and the canister containing the biohazard waste should have been immediately removed from the room and the waste properly disposed of in the biohazard room. The Infection Preventionist expressed concerns about leaving the wound vacutainer with old serous drainage in it, as it poses an increased risk of spreading infection. On 6/10/25 at 1:50 PM an interview with the Director of Nursing (DON) confirmed she saw the serous drainage left in Resident #106's room in the wound VAC, stating, It was awful. She stated that it was only used one day and should have been removed when it was discontinued. She further revealed concerns that leaving the wound VAC in the room for days after it was discontinued could increase the risk of spreading infection. Review of the admission Record revealed that Resident #106 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and an unspecified open wound to the lower leg. Record review of Resident #106's Section C of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

Based on resident and staff interview, record review, and facility policy review, the facility failed to put safety measures in place to prevent an accident during van transport for one (1) of five (5) residents reviewed. Resident #66 Findings include: Record review of the facility policy titled, Inspections, Repairs, and Maintenance, with an effective date of September 1, 2019, revealed, Statement: It is the policy of (Proper Name of Facility) to keep all vehicles well maintained and in safe, efficient operating condition at all times . Rules of vehicle operation .7. All passengers must be seated in vehicle seats with occupant restraint . Record review of the facility policy titled Vehicle Safety Guidelines with a revision date of January 1, 2023, revealed The safety of our patients/residents, passengers, team members, the public and the protection of the property of others is important to the company . An interview on 12/04/23 at 1:15 PM, with Resident #66 revealed that she was in an accident in the facility van a few months ago and suffered a fractured leg. She stated that her wheelchair was secured in the van, but the shoulder strap/seatbelt was not working, so she did not have it on and when the driver made a sudden stop, she fell out of the wheelchair. Record review of the Incident Report Form revealed, Date of incident: 10/09/2023, Approximate time of incident: 4.00 PM Location of incident: .Hwy 7 of [NAME], MS while being transported per facility van from a scheduled appointment .Resident fell face forward to the floor out of the wheelchair in the facility van when driver made a fast stop .(Proper Name of Resident #66) experienced a fall while seated in her wheelchair on the facility van. Resident was transported by EMS (emergency medical services) to local ER (emergency room ). X rays were obtained. (Proper Name of Resident #66) has a broken leg . Record review of the History and Physical from the emergency room (ER) visit dated 10/9/23 revealed, Admitting Diagnosis: Femur fracture .MVA (motor vehicle accident) .in a nursing home van in a wheelchair we had a sudden break was applied and she was thrown out of her wheelchair and sustained deep laceration to left shin, EMS (emergency medical services) was called and they reported large amount of blood on scene and she was hypotensive. In the ER she was given IV (intravenous) fluids with improvement in blood pressure .Of note patient is on Eliquis (blood thinner) .x-ray left femur showed comminuted impacted distal femoral metaphyseal fracture . An interview on 12/5/23 at 10:30 AM, with the Administrator (ADM) confirmed that she did not report the incident to the State Agency (SA) because the resident was not on the premises when it occurred. She looked at it as a motor vehicle accident. She confirmed the facility van driver should have fastened the residents' seat belt and, if the seat belt was not working, he should have moved her into the other space in the van. The ADM confirmed the van driver no longer works here. An interview with Maintenance Staff #1 on 12/07/23 at 9:21 AM, revealed he found out about the incident the next day. He stated they have a check off form the driver should do daily and document. Maintenance Staff #1 confirmed the check off was not done on 11/9/23. He stated he looked at the seat belt the next day and it was not functioning properly. He stated the Seat belt/Shoulder strap would not pull out because the ratchet was not releasing. A record review and interview with the ADM on 12/7/23 at 9:25 AM, confirmed the check off form was not done by the van driver on the day of the incident, 11/9/23. Record review of the November 2023 van calendar revealed no documentation was made on 11/9/23. Record review of the Q'STRAINT user instructions revealed, .B Secure Passenger 1. Attach Lap Belts .2. Attach Shoulder Belt Review of the Statement from Van Incident revealed the ADM interviewed the van driver on October 9, 2023. The van driver revealed he had to make a fast stop due to a vehicle in front of him turned quickly. The fast stop caused a fall to the resident. (Resident #66). The van driver revealed that he did not have the resident secured because the seatbelt didn't pull out far enough. He revealed that he did not use the other seatbelt on the bus because he was in a hurry to get the resident to her appointment. Review of the Admission Record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses that included unspecified Osteoarthritis, Muscle Weakness, Abnormal Posture, and nondisplaced comminuted fracture of shaft of Left Femur. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #66 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to complete and document a resident self-administration of medications evaluation for one (1) of 1 resident reviewed for self-administration of medications. (Resident # 28) Findings Include: Record review of the facility policy revealed that the facility has adopted Clinical Nursing Skills and Techniques, [NAME] & [NAME] as supplementary policy and procedure. A record review of Clinical Nursing Skills and Techniques, Skill 44.6, Teaching Medication Self-Administration , page 1133 revealed Assessment .2. Assess the client's cognitive, sensory, and motor function .4. Assess client's learning readiness and ability to concentrate .and learning style preference . During an observation of Resident #28's room and interview on 12/4/23 at 11:07 AM, revealed two (2) plastic vials laying on the overbed table. Resident #28 revealed that the 2 vials were her breathing treatment medications and she prefers to give herself the breathing treatment at a later time, so the nurses leave them for her. During an observation and interview with Licensed Practical Nurse (LPN) #3 on 12/4/23 at 11:11 AM, she confirmed that the 2 plastic vials laying on Resident #28's overbed table were the medications for the resident's breathing treatment. LPN #3 stated that Resident #28 did not like to take the medications when they were due so she left them in the room so the resident could give them to herself when she was ready. LPN #3 verified the medications were Arformoterol Tartrate 15 micrograms (mcg) per two 2 milliliters (ml) and Budesonide 1 milligram (mg) per two 2 ml. LPN #3 revealed that Resident #28 should have an evaluation and observation performed to make sure she could administer the medication herself and verified that Resident # 28 did not have a completed evaluation for self-administration of medications. A record review of the facility evaluation forms for Resident #28 revealed no Self-Administration of Medication forms, dated prior to 12/3/23 (date of entry of State Agency). During an interview on 12/5/23 at 3:25 PM, with the Director of Nursing (DON) she stated that if the resident expressed that they wanted to self-administer their medication an evaluation is completed. She stated the resident's Brief Interview for Mental Status (BIMS) score is checked to make sure the resident can understand how to self-administer medications and an observation of the resident administering the medication is performed. The DON revealed if the resident meets the criteria, they can self-administer the medication. The DON stated that she had been told, that in the past, Resident #28 preferred to self-administer her breathing treatments. During an interview with the DON on 12/7/23 at 8:10 AM, she verified that Resident #28 did not have a Self-Administration of Medication evaluation completed prior to 12/4/23 at 11:59 AM and agreed that she should have already had one. A record review of Resident #28's Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 10/13/23, revealed a BIMS score of 15, indicating that the resident is cognitively intact. A record review of the Admission Record for Resident #28 revealed that the resident was admitted on [DATE], with diagnoses that include Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of Right Main Bronchus.

Based on resident, staff interview, record review and facility policy review the facility failed to report an accident involving the transport van which resulted in a major injury to a resident for one (1) of 34 sampled residents. Resident #66 Findings include: Review of the facility Event Communication Pathway dated August 2021, revealed a yellow event is managed by the RVP/DCO (Regional [NAME] President/Director of Corporate Operations) and the center leadership. Examples of yellow events include but are not limited to the following: Injury related to equipment. Review of the Event Response procedure included under communication and documentation: Collaborative determination of state reporting requirements. During an interview on 12/04/23 at 1:15 PM, Resident #66 stated that she was in an accident in the facility van a few months ago and suffered a fractured leg. She stated she did not remember talking to anyone from the state about it. She stated that her wheelchair was secured in the van, but the shoulder strap/seatbelt was not working, so she did not have it on and when the driver made a sudden stop, she fell out of the wheelchair. An interview, on 12/5/23 at 10:30 AM with the Administrator (ADM) confirmed that she did not report the incident to the state agency because the resident was not on the premises when it occurred. She looked at it as a motor vehicle accident. An interview, on 12/06/23 at 9:03 AM, with the ADM confirmed that she did not feel she needed to report this incident to the state because the resident was alert and oriented and able to tell what happened and the van driver told her what happened. The ADM did agree that the issue was the facility did not secure the resident properly in the van and that is why it should have been reported because Resident #66 suffered a major injury as a result. Record review of the Incident Report Form revealed, Date of incident: 10/09/2023, Approximate time of incident: 4.00 PM Location of incident: .Hwy 7 of [NAME], MS while being transported per facility van from a scheduled appointment .Resident fell face forward to the floor out of the wheelchair in the facility van when driver made a fast stop .(Proper Name of Resident #66) experienced a fall while seated in her wheelchair on the facility van. Resident was transported by EMS (emergency medical services) to local ER (emergency room ). X rays were obtained. (Proper Name of Resident #66) has a broken leg . Record review of the History and Physical from the emergency room (ER) visit dated 10/9/23 revealed, Admitting Diagnosis: Femur fracture .MVA (motor vehicle accident) .in a nursing home van in a wheelchair we had a sudden break was applied and she was thrown out of her wheelchair and sustained deep laceration to left shin, EMS (emergency medical services) was called and they reported large amount of blood on scene and she was hypotensive. In the ER she was given IV (intravenous) fluids with improvement in blood pressure .Of note patient is on Eliquis (blood thinner) .x-ray left femur showed comminuted impacted distal femoral metaphyseal fracture . Review of the Admission Record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses that included unspecified Osteoarthritis, Muscle Weakness, Abnormal Posture, and Nondisplaced Comminuted Fracture of Shaft of Left Femur. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #66 was cognitively intact.

Based on resident, family and staff interview, record review and facility policy review the facility failed to provide written notification to the resident or resident representative regarding bed hold when the resident was sent to the hospital for an evaluation for two (2) of five (5) residents reviewed for hospitalization . Residents #74 & #28 Findings include: A record review of the facility policy Bed Hold Policy, with an effective date of 11/1/2016, revealed Procedure 1. Before the Center transfers a Resident to a hospital or the Resident goes on therapeutic leave, the Center shall provide Resident or his or her Resident Representative this Bed Hold Policy. Resident #74 Record review of the facility general notes for 11/8/23 at 9:45 AM revealed Resident #74 was sent out to the hospital for evaluation related to Altered Mental Status. Record review revealed no evidence of the bed hold form for Resident #74 in the computer. An interview on 12/07/23 at 9:45 AM, with the Business Office Manager revealed she was able to produce a bed hold for Resident #74. She confirmed the form did not include the start date for bed hold payment to begin. She stated that they send the bed hold forms by mail and scan a copy but Resident #74's form had not been scanned yet. On 12/07/23 at 9:49 AM, a phone interview with Resident #74's Resident Representative (RR) revealed that she got the transfer to the hospital form in the mail but did not get a bed hold form. Review of the Admission Record for Resident #74 revealed a facility admitted [DATE] with diagnoses that included Unspecified Dementia and Essential Hypertension. Review of the Minimum Data Set (MDS) with an Advanced Reference Date (ARD) of 11/16/23 revealed a Brief Interview for Mental Status (BIMS) score of four (4) which indicated Resident #74 had severe cognitive impairment. 47158 Resident #28 During an interview on 12/4/23 at 11:07 AM Resident #28 stated that she has never received a bed hold notification when transferred to the hospital. Resident #28 stated she is her own Responsible Party (RP). Record review of the Bed Hold Request Form for Resident #28 dated 10/22/23 reveals Resident is her own RP and staff was unsuccessful attempting to notify the resident by phone. Record review of the Bed Hold Request Forms for Resident #28 dated 1/30/23, 2/27/23, and 3/4/23 revealed they were mailed. There was no indication of what address the forms were mailed to. An interview with the Business Office Manager on 12/6/23 at 9:14 AM, she verified that she did attempt to contact the Resident #28 via phone while she was in the hospital on 10/22/23, but she was unable to reach her. She verified that she did not make any further attempts to notify Resident #28 of the bed hold policy. During an interview with the Business Office Manager on 12/6/23 at 10:34 AM, she was unable to indicate where Resident #28's Bed Hold Notices were mailed and did not have proof of the documents being mailed. During an interview with the Administrator on 12/6/23 at 10:36 AM, she verified that there was no documentation that Resident #28 ever received her bed hold notifications. A record review of Resident #28's Minimum Data Set Assessment (MDS) with and Assessment Reference Date (ARD) of 10/13/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact. A record review of the Admission Record for Resident # 28 revealed that the resident was admitted on [DATE], with diagnoses that include Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of Right Main Bronchus.

Based on record review, staff interviews and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessments for three (3) of 28 assessments reviewed. Resident #3, Resident #13 and Resident #99 Findings include: Review of the facility policy titled, RAI (Resident Assessment Instrument) Process Guideline dated September 2020, revealed .Process: .All items on the MDS are to be coded per the instructions of the CMS (Centers for Medicare and Medicaid Services) Long-Term Care Facility Assessment User's Manual MDS 3.0 . Resident #13 A record review of Resident #13's Admission Record revealed an initial admitted [DATE] and his medical diagnoses included Schizophrenia, Unspecified, with onset date of 08/14/2021. Record review of Resident #13's Annual MDS with Assessment Reference Date (ARD) of 09/22/2023 revealed Section A 1500 coded as No, Is the resident currently considered by the state level II PASARR (Pre Admission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident #13's Annual MDS with ARD of 09/22/2023 revealed Section I, Active Diagnoses, was marked 16000 Schizophrenia (e.g., schizoaffective, and schizophreniform disorders). Record review of Summary of Findings Report dated 11/20/2013 under Mental Health was documented that The individual meets criteria for having a diagnosis of mental illness as defined by PASARR Axis I primary: Schizophreniform Disorder. 47157 Resident #99 A review of progress notes for Resident #99 dated 11/13/23 revealed, Resident d/c (discharged ) home with RP (Responsible Party) (Proper Name) at 1705 (5:05 PM). Review of the Discharge MDS with ARD of 11/13/23 Section A for Resident #99 revealed, A1805: Entered From: was coded 01. Home/Community . A2105: Discharge Status: was coded 04. Short-Term General Hospital. An interview with the MDS Registered Nurse (RN) on 12/07/23 at 8:20 AM, she verified after review of Resident #99's Discharge MDS that Section A entered from and discharge status was coded incorrectly and confirmed Resident #99 entered the facility from the hospital not home as coded and was discharged home and not to the hospital. Review of the Admission Record revealed the facility admitted Resident #99 on 10/05/23 with a diagnosis of Dislocation of Internal Left Hip Prosthesis and was discharged [DATE] home. 47158 Resident #3 A record review of Resident #3's MDS with an ARD of 4/12/23 revealed A 1500 Is the resident currently considered by the state Level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? coded as No. Section I Active Diagnoses revealed Anxiety Disorder, Bipolar Disorder and Schizophrenia were checked. A record review of Resident #3's PASARR Determination, dated July 26, 2013, revealed that the PASARR Level II Determination was approved with recommendations. An interview with the MDS RN on 12/5/2023 at 2:35 PM, she stated that she has been responsible for coding A 1500 of the MDS. The MDS RN stated she was not aware that Resident #3 had a PASARR Level II when she coded the MDS. She stated that Level II's were not uploaded in the electronic record. She agreed that if the resident had had been identified as having a mental illness by the state Level II PASARR it should have been coded on the MDS. She also agreed that the purpose for accurate coding of the MDS was to ensure the resident was receiving the appropriate interventions. An interview with the Administrator on 12/5/23 at 2:40 PM, she stated that she was aware that some of the older documentation had not been uploaded in the computer system. The Administrator agreed that it was her expectation that the MDS nurses would have access to the information they needed to correctly code the MDS. A record review of the Admission Record for Resident #3 revealed that he was admitted to the facility on [DATE] with diagnoses that include Schizoaffective Disorder and Bipolar Disorder.

Based on staff interviews and record review, the facility failed to submit a change in status referral for a Level II resident review for a resident who was hospitalized for a psychiatric condition which resulted in orders for an additional psychotropic medication for one (1) of seven (7) residents reviewed for Pre-Admission Screening and Resident Review (PASARR). (Resident # 3). Findings Include: Review of a statement on facility letterhead signed by the Administrator and undated revealed, PASSAR .(Proper Name of Facility) follows the Mississippi Division of Medicaid's PASARR requirements as attached. Record review of the attached document, titled Mississippi PASARR Identifying Status Change revealed . User's Manual provides guidance .of Potential Change in Status indicators which may .require submission of a Resident Review (Status Change in MS). This includes but is not limited to, residents previously identified by PASRR to have mental illness .who: Demonstrate increased behavioral, psychiatric, or mood-related symptoms. Have behavioral, psychiatric, or mood related symptoms responsive to ongoing treatment . Record review of Resident #3's Progress Note dated 10/6/2023, revealed Patient sent to proper name of hospital with meds for psych evaluation . Record review of a Psychiatric Evaluation dated 10/6/23, on Resident #3, revealed Nursing home staff complained of resident having increased agitation. Argumentative with staff and roommate, possibly paranoid about roommate .with a psychiatric history of schizoaffective disorder bipolar type, major depressive disorder, anxiety and panic disorder . Record review of a Discharge Summary from the local hospital dated 10/12/23, for Resident #3 revealed Patient was admitted .with a new medication started, adjusted, and titrated to efficacy Buspar was increased to 10 mg (milligrams) bid (twice a day) .He was started on Seroquel on day of admission from the nursing home . Record review of Discharge Medications for Resident #3 revealed New Medications to start taking, Buspar (Buspirone)-Take 10 milligrams (mg) by mouth twice daily. During an interview with the Licensed Social Worker (LSW) on 12/6/23 at 8:57 AM, she stated she did not submit a change in status referral for a Level II resident review following Resident #3's psychiatric stay. She stated the purpose for submitting a change in status referral for a Level II resident review is to ensure that the resident is properly placed and make sure that the resident is getting the level of care needed. She stated that the change in status resident review may provide additional interventions that the resident may need and by not submitting one may prevent the resident from receiving the care he needed. During an interview with the Administrator on 12/6/23 at 9:04 AM, she verified it was her expectation that a change in status referral for a Level II resident review would have been submitted for Resident #3 following his psychiatric stay. A record review of the Admission Record for Resident #3 revealed that he was admitted to the facility on [DATE] with diagnoses that include Schizoaffective Disorder and Bipolar Disorder.

Based on observation, record review, resident interview, staff interview and facility policy review the facility failed to develop and implement a care plan for a resident who was self- administering medications (Resident #28) failed to implement a care plan for activities of daily living (ADL) care for (Resident #48 and #44) and failed to implement a care plan for fluid restriction (Resident #12) for four (4) of 28 care plans reviewed. Findings include: Review of the facility policy titled, Care Plans, dated October 2021, revealed Policy: Care plans will be developed and implemented for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Resident #12 Review of the care plan for Resident #12 titled, At risk for Alteration in Kidney Function due to DX (diagnosis) of End Stage Renal Disease (ESRD) requiring hemodialysis treatments. Interventions: . Fluid restriction as directed: 1 L (liter) fluid restriction Nursing to provide: 200 cc (cubic centimeter) on 7a-7p (AM/PM) shift, Nursing to provide 200 7p-7a (PM/AM) shift Dietary to provide: 12 oz (ounces) fluids on breakfast tray 4 oz fluids on lunch tray 4 oz fluids on dinner tray. During an observation on 12/04/23 at 11:30 AM, Resident #12 was drinking from a water pitcher and then placed the pitcher on her bedside table. Review of the December 2023 Medication Record for Resident #12, revealed Fluid restriction as directed: 1 L (liter) fluid restriction Nursing to provide: 200 cc fluids on 7a-7p shift . Nursing to provide: 200 7p-7a (shift . Dietary to provide: 12 oz fluids on breakfast tray . 4 oz fluids on lunch tray . 4 oz fluids on dinner tray . two times a day triggering at 6:00 AM and 6:00 PM with 120 cc document for both shifts with no documentation of Resident #12's 24 hour total fluid intake. Review of the Visual/Bedside Kardex Report for Resident #12 revealed, Encourage fluids within her restriction. An interview with the Director of Nursing (DON) on 12/05/23 at 2:46 PM revealed after review of the CNA (Certified Nurse Assistant) Care guide for Resident #12 the CNAs would not know the amount of fluid restriction Resident #12 is on because the Care guide does not specify the amount of fluid restriction. The DON also confirmed after review of the ESRD care plan for Resident #12 staff were not following the care plan for following fluid restriction as directed and the purpose of the care plan is to ensure the staff provide the resident specific care they need. Record review of the Admission Record revealed that the facility admitted Resident #12 to the facility on [DATE] with diagnosis of Rend Stage Renal Disease and Fluid Overload, unspecified. 47158 Resident #28 An observation of Resident #28's room and interview on 12/4/23 at 11:07 AM, revealed two (2) plastic vials laying on the overbed table. Resident #28 revealed that the 2 vials were her breathing treatment medications, and she prefers to give herself the breathing treatment at a later time, so the nurses leave them for her. On 12/4/23 at 11:11 AM, during an observation and interview with Licensed Practical Nurse (LPN) #3 she verified that Resident #28 did not like to take her breathing treatments when they were due so they left them in the room so that she could give them to herself when she was ready. A record review of Resident #28's care plan revealed that there was no care plan indicating that the resident self-administered her own breathing treatments. An interview on 12/5/23 at 3:25 PM, with the DON she verified that Resident #28's care plan did not indicate that the resident self -administered her own breathing treatments. She agreed that there was no way for the nursing staff to know that the resident preferred to or was safe to administer her own breathing treatment and that it should have been reflected on the resident's care plan. A record review of the Admission Record for Resident #28 revealed that the resident was admitted on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease and Malignant Neoplasm of Right Main Bronchus. A record review of Resident #28's MDS with an ARD of 10/13/23 revealed a BIMS score of 15, indicating that the resident is cognitively intact. 45598 Record review of Resident #44's Care Plan revealed under Focus: Self-Care Deficit related to: decreased functional abilities, impaired cognition/dementia, weakness, Alzheimer's, Dementia with the following Interventions to include: Nail, hair, and oral care daily and as needed, Provide all the effort with the following task as this resident is dependent: oral hygiene, toilet hygiene, shower/bathe self, lower body dressing, put on/take off footwear, personal hygiene Provide cueing, supervision, and assistance with ADLs as needed. An observation on 12/05/23 at 8:40 AM, revealed Resident #44 sitting up in her wheelchair in her room. Resident's front lower teeth observed with yellow and white substance on the lower teeth and gum line. When resident was asked about her mouth care and if her teeth had been brushed, she said, No one brushed my teeth. On 12/05/23 at 4:05 PM, an interview with Licensed Practical Nurse (LPN) #3 in Resident #44's room, confirmed the yellow and white substance on Resident #44's bottom front teeth and LPN #3 revealed that it didn't look like resident's teeth had been brushed. Record review of Resident #44's Comprehensive Admission Minimum Data Set (MDS) with Assessment Reference Date of 09/05/2023 under Section GG was documented under GG0130 Self Care B. that Resident #44 was dependent with the ability to use suitable items to clean teeth. Section C was documented that she had a Brief Interview for Mental Status (BIMS) score of 03 which indicated that resident had severe cognitive deficits. Record review of Resident #44's Admission Record documented admitted [DATE] and had the following diagnoses to include: Need for Assistance with Personal Care. 37399 Resident #48 Record review of the care plan for Resident #48 with a date initiated of 10/13/23 revealed Focus I have an Activities of Daily Living (ADL) self-care performance deficit .Interventions .Provide substantial/moderate assistance . with personal hygiene . An observation and interview on 12/04/23 at 12:42 PM revealed Resident #48 had facial hair approximately two (2) inches long on his face and his daughter stated a Certified Nurse Assistant (CNA) was in earlier trimming his beard with scissors. An interview, on 12/06/23 9:51 AM, with the Director of Nursing (DON) confirmed Resident #48 should have been shaved. On 12/07/23 at 10:55 AM, an interview with the Registered Nurse (RN) MDS coordinator revealed the purpose of the care plan is to let staff know how to care for the residents. If a care plan is written and the staff does not do what it says, the care plan was not followed. Review of the facility Admission Record revealed Resident #48 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side and Aphasia following Cerebral Infarction. Review of Section C of the Admission MDS with an ARD of 10/20/23 revealed a BIMS was not conducted due to Resident #48 was rarely/never understood.

Based on observation, resident , family, and staff interviews, record review, and facility policy review, the facility failed to provide oral care for a resident (Resident # 44) and failed to shave a resident (Resident #48) for two (2) of 28 residents reviewed for activities of daily living (ADL's). Findings include: Record review of Clinical Nursing Skills and Techniques, [NAME] & [NAME], page 457 documented under Oral Care the following: Maintenance of daily oral hygiene, including brushing, flossing, and rinsing, is essential for the prevention and control of plaque-associated oral diseases . The facility did not provide a policy directly related to shaving a resident. Resident #44 An observation on 12/04/23 at 2:10 PM, revealed Resident #44's front lower teeth with yellow and white substance attached to gum line and between teeth. It did not appear that mouth care was being completed on this resident. An observation on 12/05/23 at 8:40 AM, revealed Resident #44's lower teeth appeared dirty with yellow and white substance observed on the lower teeth and gum line and when asked about mouth care, the resident said no one had brushed her teeth. On 12/05/23 at 4:00 PM, an observation and interview with Lead Certified Nursing Assistant (CNA), revealed that oral care was supposed to be done on all residents every day. She revealed that this was basic care and just common sense to do this every day. Lead CNA observed Resident #44's teeth and stated, Naw they (Resident's teeth) haven't been brushed. On 12/05/23 at 4:05 PM, an interview with Licensed Practical Nurse (LPN) #3 confirmed the yellow substance on Resident #44's teeth and revealed that it didn't look like the resident's teeth had been brushed. On 12/05/23 at 4:15 PM, an interview with LPN #2 revealed that failure to brush and clean resident's teeth could cause a lot of things and lead to tooth decay and infection. On 12/06/23 at 8:15 AM, an interview with Assistant Director of Nursing (ADON) revealed that they did not have a policy on Activities of Daily Living which included oral care. She revealed that the facility adopted Clinical Nursing Skills and Techniques, [NAME] & [NAME], as a supplementary policy and procedure guide effective January of 2023. Record review of Resident #44's Comprehensive Admission Minimum Data Set (MDS) with Assessment Reference Date of 09/05/2023 under Section GG was documented under GG0130 Self Care B. that Resident #44 was dependent with the ability to use suitable items to clean teeth. Section C revealed that she had a Brief Interview for Mental Status (BIMS) score of 03 which indicated that resident had severe cognitive deficits. Record review of Resident #44's Admission Record documented admitted [DATE] and the following diagnoses to include: Alzheimer's Disease, Weakness, and Need for Assistance with Personal Care. 37399 Resident #48 An observation during the initial tour on 12/04/23 at 12:42 PM, revealed Resident #48 had facial hair approximately 2 inches long on his face. An interview with Resident #48's daughter at the same time revealed a CNA was in earlier trimming her father's beard with scissors. She stated that her father likes to be clean shaven and have his hair cut close to his head. An observation of Resident #48 and interview on 12/5/23 at 10:30 AM, with CNA #3 revealed that she shaved the resident this morning. She stated that she had to cut his beard down and then shave him. She stated she let Resident #48 see himself when she finished, and he was so happy and smiling. An interview, on 12/06/23 at 09:51 AM, with the Director of Nursing (DON) revealed that Resident #48 will put his hand up to his face when staff are attempting to help him, but it is like a natural reflex. She stated they are working with the staff on residents' individual preferences and the need to make more than one attempt at care. She confirmed Resident #48 should have been shaved. Review of Section GG- Admission with an effective date of 10/16/23 revealed in section I1. Personal Hygiene: 02. Substantial/maximal assistance. Review of the facility Admission Record revealed Resident #48 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side and Aphasia following Cerebral Infarction. Review of Section C of the Admission MDS with an ARD of 10/20/23 revealed a BIMS was not conducted due to Resident #48 was rarely/never understood.

Based on observation, staff interview, record review and facility policy review the facility failed to ensure a resident on fluid restriction was monitored for one (1) of 13 residents on fluid restriction. Resident #12. Findings include: Review of the facility policy titled, Fluid Restriction, revised 9/2017, revealed Policy Statement: A fluid restriction will be implemented only as part of a therapeutic diet prescription .Procedures: 4. The Nursing Services will be responsible for tracking and documenting the total volume consumed in accordance with the facility policy . An observation on 12/04/23 at 11:30 AM, revealed Resident #12 drinking from a water pitcher and then placed the pitcher on her bedside table. An interview on 12/05/23 at 2:00 PM, with Certified Nurse Assistant (CNA) #1 and CNA #2, both revealed that Resident #12 was not on any type of fluid restriction. An observation and interview with Licensed Practical Nurse (LPN) #1 on 12/05/23 at 2:10 PM, confirmed Resident #12 had a water pitcher with ice and water sitting on her bedside table and confirmed Resident #12 should not have the water pitcher in her room. After review of Resident # 12's physician's orders LPN # 1 confirmed Resident #12 was on a 1 Liter fluid restriction because she is on dialysis and has End-stage Renal Disease. LPN #1 revealed a possible concern from having the extra fluids in the room is fluid overload. She was unaware if Resident #12 was on Intake and Output (I & O), and she did not know where to look for the documentation. An interview with the Director of Nursing on 12/05/23 at 2:46 PM, she confirmed after review of the physician's orders for Resident # 12 that she was on a 1 (one) Liter fluid restriction and should not have a water pitcher in her room. The DON then revealed after review of the Medication Record for Resident #12 that staff were only documenting the 120 milliliters provided during medication administration for both shifts and were not monitoring the 24-hour total intake for Resident #12 and confirmed that the staff should have been doing so. She then revealed that with the water pitcher in Resident #12's room staff would not know the true amount of fluids taken in by Resident # 12. Review of the electronic medical record revealed a physician's order for Resident #12, dated 2/13/23 Fluid restriction as directed: 1 (one) L (liter) fluid restriction Nursing to provide: 200 cc (cubic centimeters) fluids on 7a-7p (AM/PM) shift . Nursing to provide: 200 cc on 7p-7a (PM/AM) shift . Dietary to provide: 12 oz (ounces) fluids on breakfast tray . 4 oz fluids on lunch tray . 4 oz fluids on dinner tray . two (2) times a day related to Dependence on Renal Dialysis; End Stage Renal Disease. Review of the December 2023 Medication Record for Resident #12, revealed Fluid restriction as directed: 1 L (liter) fluid restriction Nursing to provide: 200 cc fluids on 7a-7p shift . Nursing to provide: 200 7p-7a (shift . Dietary to provide: 12 oz fluids on breakfast tray . 4 oz fluids on lunch tray . 4 oz fluids on dinner tray . two times a day triggering at 6:00 AM and 6:00 PM with 120 cc document for both shifts with no documentation of Resident #12's 24 hour total fluid intake. Record review of the Admission Record revealed that the facility admitted Resident #12 to the facility on [DATE] with diagnosis of Rend Stage Renal Disease and Fluid Overload, unspecified. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/10/23, revealed that Resident #12 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated that she was cognitively severely impaired. Section I revealed End stage renal disease and Fluid Overload, and unspecified coded as active diagnoses.

Based on staff interview and record review the facility failed to a provide a stop date on a psychotropic as needed (PRN) medication for one (1) of four (4) residents reviewed for unnecessary psychotropic medication use. Resident 68. Findings Include: A record review of a document titled, Med Tip, Improving Quality Outcomes, provided by the facility, revealed New Guidance Around PRN Psychotropic Medications .prn psychotropic medications are ordered for no more than 14 days . A record review of Resident # 68's Hospice Physician's Order revealed an order for Lorazepam Oral Concentrate 2 (two) milligrams per milliliter (mg/ml) Give 0.25 ML by mouth every six (6) hours as needed for agitation and restlessness with an onset date of 11/20/23 and no stop date. A record review of the facility's orders for Resident #68 revealed an order for Lorazepam Oral Concentrate 2 mg/ml Give 0.25 ML by mouth every 6 hours as needed for agitation and restlessness with an onset date of 11/20/23 and no stop date. During an interview with the Director of Nursing (DON) on 12/6/23 at 2:10 PM, she stated that she was aware that as needed antianxiety medications are to have a 14 day stop date. She confirmed that Resident #68 has an order for Lorazepam Oral Concentrate 2 MG/ML every 6 hours as needed ordered on 11/20/23 that did not have a stop date. The DON stated that they check orders in their morning meeting to ensure that any antianxiety medication has a stop day and agreed that this medication was missed. During an interview with the DON on 12/7/23 at 8:25 AM, she stated that the purpose for having a stop date on an as needed anxiety medication was because the medication is likely ordered due to an acute situation and the resident would not need to receive the medication for a long period of time. During an interview with the DON on 12/7/23 at 10:47 AM, she verified it is the facility's practice to follow the Med Tip Guidance around PRN Psychotropic Medications from the 2016 State Operations Manual regarding the use of psychotropic medications. Review of the Admission Record for Resident #68 revealed the resident was admitted on [DATE] with a diagnosis of Dementia.

Based on observation, staff interview and facility policy review, the facility failed to maintain clean and sanitary kitchen appliances, as evidenced by buildup in icemaker and oven, for 1 of 2 kitchen tours. Findings include A review of the facility equipment policy statement, dated 5/2014 and revised 9/2017, revealed all food service equipment will be clean, sanitary, and in proper working order. Procedure #4 revealed all non-food contact equipment will be clean and free of debris. A review of the facility Ice policy statement dated 5/2014 and revised 9/2017, revealed ice will be prepared and distributed in a safe and sanitary manner. Procedure #4 revealed ice bins will be cleaned monthly and as needed. An observation, during the initial tour of the dietary department on 7/25/22 at 10:30 AM, revealed the two (2) ovens under the range had a heavy buildup of thick black substance on the floor of the ovens and also in the convection oven. The racks and oven doors had light brown and black build-up on the walls and doors. The ice machine in the dietary department had a thin film of gray build-up with raised particles over the inside of the door . The Dietary Manager (DM) stated she thought it was condensation but, after she wiped the inside of the door, she confirmed it was not condensation. She stated that the buildup and particles could contaminate the ice. An observation in the presence of the DM on 7/26/22 at 11:00 AM revealed dietary staff #1 got ice from the machine and left the top to the ice machine open and walked to another part of the kitchen. An interview, on 7/26/22 at 11:05 AM with the DM, revealed that the staff should close the ice machine when it is not in use to prevent contamination of the ice. The DM, revealed the cleaning schedule posted on the side of the ice machine was incomplete. She confirmed the schedule was not completed as it should be. She confirmed the cleaning schedule was last signed as cleaned in January 2022. She stated that the checks made in the November slots were marked wrong and were for March. The DM confirmed that on the cleaning schedule the line to mark when completed was blank and the cleaning schedule for the ovens was incomplete for the month of July. An interview, on 7/26/22 at 3:15 PM with the maintenance supervisor revealed that he thought the ice machine was supposed to be cleaned every three (3) months. He stated that he started working at the facility in May of this year. He confirmed that he had not cleaned the ice machine since he started here. He stated that the ice machine lid was not supposed to be left up because of contamination. An interview, on 7/26/22 at 3:30 PM with dietary Staff # 1 confirmed that she should not leave the ice machine lid up when she finishes getting ice. She stated that she does not normally leave it up but, she guessed she was moving too fast. She stated that not closing the ice machine could allow anything to fall in it. An interview, on 7/26/22 at 3:40 PM with the administrator (ADM), revealed the buildup inside the ice machine lid and leaving the lid open could cause an infection control problem or cross contamination. She stated that the buildup in the ovens could also cause contamination or a potential fire. Record review of the Ice Machine Cleaning Schedule 2022 revealed for the month of January the ice was removed, machine was cleaned and sanitized, and a signature was in place for completed by. November had check under ice removed, cleaned, and sanitized but, no signature. All other months on the schedule were blank. Record review of the daily cleaning schedule for the kitchen equipment revealed an X marked for every day of the first week of July and Sunday through Tuesday of the second week. There was no documentation of daily cleaning for the remainder of week 2, week 3 or 4. The weekly cleaning schedule for the stove and convection oven revealed an X in every day of week 1 for July and Sunday through Tuesday of the second week. There was no other X's for the remainder of week 2 nor for week 3 or 4.

Based on observations, staff and waste removal company interviews, record reviews, and policy reviews, the facility failed to provide a sanitary environment as evidenced by 2 overflowing garbage dumpsters that was visible on entry to the facility parking lot for 2 of 2 garbage dumpsters observed. Findings Include. Review of the facility policy titled Waste Control with a revision date of 08-01-2012 revealed under Policy .It is the policy of this facility to store garbage and trash in a sanitary manner until disposed of properly for infection control. This review revealed under Procedure # 3 .Trash should be discarded in the dumpster frequently and at least at the end of each shift. The dumpster must be kept closed at all times when not in use, # 4 .The dumpster should be emptied per facility contract with the waste removal company. An observation on 7/25/22 at 10:15 AM revealed two garbage dumpsters outside of the facility near the B wing that were overflowing with garbage so that the dumpster doors could not close, garbage bags piled up at the base of both garbage dumpsters and trailed off approximately 100 feet on the ground. This observation revealed that the garbage dumpsters could be seen in the parking lot when you drive up to the facility. This observation revealed there were bags of garbage on the ground that had been torn open with articles of garbage scattered on the parking lot and the grass area. This observation revealed that the articles of garbage that were scattered on the parking lot and the grass area included food storage items, such as individual milk cartons, dipping sauce bowls, napkins, Styrofoam cups, plastic bowls, drink cans and staff gloves. An observation on 7/26/22 at 09:30 AM revealed no change in the two overflowing garbage dumpsters outside of the facility near the B wing. An interview on 7/26/22 at 8:40 AM with Clinical Director revealed the garbage dumpsters being full and overflowing on the ground was nasty. An interview on 7/26/22 at 09:45 AM with the Administrator confirmed the garbage needed to be picked up and she had been trying to get someone to come get it since last Thursday. She revealed the waste removal company the facility has a contract with were supposed to pick up last Friday. She revealed she does not know why they have not picked up the garbage. An interview on 7/26/22 at 10:18 AM with the Housekeeping Director revealed she noticed last Wednesday that the garbage had not been picked up and she made the Administrator aware. She revealed she recalls this happening around this time last year and she believes it may be a bill payment issue. She revealed she thinks the waste removal company would not pick up because there was garbage on the ground and the facility is going to pay extra to have it removed. An interview on 7/26/22 at 11:00 AM with the Maintenance Director revealed it is everyone's responsibility to make sure the garbage is not laying on the ground by the dumpster. He confirmed that the dumpsters were overflowing so there was nowhere else to put the garbage and that everyone kept thinking they were coming to pick it up. He agreed that animals probably did get in the garbage laying on the ground. He revealed that [NAME] are bad out here and I use to have to catch them in traps. An interview and observation on 7/26/22 at 2:15 PM with the Administrator confirmed the garbage dumpsters were heartbreaking and they are supposed to be here today to pick up She revealed they normally pick up weekly and they told her they could not pick up because there was garbage on the ground. She confirmed that some of the garbage bags appeared animals had been in. She stated, It is just like when you put garbage out at home, animals will get in it. She agreed that excess garbage in the dumpsters could lead to bugs and pest for the facility. An interview on 7/26/22 at 3:15 PM with the Administrator revealed the city agreed to come pick up the garbage today and she is not sure why the waste removal company has not come to pick up. A phone interview on 7/27/22 at 09:30 AM with the waste removal company employee #1 Commercial Agent revealed the facility was cut off due to non-payment. She revealed that they came Monday 7/25/22 but was unable to pick up. A phone interview on 7/27/22 at 09:40 AM with waste removal company employee #2 Team Leader revealed the facilities last pick up was 7/15/22, but she could not reveal why the facility was cut off for pick up since I was not listed on the account. She revealed she nor any of their employees are able to give their last name or employee number due to company policy. An interview on 7/27/22 at 10:00 AM with the Administrator confirmed the garbage had not been picked up since 7/15/22 due to non-payment. She revealed the garbage company did not pick up Monday 7-18-22 or Wednesday 7-20-22 so she called the company on Thursday 7-21-22 and discovered it was due to non-payment. She revealed that on Friday 7-22-22 she emailed her Corporate person that pays the bill, and it is her understanding that it was paid. Review of email communication regarding unpaid waste removal invoice revealed an email thread between the Administrator and the Corporate person that handles the invoice for the waste removal company. An attempted phone interview to the person that handles the invoice for the waste removal company revealed no answer with a voice mail left to return my call. A review of an email thread received regarding the unpaid waste removal invoice revealed the invoice was missed. Review revealed the facility has a contract with a waste removal company to pick up the garbage three times a week.

Based on staff, family and resident interview, record review and facility policy review the facility failed to ensure that a resident was free from a significant medication error when another resident's medications were inaccurately entered into the medical record and administered to Resident #1 causing serious harm that required treatment at a local hospital for one (1) for four (4) residents reviewed. Resident #1. During the survey, the State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/23/21, when the facility failed to ensure a resident was free of significant medication errors when he was admitted on [DATE]. The resident's medications were inaccurately entered into the medical record and the resident received medications on the morning of 12/24/21 that were not prescribed for the resident. The resident was administered eight (8) hypertensive medications, one (1) antidepressant and two (2) diabetic medications. The incident resulted in serious harm for Resident #1. He required immediate need for a higher level of care, evaluation and monitoring and was sent to the local emergency room . This incident placed Resident #1 and all residents in a situation that caused or was likely to cause serious injury, harm, impairment, or death. On 02/23/2022 at 6:10 PM, the SA notified the Administrator of the IJ and SQC and provided the facility with the IJ template. Based on the facility's implementation of corrective actions on 12/28/2021 and SA review, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 12/28/2021, prior to the SA's entrance on 02/17/2022. Findings include: Record review of the facility policy titled, Physician's Orders, undated, revealed, .Manual Process 1. Physician Verbal and Telephone Orders that have been validated by a licensed nurse as accurate will be entered into the center's electronic record system in the individual patient's record 3. After entry, the licensed nurse accepting the order will validate accuracy of the order entry, print from the patient's electronic record, sign, and place in the patient's paper clinical record under the Physician's Order tab . Record review of the Medication Administration Competency Audit-Oral Meds, revealed . 2. Check each label with order on eMAR (electronic medical record) . Applies 6 (six) Rights of Medication Administration. Medication, Route, Time, Patient, Dosage, Documentation . Record review of Medication Error Incident Report and investigation for Resident #1 revealed LPN #1 was listed as preparing the report. The nursing description listed as: Resident was missing [MEDICATION(S)] 100 mg during morning medication pass. Pharmacy notified. Pharmacy stated that resident will need a hard copy. Resident's chart was checked for script. None noted. Admission coordinator was notified of resident needing a hard copy. She called the hospital to request one. Hospital informed her that resident was not on [MEDICATION(S)] upon discharge. Discharge med list was provided. List was different from meds on MAR (Medication Administration Record). The resident description listed as: After resident took the medications, he stated that he wasn't on as many medications before going into the hospital. I informed resident that I would have the FNP (Family Nurse Practitioner) to go over his medications with him and discuss what he was on prior to him being admitted to the hospital and she could change them accordingly. Resident started feeling lightheaded and stated that his fingers and hands were feeling numb. Immediate action taken listed as: FNP and MD (Medical Doctor) notified of medication error. They were informed that resident was experiencing [CONDITION(S)] and numbness of fingers and hands. Order was given to send to the ER for evaluation. An interview with Resident #1's Resident Representative (RR) on 2/22/22 at 1:50 PM, revealed Resident #1 had fallen and was hospitalized for a fractured pelvis, and after discharge from the hospital on 12/23/2021 between 8:00 PM to 9:00 PM, he was admitted to the facility for therapy. The next morning, on 12/24/2021, RR was talking to the resident by phone, and he informed her that the nurse made him take twelve (12) medication pills that were not his and someone on staff also tried to give him a shot of Insulin, but he told her he did not take Insulin. The RR was told by the resident that he told the nurse several times that he was not on that many medications, but she insisted they were ordered for him and he had to take them. She stated the resident told the nurse, If these meds kill me, it is your fault, and the nurse responded with No, it's not. RR stated that when the resident, who was coherent, was repeatedly telling the nurse that these were not his medications, the nurse should have listened to him and checked the record. Soon after he took the medications, the resident was on the phone with the RR and said he was feeling dizzy and had numbness of his hands and he knew it was the medications he had taken. The RR was still on the phone with the resident when he was telling her this, so she immediately called the facility and spoke to the Admission Coordinator to tell her something was wrong with the resident and they needed to check on him and send him to the hospital. He was sent to the emergency room by ambulance and she met him there. He received intravenous fluids to flush the drugs out of his system and improve his blood pressure. When released from the emergency room , the RR wanted to take the resident home with her, but he was weak and returned to the facility. The RR stated the resident was mentally competent and able to communicate his needs and he was very aware of his medications and needed care. The RR stated a Physical Therapist was either in the room or near the room when the medication administration occurred, and she probably heard the discussion between the resident and the nurse and the resident refusing to take the medication. An interview with the Director of Nursing (DON) on 2/22/22 at 3:00 PM, confirmed a medication error occurred with Resident #1. She stated that the Admission Coordinator printed the information from the hospital before the resident arrived at the facility. She stated on top of Resident #1's packet was the Face Sheet and in the back of the packet were the labs and in the middle were the pages with the hospital discharge orders that were Resident #2's orders. The Admission Coordinator was having a problem printing the orders from the hospital site, so she copied and pasted the orders onto a word document. She stated she was unsure how the packet of information for Resident #1 had the hospital discharge orders of Resident #2. The Admission Coordinator gave the packet for Resident #1 (with Resident #2's orders) to Licensed Practical Nurse (LPN) #2 and she entered the orders into Resident #1's electronic orders. The DON stated the error was found when one medication ([MEDICATION(S)]) was not in the med cart so LPN #1 went to the Admission Coordinator to ask for a hard copy of the prescription so Resident #1 could receive this med. The Admission Coordinator printed off orders for Resident #1 and it was determined that the meds were different than those entered the previous day and different from those just administered to Resident #1 by LPN #1. She stated she looked in Resident #1's record and found the face sheet and lab sheets of Resident #1 and the orders for Resident #2. She confirmed the facility failed to prevent the medication error that led to harm and emergency room treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A phone interview on 2/22/22 at 3:30 PM with Licensed Practical Nurse (LPN) #1 revealed she was giving Resident #1 his morning meds on 12/24/21. She stated he took his medications then he told the nurse that the hospital must have ordered him some extra medicines since he does not normally take that many meds. She stated one of his meds ([MEDICATION(S)]) was not in the med cart since a hard copy prescription was needed for pharmacy to fill so she went to the Admission Coordinator to have her get needed information from the hospital. She stated a copy of orders were printed off by the Admission Coordinator and it was noted to be different from the other med list and different from the meds she had just administered. She stated the error was realized and she went to check on Resident #1 whose blood pressure and glucose was dropping. He was dizzy and had numbness of hands. She stated Resident #1 was sent to the emergency room (ER) for treatment. She stated the resident did not refuse his meds and if he had refused, she would not have insisted he take them and she would have documented the refusal. She stated when she administered meds, the resident's picture was verified and the medications were verified with the orders in the computer. She stated the medications she gave were in the med cart in pharmacy cards with Resident #1's name. She stated she had been in-serviced in the past on medication administration and has been in-serviced on medication administration, entering medication orders and reporting since this incident. She stated she was in-serviced on the new procedure for receiving orders and putting orders in the computer and reporting. An interview on 2/22/22 at 4:10 PM with LPN #2, revealed prior to Resident #1's arrival to the facility, the Admission Coordinator brought her the printed packet for Resident #1 with orders and hospital information. She stated the packet had the face sheet on top and there were some other hospital reports at the back of the packet for Resident #1. She stated the orders were in the center of the packet and looked different than they normally did, and did not have resident's name on pages, so she took the packet to the Admission Coordinator's office to ask her about the packet and the order sheet looking different. The Admission Coordinator showed her on the computer that the print button on the hospital web site for the order page was not working, so she copied and pasted the orders on a word document. She stated she made a mistake and did not look at the papers closely enough and just trusted what the Admission Coordinator said and she did not notice another Resident #2's name on one page. She put the orders into the computer and sent to the pharmacy by confirming orders. She stated this led to a medication error and Resident #1 being sent to the ER for treatment. She stated she has been in-serviced on medication administration in the past and since this incident she has been in-serviced on medication administration, reporting, verifying orders, and the new procedure for putting in orders, and they will not be put in until the resident arrives with paperwork. An interview on 2/23/22 at 9:45 AM, with the Nurse Practitioner (NP) revealed she was off when Resident #1 was admitted . She stated she and the Medical Doctor (MD) were notified of the medication administration error and gave orders to send the resident to the ER for evaluation. She stated she was told there was a cross up of the medication sheets for this resident and another resident. An interview on 2/23/22 at 10:30 AM, with the Admission Coordinator revealed on 12/23/2021, there was a mix up with two (2) residents' hospital discharge orders. She stated Resident #2's orders got in the packet with Resident #1's information. She stated she printed the discharge records from the hospital site, but the site would not allow her to print the orders so she copied and pasted the orders onto a word document so she could include them in the packet. She stated she was unsure how Resident #2's medication orders were put into Resident #1's packet, but it may have been on her desk or printed information incorrectly. She stated the mistake was not discovered until the next morning after the resident received medications. She stated LPN #1 came to her office to tell her she needed a hard copy of prescription for [MEDICATION(S)] so the pharmacy would send medication. She stated she printed the orders for Resident #1 and realized there were no meds that needed a prescription. LPN #1 realized these orders on the newly printed order sheet were not the medications that she had just administered and went to assess the resident. She stated the MD, Nurse Practitioner (NP), DON, and Administrator were notified. She stated the family was then calling the facility to have staff check on Resident #1 and the resident was sent to the ER. She stated she was in-serviced on how packets are provided to the nurses, orders not entered until the resident was in the facility, and verified that the resident's name was on each page. She stated she should have verified the right resident's information with resident's name on each page was placed in the packet to have prevented the medication error. An interview on 2/23/22 at 10:45 AM, with the Administrator confirmed the facility had a medication error that caused harm to Resident #1 requiring treatment in the emergency room . An interview on 2/23/22 at 11:00 AM, with the Physical Therapist (PT) revealed she was in Resident #1's room, getting the resident ready to walk, when the medication administration occurred. She stated LPN #1 walked into the resident's room with the medications in a medication cup and the resident stated, I don't know about these meds being mine and nurse informed him they were the ones in the chart. She stated Resident #1 stated he does not take all of these meds, and the nurse stated these are the ones ordered for you to take. The PT stated that Resident #1 stated again that he does not take all of those meds and the nurse said they were his meds. The PT stated the resident was hesitant to take these and said, I will take these. I know I just got out of the hospital. If something happens to me and this kills me, it is on you. The PT stated the nurse told him something like no, I'm just doing my job and giving you meds that are ordered for you. The PT stated the conversation was friendly and not hostile, but the resident was extremely hesitant to take the medications. She stated the nurse appeared certain those meds had been ordered for Resident #1. After the nurse left, the resident got up and walked about 10-15 minutes to the door and back twice. Then he sat in his chair and was eating his breakfast when the PT left the room. The PT stated he appeared fine at that time, but a while later she heard that the resident was not feeling well, and she became concerned it was due to the medications and that maybe they were not his. An interview on 2/23/2022 at 1:35 PM, with the company's Corporate Nurse revealed she was notified of the event that occurred with Resident #1's medication administration error. She stated she has the understanding that the Admission Coordinator was trying to get Resident #1's report and orders from the hospital's web site and clicked on the wrong resident in the computer and copied and pasted Resident #2's orders and placed in Resident #1's record. She confirmed that Resident #1 was harmed from the medication administration error and needed medical treatment in the emergency room . A phone interview on 2/23/22 at 3:55 PM with LPN #3, revealed she worked the night shift of 12/23/2021 until the morning of 12/24/2021 and she administered Resident #1 medications around 6:00 AM on 12/24/2021. She stated he received the [MEDICATION(S)] by mouth, which he took without question, and was scheduled for insulin as well. She stated his blood sugar was 107 so she told the resident his blood sugar result and told him he could take his insulin or refuse his insulin at that glucose level. She stated the resident said, I'd better not take the insulin, so she did not give it and she documented he refused to receive the Insulin. She stated he did not mention that he was not a diabetic and was not on insulin, he only refused to take it since nurse gave an option. LPN #3 stated she had received in-services on medication administration, verifying orders, reporting and entering orders with discharge papers since the incident. She stated the medication she administered was in a medication card with the resident's name on it that came from the pharmacy during the night. A phone interview on 2/23/22 at 7:26 PM, with Resident #1 revealed he remembers the incident with the medication administration well and said it was terrible and the worst thing that had happened in my life. He stated he had come to the facility from the hospital on the evening before this incident. He was in his room about to get therapy from the therapist and LPN #1 came in his room with a cup full of pills. He told her he only takes a few medicines, so he knew those were not his and stated the nurse stood there and argued with me and told me these were my medicines. He stated he told her 2-3 times that these were not his medicines, but she kept telling me to go ahead and take them. He stated the nurse told him that his doctor ordered the meds and he asked her which doctor and she told him his MD. He stated he had seen his MD for a while and he had never ordered that many medications for him. He stated he told the nurse, I'll go ahead and take them, but if it kills me, it's your fault, and the nurse turned around with a rude attitude and said, No, it's not. I'm just giving you the medicines that are ordered for you. He stated he reluctantly took the medication. He stated a nurse (he was not sure if it was this nurse or another nurse) had tried to get him to take a shot of insulin, but he told her no because he was not on insulin and she did not insist he take that. After he took the pills, he was in the bathroom and blacked out for a minute and when he came to, he knocked on the door and called out for help since he could not move off the toilet or stand up. He stated his hands and feet were numb and tingling and he was dizzy and someone came and helped him to the bed. He knew he was still, but he felt like he was spinning around and his numbness and tingling was getting more intense. He was taken to the hospital to be treated to get the drugs out of his system. He stated he did not think he was going to live through it and does not want anyone else to ever have to go through this. He stated he returned to the facility that night after the ER visit due to the care he was requiring, and he wanted to finish therapy and get back home before they kill me. Record review of the SBAR Change of Condition Note dated 12/24/21 at 10:01 AM revealed, Resident complained of feeling lightheaded. He stated that he started feeling dizzy when he was coming from the bathroom. BP (blood pressure) 89/59, BS (blood sugar) 98. Resident was lying in bed on his back. He stated he know he isn't moving but it feels like he is. Resident's feet were elevated. He stated that both of his hands felt like they were going numb. Record review of Resident #1's hospital discharge summary revealed the resident was admitted to the hospital on 12/18/2021 and discharged on [DATE]. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications ordered at discharge: [MEDICATION(S)] 5 milligram (mg) tablet daily, [MEDICATION(S)] 25 mg daily, Tamsulosin 0.4 mg daily, [MEDICATION(S)]-[MEDICATION(S)] 37.5-25 mg capsule daily, [MEDICATION(S)]-Acetaminophen 5-325 mg tablet every 4 hours as needed for pain. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Order Summary Report revealed that on admission on 12/23/21 these medications were entered in the resident's electronic orders: [MEDICATION(S)] Tablet 1 MG (milligram) Give 1 (one) tablet two times a day related to Essential (Primary) Hypertension; [MEDICATION(S)] HCl 0.2 MG tablet Give 1 tablet by mouth three times a day related to Essential (Primary) Hypertension; [MEDICATION(S)] ER Tablet Extended Release 24 hour 120 MG Give one tablet by mouth 1 time a day related to Essential (Primary) Hypertension; [MEDICATION(S)] Capsule 100 mg capsules Give two capsules by mouth three times a day related to Fracture of Pelvis; [MEDICATION(S)] Tablet 5 MG Give one tablet one time a day related to Essential Primary Hypertension; [MEDICATION(S)] Tablet 80 MG tablet Give one tablet by mouth nightly for Hyperlipidemia; [MEDICATION(S)] Tablet 12.5 MG Give one tablet two times a day related to Essential (Primary) Hypertension; [MEDICATION(S)] Tablet 10 MG Give one tablet by mouth one time a day related to Adverse Effect of Unspecified Antidepressants; [MEDICATION(S)] Sulfate Tablet Delayed Release 324 MG 65 Fe (iron) Give 1 tablet by mouth two times a day related to Fracture of other parts of pelvis; [MEDICATION(S)] Tablet 4 MG Give 1 tablet by mouth two times a day related to Type 1 Diabetes Mellitus; [MEDICATION(S)] HCI Tablet 100 MG Give 1 tablet by mouth three times a day related to Essential (Primary) Hypertension; Insulin NPH(Human)([MEDICATION(S)])Suspension 100 units/ml (milliliter) Inject 12 unit subcutaneously in the morning related to Type 1 Diabetes Mellitus; Insulin NPH 100 units/ml Inject 6 unit subcutaneously in the evening related to Type 1 Diabetes Mellitus; [MEDICATION(S)] Tablet 20 MG Give one tablet by mouth one time a day related to Essential (Primary) Hypertension; Loperamide HCI Liquid 1 MG/5ML Give 10 ml every 8 hours as needed for Diarrhea; [MEDICATION(S)] HCI Tablet 1000 Mg Give one tablet by mouth two times a day related to Type 1 Diabetes Mellitus; [MEDICATION(S)] Tablet 25 MG Give 1 tablet daily related to Essential (Primary) Hypertension. Record review of electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation for the 9:00 AM medication pass revealed Resident #1 received: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] Sulfate, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] HCl. Record review of the Physician Documentation from the local emergency department dated 12/24/21 at 10:24 AM, revealed, HPI (History/Physical) .Presents with complaints of Blood Pressure Problem . Blood pressure on arrival to the emergency department at 10:24 AM was 76/42 . EKG and lab work were done in the emergency department. Lab interpretation: Normal except CHLORIDE 111; BUN 30;Creatinine 1.44;Calcium 7.9; Total Protein 5.1; [MEDICATION(S)] 2.4. ECG Clinical Impression: Abnormal EKG without significant change . Intravenous (IV) fluid was started, and resident received 1000 ml of [MEDICATION(S)] via IV. Record revealed the resident received Lomotil 2 tablets for diarrhea . Glucose level was 71. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After treatment, the resident was discharged and returned to facility on 12/24/21. Record review of Resident #1's Minimum Data Set (MDS) Section C-Cognitive, dated 12/30/2021, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the Resident #1 was cognitively intact. Record review of in-services and sign in sheets titled It 's a Golden FACT: We are all about Medication Safety dated 5/22/19 revealed content included the 5 Rights of Medication Administration and Preventing Drug Transcription Errors. LPN #1 and LPN #2 ' s signatures were listed on the in-service record as attending the in- service. Record review of a nurse sign in sheet dated 1/9/20 revealed Routine Med Pass and New Admit Documentation was handwritten on the in-service record as content. LPN #1 and LPN #2 ' s signatures were listed on the in-service record as attending the in-service. Record review of a sign in sheet titled Complete Nurses Skill Check Off ' s-Five Rights of Medication Pass dated 5/30/19 through 6/7/19 revealed LPN #1 and LPN#2 ' s signatures were listed on the in-service record as attending the in-service. Immediate Jeopardy Corrective Action Removal Plan February 23, 2022, for F842 and F760: On February 23, 2022, at 6:10 PM the State Agency notified the facility administrator of an Immediate Jeopardy (IJ) related to the facility's failure to ensure Resident #1 was free from significant medication errors. On 12/24/21 the facility failed to ensure orders upon admission were accurately entered into the correct resident ' s record resulting in Resident #1 being administered medications prescribed for Resident #2. The medications included eight (8) hypertensive medications, one (1) Antidepressant, and two (2) Diabetic Medications. As a result, Resident #1 was transferred to the hospital for treatment and evaluation. The Immediate Jeopardy template was provided to the administrator. To the best of my knowledge and belief, as an agent of Batesville Health and Rehabilitation Center, the following corrective action removal Plan constitutes a written plan demonstrating actions the center took upon awareness of the deficient practice thus removing the Immediate Jeopardy cited on February 23, 2022. Immediate Actions for All Residents Potentially Affected: 1. Resident # 1 was evaluated by the Licensed Practical Nurse (LPN) charge nurse on 12/24/2021. The resident voiced not feeling well. The Medical Director, Nurse Practitioner and family were notified. An order was obtained by the nurse, and the patient was sent to Local Medical Center emergency room via ambulance at 10:01 A.M. for a higher level of care, evaluation and monitoring. The resident returned at 9:04 PM with no adverse effects noted from the medication error. 2. Upon return to the center, the physician orders were reviewed by two nurses prior to placing them in Electronic Medical Record. This occurred on 12/24/2021. 3. A root cause analysis of the medication error was initiated immediately by the Director of Nursing. This occurred on 12/24/2021. 4. The employee making the transcription error was provided 1:1 coaching and counseling by the Administrator and the Director of Nursing regarding the importance of obtaining signed physician discharge orders prior to admission to the facility. This occurred on 12/24/2021. 5. The nurse that made the error received 1:1 education regarding safe medication administration, including the rights of medication administration on 12/24/2021 by Director of Nursing Services (DNS). 6. The Director of Nursing Services and Assistant Director of Nursing Services began in services on 12/24/2021 for all nurses regarding safe medication administration (including medication transcription, reconciliation, and administration), resident rights, and abuse/neglect. No nurses are allowed to work without completion of this training. 7. The Director of Nursing Service (DNS) and Assistant Director of Nursing Services (ADNS) reviewed previous two week ' s admissions to ensure orders transcribed into the record accurately. There were no additional errors noted. This occurred on 12/28/2021 8. An ad hoc Quality Assurance Process Improvement meeting was initiated post the medication error on 12/24/2021 with the Administrator, The Director of Nursing, the Assistant Director of Nursing (Infection Preventionist), and the Medical Director to discuss the incident and develop a plan to include monitoring of medication transcription and medication administration errors going forward. 9. Beginning 12/24/2021, the facility will assure that each patient has a signed copy of physician discharge orders on admission to the facility. 10. Beginning 12/28/2022, each new patient's orders are reconciled by a minimum of two nurses and reviewed each morning during clinical start up by the Director Nursing Services, Assistant Director of Nursing/ Infection Preventionist, and/or designees to assure the medication regimen and orders are correct. In summary, upon awareness, the center acted swiftly with the corrective actions, team member in-services, and ensured auditing measures were in place to monitor the plan developed utilizing the QAPI process to address the identified deficient practice immediately and all actions were completed on or before December 28, 2021. The facility alleges the past non-compliance Immediate Jeopardy was removed on December 28, 2021. State Agency Validation of Immediate Actions for All Residents Potentially Affected: 1. The State Agency (SA) validated through record review of physician orders, progress notes, and hospital emergency room visit records and through interviews with the Director of Nursing, Licensed Practical Nurse #1, Nurse Practitioner, Resident Representative, and Resident #1. Resident # 1 was evaluated by the Licensed Practical Nurse (LPN) charge nurse on 12/24/2021. The resident voiced not feeling well. The Medical Director, Nurse Practitioner and family were notified. An order was obtained by the nurse, and the patient was sent to Local Medical Center emergency room via ambulance at 10:01 A.M. for a higher level of care, evaluation and monitoring. The resident returned at 9:04 PM with no adverse effects noted from the medication error. 2. The SA validated through record review of physician orders and electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon return to the center, the physician orders were reviewed by two nurses prior to placing them in Electronic Medical Record. This occurred on 12/24/2021. 3. The SA validated through record review of the incident report and interview with the Director of Nursing. A root cause analysis of the medication error was initiated immediately by the Director of Nursing. This occurred on 12/24/2021. 4. The SA validated through record review of in-service provided to LPN #2 and through interviews with LPN #2 and the Director of Nursing. The employee making the transcription error was provided 1:1 coaching and counseling by the Administrator and the Director of Nursing regarding the importance of obtaining signed physician discharge orders prior to admission to the facility. This occurred on 12/24/2021. 5. The SA validated through record review of in-service provided to LPN #1 and through interviews with LPN #1 and the Director of Nursing. The nurse that made the error received 1:1 education regarding safe medication administration, including the rights of medication administration on 12/24/2021 by Director of Nursing Services (DNS). 6. The SA validated through record review of in-service sign in sheets and through interviews with the Director of Nurses, LPN #1, LPN #2, LPN #3, and other facility nursing staff. The Director of Nursing Services and Assistant Director of Nursing Services began in services on 12/24/2021 for all nurses regarding safe medication administration (including medication transcription, reconciliation, and administration), resident rights, and abuse/neglect. No nurses are allowed to work without completion of this training. 7. The SA validated through record review of hospital discharge orders, facility orders, and electronic medication administration records for Resident #2, Resident #3, Resident #4, and through interviews with the Director of Nursing, and through interviews with Resident #3 and Resident #4, who are both cognitively intact. The Director of Nursing Service (DNS) and Assistant Director of Nursing Services (ADNS) reviewed previous two week's admissions to ensure orders transcribed into the record accurately. There were no additional errors noted. This occurred on 12/28/2021 8. The SA validated through record review of the Quality Assurance meeting sign in sheet and through interviews to confirm contents of meeting with the Director of Nursing, Administrator, and through other staff members that attended the meeting. An ad hoc Quality Assurance Process Improvement meeting was initiated post the medication error on 12/24/2021 with the Administrator, The Director of Nursing, the Assistant Director of Nursing (Infection Preventionist), an [TRUNCATED]

Based on staff, family and resident interview, record review and facility policy review the facility failed to ensure that a resident's medical record was accurately documented when another resident's medications were entered into the medical record and administered to Resident #1 causing serious harm that required treatment at a local hospital for one (1) for four (4) residents reviewed. Resident #1. During the survey, the State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 12/23/21, when the facility failed to ensure a resident was free of significant medication errors when he was admitted on [DATE]. Resident #2's medications were entered into the medical record of Resident #1 and administered to Resident #1 on 12/24/21. The resident was administered eight (8) hypertensive medications, one (1) antidepressant and two (2) diabetic medications. The incident resulted in serious harm for Resident #1. He required immediate need for a higher level of care, evaluation and monitoring and was sent to the local emergency room . This incident placed Resident #1 and all residents in a situation that caused or was likely to cause serious injury, harm, impairment, or death. On 02/23/2022 at 6:10 PM, the SA notified the Administrator of the IJ and SQC and provided the facility with the IJ template. Based on the facility's implementation of corrective actions on 12/28/2021 and SA review, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 12/28/2021, prior to the SA's entrance on 02/17/2022. Findings include: Record review of the facility policy titled, Physician's Orders, undated, revealed . Manual Process 1. PHYSICIAN Verbal and Telephone Orders that have been validated by a licensed nurse as accurate will be entered into the center's electronic record system in the individual patient's record . 3. After entry, the licensed nurse accepting the order will validate accuracy of the order entry, print from the patient's electronic record, sign, and place in the patient's paper clinical record under the Physician's Order tab . Record review of the Medication Administration Competency Audit-Oral Meds, undated, revealed . 2. Check each label with order on eMAR (electronic medical record) . Applies 6 (six) Rights of Medication Administration. Medication, Route, Time, Patient, Dosage, Documentation . Record review of facility policy titled,Scanning and Uploading Documents Into the Patient's Electronic Record, dated 02-13, revealed, Guidelines: The HIMC is responsible for scanning documents into the patient's electronic record. However, other team members have access to upload documents as well. The guidelines below should be followed by all team members. All records must be scanned to ensure complete information is available to care for our patients/residents An interview on 2/22/22 at 1:50 PM, with Resident #1's Resident Representative (RR) , revealed Resident #1 had fallen and was hospitalized for a fractured pelvis, and after discharge from the hospital on 12/23/2021 between 8:00 PM to 9:00 PM, he was admitted to the facility for therapy. The next morning, on 12/24/2021, the RR was talking to the resident by phone, and he informed her that the nurse made him take twelve (12) medication pills that were not his and someone on staff also tried to give him a shot of insulin, but he told her he did not take insulin. The RR was told by the resident that he told the nurse several times that he was not on that many medications, but she insisted they were ordered for him and he had to take them. She stated the resident told the nurse, If these meds kill me, it is your fault, and the nurse responded with No, it's not. RR stated that when the resident, who was coherent, was repeatedly telling the nurse that these were not his medications, the nurse should have listened to him and checked the record. Soon after he took the medications, the resident was on the phone with the RR and said he was feeling dizzy and had numbness of his hands and he knew it was the medications he had taken. The RR was still on the phone with resident when he was telling her this, so she immediately called the facility and spoke to the Admission Coordinator to tell her something was wrong with the resident and they needed to check on him and send him to the hospital. He was sent to the emergency room by ambulance and she met him there. He received intravenous fluids to flush the drugs out of his system and improve his blood pressure. When released from the emergency room , the RR wanted to take the resident home with her, but he was weak and returned to the facility. The RR stated the resident was mentally competent and able to communicate his needs and he was very aware of his medications and needed care. The RR stated a Physical Therapist was either in the room or near the room when the medication administration occurred, and she probably heard the discussion between the resident and the nurse and the resident refusing to take the medication. On 2/22/22 at 3:00 PM, an interview with the Director of Nursing (DON) confirmed a medication error occurred with Resident #1. She stated that the Admission Coordinator printed the information from the hospital before the resident arrived at the facility. She stated on top of Resident #1's packet was the face sheet and in the back of the packet were the labs and in the middle were the pages with the hospital discharge orders that were Resident #2's orders. The Admission Coordinator was having a problem printing the orders from the hospital site, so she copied and pasted the orders onto a word document. She stated she was unsure how the packet of information for Resident #1 had the hospital discharge orders of Resident #2. The Admission Coordinator gave the packet for Resident #1 (with Resident #2's orders) to Licensed Practical Nurse (LPN) #2 and she entered the orders into Resident #1's electronic orders. The DON stated the error was found when one medication ([MEDICATION(S)]) was not in the med cart so LPN #1 went to the Admission Coordinator to ask for a hard copy of the prescription so Resident #1 could receive this med. The Admission Coordinator printed off orders for Resident #1 and it was determined that the meds were different than those entered the previous day and different from those just administered to Resident #1 by LPN #1. She stated she looked in Resident #1's record and found the face sheet and lab sheets of Resident #1 and the orders for Resident #2. She confirmed the facility failed to prevent the medication error that led to harm and emergency room treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A phone interview on 2/22/22 at 3:30 PM, with Licensed Practical Nurse (LPN) #1 revealed she was giving Resident #1 his morning meds on 12/24/21. She stated he took his medications then he told nurse that the hospital must have ordered him some extra medicines since he does not normally take that many meds. She stated one of his meds ([MEDICATION(S)]) was not in med cart since a hard copy prescription was needed for pharmacy to fill so she went to the Admission Coordinator to have her get needed information from hospital. She stated a copy of orders were printed off by the Admission Coordinator and it was noted to be different from the other med list and different from the meds she had just administered. She stated the error was realized and she went to check on the resident whose blood pressure and glucose was dropping. He was dizzy and had numbness of his hands. She stated Resident #1 was sent to the ER for treatment. She stated the resident did not refuse his meds, and, if he had refused, she would not have insisted he take them and she would have documented the refusal. She stated when administering meds the picture is matched to the name and the medications in the cart and the computer and this was done. She stated she had been in-serviced in the past on medication administration and has been in-serviced on medication administration, entering medication orders and reporting since this incident. She stated she was in-serviced on the new procedure for receiving orders and putting orders in the computer and reporting. On 2/22/22 at 4:10 PM, during an interview with LPN #2, revealed the Admission Coordinator brought her the printed packet for Resident #1 with orders and hospital information. She stated the resident had not yet arrived at the facility. She stated the packet had the face sheet on top and there were some other hospital reports at the back of packet for Resident #1. She stated the orders were in the center of the packet and looked different than they normally did, and did not have resident's name on pages, so she took the packet to the Admission Coordinator's office to ask her about the packet and the order sheet looking different. The Admission Coordinator showed her on the computer that the print button on the hospital web site for the order page was not working, so she copied and pasted the orders on a word document. She stated she made a mistake and did not look at the papers closely enough and just trusted what the Admission Coordinator said and she did not notice another resident's name (Resident #2) on one page. She stated she put the orders into the computer and sent to pharmacy by confirming orders. She stated this led to a medication error and Resident #1 being sent to the ER for treatment. She stated she has been in-serviced on medication administration in the past and since this incident she has been in-serviced on medication administration, reporting, verifying orders, and the new procedure for putting in orders, and they will not be put in until the resident arrives with the paperwork. An interview on 2/23/22 at 9:45 AM, with the Nurse Practitioner (NP) revealed she was off when Resident #1 was admitted . She stated she and the Medical Doctor (MD) were notified of the medication administration error and gave orders to send Resident #1 to the ER for evaluation. She stated she was told there was a cross up of the medication sheets for this resident and another resident. An interview on 2/23/22 at 10:30 AM, with the Admission Coordinator revealed on 12/23/2021, there was a mix up with two (2) residents' hospital discharge orders. She stated Resident #2's orders got in the packet with Resident #1's information. She stated she printed the discharge records from the hospital site, but the site would not allow her to print the orders so she copied and pasted the orders onto a word document so she could include them in the packet. She stated she was unsure how Resident #2's medication orders were put into Resident #1's packet, but it may have been on her desk or printed information incorrectly. She stated the mistake was not discovered until the next morning after the resident received medications. She stated LPN #1 came to her office to tell her she needed a hard copy of prescription for [MEDICATION(S)] so pharmacy would send medication. She stated she printed the orders for Resident #1 and realized there were no meds that needed a prescription. LPN #1 realized these orders on the newly printed order sheet were not the medications that she had just administered and went to assess the resident. She stated the MD, Nurse Practitioner (NP), DON, and Administrator were notified. She stated the family was then calling the facility to have staff check on resident and the resident was sent to the ER. She stated she was in-serviced on how packets are provided to the nurses, orders not entered until the resident was in the facility, and verified that the resident's name was on each page. She stated she should have verified the right resident's information with resident's name on each page was placed in packet to have prevented medication error. An interview on 2/23/22 at 10:45 AM, with the Administrator confirmed the facility had a medication error that caused harm to Resident #1 requiring treatment in the emergency room . An interview on 2/23/2022 at 1:35 PM, with the company's Corporate Nurse revealed she was notified of the event that occurred with Resident #1's medication administration error. She stated she had the understanding that the Admission Coordinator was trying to get Resident #1's report and orders from the hospital's web site and clicked on the wrong resident in the computer and copied and pasted Resident #2's orders and placed in Resident #1's record. She confirmed that Resident #1 was harmed from the medication administration error and needed medical treatment in the emergency room . A phone interview on 2/23/22 3:55 PM, with LPN #3 revealed she worked the night shift of 12/23/2021 until the morning of 12/24/2021 and she administered Resident #1's medications around 6:00 AM of 12/24/2021. She stated he received the [MEDICATION(S)] by mouth, which he took without question, and was scheduled for insulin as well. She stated his blood sugar was 107 so she told the resident his blood sugar result and told him he could take his insulin or refuse his insulin at that glucose level. She stated the resident said, I'd better not take the insulin, so she did not give it and documented he refused to receive the insulin. She stated he did not mention that he was not a diabetic and was not on insulin, he only refused to take it since nurse gave an option. She stated she had received in-services on medication administration, verifying orders, reporting and entering orders with discharge papers. She reported the medication she administered was in a medication card with the resident's name on it that came from pharmacy during the night. A phone interview on 2/23/22 at 7:26 PM, with Resident #1 revealed he remembers the incident with the medication administration well and said it was terrible and the worst thing that had happened in my life. He stated he had come to the facility from the hospital on the evening before this incident. He was in his room about to get therapy from the therapist and LPN #1 came in his room with a cup full of pills. He told her he only takes a few medicines, so he knew those were not his and stated the nurse stood there and argued with me and told me these were my medicines. He stated he told her 2-3 times that this was not his medicine, but she kept telling me to go ahead and take them. He stated the nurse told him that his doctor ordered the meds and he asked her which doctor and she told him MD. He stated he told the nurse, I'll go ahead and take them, but if it kills me, it's your fault, and the nurse turned around with a rude attitude and said, No, it's not. I'm just giving you the medicines that are ordered for you. He stated he reluctantly took the medication. He stated a nurse (he was not sure if it was this nurse or another nurse) had tried to get him to take a shot of Insulin, but he told her no because he was not on insulin and she did not insist he take that. After he took the pills, he was in the bathroom and blacked out for a minute and when he came to, he knocked on the door and called out for help since he could not move off the toilet or stand up. He stated his hands and feet were numb and tingling and he was dizzy and someone came and helped him to the bed. He knew he was still, but he felt like he was spinning around and his numbness and tingling was getting more intense. He was taken to the hospital to be treated to get the drugs out of his system. He stated he did not think he was going to live through it and does not want anyone else to ever have to go through this. He stated he returned to the facility that night after the ER visit due to the care he was requiring, and he wanted to finish therapy and get back home before they kill me. Record review of hospital discharge summary revealed the resident was admitted to the hospital on 12/18/2021 and discharged on [DATE]. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications ordered at discharge: [MEDICATION(S)] 5 milligram (mg) tablet daily, [MEDICATION(S)] 25 mg daily, Tamsulosin 0.4 mg daily, [MEDICATION(S)]-[MEDICATION(S)] 37.5-25 mg capsule daily, [MEDICATION(S)]-Acetaminophen 5-325 mg tablet every 4 hours as needed for pain. Record review of the Admission Record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's orders Order Summary Report revealed that on admission on 12/23/21 these medications were entered in residents electronic orders: [MEDICATION(S)] Tablet 1 MG (milligram) Give 1 (one) tablet two times a day related to Essential (Primary) Hypertension; [MEDICATION(S)] HCl 0.2 MG tablet Give 1 tablet by mouth three times a day related to Essential (Primary) Hypertension; [MEDICATION(S)] ER Tablet Extended Release 24 hour 120 MG Give one tablet by mouth 1 time a day related to Essential (Primary) Hypertension; [MEDICATION(S)] Capsule 100 mg capsules Give two capsules by mouth three times a day related to Fracture of Pelvis; [MEDICATION(S)] Tablet 5 MG Give one tablet one time a day related to Essential Primary Hypertension; [MEDICATION(S)] Tablet 80 MG tablet Give one tablet by mouth nightly for Hyperlipidemia; [MEDICATION(S)] Tablet 12.5 MG Give one tablet two times a day related to Essential (Primary) Hypertension; [MEDICATION(S)] Tablet 10 MG Give one tablet by mouth one time a day related to Adverse Effect of Unspecified Antidepressants; [MEDICATION(S)] Sulfate Tablet Delayed Release 324 MG 65 Fe (iron) Give 1 tablet by mouth two times a day related to Fracture of other parts of pelvis; [MEDICATION(S)] Tablet 4 MG Give 1 tablet by mouth two times a day related to Type 1 Diabetes Mellitus; [MEDICATION(S)] HCI Tablet 100 MG Give 1 tablet by mouth three times a day related to Essential (Primary) Hypertension; Insulin NPH(Human)([MEDICATION(S)])Suspension 100 units/ml (milliliter) Inject 12 unit subcutaneously in the morning related to Type 1 Diabetes Mellitus; Insulin NPH 100 units/ml Inject 6 unit subcutaneously in the evening related to Type 1 Diabetes Mellitus; [MEDICATION(S)] Tablet 20 MG Give one tablet by mouth one time a day related to Essential (Primary) Hypertension; Loperamide HCI Liquid 1 MG/5ML Give 10 ml every 8 hours as needed for Diarrhea; [MEDICATION(S)] HCI Tablet 1000 Mg Give one tablet by mouth two times a day related to Type 1 Diabetes Mellitus; [MEDICATION(S)] Tablet 25 MG Give 1 tablet daily related to Essential (Primary) Hypertension. Record review of electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation for the 9:00 AM medication pass revealed Resident #1 received: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] Sulfate, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] HCl. Record review of the Physician Documentation from the local emergency department dated 12/24/21 at 10:24 AM revealed, HPI History/Physical) .Presents with complaints of Blood Pressure Problem . Blood pressure on arrival to the emergency department at 10:24 AM was 76/42 . EKG and lab work were done in the emergency department. Lab interpretation: Normal except CHLORIDE 111; BUN 30;Creatinine 1.44;Calcium 7.9; Total Protein 5.1; [MEDICATION(S)] 2.4. ECG Clinical Impression: Abnormal EKG without significant change . Intravenous (IV) fluid was started, and resident received 1000 ml of [MEDICATION(S)] via IV. Record revealed the resident received Lomotil 2 tablets for diarrhea . Glucose level was 71. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After treatment, the resident was discharged and returned to facility on 12/24/21. Record review of Medication Error incident report dated 12/24/21 at 9:00 AM revealed Incident Description: Resident was missing [MEDICATION(S)] .Resident chart checked for script. None noted .Admission coordinator was notified of resident needing a hard copy .She called the hospital to request one .Discharge med list was provided. List was different from meds on MAR(Medication Administration Record) .Resident started to feeling light headed and staed that his fingers and hands were feeling numb .MD (Medical Doctor) notified of medication error .Order was given to send to the ER (emergency room ) . Record review of Resident #1's Minimum Data Set (MDS) Section C-Cognitive, dated 12/30/2021, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the Resident #1 was cognitively intact. Immediate Jeopardy Corrective Action Removal Plan February 23, 2022, for F842 and F760 On February 23, 2022, at 6:10 PM the State Agency notified the facility administrator of an Immediate Jeopardy (IJ) related to the facility ' s failure to ensure Resident #1 was free from significant medication errors. On 12/24/21 the facility failed to ensure orders upon admission were accurately entered into the correct resident ' s record resulting in Resident #1 being administered medications prescribed for Resident #2. The medications included eight (8) hypertensive medications, one (1) Antidepressant, and two (2) Diabetic Medications. As a result, Resident #1 was transferred to the hospital for treatment and evaluation. The Immediate Jeopardy template was provided to the administrator. To the best of my knowledge and belief, as an agent of Batesville Health and Rehabilitation Center, the following corrective action removal Plan constitutes a written plan demonstrating actions the center took upon awareness of the deficient practice thus removing the Immediate Jeopardy cited on February 23, 2022. Immediate Actions for All Residents Potentially Affected: 1. Resident # 1 was evaluated by the Licensed Practical Nurse (LPN) charge nurse on 12/24/2021. The resident voiced not feeling well. The Medical Director, Nurse Practitioner and family were notified. An order was obtained by the nurse, and the patient was sent to Local Medical Center emergency room via ambulance at 10:01 A.M. for a higher level of care, evaluation and monitoring. The resident returned at 9:04 PM with no adverse effects noted from the medication error. 2. Upon return to the center, the physician orders were reviewed by two nurses prior to placing them in Electronic Medical Record. This occurred on 12/24/2021. 3. A root cause analysis of the medication error was initiated immediately by the Director of Nursing. This occurred on 12/24/2021. 4. The employee making the transcription error was provided 1:1 coaching and counseling by the Administrator and the Director of Nursing regarding the importance of obtaining signed physician discharge orders prior to admission to the facility. This occurred on 12/24/2021. 5. The nurse that made the error received 1:1 education regarding safe medication administration, including the rights of medication administration on 12/24/2021 by Director of Nursing Services (DNS). 6. The Director of Nursing Services and Assistant Director of Nursing Services began in services on 12/24/2021 for all nurses regarding safe medication administration (including medication transcription, reconciliation, and administration), resident rights, and abuse/neglect. No nurses are allowed to work without completion of this training. 7. The Director of Nursing Service (DNS) and Assistant Director of Nursing Services (ADNS) reviewed previous two week ' s admissions to ensure orders transcribed into the record accurately. There were no additional errors noted. This occurred on 12/28/2021 8. An ad hoc Quality Assurance Process Improvement meeting was initiated post the medication error on 12/24/2021 with the Administrator, The Director of Nursing, the Assistant Director of Nursing (Infection Preventionist), and the Medical Director to discuss the incident and develop a plan to include monitoring of medication transcription and medication administration errors going forward. 9. Beginning 12/24/2021, the facility will assure that each patient has a signed copy of physician discharge orders on admission to the facility. 10. Beginning 12/28/2022, each new patient ' s orders are reconciled by a minimum of two nurses and reviewed each morning during clinical start up by the Director Nursing Services, Assistant Director of Nursing/ Infection Preventionist, and/or designees to assure the medication regimen and orders are correct. In summary, upon awareness, the center acted swiftly with the corrective actions, team member in-services, and ensured auditing measures were in place to monitor the plan developed utilizing the QAPI process to address the identified deficient practice immediately and all actions were completed on or before December 28, 2021. The facility alleges the past non-compliance Immediate Jeopardy was removed on December 28, 2021. State Agency Validation of Immediate Actions for All Residents Potentially Affected: 1. The State Agency (SA) validated through record review of physician orders, progress notes, and hospital emergency room visit records and through interviews with the Director of Nursing, Licensed Practical Nurse #1, Nurse Practitioner, Resident Representative, and Resident #1. Resident # 1 was evaluated by the Licensed Practical Nurse (LPN) charge nurse on 12/24/2021. The resident voiced not feeling well. The Medical Director, Nurse Practitioner and family were notified. An order was obtained by the nurse, and the patient was sent to Local Medical Center emergency room via ambulance at 10:01 A.M. for a higher level of care, evaluation and monitoring. The resident returned at 9:04 PM with no adverse effects noted from the medication error. 2. The SA validated through record review of physician orders and electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon return to the center, the physician orders were reviewed by two nurses prior to placing them in Electronic Medical Record. This occurred on 12/24/2021. 3. The SA validated through record review of the incident report and interview with the Director of Nursing. A root cause analysis of the medication error was initiated immediately by the Director of Nursing. This occurred on 12/24/2021. 4. The SA validated through record review of in-service provided to LPN #2 and through interviews with LPN #2 and the Director of Nursing. The employee making the transcription error was provided 1:1 coaching and counseling by the Administrator and the Director of Nursing regarding the importance of obtaining signed physician discharge orders prior to admission to the facility. This occurred on 12/24/2021. 5. The SA validated through record review of in-service provided to LPN #1 and through interviews with LPN #1 and the Director of Nursing. The nurse that made the error received 1:1 education regarding safe medication administration, including the rights of medication administration on 12/24/2021 by Director of Nursing Services (DNS). 6. The SA validated through record review of in-service sign in sheets and through interviews with the Director of Nurses, LPN #1, LPN #2, LPN #3, and other facility nursing staff. The Director of Nursing Services and Assistant Director of Nursing Services began in services on 12/24/2021 for all nurses regarding safe medication administration (including medication transcription, reconciliation, and administration), resident rights, and abuse/neglect. No nurses are allowed to work without completion of this training. 7. The SA validated through record review of hospital discharge orders, facility orders, and electronic medication administration records for Resident #2, Resident #3, Resident #4, and through interviews with the Director of Nursing, and through interviews with Resident #3 and Resident #4, who are both cognitively intact. The Director of Nursing Service (DNS) and Assistant Director of Nursing Services (ADNS) reviewed previous two week ' s admissions to ensure orders transcribed into the record accurately. There were no additional errors noted. This occurred on 12/28/2021 8. The SA validated through record review of the Quality Assurance meeting sign in sheet and through interviews to confirm contents of meeting with the Director of Nursing, Administrator, and through other staff members that attended the meeting. An ad hoc Quality Assurance Process Improvement meeting was initiated post the medication error on 12/24/2021 with the Administrator, The Director of Nursing, the Assistant Director of Nursing (Infection Preventionist), and the Medical Director to discuss the incident and develop a plan to include monitoring of medication transcription and medication administration errors going forward. 9. The SA validated through interviews with LPN #1, LPN #2, LPN #3, Director of Nursing, and Admission Coordinator. Beginning 12/24/2021, the facility will assure that each patient has a signed copy of physician discharge orders on admission to the facility. 10. The SA validated through interviews with LPN #1, LPN #2, LPN #3, and Director of Nursing and record review of accuracy of resident ' s orders. Beginning 12/28/2022, each new patient ' s orders are reconciled by a minimum of two nurses and reviewed each morning during clinical start up by the Director Nursing Services, Assistant Director of Nursing/ Infection Preventionist, and/or designees to assure the medication regimen and orders are correct.

Based on observation, staff interview, record review, and facility policy review the facility failed to notify the physician of significant changes related to a resident's sacral pressure ulcer as evidenced by an increase in size and drainage of a pressure ulcer for one (1) of seven (7) residents reviewed with pressure ulcers (Resident #5). Findings include: Review of the facility's policy, "Notification of Change in Resident Health Status," not dated, revealed, "The center will consult the resident's physician, nurse practitioner, or physician assistant, and if known notify the resident's legal representative or an interested family member when there is, (A) An accident which results in jury and has the potential for requiring physician intervention, (B) Acute illness or a significant change in the resident's physical, mental, or psychosocial status, (C) A need to alter treatment significantly. Nursing judgment is an integral part of the skilled care provided in this Living Center; therefore, such judgment must be applied in a case by case basis in keeping with acceptable nursing practice." Observation of Resident #5, on 2/20/14, at 9:25 AM, revealed a Stage IV Pressure Ulcer to the coccyx that was identified by Registered Nurse (RN) #4 as an Unstageable Pressure Ulcer. Resident #5's wound measured 4.0cmx4.0cmx1.2cm, had granulation and [MEDICATION NAME] tissue with some yellow slough around the edges, with a moderate amount of serous drainage and no odor as documented by RN #4 on 2/20/14. Observation also revealed undermining from nine (9) o'clock to 12 o'clock confirmed by RN #4. Record review revealed treatment notes, documented by RN #4, which reflected significant changes in Resident #5's Pressure Ulcer without any documentation that the physician was notified of the changes. On 12/26/13- "Unstageable wound to coccyx/sacrum is showing no signs of improvement. Wound has increased in size: 3.2cm x 3.4cm x 1.8cm." On 1/2/14- "Resident has Unstageable wound to coccyx: 3.2cm x 3.4cm x 1.6cm with moderate amount of yellow/green exudate with slightly foul odor. Minimal amount of necrotic tissue noted to edge of wound bed." On 1/9/14- "Unstageable wound to coccyx is 3.6cmx3.6cmx2.0cm with heavy amount of greenish very foul smelling exudate. Bed of wound is red surrounded by yellow slough and black necrotic tissue at distal edge of wound." On 1/14/14- "Spoke with RP (Responsible Party) and discussed deteriorating wound. Explained I have tried everything I can here and would like to send resident to wound care center in Grenada if he (RP) agreed. He (RP) is to call back." The physician was not notified of any of these significant changes to Resident #5's Pressure Ulcer. Interview on 2/21/14, at 10:35 AM, with the Director of Nursing (DON), revealed, "I just talked to (RN #4), and she (RN #4) told me (DON) she called for new orders but didn't tell him (Physician) about changes and she (RN #4) didn't document it." "I'm really sorry." Interview on 2/21/14, at 2:10 PM, with RN #4 revealed, "I honestly don't remember notifying the doctor, it should have been documented with that note." "If it ain't (isn't) documented, it ain't done and I know that." "That type of drainage means an infection, something should have been done." Interview with Physician, on 2/21/14, at 4:25 PM, revealed, It's hard to pinpoint days without her (Resident #5) chart in front of me. I know she has a Pressure Ulcer, but I have not seen it. I talk to the Treatment Nurse (RN #4) a lot and if she calls with concerns I address them. Record review revealed Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/31/14, revealed a Brief Interview for Mental Status Score (BIMS) of 00, which reflects severe cognitive impairment. Resident #5 is totally dependent upon one (1) to two (2) staff members for Activities of Daily Living (ADLs).

Based on observation, staff interview, record review, and facility policy review the facility failed to implement the comprehensive plan of care to address the care and management of a pressure ulcer for one (1) of seven (7) residents reviewed (Resident #5). Findings include: Review of the facility's policy entitled "Health Information Management Manual", dated October 7, 2013, revealed, "The Care Plan describes the care and treatment provided to the resident. The Care Plan includes any care or treatment that would otherwise be required for the provision of quality care, unless not provided due to a Resident's right. The Care Plan must reflect the immediate step for each goal if identification of these steps will enhance the Resident's ability to meet the goal." Review of Resident #5's Pressure Ulcer Care Plan, initiated 12/22/14, noted "I am at risk for alteration in my skin integrity." The Care Plan initiated 11/4/13, revealed the intervention of "Weekly Wound assessment by tx (Treatment) nurse and if no progress in wound, notify MD for further orders." "Conduct weekly skin inspection and monitor for signs and symptoms of infection such as redness, warm, discharge, odor notify Physician of significant findings. Monitor/document/report to MD PRN (as necessary) changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection wound size (length x width x depth) stage." Review of Resident #5's wound assessment notes revealed no weekly wound assessment for the week of 12/4/13. Further review of the weekly wound assessments revealed next wound assessment for Resident #5's buttock was on 12/11/13, (14 days later), performed by RN #4 at 07:03(AM), "Resident (#5) has unstageable ulcer to coccyx which is 2cm in diameter and 1.4cm deep. Surrounding skin appears excoriated and bright red. Moderate amount of foul smelling yellowish drainage from wound." Review of Resident #5's Physician Orders, Treatment Notes, and Treatment Record revealed no documentation of Physician notification of increase in size, foul odor or yellow drainage, yellow/green exudates, black necrotic tissue nor any new treatment for [REDACTED].#5's Care Plan revealed no new interventions to address the changes in the Pressure Ulcer. Record review revealed RN #4 documented on 12/26/13, at 05:36(AM), "Unstageable wound to coccyx/sacrum is showing no signs of improvement. Wound has increased in size; 3.2cmx3.4cmx1.8cm." Further review of RN #4 Treatment notes revealed RN #4 documented on 1/2/14, at 09:18(A.M.), "Resident has unstageable wound to coccyx; 3.2cmx3.4cmx1.6cm with moderate amount of yellow/green exudates with slightly foul odor." RN #4 also documented on 1/9/14, at 09:51(A.M.), "Unstageable wound to coccyx is 3.6cmx3.6cmx2.0cm with heavy amount of greenish very foul smelling exudate. Bed of wound is surrounded by yellow slough and black necrotic tissue at distal edge of wound." Observation of Resident #5 on 2/20/14, at 9:25 AM revealed a Stage IV Pressure Ulcer to the coccyx. Interview with RN #3, on 2/21/14, at 8:30 AM, revealed care plans are done according to the MDS (Minimum Data Set) assessments and staff should follow the care plans. Interview with the Administrator on 2/21/14 at 6:00 PM confirmed concerns with Resident #5's Care Plan interventions (weekly assessments and notifications to the physician of changes), not being implemented by staff. Record review revealed Resident #5 was admitted to the facility on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/31/14, revealed a Brief Interview for Mental Status Score (BIMS) of 00, which reflects severe cognitive impairment. Resident #5 is totally dependent upon one (1) to two (2) staff members for Activities of Daily Living (ADLs).

Based on observation, staff interview, record review, and facility policy review the facility failed to ensure appropriate wound assessments in a timely manner, and care which resulting in continued deterioration of the sacral pressure ulcer which increased in size, and developed an infection with increased drainage for one (1) of seven (7) residents reviewed (Resident #5). Findings include: Review of the facility's policy entitled "Prevention of Pressure Ulcer", not dated, revealed, "If a pressure ulcer, is present, the licensed nurse is responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided. Notification of the physician is required when a new pressure ulcer is identified as well as when treatment is not effective." Review of the facility's policy entitled "Skin Integrity Guideline", revised 2013, revealed, "Living Center develops a routine to review residents with wounds or at risk on a weekly basis and will document. Licensed nurse will be responsible for performing this skin evaluation/observation. Licensed nurse to document weekly on all wounds. DNS (Director of Nursing Services) or designee evaluates/observes wounds on a weekly basis." Review of the facility's policy entitled "Objectives for Skin Integrity/Wound Care", not dated, revealed, "Participant will demonstrate accurate methods for staging, measuring and documenting of wounds." Review of the facility's "Wound Evaluation Flow Sheet," Revised 01/10, revealed Stage IV: (4) full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Observation of Resident #5, on 2/20/14, at 9:25 AM, revealed a Stage IV (4) Pressure Ulcer to the coccyx that was identified by Registered Nurse (RN) #4 as an Unstageable Pressure Ulcer. Resident #5's wound measured 4.0cmx4.0cmx1.2cm, as documented by RN #4, observation revealed the Stage IV Pressure Ulcer had granulation and [MEDICATION NAME] tissue with some yellow slough around the edges, with a small amount of serous drainage and no odor Observation also revealed undermining from nine (9) o'clock to 12 o'clock confirmed by RN #4. Review of Resident #5's Treatment notes revealed a Stage II Pressure Ulcer was identified to her buttocks on 11/27/13. RN #4's Treatment (Tx) Note, dated 11/27/13, at 08:07(A.M.), revealed " Skin assessment performed. Area to left inner buttocks is Stage II with moderate amount of serous drainage noted, 1.2cmx1.5cm. Treatment orders changed today; adding calcium alginate." Review of Resident #5's wound assessment notes revealed no weekly wound assessment for the week of 12/4/13. Further review of the weekly wound assessments revealed next wound assessment for Resident #5's buttock was on 12/11/13, (14 days later), performed by RN #4 at 07:03(A.M.), "Resident (#5) has unstageable ulcer to coccyx which is 2cm in diameter and 1.4cm deep. Surrounding skin appears excoriated and bright red. Moderate amount of foul smelling yellowish drainage from wound." Review of MDS notes dated 1/22/14 revealed Resident #5 was hospitalized from [DATE] to 12/22/13. "This patient (Resident #5) had an acute care hospitalized from [DATE]-12/22/13. She was given a [DIAGNOSES REDACTED]." Record review revealed RN #4 documented post hospital skin assessment on 12/23/13 at 07:23. "Continues to have unstageable wound to coccyx which was debrided 12/20/13 while in hospital. Wound is 2.8cmx3.2cmx1.4cm." Review of Resident #5's Treatment notes dated on 12/26/13, documented by RN #4 at 05:36(AM), revealed "Unstageable wound to coccyx/sacrum is showing no signs of improvement. Wound has increased in size; 3.2cmx3.4cmx1.8cm." Further review revealed RN #4 documented on 1/2/14, at 09:18(AM), "Resident has unstageable wound to coccyx; 3.2cmx3.4cmx1.6cm with moderate amount of yellow/green exudates with slightly foul odor." Resident #5's Treatment notes on 1/9/14, at 09:51(AM), documented by RN #4, also revealed "Unstageable wound to coccyx is 3.6cmx3.6cmx2.0cm with heavy amount of greenish very foul smelling exudate. Bed of wound is surrounded by yellow slough and black necrotic tissue at distal edge of wound." Review of Resident #5's MDS note, dated, 1/22/14, revealed; RN #3 documented, "This 14-day assessment period covers 12/28-1/3/14. She (Resident #5) has an unstageable pressure ulcer to her coccyx that measures 3.2X3.4X1.6cm. The tx (treatment) nurse noted that on ? (one half) it had moderate amount of yellow/green drainage and a slightly foul odor and a minimal amount of necrotic tissue on the edge of the wound bed." Review of Resident #5's Treatment note on 1/14/14, at 11:17(A.M.), revealed, Spoke with RP (Responsible Party) and discussed deteriorating wound. Explained I have tried everything I can here and would like to send resident to wound care center in Grenada if he agreed. He (RP) is to call back. Review of Resident #5's Physician orders, Treatment Notes, and Treatment orders revealed Resident #5's Physician was not notified, from 12/26/13 to 1/20/14, (a total of 25 days) nor were there any changes to Resident #5's Treatments for the Pressure Ulcer during this period of documented deterioration of Resident #5's Pressure Ulcer. Record review of Resident #5's Treatment notes on 1/27/14, at 08:15(AM), revealed "Unstageable wound to coccyx is 4.2cmx4.0cmx2.4cm." Review of Resident #5's Pressure Ulcer Care Plan, initiated 12/22/14, and the I am at risk for alteration in my skin integrity Care Plan, initiated 11/4/13, revealed the intervention of "Weekly Wound assessment by tx nurse and if no progress in wound, notify MD for further orders." "Conduct weekly skin inspection and monitor for signs and symptoms of infection such as redness, warm, discharge, odor notify Physician of significant findings. Monitor/document/report to MD PRN (as necessary) changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection wound size (length x width x depth) stage." Review of Resident #5's Treatment note on, 2/4/14 at 0723, documented by RN #4 revealed, "Spoke with family and they requested we try Aloe Vera Gel with [MEDICATION NAME] (current Tx order)." Further review of Treatment note revealed that the Stage IV Pressure Ulcer was not assessed, measured, and documented on this week, which was 8 days since last measurements were documented. Interview with the Director of Nursing Services (DNS), on 2/21/14, at 9:00 AM, revealed: "The Tx Nurse (RN#4) gives me a report on wounds and I rely on her." "I haven't looked at (Resident #5's) wound." "I know we've done really bad on this one." DON provided RN #4's training record on Wound Care, which consisted of eight (8) clock hours of an online program, six (6) hours completed July 22, 2013 and two (2) hours completed July 23, 2013. The program consisted of Pressure Ulcer Assessment, Identification, Documentation, and Prevention. RN #4 did not complete the facility's Skill Validation Pressure Ulcer Assessment, that required the Clinician to identify and describe the four (4) stages of Pressure Ulcers. Interview with RN #4 on 2/21/14 at 2:10 PM revealed, "I honestly don't remember notifying the doctor." "It (notification) should have been documented with that note." "If it ain't (isn't) documented it ain't done, and I know that." "That type of drainage means an infection, something should have been done." Interview with Resident #5's RP (Responsible Party) on 2/21/14 at 3:55 PM. revealed, "I was told about the pressure ulcer, but I've never seen it. The family talked and we decided we wanted them to use the Aloe Vera Gel. They told me it's better since they started using what we asked them to use." Interview with Resident 35's physician, on 2/21/14 at 4:25 PM, revealed, "It's hard to pinpoint days without her (Resident #5) chart in front of me. I know she has a Pressure Ulcer, but I have not seen it. I talk to the Treatment Nurse (RN #4) a lot and if she calls with concerns I address them." Interview with the Administrator on 2/21/14 at 6:00 PM, confirmed concerns with Resident #5's Pressure Ulcer deteriorating changes from 12/26/13 to 1/20/14 and no documentation of the Physician being notified of the significant changes to the Pressure Ulcer to obtain new treatment orders or interventions. Record review revealed Resident #5 was admitted to the facility on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/31/14, revealed a Brief Interview for Mental Status Score (BIMS) of 00, which reflects severe cognitive impairment. Resident #5 is totally dependent upon one (1) to two (2) staff members for Activities of Daily Living (ADLs).

Based on record review, staff interview and facility policy review, the facility failed to ensure that standards of practice were followed for one (1) of four (4) resident's reviewed (Resident #1) by failing to have Resident #1 assessed by a Nurse after sustaining a fall in the facility van. CNA's transferred Resident #1 to the wheelchair and then used a sit to stand lift to transfer Resident #1 from the wheelchair to the bed. Resident #1 was assessed for a total lift. Resident #1 sustained a fracture to the hip at sometime during the fall or transfer. Findings Include: Cross refer findings to F-323 for the facility's failure to assess Resident #1 before moving her after she sustained a fall in the the facility van. Resident #1 told the facility van driver when she was picked up at [MEDICAL TREATMENT] that she did not feel that she was positioned right in the wheelchair. Resident #1 denied the need to go back in and be repositioned. Resident #1 slid out of the wheelchair and the CNA's lifted her into a wheelchair without first getting a nurse to assess her. They also used the incorrect lift for the transfer.

Based on record review, staff interview and facility policy review, the facility failed to ensure that one (1) of four (4) resident's reviewed (Resident #1) was assessed by a Nurse before being moved after sustaining a fall. Resident #1 sustained a fall on 5/24/11, in the facility van and was moved prior to being assessed. Resident #1 sustained a hip fracture at sometime during this incident. The facility failed to follow the plan of care after the fall by transferring the resident with a stand up lift instead of a total lift. Findings Include: Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/11 revealed that Resident #1 was cognitively intact. Resident #1 required extensive assistance of two (2) or more persons with bed mobility, transfers. locomotion on unit, dressing and toilet use. Resident #1 was coded as having impairment of one (1) side of the upper extremities and impairment of both lower extremities. Wheelchair was identified as primary mode of locomotion. Review of an investigation provided by the facility dated 05/24/11 at 04:15 p.m., revealed: "Resident slid from seat of wheelchair to a sitting position on the wheelchair pedals during van transportation from dialysis to living center. As van driver (C.N.A.) {Certified Nursing Assistant} was turning left onto facility property the resident stated she was sliding out of the wheelchair. The C.N.A. (passenger) quickly placed her body against the resident's legs to brace the resident as the van driver eased the van into the parking lot and stopped at the front door. The van driver ran in the living center to get assistance while the C. N. A. (passenger) continued to brace the resident in the chair. The resident began sliding again with her buttocks eventually coming to rest on the foot pedals of her wheelchair. The seat belt was still intact but had risen up across the resident's chest area. The shoulder harness was also still intact on the resident." " ASSESSMENT OF RESIDENT/DESCRIBE INJURY- 98.0 (Temperature) 82(Pulse)-22(Respirations) 145/75 (Blood Pressure) Blood Sugar 137. Resident c/o (complains of) left leg pain. NO other injuries were noted. An x-ray was done that showed a left femoral neck fracture with superior displacement. The x-ray also showed diffuse Osteopenia. The resident was transferred by am balance to the hospital for emergency care." " RESIDENT INTERVIEW SUMMARY: They did not put me in my chair right at dialysis and I slid out. (Name of staff member) tried to hold on to me to keep me from falling but she couldn't hold on." " SPECIFY RECOMMENDATIONS/INTERVENTIONS (INTERVENTIONS) TAKEN TO PREVENT REOCCURRENCE - As a precaution, nursing assistants are being retrained to have a nurse assess a resident who has fallen before moving the resident unless it is absolutely necessary for resident safety to move the resident. This training was initiated 5/26/11 and will be completed by 6/1/11." "PROVIDE SUMMARY OF INVESTIGATIVE FINDINGS: The investigation determined that despite being properly placed into the van restraint system, the resident's buttocks slid forward to the edge of the wheelchair seat with the cloth incontinent pad under her sliding forward with her. Despite the C.N.A. (Certified Nursing Assistant) efforts to use her body to brace resident in her chair, the resident slid out of the seat with her buttocks resting on the foot pedals of the wheelchair. The resident's feet were on the footrests and her legs bent as she slid down. The investigation determined that the cause of the fracture was this incident in combination with the resident's Osteopenia. The combination of the cloth incontinent pad and the resident's dress material made a slick surface that could not have been anticipated by staff. Based on investigation, this was an unavoidable accident. There was no abuse or neglect of this resident as both C.N.A.s (van driver and van passenger) acted appropriately and made every attempt to protect the resident from injury. Precautionary measures were taken by the living center and are listed above in this report." Review of a written statement from CNA #3 revealed: " I was at the hospital with another resident for their MD (Medical Doctor) appointment. (Transportation Driver) picked us up. He secured the resident into place in the van and I got in the passenger seat (located just in front of the wheelchairs). Everything was fine and I did not notice any problems until (Transportation Driver) was turning left into the facility parking lot. Resident #1 started saying she was sliding out of her chair. I looked back and told (the transporter) that. I got in front of her wheelchair and placed by body so that it was bracing her body from the knees down to keep her from sliding further. I thought I could keep her from sliding further and transporter) eased the van into the parking lot by the door so he could get us some help. While he was gone, {Resident #1) started sliding more even though I was trying to keep her from it. She ended up with her buttocks resting on the wheelchair foot pedals. Four other C.N.A.s came to help and with one on each side, on behind her and one in front we eased her pack up into the wheelchair. She said her leg was hurting as we were moving her but once we got her in the wheelchair she said she was ok. We notified the nurse as soon as we got back in with her. We always get a nurse when somebody falls before we move them but in this case, I was only thinking of the resident's safety and trying to get her in a safer position before she slid further." Review of an INTERVIEW SUMMARY conducted by the DON on 05/24/11 with CNA #5 revealed: " When we got out to the van, (Resident #1) was on the footrests of the wheelchair with her legs bent. We eased her to the floor so we could move the wheelchair back and then we lifted her into the wheelchair." Review of an INTERVIEW SUMMARY conducted by the DON on 05/24/11 with CNA #6 revealed: "We went to get her and she was sitting on the pedals of the wheelchair. Four of us (one on each side, one behind, and one in front) picked her up and placed her in the wheelchair. " Interview on 6/14/11 at 12:00 noon with the Transport CNA revealed that on the day of the incident, Resident #1 mentioned that she was not positioned good in her chair. The Transport CNA stated Resident #1 stated that she did not want to go back in to be repositioned. Interview conducted with CNA # 2 on 06/14/11 at 02:50 p.m. revealed: " (I) went to assist with other CNA's. She (Resident #1) was on footrests of wheelchair, no seatbelt on she was not saying anything. I got her by one (1) of her legs-right leg." Interview with Licensed Practical Nurse (LPN) #1 on 06/14/11 at 02:50 p.m. revealed: "They (staff) came to me afterwards when (Resident #1) was in the room in bed and complaining of pain. Then they told me that she fell out of wheelchair. I went to room (Resident #1) was hollering in pain. She said her leg (was) broken. I gave pain med (medication) and called doctor to get xray. Then they got the xray. " Registered Nurse (RN) #1 stated at that time that she was unaware the resident had fallen until she (Resident #1) was back in the building. RN #1 confirmed that in-services were conducted to educate staff that when someone falls they are not to be moved until the nurse does a head to toe assessment." Interview on 06/14/11 at 03:10 p.m. with CNA #1 confirmed that she and other CNA's went to the van to assist Resident #1 and five (5) or six (6) of the staff " picked her up and put her in her chair. " CNA #1 stated: "we took her to her room and put her in bed. We used the stand up lift. Resident #1 was able to stand up and turn a little." "Resident #1 said leg was hurting and we got nurse." Interview with CNA #3 on 06/14/11 at 03:15 p.m. revealed "CNA's came (to the van) and her (Resident #1) leg was up under (the) seat and everything was still in place, seatbelt was undone, (CNA #1) undid left wheelchair lock, eased chair back, eased her back, saying leg hurting. All four (4) of them picked her up and put in wheelchair. (Transporter) took her to room. CNA #4 and I transferred her to bed with the Sara lift-stand up lift. Normally, transferred with Marissa lift (total). We had an inservice stating do not move resident til nurse checks out. We knew that we were just trying for safety. Normally, we get the nurse." Review of a document titled " Mobility Assessment for Residents " for Resident #1 and dated 11/18/10 revealed the following assessment: " Resident can bear weight on at least one leg? No. Resident is able to follow simple instructions? Yes. "Resident is able to grip with at least one hand or a 2nd staff member is available to assist with the transfer? No. Resident is able to undergo moderate pressure to the mid to lower back? No. Resident weights less than 440 lbs (pounds)? Yes. If the five questions were answered Yes, then the patient is a candidate for the Sara Lift If any of the five questions were No, then the resident is not a SARA lift candidate. Place an X over SARA in " Lift Required " box below. Proceed to the next questions for assessment of total dependent lift: Resident can undergo a semi-reclined position as shown in the picture to the right? Yes. Resident weighs no more than 500 pounds? No. " "Lift Required (circle after completing questions above): Maxi/Move (was circled). " Review of an xray report dated 05/24/11 for Resident #1 revealed: "There is a subcapital fracture of the left femoral neck with slight impaction and slight lateral displacement. The femoral head remains in the acetabulum. No other fractures are identified. IMPRESSION: Left hip fracture " Review of a physicians order dated 05/24/11 revealed: " 5/24/11 Send to (name of hospital) RT (related to) Xray to L (left) hip showing: Subcapital Hip FX (fracture) with slight impaction and slight lateral displacement. " Review of a facility policy " Change in Condition Report-Post Fall Investigation Summary Guidelines for Completion " with a notation on the bottom left of the page " Clinical Services-Revised January 2011 Page 1 of 2 " revealed: " Purpose: To assess individual condition after a fall occurs and to identify the reason and /or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls. Fall Definition: A fall is a sudden change in position usually involving the floor. Finding a resident on the floor or lowering/assisting a resident to the floor is considered a fall. Procedure: If a resident falls ... *1. The licensed nurse will assess the resident for injuries and provide the necessary emergency treatment. Initiate the center 911 policy and procedure if appropriate. "