Based on observations, resident and staff interviews, record review, and the review of the facility policies titled, Oxygen Safety and Safe and Homelike Environment, the facility failed to: (1) maintain the laundry services area in a clean, sanitary, and safe condition; (2) maintain the [NAME] Shower tile grout in a clean and sanitary condition; (3) secure empty oxygen tanks to prevent potential hazards; (4) maintain metal Intravenous (IV) stands in a clean and sanitary condition for two of three residents (R) (R22 and R13) reviewed for enteral feedings; and (5) repair leaking air conditioning units, resulting in basins being placed on the floor in two of two rooms observed (rooms [ROOM NUMBERS]) over multiple days. These deficient practices had the potential to increase the risk of infection transmission due to unsanitary environmental conditions and equipment, as well as increased risk of injury from environmental hazards, including slips, trips, and falls related to leaking units and unsecured oxygen tanks. Findings include: 1. During an observation on 06/15/2026 at 10:54 AM, the Environmental Services Director (EVSD), accompanied by the Regional Manager, was observed entering the clean side of the laundry room. The area contained three industrial washing machines. Behind the machines, a large cement drain used for wastewater discharge was observed. Several resident slippers, a gray plastic wash basin, dried soap residue, and one pressure reduction bootie were observed on the floor beneath the machines. Tiles were missing beneath the washing machine on the right side of the room. An uncovered drain containing rusty water was also observed. Directly across from the washing machines were two service/utility sinks. Both sinks had plastic containers placed under the pipes. The wall behind the sinks showed significant water damage, including staining and an open, deteriorated area. The service/utility sink on the left contained stagnant water that was not draining. Outside of the clean area, a stack of mechanical lift slings was observed on the floor. The EVSD stated that night shift staff were responsible for gathering these items and it was not being completed. The Housekeeping/Laundry Director stated that the area would occasionally flood if an item became caught in the drain behind the machine. During an interview on 06/18/2026 at 9:14 AM, the Maintenance Director stated that staff are required to enter all maintenance requests into TELS, a computerized maintenance and operations management system commonly used in long-term care facilities. He stated that once a request is entered, he receives a text notification and then addresses the repair with staff as needed. The Maintenance Director reported the only issue he was aware of in the clean laundry room was a ceiling tile. He further stated he was not aware of any leaks in the service/utility sinks or that one sink was clogged. During an observation on 06/18/2026 at 9:55 AM in the laundry room Laundry Aide (LA1) stated she used the service/utility sinks in the clean laundry area for handwashing. LA1 stated she had informed the Maintenance Director that the sinks did not drain properly and were leaking. The EVSD was present during the interview and confirmed LA1's statements. Housekeeping/Laundry staff stated that all maintenance concerns were entered into TELS. 2. During a general tour of the shower room on 06/18/2026 at 9:14 AM, the Maintenance Director stated that staff were required to enter all broken or deficient areas to TELS. The [NAME] Shower room contained two shower stalls. A heavy black substance was observed on the grout lines on the left side of the first shower stall, and yellow/pinkish staining was observed on the grout lines on the right side. The Maintenance Director stated he was not aware that the grout required replacement and reported that this issue had not been entered into TELS. 3. During an observation on 06/15/2026 at 12:20 PM, Central Supply entered the outdoor area where the oxygen (O ) tanks were stored. This storage area was located outside, beneath the walkway connecting the facility to the laundry room. There were two sets of O cages: one designated for full tanks and the other for empty tanks. The cage designated for empty O tanks was completely full. Additionally, 19 empty O tanks were found outside of the cage. These tanks were unsecured and not labeled to indicate that they were empty. Central Supply stated that the empty tanks were scheduled for pickup today. During an interview conducted on 06/16/2026 at 1:00 PM, the Corporate Director of Respiratory stated that empty O tanks were to be secured. She confirmed the tanks were not secured and were unsafe. 4. Observations of R22 on 06/15/2026 at 12:17 PM, 1:55 PM, and 4:20 PM; on 06/16/2026 at 9:52 AM and 3:16 PM; and on 06/17/2026 at 8:46 AM revealed the resident was in bed with a metal IV stand positioned next to his bed. During these observations, a bottle of enteral formula, which was a brown colored liquid, was hanging from the IV stand. Additionally, during these observations, the IV stand and its four wheeled base were unclean with accumulated dried substances, which were brown in color, and appeared to be spilled enteral formula. An observation on 06/17/2026 at 9:25 AM with the Director of Nursing (DON) present revealed R22 was in bed with the metal IV stand next to his bed. The IV stand and its base were again observed to be unclean with an accumulated dried brown substance. During an interview on 06/17/2026 at 9:25 AM, the DON confirmed R22's IV stand and base were unclean with accumulated dried substances. The DON stated the nursing staff should clean the IV stand and its' base when enteral formula is spilled to prevent the formula from drying. The DON stated that after the formula had dried on the IV stand, the housekeeping staff or maintenance staff would need to be contacted to clean off the dried substances. 5. During observations of R13 on 06/15/2026 at 9:21 AM, 11:36 AM, and 4:13 PM; on 06/16/2026 at 10:24 AM and 3:08 PM; and on 06/17/2026 at 8:45 AM, the resident was observed in bed with a metal IV stand positioned beside the bed. A container of brown-colored enteral formula was hanging from the IV stand during each observation. The base of the IV stand was observed to be unclean, with accumulated dried, brown-colored residue consistent in appearance with spilled enteral formula. During an observation on 06/17/2026 at 9:33 AM, conducted in the presence of the DON, R13 was observed in bed with the metal IV stand positioned beside the bed. The base of the IV stand was again observed to be unclean, with an accumulation of dried brown colored substance. During an interview on 06/17/2026 at 9:33 AM, the DON confirmed R13's IV stand's base was unclean and had an accumulation of dried residue. The DON stated nursing staff are expected to clean the IV stand when enteral formula is spilled to prevent residue from drying on the equipment. The DON further stated that if the formula has dried, housekeeping or maintenance staff should be contacted to remove the dried substances. 6. During an observation of room [ROOM NUMBER] on 06/15/2026 at 11:40 AM, a basin containing clear liquid was observed beneath the air conditioning/heating unit under the window. During an observation of room [ROOM NUMBER] on 06/15/2026 at 2:45 PM, a basin containing clear liquid was observed beneath the air conditioning/heating unit located under the window. A blanket was also observed beneath the basin. During an observation of room [ROOM NUMBER] on 06/16/2026 at 10:23 AM, a basin containing clear liquid was observed beneath the air conditioning/heating unit located under the window. During an observation of room [ROOM NUMBER] on 06/16/2026 at 10:25 AM, a basin containing clear liquid was observed beneath the air conditioning/heating unit located under the window. During an interview on 06/18/2026 at 9:33 AM, the Maintenance Director confirmed the air conditioning/heating units located beneath the windows in rooms [ROOM NUMBERS] were leaking. Review of a facility policy titled Safe and Homelike Environment dated 04/2025, indicated, . ln accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of a facility policy titled Oxygen Safety, dated 09/2024, indicated, . It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. Oxygen storage locations shall be in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or gates that can be secured against unauthorized entry. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.
Every finding on record at Douglasville Center for Nursing and Healing LLC
Douglasville, Georgia · CCN 115273
33 findings across 5 inspections, in the inspector's own words, 13 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of June 19, 2026
20 findingsBased on observations, staff interviews, and the facility policy titled, Food Receiving and Storage, the facility failed to ensure food was not expired. This had the potential to affect 183 of 213 residents receiving food out of the kitchen. This failure had the potential to spread food borne illness. Findings include: During an observation and interview on 06/15/2026 at 8:44 AM, with the Dietary Manager (DM) present, expired and deteriorated foods were observed in the walk-in refrigerator. The items included seven containers of fresh strawberries with mold throughout each container, three melons with mold on the exterior, and one metal container of rice with a discard date of 06/09/2026. The DM stated she and the manager were responsible for monitoring and checking food for quality and expiration. The DM stated the strawberries were received on 06/11/2026 and the melons had been stored in the walk-in for approximately one week. The DM confirmed the expired and spoiled items and discarded them during the observation. Review of the facility's policy titled, Food Receiving and Storage, undated, documented . Foods shall be received and stored in a manner that complies with safe food handling practices .
Based on interviews, record review, and review of the facility's policy titled, Comprehensive Care Plans the facility failed to provide the opportunity for residents and/or their representatives to participate in their quarterly care plan meetings for four of 54 sampled residents (Resident (R) 56, R158, R214, and R132) reviewed for care planning. The residents were not invited to their scheduled care plan conferences, and there was no documented evidence of invitations. This failure had the potential to limit residents' rights to be involved in decisions regarding their care and treatment. Findings Include: 1. Review of R56's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R56 had been admitted to the facility on [DATE] with a diagnosis of a tracheostomy. Review of R56's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/26 and located under the MDS tab of the EMR, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident had been cognitively intact. Review of R56's EMR titled Social Services Progress Notes, located under the Prog (Progress) Note tab and dated 02/02/2026, indicated the resident had been invited to and had participated in a care conference. There had been no further evidence that the resident and/or her representative had been invited to participate in her quarterly care conference. Review of R56's MDS tab revealed a quarterly MDS update with an ARD of 03/13/2026. Review of the EMR revealed no documented evidence that the resident and/or her representative had been invited to participate in a quarterly care conference that should have been held in conjunction with the 04/13/26 quarterly MDS update. During an interview on 06/15/2026 at 9:13 AM, R56 stated she had not been invited to a care conference. 2. Review of R158's admission Record, located under the Profile tab of the EMR, indicated R158 had been admitted to the facility on [DATE] with a diagnosis of cerebral infarction. Review of R158's social services Progress Notes, located under the Prog tab of the EMR and dated 12/09/2025, indicated the resident had been invited to and had participated in a care conference. Review of R158's quarterly MDS, with an ARD of 03/19/2026 and located under the MDS tab of the EMR, indicated the resident had a BIMS score of 12 out of 15, which revealed the resident had been moderately cognitively intact. Review of R158's EMR revealed no documented evidence that the resident and/or her representative had been invited to participate in her quarterly care conference that should have been held in conjunction with the 03/19/2026 quarterly MDS update. During an interview on 06/15/2026 at 9:42 AM, R158 stated she had not been invited to her care conferences. The resident had been non verbal but could respond to yes/no questions. During an interview on 06/17/2026 at 3:29 PM, the Social Services Assistant (SSA) confirmed that she had been unable to locate any documented evidence that R56 and R158 had been invited to participate in their quarterly care conferences. The SSA stated that when residents and/or their representatives were invited and participated in their care conferences, this was to be documented in the residents' clinical records. During an interview on 06/18/2026 at 11:58 AM, the Director of Nursing (DON) stated residents and/or their representatives were to be invited to their care planning meetings so they could actively participate in decisions regarding care. 3. Review of R214's admission Record, located under the Profile tab of the EMR, revealed R214 had been admitted on [DATE] with diagnoses including dementia, bipolar disorder, depression, and anxiety. Review of R214's quarterly MDS, with an ARD of 04/27/2026 and located under the MDS tab of the EMR, revealed a BIMS score of 8 out of 15, which indicated R214 had been moderately cognitively impaired. Review of the Plan of Care Note provided by the facility revealed that care conferences had been held on 08/06/24 (no family noted as present), 11/20/2024, 05/13/2025, and 11/11/2025. No other care conference documentation was provided. During an interview on 06/18/2206 at 9:17 AM, the Social Service Director (SSD) stated they conducted care conferences on admission within 72 hours, for changes in condition, quarterly, annually, and as needed. The SSD stated that no additional care conferences had been conducted for R214. 4. Review of R132's undated admission Record, located in the resident's EMR under the Profile tab, revealed the resident had been admitted on [DATE] with diagnoses including chronic respiratory failure, gastrointestinal hemorrhage, and functional quadriplegia. Family member (F)1 had been listed as R132's Responsible Party (RP) and emergency contact. Review of R132's quarterly MDS, with an ARD of 06/01/2026 and located under the MDS tab, revealed the resident had been assessed as being in a persistent vegetative state, and a BIMS interview had not been conducted. Review of R132's Care Plan, located under the Care Plan tab, revealed the following Focus area: Nutrition risk related to multiple medical problems, dependence on PEG/TF to meet nutrition/hydration needs. HX of intolerance – requires specialized TF formula *Emesis/small TF decrease. This Focus had a creation date of 10/17/24 and had been revised on 06/14/2025, 07/07/2025, 08/03/2025, 12/11/2025, and 04/03/2026. Review of R132's Progress Notes, located under the Progress Notes tab, revealed a Social Service note dated 07/01/2025 documenting a care plan meeting held that day, with R132's RP participating via phone. During a phone interview on 06/16/2026 at 11:08 AM, F1 expressed concern that staff had not invited her to R132's care plan meetings. F1 stated that the last care plan meeting she recalled being invited to was approximately 8 to 10 months prior, which she attended by phone. F1 stated she would attend R132's care plan meetings if invited so she could discuss the residents' care and any concerns with staff. During an interview on 06/17/2026 at 11:05 AM, Social Services (SS) 2 stated that the most recent documentation of F1 being invited to R132's care plan meetings was the Social Services progress note dated 07/01/2025. SS2 stated residents and family members should be invited to attend quarterly care plan meetings. Review of the facility policy titled Comprehensive Care Plans, dated October 2025, documented Policy: It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, and all services identified in the resident's comprehensive assessment, and meet professional standards of quality.
Based on record review and interviews, the facility failed to ensure communication took place between the facility and the dialysis center for one of one resident (R) (R9), reviewed for dialysis services out of a total sample of 61. This deficient practice could result in residents who are on dialysis not receiving the needed care or services.Findings include: Review of R9's admission Record under the Profile tab in the electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (ESRD) and dependence on renal dialysis. Review of R9's Quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Review Date (ARD) of 04/16/206 revealed R9 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he was cognitively intact. The MDS indicated R9 received dialysis services. Review of the Order Summary Report under the Orders tab in the electronic medical record (EMR) revealed an order, dated 11/17/2025, which indicated, Dialysis . one time a day every Tue [Tuesday], Thur [Thursday], Sat [Saturday] for hemodialysis. An order dated 06/12/2026 indicated, Open Dialysis Communication Record in PCC [Point Click Care, the EMR] Every Tuesday, Thursday, and Saturday and ensure that our portion is complete and send copy for dialysis to complete their portion. every day shift every Tue, Thu, Sat. There was no order for dialysis communication records prior to 06/12/2026. Review of the Care Plan Report under the Care Plan tab in the EMR revealed, The resident has ESRD . resident requires hemodialysis . Date Initiated: 09/23/2024. The care plan did not include communication notes with the ESRD facility. A review of assessments under the Assessment tab in the EMR revealed Dialysis Communication Record documents dated 05/28/2026, 05/30/206, 06/02/2026, 06/132026, and 06/16/2026. No other Dialysis Communication Records were in the EMR. In an interview with Registered Nurse (RN) 2 on 06/17/2026 at 3:45 PM, who was assigned to R9, she stated she did not document on the dialysis communication notes. In an interview with [NAME] Unit Manager (WUM) on 06/17/2026 at 3:46 PM, she reviewed R9's record and confirmed there were no Dialysis Communication Records prior to May of 2026 and the only Dialysis Communication Records in R9's EMR were those dated 05/28/2026, 05/30/2026, 06/02/2026, 06/13/2026 and 06/16/2026, which were all incomplete and the one dated 05/30/2026 was blank. She stated R9 went to dialysis three times a week and there were no Dialysis Communication Records for any other dates and there should be. The WUM stated the nurses enter data thato complete the pre-dialysis assessment and when the resident comes back, the nurse was supposed to data enter what the dialysis facility staff documented on the note into PCC. In an interview with the Regional Director of Operations, on 6/17/2026 at 4:55 PM, she confirmed the Dialysis Communication notes were supposed to be in the record.
Based on observations, staff interviews, record review, and review of the facility's policies titled Oxygen Administration and Tracheostomy Care, the facility failed to administer oxygen to one of one resident (Resident (R) 15) and provide tracheostomy care to one of five residents (R265) per physician order out of six residents reviewed for respiratory care out of a total sample of 61 residents. The deficient practice had the potential to place R15 and R265 at increased risk of respiratory complications. Findings include: 1. Review of R15's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R15 was admitted to the facility on [DATE] with diagnoses of chronic diastolic (congestive) heart failure, asthma, acute and chronic respiratory failure, depression, atrial flutter, anxiety disorder, paranoid personality disorder, acute ischemic heart disease, emphysema, and chronic obstructive pulmonary disease (COPD). Review of R15's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/18/2026, located under the MDS tab of the EMR, documented the facility assessed R15 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R15's Care Plan, initiated on 07/31/2024 and located under the Care Plan tab of the EMR, revealed the resident was on oxygen related to congestive heart failure, with the head of bed elevated to prevent shortness of breath when lying flat. Interventions included administering medications as ordered. Review of R15's Physicians Orders, located under the Orders tab of the EMR, revealed an order dated 01/13/2026, for 2 [two] L [liters]/min humidified oxygen via nasal cannula every shift for emphysema, unspecified. Titrate oxygen as needed to keep saturation level at 92% [percent] or greater. During observations on 06/15/2026 at 3:26 PM and 06/17/2026 at 9:52 AM, the oxygen level on R15's oxygen concentrator was set at 4.5 liters per minute (LPM) via nasal cannula, and there was no humidification. During an observation on 06/18/2026 at 9:10 AM, the oxygen level on R15's oxygen concentrator was set at two LPM via nasal cannula, and there was no humidification. During an observation and interview on 06/18/2026 at 9:12 AM, Licensed Practical Nurse (LPN) 2 verified R15's oxygen order and verified that the level on the oxygen concentrator was set at 2 LPM as ordered, and there was no humidification. LPN2 confirmed that R15 should have a humidification bottle attached to the oxygen concentrator. LPN2 stated the O2 was at 4.5 LPM yesterday and was adjusted to two LPM as ordered. During an interview on 06/19/2026 at 3:11 PM, the Director of Nursing (DON) stated, The expectation is for nurses to follow orders as prescribed to prevent adverse reactions with respiratory issues. Review of the facility's policy titled Oxygen Administration, dated 04/25, indicated, Oxygen is administered under orders of a physician, except in the case of an emergency. 2. Review of R265's admission Record under the Profile tab in the EMR revealed R265 was admitted to the facility on [DATE] with diagnoses of encephalopathy (altered brain function), respiratory failure, and tracheostomy status. Review of the Nursing Assessment Comprehensive, dated 06/11/2026, under the Assessments tab of the EMR revealed, . 5c. Resident respiratory care: 1. Tracheostomy care . Review of the Order Summary Report under the Orders tab in the EMR revealed Change inner cannula XLT [extra long tube] every shift dated 06/11/2026, and Trach [tracheostomy] and stoma care provided every shift. On 06/15/2026 at 10:30 AM, R265 was observed in her room, lying in bed. R265 had a tracheostomy (opening in the throat for breathing). Review of the Care Plan Report under the Care Plan tab in the EMR revealed, The resident has a tracheostomy . Date Initiated: 06/17/2026 . The resident will have no s/sx [signs and symptoms] of infection . Review of the Medication Administration Record ERESPMAR [electronic respiratory medication administration record] for June 2026 under the Orders tab in the EMR revealed, Trach and stoma care provided every shift was completed on the day shift on 06/14/2026 but was blank on the night shift, and Trach and stoma care provided as needed was blank on 06/14/2026, revealing that tracheostomy and stoma care was only provided once on 06/14/2026. In an interview with Respiratory Technician (RT) 1 on 06/19/2026 at 3:35 PM, he confirmed that the Trach and stoma care provided every shift on the June MAR was blank on the 06/14/2026 night shift. In an interview with the Director of Nurses (DON) on 06/19/2026 at 3:40 PM, she confirmed there was no documented evidence that tracheostomy and stoma care was provided to R265 on the 06/14/2026 night shift as ordered, and it should have been. Review of the facility's policy titled, Tracheostomy Care revised June 2023, revealed, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care . is provided such [sic] care consistent with professional standards of practice . 3. Tracheostomy care will be provided according to the physician's orders . General considerations include: . a. Provide tracheostomy care at least twice daily.
Based on observations, staff interviews, record review, and review of the facility's policy titled Care and Treatment of Feeding Tubes, the facility failed to properly administer enteral formulas for three of 10 residents (Resident (R)132, R13, and R22) reviewed for tube feedings out of a total sample of 61. The facility failed to administer the correct enteral formula to R132 and failed to record the time on the enteral formula bottle when administration began for R13 and R22. These failures had the potential to cause gastrointestinal issues and/or weight loss for residents who require tube feedings. Findings include: 1. Review of R132's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dysphagia, chronic respiratory failure, gastrointestinal hemorrhage, and functional quadriplegia. Review of R132's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2026 and located in the resident's EMR under the MDS tab, revealed the resident was assessed as being in a persistent vegetative state and a Brief Interview for Mental Status (BIMS) was not conducted. The MDS also indicated the resident had a feeding tube and received 51 percent or more of her total calories through the feeding tube. Review of R132's current Care Plan, located in the resident's EMR under the Care Plan tab, revealed the following Focus area: Nutrition risk related to multiple medical problems, dependence on PEG /TF [Percutaneous Endoscopic Gastrostomy/Tube Feeding] to meet nutrition/hydration needs. HX [History] of intolerance- requires specialized TF formula *Emesis/small TF decrease. Care Plan interventions included Provide tube feedings and free water flushes are ordered, and Specialized TF formula- medically justified per MD. Review of R132's Physician's Orders, located in the EMR under the Orders tab, revealed the following order: two times a day for nutrition set pump to administer Vital 1.5 @ [at] 50 ml/hr [milliliters per hour] starting at 1400 [2:00 PM] and continuing until 1000ml [milliliter] volume has infused (approx. [approximately] 20hrs [hours] OFF 10 am – 1400 pm) to provide- 1500kcals [calories]/day via PEG. This order was initiated on 04/08/2026. Review of R132's Progress Notes, located in the EMR under the Prog [Progress] Note tab, revealed the following note written by the facility's Registered Dietitian (RD) on 04/13/2026: RD note: Notified of recent emesis: Nursing requests TF decrease as resident appears very full . Vital 1.5 formula specific for GI [gastrointestinal] issues . Recommend Vital 1.5 @ 50ml/hr until 1000ml volume has infused . to provide 1500kcals [calories], 68 gms [grams] protein, 764 ml free water . RD to follow prn [as needed]. During an interview on 06/18/2026 at 2:10 PM, the facility's RD stated R132 needed to receive Vital, which is a specialized-peptide-based enteral formula, because she had gastrointestinal intolerances and malabsorption issues, so she was unable to tolerate other enteral formulas. During an observation on 06/19/2026 at 10:55 AM, R132 was in bed with a bottle of TwoCal HN hanging from an Intravenous (IV) stand, which was positioned next to her bed, and a handwritten notation on the bottle indicated that it was hung for administration on 06/18 at 11:40 PM. There was approximately 600 ml of formula left in the 1000 ml bottle. During an interview on 06/19/2026 at 11:08 AM, the facility's RD stated she was unaware that R132 enteral feeding had been changed from Vital 1.5 to TwoCal HN. The RD stated that, to her knowledge, R132 was still receiving Vital 1.5. During an observation on 06/19/2026 at 11:10 AM, with the RD and Registered Nurse (RN)1 present, R132 was in bed with a bottle of TwoCal HN hanging from her IV stand with 600 ml of formula remaining in the 1000 ml bottle. During an interview on 06/19/2026 at 11:10 AM, RN1 stated R132 should not be receiving TwoCal HN because her current physician's order was for Vital 1.5 via her gastrostomy tube. During an observation on 06/19/2026 at 11:15 AM, the RD checked the supply closet, located behind the nurse's station, and showed this surveyor that bottles of Vital 1.5 were available in the supply closet for staff to administer to R132 as ordered. During an interview on 06/19/2026 at 11:2026 AM, RN2, who was assigned to care for R132 on 06/19/2026 during the 7:00 AM to 7:00 PM shift, stated her shift began at 7:00 AM, and she checked on R132, but did not notice the wrong enteral formula was being administered by her pump and gastrostomy tube. RN2 stated she should have checked R132's tube feeding more closely and caught this error. 2. Review of R13's admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominate side, and encephalopathy. Review of R13's significant change MDS, with an ARD of 05/12/2026 and located in the resident's EMR under the MDS tab, revealed a BIMS score of 99, which indicated the resident was unable to complete the interview. The MDS also indicated the resident had a feeding tube and received 51 percent or more of her total calories through the feeding tube. Review of R13's current Care Plan, located in the resident's EMR under the Care Plan tab, revealed the following Focus area: The resident requires a feeding tube r/t [related to] swallowing problem. A Care Plan intervention specified, The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Review of R13's Physician Orders, located in the EMR under the Orders tab revealed the following orders: every night shift for gastrostomy status . Enteral: Closed system container- Change feeding administration set with each new bottle; label the formula container, syringe and administration set with the resident's name, date, time, and nurse's initials and two times a day for nutrition set pump to administer Jevity 1.5 @ 50ml/hr continuous starting at 1000 [10:00 AM] and continuing until 1000 ml had infused (approx. [approximately] 20hrs [hours]) . Observations of R13 on 06/15/2026 at 9:21 AM, 11:36 AM, and 4:13 PM; on 06/16/2026 at 10:24 AM and at 3:08 PM; and on 06/17/2026 at 8:45 AM revealed the resident was in bed with an IV stand positioned next to her bed. A bottle of enteral formula was observed hanging from the stand and connected to the resident via a tube. The bottle of enteral formula was dated but did not contain a time when it was hung by staff for administration. An observation on 06/17/2026 at 9:33 AM, with the Director on Nursing (DON) present, revealed R13 was in bed with a bottle of enteral formula hanging from the IV stand that was next to her bed. The bottle of enteral formula was dated 06/16, but the time was not recorded when it was hung by staff for administration. During an interview on 06/17/2026 at 9:33 AM, the DON confirmed the bottle of enteral formula that was being administered to R13 was not timed when hung by staff. The DON stated she expected staff to write the date and time on an enteral formula bottle when it was hung for administration. 3. Review of R22's admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and dementia. Review of R22's quarterly MDS, with an ARD of 06/01/2026 and located in the resident's EMR under the MDS tab, revealed a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. The MDS also indicated the resident had a feeding tube and received 51 percent or more of his total calories through the feeding tube. Review of R22's current Care Plan, located in the resident's EMR under the Care Plan tab, revealed the following Focus area: Nutrition risk related to multiple medical problems, nutrition/hydration via PEG. Hx [History] of weight changes Skin compromised. A Care Plan intervention specified, Provide tube feedings and free water flushes as ordered. Review of R22's Physician Orders, located in the EMR under the Orders tab, revealed the following order: two times a day for nutrition set pump to administer Jevity 1.5 @ 65ml/hr starting at 1000 [10:00 AM] and continuing until 1300 ml volume has infused (approx. 20 hrs off 6AM - 10AM) . Observations of R22 on 06/15/2026 at 12:17 PM, 1:55 PM, and 4:20 PM; on 06/16/2026 at 9:52 AM and 3:16 PM; and on 06/17/2026 at 8:46 AM revealed the resident was in bed with an IV stand positioned next to his bed. A bottle of enteral formula was observed hanging from the stand and connected to the resident via a tube. The bottle of enteral formula was dated but did not contain a time when it was hung by staff for administration. During an observation on 06/17/2026 at 9:25 AM, with the DON present, R22 was observed in bed with a bottle of enteral formula hanging from the IV stand that was next to his bed. The bottle of enteral formula was dated 06/16, but it was not timed when hung for administration by staff. During an interview on 06/17/2026 at 9:25 AM, the DON confirmed the bottle of enteral formula being administered to R22 was not timed when hung by staff. The DON stated she expected staff to write the date and time on an enteral formula bottle when it was hung for administration. Review of the facility's policy titled Care and Treatment of Feeding Tubes, dated 10/2024, indicated, Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 1. Feeding tubes will be utilized according to physician's orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush .
Based on observation, interview, and record review, the facility failed to ensure the pressure-relieving air mattress was set according to manufacturer specifications for two of ten residents (Resident (R) 122 and R40) reviewed for pressure ulcers. This failure placed the resident at risk for skin breakdown and compromised pressure injury management. 1. Review of R122's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R122 was admitted to the facility on with diagnoses that included tracheostomy and diabetes mellitus. Review of R122's Care Plan, located under the Care Plan tab of the EMR and dated 10/24/2205, indicated that the resident had an actual skin impairment related to wound on the sacrum. The Care Plan did not address the use of an air mattress as a pressure ulcer prevention/healing device. Review of R122's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2026 and located under the MDS tab of the EMR, indicated staff could not determine a Brief Interview for Mental Status (BIMS) score. The assessment indicated that the resident was dependent on all activities of daily living. The assessment indicated that the resident had a stage four pressure ulcer. Review of R122's weights, located under Weight & Vitals tab of the EMR, identified R122 weighed 137.2 pounds on 06/12/2026. Review of R122's Orders, located under the Orders tab of the EMR and dated 06/15/2026, indicated the medical provider ordered the resident to be placed on an air mattress.During observations on 06/16/2026 at 9:16 AM and 06/17/2026 at 9:31 AM, R122 was observed lying in bed on an air mattress. At the foot of his bed was a control panel for the air mattress that he was on. The label identified Progressive and under the control panel labeled comfort zone it was set at 220. During an interview on 06/17/2026 at 9:57 AM, Registered Nurse (RN) 3, who was also the facility's wound nurse and the Regional Wound Care Director. RN3 stated that there were air mattresses that require a weight. RN3 and the Regional Wound Care Director stated that R122's air mattress was set at his weight.During an interview on 06/17/2026 at 11:10 AM, RN3 stated that she would review clinical records to obtain a resident's weight. RN3 was informed of R122's current weight was 137.2. RN3 confirmed the control panel of air mattress was set at 220 pounds. During an interview conducted on 06/17/2026 at 11:21 AM, the Regional Wound Care Director stated that it was important to have the correct weight set on R122's air mattress since the mattress would be firmer at a higher weight and it would not be beneficial for the resident to heal his pressure ulcer. During an interview conducted on 06/18/2026 at 12:29 PM, the DON stated that the air mattress needed to be set to the resident's correct weight. The DON stated that not entering the correct resident weight defeated the intended use of the air mattress. 2 Review of R40's admission Record under the Profile Is this supposed to be in quotes? tab in the EMR revealed R40 was admitted to the facility on [DATE] with diagnoses of cerebral hemorrhage (stroke), respiratory failure and encephalopathy (altered brain function.) Review of R40's Progress Notes under the Progress Notes tab in the EMR revealed, MD [Medical Doctor] admission H&P [history and physical], dated 05/04/2026 indicated R40 was nonverbal and nonresponsive and was admitted from the hospital with bilateral heel DTIs [deep tissue injuries] and a stage 4 sacral pressure injury [a wound with depth to the bone]. A wound note, dated 05/08/2026 indicated R40 was on a low air loss mattress.Review of the Weight Summary under the Weights tab in the EMR, revealed R40's weight was 144.8 lbs (pounds) on 05/05/2026 and 152 lbs on 06/12/2026.Review of the Care Plan Report under the Care Plan tab in the EMR revealed, The resident has pressure ulcers r/t [related to] Immobility stage 4 sacral . re-admission: stage 4 sacrum, R/L [right/left] heel . Unstageable . Created on: 05/04/2026 . The resident's . Pressure ulcer will show signs of healing . Date Initiated: 05/04/2026 .Observation on 06/15/2026 at 12:45 PM, R40 was observed in his room, unresponsive, lying in bed on a pressure-reducing mattress.On 06/17/2026 at 12:37 PM, R40 was observed in his room lying in bed, unresponsive. R40 was laying on a Proactive Protekt Aire 4000DX/5000DX low air loss mattress (LALM) which was set to 240 . LBS . Weight Setting.On 06/17/2026 at 12:40 PM, R40 was observed in his room lying in bed. His LALM was set at 180. Two certified nurse assistants (CNAs) were at R40's bedside, CNA13 and CNA 14. They both stated R40's LALM weight setting read 180. They both stated they do not adjust the weight settings on the LALM.In an interview with Registered Nurse (RN) 3, the Wound Care Nurse, on 06/17/2026 at 12:55 PM, she confirmed she was responsible for adjusting the settings on R40's LALM. She confirmed R40's LALM had been set to 240 lbs and stated it was supposed to be set to 150 because he weighed 152 lbs. Review of the Proactive medical products Operation Manual FOR Protekt Aire 4000DX/5000DX revealed, The Protekt(R) Aire 4000DX/5000DX system is designed for prevention, treatment and management of pressure ulcers . PRODUCT FUNCTION . Pump Unit . The functions of the pump for Protekt(R) Aire 4000DX/5000DX system are described below . Power Key(1) . Press Power key on the panel, the pump will start/stop operation . Press Weight Range(2) . Press up or down buttons to select the correct patient weight .
Based on observations, interviews, record review, and policy review, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for four of 61 sampled residents (R) (R251, R233, R200 and R7). Residents were observed idle for extended periods with no engagement, individualized programming, or staff led activities that reflected their cognitive abilities, interests, or past life roles. This had the potential to cause psychosocial decline, including social isolation, depression, decreased quality of life, and cognitive and functional deterioration.Findings include: 1. Review of R251's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R251 was admitted to the facility on [DATE] with a diagnosis of dementia with other behavioral disturbances. Review of R251's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2026 and located under the MDS tab of the EMR, indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, which revealed severe cognitive impairment. The assessment further documented that R251 required partial to moderate staff assistance for transfers from bed to chair. Review of R251's Care Plan, located under the Care Plan tab of the EMR and dated 06/04/2026, indicated that the resident was not interested in attending activities. The interventions included establishing and recording the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family, and the resident needed a variety of activity types and locations to maintain interests. Review of documents provided by the facility titled, Individual Programming Participation Record, for the month 04/2026, indicated the following: For the week of 04/27/2026, R251 received 20 minutes of one-on-one visits. Review of documents provided by the facility titled, Individual Programming Participation Record, for the month of 05/2026, indicated the following: For the week of 05/04/2026, R251 received 26 minutes of one-on-one visits. For the week of 05/11/2026, R251 received 25 minutes of one-on-one visits. For the week of 05/18/2026, R251 received 10 minutes of one-on-one visits. For the week of 05/25/2026, R251 received 10 minutes of one-on-one visits. Review of documents provided by the facility titled, Individual Programing Participation Record, for the month of 06/2026, indicated the following: For the week of 06/01/2026, R251 received 15 minutes of one-on-one visits. For the week of 06/08/2026, R251 received 27 minutes of one-on-one visits. 2. Review of R233's admission Record, located under the Profile tab of the EMR, revealed R233 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R233's quarterly MDS, with an ARD of 02/10/2026 and located under the MDS tab of the EMR, indicated that the staff could not determine R233's BIMS score. The assessment indicated R233 was dependent on staff for all activities of daily living. Review of R233's Care Plan, located under the Care Plan tab of the EMR, failed to indicate the resident's preferences and level of involvement in person centered activities. Review of documents provided by the facility titled, Individual Programming Participation Record, for the month 04/2026, indicated the following: for the week of 04/27/2026, R233 received 45 minutes of one-on-one visits. Review of documents provided by the facility titled, Individual Programming Participation Record, for the month 05/2026, indicated the following: For the week of 05/02/2026, R233 received 65 minutes of one-on-one visits. For the week of 05/11/2026, R233 received 30 minutes of one-on-one visits. For the week of 05/18/2026, R233 received 57 minutes of one-on-one visits. For the week of 05/25/2026, R233 received 25 minutes of one-on-one visits. Review of documents provided by the facility titled, Individual Programming Participation Record, for the month 06/2026, indicated the following: For the week of 06/01/2026, R233 received 30 minutes of one-on-visits. For the week of 06/08/2026, R233 received 25 minutes of one-on-one visits. 3. a. Review of a document titled Unit Activities Calendar, for the month of 06/2026 and provided by the facility, indicated the following scheduled activities for 06/15/2026: 9:30 AM Coffee and News, 10:00 AM Busy Table, 11:00 AM Sticky Ball Toss, 11:30 AM Arts and Crafts, 2:00 PM Baking Cookies, 3:00 PM Patio Chat, 3:30 PM Music and Snacks, and 4:00 PM Funny TV Time. During an observation conducted on 06/15/2026 at 11:20 AM, there was no music, television, or other interactive activities available in the shared room of R251 and R233. Additionally, the hallway of the secured unit, in which these residents resided, had bare walls, with no tactile or engagement-focused activities affixed to the environment. The unit was quiet and lacked natural activity engagement with the residents and staff. b. Review of a document titled Unit Activities Calendar for the month of 06/2026 and provided by the facility, indicated the following scheduled activities for 06/16/2026: 9:30 AM Coffee and News, 10:00 AM Funny TV Time, 11:00 AM Baking Time, 11:30 AM Sticky Ball Toss, 2:00 PM Ice Cream social, 3:00 PM Patio Chat, 3:30PM Arts and Crafts, and at 4:00 PM Balloon Toss. During an observation on 06/16/2026 at 1:56 PM, the unit was void of activities. Residents were in their rooms. During an interview on 06/16/2026 at 2:40 PM, Certified Nurse Aide (CNA) 6, who worked on the secured unit, stated that there were some residents who were taken off the unit to attend activities. During an observation on 06/16/2026 at 2:47 PM, activity staff were passing out orange cream popsicles to the residents on the secured unit. R251 and R233 were in their room. There was no socialization occurring while staff were passing out the popsicles. There was no group activity ongoing on the unit. During an interview on 06/16/2026 at 2:50 PM, CNA 3, who worked on the secured unit, was asked if she knew where the activity's calendar was posted. She stated that she did not know. During an observation and interview on 06/16/2026 at 2:52 PM, Activity Assistant (AA)1 stated that there were no activity staff members assigned to the secured unit. AA1 stated that she had only been in her position for the past month and stated that activities were not provided on the secured unit. R233 was in the hallway, seated in a geriatric chair. An attempt was made to interview R233, and she provided no response. During an interview on 06/16/2026 at 2:57 PM, CNA8, who worked on the secured unit, stated that she had not seen any meaningful activities for the residents on the secured unit. CNA8 stated that staff would get residents up to eat in the dining room, stationed outside of the unit. CNA8 stated that there were no items for the residents to handle or fidget with. CNA8 stated R233 fidgeted a great deal. c. Review of a document titled Unit Activities Calendar, for the month of 06/2026 and provided by the facility, indicated the following scheduled activities for 06/17/2026: 9:30 AM Coffee and News, 10:00 AM Balloon Toss, 10:30 AM Busy Table, 11:00 AM Let's Get Moving, 11:30 AM Remember when, 2:00 PM Funny TV Time, 3:00 PM Patio Chat, 3:30PM Music and Snacks, and at 4:00 PM Sticky Ball Toss. During an interview on 06/17/2026 at 12:30 PM with CNA5, who worked on the secured unit stated that there were no on-going activities on the secured unit. CNA5 stated she did not see any activity staff engaging with the residents and performing activities such as reading to the residents or providing them with hand massages. CNA5 stated R251 was currently off of the secured unit and attending an activity. CNA5 stated R251 was rarely taken off the unit for an activity. During an interview on 06/17/2026 at 12:30 PM, Licensed Practical Nurse (LPN) 6 stated she typically worked on the secured unit. LPN6 stated the activity department would occasionally provide snacks and coffee for the residents on the secured unit. LPN6 stated that the residents who were on the secured unit and could participate in activities were taken off the unit to participate in activities off the unit. LPN6 stated she had not seen any activity staff provide activities such as reading, playing music, or providing hand massages to the residents on the unit. LPN6 stated that it felt dead back on the secured unit since there were no resident specific activities being provided to the residents on the unit. 4. Review of R200's admission Record located under the Profile tab of the EMR revealed R200 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis and muscle weakness. Review of R200's admission MDS, with an ARD of 05/21/2026 and located under the MDS tab of the EMR, indicated the resident had a BIMS score of 15 out of 15, which revealed the resident was cognitively intact. The assessment indicated that it was very important for the resident to listen to music and to be involved in her favorite activities. It recorded R200 had bilateral upper extremity impairment and no impairment on her lower legs. The assessment indicated that the resident was dependent on staff for all activities of daily living. Review of R200's Care Plan, located under the Care Plan tab of the EMR and dated 05/15/2026, failed to indicate the resident's preferences and level of involvement in person centered activities. During an interview on 06/16/2026 at 8:48 AM, R200 stated initially the Activity Director came in and asked her if she wanted to participate in activities. R200 stated she wanted to and wanted to attend Bingo and the other programs that were on the activity calendar, but she had not been taken to any activity. During an interview on 06/17/2026 at 4:11 PM, the Administrator stated there were no activity logs for R200, and her expectation was for all residents to be involved in activities. The Administrator stated that the administrative staff participated in an activity development for dementia and they had not fully implemented this program. The Administrator stated that she would have expected more activities for the residents who lived on the dementia unit. During an interview on 06/17/2026 at 5:41 PM, the Activity Director (AD) stated she was currently reassessing the residents who reside on the secured unit for activities. The AD stated she had not completed assessments for all the residents. The AD stated that there was no space on the secured unit to hold activities. The AD stated the facility was in the process of revamping the activity program on the secured unit. 5. Review of R7's admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included vascular dementia, chronic obstructive pulmonary disease, and acute kidney failure. Review of R7's admission MDS, with an ARD of 05/07/2026 and located in the EMR under the MDS tab, revealed the resident had a BIMS score of 10 out of 15, which indicated R7 was moderately cognitively impaired. Further review of the admission MDS assessment revealed R7's activity preferences included: listening to music, being around animals, doing things with groups of people, doing favorite activities, and going outside to get fresh air was very important to her. Additionally, her activity preferences specified having books, newspapers, and magazines to read, keeping up with news, and participating in religious services or practices were somewhat important to her. Review of R7's Care Plan, located in the EMR under the Care Plan tab, revealed the resident's care plan was initiated on 05/02/2026. R7's care plan contained the following Focus area: The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Vascular Dementia. Further review of R7's care plan revealed a care plan Focus for the area of Activities had not been developed. Review of R7's Progress Notes, located in the resident's EMR under the Prog[[NAME]] Notes tab, revealed there were no activity progress notes written since the resident's admission to the facility on [DATE]. During observations on 06/15/2026 at 9:26 AM, at 11:25 AM, and at 4:36 PM, and on 06/16/2026 at 10:34 AM, R7 was observed in her room with no music or television playing. During these observations, no activities were observed taking place in the facility's secured unit. During an interview on 06/15/2026 at 11:25 AM, R7 was pleasantly confused and unable to answer questions regarding her activity preferences or her participation in facility activities. During an interview on 06/17/2026 at 11:14 AM, the AD stated the facility's secured unit did not have a separate activity calendar. The AD stated there were no common areas and very limited space in the facility's secured unit to have resident group activities, so the activity staff were to assist residents who resided in the secured unit to the scheduled activities outside of the unit. The AD stated that she was not sure if R7 had participated in any activities on 06/15/2026 and on 06/16/2026. The AD checked R7's activity participation records since her admission to the facility on [DATE] and showed the records to this surveyor. Review of R7's activity participation records revealed that R7 had not participated in any activities since her admission to the facility on [DATE] which was confirmed by the AD. The AD also reviewed R7's EMR and confirmed no activity progress notes had been written since her admission to the facility. The AD stated that when R7 was admitted to the facility, her activity preferences were obtained from the resident. The AD stated no plan had been developed to incorporate R7's activity preferences to ensure the resident participated in activities that she preferred, and that the facility's activity program met her individual needs. Review of a facility's policy titled, Activities dated 01/2024, indicated, . It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community.
Based on observations, record review, interviews, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure Activities of Daily Living (ADLs) were conducted for five of 61 sampled residents (R) (R47, R247, R200, R10, and R151). The facility failed to ensure timely incontinence care was provided for one resident (R47); ensure showers and/or baths were conducted for three residents (R247, R200, and R151); and ensure facial hair was trimmed and nails clipped for one resident (R10). This failure had the potential to compromise residents' hygiene and quality of life. Findings include: 1. Review of R47's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R47 was admitted on [DATE] with diagnoses which included age related physical disability and bilateral primary osteoarthritis of the knee. Review of R47's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/23/2026 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R47 was cognitively intact. The resident was identified as dependent for toileting. During an observation and interview on 06/15/2026 at 10:14 AM, R47 stated she had been wet since night shift, from night shift. She states she was unable to walk and had incontinence briefs. She stated her call light did not work, so she had a bell at her bedside. She stated the staff ignored her bell and it was ridiculous. R47 stated the staff told her they would clean her up after breakfast. By 10:23 AM, she was observed to have rung the bell several times with no response. During an interview on 06/15/2026 at 10:33 AM, the housekeeper (HSK) stated the residents were ignored by staff. At 10:42 AM, she stated there was only so much they could do with the smell, and that the staff needed to change the residents. During further observation on 06/15/2026 at 10:50 AM, a Certified Nursing Assistant (CNA) 7 went into the resident's room to assist. By 11:23 AM, CNA7 was observed to have completed the incontinence care. The brief had feces and excess, dripping urine. CNA7 stated it would not have been this wet if she had been changed the previous shift. She stated this was her first time changing her this shift. CNA7 confirmed the excess urine-soaked brief. Review of the June 2026 Documentation Survey Report for toilet use, provided by the facility, revealed 06/14/2026 was blank for incontinence care and 06/15/2026 was documented at 3:28 PM. During an interview on 06/16/2026 at 2:43 PM, the Director of Nursing (DON) confirmed the blank incontinence documentation for the previous night on 06/14/2026. The DON stated the expectation was that the residents were changed in a timely manner, at least within 30 minutes. She stated nobody should be waiting a long time and the staff should have been rounding every two hours. During an interview on 06/18/2026 at 9:34 AM, the Administrator and DON stated they were unaware of any current resident with incontinence care concerns. They stated in-services had been completed but not regarding incontinence care. 2. Review of R247's admission Record located under the Profile tab of the EMR revealed R247 was admitted on [DATE] and initial admission on [DATE] with diagnoses which included dementia and major depression. The resident was discharged on 02/27/2026. Review of R247's five-day MDS with an ARD of 12/28/2025 and located under the MDS tab of the EMR, revealed a BIMS score of 13 out of 15 which indicated R247 was cognitively intact. The resident was identified as dependent for showers/bathing. Review of the facility-provided February 2026 Documentation Survey Report for bathing revealed that the resident received a bath or shower on 02/13/2026, 02/18/2026, and 02/21/2026. There was no documentation for November 2025, December 2025, or January 2026. During an interview on 06/17/2026 at 8:22 AM, the Administration and DON stated they had a binder with shower sheets completed for the residents. They stated the bathing/showers were not documented in the EMR. They stated they did not have bath aides. They stated the CNAs had assigned residents, and restorative staff were there to assist. At 3:51 PM, the Administrator stated they did not have any bathing documentation for this resident and that they did not have that information for discharged residents. 3. Review of R200's EMR titled admission Record located under the Profile tab indicated that the facility admitted the resident on 05/15/2026 with diagnoses that included spinal stenosis and muscle weakness. Review of R200's admission MDS located under the MDS tab of the EMR with an ARD of 05/21/2026 indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment indicated that the resident was dependent on staff for all activities of daily living. Review of R200's EMR titled Care Plan located under the Care Plan tab dated 05/15/2026 indicated that the resident had an ADL self-care deficit related to musculoskeletal status. Under the Interventions column, for bathing/showering preferences failed to identify her bathing/showers preferences. Review of untitled documents provided by the facility but referred to as Bed Bathes indicated R200 had a bed bath on the following days: 05/18/2026, 05/26/2026, and 06/09/2026. During an interview on 06/16/2026 at 8:52 AM, R200 stated her bed baths were not routine. During an interview on 06/18/2026 at 8:18 AM, the Administrator confirmed there were no more bed/shower records for R200. At 12:26 PM, the Administrator stated a resident should have a shower/bath at least twice a week, and then as requested by the resident. 4. Review of R151's admission Record in the Profile tab of the EMR revealed R151 was admitted to the facility on [DATE] with a diagnosis of myocardial infarction (heart attack) Review of the Quarterly MDS with an ARD of 05/06/2026, revealed R151 had a BIMS score of 15 out of 15, indicating she was cognitively intact. The assessment indicated R151 ambulated with a walker and required partial/moderate assistance to shower/bathe. Review of the Care Plan Report under the Care Plan tab in the EMR revealed, The resident has an ADL self-care performance deficit . Bathing/Showering: The resident requires (partial assistance) by staff for (bathing/showering) as necessary . Review of the untitled documents provided by the facility as documentation of R151's showers/bathing for May and June of 2026 revealed notes for the following dates: 05/09/2026, 05/16/2026, 05/25/2026, and 06/02/2026. In an interview with R151 on 06/15/2026 at 10:00 AM, she stated she didn't get showers the way she was supposed to. She stated she used to get showers three times a week but that was changed to two times a week but sometimes she would go for days without a shower. She said she had asked staff but it had not changed. In an interview with DON on 06/19/2026 at 5:08 PM, she stated the facility changed its shower schedule from three times a week to two times a week but residents could ask for a third shower any time and they would receive one. She stated the untitled notes were the shower sheets for R151. She stated the facility's week was from Sunday to Saturday. She confirmed R151 received one shower during the weeks of 05/10/2026 and 05/24/2026, and she should have received two. 5. Review of R10's admission Record, dated 05/18/2026 in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses of a history of stroke and seizures. Review of R10's quarterly MDS with an ARD of 05/23/2026 in the EMR under the MDS tab revealed a BIMS score of 00 out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated the resident was totally dependent upon staff to complete personal hygiene. Review of R10's ADL Care Plan, dated 02/05/2026, in the EMR under the Care Plan tab indicated, .resident is dependent on staff for ADL care . On 06/15/2026 at 3:36 PM, R10 was observed lying in bed, unshaven, with left-hand fingernails visibly uneven and varying in length, with several 1/2-inch past the tips of his fingers. On 06/17/2026 at 10:05 AM R10 was observed lying in bed, unshaven, fingernails visibly uneven and varied in length, with several 1/2 inch past the tips of his fingers. During an interview on 06/17/2026 at 11:10 AM CNA16 confirmed R10 was totally dependent on staff for ADL hygiene, and he was unshaven with fingernails uneven and varied in length, with several 1/2 inch past the tips of his fingers, and confirmed he needed to be shaved and his fingernails trimmed. CNA 16 stated R10 usually receives a bed bath, and the resident was wiped down this morning. Also stated the last time she shaved him was two weeks ago. During an interview on 06/17/2026 at 11:13 AM Licensed Practical Nurse (LPN) 10 confirmed R10 was totally dependent on staff for ADL hygiene, and he was unshaven with fingernails uneven and varied in length, with several 1/2 inch past the tips of his fingers, and confirmed he needed to be shaved and his fingernails trimmed. LPN 10 stated residents receive bed baths two to three times per week and should be shaved at least weekly; nail care should be done by CNAs when the resident gets a shower. During an interview on 06/18/2026 at 10:42 AM, Administrator and Director of Nursing (DON) confirmed that personal hygiene, including shaving and nail care, should be provided every day, and a dependent resident should not be left unshaven or with fingernails in varied length, or 1/2 inch past the tips of the fingernails. Review of the facility policy titled Activities of Daily Living (ADLs), revised October 2025, revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Based on interviews, record review, and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for one of 54 sampled residents (R) R 200. The failure to develop a care plan increased the risk of incomplete and/or inconsistent care related to the resident's risk of developing pressure ulcers. Findings include: Review of R200's admission Record located under the Profile tab of the electronic medical record (EMR) indicated R200 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis and muscle weakness. Review of R200's admission MDS, with an Assessment Reference Date (ARD) of 05/21/2026 and located under the MDS tab of the EMR, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. The assessment indicated that the residents were dependent on staff for all activities of daily living. The care plan revealed that the resident was at risk for the development of pressure ulcers. Under the Care Area Assessment (CAA), the resident was identified as at risk for pressure ulcers, and staff was directed to develop a care plan for pressure ulcers. Review of R200's Care Plan, located under the Care Plan tab of the EMR, failed to address that the resident was at risk for the development of pressure ulcers. During an interview on 06/18/2026 at 11:37 AM, the MDS Coordinator (MDSC) stated that if the CAAs were triggered, the facility would follow whether to proceed, and this would be documented. The MDSC reviewed R200's care plan and stated they usually follow what the CAA triggers and see if they need to proceed with developing a care plan or not. The MDSC reviewed R200's care plan and confirmed that pressure ulcers were not addressed in her care plan. During an interview on 06/18/2026, the Director of Nursing (DON) stated that if the CAAs were triggered in a care area, staff were expected to develop a care plan. Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/2025, indicated, .The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based 'trigger' conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers . After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the IDT (Interdisciplinary Team) must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs.
Based on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident, (R) (R233), had an accurately coded Minimum Data Set (MDS) assessment. Failure to accurately code the MDS has the potential to result in inaccurate federal reimbursement and inaccurate resident assessment and care planning.Findings include: Review of R233's admission Record, located under the Profile tab of the electronic medical record (EMR), documented R233 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances. Review of a facility-provided document for R233 titled, Full QA (Quality Assurance) Report, dated 01/02/2026, documented the resident sustained an unwitnessed fall. The resident sustained bruising of her upper left arm and a laceration of her left eye. Review of R33's quarterly MDS) with an Assessment Reference Date (ARD) of 02/10/2026 and located under the MDS tab of the EMR, indicated staff were unable to determine a Brief Interview for Mental Status (BIMS) score. The MDS contained no documentation indicating the resident sustained a fall during the assessment period. During an interview on 06/18/2026 at 11:37 AM, the MDS Coordinator (MDSC) stated she typically collects resident specific data through visual assessment and review of clinical documentation and reports. The MDSC confirmed that R233's fall on 01/02/2026 was not included in the 02/10/2026 quarterly MDS and stated that it should have been included. During an interview on 06/18/2026 11:58 AM, the Director of Nursing (DON) stated that the MDS was to be accurate. Review of the RAI manual, dated October 2025 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual, revealed, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .
Based on interview, record review, and review of facility policies, the facility failed to maintain evidence the resident and resident representative (RR) were provided with a written transfer notification of the reason for the transfer and send a copy of the notice to the ombudsman and notify the resident and RR of the facility policy for bed hold for two of seven residents (Resident (R)14 and R59) reviewed for hospitalization. This failure had the potential for the residents and RR to be misinformed of the transfer out of the facility.Findings include: 1.Review of R14's admission Record located under the Profile tab of the Electronic Medical Record (EMR) revealed R14 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, diabetes mellitus, obstructive sleep apnea, acute pulmonary edema, acute kidney failure, chest pain, acute on chronic diastolic (congestive) heart failure, bipolar disorder, post-traumatic stress disorder (PTSD), acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease with (acute) exacerbation, and asthma. Review of R14's SNF/NF to Hospital Transfer From, dated 02/22/2026, and located under the Assessments tab of the EMR, revealed that R14 was sent to the hospital for pain. Review of R14's entire medical record revealed no documented evidence of written notice of transfer to R14 and/or their responsible party. There was no documented evidence that the facility notified the resident or RR of the bed hold policy. The facility was unable to provide documentation that the ombudsman was notified of the transfer. Review of R14's Hospital records dated 02/28/2026, located under the Misc. tab of the EMR, revealed a diagnosis of acute pulmonary edema. 2.Review of R59's admission Record located under the Profile tab of the EMR revealed R59 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, diabetes mellitus, asthma, epilepsy, generalized anxiety disorder, and major depressive disorder. Review of R59's SNF/NF to Hospital Transfer Form, dated 06/02/2026, and located under the Assessments tab of the EMR, revealed that R59 was sent to the hospital for abdominal pain. Review of R59's entire medical record revealed no documented evidence of written notice of transfer to R59 and/or their responsible party. There was no documented evidence that the facility notified the resident or RR of the bed hold policy. Review of R59's Hospital records dated 06/04/2026, located under the Misc tab of the EMR, revealed diagnoses of upper gastrointestinal bleed. During an interview on 06/19/2026 at 10:15 AM, the Administrator stated, We are supposed to send written notice of transfer and bed holds. We have new business office and social services. We should have sent written notice of transfer and a bed hold notice to the family on the next day but didn't. Since the transition in November, some things have gotten lost in the change. Different staff were assigned new tasks. We don't have access to emails of the old staff and therefore don't have documentation of ombudsman notification, and the ombudsman is new. Ombudsman notification for [F59] would be sent monthly the following month, so [R59's] ombudsman notification would be sent next month in July. Review of the facility's policy titled, Bed Hold Prior to Transfer, dated 03/2025, indicated, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance and at the time of a transfer for hospitalization or therapeutic leave. Review of the facility's policy titled, Transfer and Discharge, dated 03/2025, indicated, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The facility will maintain evidence that the notice was sent to the Ombudsman.
Based on interviews, record review, and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of sexual abuse for one of 11 residents (R) (R53) reviewed for abuse. The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from abuse.Findings included:A review of R53's admission Record, located under the Profile tab of the Electronic Medical Record (EMR), indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of depression, altered mental status-unspecified, and cognitive communication deficit. A review of an Incident Report, dated 03/07/26 at 8:34 PM, provided by the facility, indicated, [R53] stated while she was sitting in the admission lobby area off of the [NAME] Unit[R30] approached her and made an inappropriate comment of a sexual nature. When asked if she was touched by the resident or if any physical sexual act occurred, R53 stated no. [R30] denied making inappropriate comments to [R53]. A review of a Progress Note, dated 03/8/26 at 4:19 PM, located under the Prog Notes tab of the EMR stated, On 03/08/26 at approximately 11:30 AM, police arrived at the facility after being contacted by [R53]. [R53] reported that [R30] made inappropriate sexual comments toward her last night. [R53] stated that she reported the incident to a staff member on the [NAME] Unit, and the staff member told her she would speak with the resident. A review of R53's Minimum Data Set (MDS) dated [DATE], revealed R53 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R53 was moderately cognitively impaired. A review of a document provided by the facility titled Facility Reported Incident Follow Up, referred to as the five-day summary to the State Survey Agency (SSA), dated 03/13/26, indicated that on 03/08/26, facility staff became aware of an allegation involving R30 and R53 after local law enforcement arrived at the facility regarding a complaint initiated by [R53]. The investigation did not include interviews of staff who worked on 03/07/26, an interview of R53 regarding details of what R30 allegedly said, additional resident interviews regarding witnesses, or whether other female residents had sexual comments said to them. During an interview on 06/15/26 2:58 PM, R53 stated, [R30] said he was going to get my [private area], about two months ago. I've seen him a couple of times since then, but he was with a manager. R53 resided in an unsecured unit. During an interview on 06/19/26 12:29 PM, the Administrator indicated she was not employed at the time of the allegation. The Administrator reviewed the investigation and stated, I would also interview staff to find out who the incident was reported to, along with the CNAs [certified nurse aides], and the housekeeper who worked that night. I don't see any details regarding the details of what [R30] was alleged to have said. I would interview interviewable residents regarding other resident potential abuse in the unit where [R30] resided. The investigation does not say what time the incident was reported to the facility. I would have included documentation of the psychiatric note. I do not feel it was a thorough investigation. It's vague. A review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 10/2025, indicated, .Written procedures for investigations include: . identifying and interviewing all involved persons, including the alleged victim alleged perpetrator, witnesses, and others who might have knowledge of the allegations; . Providing complete and thorough documentation of the investigation.
Based on interviews, record review, and facility policy titled Abuse, Neglect, and Exploitation, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime and reporting of all alleged abuse violations to the State Agency (SA) for one of 11 residents (R) (R53) reviewed for abuse. The deficient practice had the potential for continued episodes of unreported abuse, which posed the potential for physical harm and/or mental anguish. Findings included:A review of R53's admission Record, located under the Profile tab of the EMR, indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of depression, altered mental status-unspecified, and cognitive communication deficit. A review of R53's quarterly Minimum Data Set (MDS) with a date of 03/10/2026, documented that the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating R53 was moderately cognitively impaired. A review of R30's admission Record, located under the Profile tab of the EMR, indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dementia and other signs and symptoms involving cognitive function and awareness. A review of R30's quarterly MDS with a date of 03/01/2026, documented that the resident had a BIMS score of nine, which indicates R30 was moderately cognitively impaired. A review of an Incident Report dated 03/07/2026 at 8:34 PM, provided by the facility, indicated, [R53] stated while she was sitting in the admission lobby area off of the [NAME] Unit [R30] approached her and made an inappropriate comment of a sexual nature - I'll take your [private area]. When asked if she was touched by the resident or if any physical sexual act occurred, she stated no. [R30] denied making inappropriate comments to [R53]. A review of a Progress Note dated 03/08/2026 at 4:19 PM, documented On 03/08/26 at approximately 11:30 AM, police arrived at the facility after being contacted by [R53]. [R53] reported that [R30] made inappropriate sexual comments toward her last night. [R53] stated that she reported the incident to a staff member on the [NAME] Unit, and the staff member told her she would speak with the resident. Further review of R53's Progress notes dated 03/08/2026 at 5:17 PM stated, Responsible party notified via telephone regarding resident report of an inappropriate verbal comment made by another resident on the evening of 03/07/26. A review of the intake form, provided by the facility and submitted to the SA, revealed that the facility submitted the allegation of resident-to-resident abuse to the SA on 03/08/2026 at 5:05 PM. A review of the facility's investigative documentation, provided by the facility, dated 03/13/2026, and submitted to the SA, stated R30 was placed on one-to-one supervision, redirected as indicated from R53's unit, and the resident representative was notified of the allegation. During an interview on 06/19/2026 at 12:29 PM, the Administrator indicated she was not employed at the time of the allegation. The Administrator confirmed that allegations of abuse must be reported within two hours. A review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated October 2025, indicated, Reporting of all alleged violations io the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes as required by regulation, including the Elder Justice Act: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
Based on record review, interviews, and policy review, the facility failed to obtain verification of nursing license background checks before the date of hire for two of nine newly hired nurses (Licensed Practical Nurse (LPN) 13 and Registered Nurse (RN) 5) and failed to update the abuse policy regarding the new state guidance regarding verification of nursing license background checks via NURSYS. The deficient practice could result in a staff member with an unknown criminal background having access to residents.Findings included:1. A review of employee records for LPN13 revealed that LPN13 was hired on 06/09/26. The NURSYS license verification check was dated 06/18/26 (the date the records were requested). 2. A review of employee records for RN5 revealed that RN5 was hired on 05/01/26. The NURSYS license verification check was dated 06/18/26 (the date the records were requested). During an interview on 6/19/26 at 8:56 AM, the Human Resources Director (HRD) stated, I should have one [NURSYS] that was printed before hire date – I don't have it. I look them up when I receive their application. I do have a checklist. I'm not sure how they slipped through the cracks. During an interview on 6/17/26 at 3:49 PM, the Administrator stated, We no longer have to do background checks at all for licensed staff. For licensed nurses, we have been given guidance from Georgia to use NURSYS verification. We have a policy indicating this. During a follow-up interview on 6/18/26 at 11:19 AM, the Administrator stated, We do not have any HR (Human Resources) policies regarding new hires. We get our policies from different states, and different states have different policies. It's not regulatory, so we don't have policies for new hires. A review of the facility's policy titled Abuse, Neglect and Exploitation, provided by the facility, dated 10/2025, indicated Screening. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The facility will maintain documentation of proof that the screening occurred. A review of the Criminal Background Check, Rap Back Monitoring, and Ongoing Eligibility Surveillance for Licensed and Unlicensed Personnel dated April 2026 revealed that upon hire, the facility is responsible for conducting a sex offender check and OIG (Office of Inspector General) screening of all Licensed Nursing Personnel.
Based on interview, record review, and a review of the facility policy titled, Use of Psychotropic Medications, the facility failed to ensure two of five residents (Resident (R) 233 and R30) reviewed for unnecessary medications, was ordered to receive as needed (PRN) psychotropic medication beyond 14 days, without an evaluation and documentation of the clinical indications to use the medication beyond the 14 days. This failure had the potential to place the residents at risk of adverse consequences. Findings include: 1. Review of R233's admission Record located under the Profile tab of the Electronic Medical Record (EMR) indicated the facility admitted the resident on 07/22/2019 with a diagnosis of dementia with behavioral disturbances. Review of R33's EMR titled Minimum Data Set (MDS) identified as significant change assessment with an Assessment Reference Date (ARD) of 11/10/2025 located under the MDS tab indicated that the staff could not determine a Brief Interview for Mental Status (BIMS) score. Review of R233's physician Orders located under the Orders tab in the EMR, dated 04/15/2026, indicated the resident was prescribed Ativan (anti-anxiety medication) 0.5 milligrams (mg), one tablet to be administered every four hours (as needed) PRN. There was no 14-day end date. Review of R233's Medication Administration Record (MAR) located under the Orders tab of the EMR for the month of 04/2026 indicated that the resident was administered Ativan 0.5mg on 04/28/2026. Further review of R233's MAR indicated that the resident was not administered Ativan 0.5mg for the month of May or June 2026. During an interview on 06/18/2026 at 12:34 PM, the Director of Nursing (DON) stated that all PRN psychotropic medications were to have a 14-day end date and to be re-evaluated by the medical practitioner for continued use. During an interview on 06/18/2026 at 1:01 PM the Consultant Pharmacist stated all PRN psychotropic medications were to have an initial 14-day stop date and then the physician could write a justification for continued use. 2. Review of R30's admission Record located under the Profile tab of the EMR, revealed R30 was admitted to the facility on [DATE] with diagnoses of dementia and other symptoms and signs involving cognitive functions and awareness. Review of R30's quarterly MDS with an ARD of 03/01/2026, located under the MDS tab of the EMR, revealed R30 had a BIMS score of nine out of 15, indicating he was moderately cognitively impaired. The assessment revealed R30 took antipsychotic and antidepressant medications. Review of R30's Care Plan dated 06/10/2025, located under the Care Plan tab in the EMR, indicated R30 took psychotropic medications but did not indicate R30's targeted behaviors that the staff was to be monitoring to justify the use of R30 taking an antipsychotic medication. Review of R30's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 09/13/2025 for Haldol [antipsychotic medication] 2.5 milligrams intramuscularly every 8 hours as needed for agitation. The stop date was 02/22/2026, which was beyond the 14-day maximum. During an interview on 06/19/2026 at 3:05 PM, the DON stated, PRN antipsychotic medications must have a 14-day stop date. There are no exceptions beyond 14 days. Review of the facility's policy titled Use of Psychotropic Medications, dated 03/2025, indicated, .PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.
Based on observations, interviews, and record review, the facility failed to respect the right to personal privacy for two of three residents (R) (R34 and R235) reviewed for privacy. Specifically, respiratory treatments were conducted in public view without any privacy measures in place, which could have negatively affected the quality of life of affected residents. The facility also failed to ensure unauthorized family members did not have access to one of one sampled (R) (R132) current status, resulting in a breach of the resident's right to privacy and confidentiality. Findings include: 1. Review of R34's admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of paraplegia, acute and chronic respiratory failure, and tracheostomy status. Review of R34's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/2026 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. The MDS indicated the resident received tracheostomy care. 2. Review of R235's admission Record in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure and tracheostomy. Review of R235's quarterly MDS with an ARD of 05/28/2026 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The MDS indicated the resident received tracheostomy care. During an observation on 06/16/2026 at 9:36AM, Respiratory Therapist (RT) 1, provided tracheostomy care to R235 with the room door open visible to anyone passing the door, the curtain between R235 and roommate, R34 was not drawn. After completing respiratory care to R235, RT1 moved to R34 and without closing the privacy curtain between R34 and R235, and without closing the room door, performed tracheostomy care to R34. During an interview on 06/18/2026 at 10:42 AM, with Administrator and Director of Nursing (DON), they confirmed privacy is expected during tracheostomy care. Review of the facility's policy titled, Tracheostomy Care, updated June 2023, provided by the Administrator, noted the following: .screen for privacy. 3. Review of R132's undated admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, gastrointestinal hemorrhage, and functional quadriplegia. Family member (F)1 was listed as R132's Responsible Party (RP) and emergency contact 1. Review of R132's quarterly MDS, with an ARD of 06/01/2026 and located in the resident's EMR under the MDS tab, revealed the resident was assessed as being in a persistent vegetative state and a BIMS interview was not conducted. During a phone interview on 06/19/2026 at 1:00 PM, F1 expressed concern that R132's name appeared in a letter the facility sent to another resident's family member. F1 specified that it was a 15-day room change notice letter, dated 03/06/26, that contained R132's name and was mailed by the facility to the other resident's family member. F1 stated that sending this information to another resident's family member violated R132's privacy. During an interview on 06/19/2026 at 2:55 PM, the Administrator confirmed that the facility had mistakenly sent a 15-day notice of room change, which included R132's name, to another resident's family member.
Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure medications were not left at bedside unless the proper self-administration of medication assessment was completed for two of 61 sample residents (Resident (R) 47 and R56) reviewed for medication at the bedside. This deficient practice had the potential to place R47 and R56 at risk for medication errors, including incorrect dosing, omission, or unsupervised ingestion, which may result in adverse drug events, injury, or decline in condition. Findings include: 1. Review of R47's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R47 was admitted on [DATE] with diagnoses that included age-related physical disability, epilepsy, anemia, and bilateral primary osteoarthritis of the knee. Review of R47's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/2026 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R47 was cognitively intact. Review of R47's EMR revealed no self-administration of medication assessment. During an observation and interview on 06/15/2026 at 10:16 AM, R47 had several pills laid out on a napkin or tissue on her bedside table. One pill/capsule was in a small, clear plastic cup. R47 stated the orange pill was an antibiotic, the large white pill was calcium, and the two small white capsules were for her neuropathy. R47 confirmed the pill/capsule in the cup was the omega-3 fatty acid. There were no staff in the room. At 10:24 AM, R47 was observed squeezing the Omega-3 fatty acid to expel the liquid into the small, clear, plastic cup. She stated that the Omega-3 was too large and that she was unable to swallow it. During an observation on 06/16/2026 at 1:16 PM, R47 had 16 pills laid out on her bedside table on a tissue. There were no staff in her room. During an interview on 06/16/2026 at 1:16 PM, Licensed Practical Nurse (LPN) 4 stated she had stepped away because the resident had a particular way she liked to take her medications. LPN4 stated she needed gloves to help R47 with the Omega-3 fatty acid because she was unable to swallow it. LPN4 stated that she stayed close by. During an interview on 06/16/2026 at 1:57 PM, the Administrator and Director of Nursing (DON) stated that if residents were allowed to self-administer medications, there would be an assessment and a physician order. They were unsure if this resident had an assessment. The DON stated staff should have stayed with the resident to ensure all medications were taken and to ensure there were no issues. During an interview on 06/17/2026 at 8:22 AM, the Administrator and DON confirmed there was no assessment for self-administration of medications, and there was no order in place for R47. They stated the physician was contacted to assess the resident. They stated residents needed to have a complete assessment, an order, and an updated care plan. 2. Review of R56's admission Record, located under the Profile tab of the EMR, indicated R56 was admitted to the facility on [DATE] with a diagnosis of Devic (a rare autoimmune disease that weakens optic nerves and the spinal cord). Review of R56's quarterly MDS, with an ARD of 04/13/2026 and located under the MDS tab of the EMR, indicated the resident had a BIMS score of 14 out of 15, which revealed the resident was cognitively intact. Review of R56's EMR failed to contain evidence that the resident was assessed to be able to administer her own medication. During an observation on 06/15/2026 at 9:14 AM, a box of prescription eye drops was observed on R56's bedside table. During an observation on 06/15/2026 at 9:29 AM, Registered Nurse (RN) 2 entered R56's room and confirmed that the eye drops were at the resident's bedside and stated that the medications were to be stored in the nurse's medication cart so other residents who may wander would not have access. During an interview on 06/18/2026 at 11:58 AM, the DON stated that medications were not to be left at any resident's bedside and that this was a safety issue. Review of the facility's policy titled, Resident Self-Administration of Medication, reviewed 03/24, revealed, . When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration; b. The resident's physical capacity . c. The resident's cognitive status . d. The resident's capability to follow directions . 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record .
Based on interviews, observations, record review, and policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident for one of 11 residents (R) (R214) reviewed for abuse. This failure had the potential to cause serious physical injury or emotional distress to residents.Findings included: A review of R97's admission Record located in the Profile section of the electronic medical record (EMR) revealed R97 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and hallucinations. A review of R97's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/27/26 and located in the MDS tab of the EMR, revealed R97 scored four out of 15 on the Brief Interview for Mental Status (BIMS), which indicated she was severely cognitively impaired. The MDS indicated R93 exhibited physical and verbal behavioral symptoms directed toward others every one to three days. A review of R97's current Care Plan, located under the Care Plan tab of the EMR, revealed that the following Focus area, which was initiated on 12/19/25, revealed that R97 had a behavior problem, which included being verbally aggressive towards staff members. It was noted that the resident was aggressive towards another resident and was involved in a resident-to-resident altercation. A care plan intervention included: Immediate physical separation from other residents when physically aggressive behavior is noted. A review of R97's behavior notes, located in the Progress Notes section of the EMR, revealed the following entry written by Licensed Practical Nurse (LPN) 6 on 05/15/26: For 9:50 AM, another resident was screaming in the hallway, this causes [R97's name] to get irritated. Her roommate said she had taken something of hers and demanded it back. [R97's name] slapped her. The residents were separated. DON [Director of Nursing] was notified. S/S [social services] were notified, and the Administrator was notified in a timely manner per protocol. Both families were called. The patient who was slapped had a skin assessment, and n/p [nurse practitioner] examined her. VS [vital signs] stable . [Staff name] from s/s spoke with both residents. Residents were separated throughout the shift. Report to the oncoming shift. During an observation on 06/17/26 at 9:17 AM, R97 was in her private room. R97 was exhibiting no problem behaviors and was pleasantly confused. R97 did not recall being in any altercations or having any concerns with other residents. A review of R241's admission Record, located in the Profile tab of the EMR, revealedR241 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, bipolar disorder, and major depressive disorder. A review of R241's quarterly MDS, with an ARD of 04/27/26 and located in the MDS tab of the EMR, revealed R241 scored eight of 15 on the BIMS, which indicated she wasmoderately cognitively impaired and had not exhibited any physical or verbal behavioralSymptoms towards others. A review of the facility's investigation of a 05/15/26 incident between R97 and R214, provided by the facility, revealed that the facility's investigation was able to determine that an altercation without injury occurred between R97 and R214. Included in the facility's investigation were witness statements from the staff who worked when the incident occurred. A witness statement written by Certified Nurse Aide (CNA) 10 indicated, On Friday, May 15, 2026, at approximately 10:30 AM, I was in the hall when [R214's name] was telling [R97's name]: ' Give me back my shirt, that's my shirt! She was pulling on the shirt on [R97's name], and [R97's name] slapped her, trying to get her to stop. I ran and separated them and called the nurse [the nurse's first name]. During an observation on 06/15/26 at 9:27 AM, R241 was in her room. The resident was not exhibiting any problem behaviors and was pleasantly confused. During an interview on 06/18/26 at 8:15 AM, the Administrator stated that staff immediately reported the 05/15/26 incident between R97 and R241, and the facility conducted an investigation. The facility's investigation determined there was an altercation between the two residents, and staff witnessed R97 slap R241's arm, but neither resident was injured as a result of the incident. The Administrator stated she expected the facility to be free of abuse. A review of the facility's policy titled Abuse, Neglect, and Exploitation dated 10/2025, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.
Based on record review, interviews, and facility policy titled, Use of Psychotropic Medications, the facility failed to ensure psychotropic medication risks versus benefits/ or consents were completed for two of five residents (R) (R16 and R30) of 61 sample residents reviewed for unnecessary medications. This failure had the potential for oversedation and lack of understanding by the residents and/or representatives.Findings Include: 1. Review of R16's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R16 had been admitted on [DATE], with an initial admission on [DATE], with diagnoses of schizophrenia, anxiety, mood disorder, and major depressive disorder. Review of R16's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/26, located under the MDS tab of the EMR, revealed R16 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R16 had been moderately cognitively impaired. Review of the Order Summary Report, located under the Orders tab of the EMR, revealed R16 had been ordered to receive: 10/31/2022 – divalproex sodium (Depakote, DVP) delayed release sprinkle capsule, 125 mg. One capsule orally every 12 hours related to mood disorder. 10/31/2022 – quetiapine fumarate (Seroquel, QTP) tablet, 25 mg(milligram). One tablet orally at bedtime related to schizophrenia. 03/11/2025 – mirtazapine (Remeron, MZT) tablet, 7.5 mg. One tablet orally at bedtime for appetite stimulation. 06/02/2025 – buspirone HCl (Buspar, BUS) tablet, 5 mg. One tablet orally every morning and at bedtime related to generalized anxiety disorder. Review of the Consent for Psychotropic Medications, located under the Misc. tab of the EMR and dated 03/17/25, revealed documented consents for the use of divalproex and mirtazapine. There had been no documented evidence of consent or education related to risks versus benefits for quetiapine or buspirone. During an interview on 06/17/2026 at 12:17 PM, the Administrator and Director of Nursing (DON) confirmed there had been no other consent or documentation of risks versus benefits for the additional medications ordered for R16. The DON stated they completed a consent form when starting a medication or when a medication change occurred. 2. Review of R30's admission Record, located under the Profile tab of the EMR, revealed R30 had been admitted to the facility on [DATE] with diagnoses of dementia and other symptoms and signs involving cognitive functions and awareness. Review of R30's quarterly MDS, with an ARD of 03/01/2026, located under the MDS tab of the EMR, revealed R30 had a BIMS score of 9 out of 15, which indicated he had been moderately cognitively impaired. The assessment revealed R30 had been receiving antipsychotic and antidepressant medications. Review of R30's Medication Administration Record (MAR) dated May 2026 and Physician Orders, located under the Orders tab of the EMR, revealed: R30 received brexpiprazole (Rexulti, BRX), 0.5 mg daily at bedtime for agitation, originating on 05/14/2026. The brexpiprazole dose was increased to 1 mg daily on 05/24/2026 and again to 2 mg daily on 06/03/2026. R30 had received donepezil (Aricept, DNP), 10 mg daily at bedtime, originating on 07/07/2025. R30 had received sertraline (Zoloft, SRT), 25 mg daily for depression, originating on 12/17/2025. Review of R30's medical records revealed no documentation that he or his representative had been provided information prior to administration regarding the risks and benefits of the prescribed medications, treatment alternatives, or other options, nor documentation that consent had been obtained. During an interview on 06/19/2026 at 3:05 PM, the DON stated, We do not have documentation that we can prove that consent was obtained prior to administration. Review of the facility's policy titled Use of Psychotropic Medications, dated March 2025, documented: .9.Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options, and the preferred option to accept or decline in a format the facility deems to use.
Inspection of October 30, 2025
1 findingBased on observations, record reviews, staff and resident interviews, and review of the facility policy Discharge and Transfer Policy, the facility failed to ensure that treatment was provided in a timely manner following a right hip fracture for one of three residents (R1). Actual harm was identified on 8/24/2025 when R1 fell and suffered a right hip fracture that was not recognized until 8/25/2025 when the resident was sent to the hospital and had to undergo surgery for an intertrochanteric fracture of the right hip.Findings include:A review of the facility policy titled Discharge and Transfer Policy, revised 7/18/2025, did not reveal details regarding emergency transfers.Review of the electronic medical record (EMR) for R1 revealed diagnoses including, but not limited to, cerebral infarction affecting the dominant right side; muscle weakness; Difficulty in walking; not elsewhere classified; altered mental status, and history of falling.Review of the most recent Annual Minimum Data Set (MDS) dated [DATE] documented that R1 had a Brief Interview for Mental Status (BIMS) score of 12, indicating some cognitive impairment.Review of the care plan dated 10/19/2024 revealed that R1 was at risk of injury due to falls.Review of the Nurses Notes dated 8/24/2025 at 4:14 pm that the R1 was heard yelling out for help, and on arrival was observed on the floor, lying on her right side next to the bed. As soon as possible, an X-ray of the right femur/hip and skull series was ordered.A review of an X-ray report completed at the facility on 8/24/2025 and signed by a physician at 1:08 pm revealed impression: questionable nondisplaced fracture of the right femoral neck. Correlate clinically and follow up with a dedicated hip exam.Review of the Nurses Notes dated 8/25/2025 at 3:45 pm revealed that R1 was sent out to the hospital by Emergency Medical Services (EMS) at 9:47 am due to signs and symptoms of pain.Review of the Hospital Discharge summary dated [DATE] revealed that R1 was admitted to the hospital on [DATE] with a fractured right hip, and surgery was performed.Interview on 10/27/2025 at 11:59 am with a Licensed Practical Nurse (LPN) AA and Registered Nurse (RN) CC on the Central Unit, where the resident resides, revealed that when a resident falls, the usual procedure is to send them out to the hospital. Both LPN AA and RN CC reported that when a resident who is immobile falls, they would use a mechanical lift to remove the resident from the floor, notify the doctor, and obtain an X-ray if ordered.Interview on 10/28/2025 at 11:30 am with R1 revealed that she remembered the night she fell and broke her femur. She stated that she did not know why they did not send her that night. R1 stated that she did get pain medication.Interview on 10/28/2025 at 12:00 pm with the Director of Nursing (DON) stated that she has always told her staff that if they have any doubt, then send the resident out. The DON revealed that the information on the X-ray was dated Sunday afternoon, and the physicians were not in the office at that time. The electronic signature and time and date from the computer on the X-ray form are dated 8/24/2025 at 2:37 p.m. She revealed that the Nurse Practitioner (NP) assessed R1 the next morning.Interview on 10/28/2025 at 12:05 pm with Unit Manager Registered Nurse (RN) BB revealed that on the morning of 8/25/2025, she called the night shift nurse, LPN AA, to ask why R1 had not been sent to the hospital. RN BB stated that the LPN AA reported to her that she had made numerous calls to the physician and nurse practitioner with no reply. RN BB stated there were two x-rays in the chart: one showing no fractures but not imaging the femur, and the second showing the femur with a displaced fracture, received on 8/24/2025 at 2:37 pm by fax machine, with NP signature stating to send R1 out.Interview on 10/29/2025 at 9:52 am with NP DD revealed that she was not in the facility on 8/24/2025, but she was notified of R1's fall when it occurred. NP DD stated that she ordered X-rays and instructed the nurse to notify the on-call physician, as she was not on call. She revealed that on 8/25/2025, she reviewed the X-ray report and dated it 8/24/2025. NP DD revealed she assessed R1 on the morning of 8/25/2025, and R1 was in excruciating pain, and she was sent out to the hospital on Monday morning, 8/25/2025.Phone interview on 10/29/2025 at 1:30 pm with the Medical Director (MD) EE of R1 who revealed that his policy on any fall or injury in the facility would be to order an X-ray if required and await the results prior to immediately sending out, unless the resident was assessed and had pain, tenderness then he expected the resident to be sent out immediately if injured.
Inspection of October 3, 2023
3 findingsBased on record review, review of the facility policy titled Comprehensive Person-Centered Care Plans, and resident and staff interviews, the facility failed to implement the care plan for two of 56 sampled residents (R) (R19 and R36). Actual harm occurred on 3/14/2023 when R19 sustained an acute fracture of the proximal fibular diaphysis after falling from the bed when one Certified Nursing Assistant (CNA) failed to follow the plan of care for Activities of Daily Living (ADL) care interventions. Findings included: A review of the facility policy titled, Comprehensive Person-Centered Care Plans, dated Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Comprehensive Person-Centered Care Plan - contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines. Pocket Care Guide - part of the Comprehensive Care Plan and used as the tool to make staff aware of the resident's daily care needs. The Daily Care Guide/Pocket Care Guide will serve as the initial care plan and will be completed upon admission. Upon a change is in condition, the Comprehensive Person-Centered Care Plan or Baseline Care Plan will be updated . 1. A review of the medical record revealed R19 was admitted to the facility on [DATE] with diagnoses of, but not limited to, dementia with behavioral disturbances, quadriplegia, and dysphagia. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R19 had short and long-term memory problems and the Brief Interview for Mental Status was not conducted due to the resident being rarely or never understood. The MDS further revealed that R19 required two-person total assistance with bed mobility and had limited range of motion bilaterally of the upper and lower extremities. A review of the care plan dated 4/18/2014 revealed R19 required total assistance with ADL care secondary to impaired functional mobility (related to) complex medical condition, severe debility. Approaches included, Provide total physical assist with all ADL activities . There was no indication on the care plan as to transferring and/or bed mobility and how many staff were required to provide ADL care. A review of the undated Daily Care Guide revealed .T&P [Turn & Position] as needed with wedge . Continued review of the Daily Care Guide revealed that there was no instruction as to transferring and/or bed mobility and how many staff were required to provide ADL care. A review of the Departmental Nursing Notes dated 3/7/2023 revealed .MDS Note for Quarterly MDS dated [DATE] .After review of the (electronic medical record) documentation in conjunction with MDS observation and interviews, it was determined that the resident was provided with the following ADL (assistance) on a daily basis: total assist one person with dressing, eating/ GT [g-tube] status, person hygiene; total (assistance) two person with bed mobility, transfers, toileting, bathing, bowel/bladder incontinent, skin integrity intact . A review of the incident report dated 3/14/2023 revealed .Fall: Resident room, non-witnessed, Resident fell out of the bed onto the floor. No injuries noted at this time . A review of the incident report follow-up dated 3/14/2023 revealed, .24 hour follow-up: (R19) lying in bed making verbal noises, it was reported by CNA that resident was moaning and grimacing during ADL care. X-ray completed and came back with possible fracture to femoral condyle [knee joint] . Resident sent to [acute care hospital] for further evaluation . A review of the Mobile Images dated 3/14/2023 for R19 revealed .Assessment is limited to a single lateral view. Left Knee findings: Faint linear radiolucency is suggested within the femoral condyle which could reflect a nondisplaced fracture. Impression: Limited assessment. Fracture in subarticular aspect of the femoral condyle is suspected . A review of the Departmental Nursing Notes dated 3/15/2023 revealed .(R19) received x-ray on 3/14/2023; findings read as followed; assessment is limited to a single lateral view left knee findings fracture in subarticular aspect of the femoral condyle is suspected. [Nurse Practitioner] called and ordered for resident to be sent to hospital . A review of the hospital records dated 3/15/2023 revealed R19 was evaluation of left knee after fall from bed .Imaging: Findings-bones are osteopenic. There is an acute fracture of the proximal fibular diaphysis. Knee is retroflexed. During a telephone interview on 9/29/2023 at 4:30 pm, CNA RRR remembered going into R19's room to change the resident. She confirmed that she was by herself. R19 bed linens and clothes had tube feeding on them because it was not attached to R19. CNA RRR stated she rolled R19 over to remove the under pad and that R19 was laying tilted and was not flat on the bed. CNA RRR stated that she then left the room to retrieve more linen and supplies. She stated that she remembered hearing a loud thud and saw R19 knees on the floor but her whole body had not hit the floor and she was trying to hold her up. CNA RRR stated that she screamed for help and other staff came to assist and they lifted the resident back in bed. CNA RRR stated she inspected R19 and did not notice any injuries. The Emergency Medical Technicians (EMT's) were called, and they conducted their own assessment. CNA RRR confirmed she was trying to change R19's linen by herself and confirmed she had not reviewed the care plan or Pocket Guide for any of the residents she provided care to. The other CNA's told her what she needed to do for the resident and had informed her that R19 required two staff for assistance. She stated, I shouldn't have changed her by myself. I couldn't find anybody, and I just wanted to get her clean. I was trying to get her changed and clean. When I saw her in that state, I took it upon myself to change her. I had changed her myself before. During a telephone interview on 9/25/2023 at 10:30 am, the Former Assistant Director of Nursing (ADON) CC stated CNA RRR left R19 unattended on the edge of the bed to get towels. R19 required assistance from two staff. A review of documentation provided by the facility revealed that the facility had 18 current residents that had falls with major injuries from 7/1/2022 and 9/26/2023. A review of the Accident and Incident log for the period of 3/1/2023 and 9/11/2023 revealed the facility had 229 falls in six months. During a telephone interview on 9/25/2023 at 10:30 am, the ADON CC confirmed the CNAs had a care guide they followed which was located at the kiosk or the nurse would give them one during a huddle. Former ADON CC confirmed the care plan should reflect the care of the residents and the bed mobility should have been on the care plan and that the MDS Coordinator was responsible for keeping up the care plan. Former ADON CC confirmed all interventions should have been on the care plan. During an interview on 9/25/2023 at 11:11 pm, the MDS Coordinator UU stated she was responsible for MDS assessments and comprehensive care plans. The Unit Managers and nurses updated the care plan for acute problems. The MDS Coordinator UU stated she usually added how many staff were required for total assistance for ADL care. MDS Coordinator UU stated if a resident required more than one staff member, she would put the number of staff required on the care plan. The MDS Coordinator UU was shown R19's care plan and the MDS Coordinator UU confirmed the bed mobility was not on the care plan with two staff members. When asked if the bed mobility should have been on R19's care plan she stated, Yes. MDS Coordinator UU revealed the CNAs did not have access to the care plans and that the Unit Managers and nurses were responsible for updating the pocket care plan, also known as the Daily Care Guide or Pocket Guide. 2. A review of the clinical record revealed that R36 was admitted to the facility on [DATE] with diagnoses to include, but not limited to, open-angle glaucoma, bilateral, insomnia, pain, dementia, and behavioral disturbances. A review of the care plan revealed that R36 was at risk for falls/injury secondary to impaired mobility and cognition, diagnosis of chronic dizziness and glaucoma; R36 is ordered psychotropic medications and is at risk for complications; mood fluctuates; and that R36 uses a walker for ambulation. Approaches included to monitor for fall related risks, provide assist with transfers and toileting as needed, remind resident to call for assist as needed, maintain environment free of clutter and safety hazards, keep call light and most frequent items most used within reach, therapies as ordered, obtain eye exam as needed, provide assistance with ADL's as needed, encourage and remind to use walker as needed, and medication review as needed. The care plan revealed that R36 had fallen on 4/27/2022, 5/12/2022, 6/5/2022, 3/19/2023, 5/10/2023, 6/21/2023, 8/31/2023, 9/4/2023. A review of the Daily Care Guide for R36 revealed that the resident required one-person assistance for bathing and dressing; required two-person assist for toileting; and that R36 was listed as a fall risk. Interventions included floor mats on both sides of the bed when resident is in the bed, non-skid socks on feet at all times, and scoop mattress. An observation of R36 on 9/25/2023 at 4:33 pm revealed R36 lying in bed. There were no fall mats on either side of the bed. Further, R36 did not have a scoop mattress or nonskid socks on during this observation. Licensed Practical Nurse (LPN) TT was interviewed at this time. She confirmed that the resident was supposed to have fall mats on both sides of the bed. She stated that the mats were taken up the week before and sent to the laundry room and they didn't have any more mats to provide to the resident. She stated that she was off over the weekend and was not sure why the mats were not put back. She didn't know why the resident was not on a scoop mattress but that she would take care of it. She stated that the resident has had multiple falls so the fall mats were supposed to be on both sides of the bed to prevent injuries because the resident continuously tries to get out of the bed. 49475
Based on record review, observations, and interviews, the facility failed to ensure that three of 54 sampled residents (R19, R40, and R36) were free of accidents related to not following the plan of care for fall risk for R19 and R36 and not completing neuro checks for R40. Also, the facility failed to store chemicals in a safe and secure manner to prevent accidents. Actual harm occurred on 3/14/2023 when R19 sustained an acute fracture of the proximal fibular diaphysis after falling from the bed when one Certified Nursing Assistant (CNA) failed to follow the plan of care for ADL care interventions. Findings included: A review of the facility document titled, ACCIDENT & INCIDENT DOCUMENTATION & INVESTIGATION RESIDENT INCIDENT, dated October 2009, January 2012, July 2018, revealed the following: Accidents and/or Incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the Long Term Care (LTC) system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents. 1. General Information: a. The Licensed Nurse assigned at the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the Supervisor, Director of Nursing, and/or the Executive Director as appropriate. b. The Licensed Nurse at the time of the incident is responsible for initiating completing the Resident Incident 2. Notification and Documentation in the Resident's Medical Record: a. The Licensed Nurse shall place the resident on the 24-Hour Report, document the incident, and notify the supervisor and Director of Nursing for follow through as needed. b. The Licensed Nurse may complete a Nurses' Notes and update the Resident Care Plan as needed. A review of the Neurological (Neuro) Evaluation Policy (no date) revealed that the policy stated, it is the policy of this facility to perform a neuro vital sign evaluation when indicated by resident condition and subsequent to a witnessed or unwitnessed fall with a suspected head injury. 1. A review of the medical record revealed R19 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbances, quadriplegia, and dysphagia. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R19 had short and long-term memory problems; was severely impaired and rarely made decisions; required two-person total assistance with bed mobility; and presented with limited range of motion of bilaterally of the upper and lower extremities. A review of the care plan revealed a problem onset date of 4/18/2014 (there was no date as to when the care plan was last updated). The care plan noted that R19 required total assistance with ADL care secondary to impaired functional mobility related to complex medical condition, and severe debility. There was no indication on the care plan as to how many staff were required for ADL care tasks. A review of the MDS Nursing Notes dated 3/7/2023 revealed Note for Quarterly MDS 2/25/2023 .After review of (electronic medical record) documentation in conjunction with MDS observation and interviews, it was determined that the resident was provided with the following ADL assist on a daily basis: total assist one person with dressing, eating/ GT [g-tube] status, person hygiene; total assist two person with bed mobility, transfers, toileting, bathing, bowel/bladder incontinent, skin integrity intact . A review of the undated Daily Care Guide revealed 'Turn & Position' as needed with wedge. The care guide failed to inform staff of how many staff were required for ADL care tasks. A review of the Departmental Nursing dated 3/14/2023 revealed .At approx. 12:50 am the CNA came to the nurse and reported that the resident was on the floor, she stated that she was a step away from the [sic] to get something and that's when she heard the resident fall on the floor, she was rendered morning care to her, on observation note resident lysing on the floor next to her with GT still intact, on assessment did note any bleeding or swelling condition, using the lift was put back in bed without incident. Call out to DON [Director of Nursing] and Family .resident is s/p fall didn't display no signs or symptoms of pain at this time resident was x-rayed per facility protocol medication given and tolerated well x-ray results pending resident will continue with plan of care . A review of the incident report dated 3/14/2023 revealed .Fall: Resident room, non-witnessed, Resident fell out of the bed onto the floor. No injuries noted at this time . A review of the incident report follow-up dated 3/14/2023 revealed, .24 hour follow-up: Resident lying in bed making verbal noises, it was reported by CNA that resident was moaning and grimacing during ADL care. X-ray completed and came back with possible fracture to femoral condyle [ also known as the knee joint] .Resident sent to HSP [hospital] for further evaluation . A review of the post incident actions dated 3/14/2023 revealed .Resident fell out of bed onto the floor. Immediate Post-Incident Action: Stay with resident at all times, and complete the task at hand, keep bed in the lowest position. Immediate Actions Taken: total body [sic] assessment done V/S [vital signs] taken, neuro checks initiated, assist back to bed using lift . A review of the Mobile Images dated 3/14/2023 revealed .Assessment is limited to a single lateral view. Left Knee findings: Faint linear radiolucency is suggested within the femoral condyle which could reflect a nondisplaced fracture. Impression: Limited assessment. Fracture in subarticular aspect of the femoral condyle is suspected . A review of the Departmental Notes: Nursing dated 3/15/2023 revealed .resident received x-ray on 3/14/2023 findings read as followed assessment is limited to a single lateral view left knee findings fracture in subarticular aspect of the femoral condyle is suspected. NP [Nurse Practitioner] called and ordered for resident to be sent to hospital . A review of the History and Physical dated 3/15/2023 revealed R19 had a history of cerebrovascular accident (CVA) and was nonverbal. Sent for evaluation of left knee after fall from bed .Imaging: Findings-bones are osteopenic. There is an acute fracture of the proximal fibular diaphysis. Knee is retroflexed. No definite effusion . During a telephone interview on 9/14/2023 at 8:58 am, the family of R19 stated they were notified of the 3/14/2023 fall and was told R19 fell because she moved. An anonymous person told them it was not possible for R19 to cause herself to fall. The family of R19 revealed R19 could not move her body. R19 could move her head and lift her arms to a certain point. Both of R19 legs were contracted which made it impossible to sit in a wheelchair. During a telephone interview on 9/29/2023 at 4:22 pm, CNA AAA stated she worked that night on 3/14/2023 and was on the unit during the fall. CNA RRR called for help. CNA RRR was trying to change R19. CNA RRR was a new staff member. CNA AAA was on the other side and heard her call for help. During a telephone interview on 9/29/2023 at 4:30 pm, CNA RRR remembered going into R19's room to change the resident. R19 bed linens and clothes had tube feeding on them because it was not attached to R19. CNA RRR had rolled R19 over to remove the under pad. R19 was laying tilted and was not flat on the bed. R19 somehow rolled over on the side of the bed closets to the door. CNA RRR then left the room to retrieve more linen and supplies. CNA RRR stated she remembered hearing a loud thud and saw R19 knees on the floor but her whole body had not hit the floor and she was trying to hold her up. CNA RRR was screaming for help and other staff came to assist and they lifted back with the under pad. CNA RRR stated she inspected R19 and did not notice any injuries. The EMTs were called, and they conducted their own assessment. CNA RRR confirmed she was trying to change R19 linen by herself. CNA RRR confirmed she had not reviewed the care plan for any of the residents she provided care to. The other CNAs told her what she needed to do. CNA RRR confirmed she was informed R19 required two staff for assistance. When asked if CNA RRR should have changed R19s linens by herself she stated, No. I shouldn't have changed her by myself. I couldn't find anybody, and I just wanted to get her clean. I was trying to get her changed and clean. When I seen her in that state, I took it upon myself to change her. I had changed her myself before. During a telephone interview on 9/25/2023 at 10:30 am, the Former Assistant Director of Nursing (ADON) CC stated CNA RRR left R19 unattended on the edge of the bed to get towels. R19 required assistance from two staff. During an interview on 10/2/2023 at 4:54 pm with the MD who stated that his expectation was that staff should have completed an incident report and the resident should have been sent out to the emergency room (ER) and receive a Computerized Tomography (CT) scan. 2. A review of the clinical record revealed that R40 was admitted to the facility on [DATE] with diagnoses of dementia, other cervical disc degeneration, other inflammatory spondylopathies, cervical region, Ataxia, other sequelae of cerebral infarction, and cerebral ischemia. A review of the MDS dated [DATE] revealed that R40 has a Brief Interview for Mental Status (BIMS) score of three, which indicated moderate cognitive impairment. A review of the care plan for R40 also revealed that resident was care planned for anticoagulant use; impaired mobility and cognition that fluctuates and impaired vision; ADL Care assistance; and risk for falls related to impaired mobility, weakness, and impaired vision. Approaches include therapy as ordered; encourage resident to use call light for assistance; keep most used item within reach; maintain resident environment free of clutter and safety hazards; monitor resident for any change of condition that may warrant increased supervision; assist with transfers as needed; VS per facility protocol and as needed; fall precautions as needed; observe resident for adverse side effects/toxicity of medications in current drug regime. Contact physician with abnormal findings. A review of the physician's orders for R40 revealed that the resident is ordered Eliquis (anticoagulant) five mg twice daily. A review of the record for R40 revealed a progress note dated 4/7/2023 stating that the resident was found on the floor in the hallway by the CNA during rounds. It was documented that the NP was made aware, neuro checks were ordered for three days, and to hold Eliquis 5mg for two days. During an interview on 10/2/2023 at 11:08 am, Licensed Practical Nurse (LPN) TT confirmed that she was not able to locate any neuro checks in the clinical record for R40. During an interview on 10/2/2023 at 11:11 am with Medical Records (MR) Staff JJJ, who stated that neuro checks are typically filed by nursing, also confirmed that she could not find any neuro checks in the medical record of R40. During an interview with the MD on 9/27/2023 at 1:44 pm, he stated that his expectations were that the nursing staff would conduct a proper neurological assessment following his/NP orders and the forms provided by the facility. During an interview on 10/2/2023 at 4:54 pm with the MD who stated that if the fall was unwitnessed and the resident was taking an anti-coagulant, then the expectation is to have the resident to be sent out of the facility to the ER. The MD further stated that the standing order for neuro checks is for the neurological checks to be performed for 72 hours. 3. A review of the clinical record revealed that R36 was admitted to the facility on [DATE] with diagnoses of hypertension, open-angle glaucoma, bilateral, severe stage, long-term current use of aspirin, gastro-esophageal reflux disease without esophagitis, insomnia, pain, and dementia with other behavioral disturb. A review of the care plan for R36 revealed that the resident is care planned for being at risk for falls/injury secondary to impaired mobility and cognition, diagnosis of chronic dizziness and glaucoma; and uses walker for ambulation. Approaches include monitor for fall related risks, remind resident to call for assist prn, maintain environment free of clutter and safety hazards, keep call light and most frequently used items within reach, provide asst with ADL's as needed, encourage and remind resident to use walker as needed. The care plan revealed that R36 had falls on 4/27/2022, 5/12/2022, 6/5/2022, 3/19/2023, 5/10/2023, 6/21/2023, 8/31/2023, 9/4/2023. A review of the Daily Care Guide for R36 revealed Resident was listed as a fall risk. Interventions included floor mats on both sides of the bed when resident is in the bed and non-skid socks on feet at all times. An observation of R36 on 9/25/2023 at 4:33 pm revealed R36 lying in bed. There were no fall mats on either side of the bed. Further, R36 did not have a scoop mattress or nonskid socks on during this observation. LPN TT was interviewed at this time. She confirmed that the resident was supposed to have fall mats on both sides of the bed. She stated that the mats were taken up the week before and sent to the laundry room and they didn't have any more mats to provide to the resident. She stated that she was off over the weekend and was not sure why the mats were not put back. She didn't know why the resident was not on a scoop mattress but that she would take care of it. She stated that the resident has had multiple falls so the fall mats were supposed to be on both sides of the bed to prevent injuries because the resident continuously tries to get out of the bed. 4. During an observation in 325's room on 9/11/2023 at 11:23 am, revealed a cleaning product .Liquid Enzyme . placed on top of a bed side table on the A-side of the room. During an interview on 9/11/2023 at 11:30 am, the Houskeeper BBB confirmed he walked out and forgot the cleaner on the bedside table because he was called to another room. 49475
Based on record review, interviews, and review of the facility's policy titled Bowel Elimination Protocol the facility failed to implement interventions to prevent discomfort for one of 54 sampled residents (R) (R8). Actual harm was identified to have occurred on 6/28/2023 when R8 was sent out to an acute care hospital for fecal impaction. Findings included: A review of an undated facility's policy titled, Bowel Elimination Protocol revealed that it is the responsibility of nursing personnel to document, monitor, and implement appropriate measures relative to the management of bowel function. The bowel regimen will be initiated by the Licensed Nurse with the approval from the attending physician as indicated. A review of the medical record revealed R8 was admitted to the facility on [DATE] with diagnoses which included gastroparesis and end stage renal disease. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive; R8 required extensive assistance with two-person assistance for toileting; and R8 was continent of bladder and bowel. A review of the care plan dated 5/4/2023 revealed the problem R8 is continent of bowel and bladder and requires assistance from staff with toileting needs. Approaches included to observe for signs and symptoms of urinary tract infection. A review of the Physician Orders dated May 2023 and June 2023 revealed R8 had no orders for stool softeners or laxatives. A review of the clinical record revealed the facility did not have any standing orders for medication to address constipation for R8. A review of the Elimination Report dated 5/1/2023 to 9/1/2023 revealed R8 did not have a bowel movement from 6/18/2023 to 6/27/2023. A review of the clinical record revealed that R8 was sent out to an acute care hospital on 6/28/2023. A review of the computerized tomography (CT) scan of the abdomen without intravenous (IV) was performed on 6/28/2023 and revealed the following .Stool packed colon and fecal impacted appearance of the rectum of maximal 6 cm (centimeters) transverse diameter . A review of the emergency department provider notes dated 6/28/2023 revealed .1:35 am Disimpaction completed, Registered Nurse (RN) assisted. Moderately firm stool in rectal vault . During an interview on 9/27/2023 at 12:45 pm, Licensed Practical Nurse (LPN) UUU stated if a resident had not had a bowel movement in three days the nurses were supposed to give them something. The Certified Nursing Assistant's (CNAs) were supposed to tell the nurses if a resident had not had a bowel movement after three days. LPN UUU could not recall if the electronic health record (EHR) alerted the nurses if residents had a bowel movement or not. During an interview on 9/27/2023 at 1:49 pm, LPN YYY stated the nurses were supposed to start the bowel protocol if no bowel movement in 48 hours and that the nurse was supposed to check every day in the EHR for the resident's bowel charting. LPN YYY confirmed the EHR alerted the nurses of no bowel movement. During an interview on 9/27/2023 at 2:25 pm, R8 stated he had spoken to the nurses about feeling constipated. R8 stated he kept reminding repeatedly and the nurses did not feel he should have gone to the hospital for constipation. Continued interview revealed the facility did not give R8 any medications such as foods which stimulate bowel movements and stool softeners. The facility had accused R8 of not agreeing to taking Colace but R8 vehemently denied it. R8 stated his family had inquired about his constipation and what could be done about it. R8 was transferred to the hospital where he received laxatives. During an interview on 10/2/2023 at 11:32 am, the Director of Nursing (DON) JJJJJ stated residents without a bowel movement after three days the nurses needed to intervene if the resident had medication to address constipation. If the resident did not have a medication or treatment to address constipation the nurse needed to contact the physician. During a telephone interview on 10/2/2023 at 12:31 pm, the Nurse Practitioner (NP) QQQ stated R8 went to the hospital twice for constipation and the medical team tried to put R8 on a bowel regime. NP QQQ confirmed R8 did not have orders to address constipation in 5/2023 and 6/2023. NP QQQ stated she expected the nurses to notify her or the physician and start the bowel protocol after so many days of no bowel movement. During a telephone interview on 10/2/2023 at 1:22 pm, the Medical Director PPP stated the facility had standing orders for the nurses to administer various medications to treat constipation. The Medical Director expected the nurses to contact him if a resident had not had a bowel movement. Continued interview revealed the Medical Director PPP confirmed R8 would have benefited from having ordered anti constipation medication. During a telephone interview on 10/2/2023 at 3:40 pm, Director of Nursing (DON) CC confirmed the facility did not have standing orders to treat constipation. The nurses were supposed to look at the care guide and it alerted them if a resident had not had a bowel movement in three days and to then call the physician.
Inspection of October 5, 2016
7 findingsBased on observation, interview, and record review, the facility was not administered in an effective manner, utilizing all its resources, resulting in Immediate Jeopardy creating the likelihood of death or serious harm (either physical, emotional, or mental) to 4 of 229 residents (R1, R9, R10, R7) residing in the facility. On 9/27/16 a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 9/27/16 at 5:55 p.m. the facility's Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. F224 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. The Immediate Jeopardy at F224, F226, F281 and F490 was identified to have existed since 9/6/16, when staff mixed [MEDICATION NAME] with Pine Sol cleaner and administered it to Resident (R) 7, with the resident sustaining burning in her throat and requiring a transfer to the hospital. The facility failed to utilize its resources and immediately report and thoroughly investigate this case of neglect of R7, as well as failed to take necessary actions to protect the resident from the potential for further neglect. On 9/28/16 at 5:30 p.m. the facilities Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F226 also constituted Substandard Quality of Care at 42 CFR 483.13. The Immediate Jeopardy at F328 was found to have existed since 9/26/16, when it was identified that the correct-sized emergency equipment was not available for 3 of 14 residents (R1, R9 and R10) residing on the specialty vent unit. In addition actual harm was cited at F469 S/S:G the failure to control roaches, as well as other insects such as gnats and flies, resulted in psychosocial harm for 2 of 52 sampled residents (R2 and R37), both of whom expressed fear of the roaches which had been seen in their rooms. An acceptable Allegation of Compliance (AoC) was received on 10/3/16, and Healthcare Management Solutions, (HCMS) LLC, on behalf of the State Survey Agency, validated the AoC. The Immediate Jeopardy was removed from all 5 areas on 10/4/16. The Scope and Severity was lowered to the following levels: F224:D, F226:F, F281:D, F328:D, F490:F while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: 1. Observations, interviews, and record review revealed that the facility was not in substantial compliance during the abbreviated/partial extended survey of 9/26/16 - 10/5/16. Refer to the following deficiencies for specific details of the noncompliance: a. Resident Rights: 483.10 F157 -Failure to notify the physician of a change in resuscitation status for R25. This was cited at a D, potential for harm that was isolated in scope. b. Resident Behavior and Facility Practices: 483.13 F224 - Failure to protect R7 from neglect. R7 was administered a medication in a solution of Pine Sol. This was cited at a J, immediate jeopardy that was isolated in scope, constituting substandard quality of care. F226 - Failure to develop and implement policies and procedures to ensure R6, R7, R16, R19, R20, R21, R23, and R24 were free from abuse, neglect, and misappropriation of property. This was cited at a J, immediate jeopardy that was isolated in scope, constituting substandard quality of care. c. Quality of Life: 483.15 F244 - Failure to address grievances of the resident group for 215 residents residing in the main building. This was cited at an E, potential for harm at a pattern in scope. F252 - Failure to ensure the facility was clean, comfortable and homelike for residents in the main building (excluding the Specialized Ventilation Unit). This was cited at an E, potential for harm at a pattern in scope. d. Resident Assessment: 483.20 F280 - Failure to revise the care plan for R6, E1, R9, and R10. This was cited at an E, potential for harm at a pattern in scope. F281 - Failure to administer medications in accordance with physician's orders [REDACTED]. R7 was administered a medication, without a physician's orders [REDACTED]. This was cited at a J, immediate jeopardy what was isolated in scope. F282 - Failure to follow care plans for R2, R4, R20, R21, and R25. This was cited at an E, potential for harm at a pattern for scope. e. Quality of care: 483.25 F312 - Failure to provide assistance with activities of daily living to R2, R4, R21, and R25. This was cited at an E, potential for harm at a pattern for scope. F323 - Failure to ensure the environment was free of accident hazards for R34, R35, R20, R29, R28, R27, R31, R28, R33, and for R42. This was cited at an E, potential for harm at a pattern for scope. F328 - Failure to ensure R1, R9 and R10 received appropriate [MEDICAL CONDITION] and respiratory care and that staff working on the Specialized Ventilator Unit were trained and competent. This was cited at a J, immediate jeopardy that was isolated in scope. f. Nursing Services: 483.30 F353 - Failure to ensure staffing was adequate to meet the needs of residents. This was cited at an F, potential for harm that was widespread in scope. g. Physical Environment: 483.70 F463 - Failure to ensure the call system was functioning properly for R17. This was cited at a D, potential for harm isolated in scope. F469 - Failure to implement an effective pest control system in one of the two residential buildings affecting residents: R2, R37, R51, R47, R48, R13, R38, R39, R17, R50, R41, R31, and R40. This was cited at a G, actual harm isolated in scope. f. Administration: 483.75 F490 - Failure to ensure the facility was administered in an effective manner. This was cited at a K, immediate jeopardy what was at a pattern for scope. F520 - Failure to ensure an effective QAA quality assurance and assessment program was in place. This was cited at an F that was widespread in scope. 2. Review of the facility Incident Log revealed that on 9/6/16, R7 ingested harmful substance. Review of the facility's investigation revealed that on that day, a nurse administered [MEDICATION NAME], for which there was no order, mixed with Pine-Sol cleaner, to the resident. The resident complained of burning to the throat and was transferred to the hospital. (Refer to F224, F226, and F281.) 3. Review of additional facility investigations revealed that multiple members of the administration team, including the current Administrator, the previous Administrator, the Director of Nursing (DON), and Social Services staff, failed to assure that all allegations of abuse, neglect, and/or misappropriation were handled in a manner that assured compliance with all 7 required components of an abuse preventions program. A total of 10 investigations were reviewed as part of the abbreviated survey. Of these investigations, 8 of the 10 failed to meet all required components. Allegations of abuse, neglect, and or misappropriation were not identified as such. These allegations were either not reported timely to the State Survey Agency, or were not reported at all. Investigations completed by the administrative staff were not thorough, utilizing all available resources to make an accurate determination as to whether abuse, neglect or misappropriation had occurred. Administrative staff failed to assure that alleged perpetrators were immediately suspended, per the facility's policy, and use their resources by assigning other staff to replace the alleged perpetrator, rather than allowing them to complete their shift, placing other residents at risk. An interview was conducted with the DON on 9/28/16 at 3:34 p.m. She related that she was aware that allegations of abuse and/or neglect were required to be reported to the state within 24 hours. Interview with the DON also revealed that multiple allegations had been handled as an internal grievance rather than allegations of abuse, neglect, or misappropriation. The DON related that the Administrator was the person who made the decisions about reporting allegations. Interview with the Administrator on 9/28/16 at 3:55 p.m. revealed that when an allegation was made If you hear the word 'neglect' 'abuse' or 'stolen', the allegation is automatically reportable. However, additional interview with the Administrator revealed that she, herself, could not define neglect, stating, I think it's - it's hard to describe. Interview with the Administrator on 9/28/16 at 4:06 p.m. revealed the facility looked at the resident to see if there were any signs/symptoms of rape or injury but, there were none. She stated the facility called the family, who told them the resident's brother had been raped in the past, and therefore it was our conclusion that this was where the resident's allegation of being raped came from. She stated that No, we didn't look at the allegation of being hit or the resident's allegations that someone was hurting him at night and his desire to not be hurt anymore as separate from the allegation of rape, stating We looked at it as one issue. Additional interview with the Administrator revealed that the regs (regulations) require us to do due diligence - a full investigation. When asked about the use of the facility's camera system as part of the investigation, she stated, No, we didn't feel the cameras were needed in this situation. The Administrator confirmed that, even though the resident had shown no physical signs of rape or being hit, it was possible that the resident could have been hit, hurt, or frightened of staff treatment, even if the allegation of rape was not true. Review of facility grievance reports revealed a Grievance Form dated 7/12/16 with an allegation from the daughter of R24, reports that she visited Friday 7/8/16 at 4 pm to find her mother in in bed, soaked in urine (wet all over.) Daughter reports that her mother had been in bed all day. Res (ident) was shaking uncontrollably. Daughter expressed that things are not getting better. Daughter stated that resident in bed all day, soak (sic) with a sore on her bottom is not helping. Daughter reports that she informed the supervisor on Friday who stated to her that she would inform the nurse .Daughter added that she cleaned her mom and there was so much dirt that was on the cloth, daughter reports when they visit they have to ask for roommate to be changed b/c (because) no one ever changes. The Administrator was also asked on 9/28/16 at 3:55 p.m. about investigating why the nurse who knew of the allegation on 7/8/16 did not immediately identify it as an allegation of neglect and report it immediately. She related that she was not sure if this was looked at and she needed to review the investigation. After a review of the investigation report attached to the grievance form, she stated the nurse had taken care of the situation at the time it occurred and the facility had in-serviced staff on customer service issues. When asked again if the facility had investigated why the first person to receive the allegation of failure to provide care did not immediately identify and report it as suspected neglect, she stated that she would check further and see if the facility could find anything else to show that this aspect had been investigated. Other administrative staff were also unaware of basic requirements related to the facility's policies related to abuse, neglect, and misappropriation. Interview with Social Worker (SW) 268 on 9/27/16 at 2:17 p.m. revealed I'm not aware of what misappropriation of property is. She added that, I don't know what they do or don't report - that's not my decision. Interview with the SW Supervisor on 9/27/16 at 2:29 p.m. revealed she also was not aware of the definition of misappropriation, nor was she aware of federal regulations regarding reporting this type of allegation. (Refer to F226.) 4. Observation, record review and interviews revealed the facility failed to effectively use its resources to assure that R1, R9, and R10 had appropriate emergency equipment (correctly sized cannulas) at the bedside and failed to ensure staff were oriented, trained, and competent to care for the specialized respiratory needs of residents residing on the Specialized Ventilator Unit. R1, R9, and R10 did not have the proper sized cannulas at the bedside. The residents were at risk of harm if the wrong sized cannulas were inserted in the event of a medical emergency. The care plans lacked specific information regarding the size of the cannulas that should have been located at the bedside of these residents. Nursing staff were employed on the Specialized Ventilation Unit without specific training regarding how to care for residents who used ventilators and had tracheostomies. Nursing staff competency was not ensured by the facility. Staff members expressed fear that they did not know how to perform specialized nursing care for the residents on the Specialized Ventilator Unit (Refer to F328, F280). Interview on 10/3/16 at 2:42 with the DON and Assistant Administrator revealed that the DON was aware of the Specialized Ventilation Unit Manager's (UM) concerns about staff training and competencies. However, the DON had not assured that the Quality Assurance committee was aware of the concerns. The DON also acknowledged that although both she and the UM were aware of issues with staff training and competency, the facility had not utilized its resources (either through providing training and verifying competency of current staff, or deploying additional staff who were trained/competent) to assure that the specialized needs of the 14 residents in the Specialized Ventilation Unit were met. The DON could not provide a rationale for this failure, stating, I've got plans in my head but don't have them actually written down about what needs to be done. (Refer to F328, F353, F520.) 5. During the group interview conducted on 9/27/16 at 11:15 a.m., 16 residents stated that they had addressed this with administrative staff at almost every resident council meeting, and although the Administrator told the staff to never turn off the light then leave .they are still doing it. 6. Staffing concerns were also identified for other units in the facility through direct observation, interviews with residents (both individual and group), family interview, interviews with direct care staff (both Nursing Assistants and nurses), and review of facility records, including resident council notes, individual grievances, resident clinical records, and staffing records. Interview with the DON on 9/28/16 at 3:34 p.m. revealed that, We know there have been delays, concerns in timely response to answering call lights/requests for assistance. Additional interview with the DON on 9/29/16 at 11:45 a.m. revealed her statement that most days the facility was meeting its staffing goals. When informed that staffing ratios on at least one unit were as high as 25:1 on 3 of 5 sampled night shifts reviewed, the DON acknowledged that this was less staff than her planned ratios and there were some residents who've expressed concerns. However, she added, Staff haven't told me about any concerns. There was no evidence that administrative staff had used the multiple sources of evidence available that indicated inadequate staffing, and utilized their resources to assure that sufficient staff was present on each unit for each shift to meet the care needs of all residents. (Refer to F226, F282, F312, F353.) Review of the Job Description for the Executive Director (Administrator) revealed that the general description for this position stated, The Executive Director leads and directs the overall operation of the facility in accordance with resident needs, government regulations, and facility policies so as to maintain quality care for the residents while achieving the facility's business objectives. Essential duties included: Maintains a working knowledge and monitors compliance with all governmental regulations and Facility Quality Assurance standards . Promotes practices that maintain high morale and staff retention . Manages turnover and verifies adequate staffing, through development of recruitment sources and through appropriate selection, orientation, training, and staff education . Standard requirements for this position included: Adheres to: Quality Assurance requirements and compliance with regulatory requirements . Immediately reports incidents of alleged resident abuse or neglect or alleged violations of residents' rights to appropriate authorities. Post survey interview on 11/4/16 at 9:04 a.m. with the Administrator revealed that she is aware of the 7 required components for the facilities abuse policy. The Administrator stated that the facilities governing body makes revisions to their policies and their governing body makes them aware of any revisions to their policies. The Administrator stated that their facilities abuse policy had last been revised 9/6/16 after R7 alleged that LPN302 administered [MEDICATION NAME] in Pine-Sol. The Administrator revealed that one component, of the abuse policy, is to protect other residents when an allegation of abuse or neglect has been made. The Administrator stated that the way you protect the residents, when an allegation of abuse or neglect has been made, against a staff member, is to immediately suspend that staff member and investigate the allegation. Further interview with the Administrator revealed, that on 9/6/16, she was aware that LPN302, an MDS nurse, had been pulled from MDS to work the medication cart because she had seen LPN302 earlier that morning in the hallway. The Administrator stated it is not unusual to have to pull staff from one area, such as MDS, to fill holes in the schedule to cover different areas such as the medication cart. The Administrator stated that, from 8/6/16 through 9/6/16, LPN302 was pulled 3 times, from MDS, to work the medication cart. The Administrator went on to say that she, and her DON, were working on various things the morning of 9/6/16, and she wasn't the person that investigated the allegation made by R7 that LPN302 mixed her [MEDICATION NAME] in Pine Sol and administered; however, she did order that a sweep, for chemicals, be made of the building. The Administrator further stated that they did have a video camera system, but that she did not review the video of LPN302 mixing the medications for R7. The Administrator stated that it did not occur to them (the Administrator or the DON) to pull LPN302 from working the cart. LPN302 continued to work, and administer medications, the remainder of her shift. The Administrator went on to say that her staff keeps her informed of what occurs in the building and that when the allegation was made, by R16, that he had been raped and hit, that she was aware of the allegation the very day that it was reported. The Administrator stated that she investigated this allegation and that she did so by talking with the resident, talking with the resident' s family, and that the nurse practitioner and the DON conducted a physical exam of R16. The Administrator stated that since R16 stated that the allegation of rape, and being hit, occurred a couple of nights before 9/9/16, that she primarily reviewed the nursing staff, in the main building, from 9/9/16 back to 9/4/16, and that there was only one male CNA who had worked, in the main building, during that time, but that CNA had not worked the night hours that R16 had indicated that the rape occurred. The Administrator stated that she did not investigate whether there were any male housekeeping staff working, in the main building, during that time, and that there could have been male staff, that worked in the vent unit during that time who had access to the main building, but that she did not look at any of the staff in the vent unit during her investigation. The Administrator stated she did not investigate any other residents in the facility, other than the resident that shares the room with R16, and that she did not review the video camera footage during her investigation. The Administrator stated that she based her decision, that the resident was not raped or hit, based on the interview with the resident's family and the physical exam conducted by the nurse practitioner and the DON. Continued interview with the Administrator, at this same time, revealed that her facilities ventilator (vent) unit is a specialty unit and that she does have previous experience with vent units. The Administrator stated that she had never asked if the staff working, in the vent unit, had received training or if they had the required skills to work with vent patients. She continue to say that she had not been aware that there were not correct size inner cannulas, in the emergency equipment, at the resident's bedside. Further interview with the Administrator revealed that even though she had received complaints from the residents about having to wait a long time for call lights to be answered, that there had been complaints of odors in the building, and that she had to frequently pull staff from other departments, to fill holes in the schedule, she did not feel that she had a major staffing problem. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents in facility have the potential to be affected. 2. On 9/28/16 the Executive Director, Assistant Executive Director and Director of Nursing Services were inserviced by the governing body on facility abuse prevention policy, as well as F-tags 223, 223, 225, and 116 including the 7 components of screening, training, prevention, identification, investigation, protection and reporting/response. 3. Executive Director or Assistant Executive Director will ensure ongoing inservicing on medication administration to include the 6 rights of medication administration - right resident, right drug, right dose, right route, right time, right documentation, administering per physician's orders [REDACTED]. Abuse prevention service to include definitions of abuse, steps to prevent/detect and report to include screening, training, prevention, identification, investigation, protection, reporting and correction action. Emergency equipment at bedside inservice to include emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION]. Bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bad and mask, gloves, gauze, 5-10ml syringe, 0.9% normal saline vial, red waste bag, H20 lubricant, round ended scissors, [MEDICAL CONDITION] is completed by 10/5/16. Competencies and skills verification [MEDICAL CONDITION] to include preparation, course of action for cleaning inner cannula, course of action of disposable inner cannula, completion of task,[MEDICAL CONDITION] suctioning - preparation, course of action for suctioning and completion of task. Shower/bath/oral care competencies to include preparation, course of action, positioning and completion of task. Transitional care [MEDICAL CONDITION] unit skills verification to include identification of alarms outside resident room, what to do when alarm sounds. In-servicing, competencies and skills verification will be completed by 10/7/16 and in-servicing is completed quarterly. 4. Director of Nursing Services or Assistant Director of Nursing will ensure newly hired nurses while in orientation will receive in-services on medication administration to include: right resident, right drug, right dose, right route, right time, right documentation, administering per physician's orders [REDACTED]. Emergency equipment at bedside for vent/trach residents to include - emergency equipment at bedside in-service to include emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION]. Bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% normal saline vial, red waste bag, H20 lubricant, round ended scissors, [MEDICAL CONDITION]. Trach care to include preparation, course of action for suctioning and completion of task [MEDICAL CONDITION]. Competency checklist completed [MEDICAL CONDITIONS] to include preparation, course of action for suctioning and completion of task and medication administration and general orientation. Transitional [MEDICAL CONDITION] skills verification to include identification of alarms outside resident room, what to do when alarm sounds. Abuse prevention service to include definitions of abuse, steps to prevent/detect and report to include screening, training, prevention, identification, investigation, protection, reporting and corrective action. 5. At the end of each orientation class RN DNS, RN ADNS through the use of audit tool will ensure all new hires receive education on medication administration: right resident, right drug, right dose, right route, right time, right documentation, administering per physician's orders [REDACTED]. Emergency equipment at bedside for vent/trach residents to include - emergency equipment at bedside in-service to include emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION]. Bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% normal saline vial, red waste bag, H20 lubricant, round ended scissors, [MEDICAL CONDITION].[MEDICAL CONDITION] to include - preparation, course of action for suctioning and completion of task [MEDICAL CONDITION]. Competency checklist completed [MEDICAL CONDITIONS] to include preparation, course of action for suctioning and completion of task and medication administration and general orientation-transitional [MEDICAL CONDITION] care unit skills verification to include identification of alarms outside resident room, what to do when alarm sounds. Audit tools will be submitted to Executive Director or Assistant Executive Director at the end of each orientation class for review and any deficient practice will be forwarded for review of the QA committee. Grievances will be submitted to Executive Director, Assistant Executive Director or Director of Nursing Services daily for review and reported in compliance with prevention policy. Findings will be discussed in QA. 6. QA meeting was held on 9/29/16. Participants were ED, AED, DNS, ADNS, SS, and Director of [MEDICAL CONDITION] Services. HCMS, on behalf of the State Survey Agency, validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. No action plan in this statement to verify. 2. Documentation of the in-service provided by the governing body to facility administrative staff on 9/28/16 was reviewed. Interviews about this in-service were conducted with the Administrator and Assistant Administrator on 10/4/16 at 2:27 p.m. and revealed they had both attended the in-service provided by the governing body representative. They confirmed that the in-service included a review of the 7 components of the facility's abuse policy, as well as the federal requirements for F223, F224, F225, and F226. Both stated that, as a result of the in-service, they had a much better understanding of the regulatory requirements related to this area, and the procedures the facility must implement to assure residents were free of abuse/neglect and now had a much better understanding of the regulatory requirements related to the areas which had been identified as constituting Immediate Jeopardy. 3. On 10/4/16 at 2:54 p.m., the Administrator provided the ongoing calendar of in-servicing which listed these topics to demonstrate the plan for assurance of ongoing compliance. The calendar was reviewed, and it was confirmed that the topics referenced in the CARJ have been scheduled for the next quarterly training review in [DATE]. 4. Interview with Human Resources staff on 10/4/16 at 11:35 a.m. revealed there were three newly hired nurses in the last week. The personnel and training records of these three staff were reviewed. All three staff had evidence of the in-services alleged in the CARJ during orientation. Interview with LPN Orientee 308 at 9:40 a.m. on 10/4/16, confirmed that she received training during her orientation on the topics alleged in the CARJ. 5. Interview with the Administrator on 10/4/16 at 11:06 a.m. revealed that as of this date, the facility has not finished a new orientation class; however, when a class is completed, the competency tool already in place for auditing these areas will be used. The tool was reviewed to assure that all areas mentioned in the AOC were addressed. 6. Documentation of the 9/29/16 QA meeting was reviewed. The signature sheet verified the presence (either in person) or by telephone (in the case of the Medical Director) for this meeting in which the action plans for the AOC were developed. Interviews were conducted with the Administrator and Assistant Administrator on 10/4/16 at 2:27 p.m. to verify the topics discussed and actions planned for correction of identified Immediate Jeopardies.
Based on interview, record review, and review of the facility's policy titled, Quality Improvement Committee, the facility failed to maintain a Quality Assurance (QA) program which reviewed, developed, and implemented plans to correct quality deficiencies for all 229 residents living in the facility as of 9/26/16. The facility's QA program failed to: identify and respond to a pattern of failures regarding the identification, protection, and timely reporting of allegations of neglect, abuse, and misappropriation of property. Failed to identify and respond to a failure to have emergency equipment, proper sized cannulas, at the bedside for residents in the ventilator (vent) unit and address staff competencies. Failed to conduct root cause analysis of known problems and implement solutions. The facility was aware of multiple and repeated individual grievances from residents, families, and the resident council regarding staffing, pest control, and dietary services. The census was 229 and the sample size was 52. An abbreviated and partial extended survey was conducted from 9/26/16 through 10/5/16 to investigate complaints, GA 372, GA 244, GA 972, GA 111, GA 424, GA 053, the survey was conducted by Healthcare Management Solutions (HCMS), LLC on behalf of the Georgia State Survey Agency (SSA). The facility was found to not be in substantial compliance with the Medicare/Medicaid regulations at 42 CFR 483 Subpart B requirements for Long Term Care Facilities. The following deficiencies resulted from the facility's non-compliance related to GA 244, GA 972, GA 11, GA 424, and GA 053. The census was 229 residents and the sample size was 52 residents. On 9/27/16 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 9/27/16 at 5:55 p.m. the Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. F224 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. The Immediate Jeopardy at F224, F226, F281 and F490 was identified to have existed since 9/6/16, when staff mixed [MEDICATION NAME] with Pine Sol cleaner and administered it to Resident (R) 7, with the resident sustaining burning in her throat and requiring a transfer to the hospital. The facility failed to utilize its resources and immediately report and thoroughly investigate this case of neglect of R7, as well as failed to take necessary actions to protect the resident from the potential for further neglect. On 9/28/16 at 5:30 p.m. the facility's Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F226 also constituted Substandard Quality of Care at 42 CFR 483.13. The Immediate Jeopardy at F328 was found to have existed since 9/26/16, when it was identified that the correct-sized emergency equipment was not available for 3 of 14 residents (R1, R9 and R10) residing on the specialty vent unit. In addition actual harm was cited at F469 S/S:G the failure to control roaches, as well as other insects such as gnats and flies, resulted in psychosocial harm for 2 of 52 sampled residents (R2 and R37), both of whom expressed fear of the roaches which had been seen in their rooms. An acceptable Allegation of Compliance (AoC) was received on 10/3/16, and Healthcare Management Solutions, (HCMS) LLC, on behalf of the State Survey Agency, validated the AoC. The Immediate Jeopardy was removed from all 5 areas on 10/4/16. The Scope and Severity was lowered to the following levels: F224:D, F226:D, F281:D, F328:D, F490:F while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes: After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: Interview with the Director of Nursing (DON) and Administrator on 10/3/16 at 2:42 p.m. revealed that she and the Administrator had shared responsibility for the facility's Quality Assurance and Performance Improvement (QAPI) program. The Administrator stated she was working on a credible allegation to remove immediate jeopardy, and therefore, the Assistant Administrator would be present to assist the DON in answering questions about the QAPI program. Deficient areas that were identified through observations, interviews, and record review during the abbreviated survey were discussed as examples to determine how the facility's QAPI program functioned. 1. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked if the QA committee had identified the failure to identify, immediately report, thoroughly investigate, and take immediate actions to protect residents from potential abuse, neglect, and/or misappropriation. If this area had been identified through the QA process, the DON and Assistant Administrator were asked to provide evidence the QA committee had taken the issue through their QAPI process. (Refer to F224 and F226.) Interview with the DON, during the meeting which began on 10/3/16 at 2:42 p.m., revealed the QA committee did not formally review allegations of abuse and neglect, including the identification of possible patterns and whether there was a need to take action. The DON stated there was no audit of the information contained in each individual allegation to determine possible commonalities, such as the same perpetrator, same shift, and same unit. Likewise, there was no review of allegations to identify systemic problems needing correction, such as failure to identify alleged abuse/neglect/misappropriation of property; failure to immediately report allegations; or failure to immediately suspend alleged perpetrators when an allegation was made. The DON stated grievances were reviewed and provided July and August 2016 documentation, which noted the number and concern areas from the grievances for each unit. Review of this documentation showed a lack of sufficient information to determine if grievances might, in fact, have actually constituted allegations of abuse, neglect or misappropriation of property. In addition, review of this document revealed issues with accuracy. For example: Although the report stated there was a total of 13 grievances for July 2016, review of the documentation revealed there was a total of 22 grievances (8 on the 300 Unit, 2 on the Central Hall, 5 on West Unit; 6 on Magnolia Terrace, and 1 on the ventilator unit.) Although the report stated there was a total of 16 grievances for August 2016, review of the documentation revealed there was a total of 22 grievances (9 on the 300 Unit, 9 on the Central Hall, 2 on Magnolia Terrace - 2 and 2 on the Ventilator Unit.) Further interview with the DON revealed the QA committee had not identified any systemic problems with its abuse/neglect prevention program, even though 8 of the 10 incidents reviewed by the survey team, were found to be deficient in at least one of the 7 required components to prevent abuse/neglect (Refer to F226). The DON stated, We had identified some staff reluctance to report. However, she was unable to provide a date when the QA committee had identified this problem. The DON related the problem of reluctance to report had not been taken through the QAPI process. She stated a root cause analysis, per facility policy, of possible reasons for the reluctance of staff to report abuse was not conducted and she verified no action plan was developed to resolve the concern. The DON stated the facility routinely provided training on reporting of abuse; however, this routine training had not been a part of the QAPI process. The DON had no evidence of evaluation of the training to determine whether the training was correcting the problem of a reluctance to report. The DON stated, That's what we're working on now (evaluation of the training), verifying this was in response to immediate jeopardy being found by the survey team. 2. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked how the QA committee was monitoring and identifying potential care concerns in the Specialty Ventilator Unit, which was a separate, stand-along building on the facility's campus (Refer to F328). Interview with the DON revealed the Unit Director of the Specialized Ventilator Unit was a member of the QA committee, as well as an active participant in the facility's morning meetings where individual resident concerns were addressed. She reviewed the sign in sheets and confirmed that he had attended the last full quarterly QAPI meeting on 7/28/16. The DON was informed that the Unit Manager (UM)/Registered Respiratory Therapist (RRT) had informed the survey team of staffing competency concerns for the unit and was asked whether the QA committee had addressed these concerns. Continued interview with the DON revealed the DON was aware of staff training and competency concerns, for staff in the Specialized Ventilator Unit, because the UM shared these concerns during the daily stand up meetings. The DON stated, he told me directly about the problem. However, after a review of QA documentation, she stated, Those concerns didn't make it to formal QA. She reviewed the notes from the meeting and stated that the QA committee looked at audits on long-stay pain (based on Quality Measures) and the use of mittens (hand restraints) on the Specialized Ventilator Unit, as well as talked about one resident with a catheter and one resident with a skin condition. However, she continued and stated, the UM did not tell the formal QA committee that the nurses needed extra training, competencies. The DON was asked if a QAPI plan was developed, since both she and the UM were aware of issues with staff training and competency. The DON stated that in response to the UM concerns, I've got plans in my head but don't have them actually written down about what needs to be done. Further interview with the DON on 10/3/16 at 2:42 p.m., revealed the QA committee had not monitored or identified the failure to have correctly-sized emergency equipment at the bedside for residents on this unit, and was unaware of the problem, prior to identification by the survey team on 9/26/16. 3. Review of Resident council meeting notes beginning 5/5/16 documented residents' concerns about insufficient staffing. Residents' complaints included can't find staff on hall 3-11 shift. Review of resident grievances for July 2016, August 2016 and September 2016 revealed individual complaints about lack of care from staff, delays in answering call lights, and insufficient staff to meet resident needs. Review of resident council meeting notes dated 9/1/16 revealed additional complaints about insufficient staffing/call light response time. Observations, interviews, and record review during the abbreviated survey, beginning on 9/26/16, revealed that the problem had not been solved and was ongoing (Refer to F353). During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of a QAPI plan which included their analysis of possible root causes of the staffing problem, action plan to correct the problem, evidence of implementation of this plan, and analysis of the results/determination of how well the plan worked. The DON related that the QA committee developed an action plan on 5/27/16 for recruitment and retention of staff, stating that things were done for morale such as a nurse recognition activity in June 2016. She stated the facility also boosted its orientation efforts, they began completing panel interviews, and fliers were sent out to the community stating the facility was hiring. Further interview with the DON revealed that the facility had not performed a root cause analysis, per facility policy, to determine the basis of the problem before implementing these activities. The DON was asked how the QA committee monitored if these efforts worked well, especially based on the ongoing complaints of lack of sufficient staffing. She related that Human Resources staff maintained retention/turn-over statistics. However, she did not have evidence of this as part of the QA documentation and would have to contact HR to see what information they could provide. Interview with the Human Resources (HR) Director on 10/3/16 at 3:36 p.m. revealed the staff-turnover rate went from 46.6% to 76.5% between April 2016 and May 2016. By August 2016, the staff turnover rate as reported at the September 2016sub-QA meeting (monthly meetings held in which the Medical Director was not present, as opposed to the quarterly meetings where she was) had increased to 84.5% The HR Director related that the staffing problem was discussed in QA and determined to be an issue of retention. She stated, It wasn't an issue of hiring new, was retaining old. The HR, DON, and Assistant Administrator were asked to provide evidence of the action plan taken in response to this analysis, as well as evidence of implementation of how well it worked. Although they noted several actions, such as having an employee of the month on 8/15/16 and placing a banner out by the road in front of the facility, stating that they were hiring (also 8/15/16), they confirmed that there was no written action plan or evidence of monitoring to determine if the QA committee's actions had worked. 4. Review of resident council meeting documentation dated 5/5/16, demonstrated residents' concerns about pests. Residents council meeting documentation dated 6/2/16 revealed resident concerns were not resolved. Review of resident council meeting notes revealed the problem of insects continued to be noted as a resident concern in 7/7/16 and 8/4/16 resident council meetings. Observations, interviews, and record review during the abbreviated survey, which began on 9/26/16, revealed that the problem was still ongoing (Refer to F469). During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of a QAPI plan which included their analysis of possible root causes of the problem, action plan to correct the problem, evidence of implementation of this plan, and analysis of the results/determination of well the plan worked. The Assistant Administrator related the facility notified the bug people whenever pests were seen, and provided multiple invoices to show that specific halls/rooms had been treated in response to individual complaints/sightings of insects. However, the Assistant Administrator acknowledged the routine monthly visits, plus additional call-backs as necessary, were what the facility had always done, and were not an action plan in response to the uncontrolled pest problem this year. She stated she was not aware if the ongoing problem of pests had been taken to the QA committee for review, if the QA had completed a root cause analysis to determine why the facility's pest control measures were not working, or if they had developed an action plan in response. Further interview with the Assistant Administrator revealed she would check and provide any additional information she could locate. No further information was provided related to QA activities in response to this problem prior to exit on 10/5/16 at 11:00 a.m. 5. Review of Resident Council meeting documentation, dated 4/12/16 revealed that under old business 15 residents indicated that their previous complaints about staff not serving trays in DR (dining room) timely had not been resolved to their satisfaction. Under new business residents expressed concerns about the 300 Hall not getting first shift ice passed, and not being offered HS (bedtime) snacks. A review of the departmental response form dated 4/15/16 revealed that a QAPI tool done. Will check progress with council and discuss QAPI mtg (meeting). Review of the 5/5/16 Resident Council meeting notes revealed that under Old Business 16 residents stated that trays were still not being served timely. Sixteen residents also indicated their other concerns were not resolved, as they were still not being offered HS snacks, or having ice passed on the first shift. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of the QAPI plans for both the old and new business concerns, including their analysis of possible root causes of the problem, action plan, evidence of implementation of this plan, the QAPI tool mentioned in the response, and analysis of the results/determination of the how well the plan worked. The DON related that she would have to look for information on the QAPI plan and tool that was alleged in the 4/15/16 departmental response. As of 3:34 p.m., the DON was still looking for evidence that a performance improvement plan had been developed as alleged in the response to the resident council. As of 4:49 p.m., the DON related that she could not find a QAPI plan related to the delays in food service. She did state that she had located an audit that identified a problem with residents not receiving bedtime snacks and ice water in a timely manner that was completed on 6/1/16, 1 ½ months after the departmental response stated the tool was completed. The DON related that in response to the findings of the audit, the facility had done reeducation. Review of the reeducation documentation revealed that the in-services were not completed until 9/5/16 - 9/8/16, 4 months after the residents voiced concerns about snacks. At this time, the DON also provided a documented titled QA/QI HS snacks. The DON described this as a sample audit tool that would be used to monitor the facility's corrective actions. Interview with the DON revealed she had no completed audit tools to verify that staff had monitored that snacks were now being offered and ice water was present for the residents. The Assistant Administrator concluded the interview about Quality Assurance on 10/3/16 at 4:55 p.m. by acknowledging that the QA committee didn't do 'official' written action plans and they had nothing to show to indicate who was responsible for specific actions, who would monitor the identified actions, who would report back to the committee, or what information would be captured, analyzed, and reported to determine if a specific identified care concern had, in fact, been corrected. Review of the policy for Quality Improvement Committee dated December 2013 revealed that The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identify potential systemic problems. The committee will implement and systemically evaluate processed to identify problems in order to proactively improve health care deliver . Create systems to provide care and achieve compliance with nursing home regulations. Strive to achieve improvements in specific benchmarks. Utilize data obtained from a variety of sources to identify quality problems, opportunities for improvement, and set priorities for actions. Performance Improvement is a pro-active and continuous study of processed with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix causes of persistent/systematic problems. Performance Improvement Projects will be assigned to focus on a particular problem in one area of the facility or facility wide. Perform root cause analysis, set targets, implement corrections to improve the process. Procedures for this policy included that the QA committee would: Review results of previous audits and identify action plans for any areas needing improvement . Identify quality Improvement opportunities. Assign committee members audits related to any area of concerns Provide training and education as needed to facility staff. ** F328 AOC and Validation The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents on ventilators or with trachs ([MEDICAL CONDITION]) have the potential to be affected. 2. On 9/28/16 residents with trach/vents rooms were checked to ensure emergency equipment to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu (artificial manual breathing unit) bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] were available to bedside by RN/RT and equipment was at residents bedside. 3. On 9/27/16 started reinservicing licensed staff by RN/RT, Director of the [MEDICAL CONDITION] Unit that: Emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. On 9/28/16 in-services continued to be provided by RN/RT, the Director of the [MEDICAL CONDITION] Unit. In-services will continue by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Assistant Director of Nursing Services, RN Unit Manager. In-services will continue until licensed personnel that work in the vent unit have been in-serviced. 100% of in-services will be completed on 10/7/16. 80% of licensed personnel on vent unit have been in-serviced. 4. On 9/28/16 started competencies on licensed staff [MEDICAL CONDITIONS] by RN/RT.[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task. [MEDICAL CONDITION] suctioning included preparation, course of action of suctioning, and completion of task. Competencies will continue until 100% of licensed personnel that work the vent (ventilator) unit have been in-serviced. Competencies will continue to be provided by RN/RT Director of the [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 100% of competencies will be completed by 10/7/16. Licensed staff will not be allowed to work until competency completed 5. [MEDICAL CONDITION] care competency includes: preparation, course of action for cleansing inner cannula, course of action for disposable inner cannula, completion of task. 6. [MEDICAL CONDITION] suctioning competency includes: preparation, course of action for suctioning, completion of task. 7. Nurses that work the vent unit will have a competency checklist completed [MEDICAL CONDITIONS]. Competencies started 9/28/16 by RN/RT. Competencies will be continued by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will continue until licensed nurses assigned to vent unit have been completed. 100% of competencies will be completed by 10/7/16. 8. General orientation - Transitional [MEDICAL CONDITION] Care Unit skills verification to include identification of alarms outside resident rooms, what to do when alarm sounds, will be completed for staff working vent units to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants. Verifications started on 9/27/16 by RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification continued on 9/28/16 aby RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification will continue by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Verification will continue until staff working vent unit are completed. 100% of verifications will be completed by 10/7/16. Staff will not be allowed to work vent unit until verification completed. 80% of staff working vent unit have been completed. 9. During orientation process, newly hired nurses will have a competency checklist completed [MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task [MEDICAL CONDITION] to include preparation, course of action for suctioning and completion of task if working on the vent unit by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 10. Certified nursing assistants working the vent unit will have competencies completed on oral care/bathing/showering of residents with vents and trachs to include: preparation, course of action, positioning, and completion of task by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will be completed by 10/7/16. Certified Nursing Assistants working the vent unit will not be allowed to take an assignment until competency is completed. If certified nursing assistant is pulled from the main building, employee will not be allowed to take an assignment until competency completed. 11. No staff will be allowed to work until competencies and in-servicing are completed. 12. During orientation process, newly hired staff working vent unit will have general orientation-transitional [MEDICAL CONDITION] care until skill verification to include verification to include identification of alarms outside resident room. What to do when alarm sounds. Will be completed by RN/RT Director of [MEDICAL CONDITION] Director or RN Assistant Director of Nursing, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor (sic.) 13. RN Director of Nursing Services or RN Assistant Director of Nursing Services will audit weekly x 4 weeks then monthly x 2 months for emergency equipment at the bedside to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] and ensure emergency kit is placed in wall mount cabinet in resident rooms. Audit findings will be discussed on QA. If problem is noted the problem will be corrected then presented to the Director of Nursing for appropriate action (example 1:1 in-service, disciplinary action.) 14. If a licensed nurse is pulled from the main building to work on the vent unit, employee will be in-serviced on emergency equipment at bedside to be kept in plastic bag in wall counted cabinet in room next to be with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION].[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, course of action for disposing of inner cannula, completion of task.[MEDICAL CONDITION] to include preparation, course of action for suctioning, completion of task. (sic) Any other staff member to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants will be in-serviced on transitional [MEDICAL CONDITION] care unit. Skill verification to include identification of alarms outside resident's room, what to do when alarm sounds. In-service/training will be conducted by RN or RT on the vent unit. The staff member will be in-serviced prior to taking an assignment on the vent unit and on new nurses in orientation. 15. QA meeting was held 9/29/16. Participants were Executive Director, Assistant Executive Director, Social; Service Director, Director of [MEDICAL CONDITION] Services, Medical Director. 16. In-services for emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. Will be completed quarterly on licensed staff. (sic) HCMS on behalf of the State Survey Agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. No action plan was listed in this statement for verification. 2. Documentation of the 9/28/16 room checks were verified during the abbreviated survey. Observation during a tour of the unit on 10/4/16 at 3:30 p.m. found that all resident rooms on the TPCU (Specialized Ventilator Unit) were equipped with the correct size equipment, as well as all other emergency equipment listed in the AoC. Observation of the bedside cabinets containing emergency equipment were checked for 13 residents (residing in Resident Rooms: 101D, 102W, 104D, 104W, 106D, 107W, 110W, 110D, 111W, 111D, 112, 113W, and 115D). Emergency equipment observed including 2 replacements [MEDICAL CONDITION] cannulas (one the same size as what was currently in place for the resident, and one a size smaller, an ambu bag, a pulse ox machine, gloves, gauze, [MEDICAL CONDITION] ties, scissors, vials of Normal Saline, syringe, lubricant, suction catheter and red biohazard bag, was found at each bedside. 3. In-servicing records for all licensed/certified staff working in the vent unit were reviewed, and matched against the staffing schedule, as well as direct observation of staff and interviews on 10/4/16. All licensed/certified staff working in this unit was found to have the in-service records alleged in the AOC. Based on interviews with staff and the review of the facility documentation staff are not being allowed to work in this unit without first attending this training, based on interviews with staff, and a review of facility documentation. Interviews were held on 10/4/16 with the following staff: RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., LPN 288 at 10:15 a.m., LPN Orientee 308 at 9:40 a.m., CNA 292 at 9:50 a.m., CNA 166 at 11:55 a.m., CNA 151 at 11:15 a.m., RT 251 at 11:25 a.m., RT 257 11:40 a.m., SW 270 at 9:20 a.m., and PT 309 at 12:20 p.m., as well as the Unit Secretary at 9:10 a.m. The in-service records revealed that each staff received in-service training regarding the general orientation to the TCPU which included but was not limited to general care of reside
Based on record review and interviews the facility failed to develop and implement policies and procedures to ensure 8 of 52 sampled residents (R6, R7, R16, R19, R20, R21, R23, and R24) were free from abuse, neglect, and misappropriation of property. Abuse policies and procedures were not developed to reflect the seven required components of an abuse policy and was not implemented in a manner that protected the residents. The facility failed to complete thorough investigations resulting in it being unclear whether alleged abuse and neglect occurred, whether the facility came to the correct conclusion based on their investigation, and whether the facility took the appropriate course of action following investigation. The facility census was 229. The facility failed to identify possible neglect when a nurse mixed a medication, for which there was no order, with Pine Sol cleaning solution, without checking the label of the product. The hazardous solution was administered to R7. After staff administered Pine Sol to the resident and the resident took a sip of the solution, she complained of burning in the throat and required transportation to the hospital emergency room for evaluation. The facility failed to protect R7, and other residents, by not immediately suspending the nurse, and reporting neglect to the State Survey Agency (SSA), State Board of Nursing, and police in accordance with the Elder Justice Act. (Refer to F224, F281, F490.) In addition, the facility failed to: report allegations to the SSA of abuse and/or neglect of R6. The facility failed to conduct thorough investigations. As a result of one incident, staff determined that, to protect the resident, the alleged perpetrator would no longer work with the resident. However, the same staff member continued to work with the resident was later alleged to have abused R6 a second time. Although staff were aware of the second allegation of abuse, the facility's policy on immediate suspension was not implemented, and the staff member was allowed to continue to work with other dependent residents, placing them at risk. The facility failed to report an allegation of abuse of R21 to the SSA for 4 days. The Certified Nursing Assistant (CNA), alleged to have been abusive by not delivering needed care, was not immediately suspended, and was allowed to continue to work with residents, even though facility staff were aware of the allegation. The facility also failed to conduct a thorough investigation to determine the presence of abuse or neglect. The facility failed to identify an allegation of neglect of R24, when the family alleged that the resident had been left lying in bed all day, soaked in urine. The facility failed to immediately report the allegation to the SSA and failed to conduct a thorough investigation, reviewing all possible sources of information. The facility failed to report to the SSA and thoroughly investigate an allegation of misappropriation of property for R19. Although the resident, who was alert and oriented, named a specific staff as the perpetrator, the facility failed to immediately suspend the staff, pending investigation, to protect R19 and other residents. The facility also failed to report and thoroughly investigate an allegation of misappropriation of property for R23. The facility failed to assure immediate reporting to the administrator or their designee, as well as the SSA, of an allegation of abuse of R20. Although 4 different staff witnessed/had direct knowledge of the allegation, the alleged perpetrator was not immediately suspended, per facility policy, to assure the protection of R20 and others. The facility failed to immediately report to the SSA when R16 alleged that he was raped, hit, and was being hurt at night. The facility also failed to conduct a thorough investigation regarding the allegations of being hit and hurt at night. The facility failed to develop and implement screening policies to assure residents were not under the care of staff with prior histories of abuse and neglect. All staff were not screened against the state Nurse Aide Abuse Registry; the policy failed to address this specific requirement. The facility's failure to develop and implement policies and procedures designed to protect residents from neglect and abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. On 9/27/16 at 5:55 p.m. the facility's Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. F224 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. The Immediate Jeopardy at F224, F226, F281 and F490 was identified to have existed since 9/6/16, when staff mixed [MEDICATION NAME] with Pine Sol cleaner and administered it to Resident (R) 7, with the resident sustaining burning in her throat and requiring a transfer to the hospital. The facility failed to utilize its resources and immediately report and thoroughly investigate this case of neglect of R7, as well as failed to take necessary actions to protect the resident from the potential for further neglect. On 9/28/16 at 5:30 p.m. the facility' s Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F226 also constituted Substandard Quality of Care at 42 CFR 483.13. The Immediate Jeopardy at F328 was found to have existed since 9/26/16, when it was identified that the correct-sized emergency equipment was not available for 3 of 14 residents (R1, R9 and R10) residing on the specialty vent unit. An acceptable Allegation of Compliance (AoC) was received on 10/3/16 and Healthcare Management Solutions (HCMS), LLC on behalf of the Georgia State Survey Agency (SSA) validated the AoC. The Immediate Jeopardy was removed on 10/4/16. The Scope and Severity was lowered to an D while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F 226 was increased to F226:K. Findings include: 1. R7 was admitted to the facility most recently on 5/28/16. A review of the physician orders [REDACTED]. (Refer to F281). A quarterly Minimum Data Set (MDS) assessment, dated 7/14/16, indicated R7 exhibited no cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. During an interview with R7 at 4:45 p.m. on 9/26/16, she reported that a couple weeks prior a nurse mixed her [MEDICATION NAME] (medication for constipation) with Pine Sol disinfectant (purchased by the family of R7 and kept in R'7's closet) instead of green tea (also kept in R7's closet). R7 said that the nurse entered the room, opened the closet, and took out a bottle of liquid to mix the [MEDICATION NAME] with. R7 said she kept a bottle of Pine Sol in the closet and she also kept her bottles of green tea in the closet. R7 said the nurse (could not recall exact name or date) took a bottle out of her closet, left the room and returned with the [MEDICATION NAME] mixture in a cup which she gave to R7 and R7 took a sip and swallowed the mixture. R7 said that as soon as she took a sip, her throat burned and she told the nurse, You mixed it with Pine Sol! According to the Nurse's note, dated 9/6/16, at 11:06 a.m., the Nurse Practitioner (NP) was on the unit and R7 was assessed by the NP. Poison Control was notified and had no recommendations. R7 was transferred to the Hospital for evaluation at 10:35 a.m. R7 was evaluated at the Hospital and no issues related to the ingestion of the Pine Sol were identified according to the emergency room Course notes, dated 9/6/16. emergency room Course notes documentation revealed that other unrelated medical issues were identified, the Hospital wanted to have R7 remain for assessment and R7 signed out of the Hospital AMA (against medical advice). An interview with the NP at 12:00 p.m. on 9/27/16 revealed that she was making rounds on the West Unit at the time of the incident on 9/6/16 and was asked to assess R7. She said R7 told her that she drank some of the [MEDICATION NAME] mixture which she reported LPN302 had mixed with Pine Sol and that her (R7) throat was burning. The NP said R7 did not exhibit any acute symptoms related to the ingestion, but requested to go to the Hospital. The NP said that R7 appeared very anxious. She said that facility staff notified the Poison Control Center. Review of an Incident Log, dated 9/6/16, revealed R7 ingested a harmful substance at approximately 9:15 a.m. and potentially received a medication that there was no order for (Refer to F281). Review of the Safety Data Sheet, dated 1/5/15, for Pine Sol multi-surface cleaner and disinfectant (from the Clorox Company manufacturer), the product was considered hazardous under the Occupational Safety and Health Administration's (OSHA) Globally Harmonized System of Classification and Labeling of Chemicals (GHS). The Safety Data Sheet indicated, Ingestion may cause irritation to mucous membranes and gastrointestinal irritation, nausea, vomiting, and diarrhea. First aid instructions included calling a Poison Control center or physician immediately and having the individual take small sips of water if possible. Ingredients included alcohol and [MEDICATION NAME] acid. During an interview with LPN302 at 11:38 a.m. on 9/27/16, LPN302 said that she grabbed what she thought was the green tea from R7's closet, took it to the medication cart and mixed it with the [MEDICATION NAME]. She said she took the cup back to the room and gave it to R7. She said R7 was rushing her and she did not follow the correct procedure for medication administration. LPN302 said she did not check the Medication Administration Record [REDACTED] Review of LPN302's personnel record revealed there was no documentation that would indicate previous medication errors or nurse practice issues. LPN302 had been employed by the facility since 4/19/04 as the MDS Assistant. On 9/6/16, LPN302 was assigned to the West Unit to pass medications and provide nursing care. LPN302 was terminated on 9/9/16. Investigation: The investigation file contained two written statements from LPN302, both dated 9/6/16 at 10:30 a.m. Review of one of LPN302's written statements revealed that after R7 took a sip of the medication, she called out that her throat was burning and LPN302 gave her a drink of root beer. In one statement LPN302 denied the incident and the other statement she indicated the incident occurred, but was accidental. Protection: Review of the time card, dated 9/6/16, indicated that LPN302 was allowed to finish the shift and punched out of the facility at 2:00 p.m. (incident occurred at approximately 9:15 a.m.) Reporting: Review of the investigation file relative to this incident revealed that there was no documentation to indicate that this was reported to the SSA, the local police or the Board of Nursing. Interview with the Director of Nursing at 10:15 a.m. on 9/28/16 revealed that although the incident was discussed with administrative staff members, it was viewed as an isolated issue for the nurse involved and there were no witnesses. She said the discussion of reporting this to the SSA, the local police, or to the state Board of Nursing did not occur to her and the incident was not reported to any of these agencies. 2. Review of closed records for R6 revealed a face sheet (demographic information) that noted the resident's [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION] (opening surgically created through the neck into the trachea or windpipe to facilitate respiration and ventilation) and resided on the facility's specialty [MEDICAL CONDITION] unit for residents with tracheostomies and/or who were ventilator dependent. The Minimum Data Set (MDS) for R6 dated 12/6/16, the resident, who could communicate, was cognitively intact, and had no memory loss, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. Per this MDS, the resident had no behaviors, resistance to care, and her only mood concern was feeling down, depressed or hopeless. Per the resident's comprehensive care plan, initiated 10/20/15, R6 is alert and can communicate her needs. The resident required total assistance with personal hygiene, dressing, bathing, feeding, toileting, transfers, and bed mobility. The care plan for R6 also noted the resident Requires O2 (oxygen) use, suctioning, neb (nebulizer) txs (treatment). Risk for respiratory distress, infection, dehydration, and decannulation. In response, staff were to Provide O2, nebs, meds, suctioning, V/S (vital signs),[MEDICAL CONDITION] as ordered/needed. Review of clinical records for R6 revealed no evidence of any allegations of abuse or neglect. Interview with the Administrator on 9/26/16 at 1:03 p.m., revealed there would be nothing documented about investigations of abuse or neglect in the resident's record, as all investigation reports were maintained in a separate file. In response, the Administrator was asked to provide documentation related to any allegations made by R6 and/or her family, as well as any investigations related to the resident. a. The first allegation involved a staff member telling R6 she wished the resident would die as she was transported to the hospital. Review of Departmental notes for R6 revealed the resident was transferred to the hospital on [DATE]. Review of a Witness Statement form revealed that on 12/15/15, the resident's Responsible Party (RP) informed the Social Worker (SW) that the resident (who was currently in the hospital) had informed her that on day she was sent to hospital .a staff said to her, 'I wish you would die' before the ambulance arrived. The reported statement was made in the presence of the ambulance personnel. SW asked if the resident appeared confused, family said no. The RP said the SW should not make a big deal of it because when the resident returned (to the facility) she wanted things to be okay. Per family, resident did not give names. Reporting: Although the facility provided witness statements to verify that they had investigated this allegation, review of facility investigation records revealed no evidence that this allegation was ever reported to the State Survey Agency. Interview with the Director of Nursing (DON) on 9/26/16 at 4:00 p.m. confirmed the allegation that an unidentified staff told the resident, I wish you would die was not reported to the State Survey Agency (SSA.) The DON related that, possibly this allegation should have been reported as an allegation of verbal abuse. However, she continued that the facility's investigation found that nothing happened. Further interview with the DON confirmed that the facility was not aware that nothing happened when the allegation was first reported, and only made this determination based on the interviews obtained during their investigation. b. The second allegation, occurred on 12/25/15, concerned R6 reporting that Respiratory Therapist (RT) RT265 was mean to her and refused to provide care. Further review of the facility investigation information about R6 revealed two Witness Statement forms completed at 11:00 p.m. on 12/25/15. In the first statement, a Registered Nurse (RN) wrote that R6 had asked to see her nurse. PT (patient) unable to speak clearly, so I (RN name) provided pen and paper (Pt letter attached). Pt unhappy with care from (Name - Respiratory Therapist (RT) 265). Pt described RT265 as mean and does not care about her. The RN noted that he reassigned a different RT to R6 for the rest of the shift, and R6 was reassured I would follow DNRC (name of facility) policy regarding her concerns and follow up. (RT255) RT who I assigned to (R6) witness statement attached. House Supervisor notified. Review of RT255's written witness statement revealed that on 12/25/16, he was called to the room of R6 by a Registered Nurse (RN) to listen to statements made by R6. Apparently (R6) stated that (RT265) has been mean to her lately and refused to deliver (care) upon request repeatedly. Therefore, she's very uncomfortable having (RT265) caring for her, does not want her to continue the delivery of care to her. Having discussing (sic) it with (RT265) she does not return to the room. I take over the continuum of care to (R6) to assure her confidence. Review of signed, handwritten (undated) statement for R6 revealed that although the wording in all sentences was not clear, R6 did indicate problems with care of my breathing vent and told me early that nothing change, meaning she still mean to me. Do you have someone to take her place to night? Give me someone else that kind .She kind of mean. Identification: Review of facility records revealed no evidence that the facility followed up with the resident to determine what she meant when she stated that the RT was mean, in order to identify if the resident was alleging abuse (either physical or verbal.) Reporting: Review of facility records revealed no evidence this allegation of neglect (refusal to deliver requested care), as well as possible abuse, was reported to the SSA. Investigation: Review of facility records revealed no evidence to demonstrate this allegation was thoroughly investigated. There was no evidence of witness statements from other persons who might have knowledge of the allegation, such as another staff. There was no evidence of attempt to interview other residents to determine if they had concerns with abuse or neglect from RT265. There was no evidence of a witness statement or interview of the alleged perpetrator, RT265. Protection: Review of the facility's policy titled, Abuse Prevention (revised 9/16, but in place at the time of this incident) revealed that the Protection component stated, Any allegation of abuses (sic) or neglect against any employee must result in his/her immediate suspension to protect the resident. Review of personnel records revealed that although R6 named a specific perpetrator (RT265), she was not suspended pending investigation of this incident. In addition, although the witness statements noted that RT265 would no longer care for R6, review of comprehensive care plan for R6 revealed it was not updated with this intervention. Interview with the DON on 9/26/26 at 3:25 p.m. confirmed that the allegation of neglect and possible abuse made by R6 on 12/25/16 was never reported to the SSA. Further interview with the DON on 9/26/16 at 4:00 p.m. revealed that at the time of the allegation, the supervisor who was going off duty gave RT265 a different assignment so that she would no longer provide care for R6. However, she confirmed, the RT alleged to have been abusive remained on the unit, and was responsible for providing care to other residents. She stated that in response to the allegation, She should have been suspended immediately - and not waited until the end of the shift. The DON related that, I don't know why this allegation had never been reported to the SSA, noting that the Administrator who made the decisions about reporting at this time was no longer working at the facility. c. Review of a Witness Statement dated 12/28/15 revealed that on that day, a Certified Nursing Assistant (CNA 305) went into the room of R6. She had put the light on. She told me she wanted to speak to the nurse because (RT'S first name) was being mean to her. She shoved the suction nozzle down her throat and made her throat sore and it was bleeding. She said she didn't want her back in her room no more because she's mean to her. I informed her I would get the nurse for her and I did. Review of the Registered Nurse's (RN306) witness statement dated 12/28/15 at 9:30 p.m. confirmed that on that date, the CNA called the nurse to R6's room. Upon entering (room), Res told me the (sic) RT that she had for the night was suctioning her hard and it caused her to bleed. She also stated that she did not want that RT caring for her. The RN spoke with the RT (different RT than that of the 12/25/15 incident) and assigned a different RT for the remainder of the shift. Review of facility records revealed that in response to this complaint, on 12/31/15, 6 staff were provided an educational in-service on customer service. It was unknown if the RTs, that were named in the complaint, were part of the 6 staff who were interviewed. There was no evidence that the facility investigated further to determine the possibility of abuse or neglect. The facility did not report the allegation to the SSA. d. The fourth allegation involved a report of R6 being hit by a staff member. On 1/25/16, the facility reported as allegation to the SSA that R6 had been hit by a staff member. Review of the report to the SSA revealed that In a phone conference today, the family told us a staff mistreated her here and punched her. They stated they were not going to tell us. They state it is a staff who is black/looks Hispanic. Family would not provide more details/dates/descriptions (psych sees her for depression.) On the Supervisor Investigation Form, staff noted that the family might be reporting this because they want resident transferred to Michigan, but is lacking funds. An investigation was conducted and review of the follow-up summary forwarded to the SA revealed that due to the delayed/vague information from the family and resident not alledging (sic) abuse, we were unable to substantiate. e. The fifth allegation occurred on 3/17/16; R6 alleged RT265 delayed the provision of care and she felt abused by RT265. On 3/18/16, the facility reported another allegation of abuse of R6 to the state. Review of the Facility Incident Report form revealed that on 3/17/16, the pt (patient) c/o (complained of) speaking rude to her and delaying care of her requesting neck to be checked. Pt felt abused. Doesn't want therapist again. Resident family upset - heard the therapist over phone being rude. Resp (respiratory) therapist suspended pending investigations. Review of a witness statement dated 3/17/16 at 11:00 p.m. revealed the type of event was complaint - verbal abuse. In the witness statement, the unit supervisor documented a phone interview with the family of R6. Per the witness statement, the family member stated she was on phone with sister and she heard resp (respiratory therapist) come in and yell at her, saying What do you want now? I was just here 10 mins ago. A witness statement dated 3/21/16 documented an interview with R6 by a Social Worker (SW). In this interview, 4 days after the incident, the resident stated she feels verbally abused due to RT raising her voice at her for no reason. Asked her if she feels safe/comfortable w (with) RT continuing care. Resident said No do not wish for RT to offer care. The witness statement did note that the resident did not want the RT to get into trouble because she is usually a nice person. Protection: Review of personnel records revealed that the RT who was suspended on 3/18/16 was RT265, the same RT named as being neglectful and mean by the resident in December 2015. Although the notification to the SSA stated that the RT was suspended, review of facility records, including time cards revealed that this did not occur immediately, per facility policy, for the protection of residents. The Supervisor Investigation Summary form noted that this incident occurred on 7:00 p.m. - 7:00 a.m. shift near 11pm. Review of the time card for RT265 revealed she was not immediately suspended, and continued to work the remainder of the shift, clocking out at 7:18 a.m. the following morning, approximately 8 hours after facility staff were first aware of the allegation of abuse. In addition, review of the facility's investigation revealed no evidence that they identified that the RT who was alleged to be abusive on 3/17/16, had previously been named by the residents as an alleged perpetrator of neglect/possible abuse. In response to the 12/25/15 incident, the decision was made to not have RT265 work with R6. There was no evidence that as part of the investigation, the facility identified that the resident's care plan had never been updated with this approach. Investigation: Review of the investigation revealed that it was not thorough. R6, the resident making the allegation, was the only resident interviewed. There was no evidence that the facility identified other residents for whom RT265 had provided care to see if there were additional concerns about abuse and neglect. Review of the Follow Up Summary form forwarded to the SSA on 3/24/16 revealed that There were no witnesses or physical injury .we were unable to substantiate abuse or neglect. However, this statement was not accurate. There was at least one witness - the family member who heard the conversation between R6 and RT265. According to the witness statement, in which the SW documented her interview with the family member, the RP stated that she had been on the phone with R6 when RT265 entered the room. The resident placed her phone on the bed and the RP overheard RT shouting at resident and said to the resident, 'What do you want now (R6)? You keep calling staff so much time to come into your room. In addition, the Follow Up Summary noted, . She (RT265) has a clean file with no issues. The summary failed to note that there was a previous history that R6 had alleged abuse/neglect by RT265, or identify that staff had already identified the need for RT265 to not work with R6. Interview with the DON on 9/26/16 at 4:00 p.m. revealed her conclusion that, I think it was unsubstantiated because later she (R6) changed her mind. She provided no explanation when shown the 3/21/16 report in which the resident was still stating that she felt verbally abused. Further interview with the DON revealed she was unaware that R6 had previously asked to not have RT265 work with her (in December) due to allegations of her failing to provide care and being mean. An interview was conducted with the Director of Human Resources (HR) on 9/26/16 at 2:00 p.m. She confirmed that RT265 was not immediately suspended when the allegation of abuse became known at approximately 11:00 p.m. on 3/17. Instead, she verified, she worked the rest of the shift (7:00 p.m. - 7:00 a.m. for 3/17/18 - 3/18/16) and was not suspended until the day after the alleged abuse. Interview with the Administrator on 9/26/16 at 2:15 p.m. revealed she had started in her position in May, 2016, and was not present at the time of these alleged instances of abuse or neglect. She related that the facility's policy was for the alleged perpetrator to be suspended immediately - they are not allowed to finish their shift. The Administrator related the immediate suspension was to assure protection of the residents. 3. Review of face sheet for R21 revealed the resident's [DIAGNOSES REDACTED]. Per the resident's quarterly Minimum Data Set (MDS) of 7/1/16, the resident was severely cognitively impaired. Section G (Physical Function) of this MDS documented the resident required extensive assistance with toileting/personal hygiene and was always incontinent of bowel and bladder. Review of a Supervisor Investigation Summary Form revealed that at approximately 4:00 p.m. on 8/28/16, the family, of R21, was visiting and reported allegation abuse d/t (due to) found her father's incontinent care was delayed. Review of a witness statement completed by the nurse at 6:00 p.m. on 8/28/16 revealed the family notified the nurse that When she came in, her father was in bed with fruit flies and flys (sic) all around him. She stated she pulled his brief back, he was not wet but the brief was stained and yellow and he smelled like BM (bowel movement); the covers smelled like BM also. She stated his scrotum and bottom are very red and irritated and he had no cream on to protect his skin. a. Reporting - Review of the Supervisor Investigation Summary Form revealed the comment that issue reported to State. However, further review of facility records revealed that the allegation of abuse was not reported to the State Survey Agency (SSA), in accordance with Federal Regulations, until 4 days later, on 9/1/16 at 4:20 p.m. b. Protection - Review of the facility's policy titled, Abuse Prevention (revised 9/16) revealed that the Protection component stated, Any allegation of abuses (sic) or neglect against any employee must result in his/her immediate suspension to protect the resident. Review of the Supervisor Investigation Summary Form revealed that in response to this allegation of abuse, Certified Nurse Aide (CNA)188 was suspended on 9/1/16. Review of the facility investigation revealed no evidence or explanation why the CNA (for whom the allegation of abuse was received on 8/28/16) was not suspended until 9/1/16. In addition, review of the time card for CNA188 for 8/28/16 revealed that even though the facility was aware of the allegation of abuse at approximately 4:00 p.m., CNA188 was not immediately suspended. CNA188 was allowed to continue working until the end of the scheduled shift, at 7:29 p.m. on 8/28/16. c. Investigation - Review of the Investigation Summary and witness statements revealed the facility failed to conduct a thorough investigation, exploring all possible sources of information. There was no evidence of an attempt to interview the roommate of R21, or explanation regarding why this interview was not conducted. The investigation included notes of interviews with 3 residents. However, review of these notes revealed the residents interviewed did not know the CNA who was alleged to be abusive. Other sources of potential information, were not explored in order to illustrate a thorough investigation was conducted. For example, review of the statement by the alleged perpetrator revealed that the facility had a camera system and the results could be checked to verify if she had provided incontinent care for the resident. Review of the investigation revealed no evidence that the camera system was reviewed as part of this investigation. An interview was conducted about this investigation with the Director of Nursing (DON) on 9/28/16 at 10:18 a.m. The DON confirmed that she was aware all allegations of abuse and/or neglect were to be immediately reported to the SSA. The DON was then asked about the 4-day delay in reporting the allegation of abuse of R21. The DON initially stated that when the family first reported their concern to the facility, They wanted several days to think about how serious they wanted to take it. On September 1, they said they wanted it reported as neglect. The DON was shown the report written on 8/28/16 which used the word abuse and was asked to clarify why the facility failed to report when they knew that an allegation of abuse had been made at that time. She reiterated that the facility just didn't report it (on 8/28/16) based on the family saying they were thinking about it. The DON acknowledged that in retrospect, the allegation of abuse/neglect should have been immediately reported to the state. In addition, she confirmed CNA188 should have been i
Based on interview and review of resident records, the Georgia Practical Nurses Practice Act professional standards published in the Lippincott Procedures for Safe Medication Administration Practice, General, and the facility policy titled, Medication Administration General Guidelines, the facility failed to ensure that the services provided to 4 of 52 sampled residents (R7, R5, R25, and R34) met professional standards for medication administration. Specifically: Resident (R) 7 was given [MEDICATION NAME] (laxative medication) without a physician order and the [MEDICATION NAME] was mixed with Pine-Sol cleaning solution, without checking the label of the product. The hazardous solution was administered to R7. After staff administered the Pine-Sol to the resident and the resident took a sip of the solution, she complained of burning in her throat and required transportation to the hospital emergency room for evaluation. The facility failed to administer medication to R5 prior to a surgical procedure, as ordered by the physician. The facility failed to administer an antibiotic medication, to R25, until 3 days after it was ordered for an infection. The facility administered three doses of [MEDICATION NAME] (opioid pain medication) to R34 after the medication was discontinued by the physician. The census was 229. The facility's failure to ensure that medications were administered based on physician order caused, or was likely to cause serious injury, harm, impairment, or death to a resident. On 9/27/16 at 5:55 p.m. the Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. On 9/28/16 at 5:30 p.m. the Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F224 and F226 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. An acceptable Allegation of Compliance (AOC) was received on 10/3/16 and Healthcare Management Solutions (HCMS), LLC, on behalf of the State Survey Agency, validated the AoC. The Immediate Jeopardy was removed on 10/4/16. The deficient practice remained at a D (potential for more than minimal harm) while the facility developed and implemented the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitored the effectiveness of the systemic changes. After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: 1. TITLE 43. PROFESSIONS AND BUSINESSES CHAPTER 26. NURSES ARTICLE 2. LICENSED PRACTICAL NURSES § 43-26-30. Short title: This article shall be known and may be cited as the Georgia Practical Nurses Practice Act. HISTORY: Code 1981, § 43-26-30, enacted by Ga. L. 1992, p. 2151, § 1. § 43-26-31. Purpose of article the purpose of this article is to protect, promote, and preserve the public health, safety, and welfare through regulation and control of practical nursing education and practice. This article ensures that any person [MEDICATION NAME] or offering to practice practical nursing or using the title Licensed Practical Nurse, as defined in this article, within the State of Georgia, shall be licensed as provided in this article . The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law . Such care shall relate to the maintenance of health and prevention of illness through acts authorized by the board, which shall include, but not be limited to, the following: (A) Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations; (B) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, home health care, or other such areas of practice; (C) Performing comfort and safety measures; (D) Administering treatments and medication; and (E) Participating in the management and supervision of unlicensed personnel in the delivery of patient care . The statutory materials reprinted or quoted verbatim on the following pages are taken from the Official Code of Georgia Annotated, Copyright 1984, 1988, 1991, 1994, 1999, 2002, 2005, 2006, 2007, 2009, 2010, 2011, 2012, 2013 by the State of Georgia, and are reprinted with the permission of the State of Georgia. All rights reserved: According to Lippincott Procedures for Safe Medication Administration Practice, General, dated 10/2/15, relative to Verifying the Medication Order: Follow a written or typed order or an order entered into a computer order-entry system because these types of orders are less likely to result in error or misunderstanding. Make sure that the prescriber's order contains a diagnosis, a condition, or an indication for the medication. Verify that other essential elements of the medication order are present, including the patient's name, age, and weight (preferably in kilograms);9 the date and time the order was written; the name of the drug to be administered; the dosage of the drug; the route by which the drug is to be administered; the frequency of administration of the drug; dose calculation requirements (when applicable); exact strength or concentration of the drug (when applicable); the quantity of the drug or duration of administration (when applicable); specific instructions for use (when applicable); and the signature of the person writing the information. The facility Medication Administration General Guidelines revealed that medications are administered in accordance with written orders of attending physicians, prior to administration the medication and dosage schedule on the Medication Administration Record [REDACTED]. If a dose of medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the MAR for as needed medication documentation. 1. R7 was admitted to the facility most recently on 5/28/16. A review of physician orders dated from 5/28/16 through 9/6/16 revealed there was no order for R7 to receive [MEDICATION NAME]. (Refer to F281). A quarterly Minimum Data Set (MDS) assessment, dated 7/14/16, indicated R7 exhibited no cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. A review of the most recent plan of care to address medications, revealed that R7 should receive medications as ordered and be monitored for side effects. Review of a Supervisor Investigation Summary Form, dated 9/6/16, revealed R7 ingested a harmful substance (Cross Reference to F224) and received a medication ([MEDICATION NAME]) without a physician order. The form indicated that LPN302 administered the harmful substance and [MEDICATION NAME]. R7 was transferred to the Hospital for evaluation following the incident and returned the same day after signing out AMA (against medical advice). There was no change in her physician orders on return from the Hospital. A review of the physician orders for R7, dated from admission on 5/28/16 until 9/6/16 revealed there was no physician order for [REDACTED].>Medication Administration records (MAR), dated 9/6/16, revealed there was no order for [MEDICATION NAME] noted on the MAR. According to the Nurse's note, dated 9/6/16, at 11:06 a.m., the Nurse Practitioner (NP) was on the unit and R7 was assessed by the NP. Poison Control was notified and had no recommendations. R7 was transferred to the hospital for evaluation at 10:35 a.m. R7 was evaluated at the hospital and no issues related to the ingestion of the Pine-Sol were identified according to the emergency room Course notes, dated 9/6/16. emergency room Course notes documentation revealed that other unrelated medical issues were identified, the hospital wanted to have R7 remain for assessment and R7 signed out of the hospital AMA (against medical advice). An interview with the NP at 12:00 p.m. on 9/27/16 revealed that she was making rounds on the West Unit at the time of the incident on 9/6/16 and was asked to assess R7. She said R7 told her that she drank some of the [MEDICATION NAME] mixture which she reported LPN302 had mixed with Pine-Sol and that her (R7) throat was burning. The NP said R7 did not exhibit any acute symptoms related to the ingestion, but requested to go to the hospital. The NP said that R7 appeared very anxious. She said that facility staff notified the Poison Control Center. A physician order, dated 9/13/16, (7 days after R7 received the [MEDICATION NAME] on 9/6/16), revealed an order for [REDACTED]. During an interview with R7 at 4:45 p.m. on 9/26/16, she reported that a couple weeks prior a nurse mixed her [MEDICATION NAME] (medication for constipation) with Pine Sol disinfectant (purchased by R7's family and kept in R'7's closet) instead of green tea (also kept in R7's closet). R7 said that the nurse entered the room, opened the closet, and took out a bottle of liquid to mix the [MEDICATION NAME] with. R7 said she kept a bottle of Pine Sol in the closet and also kept her bottles of green tea in the closet. R7 said the nurse (could not recall exact name or date) took a bottle out of her closet, left the room and returned with the [MEDICATION NAME] mixture in a cup which she gave to R7 and R7 took a sip and swallowed the mixture. R7 said that as soon as she took a sip, her throat burned and she told the nurse, You mixed it with Pine Sol! During an interview with LPN302 at 11:38 a.m. on 9/27/16, LPN302 said that she grabbed what she thought was the green tea from R7's closet, took it to the medication cart and mixed it with the [MEDICATION NAME]. She said she took the cup back to the room and gave it to R7. She said R7 was rushing her and she did not follow the correct procedure for medication administration. LPN302 said she did not check the Medication Administration Record [REDACTED] Review of the personnel record for LPN302 revealed there was no documentation that would indicate previous medication errors or nurse practice issues. LPN302 had been employed by the facility since 4/19/04 as the MDS Assistant. On 9/6/16, LPN302 was assigned to the West Unit to pass medications and provide nursing care. LPN302 was terminated on 9/9/16. Review of the Skills Validation related to medication administration revealed LPN302 attended the training in July 2015. Interview with the Director of Nursing (DON) at 9:45 a.m. on 9/27/16 revealed that there was no order for R7 to receive [MEDICATION NAME] on 9/6/16. The DON confirmed that LPN302 was allowed to finish her shift on 9/6/16, the incident was not reported to the SSA or the Board of Nursing in Georgia. 2. R34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The December 2015 MAR, for R34, revealed that on 6/22/15 the physician ordered [MEDICATION NAME] (opioid pain medication) 5/325 milligrams, 1 tablet by mouth every 6 hours as needed for mild to moderate pain and 2 tablets by mouth every 6 hours as needed for moderate to severe pain. Review of the clinical record for R34 revealed that [MEDICATION NAME] was discontinued per a physician order on 1/12/16. Review of the Janaury 2016 MAR indicated [REDACTED]. Interview with LPN137 at 4:30 p.m. on 10/3/16, revealed that R34 had an order for [REDACTED]. LPN137 said she did not follow correct medication administration procedures relative to checking the physician order against the medication container three times prior to administration. LPN137 said she recalled giving the medication a second time, after it was discontinued. She said that she administered the dose on 1/12/16 prior to the time the order was written to discontinue the medication. There was no time noted on the physician order to discontinue it. She could not provide a reason for not following correct procedure. The MAR indicated [REDACTED]. Review of the Skills Validation related to medication administration revealed LPN137 attended the training in July 2015. The Supervisor Investigation Summary Form dated 2/4/16 (when the issue was discovered) indicated disciplinary action was taken, (counseling), and the physician was notified. Interview with the DON at 9:00 a.m. on 10/3/16 revealed that the incident was reviewed, and LPN137 was written up and participated in med pass with pharmacy and facility staff, however, the incidents were not reported to the SSA or the Board of Nursing. The DON said that the correct procedure for medication administration was to verify the physician order on the MAR indicated [REDACTED]. 3. R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission assessment documentation, dated 4/20/16, revealed that R5 was alert and oriented to person, place, and time. The Admission physician orders for R5 revealed that she was scheduled for a surgical procedure on 4/25/16. A physician order, dated 4/20/16, revealed R5 was to have nothing by mouth after midnight on 4/24/16. R5's Preadmission Teaching and Testing form, dated 4/22/16, revealed that R5 should arrive at the surgery center on the morning of 4/25/16. The form indicated R5 was allowed to have the following medications, with a sip of water, prior to surgery on the morning of 4/25/16: [MEDICATION NAME] (pain medication) if needed, [MEDICATION NAME] (anti-anxiety medication) if needed, [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]), ProAir ([MEDICATION NAME][MEDICATION NAME]) if needed, [MEDICATION NAME] (Beta blocker), Dexilant (proton pump inhibitor to treat reflux), [MEDICATION NAME] (allergy medication), [MEDICATION NAME] ([MEDICAL CONDITION] hormone), [MEDICATION NAME] (narcotic pain medication), Liothyronine ([MEDICAL CONDITION] hormone), [MEDICATION NAME] (to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (SSRI to treat depression). Physician orders for R5, dated for April 2016, revealed that R5 had physician orders to receive the following medications: [REDACTED]. Medication Administration Record [REDACTED]. However, there was no documented explanation for not administering the medications. The MAR for R5 dated 4/25/16 at 9:00 a.m. revealed that the signature area was blank for the following medications: [REDACTED] Interview with R5 at 1:20 p.m. on 9/28/16 revealed that she was given a list of medications that she was allowed to take on the morning of 4/25/16, prior to a planned surgical procedure. R5 said that she did not receive any of the medications. R5 could not recall the name of the nurse assigned to her that day. Review of the staff schedule for the West unit on 4/25/16 revealed that LPN147 was assigned to provide care for R5. An interview with LPN147 at 10:15 a.m. on 9/29/16 revealed that she worked the West unit where R5 resided. LPN147 said that she could not recall R5 or specifics related to the morning of 4/25/16 when R5 was scheduled for a surgical procedure, however, she confirmed that some of the medications on the MAR indicated [REDACTED]. She said that her practice was to circle medications that were not given. She said that R5 may have refused the morning medications, but she could not be sure. LPN147 said that if the medications on the MAR indicated [REDACTED]. She said she could not recall details because it was a long time ago. Interview with the Director of Nursing at 9:30 a.m. on 9/30/16 revealed that LPN147 did not follow the correct procedure/facility policy relative to medication administration, following physician orders for R5 and did not provide, according to the MAR, medications as ordered to R5 on 4/25/16. She said there was no further investigation of the incident. 4. R25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Laboratory results, dated 7/5/16, for a urinalysis indicated R25 had a urinary tract infection and an order was given for an antibiotic medication. Physician order for [REDACTED]. A Medication Error Report, dated 7/8/16, revealed that due to a transcription error, R25 did not receive the [MEDICATION NAME] until 7/8/16. The report indicated the Director of Nursing was notified of the error at 1:30 p.m. and the Physician was notified at 2:00 p.m. The report indicated the [MEDICATION NAME] was taken from the E-kit and started as soon as the error was found. The report indicated that the nurse, LPN109, who took the telephone order failed to write the order on the MAR for R25. Physician order for [REDACTED]. Attempts were made to reach LPN109, by telephone on 10/2/16 and 10/3/16. The surveyor was not able to leave a message for a call back as there was no answering machine. The Supervisor Investigation Form indicated that LPN109 was counseled on prompt initiation of medications. Interview with the DON at 10:00 a.m. on 10/3/16 revealed that there was no negative outcome to this incident and LPN109 was counseled relative to prompt initiation of medications. She said the nurse taking an order was responsible for adding it to the MAR. A group interview was conducted on 9/27/16 at 11:15 a.m. with residents whom the facility and/or survey team had identified as alert and oriented who could provide resident feedback on various concerns. During this interview, one resident stated, They try to give you the wrong one (medication) or at the wrong time. You have to tell the nurse 'That's wrong. The facility implemented the following actions to remove the Immediate Jeopardy: 1) All residents receiving medications have the potential to be affected. 2) Affected resident-chemical removed from resident room. QA team consisting of Activities, Housekeeping, Dietician, Social Service, Central supply, Medical records, and Human Resources will conduct rounds with census sheet as an audit tool weekly x 4 then monthly x 2 for chemicals in facility. Findings of audits will be discussed in QA meeting. 3) Facility wide chemical sweep conducted by Registered Nurse, Medical Records, Registered Dietician, Social Services, CNA, Assistant Executive Director, Human Resources, Central Supply, Business Office Manager, Assistant Director of Nursing, Director of Nursing, Dietary Manager, Executive Director on 9/6/16, 9/12/16, 9/19/16. Week of 9/26/16, Facility wide chemical sweeps continued by 3 R.N.s, 3Medical Records, CNA, 2 LPNs, 2 Activities, 2 Social Services, 2 Registered Dieticians, Central Supply, Business Office Manager, Dietary Manager. QA members consisting of Activities, Housekeeping, Dietician, Social Services, Central Supply, Medical Records, Human Resources and CNA, will continue to conduct rounds with the census sheet as audit tool weekly x 4 then monthly and give to the ED/AED for review and any deficient practice will be forwarded for review to the QA committee. 4) Affected resident has current order for [MEDICATION NAME] obtained on 9/13/16. 5) Nursing staff reinserviced on medication administration policy to include 6 rights of medication administration-right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. In-service began 9/27/16 by ADNS and RN/RT, Director of [MEDICAL CONDITION] Services. In-services will continue until licensed nurses have been reinserviced. On 9/28/16, in-services continue and the presenters are RN Case Mix Consultant, RN Assistant Director of Nursing, and RN/RT, Director of [MEDICAL CONDITION] Services. As of 9/29/16, in-services continue by LPN Pharmacy Consultant, and RN Case Mix Consultant. In-services will continue by LPN Pharmacy Consultant, Staff Development Coordinator, RN Unit Manager, RN Supervisor, LPN Supervisor, RN Assistant Director of Nursing, and RN/RT Director of [MEDICAL CONDITION] Unit. In-services will continue until 100% of licensed nurses have been reinserviced by 10/5/16.No licensed nurse will be allowed to work until in-service on medication administration has been completed. As of 10/3/16, 86% of licensed nurses have been reinserviced. 6) Medication administration skills competencies to include preparation, steps to perform medication administration of medication and completion of task related to the following competencies for medication administration: nebulizer, ear drop, eye drop, eye ointment, enteral tube,, nasal, insulin, nose drop, oral inhaler, oral powder inhaler, rectal suppository, sublingual, intramuscular injection and [MEDICATION NAME]. Competencies began on 9/27/16 by RN/RT, Director of [MEDICAL CONDITION] Unit, and RN Assistant Director of Nursing. Competencies continued on 9/28/16 by LPN Pharmacy Consultant. Competencies will continue by LPN Pharmacy Consultant, LPN Staff Development Coordinator, RN/RT Director of [MEDICAL CONDITION] Unit, RN Unit Manager, LPN Supervisor, RN Supervisor, RN Director of Nursing Services and RN Assistant Director of Nursing Services until complete. No licensed staff will be allowed to work prior to medication administration policy in-service to include medication administration skills competencies 7) Newly hired nurses will be in-service during orientation process on medication administration to include the 6 rights of medication administration-right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration by RN Director of Nursing or RN Assistant Director of Nursing, LPN Staff Development Coordinator, RN Supervisor, LPN Supervisor. 8) RN Director of Nursing, RN Assistant Director of Nursing, RN Supervisor, RN Unit Manager, LPN Supervisor, RN/RT Director of [MEDICAL CONDITION] Unit, LPN Staff Development Coordinator, will audit weekly x 4 then monthly with a total of 10 nurses for administering medications per medication administration policy including 6 rights of medication administration- right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. Medication administration observations will be given to ED/AED for review and any deficient practice will be forwarded for review by the QA committee. 9) Amendment made on 9/30/16 to admission paperwork/packet to include statement no cleaning chemicals i.e. Pine Sol, Clorox, Mr. Clean etc. not allowed to be kept in resident rooms. Additionally, this amendment will be presented to residents that are their own responsible party and provided to responsible partied for residents. 10) QA meeting was held on 9/29/16. Participants were: Executive Director, Assistant Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Director, Director of [MEDICAL CONDITION] Services, and Medical Director. 11) In-servicing related to chemicals found in resident rooms will continue quarterly for all staff. 12) Medication administration to include the 6 rights of medication administration- right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration will be in-service quarterly for licensed nurses. HCMS, on behalf of the State Survey agency, validated the implementation of the facility's Credible Allegation of Jeopardy removal as follows: 1) No action plan in this statement to verify. 2) The absence of chemicals in R7's room was verified during daily observations made during the complaint investigation of 9/26/16 through 10/4/16. The weekly audit from 10/3/16 was reviewed. Observations of 36 resident rooms (TCPU: 101, 102, 103, 104, 106, 107, 108, 109, 110, 111, 112, 113, and 114, and Main Building: 312, 308, 303, 221, 204, 56, 55, 54, 53, 52, 51, 38, 41, 40, 35, 33, 31, 30, 26, 22, 17, 11 and 4 ) on 10/4/16 verified no chemicals were present in resident rooms. 3) Documentation of the resident room sweeps for chemicals was reviewed. These sweeps occurred 9/6/16, 9/12/16, 9/19/16, 9/27/16 and 9/28/16. Documentation reviewed no chemicals were found in resident rooms. 4) A new physician order for [REDACTED]. 5. In-service records of 16 nurses (RN272, RN273, RN 277, RN94, LPN288, LPN283, LPN147, LPN137, LPN135, LPN133, LPN128, LPN120, LPN116, LPN110, LPN108, and LPN105,) passing medications on 10/4/16 revealed that all had received the in-service identified in the AOC. During interviews conducted on 10/4/16 with RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., RN 277 at 10:25 a.m., RN 94 at 8:40 a.m., LPN 288 at 10:15 a.m., LPN 147 at 8:25 a.m., LPN 283 at 11:05 a.m., LPN 147 at 8:25 a.m., LPN 137 at 8:40 a.m., LPN 135 at 8:40 a.m., LPN 133 at 8:32 a.m., LPN 128 at 10:09 a.m., LPN 120 at 9:25 a.m., LPN 116 at 8:26 a.m., LPN 110 at 9:30 a.m., LPN 108 at 8:27 a.m., and LPN 105 at 8:29 a.m., the 16 nurses interviewed on 10/4/16 verified their attendance at in-services on medication administration. 45 random nurse records were also reviewed for in-servicing on medication administration. All nurse records that were reviewed were found to contain evidence of the in-service described in the AOC. 45 random nurse records were also reviewed for in-servicing on medication administration. All nurse records that were reviewed were found to contain evidence of the in-service described in the AOC. 6) Medication competency records of 16 nurses (RN272, RN273, RN 277, RN94, LPN288, LPN283, LPN147, LPN137, LPN135, LPN133, LPN128, LPN120, LPN116, LPN110, LPN108, and LPN105,) passing medications were reviewed and these 16 nurses were observed to be present on 10/4/16. During interviews conducted on 10/4/16 with RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., RN 277 at 10:25 a.m., RN 94 at 8:40 a.m., LPN 288 at 10:15 a.m., LPN 147 at 8:25 a.m., LPN 283 at 11:05 a.m., LPN 147 at 8:25 a.m., LPN 137 at 8:40 a.m., LPN 135 at 8:40 a.m., LPN 133 at 8:32 a.m., LPN 128 at 10:09 a.m., LPN 120 at 9:25 a.m., LPN 116 at 8:26 a.m., LPN 110 at 9:30 a.m., LPN 108 at 8:27 a.m., and LPN 105 at 8:29 a.m., the 16 nurses revealed they were responsible for medication administration, and revealed that all had in-service trainng and passed the competencies identified in the AOC and performed by the administrative staff. The records of the 16 nurses were found to contain evidence of medication competency testing. All of these nurses' records were found to contain evidence of the in-service training and the medication competency testing. An abbreviated medication pass was conducted on 10/4/16. Fourteen medication opportunities were observed with three different nurses, on three different units. LPN 120 was observed between 4:20 p.m. and 4:55 p.m. administering medications to a resident on the West Unit. Four opportunities were observed including a liquid suspension and blood pressure monitoring related to the medication. Beginning at 4:18 p.m., LPN 143 was observed administering medications to a resident on the Upper Central Hall, with 3 opportunities (2 injection and 2 oral medications.) LPN124 was observed passing medications to a resident on the Lower Central Hall beginning at 4:44 p.m. six opportunities, including 1 injection and 5 oral medications, were observed. Methods of administration during this medication pass included PO meds, injections, and liquid suspensions. No errors were identified in the medication pass. A full medication pass, with 25 Medication opportunities, was also observed during the week of 9/26/16 through 9/30/16 as part of the abbreviated and partial extended survey. No errors were identified during that medication pass. 7) Interview with Human Resources staff on 10/4/16 at 11:35 a.m. revealed there were three newly hired nurses in the last week. The personnel and training records of these three staff were reviewed. All three staff had evidence of in-service during orientation on medication administration. Interview with LPN Orientee 308 at 9:40 a.m. on 10/4/16, revealed that she received training during her orientation on correct medication administration. 8) Audits of medication pass observations made by the DON were reviewed. The DON was observed on 10/4/16 auditing two different nurses passing medications. 9) Interview with LPN6 (Admissions Staff) on 10/4/16 at 8:36 a.m. confirmed that the admission paperwork had been amended. She provided a copy of the revised document, which contained the language alleged in the AOC. A letter was also sent to families of current residents after the 9/6/16 incident, informing the families that residents were not to have chemicals stored in resident rooms. 10) Documentation of the 9/29/16 QA meeting was reviewed. The signature sheet ver
Based on observation, clinical record review, facility ' s policy titled, Accidental [MEDICAL CONDITION] Decannulation Guidelines , professional reference material titled, [MEDICAL CONDITION] , professional reference material posted in the American Association for Critical-Care Nurses, education records, record review, personnel files, and staff interview, the facility failed to ensure 3 of 14 sampled residents (R1, R9 and R10) with a [MEDICAL CONDITION] and artificial ventilation received proper care and treatment in accordance with the residents' comprehensive assessment and plan of care. Specifically, (R1, R9 and R10) did not have the correct inner cannula size at the residents' bed side in the event their inner cannulas became dislodged and required emergency replacement. The total sample was 52 and the total facility census was 229. The facility's failure to ensure residents received [MEDICAL CONDITION] and respiratory care as evidenced by the incorrect inner cannula size in their emergency backup box at their bedside, the lack of orientation to the ventilator unit and the lack of documentation that 5 of 5 nursing staff (CNA292 and CNA158; RN275; LPN281 and LPN131) had been oriented to the ventilator unit or evaluated for their competency skills, was likely to cause serious injury, harm, impairment or death to a resident. On 9/27/16 at 5:55 p.m. the facility's Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. F224 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. The Immediate Jeopardy at F224, F226, F281 and F490 was identified to have existed since 9/6/16, when staff mixed [MEDICATION NAME] with Pine Sol cleaner and administered it to Resident (R) 7, with the resident sustaining burning in her throat and requiring a transfer to the hospital. The facility failed to utilize its resources and immediately report and thoroughly investigate this case of neglect of R7, as well as failed to take necessary actions to protect the resident from the potential for further neglect. On 9/28/16 at 5:30 p.m. the facility' s Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F226 also constituted Substandard Quality of Care at 42 CFR 483.13. The Immediate Jeopardy at F328 was found to have existed since 9/26/16, when it was identified that the correct-sized emergency equipment was not available for 3 of 14 residents (R1, R9 and R10) residing on the specialty vent unit. An acceptable Allegation of Compliance (AoC) was received on 10/3/16, and Healthcare Management Solutions, (HCMS) LLC, on behalf of the State Survey Agency, validated the AoC. The Immediate Jeopardy was removed from all 5 areas on 10/4/16. The Scope and Severity was lowered to the following level: F328:D, while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes: After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: 1. During initial tour of the ventilator unit with the Unit Manager (UM)/Registered Respiratory Therapist (RRT) on 9/26/16, at 12:06 p.m., the UM/RRT indicated that inner cannula for R1 was a size #6. When asked if the resident had a backup cannula, the UM pointed to the emergency box located at the resident's bedside. Observation of the contents of the emergency box revealed that the backup inner cannula was a size #8. The UM confirmed at this time that this was the incorrect inner cannula size in the emergency box. The UM stated he would ensure the correct inner cannula size #6 would be placed into the box. On 9/26/16, at 12:06 p.m. when rounds were conducted with the RRT, he confirmed there was no system in place to ensure an extra inner cannula of the correct size was located at the bedside for each resident. The RRT stated there was no system in place for periodic checking of the bedside back up inner cannulas. The RTT reported the facility's common practice was that once a resident was admitted , the resident was immediately seen by a RT and it was the responsibility of the RT to place a backup inner cannula in the emergency box located in each resident's room. The RT further stated insertion of the incorrect inner cannula size could harm the resident. On 9/27/16 at 9:36 a.m. rounds were conducted with the UM. The UM indicated that the inner cannula for R1 was a size #6 and that there was a size #6 inner cannula in emergency box, for R1, at the resident's bedside. As the UM opened the emergency box, the UM stated that R1 now has the correct size #6 inner cannula in the event of an emergency. Review of the clinical record revealed R1 was admitted to the facility's ventilation unit on 6/20/16 with [DIAGNOSES REDACTED]. R1 was ventilator dependent. Review of the admission Minimum Data Set (MDS), for R1, dated 9/13/16, revealed the resident was unable to express ideas or wants, his speech was unclear and he was unable to understand others. The resident, as indicated on the MDS, was totally dependent on staff for all care. Review of the physician's orders [REDACTED].#8 [MEDICAL CONDITION] cannula PRN as needed. The UM indicated at this time that the Physician for R1 must have written a new order for the resident to begin using a size #6 inner cannula. The UM was unable to locate a physician order [REDACTED].#8 to a size #6. During an interview on 9/27/16 at 4 p.m., the UM indicated, The physician told me to change the [MEDICAL CONDITION] inner cannula for R1 to a size #6. However, the UM was unable to locate a physician's orders [REDACTED].#6. 2. During the initial tour on 9/26/16 at 12:22 p.m., RRT250 indicated that the inner cannula for R9 was a size #4. The RRT250 opened the emergency box at the resident's bedside and inside were three different sizes of inner cannulas (size #4, #6 and #8) in the emergency box. RRT250 confirmed that the inner cannulas size #6 and #8 should not have been in R9's emergency box at the bedside. The RRT stated at this time that in the event size #4 inner cannula, for R9, was dislodged, the other RRTs might insert the incorrect cannula size. R9 was admitted to the facility's ventilation unit on 6/21/16 with [DIAGNOSES REDACTED]. Review of the MDS, for R9, dated 6/22/16 revealed the resident usually understood others; however, her speech was unclear. Review of the Physician Order, for R9, dated September 2016 and signed by the Physician, for R9, on 9/7/16 revealed, Staff to change the size #4 Shiley inner cannula (PRN) as needed. 3. During the initial tour with the UM on 9/26/16 at 12:18 p.m., the UM indicated that the inner cannula for R10 was a size #8. The UM opened the emergency box, for R10, that was at the resident's bedside and inside was a size #7 inner cannula. The UM confirmed that the size #7 should not have been at bedside in the event the cannula became dislodged. The other RRTs could insert the wrong size inner cannula. During an interview, at this time with the UM, he reported that the size #7 was placed at the bed side in error. During a follow-up observation with the UM on 9/27/16 at 9:36 a.m. it was observed that R10 wore a size #8 inner cannula and the size #7 inner cannula continued to be located in the emergency box at the resident's bedside. The UM and surveyor observed that inside the emergency box, for R10, was also a size #6 and a size #4 inner cannula. During an interview at this time, the UM stated, They must have made rounds last night and put cannulas in all the emergency boxes. I do not know how these wrong inner cannulas are in the emergency box for R10. R10 was admitted to the facility's ventilation unit originally on 5/21/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of admission MDS, for R10, dated 8/23/16 revealed R10 was alert, has adequate hearing, his speech was unclear but he has clear comprehension of what is said to him and around him. His functional status indicated he was totally dependent on staff for care. Review of the physician's orders [REDACTED].# 8 Shiley DCT (Disposable Cuff Trach) Inner Cannula daily. During review of the care plans for R1, R9, and R10, on 9/30/16 at 10:00 a.m. with the MDS coordinator, she confirmed that all three care plans failed to include the size of the inner cannula for residents with a [MEDICAL CONDITION]. The MDS Coordinator indicated that staff would have to refer to the resident's physician's orders [REDACTED]. Review of the facility's ventilator unit policies, which was located at the nurses' station on the unit, revealed the [MEDICAL CONDITION] policy titled, Accidental [MEDICAL CONDITION] Decannulation Guidelines which was divided into four sections. The section of the policy labeled, Equipment instructed staff to Have readily available at bedside an [MEDICAL CONDITION]. One of the items in the box should be A [MEDICAL CONDITION] same size and make/model. According to review of professional reference material: (http://rc.rcjournal.com/content/59/6/956.full, Hess, R, titled, [MEDICAL CONDITION] Respiratory Care, June 1, 2014 vol. 59 no. 6 956-973. For patients with ventilators, implications of inserting the incorrect sized cannula are significant. [MEDICAL CONDITION] that might at first seem similar may in fact be quite different in their dimensions. When selecting a [MEDICAL CONDITION], the inner diameter, outer diameter, and length must be considered. If the inner diameter is too small, it will increase the resistance through the tube and make airway clearance more difficult. A smaller inner diameter may also result in a smaller outer diameter, which increases the cuff pressure required to create a seal in the trachea. If the outer diameter is too large, the leak with the cuff deflated will be decreased, and this will affect the ability to use the upper airway with cuff deflation for speech. A tube with a larger outer diameter will also be more difficult to pass through the stoma. A 10-mm outer diameter tube is usually appropriate for adult women, and an 11-mm outer diameter tube is usually appropriate for adult men as an initial [MEDICAL CONDITION] size. A difference in [MEDICAL CONDITION] length between tubes with the same inner diameter but from different manufacturers is not commonly appreciated, and can have important clinical implications. Review of an article posted in the American Association for Critical-Care Nurses, Vol 33, No. 5, OCTOBER 2013, revealed, .For that reason, it is important to keep a tube of the same size and one a size smaller at the bedside at all times. <http://www.aacn.org/wd/Cetests/media/C135.pdf>, [MEDICAL CONDITION] Care and Complications in the Intensive Care Unit. During an interview on 9/27/16 at 2:39 p.m. with Registered Nurse (RN)275, revealed that she had no formal training to work on the specialty ventilation unit and had no previous history of working with ventilator or [MEDICAL CONDITION] patients. Additionally, she reported that no training in the areas of ventilators and tracheostomies had been offered to her since employed by the facility on 3/1/16. RN275 stated she was routinely scheduled on the ventilator unit. Interview with Licensed Practical Nurse (LPN) 281 on 9/27/16 at 2:39 revealed she had received no training to care for residents on a ventilators or tracheostomies prior to, or after her employment, on 5/21/13. LPN281 stated she was pulled to work on the ventilator unit when the unit was short staffed. LPN281 stated that now she was scheduled to work on the unit full time. LPN281 stated that she did not know how to suction residents. Interview with the Treatment Nurse (LPN) 131 on 9/26/16 at 2:10 p.m. revealed she was recently hired 2 weeks ago on 9/7/16. When asked if she received any training prior to being assigned to the unit, the Treatment Nurse (LPN 131) stated she had not received any training and was scared by the high level of care and possible negative consequences that could occur for residents on ventilators if care was not performed correctly. Interview with CNA292 and CNA158 was conducted on 9/26/16 at 2:15 p.m. both CNAs reported they received no training prior to working on the unit. CNA292 was hired on 1/26/16 and CNA158 was hired on 10/26/15. CNA292 and CNA158 reported that several months ago, while they were giving a bed bath to a resident who no longer resided at the facility, parts of the ventilation tubing came apart. Both CNAs stated they did not know what to do and yelled for a RRT to come and assist. CNA158 stated she was uncomfortable performing bed baths since that occurrence, verifying she had not received instruction following the incident relative to bathing residents with ventilators. During an interview with the Administrator on 9/27/16 at 10:00 a.m. she reported she did not recall being asked to allow therapists to conduct training on the ventilator unit. She stated she would check with her Staff Development Coordinator regarding training on the unit. During an interview with the Staff Development Coordinator (SDC) on 9/27/16 at 1:56 p.m. she reported there was a need for nursing education on the specialty ventilator unit in addition to what was received in general orientation. She had been instructed to focus on orientation of new hires for nursing. She stated that she had asked the Director of Nursing (DON) if she could provide specialized training to the CNAs and nurses who worked on the ventilator unit and was told orientation for newly hired staff was her priority. The DON was asked to provide all training records specific to nurses and CNAs working on the specialty ventilator unit. Review of the Education Records provided by the DON on 9/27/16 revealed sporadic education on topics related to complaints voiced by family members. There were no evidence of any records demonstrating any specialized training for nursing staff related to [MEDICAL CONDITION] care, suctioning, or care specific to resident dependent on ventilators. Review of the personnel record for CNA297 with the Human Resource Director (HRD) on 9/26/16 at 5:15 p.m. revealed there was no documentation of orientation to the ventilator unit or documentation that competency skills for CNA297 had been evaluated. Review of the personnel record for RN275 revealed there was no documentation of an orientation to the ventilator unit or documentation of competency skills for RN275. During the review of all of the staff that were interviewed who indicated that they had not received orientation to the ventilator unit or training regarding how to care for these residents, the HRD confirmed again that there was no documentation in their personnel records of the employees' orientation to the ventilator unit or evaluation of their competency skills. The HRD indicated on 9/26/16 at 5:15 p.m. that only respiratory therapists were assessed for their competency skills and that nurse aides or nurses would not have any documentation of an orientation to the ventilator unit or documentation that their competency skills had been evaluated. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents on ventilators or with trachs ([MEDICAL CONDITION]) have the potential to be affected. 2. On 9/28/16 residents with trach/vents rooms were checked to ensure emergency equipment to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu (artificial manual breathing unit) bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] were available to bedside by RN/RT and equipment was at residents bedside. 3. On 9/27/16 started reinservicing licensed staff by RN/RT, Director of the [MEDICAL CONDITION] Unit that: Emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. On 9/28/16 in-services continued to be provided by RN/RT, the Director of the [MEDICAL CONDITION] Unit. In-services will continue by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Assistant Director of Nursing Services, RN Unit Manager. In-services will continue until licensed personnel that work in the vent unit have been in-serviced. 100% of in-services will be completed on 10/7/16. 80% of licensed personnel on vent unit have been in-serviced. 4. On 9/28/16 started competencies on licensed staff [MEDICAL CONDITIONS] by RN/RT.[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task. [MEDICAL CONDITION] suctioning included preparation, course of action of suctioning, and completion of task. Competencies will continue until 100% of licensed personnel that work the vent (ventilator) unit have been in-serviced. Competencies will continue to be provided by RN/RT Director of the [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 100% of competencies will be completed by 10/7/16. Licensed staff will not be allowed to work until competency completed 5. [MEDICAL CONDITION] care competency includes: preparation, course of action for cleansing inner cannula, course of action for disposable inner cannula, completion of task. 6. [MEDICAL CONDITION] suctioning competency includes: preparation, course of action for suctioning, completion of task. 7. Nurses that work the vent unit will have a competency checklist completed [MEDICAL CONDITIONS]. Competencies started 9/28/16 by RN/RT. Competencies will be continued by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will continue until licensed nurses assigned to vent unit have been completed. 100% of competencies will be completed by 10/7/16. 8. General orientation - Transitional [MEDICAL CONDITION] Care Unit skills verification to include identification of alarms outside resident rooms, what to do when alarm sounds, will be completed for staff working vent units to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants. Verifications started on 9/27/16 by RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification continued on 9/28/16 aby RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification will continue by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Verification will continue until staff working vent unit are completed. 100% of verifications will be completed by 10/7/16. Staff will not be allowed to work vent unit until verification completed. 80% of staff working vent unit have been completed. 9. During orientation process, newly hired nurses will have a competency checklist completed [MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task [MEDICAL CONDITION] to include preparation, course of action for suctioning and completion of task if working on the vent unit by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 10. Certified nursing assistants working the vent unit will have competencies completed on oral care/bathing/showering of residents with vents and trachs to include: preparation, course of action, positioning, and completion of task by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will be completed by 10/7/16. Certified Nursing Assistants working the vent unit will not be allowed to take an assignment until competency is completed. If certified nursing assistant is pulled from the main building, employee will not be allowed to take an assignment until competency completed. 11. No staff will be allowed to work until competencies and in-servicing are completed. 12. During orientation process, newly hired staff working vent unit will have general orientation-transitional [MEDICAL CONDITION] care until skill verification to include verification to include identification of alarms outside resident room. What to do when alarm sounds. Will be completed by RN/RT Director of [MEDICAL CONDITION] Director or RN Assistant Director of Nursing, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor (sic.) 13. RN Director of Nursing Services or RN Assistant Director of Nursing Services will audit weekly x 4 weeks then monthly x 2 months for emergency equipment at the bedside to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] and ensure emergency kit is placed in wall mount cabinet in resident rooms. Audit findings will be discussed on QA. If problem is noted the problem will be corrected then presented to the Director of Nursing for appropriate action (example 1:1 in-service, disciplinary action.) 14. If a licensed nurse is pulled from the main building to work on the vent unit, employee will be in-serviced on emergency equipment at bedside to be kept in plastic bag in wall counted cabinet in room next to be with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION].[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, course of action for disposing of inner cannula, completion of task.[MEDICAL CONDITION] to include preparation, course of action for suctioning, completion of task. (sic) Any other staff member to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants will be in-serviced on transitional [MEDICAL CONDITION] care unit. Skill verification to include identification of alarms outside resident's room, what to do when alarm sounds. In-service/training will be conducted by RN or RT on the vent unit. The staff member will be in-serviced prior to taking an assignment on the vent unit and on new nurses in orientation. 15. QA meeting was held 9/29/16. Participants were Executive Director, Assistant Executive Director, Social; Service Director, Director of [MEDICAL CONDITION] Services, Medical Director. 16. In-services for emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. Will be completed quarterly on licensed staff. (sic) HCMS, on behalf of the State Survey Agency, validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. No action plan was listed in this statement for verification. 2. Documentation of the 9/28/16 room checks were verified during the abbreviated survey. Observation during a tour of the unit on 10/4/16 at 3:30 p.m. found that all resident rooms on the TPCU (Specialized Ventilator Unit) were equipped with the correct size equipment, as well as all other emergency equipment listed in the AoC. Observation on 10/4/16 at 3:30 p.m. of the bedside cabinets containing emergency equipment were checked for 13 residents (residing in Resident Rooms: 101D, 102W, 104D, 104W, 106D, 107W, 110W, 110D, 111W, 111D, 112, 113W, and 115D). Emergency equipment observed including 2 replacements [MEDICAL CONDITION] cannulas (one the same size as what was currently in place for the resident, and one a size smaller), an ambu bag, a pulse ox machine, gloves, gauze, [MEDICAL CONDITION] ties, scissors, vials of Normal Saline, syringe, lubricant, suction catheter and red biohazard bag, was found at each bedside. 3. In-servicing records for all licensed/certified staff working in the vent unit were reviewed, and matched against the staffing schedule, as well as direct observation of staff and interviews on 10/4/16. All licensed/certified staff working in this unit was found to have the in-service records alleged in the AOC. Based on interviews with staff and the review of the facility documentation staff are not being allowed to work in this unit without first attending this training, based on interviews with staff, and a review of facility documentation. Interviews were held on 10/4/16 with the following staff: RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., LPN 288 at 10:15 a.m., LPN Orientee 308 at 9:40 a.m., CNA 292 at 9:50 a.m., CNA 166 at 11:55 a.m., CNA 151 at 11:15 a.m., RT 251 at 11:25 a.m., RT 257 11:40 a.m., SW 270 at 9:20 a.m., and PT 309 at 12:20 p.m., as well as the Unit Secretary at 9:10 a.m. The in-service records revealed that each staff received in-service training regarding the general orientation to the TCPU which included but was not limited to general care of residents with tracheostomies, alarms on the unit and what they meant, and emergency equipment procedures. All staff was also in-serviced on abuse and neglect, and the facility's policy related to chemicals in resident rooms. 4. Competency records for all licensed/certified staff working in the vent unit were reviewed, and matched with the staffing schedule, as well as direct observation of staff and interviews on 10/4/16. All licensed/certified staff working in this unit was found to have [MEDICAL CONDITION] and suctioning competency evaluations alleged in the AoC. Interviews held on 10/4/16 with the following staff: RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., LPN 288 at 10:15 a.m., LPN Orientee 308 at 9:40 a.m., CNA 292 at 9:50 a.m., CNA 166 at 11:55 a.m., CNA 151 at 11:15 a.m., RT 251 at 11:25 a.m., RT 257 11:40 a.m., SW 270 at 9:20 a.m., and PT 309 at 12:20 p.m. confirmed their attendance at the orientation as well as the basic knowledge needed to perform their duties. These same interviews, and review of facility documentation, revealed that each staff member had received a general orientation to the TCPU which included, but was not limited to, general care of residents with tracheostomies, alarms on the unit and what they meant, and emergency equipment procedure. These same interviews and record review revealed that staff are not allowed to work on this unit without first being in-serviced and passing a competency test. All staff was also in-serviced on abuse, neglect, policy related to chemicals in resident rooms. 5. Review of the competency for [MEDICAL CONDITION] care testing material used for these staff revealed that it covered all topics alleged in the AoC. Three staff (RN273, LPN288, and RN272) was observed performing [MEDICAL CONDITION] care throughout the 7 a.m. - 7 p.m. shift on 10/4/16 with no concerns. 6. Review of the competency testing material for suctioning used for these staff revealed that it covered all topics alleged in the AoC. Three staff (RN 273, LPN288, and RN 272) was observed performing [MEDICAL CONDITION] suctioning throughout the 7 a.m. - 7 p.m. shift on 10/4/16 with no concerns. 7. Competency records for all licensed/certified staff working in the vent unit were reviewed, and matched with the staffing schedule, as well as direct observation of staff and interviews on 10/4/16. All licensed staff working in this unit were found to have [MEDICAL CONDITION] and suctioning competency evaluations as alleged in the AoC. Per observation and interviews, and facility documentation staff are not allowed to work in this unit without first being in-serviced and passing competency testing. (Refer to #4.) 8. General orientation records to the TPCU vent unit were reviewed. All 12 staff assigned to the unit including RN 272, RN 273, LPN 288, LPN Orientee 308, CNA 292, CNA 166, CNA 151, RT 251, RT 257, SW 270, PT 309, and the Unit Secretary at 9:10 a.m., had received a general orientation which included all areas stated in the AoC. Interviews on 10/4/16, with RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., LPN 288 at 10:15 a.m., LPN Orientee 308 at 9:40 a.m., CNA 292 at 9:50 a.m., CNA166 at 11:55 a.m., CNA151 at 11:15 a.m., RT251 at 11:25 a.m., RT 257 11:40 a.m., SW 270 at 9:20 a.m., PT 309 at 12:20 p.m., and the Unit Secretary at 9:10 a.m., that confirmed their attendance at the orientation as well as the basic knowledge needed to perform their duties. These same interviews revealed that each received a general orientation to the TCPU which included but was not limited to general care of residents with tracheostomies, alarms on the unit and what they meant, and emergency equipment procedure. All staff was also in-serviced on abuse, neglect, policy related to chemicals in resident rooms. 9. Interview with Human Resources (HR) 45 on 10/4/16 at 11:35 a.m., revealed there had been one new nurse (LPN Orientee 308) hired for the TPCU Unit in the last week. Review of facility documentation confirmed this nurse had received the required orientation, as well as had been checked off on the competency check list [MEDICAL CONDITION]. Interview with LPN Orientee 308 at 9:40 a.m. on 10/4/16 revealed that she received classroom orientation relative to the facility and orientation specific to the TCPU which included alarms, [MEDICAL CONDITION] care, and emergency equipment. 10. Competency records for all CNAs working in the vent unit were reviewed, and matched with the staffing schedule, as well as direct observation of staff and interviews on 10/4/16. All CNA s
Based on record review and interview, and product information review, the facility failed to ensure that 1 of 52 sampled residents was protected from neglect (R7). Resident (R) 7 was given [MEDICATION NAME] (laxative medication) without a physician order and it was mixed with Pine-Sol cleaning solution, without checking the label of the product. The hazardous solution was administered to R7. After staff administered Pine-Sol to the resident and she took a sip of the solution, she complained of burning in the throat and required transportation to the hospital emergency room for evaluation (Cross Reference F281 and F226). The facility's failure to ensure that residents were protected from neglect as it related to the care received from staff had caused, or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate jeopardy was identified on 9/27/16 and determined to exist on 9/6/16. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 9/27/16 at 5:55 p.m. On 9/28/16 at 5:30 p.m. the facility ' s Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F226 also constituted Substandard Quality of Care at 42 CFR 483.13. The Immediate Jeopardy at F328 was found to have existed since 9/26/16, when it was identified that the correct-sized emergency equipment was not available for 3 of 14 residents (R1, R9 and R10) residing on the specialty vent unit. In addition actual harm was cited at F469 S/S:G the failure to control roaches, as well as other insects such as gnats and flies, resulted in psychosocial harm for 2 of 52 sampled residents (R2 and R37), both of whom expressed fear of the roaches which had been seen in their rooms. An acceptable Allegation of Compliance (AOC) was received on 10/3/16 and HCMS on behalf of the State Survey Agency validated the Immediate Jeopardy was removed on 10/4/16 as alleged. The deficient practice remained at a D (potential for more than minimal harm) while the facility developed and implemented the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitored the effectiveness of the systemic changes. After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: The facility Medication Administration General Guidelines revealed medications are administered in accordance with written orders of attending physicians, prior to administration the medication and dosage schedule on the Medication Administration Record [REDACTED]. R7 was admitted to the facility most recently on 5/28/16. A review of physician orders dated from 5/28/16 through 9/6/16 revealed there was no order for R7 to receive [MEDICATION NAME]. (Refer to F281). A quarterly Minimum Data Set (MDS) assessment, dated 7/14/16, indicated R7 exhibited no cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The most recent and current plan for R7, revealed that R7 should receive medications as ordered and be monitored for side effects. Physician orders for R7, dated from admission on 5/28/16 until 9/6/16 revealed there was no physician order for [REDACTED].>MAR, dated 9/6/16, for R7 revealed there was no order for [MEDICATION NAME] noted on the MAR. Review of a Supervisor Investigation Summary Form, dated 9/6/16, revealed R7 ingested a harmful substance (Cross Reference to F224) and received a medication ([MEDICATION NAME]) without a physician order. The form indicated that LPN302 administered the harmful substance and [MEDICATION NAME]. R7 was transferred to the Hospital for evaluation following the incident and returned the same day, via ambulance, after signing out AMA (against medical advice). Hospital triage and Emergency Records were received and indicated for the resident to resume previous physician orders on return from the Hospital. Interview with R7 at 4:45 p.m. on 9/26/16 revealed that she received [MEDICATION NAME] on 9/6/16. She said the [MEDICATION NAME] was mixed with Pine-Sol which belonged to her and that she kept in her closet, in the same area as she kept multiple bottles of green tea. R7 said when she requested the [MEDICATION NAME] be mixed with green tea on 9/6/16, the nurse (she was unable to recall the exact name) removed a bottle from the closet. She said the nurse returned to the medication cart in the hallway to prepare medications. R7 said when the nurse returned she handed her a cup of liquid with a straw and when she took a sip her throat began to burn. She said the nurse had mixed the [MEDICATION NAME] with the Pine-Sol she kept in her closet, rather than the green tea. She said she went to the hospital for evaluation, and returned the same day. According to the Nurse's note, dated 9/6/16, at 11:06 a.m., the Nurse Practitioner (NP) was on the unit and R7 was assessed by the NP. Poison Control was notified and had no recommendations. R7 was transferred to the hospital for evaluation at 10:35 a.m. R7 was evaluated at the hospital and no issues related to the ingestion of the Pine-Sol were identified according to the emergency room Course notes, dated 9/6/16. An interview with the NP at 12:00 p.m. on 9/27/16 revealed that she was making rounds on the West Unit at the time of the incident on 9/6/16 and was asked to assess R7. She said R7 told her that she drank some of the [MEDICATION NAME] mixture which she reported LPN302 had mixed with Pine-Sol and that her (R7) throat was burning. The NP said R7 did not exhibit any acute symptoms related to the ingestion, but requested to go to the hospital. The NP said that R7 appeared very anxious. She said that facility staff notified the Poison Control Center. Telephone interview with licensed practical nurse (LPN) 302 at 11:38 a.m. on 9/27/16 revealed on 9/6/16 she was assigned to work on the West unit on the hall where R7 resided. LPN302 said her regular position at the facility was as an MDS Nurse, but she was pulled from her regular duties to work the floor. LPN302 said that on 9/6/16, at approximately 9:15 a.m. she entered R7's room with medications and R7 requested [MEDICATION NAME] due to constipation. LPN302 said R7 told her that she took the [MEDICATION NAME] with green tea which was kept in her closet. LPN302 said she went to the closet and removed a bottle of liquid which she thought was the green tea, returned to the medication cart and mixed the liquid with the [MEDICATION NAME], LPN302 said she returned to the room, gave R7 the cup of liquid and R7 took a sip. LPN302 said as soon as R7 took a sip she told her that she had mixed the medication with Pine-Sol and her throat was burning. LPN302 said she did not read the label on the bottle that she removed from the closet and did not notice any odor when she opened the bottle of Pine Sol. LPN302 said she did not check the MAR indicated [REDACTED]. She said she did not realize until later that there also was no order for the [MEDICATION NAME]. LPN302 said the whole thing was a stupid mistake and was not done intentionally. She said she did not follow correct procedure for medication administration and did not check the medication against the physician order. She said she did not verify what the liquid was that she was mixing the [MEDICATION NAME] with and must have grabbed the Pine-Sol by mistake. LPN302 said she was terminated from the facility, via telephone on 9/9/16. According to the Pine-Sol website, Pine-Sol has a distinctive crisp, clean pine scent every time you use it to clean, deodorize and disinfect your home. Read more at https://www.pinesol.com/products/original-pine-cleaner/#3jgSdJb5gd34lj3Z.99 Review of the personnel file for LPN302 revealed a date of hire of 4/19/04. There was evidence of a counseling relative to attendance and unauthorized overtime, but no evidence of prior nursing practice concerns. The last annual evaluation was done on or about 4/15. LPN302 was terminated from the facility, via telephone on 9/9/16. Review of the Skills Validation related to medication administration revealed LPN302 attended the training in July 2015. Interview with the Director of Nursing (DON) at 9:45 a.m. on 9/27/16 revealed there was no order for R7 to receive [MEDICATION NAME] on 9/6/16. She said she had reviewed a video tape of the area at the time of the incident and saw LPN302 come out of the room with a bottle, but was unable to read the label on the bottle. The videotape was not available at the time of survey due to the type of video taping system that was on a continuous loop of recording. The DON said that the video tape system had not been changed to allow for extended viewing time and said that the tape of LPN302 exiting R7's room with the bottle in her hand was not preserved. The DON said that the expectation was that licensed nurses followed the 6 rights of medication administration - right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. She said LPN302 did not check for a physician order for [REDACTED]. Interview with the Administrator at 4:00 p.m. on 9/28/16 revealed that the video tape system ran on a 72 hour continuous loop that taped over previous footage. She said the tape of 9/6/16 was not available for that reason. The facility implemented the following actions to remove the Immediate Jeopardy: 1) All residents receiving medications have the potential to be affected. 2) Affected resident - chemical removed from resident room. QA team consisting of Activities, Housekeeping, Dietician, Social Service, Central supply, Medical records, and Human Resources will conduct rounds with census sheet as an audit tool weekly x 4 then monthly x 2 for chemicals in facility. Findings of audits will be discussed in QA meeting. 3) Facility wide chemical sweep conducted by the following staff members: Registered Nurse, Medical Records, Registered Dietician, Social Services, CNA, Assistant Executive Director, Human Resources, Central Supply, Business Office Manager, Assistant Director of Nursing, Director of Nursing, Dietary Manager, Executive Director on 9/6/16, 9/12/16, 9/19/16. Week of 9/26/16, Facility wide chemical sweeps continued by 3 RNs, 3 Medical Records, CNA, 2 LPNs, 2 Activities, 2 Social Services, 2 Registered Dieticians, Central Supply, Business Office Manager, Dietary Manager. QA members consisting of Activities, Housekeeping, Dietician, Social Services, Central Supply, Medical Records, Human Resources and CNA, will continue to conduct rounds with the census sheet as an audit tool weekly x 4 weeks, then monthly and give the audit tool to the ED/AED for review and any deficient practice and the audit tool will also be forwarded, for review, to the QA committee. 4) Affected resident: current order for [MEDICATION NAME] was obtained on 9/13/16. 5) Nursing staff reinserviced on the medication administration policy to include 6 rights of medication administration including: right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. In-service began 9/27/16 by ADNS and RN/RT, Director of [MEDICAL CONDITION] Services. In-services will continue until licensed nurses have been reinserviced. On 9/28/16, in-services continue and in-services are presented by the RN Case Mix Consultant, RN Assistant Director of Nursing, and RN/RT, Director of [MEDICAL CONDITION] Services. As of 9/29/16, in-services continue by LPN Pharmacy Consultant, and RN Case Mix Consultant. In-services will continue by LPN Pharmacy Consultant, Staff Development Coordinator, RN Unit Manager, RN Supervisor, LPN Supervisor, RN Assistant Director of Nursing, and RN/RT Director of [MEDICAL CONDITION] Unit. In-services will continue until 100% of licensed nurses have been reinserviced by 10/5/16. No licensed nurse will be allowed to work until in-service on medication administration has been completed. As of 10/3/16, 86% of licensed nurses have been reinserviced. 6) Medication administration skills competencies to include: preparation, steps to perform medication administration of medication, and completion of task related to the following competencies for medication administration: nebulizer, ear drop, eye drop, eye ointment, enteral tube, nasal, insulin, nose drop, oral inhaler, oral powder inhaler, rectal suppository, sublingual, intramuscular injection and [MEDICATION NAME]. Competencies began on 9/27/16 by RN/RT, Director of [MEDICAL CONDITION] Unit, and RN Assistant Director of Nursing. Competencies continued on 9/28/16 by LPN Pharmacy Consultant. Competencies will continue by LPN Pharmacy Consultant, LPN Staff Development Coordinator, RN/RT Director of [MEDICAL CONDITION] Unit, RN Unit Manager, LPN Supervisor, RN Supervisor, RN Director of Nursing Services and RN Assistant Director of Nursing Services until complete. No licensed staff will be allowed to work prior to medication administration policy in-service to include medication administration skills competencies 7) Newly hired nurses will be in-serviced during orientation process on medication administration to include the 6 rights of medication administration-right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration by RN Director of Nursing or RN Assistant Director of Nursing, LPN Staff Development Coordinator, RN Supervisor, LPN Supervisor. 8) RN Director of Nursing, RN Assistant Director of Nursing, RN Supervisor, RN Unit Manager, LPN Supervisor, RN/RT Director of [MEDICAL CONDITION] Unit, LPN Staff Development Coordinator, will audit weekly x 4 then monthly with a total of 10 nurses for administering medications per medication administration policy including 6 rights of medication administration- right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. Medication administration observations will be given to ED/AED for review and any deficient practice will be forwarded for review by the QA committee. 9) Amendment made on 9/30/16 to admission paperwork/packet to include statement no cleaning chemicals i.e. Pine Sol, Clorox, Mr. Clean etc. allowed to be kept in the resident rooms. Additionally, this amendment will be presented to residents that are their own responsible party and provided to responsible parties for residents. 10) QA meeting was held on 9/29/16. Participants were: Executive Director, Assistant Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Director, Director of [MEDICAL CONDITION] Services, and Medical Director. 11) In-servicing related to chemicals found in resident rooms will continue quarterly for all staff. 12) Licensed Nurses will receive in-services quarterly regarding Medication administration to include the 6 rights of medication administration - right resident, right drug, right dose, right route, right time, right documentation, administering per physician order, shaking of liquid medication prior to administration unless contraindicated, procedure to prepare, administer and record medication administration. HCMS on behalf of the State Survey agency validated the implementation of the facility's Credible Allegation of Jeopardy removal (AOC) as follows: 1. No action plan in this statement to verify. 2. The absence of chemicals in R7's room was verified during daily observations made during the complaint investigation of 9/26 - 10/4/16. The weekly audit from 10/3/16 was reviewed. Observations of 36 resident rooms (TCPU: 101, 102, 103, 104, 106, 107, 108, 109, 110, 111, 112, 113, and 114, and Main Building: 312, 308, 303, 221, 204, 56, 55, 54, 53, 52, 51, 38, 41, 40, 35, 33, 31, 30, 26, 22, 17, 11 and 4 ) on 10/4/16 verified no chemicals were present in resident rooms. 3. Documentation of the resident room sweeps for chemicals was reviewed. These sweeps occurred 9/6, 9/12, 9/19 and 9/27 - 9/28/16. Documentation reviewed no chemicals were found in resident rooms. 4. R7's new physician order for [REDACTED]. 5. In-service records of 16 nurses (RN272, RN273, RN 277, RN94, LPN288, LPN283, LPN147, LPN137, LPN135, LPN133, LPN128, LPN120, LPN116, LPN110, LPN108, and LPN105,) passing medications on 10/4/16 revealed that all had received the in-service identified in the AOC. During interviews conducted on 10/4/16 with RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., RN 277 at 10:25 a.m., RN 94 at 8:40 a.m., LPN 288 at 10:15 a.m., LPN 147 at 8:25 a.m., LPN 283 at 11:05 a.m., LPN 147 at 8:25 a.m., LPN 137 at 8:40 a.m., LPN 135 at 8:40 a.m., LPN 133 at 8:32 a.m., LPN 128 at 10:09 a.m., LPN 120 at 9:25 a.m., LPN 116 at 8:26 a.m., LPN 110 at 9:30 a.m., LPN 108 at 8:27 a.m., and LPN 105 at 8:29 a.m., the 16 nurses interviewed on 10/4/16 verified their attendance at in-services on medication administration. 45 random nurse records were also reviewed for in-servicing on medication administration. All nurse records that were reviewed were found to contain evidence of the in-service described in the AOC. 6. Medication competency records of 16 nurses (RN272, RN273, RN 277, RN94, LPN288, LPN283, LPN147, LPN137, LPN135, LPN133, LPN128, LPN120, LPN116, LPN110, LPN108, and LPN105,) passing medications were reviewed and these 16 nurses were observed to be present on 10/4/16. During interviews conducted on 10/4/16 with RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., RN 277 at 10:25 a.m., RN 94 at 8:40 a.m., LPN 288 at 10:15 a.m., LPN 147 at 8:25 a.m., LPN 283 at 11:05 a.m., LPN 147 at 8:25 a.m., LPN 137 at 8:40 a.m., LPN 135 at 8:40 a.m., LPN 133 at 8:32 a.m., LPN 128 at 10:09 a.m., LPN 120 at 9:25 a.m., LPN 116 at 8:26 a.m., LPN 110 at 9:30 a.m., LPN 108 at 8:27 a.m., and LPN 105 at 8:29 a.m., the 16 nurses revealed they were responsible for medication administration, and revealed that all had passed the competencies identified in the AOC and performed by the administrative staff. The records of the 16 nurses were found to contain evidence of medication competency testing. All of these nurses' records were found to contain evidence of medication competency testing. An abbreviated medication pass was conducted on 10/4/16. Fourteen medication opportunities were observed with three different nurses, on three different units. LPN 120 was observed between 4:20 p.m. and 4:55 p.m. administering medications to a resident on the West Unit. Four opportunities were observed including a liquid suspension and blood pressure monitoring related to the medication. Beginning at 4:18 p.m., LPN 143 was observed administering medications to a resident on the Upper Central Hall, with 3 opportunities (2 injection and 2 oral medications.) LPN124 was observed passing medications to a resident on the Lower Central Hall beginning at 4:44 p.m. six opportunities, including 1 injection and 5 oral medications, were observed. Methods of administration during this medication pass included PO meds, injections, and liquid suspensions. No errors were identified in the medication pass. A full medication pass, which included 25 medication opportunities, was also observed during the week of 9/26 - 9/30/16 as part of the abbreviated and partial extended survey. No errors were identified during that medication pass. 7. Interview with Human Resources staff on 10/4/16 at 11:35 a.m. revealed there were three newly hired nurses in the last week. The personnel and training records of these three staff were reviewed. All three staff had evidence of in-service during orientation on medication administration. Interview with LPN Orientee 308 at 9:40 a.m. on 10/4/16, revealed that she received training during her orientation on correct medication administration. 8. Audits of medication pass observations made by the DON were reviewed. The DON was observed on 10/4/16 auditing two different nurses passing medications. 9. Interview with LPN6 (Admissions Staff) on 10/4/16 at 8:36 a.m. confirmed that the admission paperwork had been amended. She provided a copy of the revised document, which contained the language alleged in the AOC. A letter was also sent to families of current residents after the 9/6/16 incident, informing the families that residents were not to have chemicals stored in resident rooms. 10. Documentation of the 9/29/16 QA meeting was reviewed. The signature sheet verified the presence (either in person) or by telephone (in the case of the Medical Director) for this meeting in which the action plans for the AOC were developed. Interviews were conducted with the Administrator and Assistant Administrator on 10/4/16 at 2:27 p.m. to verify the topics discussed and actions planned for correction of identified Immediate Jeopardies. 11. On 10/4/16 at 2:54 p.m., the Administrator provided the annual calendar of training, which showed that each of the in-service topics, including chemical storage, had been added to the quarterly training, and would next be discussed in December 2016. 12. On 10/4/16 at 2:54 p.m., the Administrator provided the annual calendar of training, which showed that each of the in-service topics, including medication administration, had been added to the quarterly training schedule, and would next be discussed on December 30, 2016.
Based on observation, interview, and record review, the facility failed to have an effective pest control system in place. The failure to control roaches, as well as other insects such as gnats and flies, was noted in one of the two residential buildings which housed 215 of the 229 residents in the facility. The failure by the facility resulted in psychosocial harm to 2 of 52 sampled residents (R2 and R37), both of whom expressed fear of the roaches which had been seen in their rooms. Findings include: 1. Observations and Resident Interviews Observation on Monday, 9/26/16 at 9:18 a.m. during the initial tour of the facility, revealed a dead cockroach on the floor of resident room 313. R51, who was present in the room, stated, We see them all the time. Certified Nursing Assistant (CNA) 152, who was also in the room at this time, confirmed that the roaches were a real problem. Review of the most recent Minimum Data Set (MDS) for R51, an annual assessment, dated 6/14/16, indicated the resident had no cognitive impairment or memory loss, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Observation on 9/26/16 at 9:55 a.m. during the tour of the lower level of the main building revealed flying gnats in the shower room used by residents. A dead bug (type unidentifiable) was squished on the floor. Observation on 9/26/16 at 10:00 a.m. revealed a dead cockroach on the floor of the conference room to which the survey team had been assigned. During an interview on 9/26/26 at 9:45 a.m., R2 voiced multiple complaints about insects. She stated, I had a roach in my bed several weeks ago. I couldn't go to sleep till they got it. She added, It's happened several times. I still go to bed every night checking around the walls. I'm afraid. Oh Lord have mercy - I can't move very quickly to get away from the roaches. R2 added, I've had to sleep with the lights on; I'm scared. Review of the most recent MDS for R2, a quarterly assessment dated [DATE], indicated the resident was alert, and oriented with no memory or cognitive deficits as evidenced by a BIMS score of 15 out of 15. This MDS also noted the resident has limitations for her ability to move, as she required extensive assistance from staff for bed mobility and transfers. Further review of the MDS history for R2 revealed that the resident had experienced a decline in mood from her 5/5/16 quarterly MDS which showed no mood concerns,compared to her MDS dated [DATE] which showed that the resident was feeling down, depressed or hopeless for 7 - 11 (half or more) days of the last two weeks. On 9/26/16 at 9:06 p.m. R37 was interviewed. She stated, There are gnats and flies here that have taken over the basement level where my room is located. Just several days ago the medication man found a box of junk underneath a bed. Oh my goodness, the gnats and flies and roaches took over the basement. My goodness I am scared of roaches. I see them crawling in my room crawling on the floor and the walls every night. I try to kill them but I'm scared. When I do get the nerve to kill the roaches they curl up and there is no one to pick the dead roaches up off the floor. I talked to the spray man and he said they are called wood roaches. I have never heard that term before but you should go down to the basement floor you will see gnats flies and roaches. I am so afraid those roaches are going to get in my bed I can't even sleep at night. Let's just pray the spray man kills them. Review of the quarterly MDS for R37 dated 5/26/16 indicated the resident was cognitively intact with a BIMs score of 15 out of 15. The 5/26/16 MDS indicated the resident had trouble falling or staying asleep, or sleeping too much as well as having little pleasure doing things, feeling down, depressed or hopeless. During the initial tour of the facility on 9/26/16 at 8:30 a.m., additional residents voiced complaints about insects. R47, who resided on the Central Hall stated, There is a real problem with pests crawling around here. Review of the most recent MDS for R47, an annual assessment, dated 8/2/16, indicated the resident had no memory loss or cognitive impairment as evidenced by a BIMS score of 15 out of 15. Also at 8:30 a.m., R48 stated the insects included roaches, ants, and flying stuff. He described it as an awful problem and that he just saw one (a roach) on Friday. Review of the most recent MDS for R48, an annual assessment, dated 7/11/16, indicated the resident had no cognitive impairment or memory loss, as evidenced by a BIMS score of 15 out of 15. During a tour of the West Unit at 9:00 a.m. on 9/26/16, R13, R38, and R39 (residents on the West Unit) reported seeing water bugs in their rooms. (Note - Per Wikipedia, term water bug can refer to one of several insects including the American cockroach, the German cockroach, and the Oriental cockroach.) R13 stated she saw water bugs in her bathroom area on several occasions. R13 could not provide specific dates or times. R38 and R39 stated they had observed ants and water bugs in their rooms and/or bathrooms, but were unable to provide specific dates or times. During an interview on 9/26/16 at 9:07 a.m., when asked about seeing roaches, R17 stated, I certainly have and noted that she had seen roaches as recently as this weekend even though they've sprayed. Review of the most recent MDS for R17, an annual assessment dated [DATE], indicated the resident had no cognitive impairment or memory loss, as evidenced by a BIMS score of 15 out of 15. During a second interview with R17 on 10/4/16 at 3:56 p.m. (one week after the initial interview), R17 stated that pests continued to be a problem. She related that she saw three roaches the previous evening in her bathroom, and she had killed one by squishing it. Interviews with residents on the 300 Hall also revealed their complaints about insects. On 9/26/16 at 9:27 a.m., R50 stated he had seen roaches on occasion, but not all the time. Review of the quarterly MDS, for R50, dated 5/24/16, indicated the resident had no cognitive impairment or memory loss, as evidenced by a BIMS score of 15 out of 15. During an interview on 9/27/16 at 9:30 a.m., R41 stated she saw a big black water bug in her room the previous night. She stated, Yes, it was a roach. The resident stated that she was watching television when it came out, ran under my shoes to under the dresser. The resident stated she didn't tell staff this time - there is no point. We've told them and told them. They just say, We'll spray' but it hasn't fixed it. They're still here. Review of the quarterly MDS for R41, with an Assessment Reference Date (ARD) of 7/13/16, indicated the resident was alert and oriented with no memory or cognitive deficits, as evidenced by a BIMS score of 15 out of 15. During an interview with R31, a resident living on the lower level, on 9/26/16 at 10:06 a.m., the resident stated, had big water bugs about 3 weeks ago. The resident stated they did not see the water bugs on a daily basis but It has been a problem. Review of the most recent MDS for R31, a quarterly assessment, dated 8/3/16, indicated the resident was cognitively intact, and had no memory loss, as evidenced by a BIMS score of 14 out of 15. During an interview with R41 on 9/26/16 at 9:40 a.m., the resident stated there were cockroaches as big as my thumb in the building. The resident stated she observed them on the ceiling and in the track where the privacy curtain was attached. Review of the 7/13/16 quarterly MDS indicated the resident was cognitively intact (Brief Interview for Mental Status score of 15 out of 15). During an interview with R40, who lived in Room 317, on 9/26/16 at 9:50 a.m., the resident stated she observed cockroaches under the air conditioning unit and on the floor in the bath room. Review of a 6/28/16 quarterly MDS assessment indicated the resident was cognitively intact (Brief Interview for Mental Status score of 15 out of 15). During a group interview conducted on 9/27/16 at 11:15 a.m., 16 residents whom the facility and/or survey team had identified as alert and oriented, and who could provide resident feedback on various concerns provided their input regarding the pest concern. Residents on both floors of the main building stated there were bugs everywhere. One resident stated the water bugs were bigger than your thumb. Two residents stated they saw cockroaches in their beds, with one resident stating the roaches were sticky - it crawled on me. Residents stated the pests, which also included flies and gnats, were in the halls, in our rooms, everywhere. One resident stated that the resident council has been trying to get pest control out here to treat the whole building, but it's not happening. The other residents confirmed that they had continuously brought up the subject of pests in their monthly resident council meetings, but the building had not been sprayed for 2 to 3 months to correct the problem. A resident concluded by stating, It's the nastiest place I've ever lived, look at it. 2. Grievances/Resident Council Review of facility grievance records indicated the records contained complaints about big roaches in July 2016, as well as roaches seen in September 2016. Review of resident council meeting notes revealed that residents voiced complaints about pests during the 5/5/16, 6/2/16, 7/7/16, and 8/4/16 meetings. 3. Pest Control Staff Interviews and Pest Control Treatment During an interview with the Pest Control Technician on 9/28/16 at 1:45 p.m., he confirmed that the facility was having a problem with roaches, and he had just sprayed one hall (300 Unit) this week. He stated, These are not indoor roaches - they are outdoor roaches that are coming in through plumbing and air conditioner vents. He stated that the roaches were an issue throughout the area (not just this facility) for the past couple of months this past summer. The technician stated, We've been trying to figure out where they're coming from but haven't identified it yet and the roaches are just coming in through the plumbing. He added, I'm spraying like crazy but not accomplishing a lot without identifying the actual entry points into the facility. During an interview with the Payroll and Accounts Receivable Specialist on 9/27/16 at 12:39 p.m., she provided pest control invoices from 8/24/16 to the present. Review of the pest control records provided by the facility on 9/27/16 indicated the following treatments: a. 8/24/16: fungus gnats targeted. b. 9/12/16: bait placement for fungus gnats and roaches on unidentified hallways and shower. c. 9/14/16: crack and crevice treatment for [REDACTED]. d. 9/19/16: fly bait - Rooms 23, 24, 25, 26; multi pest treatment for [REDACTED]. A review of the pest control invoice for 9/26/16 indicated that crack and crevice treatment for [REDACTED]. There was no evidence that individual resident rooms on the 300 Hall, or any locations on the West Wing were treated. Further review of these invoices indicated that none of them were marked as a routine, monthly visit. Each invoice was marked to show it was a call back or follow up for service. During an additional interview with the Pest Control Technician by telephone on 10/1/16 at 2:12 p.m., the technician stated he could not identify which of the above listed visits was the actual routine monthly visit versus an additional call, as he simply marked, Follow-up or call back on each form. He stated he came to the facility at least once a month; however, even during his routine monthly visit, he did not always do the entire building. When asked to explain what the monthly service consisted of, he stated, It just depends on what they tell me as to what and where there was a problem. He confirmed the group meeting interviews, stating I try to not spray the whole building unless we have to because it's a nursing home. Review of additional invoices provided by the facility on 10/3/16 indicated that the entire perimeter of the facility had not been treated since 8/2/16. Review of the invoices, which dated back to April 2016, provided no evidence that the entire facility was ever treated at one time, with multiple visits being for only one hall, a limited (less than 10) resident rooms, or administrative offices. During an additional interview conducted with the Pest Control Technician on 10/3/16 at 5:00 p.m., he confirmed that the entire building had not been treated/sprayed at one time for at least the past 6 months, until 10/2/16, after the initiation of the complaint survey, and stated, I tried to solve the problem from the outside of the building but it was not working. 4. Staff Interviews: During an in interview with Licensed Practical Nurse (LPN) 116 on 9/28/16 at 2:30 p.m., the LPN stated that the concerns expressed in the group meeting held on 9/27/16 were accurate, and added, Everything those residents said in the group was true and that, The big old roaches, they're in peoples' beds. During an interview with the Maintenance Supervisor on 9/27/16 at 12:27 p.m., the Maintenance Supervisor stated that he was aware of resident concerns about pests. He related that the pest control service had been there the previous day and did all of 300 (Hall) and West (a different unit.) The Maintenance Supervisor stated that in the three weeks he had been employed at the facility, I've been called in several times for gnats, water bugs. The Maintenance Supervisor stated that he personally had not seen any roaches, but that CNAs (Certified Nursing Assistants) have brought dead ones to me. He stated that the pest exterminator told him that due to the dry weather conditions, the roaches were coming into the building to find water, but could not survive inside. The Maintenance Supervisor stated, In a building this size, we patch every crack and crevice we find. However, the facility has open acoustic ceilings so, It's not possible to find where they're coming from. He stated, I don't know if we're succeeding but we are really, really trying. In interview was conducted with CNA221 on 9/28/16 at 9:55 a.m. The CNA stated there had been lots of cockroaches the last couple of months, not sure why, but they can't seem to get rid of them. An interview was conducted with CNA222 on 9/28/16 at 10:30 a.m. confirmed a long time issue with cockroaches in the building. CNA222 stated, The pest control company came in and put little boxes under resident beds and other areas where they did not have to worry about someone getting in to them.
Inspection of April 3, 2012
2 findingsBased on record review, Daily Care Guide review, hospital ED Record review, and staff interview, the facility failed to ensure that staff utilized safe technique, by failing to provide two persons to assist during transfer, to reduce the fall-risk for one (1) resident (#1) who had been assessed to be at risk for falls, on the survey sample of (3) residents. This resulted in harm to Resident #1, who experienced a fall during transfer and sustained a laceration to the base of the head requiring two (2) staples, and a knot with bruising to her back. Findings include: Review of the medical record for Resident #1 revealed a Care Plan Problem/Need dated 11/30/2011 which identified that the resident was at risk for falls and included as an Approach for staff to assist the resident with all transfers. The Daily Care Guide for Resident #1 dated 03/14/2012 specified to transfer the resident using a Marissa lift, using a medium sling and two-person assist. A Departmental Note for Resident #1 dated 03/14/2012 at 4:02 p.m. documented that the resident had a fall in the room at 10:20 a.m. while being transferred via mechanical lift by a staff member. The same Note indicated the resident was bleeding from a small laceration on the base of her head, and also documented a raised knot with bruising on her mid-back. This Note documented that pressure was applied and the bleeding stopped, and that the resident's vital signs were taken, revealing a blood pressure of 127/75, a pulse of 76, and respirations of 22. This Note further documented that the resident's pupils were equal, round, and reactive to light, that the resident was alert, and that the physician was notified. This Note also documented that the ambulance was called and the resident was transferred to the hospital emergency room for further evaluation. The hospital ED Record dated 03/14/2012 documented that Resident #1 had sustained a fall and a laceration to the scalp, and also noted that the resident had received staples. Further review of Resident #1's medical record revealed a Departmental Notes entry dated 03/14/2012 at 9:39 p.m. which documented the resident had returned to the facility at 4:30 p.m. alert and responsive, with two (2) staples and a bruise to the back of the head and a swollen area to her mid-back. On 04/03/2012 at 2: 45 p.m., during an interview the Director of Nursing (DON), the DON stated Resident # 1 had fallen to the floor while Certified Nursing Assistant (CNA) "AA" used a Marissa lift to transfer the resident from the bed to the Geri-Chair by herself. The DON also acknowledged that the resident was supposed to be transferred utilizing two-person assist, but further acknowledged that CNA "AA" decided to transfer the resident by herself.
Based on record review, Daily Care Guide review, and staff interview, the facility failed to provide care in accordance with a specific intervention, related to the need for two-person assist during transfer, to reduce the fall-risk of one (1) resident (#1), who had been assessed to be at risk for falls, on the survey sample of (3) residents. This resulted in harm to Resident #1, who experienced a fall during transfer and sustained a laceration of the head and a knot with bruising to the back. Findings include: Cross refer to F323 for more information regarding Resident #1. Review of the medical record for Resident #1 revealed a Care Plan entry dated 11/30/2011 which documented, as a Problem/Need, that the resident was at risk for falls secondary to impaired mobility, and included as an Approach for staff to assist the resident with all transfers. An additional 11/30/2011 entry on this Care Plan referenced activities of daily living and included an Approach of utilizing a Marissa lift during transfer. Each of these Care Plan entries were documented as having been reviewed and continued on 02/22/2012. The Daily Care Guide for Resident #1 dated 03/14/2012 at 7:29 a.m. specified to transfer the resident using a Marissa lift, a medium sling, and a two-person assist A Departmental Note for Resident #1 dated 03/14/2012 at 4:02 p.m. documented that the resident had a fall while being transferred via mechanical lift and sustained a small laceration on the base of her head and a raised knot with bruising on her mid-back. This Note documented that the resident was transferred to the hospital. A Departmental Notes entry dated 03/14/2012 at 9:39 p.m. documented Resident #1 returned to the facility with two (2) staples and a bruise to the back of the head and a swollen area to her mid-back. During an interview conducted on 04/03/2012 at 2: 45 p.m., the Director of Nursing stated Resident # 1 had fallen while Certified Nursing Assistant (CNA) "AA" used a Marissa lift to transfer her, but further stated that CNA "AA" had transferred the resident by herself instead of utilizing a two-person assist.
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