Every finding on record at Glen Rose Nursing and Rehab Center

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed food safety. The facility failed to ensure foods were labeled properly in the kitchen. The facility failed to dispose of foods after the use by / shelf life date.These failures could place residents that eat out of the kitchen at risk for food borne illnesses.Findings includedDuring an observation on 1/13/2026 between 8:48 a.m. and 9:05 a.m., the kitchen revealed: Dry Storage: 1. Opened bag of potato chips in a see-through plastic bag that was closed to air not labeled with open date. 2. Opened bag of what appeared to be ten slices of bread stored outside of the original container not labeled with description, open date, or use by date. Refrigerator:1. Opened bag of sliced white cheese stored outside of the original container not labeled with use by date.2. Opened bag of what appeared to be sliced yellow cheese stored outside of the original container not labeled with description or use by date.3. Opened bag of smoked sliced turkey breast stored in a see-through sealed plastic bag. There was a freeze by date or use by date of 11/25/2025 on the original packaging of the sliced turkey breast. There was a date written on the bag 12/13 with no year and did not specify what the date was for. Freezer: 1. Opened bag of what appeared to be ground meat patties stored outside of the original container not labeled with description, opened date, or use by date.2. Opened see-through plastic bag labeled pepperoni dated 10/12/2025 with shelf life of 3 days written on it (stored 90 days after shelf life).3. Opened see-through plastic bag that was labeled chicken flour tortilla on it with an open date of 1/8/2026 and a use by date of 1/11/2026 (stored 2 days past use by date).4. Opened see-through plastic bag of what appeared to be cookie dough stored outside of the original container not labeled with description, opened date, or use by date.5. Opened see-through plastic bag of beef burritos not labeled with a use by date.6. Opened plastic tub of vanilla ice cream not labeled with an open date.7. Five logs of what appeared to be ground meat in the original package with no description on them.During an interview on 1/13/2026 at 9:14 a.m., the DM stated she expected for all stored items to have an open date and a use by date labeled on them if the item had been opened. She expected items to have a description on them. She stated all staff were responsible for labeling the food items when they were storing them which would include the cook, dietary aides, and activities director. She stated she monitored that items in the storage areas were labeled appropriately. She stated she expected food items stored in the refrigerator that were open to be used in 7 days if there was no use by date labeled on it. She stated she expected items in the freezer to be used or discarded 6 months after they had been opened if there was no use by date labeled on it. She stated she expected items in the dry storage area to be used up or discarded within 3 days of being opened if there was no use by date on the package. She stated not labeling the food items with a use by date could cause the food to be served past the use by date. She stated not labeling the food items with a description could have caused the cook to not know what the food item was. She stated the turkey in the fridge would have been frozen prior to being kept in the refrigerator but would still need to have an open date and a use by date so that staff knew when it was no longer to be used. She stated she was unsure when the turkey had moved to the refrigerator. During an interview on 1/13/2026 at 9:17 a.m., [NAME] C stated she was trained on food labeling and would have put a label on the food items when she stored them. She stated she had been on vacation for the last two weeks and did not know why food items in the dry storage, refrigerator, and freezer did not have labels. During a telephone interview on 1/14/2026 at 8:28 a.m., the dietician stated foods stored should always have an end date. She stated if food was taken out of its original package, there should have been an expiration date written on the new packaging and it should have a description of the food written on the package. She stated chips were good for seven days once opened and would need an open date written on the package. She stated bread stored outside of original package should have a description written on it and an open date. She stated foods stored in the refrigerator should have a use by date written on the storage container. She stated the recommendation for cheese was to use it by one to two months after the package had been opened and one hundred and eighty days if the package had not been opened. She stated the cheese should have a use by date written on the package when being stored. The dietician stated the smoked sliced turkey breast should have been dated when it moved from the freezer into the refrigerator. She stated turkey would last seven days after being thawed in the refrigerator. She stated the items in the freezer would need to have a description on them so that staff would know what the item was. She stated frozen meat lasts nine months in the freezer and she did not know why the pepperoni had three-day shelf life written on the bag. She stated frozen ground meat patties would need to be labeled with description and date when it came into the facility. She stated ground meat would be good for three to four months frozen. She stated it was important to label items in storage so people would know what it was, so they would know when to use the food item or when to dispose of that item. She stated not labeling foods with description could cause a resident to get a food that they had an allergy to. She stated if a food item did not have an end date, it could have potentially been served after it had expired. She stated serving food without an open date could have caused a chance of food borne illness. She stated the employee who stored the food was responsible for making sure it was labeled. She stated the DM and the assistant DM were who monitored that food was stored appropriately. She stated the kitchen staff were trained on food labeling through continuing education that they complete on the computer and were educated by the DM, the assistant DM or me as well. She stated the kitchen staff were trained at least annually but did not know for sure how often staff were trained. She stated the DM and herself do in-services when they see issues as needed in the moment. She stated she came to the facility twice a month with another dietician due to the size of the facility. She stated she honestly did not know why the foods would not have been labeled appropriately. Record review of the facility policy titled Food Storage, dated 2023, reflected: Food should be dated as it is placed on the shelves if required by state regulation. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat food should be consumed, sold or discarded.Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded per the 2022 Federal Food Code. Review of the Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 1/14/2026 reflected 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interviews and record review, the facility failed to ensure residents had the right to formulate an advanced directive for 1 of 18 (Resident #13) residents reviewed for advanced directives. The facility failed to ensure that Resident #13's advanced directive consent, Out of Hospital Do Not Resuscitate (OOH-DNR) order, was signed by physician in section D.This failure could place residents at risk of receiving interventions that go against their personal preferences. Finding includedRecord review of Resident #13's face sheet, dated [DATE], reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including COPD. Further review reflected advance directive Do Not Resuscitate.Record review of Resident #13's quarterly MDS, dated [DATE], reflected Resident #13 had a BIMS of 15 meaning her cognition was intact. Further review of the MDS reflected she did not have a life expectancy of less than 6 months.Record review of Resident #13's care plan, initiated on [DATE], reflected Resident #13 had an order for Do Not Resuscitate (DNR), her decision for DNR would be honored, and social services to consult with Resident #13 regarding her decision to continue DNR.Record review of Resident #13's electronic physician orders, reviewed on [DATE], reflected an order for DNR dated [DATE]. Record review of Resident #13's OOH-DNR, dated [DATE], reflected no evidence of physician signature in section D. Declaration by physician. Record review of Resident #13's progress note, dated [DATE] created by SW, reflected a care plan meeting was conducted and DNR code status was chosen. DNR form sent to physician.Record review of Resident #13's progress note, dated [DATE] created by SW, reflected a care plan meeting was conducted and DNR was code status. During an interview on [DATE] at 9:37 a.m., the SW stated she was responsible for making sure OOH-DNR forms were filled out completely and uploaded into the resident's chart. She stated a physician would have needed to sign in section D of Resident #13's OOH-DNR for the form to be completed. She stated she did not know why she had missed that the physician had not signed the OOH-DNR form in Section D and stated she reviewed those forms during care plan meetings that occurred quarterly. She stated not having the physician's signature could cause another facility to not honor the resident's wishes. During an interview on [DATE] at 10:10 a.m., the ADMN stated she expected DNR forms to have physician signature in the physician signature part as well as in the bottom of the form. She stated she monitored that the forms were completed, and the facility staff had just done an audit one or two months ago. She stated Resident #13's physician signature on the form had been missed during that audit. She stated not having the signature would not affect the facility's staff responding appropriately to the resident's wishes. She stated the form not being completed could cause another facility to not honor Resident #13's wishes if she was transferred to another facility for treatment. Record review of facility policy titled, Advanced Directives, revised on [DATE], reflected Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used.If the Resident Does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. 3. The attending physician provides information to the resident and legal representative regarding the residents health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan.Record review of website titled Out of Hospital Do No Resuscitate Program located https://www.dshs.texas.gov/emstraumasystems/dnr.shtm accessed on [DATE] revealed: APPLICABILITY: This OOH-DNR Order applies to health care professionals in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows:. Section D - If the person is incompetent and his/her attending physician has seen evidence of the person's previously issued proper directive to physicians or observed the person competently issue an OOH-DNR Order in a nonwritten manner, the physician may execute the Order on behalf of the person by signing and dating it in Section D. Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #55 and Resident #72) reviewed for care plans. The facility failed to address Resident #55's indwelling urinary catheter on her comprehensive resident-centered care plan. The facility failed to include measurable goals and appropriate interventions on Resident #72's comprehensive resident-centered care plan regarding weight loss. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.The findings included: 1.Record review of Resident #55's electronic face sheet, dated 01/14/2026, revealed a [AGE] year-old female admitted on [DATE] with medical diagnoses of chronic kidney disease and history of urinary tract infections. Record review of Resident #55's admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 10 out of 15, indicating moderately impaired cognition. Record review of Resident #55's Care Plan Conference Report dated 08/05/2025, revealed in the section titled Therapy Continent Status, Supra pubic cath was noted. Record review of physician's assessment History and Physical dated 07/29/2025, revealed Assessment and Plan 4. Suprapubic urinary catheter in situ (situated in the original place). Record review of Resident #55's Baseline Care Plan with a date of 08/01/2025 revealed in Section A. Health Condition/Special Treatments 1i1. Other (specify) s/p cath supplies was entered and Section C. Bowel and Bladder 4. Bowel and bladder appliances a. Indwelling catheter (including suprapubic catheter and nephrostomy tube) was selected. Record review of physician orders dated 09/01/2025 revealed Change suprapubic Catheter q28 days and prn complications every 24 hours as needed for suprapubic cath complications and supra-pubic cath care every shift. every shift. Record review of Resident #55's Comprehensive Care Plan with a date of 10/21/2025 as last care plan review completed, revealed no evidence of suprapubic urinary catheter. During an observation on 01/13/2026 at 8:21 am, Resident #55's indwelling urinary catheter collection bag was hanging under her bed on the left side. During an interview on 01/14/2026 at 7:57 am, Resident #55 stated she had problems with kidney stones for years but not since the indwelling catheter had been placed. She stated staff changed the catheter and emptied the collection bag as needed. No complaints were made by the resident concerning the catheter. 2.Record review of Resident #72's electronic face sheet, dated 01/14/2026, revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with medical diagnoses of osteomyelitis of vertebra (infection in the spine), anxiety, dysphagia (difficulty swallowing), Alzheimer's disease, spinal stenosis (stiffening of the spine), weakness, high cholesterol, glaucoma, high blood pressure, atrial fibrillation (irregular heart rhythm) and cerebral infarction (stroke). Record review of Resident #72's Significant Change MDS dated [DATE], revealed the following:*Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed he had a BIMS score of 4 out of 15, indicating severe cognitive impairment. *Section K - Swallowing/Nutritional Status, subsection K0300 Weight Loss, 2. Yes, not on physician-prescribed weight-loss regimen. *Section V Care Area Assessment (CAA) Summary, subsection 0200 CAA's and Care Planning, A. CAA Results, Care Area, 12. Nutritional Status, column A. Care Area Triggered was checked and column B. Care Planning Decision was checked with a notation CAA WS dated 01/14/2026. Record review of Resident #72's Comprehensive Care Plan with a date of 01/12/2026 as last care plan review completed, revealed Focus [Resident #72] has nutritional problem or potential nutritional problem (depression). Goal [Resident #72] will maintain adequate nutritional status as evidence by maintaining weight within (X)% of (SPECIFY BASELINE), no s/sx of malnutrition, and consuming at least (X)% of at least (X) meals daily . and Interventions/Tasks Offer activities of choice to help divert attention from food date initiated 10/14/2025. During an interview on 01/15/2026 at 9:23 am, the DON stated she, the ADON, and the MDS Coordinator were responsible for creating care plans. She stated she was responsible for monitoring for accuracy. The DON was unable to provide an explanation as to why Resident # 55's suprapubic catheter was not addressed on the care plan or why Resident #72's goals were not measurable, and why an inappropriate intervention was documented. Her expectation was for the goals to be individualized to meet the needs of the residents. She explained that training on care plans was provided upon hire, when a staff member changes roles to include participation in care planning or when a need for re-education was identified. The DON stated her expectation was for all care plans to be accurate and timely. The DON stated a possible effect on a resident if a care plan was not accurate was that the resident may not receive appropriate care. During an interview on 01/15/2026 at 11:11 am, the MDS Coordinator stated the care plans were a team effort. She explained the DON created the baseline care plan and the MDS Coordinator entered the biggest part. She stated the care plans were updated quarterly after the MDS was completed and after off cycle MDS's, for example a Significant Change MDS. She stated an RN must sign that an MDS was complete and it was her responsibility to monitor for accuracy. She stated occasionally issues may have been missed due to 'human error. The MDS Coordinator stated the effect an inaccurate care plan may have had on a resident was that staff would not be aware of interventions that needed to be implemented or information on a resident would not be readily available. She stated training on MDS's was provided by a corporate MDS nurse and through competency training online. During an interview on 01/15/2026 at 12:17 pm, the ADON stated she was responsible for entering the infection control information on the care plans. She explained her training consisted of 20 years of nursing experience and on the job training. The ADON stated monitoring the accuracy of the care plans was the responsibility of the DON, the MDS Coordinator, Admin, and corporate staff. She was unable to state why a care plan would not have been accurate or why a care area may have been missed. She stated an inaccurate or incomplete care plan could have affected a resident because an issue may not be addressed by staff. She stated catheters should be on the care plan due to the increased risk for infection. Staff may not have known to empty the urinary collection bad which could have caused output to back up into the bladder and caused an infection. During an interview on 01/15/2026 at 1:45 pm, the ADMN stated responsibility for the comprehensive resident-centered care plans was multidisciplinary. She explained specific areas were addressed by identified personnel. The ADMN stated training was provided by a corporate MDS nurse upon hire, annually, and as needed. She explained monitoring for accuracy was the responsibility of each discipline involved. But overall, the DON was responsible for accuracy. The ADMN stated her expectations for accuracy of comprehensive resident-centered care plans was high because she felt the facility had a good team in place. She stated the effect on residents of failure to address care needs on the care plan was not significant. She explained the staff had physician's orders, implemented those orders and followed up on effectiveness of the orders. She stated direct care was mandated by the physician's orders which were more comprehensive. Record review of the facility policy titled Care Pans, Comprehensive Person-Centered , dated March 2022, revealed in part A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being; and 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observations, interviews and record reviews, the facility failed to assess the resident for risk of entrapment from bed rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 of 18 (Resident #3 and Resident #19) residents whose records were reviewed for the use of side rails. The facility failed to assess Resident #3 and Resident #19 for risk of entrapment from bed rails prior to installation. The facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for Resident #3 and Resident #19. The facility failed to follow the manufacturers' recommendations for maintaining bed rails for Resident #3 and Resident #19.These failures could put any residents who used bed rails at risk for avoidable accidents and could cause residents or their representatives not to be aware of risks from bed rail use.Findings includedRecord review of Resident #3's electronic face sheet, dated 1/15/2026, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength).Record review of Resident #3's quarterly MDS assessment, dated 11/24/2025, reflected a BIMS score of 10 indicating moderate cognitive impairment. Further review of the MDS reflected he was dependent on staff to roll from left to right, go from sitting to lying, and go from lying to sitting. Record review of Resident #3's care plan, reviewed on 1/14/2026, reflected no evidence that Resident #3 used bed rails. Record review of Resident #3's electronic physician orders assessed on 1/15/2026 reflected no evidence that Resident #3 had an order for bed rails.Record review of Resident #3's care plan conference report, dated 5/02/2024, 3/25/2025, 6/05/2025, & 9/30/2025, reflected no safety devices/risks.Record review of Resident #3's EMR reflected no evidence there was consent for use of bed rails, no evidence that bed rails were being inspected, and no evidence that Resident #3 had an entrapment risk assessment prior to bed rails being used.During an observation and interview on 1/14/2026 at 8:50 a.m., Resident #3 was lying in his bed watching television. Both sides of his bed had bed rails in the up position. Resident #3 stated the bed rails were to keep him in the bed. He stated he did not remember anyone telling him and risk of the bed rails.Record review of Resident #19's electronic face sheet, dated 1/15/2026, reflected an [AGE] year-old male admitted on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength). Further review of the face sheet reflected that Resident #19 was his own responsible party.Record review of Resident #19's quarterly MDS assessment, dated 11/07/2025, reflected a BIMS score of 6 meaning severe cognitive impairment. Further review of the MDS reflected he required supervision to roll from left to right, go from sitting to lying, and go from lying to sitting.Record review of Resident #19's care plan, reviewed on 1/14/2026, reflected no evidence that bed rails were included in care plan prior to 1/14/2026. Further review of care plan reflected Resident #19 should be re-evaluated quarterly and as needed for continued appropriateness of handrails to assist in bed mobility.Record review of Resident #19's electronic physician orders assessed on 1/15/2026 reflected no evidence that Resident #19 had an order for bed rails.Record review of Resident #19's care plan conference report, dated 7/30/2025, 11/11/2025, & 11/18/2025, reflected no safety devices/risks.Record review of Resident #19's EMR reflected no evidence there was consent for use of bed rails, no evidence that bed rails were being inspected, and no evidence that Resident #19 had an entrapment risk assessment prior to bed rails being used.During an observation on 1/15/2026 at 8:55 a.m., Resident #19 was lying in bed. There was a bed rail in the raised position to the left of his bed.During an interview on 1/15/2026 at 10:35 a.m., Resident #19 stated he did not mind the rails being on his bed. He stated he did not remember anyone ever telling him about the risks of having the rails on his bed.During an interview on 1/15/2026 at 9:15 a.m., LVN A stated Resident #3 needed a lot of assistance for bed mobility. She stated Resident #3 could grab the bed rail to help staff when turning him in the bed. She stated Resident #19 used bed rails to get out of bed. She stated she did not get consents signed on bed rails. She stated she would get consent when a new order was placed into the resident's chart for new medications requiring consent but had never been told to get consent on bed rails. She stated she did not know where consent for bed rails would have been stored. She stated paperwork that needed to be scanned into the chart would have been placed in a wire basket behind the nurses' station for medical records to upload them.During an interview on 1/15/2026 at 9:21 a.m., CNA B stated Resident #3 used the bed rail during bed mobility with staff present. She stated he was able to move around in bed with the rails in place. She stated Resident #19 used the rails to help with exiting the bed.During an interview on 1/15/2026 at 9:31 a.m., Med Rec stated if there was any consent for bed rails, it would have been in the documents section in EMR. He stated he would have scanned documents into the EMR, and no documents were waiting to be uploaded for Resident #3 or Resident #19.During an interview on 1/15/2026 at 9:34 a.m., Maint D stated he did put on the bed rails but did not have a schedule to go back and assess the bed rails unless he was told that they had issues. He stated he did not perform inspections of bed rails or perform any entrapment risk assessments. He stated the nurses and CNAs would have let him know of issues by documenting them in the maintenance binder behind the nurses' station.During an interview on 1/15/2026 at 9:48 a.m., the DOR stated Resident #3 was on physical, occupational and speech therapy services that he used the bed rails to roll and sit up. She stated Resident #19 was on occupational therapy because he had a fall. She stated Resident #19 used bed rails to get out of bed. She stated the therapy department would have assessed that staff were using bed rails for mobility. She stated she had not performed any entrapment risk assessment or education residents or their representatives of risks of using the bed rails. She stated during care plan meetings, she would discuss whether the bed rails were still appropriate for mobility.During an interview on 1/15/2026 at 1:00 p.m., the ADMN stated the initial observation for bed rails would have been done by the nurses or therapy services within 72 hours of bed rail use. She stated therapy was involved in all care plan meetings and the resident's capabilities would have been discussed during the care plan meetings quarterly to make sure there were no changes needed. She stated the residents, and their families were involved in those care plan meetings. She stated she did not know if there was an assessment for entrapment risk when utilizing bed rails. She stated the beds were ordered and bed rails would have come in the package with the bed. She stated the bed rails were made specifically for the bed. She stated she believed that rails used were enablers and did not need alternative treatments, informed consents, or physician orders prior to being installed. She stated that if any of the rails were deemed as a restraint, then an assessment would be done to determine the justification of the bed rail, and a consent would have been obtained. She stated the DOR would review the equipment needs, benefits, and/or risks during the care plan meetings. The ADMN could not give date of when Resident #3 or Resident #19 had bed rails initiated. She stated she did not sit in on every care plan but that the facility utilized a checklist of things that were discussed during the care plan meetings and that checklist could be where risks would be documented. She stated she expected the facility's policy to be followed on bed rails but had not considered enable bars bed rails. She stated the effect of not performing entrapment risk assessments on residents with bed rails installed potentially could have led to an injury of the resident. Review of facility policy titled Bed Safety and Bed Rails, revised on August 2022, reflected For the purpose of this policy bed rails include: a. side rails; b. safety rails; and c. grab/assist bars.3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for us of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. 4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards; b. foam bumpers; c. lowering the bed; and/or d. use of concave mattresses to reduce rolling off the bed. 5. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; b. the resident's risk associated with the use of bed rails; c. input from the resident and/or representative; and d. consultation with the attending physician. 6. The resident assessment to determine risk of entrapment.7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards; (1) The resident could attempt to climb over, around, between, or through the rails, or over the foot board; and/or (2) A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress. b. Restricted mobility:.c. Psychosocial outcomes:.8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to [NAME] the resident's needs; and d. The alternatives that were considered but not attempted and the reasons.Review of the instructions for use service manual of The Liberty Bed, dated May 2015, reflected The guidelines set forth by the FDA Guidance layout specific dimensional limitations on potentially injury-threatening gaps and spaces that can occur between bed system components, such as rails, when not properly installed.recommended maintenance every 6 months inspect all fasteners for wear and looseness.optional half rail installation.WARNING: When assessing the Risk of Entrapment, consider the bed, mattress, headboard, footboard, assist devices (i.e. rails and assist bars) and other accessories as an entire system.Review of the owner's manual of 1000-Flex bed, no date, reflected Visually inspect bed and accessories for broken welds or cracks, and check for loose hardware on a monthly basis.

Based on interviews and record reviews, the facility failed to ensure nursing staffing information was posted in a prominent place readily accessible to resident and visitors that included: the census, the total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift on 1 of 3 days (01.15.2025) reviewed for required postings. The facility failed to ensure the daily staffing information for licensed and unlicensed nursing staff was posted in a prominent location on 01.15.2026 with the census, the total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocation nurses and certified aides directly responsible for resident care per shift. This failure could place residents, their families and visitors at risk of not knowing how many nursing staff were currently working and the total number of hours were to be worked by nursing staff to provide care on all shifts.Findings included: During an observation on 11.15.2026 at 11:04 a.m. the daily nursing staffing was located on 1 of 4 units in the nurse's station. The form did not have the daily census, the total number and the actual hours worked for the Registered Nurse, the LVN's or the CNAs. The daily nursing staffing was not posted on any of the other 3 units in the facility. During an interview on 01.15.2026 at 11:40 AM the DON stated the daily staffing should have the total number of hours an RNorking that day, the total number of hours LVNS were working that day and the total number of hours CNAs were working that day as well as how many of each discipline are working. The DON stated this information should have been available to anyone who wanted to see it. The DON stated the public might view this as how it could affect care. The DON stated the staffing coordinator was responsible for ensuring the daily staffing was posted. The DON stated she was responsible for monitoring this task. The DON stated this failure may have occurred due to switching computer systems. During an interview on 01.15.2026 at 11:45 a.m. the ADMN stated her expectations were that the daily nursing staffing be posted each day on the table in the front lobby and on each unit. The ADMN stated not having the daily nursing staffing posted would have kept the residents and visitors from knowing how many staff were working that day. The ADMN stated she did not know how this failure occurred. The ADMN stated the facility did not have a policy regarding the posting of the daily nursing staff.

Based on observation, record review and interview, the facility failed to have reports with respect to last 3 surveys, certifications and investigations made respecting the facility and any plan of correction in effect with respect to the facility available for any individual to review upon request for 3 of 3 days (01.13.2026, 01.14.2026, 01.15.2026). The facility failed to have surveys and investigation reports with the plan of corrections available for family members and residents (11.16.2025, 12.22.2025 and 12.26.2025) [JW1] to review. This failure could affect residents who resided in the facility and could result in a lack of awareness of the investigation results and the plan of corrections by visitors, family and residents.The findings included: During an observation on 01.15.2026 at 10:55 a.m. the survey results binder was observed in a file holder outside the door to the administrative offices. The survey results binder only contained the last re-certification results date 10.10.2024. The survey results binder did not contain the results for last 3 surveys or for the last investigation surveys dated 11.16.2025, 12.22.2025 and 12.26.2025. During an interview on 11.15.2026 at 11:40 a.m. the ADM stated she thought only the last full book survey results should have been kept in the survey results book. The ADM stated not having the investigation survey results in the survey book would have meant anyone wanting to look would not have all the information. The ADM stated this failure occurred due to her not knowing the investigation surveys results should have been in the book. The ADM stated she was responsible for ensuring the survey results book was kept up to date. The ADM stated the facility did not have a policy regarding the posting of survey results.

Based on interview and record review, the facility failed to describe in the care plan the services provided due to the resident's exercise of rights and failed to describe in the care plan the resident's preference and potential for future discharge for 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) of 7 residents reviewed for care plans.The facility failed to include the residents' preference for discharge and if their desire to return to the community had been assessed in Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 care plans.The facility failed to update the care plan of an advanced medical directive ordered for Resident #1. This failure could put the residents at risk of their person-centered care plan not being implemented to meet their preferences and goals which could affect their medical, physical, mental and psychosocial needs. Findings included: 1.Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date [DATE], Diagnoses: anxiety disorder (anxiety that interferes with daily activities), senile degeneration of brain (progressive decline in memory, behavior, and cognitive skills), major depressive disorder, recurrent, severe with psychotic symptoms (persistent and overwhelming sadness with delusions or false beliefs), bipolar II disorder (alternating periods of elevated mood and major depressive episodes), generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities). BIMS of 04, severely impaired cognition. Record review of Resident #1's Care Plan dated [DATE] revealed no mention of discharge planning.Record review of Resident #1's Out-Of Hospital-Do-Not-Resuscitate Order dated [DATE] revealed Resident #1's MPOA directs that none of the following resuscitation measures be initiated or continued for the person: CPR, cardiac pacing, defibrillation, advanced airway management, artificial ventilation.Record review of Resident #1's Order in her electronic health record dated [DATE] revealed DNR as current and verified.Record review of Resident #1's Care Plan dated [DATE] revealed Full Code CPR order in place along with a POA. Interventions included to review the medical record to ensure the proper documents are signed. In an interview on [DATE] at 9:52am with RN A, she stated Resident #1 was a DNR. She stated she would look for if a resident was DNR or CPR status in the chart, on the computer, and not on the care plan. RN A stated the DON and SW do care plan meetings with families and residents, and she does not attend those or update any care plans. RN A stated she does not know who updates the care plans.In an interview on [DATE] at 10:03am with the DON, she revealed the SW updates the DNR in care plans or possibly the MDS Coordinator. The DON stated she did not know the DNR status had not been updated in the care plan for Resident #1, but she knew it was to be done.In an interview on [DATE] at 11:33am with the MDS Coordinator, she stated the SW was the one that should put the DNR in the care plan. The MDS coordinator stated that when she did a quarterly MDS, she would check the care plans to check that the DNR status, diagnosis, and diet are up to date because those are things that change. She stated that she was not aware that Resident #1's care plan was not updated.In an interview on [DATE] at 11:45am with the ADM, she stated the SW would receive the DNR and put in the Order and update it in the electronic medical records. The ADM stated she was not sure when the SW would put it in the care plan but assumed it was when she completed the review. The ADM stated care plans are multi-disciplinary on who was responsible, but the SW was who did it. When an interview was attempted, the ADM stated the SW was on PTO and not available to be interviewed but the ADM stated the SW did not know about the DNR status not being updated in this record, or it would have been done. 2.Record review of Resident #2's electronic health record revealed a [AGE] year-old male, admission date [DATE], Diagnoses: atrial fibrillation (rhythm disorder where the upper chambers beat irregularly and rapidly), cerebral infarction (blood flow to the brain is interrupted causing brain cells to die), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis & weakness), generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities), vascular dementia, moderate, with other behavioral disturbance (cognitive decline caused by damage to blood vessels in the brain), major depressive disorder, recurrent, severe with psychotic symptoms (persistent and overwhelming sadness with delusions or false beliefs). BIMS of 03, severely impaired cognition.Record review of Resident #2's Care Plan dated [DATE] revealed no mention of discharge planning. 3.Record review of Resident #3's electronic health record revealed a [AGE] year-old female, admission date [DATE], Diagnoses: senile degeneration of brain (progressive decline in memory, behavior, and cognitive skills), atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup that restricts blood flow but not yet severe enough to cause chest pain), radiculopathy, lumbar region(nerve root is compressed or irritated), chronic pain syndrome(lasting longer than 3 months impacting quality of life), muscle wasting and atrophy (wasting & thinning of muscles). BIMS of 00, severely impaired cognition.Record review of Resident #3's Care Plan dated [DATE] revealed no mention of discharge planning. 4.Record review of Resident #4's electronic health record revealed a [AGE] year-old female, admission date [DATE], Diagnoses: dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline in cognitive ability such as memory, thinking, reasoning and judgement), type 2 diabetes mellitus without complications(persistently high blood sugar without nerve damage or kidney disease), senile degeneration of brain (progressive decline in memory, behavior, and cognitive skills). BIMS of 00, severely impaired cognition.Record review of Resident #4's Care Plan dated [DATE] revealed no mention of discharge planning. 5.Record review of Resident #5's electronic health record revealed a [AGE] year-old male, admission date of [DATE], Diagnoses: acute on chronic systolic (congestive) heart failure(weakened heart muscle cannot pump blood effectively and sudden worsening symptoms), morbid (severe) obesity due to excess calories(excessive body weight due to consuming more calories than the body burns), combined systolic (congestive) and diastolic (congestive) heart failure(heart muscle is impaired in both its ability to contract and its ability to relax and fill with blood), acute and chronic respiratory failure with hypoxia(blood's oxygen level are extremely low both suddenly and long-term), acute and chronic respiratory failure with hypercapnia(lungs cannot remove carbon dioxide), chronic respiratory failure with hypoxia(lungs fail to provide oxygen), primary osteoarthritis (cartilage wear down and cause pain), longstanding persistent atrial fibrillation(rhythm disorder where the upper champers beat irregularly and rapidly), chronic peptic ulcer, site unspecified, without hemorrhage or perforation(recurrent sores in lining of stomach or small intestine), gout (inflammatory arthritis), chronic kidney disease, stage 3 (moderate level of kidney damage), cerebral infarction (blood flow to the brain is interrupted causing brain cells to die). BIMS of 15, little to no impairment of cognition (Normal thinking and memory).Record review of Resident #5's Care Plan dated [DATE] revealed no mention of discharge planning. In an interview on [DATE] at 10:03am with the DON, she stated she knew discharge planning was to be in the care plan because it was asked at every care plan meeting. She stated she did not know the discharge plan was not in the care plan for Resident #1, Resident #2, Resident #3, Resident #4, or Resident #5. The DON stated she believed it to be the MDS Coordinator or the SW that would put that information in the care plan but probably the SW because she worked discharge planning. In an interview on [DATE] at 11:33am with the MDS Coordinator, she stated she did not know that resident discharge planning preference had to go in the care plan unless there was a discharge plan and the SW was the one to work that so the SW would update that in the care plan. In an interview on [DATE] at 11:45am with the ADM, she stated the SW would put in the update to care plans for discharge planning but that she did not know that resident preference on the discharge plan was a requirement in the care plan if there was no plan for them to discharge. When an interview was attempted with the SW, the ADM stated the SW was on PTO, so she was not available to interview. The ADM stated she would have the SW update the care plans upon her return. The ADM stated she was sure the SW did not know, or it would have been done. The ADM stated she did not know of any effects to the residents if this information was not in the care plan if there was no discharge plan in place.

Based on interview and record review, the facility failed to keep the residents free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Resident #1, Resident #2) of 7 residents reviewed. The facility failed to prevent Resident #2 from being slapped by her spouse which led to redness to the cheek. The facility failed to prevent verbal abuse to Resident #1 by a hospitality aide (HA). The noncompliance was identified as PNC. The noncompliance began 3/2/25 and ended on 4/24/25. The facility had corrected the noncompliance before the investigation began. This failure could place the residents at risk of physical harm, pain, or mental anguish. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old male, admission date 9/16/24, Diagnoses: delusional disorder (persistent false beliefs that are not based on reality), impulse disorder (difficult to resist urges), cerebral infarction (blood flow to brain is blocked), senile degeneration of brain (progressive decline in memory, behavior, and cognitive skills), dementia with other behavioral disturbances (impairment of at least two brain functions such as memory and judgement), Generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities), vascular dementia with agitation (impaired blood flow and can lead to agitation), repeated falls, muscle wasting and atrophy (shrinking and weakening of muscle tissue). Record review of Resident #1's Progress note dated 3/2/2025 revealed 'Resident noted to keep standing up from his wheelchair HA C kept yelling rudely at resident to sit down. Resident yelled back and stated, I'm wet bitch. HA C then said, you don't talk to me like that you fucking dick head she then told him when you can wipe your own ass you can let me know she then said to this RN that she wasn't going to provide care for him and stated you or [HA B] can do it but I refuse to do it.' In an interview on 5/10/25 at 12:10pm with RN, she stated she was seated at the nurse's station and heard the HA C telling Resident #1 she wasn't going to change him and called him a fucking dickhead. RN removed HA C and had an aide take the resident to his room and change him. When RN removed HA C, she told RN that Resident #1 called her a bitch and she didn't feel good, and RN told her it did not matter, and she could not act like that to a resident. RN stated she told the HA C that it was abuse. RN stated the other aide cleaned Resident #1 up and when the RN assessed him, he had no recall of the event with no adverse effects. RN reported to abuse coordinator. RN stated that HA C was fired . In an interview on 5/11/25 at 9:28am with CNA, she stated that Resident #1 was sitting against the wall in his wheelchair across from the nurse's station and the HA C was sitting at the end of the nurse's station and CNA and RN were there. CNA stated Resident #1 stood up and CNA told him to sit down before he falls, and Resident #1 stated he could not sit down, and HA C asked him why not. Resident #1 stated he was wet, and HA C asked him why and Resident #1 called her bitch and HA C blew up and yelled at him cursing and stated, when you start wiping your own ass, let me know. CNA stated the RN contacted the DON and the HA C told the RN she would not care for Resident #1. Another aide came and took care of Resident #1. HA C was taken off the schedule. CNA stated that this was verbal abuse and felt the HA C had intent to be disrespectful to Resident #1. She stated that Resident #1 did not remember the incident. In an interview on 5/11/25 at 11:06am with HA C, she stated she probably said something to Resident #1 and should not say things like that. HA C stated she yelled at the nurse, and she was a battered woman and was triggered. HA C stated she did not really remember what she said to the resident but probably said something. HA C stated she remembers Resident #1 kept calling her a bitch, and another girl came and took him. Facility had her leave. HA C stated she thinks she said something like, well, I've got your fucking bitch but she did not punch him or anything. HA C stated she did tell the nurse she needed to care for Resident #1 because she was not. HA C stated she did not believe it to be abuse but she just got triggered. In an interview on 5/11/25 at 1:15pm with the DON, she stated the incident with Resident #1 and the HA C was abuse and Resident #1 yelled at HA C and her at him , but staff did immediately intervene and kept him safe. DON stated they suspended and terminated the HA C. DON stated the HA C had been trained on abuse and neglect and dementia care at hire and they do regular in-services. In an interview on 5/11/25 at 2:11pm with the ADM, she stated the HA C had verbally abused Resident #1 and it was witnessed, and she was suspended and terminated. The ADM stated Resident #1 had no emotional distress or any recollection of the event. All staff were retrained, and they did what they were supposed to [removed the resident to safety and reported to the abuse coordinator]. Record review of the HA C employee file revealed Abuse and Neglect training on 1/26/24 and 4/2/24. Record review of the facility's Abuse/Neglect policy dated 10/4/2022 revealed The resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation as defined in this subpart .3. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability . Record review of Resident Rights policy dated February 2021 revealed Employees shall treat all residents with kindness, respect, and dignity .b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation;. The facility took the following actions to correct the noncompliance: HA C immediately removed from resident care. Resident assessed and no injury or recall of the incident. Monitored for distress by staff. Continued psych services. Record review of Employee Disciplinary Report dated 3/3/25 for HA C revealed discharge due to verbal abuse towards a resident. SW interview of resident dated 3/3/25 for emotional distress and found no recall or concern. Life safety rounds for 10 residents dated 3/3/25 with no concerns regarding this HA C or abuse noted. Inservice on Abuse and Neglect dated 3/4/25 for 43 employee staff. HR attempted to refer HA C to EMR through email on 3/10/25. This writer interviewed on 5/9/25 at 5:10pm -5/11/25 at 11:25am 1 MA/CNA, 1 CNA, 1 RN Charge nurse, 2 LVN charge nurses, 1 ADON, and 2 Hospitality Aides and they have been trained on abuse and neglect and knew what to do in the event of an incident of abuse. This writer observed Resident #1 on 5/9/25 at 5:03pm, and he smiled and waved but did not answer questions about the incident. No noted distress or fear of staff. This writer interviewed 2 alert residents on 5/10/25 at 10:14am and 11:02am and they stated they had not experienced abuse and felt safe in the facility. Record review of Resident #2's electronic health record revealed an [AGE] year-old female, admission date 04/9/25. Diagnoses: senile degeneration of brain (progressive decline in memory, behavior, and cognitive skills), major depressive disorder, single episode (period of at least two weeks of persistent low mood and loss of interest in activities with a history of previous depressive episodes), mild cognitive impairment of unknown etiology (memory or other cognitive difficulties are noticeable but not severe enough to interfere with basic living), dementia (impairment of two brain functions such as memory loss and judgement), psychotic disturbance, mood disturbance, and anxiety (loss of touch with reality, delusions, effect emotional state, excessive worry and panic), pseudobulbar affect (inappropriate and involuntary laughing and crying due to nervous system disorder). Record review of Resident #2's progress report dated 4/22/25 by DON revealed received phone call from staff and reported that resident spouse slapped her and to please come to unit. Upon arrival to unit, spouse was leaving unit and was upset stating that he had never slapped her before. He stated that she spit the water on him and then he in turn, slapped her. In an observation on 5/9/25 at 5:03pm, the spouse of Resident #2 was sitting next to Resident #2 on the couch in the common area in the secured unit. Two aides and one nurse were within sight of spouse and Resident #2. Resident #2 leaning on spouse hugging him. No distress of fear noted. In an interview on 5/9/25 at 5:27pm with the spouse of Resident #2, he spoke about how difficult it has been to watch his wife (Resident #2) decline. Spouse did not answer questions regarding the incident and appeared shocked and spoke about Resident #2's care. In an interview on 5/10/25 at 11:56am with HA B, she stated that she was standing at the nurse's station prepping trays and the spouse and Resident #2 were behind her at the table, and she heard a slap and turned around and saw the spouse of Resident #2 slap her and say, Don't you do that again to me. HA B stated she was not sure if Resident #2 slapped him, and he slapped her back or if he slapped her twice. HA B immediately took Resident #2 to her room and told the spouse to go to the front. HA B stated the facility staff now had them in sight at all times and there had been no issues since. HA B believed the spouse was hurt over it and a little embarrassed. In an interview on 5/10/25 at 6:04pm with the ADON , she stated she was not sure if Resident #2 slapped the spouse first, but he said she spit on him. The ADON did not feel it was intentional but a reaction. ADON stated Hospice talked to the spouse and his family had to be at the facility with him at all times for the last couple of weeks and now facility staff have to be in line of sight. ADON stated the spouse was torn up about it and thought it was instinct, like a reflex. ADON stated the spouse of Resident #2 comes every day and spends time with her. In an interview on 5/11/25 at 9:28am with CNA, she stated she was standing at the nurse's desk and discussing another resident with staff and Resident #2 was sitting on the couch and the spouse was giving her water or something and she spit it out and CNA heard a slap, slap (twice) and witnessed the spouse slap Resident #2 and ran over and removed Resident #2. CNA stated Resident #2 had redness on her cheek but okay other than that and not out of baseline. CNA stated the spouse could come with supervised visitation and the past week has had to be in line of sight with staff. No incidents before or since. In an interview on 5/11/25 at 11:46am with Family Member, son of Resident #2, he stated he was not aware of any domestic violence or physical aggression from his dad in the past. Family Member did not believe the spouse of Resident #2 understands she is dying and not going to get better. Family Member stated he or his sister had to be with their dad when he came to visit Resident #2 for about two weeks and now, they allow him there under their supervision and could not take her out of the facility. Family Member believed the facility did do counseling for the spouse and that was the plan. In an interview on 5/11/25 at 1:15pm with DON, she stated she caught the spouse of Resident #2 coming out of the secure unit right after the incident and he stated he could not believe he did that and had never done that before. Resident #2 had a slight red mark, and it did not bruise and was barely red. No change in behavior. Facility referred Resident #2 to psych services and the counselor has been seeing him. Family had to be here to supervise and now staff monitor him, and he knows he could not be alone with her. DON stated she did not feel there was intent, and psych picked them up for family counseling. Record review of Diagnostic Assessment for Resident #2 dated 4/25/25 revealed female unable to answer questions in a linear fashion. Her husband has been providing care for her the last two years with help from hospice the past 6 months. He notes a general slow decline over several years. Severe cognitive impairment suggests she will not benefit from individual psychotherapy. We are offering family services to assist her husband in appropriate care taking including demonstrating of safe space, demonstration of safe interactions, and monitoring behaviors while keeping the patient safe. This will include medication management and safe eating. Record review of Abuse/Neglect policy dated 10/4/22 revealed The resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation as defined in this subpart .4. Physical Abuse: Includes, hitting, slapping, pinching, and kicking. The facility took the following actions to correct the noncompliance: Resident immediately removed from spouse and spouse removed from facility. Resident assessed and had slight red mark that disappeared with no bruise or further injury. No emotional distress or recall out of baseline. Facility referred Resident #2 to psych services on 4/24/25. Psych assessment on 4/25/25. Facility and spouse following psych recommendations of supervision and counseling for spouse. Family supervision in facility for two weeks and now on facility staff supervision. Inservice of facility staff on abuse and neglect dated 4/22/25. This writer observed 3 staff in line of sight providing supervision with Resident #2 and spouse on 5/9/25, 5/10/25 and 5/11/25 with no distress or fear noted from Resident #2.

Based on interview and record review, the facility failed to report the results of an investigation to the State Survey Agency within 5 working days of the incident for 1 (Resident #4) of 5 Residents reviewed. The Administrator failed to report the findings of an investigation concerning Resident #4 to the State Survey Agency within 5 working days of the incident. This failure could put the residents at risk of compromised protection and oversight of the state agency. Findings included: Record review of Resident #4's electronic health record revealed a [AGE] year-old female, admission date 02/01/25. Diagnoses: unspecified dementia (decline in cognitive function), senile degeneration of brain (progressive decline in cognitive abilities that occurs with aging), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), major depressive disorder (persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life), muscle weakness. Record review of the Provider Investigation Report dated 3/21/25 revealed Resident #4 was noted pounding on the secure unit door and was agitated but redirected. Staff looked in resident room during next round, within 30 minutes, and found the air conditioning unit on the floor and the window open. Staff began search of resident and located her in the secure unit courtyard area potentially hiding from staff within 30 minutes. No injury noted but agitated and resisting to come inside for breakfast. discharged to behavioral health hospital and staff in-serviced on missing residents. No investigatory findings noted in file. In an interview on 5/10/25 at 6:50pm with the ADM , she stated she did not submit a 5-day for the incident because she determined it was not an elopement. ADM stated she only reported because she was iffy (unsure) if she needed to and then came to the realization that elopement didn't happen. ADM stated that in her mind it didn't even need to be reported and the resident was never out of a safe environment, so she did not do the 5-day. The ADM stated the weather was mild and secure unit residents have access to that area, and it was safe. In an interview on 5/11/25 at 9:28am with CNA, she stated that a little after 6:00am she heard Resident #4 kicking the secure unit door and redirected her. CNA stated she was rounding getting residents up for breakfast and around 615am-620am, CNA went into Resident #4's room and saw the air conditioner on the floor and the window open and ran and told the nurse and started searching. CNA stated she walked all around outside and come to find out Resident #4 was in the garden area, and no one thought to look there for maybe 30 minutes. CNA stated Resident #4 never eloped and was safe. Record review of progress notes dated 3/21/25 at 7:10am revealed resident was found in secure unit courtyard, no injuries upon assessment. Resident is on one-on-one monitoring. Record review of progress note dated 3/21/25 at 11:00am revealed resident transported to behavioral health hospital. In an interview on 5/11/25 at 1:15pm with the DON, she stated that the ADM is responsible for completing the 5-day report. In an interview on 5/11/25 at 2:11pm with the ADM, she stated she reported the 5-day today. Record review of the facility's Abuse/Neglect policy dated 10/4/22 revealed Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist .1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC .f. The written report must be sent to HHSC no later than the fifth working day after the initial report.

Based on interview and record review the facility failed to ensure resident was free from misappropriation of all controlled drugs is maintained and periodically reconciled for 1 (Resident #3) of 7 residents reviewed for controlled substances. The facility failed to ensure LVN B conducted proper counting of the medications at shift change. The facility failed to ensure LVN B reported an identified drug discrepancy for Resident #3. This failure may put the residents at risk of drug diversion and their pharmaceutical needs not being met. Findings included: Record review of Resident #3's electronic health record revealed an [AGE] year-old female, admission date 07/03/24. Diagnoses: congestive heart failure (heart doesn't pump blood as well as it should), type 2 diabetes (adult-onset diabetes), presence of cardiac pacemaker (device provides electronic pulse to heart as needed to regulate heart rate), senile degeneration of brain (progressive decline in memory, behavior, and cognitive skills), muscle wasting and atrophy (loss of muscle mass and strength). Record review of Provider Investigation Report 573259 dated 3/25/25 revealed blister packet on medication room counter at 6:16am on 3/25/25 by LVN C. LVN C inquired with off going night nurse (LVN B) to inform her the count was off. LVN B stated that she noted it during the night but did not want to wake the previous nurse (LVN A). LVN A stated she was not aware and did not administer the med. LVN C reported to DON and ADM . Search initiated and all other narcotics accounted for. Police notified and began drug screening. LVN B did not show up for drug screen and others tested negative. Self-termination for failure to report timely for drug screening. Reviewed Narc count sheet and revealed the count at 21. Staff re-educated. Statement from LVN A revealed LVN B would not count with her upon shift change the evening of 3/24/25 but LVN A counted on her own and it was correct. Record review of written statement dated 3/24/25 by LVN B revealed Resident #3's Tramadol was 1 tablet short. Resident #3 had passed away at 8:45pm that evening and her hospice nurse showed up at shift change so they never counted. Record review of written statement dated 3/26/25 by DON revealed medication count for Resident #3 Tramadol was off by one tablet. Count sheet said 21 but actual count was 20. Medication card located in locked cabinet but not in basket. LVN B verbalized to LVN C she knew the count was off and she thought LVN A had given it and forgot to write it down. LVN A stated she did not. LVN B stated she counted at 2am and realized the difference in count. DON received text from LVN B stating she had counted cabinet with LVN A but not lock box because hospice was there, and she didn't get to. Did not want to call LVN A in the night. DON contacted LVN B at 1:20pm and told her she needed her to come write a statement and do urine screen and she said she would be right in. At 3:05pm, DON text LVN B again asking when she would be coming and to come as soon as possible. As of 6:38pm, ADM nor DON have had conversation with LVN B. Record review of written statement dated 3/26/25 by LVN C revealed she went into med room to count meds at 6:15am on 3/25/25. Resident #3 tramadol was sitting with the count sheet folded over it next to the basket of narcotics. I pulled it first and noticed the count was off by 1. LVN C asked LVN B why it was short, and she stated she noticed last night about 2am and thought LVN A who worked forgot to sign it out and didn't want to text her in the middle of the night. LVN C told her she would get with LVN A to ask her. LVN C asked LVN A, and she stated no. LVN C then took it to DON. Record review of statement dated 3/26/26 from MA B stated on 3/23/25 she gave Resident #3 her morning meds of tramadol and her meds were discontinued shortly after, so she didn't give her anymore. MA B counted after 6am-2pm and 2pm-10pm shift and count was correct. Record review of written statement dated 3/26/25 by LVN A revealed on 3/23/25 she was notified that Resident #3 would be on hospice care. At this time during 6am-2pm shift maintenance meds had not been discharged . At that time, MA B and LVN A gave Resident #3's morning meds crushed in pudding. LVN A stated she was present, and Resident #3 took her medications without incident. After that scheduled dose of meds a new order from hospice came and it was to discontinue all maintenance meds, only comfort meds were to be given. The 23rd was the last time scheduled Tramadol was given. On 3/25/25 LVN A was notified by LVN B that Tramadol was off by 1 pill and had I administered another dose and I stated no. On the morning of 24th my count was correct. Evening of 23rd I counted with the other nurse and correct. Evening of 24th LVN B did not count with me. I counted for my own accountability. On the night of 3/24/25 Resident #3 passed away and LVN B came in after 8pm. We did not count together hospice nurse was there and we were answering her questions, but LVN A had counted. On, 3/25/25 - LVN B contacted me and asked had I used it for another patient. Record review of 5 Panel Test Result Records for LVN A dated 3/26/25 was negative. Record review of Resident #3's electronic record revealed Tramadol discontinued 3/23/25 and hospice care and comfort measures put in place. Record review of eMAR dated March 2025 for Resident #3 revealed last Tramadol given was 3/23/25 at 8am. Record review of Resident #3's electronic health record revealed she passed away 3/24/25 at 8:45pm. Family at bedside. In an interview on 5/10/25 at 11:25am with MA A, she stated she is not aware of any missing medications. Staff count the cart at change of shift with oncoming nurses. MA A stated they always count and have always had to count. They are no longer to keep the keys when going to another unit and must count and turn in the keys when going to another unit and again when coming back to the other unit, so the keys are always with the nurses. MA A stated that the key thing started a couple of months ago. MA A stated if the count is off, you immediately report to DON and ADM. In an interview on 5/10/25 at 12:10pm with RN, she stated staff count the carts and med rooms at change of shift. If there are any missing meds, they call the DON. It has always been the policy. RN stated when the missing medication happened, they tested everyone, and one nurse did not show, and she got terminated. No one tested positive. In an interview on 5/10/25 at 6:04pm with the ADON , she stated LVN B was notorious for being late, like an hour late, and staff never knew when she would get there so staff counted themselves because they have to be back for another shift. ADON stated she tried hard to get LVN B to come on time, but she always had excuses and they tried to get her to come do a drug test and she was too busy. ADON stated that LVN B never wanted to count meds. ADON stated LVN B was trained and counseled on the issues of being late and not counting meds several times, sometimes by ADON herself. In an interview on 5/11/25 at 11:25am with LVN A, she stated on 3/24/25 Resident #3 passed away and she remembers LVN B coming in and LVN A stated she stayed to help, and hospice had come in and LVN B was very late, and she did not count with LVN A. LVN A stated she herself did count anyway but LVN B said, No, we're good and so LVN A counted on her own and that was norm for LVN B. LVN A stated the count was accurate and she left. LVN A stated she was called in to do the urine test. LVN A stated she had been trained on counting at change of shift and that was the expectation. In an interview on 5/11/25 at 1:15pm with the DON, she stated staff count the med carts, the med rooms, and the discontinued meds which is in the med rooms at every change of shift. DON stated she was informed there was a missing tramadol and looked and ADM and DON couldn't find anything and started calling staff in to do drug testing and one of the staff, LVN B, was notified and she said she'd be in and never came in and notified her again several times and always had an excuse and it was 5-6 in the evening and the next message she got the next day she could come in and then still didn't come and had to go to the doctor to be drug tested but she just couldn't get her in and policy states they have 3 hours after the request to come in when made and she tried every opportunity to get her to come in and so she self-termed. DON stated she felt LVN B very well could have taken the pill because she wouldn't come in. DON stated Resident #3 passed away and that same night was when the pill went missing. DON stated they have monitored closely and in-serviced staff regarding counts and try to pull the discontinued medications off the units and staff have to count with her and they have to sign off on it. DON stated she went weekly to remove discontinued meds but did try to do it more frequently like 2-3 times a week. The tramadol for Resident #3 had just been discontinued the day before on 3/23/25 and Resident #3 passed away 3/24/25 and they noticed it was gone the morning of 3/25/25. DON stated she did random audits now and went behind staff now to make sure counts were done. DON stated she had been informed that LVN B would come late and refuse to do counts. DON stated she counseled LVN B and LVN B assured DON she was doing it. In a record review of Controlled Substances policy dated November 2022 revealed .Dispensing and Reconciling Controlled Substances .3. Nursing staff count controlled medications inventory at the end of each shift, using these records to reconcile inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observations, interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 2 (Resident #3 and Resident # 7) of 7 residents reviewed for resident records. The facility failed to ensure skin assessments were documented in medical record for Resident #3 and Resident # 7. This failure could place residents at risk of having errors in care and treatment. The Findings included: Resident #3 Record review of Resident #3's face sheet dated 11/21/2024 revealed a [AGE] year-old-male admitted on [DATE], with the following diagnosis Alzheimer's disease, heart disease, high blood pressure, and repeated falls. Record review of Resident #3's Admission MDS assessment dated [DATE] revealed; Section C- Cognitive Patterns: Resident #2 had a BIMS score of 0 (meaning severe cognitive impairment). Record review of Resident #3's care plan dated 10/25/2024 revealed Resident #2 required weekly skin inspections. Record review of Resident #3's electronic medical chart revealed no evidence of weekly skin inspections completed between his admission on 10/24/2024 and November 18, 2024. During an observation on interview on 11/21/2024 at 1:48 PM, Resident #3 had a rash to the back and both arms, and rash on the outer side of his legs and calves. RN A stated Resident #3 skin had been assessed, and benadryl had been added to his regime for itching on 11/10/24 and hospice had orders ointment for resident's skin. RN A stated she had assessed Resident #3's skin but had forgotten to complete the skin assessment because the treatment nurse had been completing the assessements and had been out on personal leave for several weeks. Resident #7 Record review of Resident #7's face sheet dated 11/21/2024 revealed [AGE] year-old-female admitted on [DATE] with the following diagnosis senile degeneration of brain, dementia, repeated falls, and Type 2 diabetes mellitus. Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed; Section C- Cognitive Patterns: Resident #1 had a BIMS score of 6(meaning severe cognitive impairment). Record review of Resident #7's care plan dated 10/19/2024 revealed Resident #1 required weekly skin inspections. Record review of Resident #7's electronic medical chart revealed no evidence of weekly skin inspections completed between 10/03/2024 and 11/06/2024. During an observation and interview on 11/21/2024 at 1:09 PM, Resident #7 had right elbow small circular scabbed wound and left shoulder blade abrasion. DON stated Resident #7 had a fall which led to the scabbed wound and shoulder blade abrasion. DON stated Resident #7 had been assessed and was treated for the abrasion. During an interview on 11/21/2024 at 12:45 PM, RN A stated every resident should have a skin assessment weekly. RN A stated skin assessments populate when needed to be completed and the nurse that was working that day was responsible to complete the skin assessment. RN A stated the skin assessment were not documented as expected in electronic medical record. RN A stated residents skin was assessed daily when providing incontinent care and during resident showers. During an interview on 11/21/2024 at 2:55 PM, the DON stated every resident was supposed to have had weekly skin assessments documented in their electronic chart. The DON stated skin assessments were triggered weekly for nursing staff to complete. The DON stated the treatment nurse was responsible to ensure they were completed, but she had been out for a family emergency and the nurses were supposed to have documented the assessments. The DON state residents skin was being assessed daily during incontinet care, showers and treatments. The DON stated she felt skin assessments were being done, they were just not documented in the medical chart. The DON was responsible to monitor to ensure they were being done. The DON stated what led to failure of skin assessments being undocumented was the treatment nurse was not in the building. During an interview on 11/21/2024 at 3:15 PM, the ADMN stated it was her expectation that skin assessments be completed and documented weekly for every resident. The ADMN stated the effect on residents having undocumented skin assessments could be potentially missing a skin condition that could have worsened or turned into an infection. The ADMN stated the DON was responsible to monitor to ensure skin assessments were being completed. The ADMN stated what led to failure of not skin assessments not being documented was the treatment nurse had been out, and some slipped thru the cracks. Record review of facility policy titled, Skin Assessment: New Admits or Resident Returning from Hospital Stay. Dated March 7, 2007, revealed It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate interventions be initiated in a timely manner.

Based observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 4 of 6 (SS Cart 1, SS Cart 2, SS Cart 3 and GV Cart) medication/treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication carts SS Cart 1 and SS Cart 2 were not left unlocked, unsecured, and unattended. The facility failed to ensure treatment carts, SS Cart 3 and GV Cart were not left unlocked, unsecured, and unattended. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions. Findings included: During an observation on 11/16/2024 at 12:15 PM and 12:30 PM SS Cart 1 and SS Cart 2 were parked against the wall with drawers facing the hallway , both carts were unlocked and were not in line of site of a staff. A resident was observed propelling himself in his wheelchair down the hall within arms length of SS Cart 1 and SS Cart 2. On the opposite hall SS Cart 3 was parked against the wall with the drawers facing the hallway unlocked and not in line of site of staff. SS Cart 1 and SS Cart 2 contained the following medications: Lasik, Levetiracetam, Losartan, Sertraline, Risperidone, Lisinopril, Tamsulosin, Baclofen, Trazadone, Mirtazapine, Fluoxetine, Fluphenazine, Divalproex, Metoprolol, Sucralfate, Gabapentin, Olanzapine, Bicalutamide, Eliquis, Rosuvastatin, Ranolazine, Buspar, Desmopressin, Albuterol, Mucinex, and Nasal Spray . SS Cart 3 contained the following items contained wound care creams (zinc oxide ointments, skin protectant ointment, and Vitamin A&D ointment) inhalers and eyedrops. During an interview on 11/16/2024 at 12:30 PM RN A stated she was not responsible for SS Cart 1 and SS Cart 2 and was not sure why the nurse did not secure the carts or where the nurse was at that time. RN A then secured the medications carts. RN A stated she was responsible for SS Cart 3 and she had gotten distracted by talking with a visitor and forgot to lock the cart. RN A stated residents could have been affected by the medication carts being left open by getting medications that were not theirs. During an interview on 11/16/2024 at 12:40 PM MA B stated she was responsible for SS Cart 1 and SS Cart 2, she stated she did not know why she had left the carts open. MA B stated medication and treatment carts should have been locked when she was not with them. MA B stated the affect on residents could have been possible overdose. MA B stated she was responsible to ensure carts were locked. MA B stated what led to the failure was it was Saturday and she had gotten in a hurry because she wanted to go home. During an observation on 11/16/2024 at 12:45 PM GV Cart was parked at the edge of the nurse's station with the drawers facing the residents in the secure unit. The GV Cart was unlocked, and the top drawer was slightly open, four residents were standing/sitting with arm's reach of the GV Cart. RN C was on the other side of the room with her back to Cart GV. During an interview on 11/16/2024 at 12:50 PM RN C stated the cart should have been locked. During an interview 11/21/2024 at 2:55 PM the DON stated her expectation was that medication and treatment carts should have been locked when unattended. The DON stated the nurse assigned to cart is responsible to ensure the cart was locked and the DON monitors. The DON stated the effect on residents could have been injury. The DON did not have a response to what led to failure of the medication carts being left unlocked. During an interview on 11/21/2024 at 3:15 PM the ADMN stated her expectation was that medication carts should have been locked when the cart was unattended. The ADMN stated the nurse who carried the keys to the cart was responsible to ensure the cart was secure, and the DON was responsible to monitor. The ADMN stated the effect on residents could have been residents advertently getting medication they were no supposed to. The ADMN stated what led to failure was oversight by the staff. Record Review of the facility's policy titled, Security of Medication Cart dated April 2007 revealed, The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with the doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the nurse's station or inside the medication room.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure: 1. All opened items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. 2. The ice machine was cleaned properly. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: During observation on [DATE] at 10:15 AM the facility kitchen revealed: Refrigerator #1 of 2 1 container of sliced pickles, outside the original container and covered with plastic wrap, unlabeled, or dated. 1 large container labeled Ranch dated [DATE] with no use by date. 1 large container labeled Gravy dated ,d+[DATE] with no use by date. 1 large container labeled Gravy dated [DATE] with no use by date. 1 large container labeled Minestrone Soup dated ,d+[DATE] with no use by date. 1 large container labeled Greens dated ,d+[DATE] with no use by date. 1 large container labeled Diced chicken dated ,d+[DATE] with no use by date. 1 large container labeled Pineapple Tidbits dated ,d+[DATE] with no use by date. 1 large container labeled Chili dated ,d+[DATE] with no use by date. Refrigerator #2 of 2 5 opened 46 oz. cartons of Ready Care Tea with no opened date. 1 large container labeled Cherry Jello dated [DATE] with no use by date. 1 opened gallon of milk with no opened date. 1 large container of Orange Jello dated [DATE] with no use by date. Kitchen dry storage (Pantry) 1 of 1 1 opened 5 lbs. container Creamy Peanut Butter with no opened date. 1 opened 10 lb. container of Baking Powder with no opened date. 1 opened 1 gallon container of soy sauce with no opened date. 1 opened bag of wheat bread with no opened date. 1 opened bag of hamburger buns with no opened date. Freezer 1 of 1 1 clear opened gallon bag of what appeared to be chicken strips, unlabeled, received date, opened date or use by date. 1 clear opened bag of what appeared to be meat balls with no received date, opened date or use by date. 10 frozen briskets, unlabeled or received date. 2 frozen pizzas, unlabeled and no received date. 3 clear bags of what appeared to be tator tots, unlabeled and no received date. 3 packets if frozen bacon, unlabeled and no received date. 2 packages of ham with no received date. During an interview on [DATE] at 10:20 AM, DA A stated all items should have been labeled and dated with a received and use by date. During an interview on [DATE] at 10:28 AM, the DM stated all opened food items should have opened dates. She stated all refrigerated items should have the date opened and use by date. The DM stated she monitored all areas of the kitchen. She stated the negative impact to residents could have been spoiled food which would have possibly made the residents sick. She stated staff had not paid attention to detail and that led to the failure. The DM stated her expectations was for staff to follow the rules and regulations as well as facility policies. During an interview on [DATE] at 10:27 AM, the ADMN stated the policies and procedures were to follow the guidelines of having all food products labeled and dated. She stated the DM monitored her staff and followed up with in-services. The ADMN stated the negative impact for residents was that they could have potentially received old food which placed them at risk for gastrointestinal issues. She stated the delay in following up with the DM and supervisors led to the failure. The ADMN's expectations were to increase the audits and in-services on top of the ones they already had. During an interview on [DATE] at 10:30 AM the Dietician stated all food items should have been dated, labeled with a use by date if in the refrigerator. During an interview on [DATE] at 10:35 AM, DA B stated all refrigerated items should have had a use by date. She stated she knew the regulations and policies required staff to do so. Ice Machine During an observation on [DATE] at 10:39 AM, the panel of the ice machine revealed dirty black substance on the inside panel of the ice machine. During an interview on [DATE] at 10:40 AM, the DM stated the maintenance man (MM) cleaned the ice machine on a regular basis and did not know when the last time it had been cleaned. She stated the MM had a logbook of his maintenance and cleaning of the ice machine. The DM stated the MM also changed the filters on the ice machine when needed. The DM stated it was her and DA C who monitored. She stated the negative impact was that residents could have received dirty ice. The DM stated, not cleaning the ice machine and being lazy, as well as not taking the time to get the task completed led to the failure. She stated her expectations was that she expected it to be clean as she would not want ice for herself with the dirty panel inside of it. During an Interview on [DATE] at 3:25 PM, the MM stated he did not have a logbook for cleaning the ice machine. He stated he only cleaned the filter and decalcified the lines. The MM stated he had never wiped down and/or cleaned inside of the ice machine, nor had he been told to do so. During an interview on [DATE] at 10:08 AM, the ADMN stated it was the kitchen staff's duty to clean the ice machine. She stated there was a schedule for cleaning the equipment, with the ice machine being on Sundays. She stated she had done an audit two weeks ago and had not noticed the inside panel being dirty, but today, had noticed the inside panel being unclean with black stuff. She stated it was not the MM duty to clean the inside of the ice machine. The DM stated she felt the staff had not followed the cleaning schedule and that was what led to the failure. She stated she monitored the cleaning of equipment but had gotten busy with other things and assumed it had been done. The ADMN stated her expectations was to have all equipment cleaned in a timely manner. Record review of facility policy titled Storage Refrigerators dated 2012 revealed: All storage refrigerators shall be maintained clean and have a proper temperature for food storage and to ensure a proper environment and temperature for food storage. Procedure: 5. Food must be covered when stored, with a date label identifying what is in the container. Record review of facility policy titled Dry Storage and Supplies dated 2012 revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedures: 4.Open packages of food are stored in closed containers with tight covers and dated as to when opened. Review of FDA Food Code 2022: Full Document accessed on [DATE] in annex 7 page 37, 38 revealed: Applicable Code Sections: ,d+[DATE].16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed [DATE] revealed: ,d+[DATE].11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. There was no policy provided concerning the cleaning of equipment provided prior to exit.

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 4 dietary staff (DA A) reviewed for dietary support personnel. The facility failed to ensure that dietary staff (DA A) serving in kitchen were working with a current Food Handlers Certificate. This failure could place residents at risk of not having their nutritional needs met and food borne illnesses due to lack of dietary staff training. Findings included: During an observation on 10/08/2024 at 10:15 AM of the kitchen, DA A was in the kitchen preparing the lunch meal. During an interview on 10/08/2024 at 10:15 AM the DM stated DA-A's Food Handler Certificate was in progress. She stated DA-A had been in the facility for 2 months in the position. Record review on 10/08/2024 at 11:30 AM, of DA A's employee file revealed she had no Food Handlers certificate. During an interview on 10/09/24 at 1:34 PM, the ADMN stated the dietary staff should have their Food Handlers Certification as soon as possible. She stated they asked DA A every day, if she had completed it, which she failed to provide. The ADMN stated the DM should have monitored closer and ensured it was completed. She stated DA A mostly spoke Spanish and felt maybe that was why she had not provided the certificate, but there were adequate translation capabilities, and should have still been done. She stated the negative impact for residents in not having the Food Handlers certificate was the compromising of food and cross contamination with infection control related to sanitation and service in general. The ADMN stated that proper education with all of the dietary information and regulations and the DM not following up, led to the failure. She stated her expectation would have been for all dietary staff to be certified before placing them on the floor for food preparation and food service. During an interview on 10/09/2024 at 10:35 AM, the dietician stated, the standard regulations for dietary staff to get certified should have been within 30 days of hire. She stated if the kitchen staff had not received it, it could hinder in proper preparations of food provided to residents and cause cross contamination. She stated the negative impact could have been residents getting sick if they consumed unfit food. The dietician stated her expectations were for all kitchen staff to follow the regulations and education provided to them. During an interview on 10/10/24 at 11:38 AM, the DM stated, DA A only knew Spanish, and she could not translate the test. She stated the DM monitored what staff had their Food Handlers certificates and was herself that was responsible in having dietary staff complete and provide for their files. The DM stated the negative impact for residents could have been not knowing to check temperatures, or using wrong size of ladles, causing the resident to have too much food, or not enough which would lead to residents' incomplete nutritional value, causing weight loss. She stated she had not been aware of the time frame for staff to get certified which led to the failure. The DM stated her expectations were to pay more attention to all Food Handlers certificates and when each staff member was due to have it completed. Record review of DA A's personnel files, accessed on 10/10/2024 revealed no evidence of her Food Handlers Certificate with a hire date of 08/28/2024. Record review of DA A's Job Description Dietary Service Worker, signed by DA A and dated on 08/28/2024 revealed: The following is a non-exhaustive criterion that relates to the job of a Dietary Service Worker, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Dietary Service Worker and are related to the functions that are essential to the job of a Dietary Service Worker. KNOWLEDGE BASE: o Ability to ensure duties are completed in a timely, efficient manner-according to the schedule. o Ability to function as team member. o Ability to perform work tasks within the physical demand requirements as outlined below. o Genuine care for and interest in elderly and handicapped people. o Ability to comply with the Patient [NAME] of Rights and the Employee Responsibilities. o Ability to comply with Company and departmental policies and procedures. o Ability to properly wash, sanitize, and store all dishes, utensils, and cooking equipment. o Assist in tray assembly and deliver carts to the appropriate nursing or dining areas. o Dispose of refuse according to departmental policy and procedures. o Assemble and deliver floor supplies according to the posted standards. o Put food and supplies away following the correct rotation (firs in, first out). o Ability to prepare all foods according to the menu and the standardized recipes in a safe, efficient, and sanitary manner. o Ability to ensure the proper preparation, portioning and serving of foods as indicated on the spreadsheets and the recipes. PHYSICAL DEMANDS: Sitting: 1 - 2 hours in an 8 hour work shift. Standing: 3-7 hours in an 8 hour work shift. Alternates continuous to walking. Walking: 3-7 hours in an 8 hour work shift. Alternates occasionally to standing. Lifting: 50 lbs. Reliability, trustworthiness and consistency with regard to attendance is extremely important to thisjob. The ability to regularly and timely attend work, cooperative and politely work and deal with others, and to effectively multi-task and work in a stressful environment are also essential functions to this job. STATEMENT: This position reports directly to the Dietary Service Manager. APPLICANT DECLARATION: I have read the qualifications and requirements of the position of DIETARY SERVICE WORKER. I understand and-certify that the foregoing is a non-exhaustive criteria that is consistent with the business needs of this facility and is a legitimate measure of the qualifications fora Dietary Service Worker; and relates to the functions that are essential to the job of a Dietary Service Worker. To the best of my knowledge; I believe that I can perform these duties. There was no policy provided concerning when the Food Handlers Certificate should have been obtained prior to exit.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1) The facility did not ensure Resident #1 had the chair/bed alarm in place while resident #1 was sitting in the reclining chair. The resident fell and fractured her nose. This failure could place the only resident using a bed/chair alarm as an assistive device at risk for accidents or falls. Findings included: Review of Resident #1's Face sheet dated 12/29/2023 revealed a [AGE] year-old, admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Dysphagia (difficulty swallowing), Cognitive Communication Deficit, Repeated Falls, Anxiety Disorder, Osteoporosis, and Unspecified Dementia. Review of quarterly MDS assessment dated [DATE], indicated Resident #1 had a BIMS (Brief Interview for Mental Status) of 00, which indicated a severe cognitive impairment and indicated the resident can walk ten feet with partial/moderate assistance. Review of care plan dated 12/21/2023, indicated Resident #1 was at risk for falls, related to history of falls, weakness, and confusion. Interventions included anticipating needs, ensuring call light was in reach as needed, educating the resident/family/caregivers about safety reminders, encouraging activities that promote exercise and physical activity, ensuring proper footwear, following fall protocol, ensuring a safe walking environment, ensure the bed/chair alarm was always in place, encourage evaluation from Physical Therapy as needed, review falls, and find the root cause . Review of Physician orders dated 4/9/2023, indicated Resident #1 has an order for a bed/chair alarm. Review of Hospital discharg summary notes dated 12/18/2023, indicated that Resident #1's medical problems treatment included nasal bone and nasal septum fractures, urinary tract infection, dementia, and baseline confusion. Resident #1 required treated for both nasal bone and nasal septum fractures. Review of nursing notes dated 12/18/23, indicated Resident #1 was discovered by CNA A. Nurse assessed resident for injuries which included a large bump on the left side of her head, a large skin tear on middle of her forehead, bruising to the bridge of her/his nose with a small tear. Resident showed no signs of pain. The nursing notes also indicated LVN A set eyes on the resident around 5:10am and the resident was in the recliner with feet up and covered up with a cover . During a telephone interview on 1/4/2024 at 8:55 p.m., LVN A said the Hospice aid came in to provide the activities of daily living for resident #1 between 4:30 a.m. and 5:00 a.m. on 12/18/2023. LVN A stated Resident #1 was found on the floor just after the Hospice aid left (approximately 10 minutes). LVN A stated she laid eyes on Resident #1 after the aid left and Resident #1 was in the recliner. LVN A was informed the resident had fallen by CNA A about 5:15 a.m., the resident was on the floor, in the doorway between the room, and the hallway. LVN A performed a nurse assessment which revealed a goose egg on the left side of the head, a skin tear, and a swollen purple zig zagged nose. We cleaned up the resident and I sent her and the aid to the be assessed at the hospital. LVN A stated there was no bed alarm or chair alarm in the room from what she could see after performing the assessment. During a telephone interview on 1/4/2024 at 9:20 a.m., CNA A stated she was taking the trash out on 12/18/2023 at 5:15 a.m. and heard a loud sound. She stated she discovered Resident #1 on the floor of a room in the hallway. CNA A stated she reported the incident to LVN A. CNA A stated the resident was treated by LVN A and transferred to the hospital . CNA A did not note a bed/chair alarm in place at the time of the incident. During a telephone interview on 1/5/2024 at 10:14 a.m., the Hospice aide stated she helped a facility aide (name unknown) place the resident in the recliner in her room before leaving the morning of 12/18/2023. There was no bed/chair alarm in the room at this time. The Hospice Aide stated she did place non-slip socks on Resident #1 and left with the call light within reach of Resident #1 . During a telephone interview on 1/5/2024 at 6:12 p.m., the relative of Resident #1 indicated he was informed about the fall on 12/18/2023 at about 6:15 a.m. and met Resident #1 at the emergency room . He was told Resident #1 was found face first on the floor and broke her nose. The hospital wanted to perform surgery, but he refused due to her inability to manage anesthesia . During an observation of Resident #1 and interview of LVN B on 1/5/2024 at 2:15 p.m., Resident #1 was lying in bed with the bed alarm in place. LVN B tested the bed alarm, and it was in proper working order at that time. LVN B stated when the alarm goes off it rings at the nurse's station, and they must go to the resident, and ensure her safety . During an interview on 1/5/2023 at 3:15 p.m., the DON and the Administrator stated the facility expects staff to adhere to care plans and the interventions in place to keep residents safe. This resident does have an order for a bed/chair alarm and a care plan noting its use. It is also the expectation of staff to follow the policy and protocols set in place. The bed/chair alarm not being utilized appropriately does not meet the expectation set by the policy. Review of the faciliy's Policy, Falls/ Ambulation Difficulty, MM FR 03-2.0, revealed the following: [in part] Prevention of Unsafe Transfers or Ambulation Adaptive equipment to include Chairs that prevent rising or alarms may be necessary as the least restrictive type of restraint. Preventive Strategies to Reduce Fall Risk Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: - The facility will complete a fall risk assessment on each resident at the time of admission to the facility. The Fall Assessment Tool will be used to assess the resident's risk of falls. - Residents that score in the high risk category (10 points or greater) will be placed on fall precautions and care planned for fall prevention. - The clinical record and resident will be flagged to alert personnel of the resident' s risk status. Interventions will be designed to protect the resident's privacy. - After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. - Medical Strategies: a) Identify residents at risk for falls, b) Identify sign/symptom of underlying disease or medication effect that requires a clinician' s attention in order to rule out reversible acute problems, c) Identify chronic medical conditions that may contribute to fall risk and treat appropriately, d) Assess medications, e) Provide PT/OT evaluation and treatment as needed. - Residents who fail to respond or improve with medical treatment and continue to remain fall risks may respond to a number of rehabilitative strategies. Rehabilitative strategies will be evaluated for all high risk residents . - Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). - Nursing Care: Maintain regular toileting schedules. Use bedside commodes during hours of sleep, if needed. Provide properly fitting, nonslip footwear. Place confused residents close to nurses' station for close observation, if possible. Establish frequent nursing rounds on high risk residents. Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. - Environment: Place the call light and other objects within easy reach. Use bed/chair alarm systems to monitor unsafe activity as needed.

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (CNA-C, and MA-D) staff observed for infection control. 1. The facility failed to ensure MA-D did not sanitize the blood pressure cuff before or after use between residents. 2. The facility failed to ensure CNA-C performed proper peri-care (incontinent care) or proper hand hygiene for Resident #18. These failures could place residents of the facility at risk of infections due to unclean BP cuffs and incontinent care. Findings included: Observation on 09/13/2023 between 7:37 AM and 8:00 AM, MA-D did not sanitize the blood pressure cuff before or after use between 3 of 3 residents (Resident #56, 47, and 71) during morning resident medication pass. An interview on 09/13/23 at 8:20 AM, MA-D stated the blood pressure cuff should have been cleaned and sanitized before and after each resident. She stated she had not cleaned the Blood Pressure Cuff because the was nervous. She stated the negative impact to residents could have been possible cross contamination between residents. An interview on 09/13/2023 at 2:34 PM, the DON stated the staff should have followed the facility policy. She stated the ICP should have monitored staff members for proper infection control practices. She stated the negative impact could have been passing infections from one resident to another. The DON stated the MA was PRN was called in short notice. She stated it was that that led to the failure. Her expectations were for the residents to be correctly taken care of with staff following the facility policies. Record Review of In Service Training Attendance roster for Disinfecting Small Equipment dated 08/24/2023 revealed: Cleaning of small equipment related to disinfecting. All small equipment to include but not limited to: .4. Blood Pressure Cuffs Must be cleaned between Clients. Process for disinfecting is to wipe the device completely outer and inside surfaces with available disinfecting wipe. Please use wipes and apply designated kill times to ensure that adequate time is taken between use. Record Review revealed MA-D had not been in attendance Disinfecting of Small Equipment dated 08/24/2024. There were no further policies provided concerning disinfecting of small equipment before exit of facility. Record Review of the resident #18's Face Sheet dated 09/11/2023, revealed he was an 88 yr. old male. His original admit to the facility was 07/18/2020. Resident #18 had a diagnosis of Cerebral Infarction (stroke). The MDS assessment Section C, Cognitive Patterns dated 08/22/2023, revealed a BIMS score of an 11 (moderately impaired) and Section G, Functional status of personal hygiene was extensive assistance. Record review of Resident #18's Care Plan dated 07/03/2023 revealed Resident #18 had an ADL self-care performance deficit related to activity intolerance. The goal for Resident #18 would be to improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the review date. Observation on 09/13/2023 at 1:26 PM, CNA-C performed incontinent care for Resident #18, folding the same wipe two and three times each before discarding. CNA-C also did not pull Resident #18'a foreskin back to clean underneath cleaning in a downward swipe. An interview on 09/13/2023 at 1:59 PM, CNA-C stated she should have pulled the foreskin back to help prevent bacteria buildup as well as infection. She stated Resident #18 was known for yelling while being cleaned and did not want him to do that in front of surveyor observation. CNA-C stated she had been taught the one-wipe, one swipe but she was in a hurry to finish not taking the time to get a new one. An interview on 09/13/23 at 2:34 PM, the DON stated the foreskin should have been pulled back and cleaned correctly. The DON stated she had always taught the one wipe one swipe rule. The DON stated it was herself as well as the ADON who monitored the staff checkoffs, doing that on a weekly basis but had no documentation for those. The DON stated the negative impact to residents was a potential for a UTI. The DON stated what led to the failure was not following something they go over frequently which was one wipe one swipe. She stated she would not have felt comfortable with the three-fold for a bowel movement. Her expectations for staff were to follow facility policy and procedures. An interview 09/13/23 04:50 PM the DON stated CNA-C had no previous in-services documented concerning un-circumcised male incontinent care. Record review titled Certified Nurse Aide Competency Verification for CNA-C was dated 02/04/2022. Record review of the policy titled Perineal Care Male dated 08/08/2023 revealed: Purpose: To clean the male perineum without contaminating the urethral area with germs from the rectal area. Procedural Guidelines . F .DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE TISSUE OR WIPES . I .Gently wash perineal area, wiping from clean urethral area toward dirty rectal area to avoid contaminating urethral area to avoid contaminating urethral area with germs from the rectum. DO NOT WIPE MORE THAN ONCE WITH THE SAME SURFACE OF THE WASHCLOTH OR PRE-MOISENED CLEANSING WIPE Retract foreskin of uncircumcised male Wash the urethral area in a circular motion

Based on observations, interviews, and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 (Resident #53 and 78) of 8 residents reviewed for medical records. Facility failed to document follow-up observations and monitoring for Resident #53 after she had falls. Facility failed to document follow-up observations and monitoring for Resident #78 after he had falls, behaviors, and antibiotic therapy. These failures placed residents at risk for continuity of care and early detection of complications related to medications and injuries. Findings included: Resident # 53 Record review of Resident #53's Facesheet dated 09/13/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis list that included Vascular dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary), Muscle wasting and atrophy, Senile degeneration of brain, Schizoaffective disorder bipolar type, osteoporosis without current pathological fracture. Record review of Resident #53's Quarterly MDS dated [DATE] revealed No BIMS score with problems with short- and long-term memory issues. She had at least 1 fall in the previous 3 months. She needed extensive 2-person assistance for transfers and supervision with 1-person for walking. Record review of Resident #53's Care plan last updated 09/11/23 revealed: is a high risk for falls r/t Confusion. Fall without injury 01/12/23, Fall without injury 01/26/23, fall without injury 02/22/23, fall without injury 04/07/23, fall with injury 07/09/23 (laceration), fall without injury 09/11/23. The resident will be free of minor injury through the review date. #53 will have a reduction in falls through the review date. Anticipate and meet Resident #53's needs. Be sure Resident #53's call light is within reach and encourage her to use it for assistance as needed. Educate Resident #53/family/caregivers about safety reminders and what to do if a fall occurs. Encourage Resident #53 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that Resident #53 is wearing appropriate footwear, shoes or non-skid socks when ambulating or mobilizing in w/c. Follow facility fall protocol. Resident #53 needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach. low bed with fall mat in place while in bed, hipsters on at all times. PT to evaluate and treat as ordered or PRN. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate Resident #53/family/caregivers/IDT as to causes. Record review of Resident #53's Progress from 04/12/23 to 09/15/23 revealed: 04/12/23 through 05/13/23 Effective Date: 05/07/2023 14:30 Type: Nursing Note Note ext: resident found laying on her back on floor in room resident assessed moves all ext well no s/s or c/o pain no injuries noted. resident wearing hipsters and no slide socks notified RP, PCP, ADONS DON ADMIN No additional notes after fall on 5/7/23 over the next 3 days. 06/13/23 through 07/13/23 Effective Date: 07/09/2023 20:00 Type: Nursing Note Note Text : RESIDENT SENT TO ER POST FALL DUE TO HEAD LACERATION 2 STAPLES APPLIED REMOVE STAPLES IN 10 DAYS. Effective Date: 07/09/2023 18:45 Type: Nursing Note Note Text : CNA REOPORTED TO THIS RN THAT RESIDENT HAD FALLEN RESIDENT FOUND LAYING ON HER LEFT SIDE ON MAT WITH HEAD NEXT TO NIGHTSTAND RESIDENT ASSESSED MOVES ALL EXT W/O S/S OR C/O PAIN NOTED 2CM LACERATION TO LEFT SIDE OF HEAD. CLEANED WITH NSS AND GAUZE RESIDENT SENT TO THE ER FOR EVALUATION AND SUTURESNOTIFIED DON ADMIN RP AND PCP No additional notes after fall on 7/9/23, or follow-up monitoring for staples. 07/14/23 to 08/14/23. No progress notes at all. 08/15/23 through0 9/15/23 No note regarding fall on 09/11/23. During an observation and interview on 09/11/23 at 11:47AM with Resident #53, surveyor observed Resident #53 in her room, in the middle of the floor behind her wheelchair with her door closed, and the lights off. There was a floor mat leaning against Resident #53's roommate's bed. Resident#53 was making a noise, like a cutting ahahahahah noise. Surveyor pushed resident call light and went to the hallway and seen housekeeping and asked that they get a nurse, as resident was in the floor. Surveyor asked Resident #53 if she was in pain and she said yes. She was asked where she was hurting and did not answer and again began making the ahahahah sound. Resident #53 was observed scooting around on the floor frequently while awaiting assistance from staff and had been in the process of trying to get up out of the floor per self when RN B entered her room. Resident #53 then finished getting up after RN B provided her hand to resident. Resident #53 was observed with a bulkiness to her hips and RN B said Resident #53 had hipsters on to protect her hips during a fall, a low bed, and also a fall mat. She said Resident #53 had a history of frequent falls. Resident #53 appeared wet from incontinent episode through her sweatpants. An aide had entered Resident #53's room then went out to get another set of hipsters and nurse stayed with resident. RN B asked Resident #53 if she was hurting, Resident #53 said yes but then would not say, point or indicate where the pain was. Resident#53 began to pace around room and began moving things from 1 part of the room to another part of the room and then began opening and shutting dresser drawers. RN B said Resident #53 was able to ambulate well per self and rarely would sit in her wheelchair. Nurse aide returned to room as the nurse was opening the door to look out for aide, Resident #53 just began walking out of room, so aide decided they would take resident to the shower room. Aide said that hospice had just been in and did Resident #53's shower not too long ago. Resident#53 did well ambulating in her room without need of assistance of the staff as well as walking through the hallway and she did not ambulate with the appearance of difficulty or pain. RN B said, Resident #53 had not had a true fall in quite some time. She said Resident #53 did scoot off her bed or the chair in her room or sometimes even her wheelchair, and she would just sit down in the floor and scoot around on her bottom sometimes. Resident # 78 Record review of Resident #78's Facesheet dated 09/13/23 revealed An [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: Dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary), Muscle wasting and atrophy, Other idiopathic peripheral autonomic neuropathy. Record review of Resident #78's Admission MDS dated [DATE] revealed no BIMS score with difficulty with short- and long-term memory. He needed ADL assistance of extensive 2-person assistance for transfers and supervision of 1-person for ambulating. He did utilize a wheelchair. Resident #78 had at least 1 fall since admission. Record review of Resident #78's Careplan last updated 9/13/23 revealed: The resident is high risk for falls r/t Confusion, Gait/balance problems. 08/16/23 fall with injury, 08/17/23 fall with injury, 08/19/23 fall with injury, fall with injury 09/02/23 fall with injury (hematoma, skin tear) 09/13/23. The resident will be free of falls through the review date. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it or assistance as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear (Specify and describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non- skid socks) when ambulating or mobilizing in w/c. Follow facility fall protocol. Hipsters to be worn at all times to prevent injury from falls. Resident #78 to wear soft helmet while OOB and ambulating to prevent further injury from falls. Pt evaluate and treat as ordered or PRN. The resident needs a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach). The resident needs activities that minimize the potential for falls while providing diversion and distraction. Record review of Resident #78's Progress notes dated 08/14/23 through 09/14/23 revealed: Effective Date: 08/17/2023 14:20 Type: Nursing Note Note Text: notified PCP of change in condition, PCP ordered resident to be sent to ER for EVAL. (RP) notified. Effective Date: 08/17/2023 03:11 Type: Nursing Note LATE ENTRY Note Text: CNA notified this nurse that resident was on the floor. He was on his back with head by the closed bathroom door and his legs were straight out in front of him. Vital signs obtained, head to toe assessment done with no new injuries noted. Assisted resident back to his bed. No s/s of pain or discomfort. Bed in lowest position and call light in reach. Notified (RP), PCP, and admin. Effective Date: 08/18/2023 22:11 Type: Nursing Note Note Text: this nurse heard a noise and observed resident lying on the floor in the hallway. this nurse assessed resident for injury a hematoma was forming on the left side of forehead (same area from a previous fall) and the dressing on resident's left elbow had been scraped open. resident moves all extremities without pain or discomfort admin., DON, on call DR and (RP) were all notified neuros. Initiated. Effective Date: 08/19/2023 10:00 Type: Nursing Note Note Text: RN IN ER CALLED AND INFORMED THAT TEST RESULTS CAME BACK ON HIS URINE AND HE HAS ECOLI IN HIS URINE NEW ORDER RECIEVED FROM ER DR FOR MACROBID BID X 10 DAYS RESIDENTS RP CALLED AND NOTIFIED Effective Date: 09/02/2023 05:45 Type: Activity Note Text: this RN heard a crash found resident lying on his back on the floorresident assessed resident moves all ext w/o s/s or c/o pain noted raised knot with a 1 cm laceration on top first aid admin neuros started. notified RP PCP DON AND ADMINISTRATOR Effective Date: 09/07/2023 10:11 Type: Nursing Note Note Text: Resident having increase in behaviors hitting at staff and using foul language. Staff attempting to redirect resident, resident continues to hit and kick at staff, cursing while doing it. Effective Date: 09/09/2023 12:34 Type: Nursing Note Note Text: Resident standing in room holding on to his wheelchair running it into the bathroom door over and over cursing and yelling at staff. Resident redirected, attempted to get in bed staff helped resident to bed, fall mat next to bed. WCTM Effective Date: 09/13/2023 06:30 Type: Nursing Note Note Text: Resident using foul language hitting punching at staff trying to bite staff. Staff attempts to redirect resident not easily redirectable. DR. notified of behavior prn lorazepam 0.5mg Q6 hrs. prn. (Draft) No follow up notes from any shifts regarding resident behaviors, falls, or antibiotic use. During an observation on 09/11/23 at 12:09PM of Resident #78, he had a soft open helmet on. He was observed several times getting out of wc and ambulating towards a closet in the dining/activity area. Resident #78 did not respond to any questions and only looked at surveyor during questions. During an interview on 09/13/23 at 02:53 PM with ADM, she said the expectation was to document daily per shift x 3 days (72 hours) when there has been a fall or a change of condition. She said if a resident had an antibiotic, the nurses should have charted on each shift the entire time the resident was taking the antibiotic and then for3 days after. ADM reviewed Resident #78's progress notes from admission 8/15/23 to 9/13/23 and verified that the staff did not chart per their policy for documentation. During an interview on 09/13/23 at 3:39PM with DON she said she expected that the nurses documented in a progress note for a fall at the time of the incident and then each shift for the next 3 days afterwards. She said if a resident was taking an antibiotic, the nurses should have been documenting a progress note each shift the entire time the resident took an antibiotic and then for an additional 3 days each shift after the resident completed the antibiotic. During an interview on 09/13/23 at 5:36PM with LVN E, she said any time a resident had a fall, the nurses were to complete an incident report and if the fall had been unwitnessed or the resident hit their head, the nurse was supposed to start neurological checks. She said the nurses were supposed to do a nurses note with details about the fall and then put the fall on the 24-hour report to alert all other nurses to the fall. LVN E said that would be followed up by all 3 shifts of nurses writing a progress note for the next 3 days after the fall. She said any resident that had a new medication would have all 3 shifts of nurses to write a nurses note for 3 days after the new medication was started and if a resident had an antibiotic, then the nurses were supposed to write a nurses note each shift the entire time a resident was on an antibiotic and then for 3 days after the resident stopped the antibiotic. LVN E said if a nurse did not chart as she had explained, it could have been because they had just been too busy, or they simply forgot to chart something. She said if the residents did not have that type of charting completed during events of falls or antibiotics, then their medical records were not accurate, and it could place the residents at risk because they would not have documentation to assist in early detection of problems. LVN E said that each unit had a cheat sheet inside the 24 hour report binder that assisted the nurses with what to chart and how often to chart for different events. During an interview on 09/13/23 at 5:53PM with DON, she said herself and the ADON monitored all unit's 24-hour report sheets, and they would monitor the nurses charting to ensure that the nurses were charting as they were supposed to. She said they had trained all their nurses when they first started on the type of charting and how often they were supposed to chart, as well as different in-services throughout her time as the DON. She said even though she was responsible for monitoring the nurses charting, she had obviously not monitored everyone because of the issues that had been brought to her attention. Record review of facility policy labeled Documentation last revised 2/13/07 revealed: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge) . Complete documentation in narrative nursing notes in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. Daily documentation X 72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Daily summaries per shift will be required on residents requiring acute care. Record review of facility policy labeled User Friendly Guide on when to complete assessments undated revealed: Behavior Assessment Q 8 hours for 3 days post resident to resident incident . Fall Nurses Note when a resident falls and every 8 hours for 3 days post fall . UTI Assessment every 8 hours while on treatment and then for 3 days post treatment.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that staff utilized proper personal hygiene practices. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation on 09/11/2023 between 10:30 AM and 11:30 AM of the kitchen revealed: Freezer 1. Two packages of salami that were not labeled with a receive date or food item description. 2. One package of salami that was not labeled with a receive date or food item description; and meat was covered with ice crystals. 3. One package of hamburger patties that were in a plastic bag with a seal that was not sealed and open to air. 4. One hamburger patty laying on shelf in the freezer not covered or stored in storage container. During an interview on 09/11/2023 at 10:45 AM, the DM stated food items should have been labeled with a received date, an open date and item description if food was out of the original package. The DM stated what led to failure was staff get in a hurry and do not take the time to write on food items or seal them correctly. The DM stated the hamburger patty should not have been laying on shelf uncovered. The DM stated she was responsible to monitor staff. The DM stated food not being stored or labeled correctly could have led to residents getting sick or food lose quality. Observation on 09/13/23 between 10:00 AM and 10:30 AM of the kitchen revealed Cook A did not perform hand hygiene after removing gloves and putting on clean gloves before and/or after pureeing broccoli. Cook A did not perform hand hygiene after removing gloves and putting on clean gloves before and/or after pureeing beans. During an interview on 09/13/2023 at 10:35 AM, Cook A stated she should have washed her hands every time she changed her gloves. Cook A did not provide a response as to why she did not wash her hands after changing gloves. During an interview on 09/13/2023 at 10:45 AM, the DM stated staff should have washed their hands with soap and water every time they change their gloves. The DM stated not performing hand hygiene could have caused cross contamination and residents could have gotten sick. The DM stated staff getting in hurry and forgetting led to failure of not washing hands. During an interview on 09/13/2023 at 4:45 PM, the ADMN she stated hand hygiene should occur before you put on gloves and after you remove gloves. The ADMN stated food items should have been labeled with an open date, a receive date and description of food item (if not in original packaging). The ADMN stated not performing proper hand hygiene and/or storing and labeling food correctly could have led to residents getting sick. The ADMN stated staff in hurry and new staff may have led to failures in the kitchen. Record review of facility policy titled, Storage Refrigerators, without a date revealed Food must be covered when stored, with a date label identifying what is in the container. Record Review of facility policy titled, Fundamental of Infection Control Precautions, dated 10/21/22 revealed: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situation that require hand hygiene . After removing gloves . wearing gloves does not replace the need for hand washing because gloves may have small inapparent defect or be torn during use

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents (Resident #55) reviewed for quality of care. in that: The facility failed to address or document Resident #55's incident resulting in a fractured ankle on 07/13/2023 until 07/17/2023. The facility failed to have a physician's order for an ankle boot to Resident #55's right ankle and to have physicians' orders to monitor for circulation or check skin integrity underneath ankle boot for Resident #55. The facility failed to update Resident #55's comprehensive care plan regarding non weight bearing status or the use of ankle boot for Resident #55. These failures could place residents at risk for pain, injury, pressure ulcers, and decreased level of functioning and quality of life. Findings included: Review of Resident #55's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: chronic pain, type 2 diabetes, and depression. Further review of the electronic face sheet revealed no evidence of fractured ankle. Review of Resident #55's Quarterly MDS dated [DATE], revealed: Section C: Cognitive Patterns a BIMS score of 14' indicated no cognitive impairment. Section G: Functional Status: Transfers required total dependence with 2 or more person's physical assist. Review of Resident #55's electronic comprehensive care plan last revised on 08/07/2023, revealed: Focus: has the potential for pressure ulcer development r/t Immobility. Goal: will have intact skin, free of redness, blisters, or discoloration by/through review date. Interventions: Educate resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Further review of the electronic comprehensive care plan revealed no evidence of Resident #55 having a boot to right lower extremity. During an observation and interview on 09/11/23 at 11:33 AM, revealed Resident #55 resting in bed with boot to right lower extremity. Resident #55 stated she broke her ankle a couple of weeks ago and they just threw a boot on it. She stated the staff never removed the boot and had never checked the skin underneath it. There were no concerns with circulation or skin integrity to Resident #55s lower extremity. Review of Resident #55's electronic physicians' orders revealed: non weight bearing to right lower extremity with a start date of 07/17/2023. Review of the electronic physicians' orders revealed no evidence of an order for the boot to her right ankle and no orders to check for circulation of skin integrity underneath the boot. Further review of the electronic physicians' orders revealed no evidence of an order for x-rays of the ankle or referral to orthopedic doctor. Review of Resident #55's electronic nurses notes revealed no evidence of documentation related to resident's right ankle injury until 07/17/2023. Review of the electronic progress note dated 07/17/2023 at 09:27 am, revealed: Physician contacted facility to report that patient had a possible fracture to ankle. New orders received 1.) NWB to RLE, 2.) Consult with orthopedics. Review of electronic nurses noted dated 07/26/2023 at 2:10 pm, revealed: When returned from orthopedic doctor Resident #55 was in walking boot on right foot no orders were returned with Resident #55. Resident #55 stated she is to further exam of her right foot. Review of the X-ray report for Resident #55 dated 07/14/2023 at 3:30 pm, revealed: Procedure: X-ray ankle. Conclusion: Suspected lateral malleolar fracture although the evaluation is limited due to the patients positioning. Review of Resident #55's electronic record revealed no evidence of an incident report regarding Resident #55's ankle injury. During an interview on 09/13/23 at 05:35 PM, the DON stated Resident #55 went to a neurologist appointment on 07/13/2023 around 12:00 PM, CNA F was transferring Resident #55 from mechanical lift to the electric wheelchair when Resident #55 stated her foot hurt. She stated an x-ray was performed on 07/14/2023. The DON stated on 07/17/2023 the physician called the facility and said Resident #55 had a fractured ankle. The DON stated orders were received to make Resident #55 non weight bearing and to consult orthopedics. The DON stated Resident #55 saw the orthopedic doctor on 07/26/2023 and returned to the facility with and ankle boot on but no orders. The DON stated there should have been more follow up when informed ankle was hurt. The DON stated the documentation should have been better. She stated the nurses' notes should have told a complete story of the incident and everything that was done. She stated the incident where her ankle was hurt should have been documented but did not require an incident report because there was not an actual incident that took place. She stated when Resident #55 came back from the doctor with a boot and no orders the nurse should have contacted the doctor to get orders. She stated there should have been an order for the boot and for checking pulses and monitoring skin integrity for the boot. The DON stated the boot should have been care planned. She stated this was just a lack in documentation and it was her place to ensure the nurses were documenting accurately. The DON stated these failures could have resulted in lack of treatment, increased pain, and possible skin issues. During an interview on 9/13/2023 at 6:05 PM, Resident #55 stated she had an appointment with the neurologist but could not recall the date. She stated there were 2 staff members that assisted her in the mechanical lift to her electronic chair. She stated she was not positioned correctly in her chair due to her hips working. She stated CNA F was there when Resident #55 stated she could reposition herself. She stated when she placed pressure on her right foot, she experienced excruciating pain. She stated she went to the appointment then back to the facility. She stated she went overnight without being seen or sent to the emergency room the next day. She stated she informed the nurses she was hurting and had injured her ankle, and nothing was done until the evening of the next day because she insisted. During an interview attempt on 09/13/2023 at 6:00 PM, CNA F did not answer her phone. A voicemail was left with no return phone call. During an interview on 09/13/2023 at 6:30 PM, the Administrator stated she did not consider Resident #55's ankle injury a suspicious injury. They stated they did not feel the need to investigate because Resident #55 stated what happened. The Administrator stated there was no abuse or neglect. She stated Resident #55 hurt her ankle when adjusting herself in her chair. The Administrator stated she felt that Resident #55's ankle injury was handled appropriately. Review of the facility policy titled, Immobilization Devices, Splints/Slings/Collars/Straps dated 2003, Revealed in part: immobilization devices are splints, sling, cervical collars, and clavicle straps that are applied to restrict movement support and preserve the integrity of an injured area . Major considerations involved in administering these applications are proper alignment and optical peripheral neurovascular function in the body part immobilized. Goals: 1. The resident will achieve safe and effective application of supportive immobilization devices. 2. The resident will maintain baseline neurovascular and skin integrity status. 3. The resident will be free from injury associated with immobilization devices. Procedure: .8. All immobilization devices except clavicle straps, should be removed periodically. All devices will be monitored on every two hour schedule. Monitoring will be documented in the clinical record or flow sheet. 9. Neurovascular assessment should be performed during. And after the application of the immobilization device. 10. Skin integrity should be assessed periodically when the device is removed.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses. Findings included: Review of the DM's employee file revealed a hire date of 06/16/2022 as the DM. There was no documented evidence of a Dietary Manager Certificate found in the file. During an interview on 09/13/2023 at 10:15 AM, the DM stated she had taken the certification several months ago but did not have the certificate. The DM stated she didn't know why she did not have a copy of the certificate. The DM stated it was in her email and she could not open her email. During an interview on 09/13/2023 at 2:30 PM, the ADMN stated the DM had completed the course for her certification but did not know why the facility did not have a copy. The ADMN stated the facility should have had a copy of the DM's certification, and the certificate would be the only evidence to proof she had completed the certification course. The ADMN stated the DM went home to print her certificate and would bring the certification as soon as she got it. The ADMN stated the importance of having a certified DM was to ensure residents received food that stored and cooked correctly and met their nutritional needs. During an interview on 09/13/2023 at 4:45 PM, the ADMN stated she had not been able to get a copy of the certification and was not able to reach the DM. During an interview on 09/13/2023 at 7: 30 PM, the AMDN stated she was not able to provide further evidence of the DM's certification Review of facility job description titled, Dietary Service Manager signed 06/16/2022 by the DM revealed; Current certification by state as required.

Based on observation, interview and record review, it was determined, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #2) of six residents reviewed for neglect. 1. Resident #2 received a crushed [MEDICATION NAME] (Opioid [MEDICATION NAME]) ER 60 mg tablet on 02/13/14, which was Resident #1's medication. Resident #2 did not have an order for [REDACTED]. Resident #2 experienced a decreased level of consciousness, an elevated heart rate and decreased oxygen saturation on 02/13/14. Resident #2 was then transferred to the emergency roiagnom on [DATE] and admitted to the hospital that day. Resident #2 was discharged from the hospital and then readmitted to the nursing facility on 02/15/14 with [DIAGNOSES REDACTED]. An IJ was identified on 03/04/14. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the other 36 residents, who received medication from MA A, by placing them at risk for not receiving physician-ordered medication, receiving the wrong medication, exacerbation of medical conditions, and/or death. 2. The facility failed to review Resident #2's urine Culture and Sensitivity Report from the hospital. The facility failed to inform the physician the antibiotic, [MEDICATION NAME], that was ordered for Resident #2's UTI, would not be effective against the organism that caused the infection. After surveyor intervention, the facility obtained another urinalysis, which indicated Resident #2 had a UTI from the same organism, the infection had worsened. She received a [MEDICATION NAME] (antibiotic) injection and was ordered [MEDICATION NAME] (antibiotic) 500 mg twice a day for 10 days. These failures could affect all 93 residents by placing them at risk for continued or increased urinary infections which could result [MEDICAL CONDITION], kidney failure and even death. Findings included: 1. The facility's current Abuse/Neglect Policy, from the Nursing Policy and Procedure Manual, dated 2003, reflected, "...6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently...." The policy also reflected, "...6. Neglect Allegations: Report serious accidental injury that results from a facility practice, action/inaction by staff, incidents that are suspicious in nature or circumstances within the facility. (The facility must determine if the injury, harm, or death of the resident was due to facility failure to provide services, treatment of [REDACTED]...8. hospitalization resulting From Facility Practice: Report when a resident has to be taken to a hospital or other emergency care facility for evaluation and/or treatment, regardless of whether or not treatment is rendered, a resident is admitted to a hospital as an inpatient, or retained overnight for observation resulting from a facility practice, inaction/action by staff, or circumstances within the facility." 2. Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Anxiety Disorder, Depression, and [MEDICAL CONDITION], per the most recent MDS assessment, dated 02/26/14. Her cognition was intact, and she was not suffering from any [MEDICAL CONDITION] or acute mental changes. She was also hard of hearing. Resident #2 needed the assistance of one person with bed mobility, transferring, walking in the room or corridor, dressing, toileting and personal hygiene. Resident #2 was frequently incontinent of urine and incontinent of bowel. Review of the care plan for Resident #2 reflected an admission date of [DATE]. The care plan reflected the Resident required staff assistance with all ADLs dated 12/02/2013. It stated that the resident would maintain a current level of functioning for 90 days by requiring one CNA to assist for all toileting, bathing and personal hygiene. The care plan reflected Smart Chart Tasks (A delegated list of care that must be done and charted) and assigned nine particular tasks to the CNA. The tasks included Bowel Movement, Voiding, Behaviors, AM/PM snacks, Snacks, Sleep, Diet: Regular, Bath day, Mobility alarm in Place and functioning properly when in bed. The Smart chart tasks had an onset dated 12/02/13 and included approaches for Voiding with the CNA. The care plan reflected Dehydration/Fluid Deficit Risk dated 12/02/13 which stated that the Resident will remain free from signs and symptoms of dehydration for 90 days and included the approach of monitoring for decreased urine output. Review of LVN C's Nurse's Note, dated 02/13/14 at 11:30 PM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 3:08 PM, revealed the resident was complaining of pain by touching her "stomach." Both of her pupils were assessed, and they were equal and reactive. The Note also reflected the resident said she was "fine" and "cold." Resident #2 went to lunch and returned at 1:15 PM and was reassessed as alert and oriented. Review of LVN D's Nurse's Note, dated 02/13/14 at 3:45 PM, which was a late entry placed in Resident #2's clinical record on 02/13/14 at 7:09 PM, revealed the resident had pin point pupils with the left pupil slow to respond, and the right pupil non-reactive. She could not follow verbal commands and only blinked her eyes after a sternal rub. Her oxygen saturation level was at 82% on room air and her heart rate was 125 beats per minute. The note reflected Resident #2 was transferred to the ER, and her PCP and family were notified. Review of Resident #2's hospital Serum Drug screen, dated 02/13/14 at 6:41 PM, revealed a positive result for Opiates. Review of LVN E's facility's Nurse's Note, 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which reflected Resident #2 was admitted to the hospital on [DATE] for AMS and an UTI. The Note also reflected she had "...some form of long acting drug overdose, and that [MEDICATION NAME] was given several times." An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] reflected a UTI and a possible overdose. Resident #2's admission orders [REDACTED]. The facility's Provider Investigation Report, dated 02/16/14 (the day the report was sent via facsimile to DADS), reflected, "Client was received from hospital, physician at this time confirmed client Altered Mental Status, UTI and [MEDICAL CONDITION]. Physician identified that client had received an opiate, as identified by drug screen, suspected medication had caused the AMS. Upon review of the medication list, establish a medication error had occurred related to client had no orders for opiate narcotic. At transfer to hospital, 2/13/14, client was noted to have altered mental status, HR 125, B/P 102/67, 14 (respirations), 98.0, and O2 sat 95%. Client exhibited decreased responsiveness and pupils slow to react. Physician notified and client transferred out to ER for further evaluation, assessment completed by (LVN D). No suspected injury/occurrence at this time." The report also reflected the PCP identified the opiate was received approximately six hours prior to the AMS, staff would be in-serviced on medication administration's five rights, preventing medication errors, pharmacy consult, and one-on-one in-service for MA A for prevention of medication errors and a medication pass review. MA A's signed written statement, dated 02/15/14, reflected on 02/13/14 she pulled Resident #1's medications including [MEDICATION NAME] ER 60 mg and crushed them. She wrote she gave Resident #1 his medications, but he was yelling out, so she got help and was told hospice was coming to see him. MA A then went to the next resident to continue passing medications. Two attempts for a telephone interview with MA A were unsuccessful on 03/04/14 at 12:35 PM and 03/05/14 at 10:18 AM. An interview with the DON on 03/04/14 at 9:25 AM revealed MA A and she retraced the MA's steps during the morning medication pass on 02/13/14 and concluded MA A went to Resident #2's room directly after Resident #1's room. MA A's written interview, conducted on 02/15/14 by the DON and Administrator and signed by the Weekend Nursing Supervisor, revealed each time she told them her recollection of the events, her certainty of giving Resident #1 his medications became less and less until she was not sure at all if she gave him his medication, before moving to the next room. The written interview reflected MA A described how she put medications together to crush them, including narcotics. Resident #1's February 2014 MAR indicated [REDACTED]. National Library of Medicine (NLM) http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id= reflected, "[MEDICATION NAME] sulfate extended-release tablets contain [MEDICATION NAME] sulfate, an opioid agonist and a Schedule II controlled [MEDICATION NAME] sulfate extended-release tablets are an extended-release oral formulation of [MEDICATION NAME] sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid [MEDICATION NAME] is needed for an extended period of [MEDICATION NAME] sulfate extended-release tablets 100 and 200 mg ARE FOR USE IN OPIOID-TOLERANT PATIENTS ONLY. These tablet strengths may cause fatal respiratory depression when administered to patients not previously exposed to opioids. [MEDICATION NAME] SULFATE EXTENDED-RELEASE TABLETS ARE TO BE SWALLOWED WHOLE AND ARE NOT TO BE BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED [MEDICATION NAME] SULFATE EXTENDED-RELEASE TABLETS LEADS TO RAPID RELEASE AND ABSORPTION OF A POTENTIALLY FATAL DOSE OF [MEDICATION NAME]." (retrieved on 03/31/14). Resident #2's February 2014 Physician's Orders did not reflect an order for [REDACTED]. Review of Resident #2's February 2014 MARs did not reveal an entry for [MEDICATION NAME] ER 60 mg. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]." An interview with MA B on 03/04/14 at 12:41 PM revealed Resident #2 took all of her medications crushed. Interview with Resident #2's family member on 03/04/14 at 10:20 AM revealed the resident received a [MEDICATION NAME] 60 mg tablet that was not ordered for her, and she was allergic to [MEDICATION NAME]. The family member explained Resident #2 had to go to the hospital because of this error. Review of the facility's current Medication Administration Procedures, from the Pharmacy policy and procedure Manual dated 2003, reflected, "...12. Medications prescribed for one resident are not to be administered to any other resident." Review of the facility's current policy, Oral Solid Medication Administration, from the Pharmacy Policy and Procedure Manual dated 2003, reflected, "...3. Some preparations are not meant to be opened or crushed; such as [MEDICATION NAME] coated, sustained release, and sublingual products...Certified (sic) Medication Aids (CMAs) (sic) may not crush any medication without approval." MA A's Employee Performance form, dated 02/21/14 reflected she received a written counseling related to the medication policy violation for dispensing medications. She also received a suspension during the investigation. The Discussion of Investigation Findings reflected the DON spoke with MA A on 02/25/14 at 10:00 AM. MA A would be removed from her role as a MA and was offered a role in which she would not be handling medications. MA A declined and gave her resignation. The facility's In-Service for: Medication Administration, 5 Rights to Medication Administration, dated 02/17/14, reflected 28 staff signatures. The Educational material consisted of the right client, right medication, right time, right dose and right route. Review of the Medication Pass Audits, dated 02/17/14 through 02/28/14, revealed 10 staff signatures. The audit material consisted of 38 items that were in accordance with the standards of practice, facility policy and regulation requirements. On 03/18/14 an IJ was identified. On 03/18/14 at 10:00 AM, the Administrator was notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 03/19/14, reflected there were eight residents whom received crushed medications from MA A and had the potential for a medication error. In-Services were initiated on 02/17/14, which included medication pass competency evaluations with a 100% pass rate. The pharmacy consultant was notified on 02/17/14 and assisted with an audit of controlled substances to identify discrepancies and review the MARs for affected residents. The pharmacy consultant initiated an In-Service for Prevention of Medication Error that included medications, which could not be crushed, the five rights of administration, steps to avoid medication errors, definitions of extended release and time released medications. That In-Service was held on 03/05/14. Nine staff members who were responsible for giving the medications were employed by the facility and received the In-Services. Review of the In-Service for Medication Pass presented by the pharmacy, dated 03/05/14, revealed 20 staff signatures. The Education material included the 5 rights of a medication administration, steps to avoid medication error, extended release medications and a list of medications that were not to be crushed. An interview with the DON on 03/20/14 at 3:20 PM revealed she believed the IJ occurred because MA A was distracted during the medication pass. She could not explain why MA A crushed an extended release medication. The DON explained in-services were completed that specifically addressed the failures that might have led to the error. An interview with the Administrator on 03/20/14 at 3:35 PM revealed the IJ occurred because MA A was distracted at the time of the medication pass and lacked organizational skills that would have prevented the error. He was unable to explain why MA A crushed an extended release medication. He revealed there had been a lot of in-services to retrain the staff about medication errors. The Administrator explained he monitored the DON through tracking and trending, monthly quality assurances and monthly meetings where they have discussed medication errors. Interviews with MA B, LVN C, MA H, MA I, MA J, MA K, LVN L, LVN M, LVN N, MA O, and MA P, conducted from 03/19/14 through 03/20/14 between 10:36 AM and 3:15 PM, revealed they identified the five rights of medication administration; medications that could not be crushed included: extended release, [MEDICATION NAME] coated, potassium, capsules and continuous release medications; they verbalized how to locate if a medication could or could not be crushed by viewing the electronic MARs, the medication packet, a list of non-crushable medications on all three medication carts and the nurses' drug book; they stated they identified a resident prior to medication administration by electronic MAR pictures, photographic pictures on the chart, asking the resident their names, date of birth and that they would check with the staff nurse in the event of a question. The IJ was removed on 03/20/14. On 03/20/14 at 3:15 PM the Administrator was notified the IJ was removed. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. A facsimile was received from the DON on 03/17/14 at 12:20 PM, which reflected 37 residents received medications from MA A. Non-Immediate Jeopardy findings 3. Review of Resident #2's admission orders [REDACTED]. Resident #2 was readmitted to the nursing facility with an order for [REDACTED]. Resident #2's Care Plan, printed on 03/04/14 at 5:30 PM did not address her UTI. Review of Resident #2's hospital Urinalysis, dated 02/13/14, revealed her urine was clear, 1+ leukocytes (white blood cells) with a reference range of negative for leukocytes, white blood cells of 40 -50 with a reference range of none, and moderate bacteria. Resident #2's hospital Culture and Sensitivity Report, which resulted on 02/15/14 at 10:03 AM, revealed Escherichia Coli (a gram-negative bacillus in the human colon) in her urine, which indicated an infection. The report also reflected the Escherichia Coli was resistant to the antibiotic, [MEDICATION NAME]. The report was found in the back of Resident #2's clinical record. Review of LVN E's Nurse's Note, dated 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which indicated the resident was admitted to the hospital on [DATE] for AMS and a UTI. An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] did include a UTI. She stated she circled the physician's order for [MEDICATION NAME] and faxed it to the pharmacy. LVN E revealed she placed all of Resident #2's hospital medical records in the back of the resident's clinical record without reviewing them. She stated she did not typically review the medical records. LVN E revealed the DON and ADON A reviewed the records. An interview with the facility's only Weekend Nursing Supervisor on 03/05/14 at approximately 2:45 PM revealed it was the Charge Nurse's responsibility to review the hospital packet of information, which accompanied the resident coming back from the hospital. She confirmed LVN E was the Charge Nurse when Resident #2 returned from the hospital on [DATE]. During the interview with the DON on 03/04/14 at 11:55 AM, she was shown the urine culture and sensitivity results from the local hospital, dated 02/15/14 at 10:03 AM, which reflected the organism was resistant to [MEDICATION NAME]. The DON was also shown Resident #2's PCP's order for [MEDICATION NAME] dated 02/15/14. The DON acknowledged they should have noticed this. She stated when tests were ordered in the hospital, the results would be received in the packet when the resident returned. The DON stated she would contact Resident #2's PCP with these findings. A telephone interview with Resident #2's PCP on 03/04/14 at 2:04 PM revealed giving an antibiotic that an infection was resistant to would not "kill the infection." She stated the facility had not contacted her about the culture and sensitivity results that reflected the [MEDICATION NAME] would be ineffective in this situation. An interview with CNA F on 03/04/14 at 2:38 PM revealed Resident #2 had been voiding a small amount of urine, an average of six times during her shift. She stated the resident had gone to the bathroom a lot more that last week. Interview with Resident #2's family member was conducted on 03/04/14 at 10:20 AM. The family member expressed concern the resident was suffering from recurrent UTIs, and the family member did not know why this kept happening to the resident. An interview on 03/04/14 at approximately 4:00 PM revealed a urine specimen was obtained from Resident #2 on 03/04/14 at 3:51 PM and sent for analysis. The Urinalysis Results, dated 03/04/14 at 3:51 PM, reflected slightly cloudy urine, positive for [MEDICATION NAME], 2+ leukocytes, greater than 100 white blood cells and many bacteria, which indicated a current UTI. The Urine culture for Resident #2, dated 03/06/14 at 12:43 PM, reflected Escherichia Coli. The DON was interviewed on 03/04/14 at approximately 5:30 PM and acknowledged having contacted the PCP with the results. She stated the PCP was in house and had written an order for [REDACTED]. Resident #2's PCP's Physician's Telephone Order, dated 03/04/14 and timed at 4:53 PM, reflected [MEDICATION NAME] 1 gram Intramuscular (injection) once for a [DIAGNOSES REDACTED]. The facility's In-Service for Lab, dated 03/05/14, reflected a post test was completed by 19 staff members. Education material included urine test results and key areas to note, culture and sensitivity definition, documentation, reporting to the doctor and documenting on the 24 hour report sheet what was done and any abnormal symptoms. Review of the Employee Performance Forms for LVN E, LVN G, the DON and ADON A, dated 03/05/14, revealed written counselings for failure to follow appropriate policies and/or procedures resulting in harm, to a resident specifically referring to the failure to identify sensitivity and antibiotic correlation and the failure to review all documentation received from the facility upon admission, to include prior labs and [DIAGNOSES REDACTED]. The facility's current resident census report dated 03/18/14 reflected the facility had a total census of 93 residents.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #2) of six residents reviewed for neglect. 1. Resident #2 received a crushed [MEDICATION NAME] (an opioid [MEDICATION NAME]) ER 60 mg tablet on 02/13/14, which was Resident #1's medication. Resident #2 did not have an order for [REDACTED]. Resident #2 experienced a decreased level of consciousness, an elevated heart rate and decreased oxygen saturation on 02/13/14. Resident #2 was then transferred to the emergency roiagnom on [DATE] and admitted to the hospital that day. Resident #2 was discharged from the hospital and then readmitted to the nursing facility on 02/15/14 with [DIAGNOSES REDACTED]. An IJ was identified on 03/04/14. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the other 36 residents, who received medication from MA A, by placing them at risk for not receiving physician-ordered medication, receiving the wrong medication, exacerbation of medical conditions, and/or death. 2. The facility failed to review Resident #2's urine Culture and Sensitivity Report from the hospital. The facility failed to inform the physician the antibiotic, [MEDICATION NAME], that was ordered for Resident #2's UTI, would not be effective against the organism that caused the infection. After surveyor intervention, the facility obtained another urinalysis, which indicated Resident #2 had a UTI from the same organism, the infection had worsened. She received a [MEDICATION NAME] (antibiotic) injection and was ordered [MEDICATION NAME] (antibiotic) 500 mg twice a day for 10 days. These failures could affect all 93 residents by placing them at risk for continued or increased urinary infections which could result [MEDICAL CONDITION], kidney failure and even death. Findings included: 1. Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Anxiety Disorder, Depression, and [MEDICAL CONDITION], per the most recent MDS assessment, dated 02/26/14. Her cognition was intact, and she was not suffering from any [MEDICAL CONDITION] or acute mental changes. She was also hard of hearing. Resident #2 needed the assistance of one person with bed mobility, transferring, walking in the room or corridor, dressing, toileting and personal hygiene. Resident #2 was frequently incontinent of urine and incontinent of bowel. Review of the care plan for Resident #2 reflected an admission date of [DATE]. The care plan reflected the Resident required staff assistance with all ADLs dated 12/02/2013. It stated that the resident would maintain a current level of functioning for 90 days by requiring one CNA to assist for all toileting, bathing and personal hygiene. The care plan reflected Smart Chart Tasks (A delegated list of care that must be done and charted) and assigned nine particular tasks to the CNA. The tasks included Bowel Movement, Voiding, Behaviors, AM/PM snacks, Snacks, Sleep, Diet: Regular, Bath day, Mobility alarm in Place and functioning properly when in bed. The Smart chart tasks had an onset dated 12/02/13 and included approaches for Voiding with the CNA. The care plan reflected Dehydration/Fluid Deficit Risk dated 12/02/13 which stated that the Resident will remain free from signs and symptoms of dehydration for 90 days and included the approach of monitoring for decreased urine output. Review of LVN C's Nurse's Note, dated 02/13/14 at 11:30 PM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 3:08 PM, revealed the resident was complaining of pain by touching her "stomach." Both of her pupils were assessed, and they were equal and reactive. The Note also reflected the resident said she was "fine" and "cold." Resident #2 went to lunch and returned at 1:15 PM and was reassessed as alert and oriented. Review of LVN D's Nurse's Note, dated 02/13/14 at 3:45 PM, which was a late entry placed in Resident #2's clinical record on 02/13/14 at 7:09 PM, revealed the resident had pin point pupils with the left pupil slow to respond, and the right pupil non-reactive. She could not follow verbal commands and only blinked her eyes after a sternal rub. Her oxygen saturation level was at 82% on room air and her heart rate was 125 beats per minute. The note reflected Resident #2 was transferred to the ER, and her PCP and family were notified. Review of Resident #2's hospital Serum Drug screen, dated 02/13/14 at 6:41 PM, revealed a positive result for Opiates. Review of LVN E's facility's Nurse's Note, 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which reflected Resident #2 was admitted to the hospital on [DATE] for AMS and an UTI. The Note also reflected she had "...some form of long acting drug overdose, and that [MEDICATION NAME] was given several times." An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] reflected a UTI and a possible overdose. Resident #2's admission orders [REDACTED]. The facility's Provider Investigation Report, dated 02/16/14 (the day the report was sent via facsimile to DADS), reflected, "Client was received from hospital, physician at this time confirmed client Altered Mental Status, UTI and [MEDICAL CONDITION]. Physician identified that client had received an opiate, as identified by drug screen, suspected medication had caused the AMS. Upon review of the medication list, establish a medication error had occurred related to client had no orders for opiate narcotic. At transfer to hospital, 2/13/14, client was noted to have altered mental status, HR 125, B/P 102/67, 14 (respirations), 98.0, and O2 sat 95%. Client exhibited decreased responsiveness and pupils slow to react. Physician notified and client transferred out to ER for further evaluation, assessment completed by (LVN D). No suspected injury/occurrence at this time." The report also reflected the PCP identified the opiate was received approximately six hours prior to the AMS, staff would be in-serviced on medication administration's five rights, preventing medication errors, pharmacy consult, and one-on-one in-service for MA A for prevention of medication errors and a medication pass review. MA A's signed written statement, dated 02/15/14, reflected on 02/13/14 she pulled Resident #1's medications including [MEDICATION NAME] ER 60 mg and crushed them. She wrote she gave Resident #1 his medications, but he was yelling out, so she got help and was told hospice was coming to see him. MA A then went to the next resident to continue passing medications. Two attempts for a telephone interview with MA A were unsuccessful on 03/04/14 at 12:35 PM and 03/05/14 at 10:18 AM. An interview with the DON on 03/04/14 at 9:25 AM revealed MA A and she retraced the MA's steps during the morning medication pass on 02/13/14 and concluded MA A went to Resident #2's room directly after Resident #1's room. MA A's written interview, conducted on 02/15/14 by the DON and Administrator and signed by the Weekend Nursing Supervisor, revealed each time she told them her recollection of the events, her certainty of giving Resident #1 his medications became less and less until she was not sure at all if she gave him his medication, before moving to the next room. The written interview reflected MA A described how she put medications together to crush them, including narcotics. Resident #1's February 2014 MAR indicated [REDACTED]. National Library of Medicine (NLM) http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id= reflected, "[MEDICATION NAME] sulfate extended-release tablets contain [MEDICATION NAME] sulfate, an opioid agonist and a Schedule II controlled [MEDICATION NAME] sulfate extended-release tablets are an extended-release oral formulation of [MEDICATION NAME] sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid [MEDICATION NAME] is needed for an extended period of [MEDICATION NAME] sulfate extended-release tablets 100 and 200 mg ARE FOR USE IN OPIOID-TOLERANT PATIENTS ONLY. These tablet strengths may cause fatal respiratory depression when administered to patients not previously exposed to opioids. [MEDICATION NAME] SULFATE EXTENDED-RELEASE TABLETS ARE TO BE SWALLOWED WHOLE AND ARE NOT TO BE BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED [MEDICATION NAME] SULFATE EXTENDED-RELEASE TABLETS LEADS TO RAPID RELEASE AND ABSORPTION OF A POTENTIALLY FATAL DOSE OF [MEDICATION NAME]." (retrieved on 03/31/14). Resident #2's February 2014 Physician's Orders did not reflect an order for [REDACTED]. Review of Resident #2's February 2014 MARs did not reveal an entry for [MEDICATION NAME] ER 60 mg. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]." An interview with MA B on 03/04/14 at 12:41 PM revealed Resident #2 took all of her medications crushed. Interview with Resident #2's family member on 03/04/14 at 10:20 AM revealed the resident received a [MEDICATION NAME] 60 mg tablet that was not ordered for her, and she was allergic to [MEDICATION NAME]. The family member explained Resident #2 had to go to the hospital because of this error. Review of the facility's current Medication Administration Procedures, from the Pharmacy policy and procedure Manual dated 2003, reflected, "...12. Medications prescribed for one resident are not to be administered to any other resident." Review of the facility's current policy, Oral Solid Medication Administration, from the Pharmacy Policy and Procedure Manual dated 2003, reflected, "...3. Some preparations are not meant to be opened or crushed; such as [MEDICATION NAME] coated, sustained release, and sublingual products...Certified (sic) Medication Aids (CMAs) (sic) may not crush any medication without approval." The facility's current Abuse/Neglect Policy, from the Nursing Policy and Procedure Manual, dated 2003, reflected, "...6. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently...." The policy also reflected, "...6. Neglect Allegations: Report serious accidental injury that results from a facility practice, action/inaction by staff, incidents that are suspicious in nature or circumstances within the facility. (The facility must determine if the injury, harm, or death of the resident was due to facility failure to provide services, treatment of [REDACTED]...8. hospitalization resulting From Facility Practice: Report when a resident has to be taken to a hospital or other emergency care facility for evaluation and/or treatment, regardless of whether or not treatment is rendered, a resident is admitted to a hospital as an inpatient, or retained overnight for observation resulting from a facility practice, inaction/action by staff, or circumstances within the facility." MA A's Employee Performance form, dated 02/21/14 reflected she received a written counseling related to the medication policy violation for dispensing medications. She also received a suspension during the investigation. The Discussion of Investigation Findings reflected the DON spoke with MA A on 02/25/14 at 10:00 AM. MA A would be removed from her role as a MA and was offered a role in which she would not be handling medications. MA A declined and gave her resignation. The facility's In-Service for: Medication Administration, 5 Rights to Medication Administration, dated 02/17/14, reflected 28 staff signatures. The Educational material consisted of the right client, right medication, right time, right dose and right route. Review of the Medication Pass Audits, dated 02/17/14 through 02/28/14, revealed 10 staff signatures. The audit material consisted of 38 items that were in accordance with the standards of practice, facility policy and regulation requirements. On 03/18/14 an IJ was identified. On 03/18/14 at 10:00 AM, the Administrator was notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 03/19/14, reflected there were eight residents whom received crushed medications from MA A and had the potential for a medication error. In-Services were initiated on 02/17/14, which included medication pass competency evaluations with a 100% pass rate. The pharmacy consultant was notified on 02/17/14 and assisted with an audit of controlled substances to identify discrepancies and review the MARs for affected residents. The pharmacy consultant initiated an In-Service for Prevention of Medication Error that included medications, which could not be crushed, the five rights of administration, steps to avoid medication errors, definitions of extended release and time released medications. That In-Service was held on 03/05/14. Nine staff members who were responsible for giving the medications were employed by the facility and received the In-Services. Review of the In-Service for Medication Pass presented by the pharmacy, dated 03/05/14, revealed 20 staff signatures. The Education material included the 5 rights of a medication administration, steps to avoid medication error, extended release medications and a list of medications that were not to be crushed. An interview with the DON on 03/20/14 at 3:20 PM revealed she believed the IJ occurred because MA A was distracted during the medication pass. She could not explain why MA A crushed an extended release medication. The DON explained in-services were completed that specifically addressed the failures that might have led to the error. An interview with the Administrator on 03/20/14 at 3:35 PM revealed the IJ occurred because MA A was distracted at the time of the medication pass and lacked organizational skills that would have prevented the error. He was unable to explain why MA A crushed an extended release medication. He revealed there had been a lot of in-services to retrain the staff about medication errors. The Administrator explained he monitored the DON through tracking and trending, monthly quality assurances and monthly meetings where they have discussed medication errors. Interviews with MA B, LVN C, MA H, MA I, MA J, MA K, LVN L, LVN M, LVN N, MA O, and MA P, conducted from 03/19/14 through 03/20/14 between 10:36 AM and 3:15 PM, revealed they identified the five rights of medication administration; medications that could not be crushed included: extended release, [MEDICATION NAME] coated, potassium, capsules and continuous release medications; they verbalized how to locate if a medication could or could not be crushed by viewing the electronic MARs, the medication packet, a list of non-crushable medications on all three medication carts and the nurses' drug book; they stated they identified a resident prior to medication administration by electronic MAR pictures, photographic pictures on the chart, asking the resident their names, date of birth and that they would check with the staff nurse in the event of a question. The IJ was removed on 03/20/14. On 03/20/14 at 3:15 PM the Administrator was notified the IJ was removed. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. A facsimile was received from the DON on 03/17/14 at 12:20 PM, which reflected 37 residents received medications from MA A. Non-Immediate Jeopardy findings 2. Review of Resident #2's admission orders [REDACTED]. Resident #2 was readmitted to the nursing facility with an order for [REDACTED]. Resident #2's Care Plan, printed on 03/04/14 at 5:30 PM did not address her UTI. Review of Resident #2's hospital Urinalysis, dated 02/13/14, revealed her urine was clear, 1+ leukocytes (white blood cells) with a reference range of negative for leukocytes, white blood cells of 40 -50 with a reference range of none, and moderate bacteria. Resident #2's hospital Culture and Sensitivity Report, which resulted on 02/15/14 at 10:03 AM, revealed Escherichia Coli (a gram-negative bacillus in the human colon) in her urine, which indicated an infection. The report also reflected the Escherichia Coli was resistant to the antibiotic, [MEDICATION NAME]. The report was found in the back of Resident #2's clinical record. Review of LVN E's Nurse's Note, dated 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which indicated the resident was admitted to the hospital on [DATE] for AMS and a UTI. An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] did include a UTI. She stated she circled the physician's order for [MEDICATION NAME] and faxed it to the pharmacy. LVN E revealed she placed all of Resident #2's hospital medical records in the back of the resident's clinical record without reviewing them. She stated she did not typically review the medical records. LVN E revealed the DON and ADON A reviewed the records. An interview with the facility's only Weekend Nursing Supervisor on 03/05/14 at approximately 2:45 PM revealed it was the Charge Nurse's responsibility to review the hospital packet of information, which accompanied the resident coming back from the hospital. She confirmed LVN E was the Charge Nurse when Resident #2 returned from the hospital on [DATE]. During the interview with the DON on 03/04/14 at 11:55 AM, she was shown the urine culture and sensitivity results from the local hospital, dated 02/15/14 at 10:03 AM, which reflected the organism was resistant to [MEDICATION NAME]. The DON was also shown Resident #2's PCP's order for [MEDICATION NAME] dated 02/15/14. The DON acknowledged they should have noticed this. She stated when tests were ordered in the hospital, the results would be received in the packet when the resident returned. The DON stated she would contact Resident #2's PCP with these findings. A telephone interview with Resident #2's PCP on 03/04/14 at 2:04 PM revealed giving an antibiotic that an infection was resistant to would not "kill the infection." She stated the facility had not contacted her about the culture and sensitivity results that reflected the [MEDICATION NAME] would be ineffective in this situation. An interview with CNA F on 03/04/14 at 2:38 PM revealed Resident #2 had been voiding a small amount of urine, an average of six times during her shift. She stated the resident had gone to the bathroom a lot more that last week. Interview with Resident #2's family member was conducted on 03/04/14 at 10:20 AM. The family member expressed concern the resident was suffering from recurrent UTIs, and the family member did not know why this kept happening to the resident. An interview on 03/04/14 at approximately 4:00 PM revealed a urine specimen was obtained from Resident #2 on 03/04/14 at 3:51 PM and sent for analysis. The Urinalysis Results, dated 03/04/14 at 3:51 PM, reflected slightly cloudy urine, positive for [MEDICATION NAME], 2+ leukocytes, greater than 100 white blood cells and many bacteria, which indicated a current UTI. The Urine culture for Resident #2, dated 03/06/14 at 12:43 PM, reflected Escherichia Coli. The DON was interviewed on 03/04/14 at approximately 5:30 PM and acknowledged having contacted the PCP with the results. She stated the PCP was in house and had written an order for [REDACTED]. Resident #2's PCP's Physician's Telephone Order, dated 03/04/14 and timed at 4:53 PM, reflected [MEDICATION NAME] 1 gram Intramuscular (injection) once for a [DIAGNOSES REDACTED]. The facility's In-Service for Lab, dated 03/05/14, reflected a post test was completed by 19 staff members. Education material included urine test results and key areas to note, culture and sensitivity definition, documentation, reporting to the doctor and documenting on the 24 hour report sheet what was done and any abnormal symptoms. Review of the Employee Performance Forms for LVN E, LVN G, the DON and ADON A, dated 03/05/14, revealed written counselings for failure to follow appropriate policies and/or procedures resulting in harm, to a resident specifically referring to the failure to identify sensitivity and antibiotic correlation and the failure to review all documentation received from the facility upon admission, to include prior labs and [DIAGNOSES REDACTED]. The facility's current resident census report dated 03/18/14 reflected the facility had a total census of 93 residents.

Based on observation, interview and record review, it was determined the facility failed to provide pharmaceutical services that assure the accurate dispensing and administration of drugs to one (Resident #2) of the six residents reviewed for medication. 1. Resident #2 received a crushed Morphine (Opioid analgesic) ER 60 mg tablet on 02/13/14, which was Resident #1's medication. Resident #2 did not have an order for [REDACTED]. Resident #2 experienced a decreased level of consciousness, an elevated heart rate and decreased oxygen saturation on 02/13/14. Resident #2 was then transferred to the emergency roiagnom on [DATE] and admitted to the hospital that day. Resident #2 was discharged from the hospital and then readmitted to the nursing facility on 02/15/14 with [DIAGNOSES REDACTED]. An IJ was identified on 03/04/14. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the other 36 residents, who received medication from MA A, by placing them at risk for not receiving physician-ordered medication, receiving the wrong medication, exacerbation of medical conditions, and/or death. 2. The facility failed to review Resident #2's urine Culture and Sensitivity Report from the hospital. The facility failed to inform the physician the antibiotic, Ciprofloxacin, that was ordered for Resident #2's UTI, would not be effective against the organism that caused the infection. After surveyor intervention, the facility obtained another urinalysis, which indicated Resident #2 had a UTI from the same organism, the infection had worsened. She received a Rocephin (antibiotic) injection and was ordered Augmentin (antibiotic) 500 mg twice a day for 10 days. These failures could affect all 93 residents by placing them at risk for continued or increased urinary infections which could result in sepsis, kidney failure and even death. Findings included: 1. Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Anxiety Disorder, Depression, and Osteoporosis, per the most recent MDS assessment, dated 02/26/14. Her cognition was intact, and she was not suffering from any delirium or acute mental changes. She was also hard of hearing. Resident #2 needed the assistance of one person with bed mobility, transferring, walking in the room or corridor, dressing, toileting and personal hygiene. Resident #2 was frequently incontinent of urine and incontinent of bowel. Review of the care plan for Resident #2 reflected an admission date of [DATE]. The care plan reflected the Resident required staff assistance with all ADLs' dated 12/02/2013. It stated that the resident would maintain a current level of functioning for 90 days by requiring one CNA to assist for all toileting, bathing and personal hygiene. The care plan reflected Smart Chart Tasks (A delegated list of care that must be done and charted) and assigned nine particular tasks to the CNA. The tasks included Bowel Movement, Voiding, Behaviors, AM/PM snacks, Snacks, Sleep, Diet: Regular, Bath day, Mobility alarm in Place and functioning properly when in bed. The Smart chart tasks had an onset dated 12/02/13 and included approaches for Voiding with the CNA. The care plan reflected Dehydration/Fluid Deficit Risk dated 12/02/13 which stated that the Resident will remain free from signs and symptoms of dehydration for 90 days and included the approach of monitoring for decreased urine output. Review of LVN C's Nurse's Note, dated 02/13/14 at 11:30 PM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 3:08 PM, revealed the resident was complaining of pain by touching her "stomach." Both of her pupils were assessed, and they were equal and reactive. The Note also reflected the resident said she was "fine" and "cold." Resident #2 went to lunch and returned at 1:15 PM and was reassessed as alert and oriented. Review of LVN D's Nurse's Note, dated 02/13/14 at 3:45 PM, which was a late entry placed in Resident #2's clinical record on 02/13/14 at 7:09 PM, revealed the resident had pin point pupils with the left pupil slow to respond, and the right pupil non-reactive. She could not follow verbal commands and only blinked her eyes after a sternal rub. Her oxygen saturation level was at 82% on room air and her heart rate was 125 beats per minute. The note reflected Resident #2 was transferred to the ER, and her PCP and family were notified. Review of Resident #2's hospital Serum Drug screen, dated 02/13/14 at 6:41 PM, revealed a positive result for Opiates. Review of LVN E's facility's Nurse's Note, 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which reflected Resident #2 was admitted to the hospital on [DATE] for AMS and an UTI. The Note also reflected she had "...some form of long acting drug overdose, and that Narcan was given several times." An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] reflected a UTI and a possible overdose. Resident #2's admission orders [REDACTED]. The facility's Provider Investigation Report, dated 02/16/14 (the day the report was sent via facsimile to DADS), reflected, "Client was received from hospital, physician at this time confirmed client Altered Mental Status, UTI and CVA. Physician identified that client had received an opiate, as identified by drug screen, suspected medication had caused the AMS. Upon review of the medication list, establish a medication error had occurred related to client had no orders for opiate narcotic. At transfer to hospital, 2/13/14, client was noted to have altered mental status, HR 125, B/P 102/67, 14 (respirations), 98.0, and O2 sat 95%. Client exhibited decreased responsiveness and pupils slow to react. Physician notified and client transferred out to ER for further evaluation, assessment completed by (LVN D). No suspected injury/occurrence at this time." The report also reflected the PCP identified the opiate was received approximately six hours prior to the AMS, staff would be in-serviced on medication administration's five rights, preventing medication errors, pharmacy consult, and one-on-one in-service for MA A for prevention of medication errors and a medication pass review. MA A's signed written statement, dated 02/15/14, reflected on 02/13/14 she pulled Resident #1's medications including Morphine ER 60 mg and crushed them. She wrote she gave Resident #1 his medications, but he was yelling out, so she got help and was told hospice was coming to see him. MA A then went to the next resident to continue passing medications. Two attempts for a telephone interview with MA A were unsuccessful on 03/04/14 at 12:35 PM and 03/05/14 at 10:18 AM. An interview with the DON on 03/04/14 at 9:25 AM revealed MA A and she retraced the MA's steps during the morning medication pass on 02/13/14 and concluded MA A went to Resident #2's room directly after Resident #1's room. MA A's written interview, conducted on 02/15/14 by the DON and Administrator and signed by the Weekend Nursing Supervisor, revealed each time she told them her recollection of the events, her certainty of giving Resident #1 his medications became less and less until she was not sure at all if she gave him his medication, before moving to the next room. The written interview reflected MA A described how she put medications together to crush them, including narcotics. Resident #1's February 2014 MAR indicated [REDACTED]. National Library of Medicine (NLM) http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id= reflected, "Morphine sulfate extended-release tablets contain morphine sulfate, an opioid agonist and a Schedule II controlled substance...Morphine sulfate extended-release tablets are an extended-release oral formulation of morphine sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time...Morphine sulfate extended-release tablets 100 and 200 mg ARE FOR USE IN OPIOID-TOLERANT PATIENTS ONLY. These tablet strengths may cause fatal respiratory depression when administered to patients not previously exposed to opioids. MORPHINE SULFATE EXTENDED-RELEASE TABLETS ARE TO BE SWALLOWED WHOLE AND ARE NOT TO BE BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED MORPHINE SULFATE EXTENDED-RELEASE TABLETS LEADS TO RAPID RELEASE AND ABSORPTION OF A POTENTIALLY FATAL DOSE OF MORPHINE." (retrieved on 03/31/14). Resident #2's February 2014 Physician's Orders did not reflect an order for [REDACTED]. Review of Resident #2's February 2014 MARs did not reveal an entry for Morphine ER 60 mg. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]." An interview with MA B on 03/04/14 at 12:41 PM revealed Resident #2 took all of her medications crushed. Interview with Resident #2's family member on 03/04/14 at 10:20 AM revealed the resident received a Morphine 60 mg tablet that was not ordered for her, and she was allergic to morphine. The family member explained Resident #2 had to go to the hospital because of this error. Review of the facility's current Medication Administration Procedures, from the Pharmacy policy and procedure Manual dated 2003, reflected, "...12. Medications prescribed for one resident are not to be administered to any other resident." Review of the facility's current policy, Oral Solid Medication Administration, from the Pharmacy Policy and Procedure Manual dated 2003, reflected, "...3. Some preparations are not meant to be opened or crushed; such as enteric coated, sustained release, and sublingual products...Certified (sic) Medication Aids (CMAs) (sic) may not crush any medication without approval." MA A's Employee Performance form, dated 02/21/14 reflected she received a written counseling related to the medication policy violation for dispensing medications. She also received a suspension during the investigation. The Discussion of Investigation Findings reflected the DON spoke with MA A on 02/25/14 at 10:00 AM. MA A would be removed from her role as a MA and was offered a role in which she would not be handling medications. MA A declined and gave her resignation. The facility's In-Service for: Medication Administration, 5 Rights to Medication Administration, dated 02/17/14, reflected 28 staff signatures. The Educational material consisted of the right client, right medication, right time, right dose and right route. Review of the Medication Pass Audits, dated 02/17/14 through 02/28/14, revealed 10 staff signatures. The audit material consisted of 38 items that were in accordance with the standards of practice, facility policy and regulation requirements. On 03/18/14 an IJ was identified. On 03/18/14 at 10:00 AM, the Administrator was notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 03/19/14, reflected there were eight residents whom received crushed medications from MA A and had the potential for a medication error. In-Services were initiated on 02/17/14, which included medication pass competency evaluations with a 100% pass rate. The pharmacy consultant was notified on 02/17/14 and assisted with an audit of controlled substances to identify discrepancies and review the MARs for affected residents. The pharmacy consultant initiated an In-Service for Prevention of Medication Error that included medications, which could not be crushed, the five rights of administration, steps to avoid medication errors, definitions of extended release and time released medications. That In-Service was held on 03/05/14. Nine staff members who were responsible for giving the medications were employed by the facility and received the In-Services. Review of the In-Service for Medication Pass presented by the pharmacy, dated 03/05/14, revealed 20 staff signatures. The Education material included the 5 rights of a medication administration, steps to avoid medication error, extended release medications and a list of medications that were not to be crushed. An interview with the DON on 03/20/14 at 3:20 PM revealed she believed the IJ occurred because MA A was distracted during the medication pass. She could not explain why MA A crushed an extended release medication. The DON explained in-services were completed that specifically addressed the failures that might have led to the error. An interview with the Administrator on 03/20/14 at 3:35 PM revealed the IJ occurred because MA A was distracted at the time of the medication pass and lacked organizational skills that would have prevented the error. He was unable to explain why MA A crushed an extended release medication. He revealed there had been a lot of in-services to retrain the staff about medication errors. The Administrator explained he monitored the DON through tracking and trending, monthly quality assurances and monthly meetings where they have discussed medication errors. Interviews with MA B, LVN C, MA H, MA I, MA J, MA K, LVN L, LVN M, LVN N, MA O, and MA P, conducted from 03/19/14 through 03/20/14 between 10:36 AM and 3:15 PM, revealed they identified the five rights of medication administration; medications that could not be crushed included: extended release, enteric coated, potassium, capsules and continuous release medications; they verbalized how to locate if a medication could or could not be crushed by viewing the electronic MARs, the medication packet, a list of non-crushable medications on all three medication carts and the nurses' drug book; they stated they identified a resident prior to medication administration by electronic MAR pictures, photographic pictures on the chart, asking the resident their names, date of birth and that they would check with the staff nurse in the event of a question. The IJ was removed on 03/20/14. On 03/20/14 at 3:15 PM the Administrator was notified the IJ was removed. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. A facsimile was received from the DON on 03/17/14 at 12:20 PM, which reflected 37 residents received medications from MA A.

Based on interview and record review, it was determined the facility failed to ensure residents were free of any significant medication errors for one (Resident #2) of six residents reviewed for medication errors. 1. Resident #2 received a crushed [MEDICATION NAME] (Opioid [MEDICATION NAME]) ER 60 mg tablet on 02/13/14, which was Resident #1's medication. Resident #2 did not have an order for [REDACTED]. Resident #2 experienced a decreased level of consciousness, an elevated heart rate and decreased oxygen saturation on 02/13/14. Resident #2 was then transferred to the emergency roiagnom on [DATE] and admitted to the hospital that day. Resident #2 was discharged from the hospital and then readmitted to the nursing facility on 02/15/14 with [DIAGNOSES REDACTED]. An IJ was identified on 03/04/14. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the other 36 residents, who received medication from MA A, by placing them at risk for not receiving physician-ordered medication, receiving the wrong medication, exacerbation of medical conditions, and/or death. 2. The facility failed to review Resident #2's urine Culture and Sensitivity Report from the hospital. The facility failed to inform the physician the antibiotic, [MEDICATION NAME], that was ordered for Resident #2's UTI, would not be effective against the organism that caused the infection. After surveyor intervention, the facility obtained another urinalysis, which indicated Resident #2 had a UTI from the same organism, the infection had worsened. She received a [MEDICATION NAME] (antibiotic) injection and was ordered [MEDICATION NAME] (antibiotic) 500 mg twice a day for 10 days. These failures could affect all 93 residents by placing them at risk for continued or increased urinary infections which could result [MEDICAL CONDITION], kidney failure and even death. Findings included: 1. Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Anxiety Disorder, Depression, and [MEDICAL CONDITION], per the most recent MDS assessment, dated 02/26/14. Her cognition was intact, and she was not suffering from any [MEDICAL CONDITION] or acute mental changes. She was also hard of hearing. Resident #2 needed the assistance of one person with bed mobility, transferring, walking in the room or corridor, dressing, toileting and personal hygiene. Resident #2 was frequently incontinent of urine and incontinent of bowel. The care plan for Resident #2 reflected an admission date of [DATE]. The care plan dated 12/02/13 reflected the resident required staff assistance with all ADLs. It reflected the resident would maintain a current level of functioning for 90 days by requiring one CNA to assist for all toileting, bathing and personal hygiene. The care plan reflected Smart Chart Tasks (A delegated list of care that must be done and charted) and assigned nine particular tasks to the CNA. The tasks included Bowel Movement, Voiding, Behaviors, AM/PM snacks, Snacks, Sleep, Diet: Regular, Bath day, Mobility alarm in Place and functioning properly when in bed. The Smart chart tasks had an onset dated 12/02/13 and included approaches for Voiding with the CNA. The care plan reflected Dehydration/Fluid Deficit Risk dated 12/02/13 which stated that the Resident will remain free from signs and symptoms of dehydration for 90 days and included the approach of monitoring for decreased urine output. Review of LVN C's Nurse's Note, dated 02/13/14 at 11:30 PM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 3:08 PM, revealed the resident was complaining of pain by touching her "stomach." Both of her pupils were assessed, and they were equal and reactive. The Note also reflected the resident said she was "fine" and "cold." Resident #2 went to lunch and returned at 1:15 PM and was reassessed as alert and oriented. Review of LVN D's Nurse's Note, dated 02/13/14 at 3:45 PM, which was a late entry placed in Resident #2's clinical record on 02/13/14 at 7:09 PM, revealed the resident had pin point pupils with the left pupil slow to respond, and the right pupil non-reactive. She could not follow verbal commands and only blinked her eyes after a sternal rub. Her oxygen saturation level was at 82% on room air and her heart rate was 125 beats per minute. The note reflected Resident #2 was transferred to the ER, and her PCP and family were notified. Review of Resident #2's hospital Serum Drug screen, dated 02/13/14 at 6:41 PM, revealed a positive result for Opiates. Review of LVN E's facility's Nurse's Note, 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which reflected Resident #2 was admitted to the hospital on [DATE] for AMS and a UTI. The Note also reflected she had "...some form of long acting drug overdose, and that [MEDICATION NAME] was given several times." An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] reflected a UTI and a possible overdose. Resident #2's admission orders [REDACTED]. The facility's Provider Investigation Report, dated 02/16/14 (the day the report was sent via facsimile to DADS), reflected, "Client was received from hospital, physician at this time confirmed client Altered Mental Status, UTI and [MEDICAL CONDITION]. Physician identified that client had received an opiate, as identified by drug screen, suspected medication had caused the AMS. Upon review of the medication list, establish a medication error had occurred related to client had no orders for opiate narcotic. At transfer to hospital, 2/13/14, client was noted to have altered mental status, HR 125, B/P 102/67, 14 (respirations), 98.0, and O2 sat 95%. Client exhibited decreased responsiveness and pupils slow to react. Physician notified and client transferred out to ER for further evaluation, assessment completed by (LVN D). No suspected injury/occurrence at this time." The report also reflected the PCP identified the opiate was received approximately six hours prior to the AMS, staff would be in-serviced on medication administration's five rights, preventing medication errors, pharmacy consult, and one-on-one in-service for MA A for prevention of medication errors and a medication pass review. MA A's signed written statement, dated 02/15/14, reflected on 02/13/14 she pulled Resident #1's medications including [MEDICATION NAME] ER 60 mg and crushed them. She wrote she gave Resident #1 his medications, but he was yelling out, so she got help and was told hospice was coming to see him. MA A then went to the next resident to continue passing medications. Two attempts for a telephone interview with MA A were unsuccessful on 03/04/14 at 12:35 PM and 03/05/14 at 10:18 AM. An interview with the DON on 03/04/14 at 9:25 AM revealed MA A and she retraced the MA's steps during the morning medication pass on 02/13/14 and concluded MA A went to Resident #2's room directly after Resident #1's room. MA A's written interview, conducted on 02/15/14 by the DON and Administrator and signed by the Weekend Nursing Supervisor, revealed each time she told them her recollection of the events, her certainty of giving Resident #1 his medications became less and less until she was not sure at all if she gave him his medication, before moving to the next room. The written interview reflected MA A described how she put medications together to crush them, including narcotics. Resident #1's February 2014 MAR indicated [REDACTED]. National Library of Medicine (NLM) http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id= reflected, "[MEDICATION NAME] sulfate extended-release tablets contain [MEDICATION NAME] sulfate, an opioid agonist and a Schedule II controlled [MEDICATION NAME] sulfate extended-release tablets are an extended-release oral formulation of [MEDICATION NAME] sulfate indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid [MEDICATION NAME] is needed for an extended period of [MEDICATION NAME] sulfate extended-release tablets 100 and 200 mg ARE FOR USE IN OPIOID-TOLERANT PATIENTS ONLY. These tablet strengths may cause fatal respiratory depression when administered to patients not previously exposed to opioids. [MEDICATION NAME] SULFATE EXTENDED-RELEASE TABLETS ARE TO BE SWALLOWED WHOLE AND ARE NOT TO BE BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED. TAKING BROKEN, CHEWED, DISSOLVED, OR CRUSHED [MEDICATION NAME] SULFATE EXTENDED-RELEASE TABLETS LEADS TO RAPID RELEASE AND ABSORPTION OF A POTENTIALLY FATAL DOSE OF [MEDICATION NAME]." (retrieved on 03/31/14). Resident #2's February 2014 Physician's Orders did not reflect an order for [REDACTED]. Resident #2's February 2014 MARs did not reveal an entry for [MEDICATION NAME] ER 60 mg. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]." An interview with MA B on 03/04/14 at 12:41 PM revealed Resident #2 took all of her medications crushed. Interview with Resident #2's family member on 03/04/14 at 10:20 AM revealed the resident received a [MEDICATION NAME] 60 mg tablet that was not ordered for her, and she was allergic to [MEDICATION NAME]. The family member explained Resident #2 had to go to the hospital because of this error. The facility's current Medication Administration Procedures policy and procedure dated 2003 reflected: "...12. Medications prescribed for one resident are not to be administered to any other resident." The facility's current Oral Solid Medication Administration policy and procedure dated 2003 reflected, "...3. Some preparations are not meant to be opened or crushed; such as [MEDICATION NAME] coated, sustained release, and sublingual products...Certified (sic) Medication Aids (CMAs) (sic) may not crush any medication without approval." MA A's Employee Performance form, dated 02/21/14 reflected she received a written counseling related to the medication policy violation for dispensing medications. She also received a suspension during the investigation. The Discussion of Investigation Findings reflected the DON spoke with MA A on 02/25/14 at 10:00 AM. MA A would be removed from her role as a MA and was offered a role in which she would not be handling medications. MA A declined and gave her resignation. The facility's In-Service for: Medication Administration, 5 Rights to Medication Administration, dated 02/17/14, reflected 28 staff signatures. The Educational material consisted of the right client, right medication, right time, right dose and right route. Review of the Medication Pass Audits, dated 02/17/14 through 02/28/14, revealed 10 staff signatures. The audit material consisted of 38 items that were in accordance with the standards of practice, facility policy and regulation requirements. On 03/18/14 an IJ was identified. On 03/18/14 at 10:00 AM, the Administrator was notified of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 03/19/14, reflected there were eight residents who received crushed medications from MA A and had the potential for a medication error. In-Services were initiated on 02/17/14, which included medication pass competency evaluations with a 100% pass rate. The pharmacy consultant was notified on 02/17/14 and assisted with an audit of controlled substances to identify discrepancies and review the MARs for affected residents. The pharmacy consultant initiated an In-Service for Prevention of Medication Error that included medications, which could not be crushed, the five rights of administration, steps to avoid medication errors, definitions of extended release and time released medications. That In-Service was held on 03/05/14. Nine staff members who were responsible for giving the medications were employed by the facility and received the In-Services. Review of the In-Service for Medication Pass presented by the pharmacy, dated 03/05/14, revealed 20 staff signatures. The Education material included the 5 rights of a medication administration, steps to avoid medication error, extended release medications and a list of medications that were not to be crushed. An interview with the DON on 03/20/14 at 3:20 PM revealed she believed the IJ occurred because MA A was distracted during the medication pass. She could not explain why MA A crushed an extended release medication. The DON explained in-services were completed that specifically addressed the failures that might have led to the error. An interview with the Administrator on 03/20/14 at 3:35 PM revealed the IJ occurred because MA A was distracted at the time of the medication pass and lacked organizational skills that would have prevented the error. The Administrator was unable to explain why MA A crushed an extended release medication. He revealed there had been a lot of in-services to retrain the staff about medication errors. The Administrator explained he monitored the DON through tracking and trending, monthly quality assurances and monthly meetings where they have discussed medication errors. Interviews with MA B, LVN C, MA H, MA I, MA J, MA K, LVN L, LVN M, LVN N, MA O, and MA P, conducted from 03/19/14 through 03/20/14 between 10:36 AM and 3:15 PM, revealed they identified the five rights of medication administration; medications that could not be crushed included: extended release, [MEDICATION NAME] coated, potassium, capsules and continuous release medications; they verbalized how to locate if a medication could or could not be crushed by viewing the electronic MARs, the medication packet, a list of non-crushable medications on all three medication carts and the nurses' drug book; they stated they identified a resident prior to medication administration by electronic MAR pictures, photographic pictures on the chart, asking the resident their names, date of birth and that they would check with the staff nurse in the event of a question. The IJ was removed on 03/20/14. On 03/20/14 at 3:15 PM the Administrator was notified the IJ was removed. While the IJ was removed on 03/20/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. A facsimile was received from the DON on 03/17/14 at 12:20 PM, which reflected 37 residents received medications from MA A. Non-Immediate Jeopardy findings 2. Review of Resident #2's admission orders [REDACTED]. Resident #2 was readmitted to the nursing facility with an order for [REDACTED]. Resident #2's Care Plan, printed on 03/04/14 at 5:30 PM did not address her UTI. Review of Resident #2's hospital Urinalysis, dated 02/13/14, revealed her urine was clear, 1+ leukocytes (white blood cells) with a reference range of negative for leukocytes, white blood cells of 40 -50 with a reference range of none, and moderate bacteria. Resident #2's hospital Culture and Sensitivity Report, which resulted on 02/15/14 at 10:03 AM, revealed Escherichia Coli (a gram-negative bacillus in the human colon) in her urine, which indicated an infection. The report also reflected the Escherichia Coli was resistant to the antibiotic, [MEDICATION NAME]. The report was found in the back of Resident #2's clinical record. Review of LVN E's Nurse's Note, dated 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which indicated the resident was admitted to the hospital on [DATE] for AMS and a UTI. An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] did include a UTI. She stated she circled the physician's order for [MEDICATION NAME] and faxed it to the pharmacy. LVN E revealed she placed all of Resident #2's hospital medical records in the back of the resident's clinical record without reviewing them. She stated she did not typically review the medical records. LVN E revealed the DON and ADON A reviewed the records. An interview with the facility's only Weekend Nursing Supervisor on 03/05/14 at approximately 2:45 PM revealed it was the Charge Nurse's responsibility to review the hospital packet of information, which accompanied the resident coming back from the hospital. She confirmed LVN E was the Charge Nurse when Resident #2 returned from the hospital on [DATE]. During the interview with the DON on 03/04/14 at 11:55 AM, she was shown the urine culture and sensitivity results from the local hospital, dated 02/15/14 at 10:03 AM, which reflected the organism was resistant to [MEDICATION NAME]. The DON was also shown Resident #2's PCP's order for [MEDICATION NAME] dated 02/15/14. The DON acknowledged they should have noticed this. She stated when tests were ordered in the hospital, the results would be received in the packet when the resident returned. The DON stated she would contact Resident #2's PCP with these findings. A telephone interview with Resident #2's PCP on 03/04/14 at 2:04 PM revealed giving an antibiotic that an infection was resistant to would not "kill the infection." She stated the facility had not contacted her about the culture and sensitivity results that reflected the [MEDICATION NAME] would be ineffective in this situation. An interview with CNA F on 03/04/14 at 2:38 PM revealed Resident #2 had been voiding a small amount of urine, an average of six times during her shift. She stated the resident had gone to the bathroom a lot more than last week. Interview with Resident #2's family member was conducted on 03/04/14 at 10:20 AM. The family member expressed concern the resident was suffering from recurrent UTIs, and the family member did not know why this kept happening to the resident. An interview on 03/04/14 at approximately 4:00 PM revealed a urine specimen was obtained from Resident #2 on 03/04/14 at 3:51 PM and sent for analysis. The Urinalysis Results, dated 03/04/14 at 3:51 PM, reflected slightly cloudy urine, positive for [MEDICATION NAME], 2+ leukocytes, greater than 100 white blood cells and many bacteria, which indicated a current UTI. The Urine culture for Resident #2, dated 03/06/14 at 12:43 PM, reflected Escherichia Coli. The DON was interviewed on 03/04/14 at approximately 5:30 PM and acknowledged having contacted the PCP with the results. She stated the PCP was in house and had written an order for [REDACTED]. Resident #2's PCP's Physician's Telephone Order, dated 03/04/14 and timed at 4:53 PM, reflected [MEDICATION NAME] 1 gram Intramuscular (injection) once for a [DIAGNOSES REDACTED]. The facility's In-Service for Lab, dated 03/05/14, reflected a post test was completed by 19 staff members. Education material included urine test results and key areas to note, culture and sensitivity definition, documentation, reporting to the doctor and documenting on the 24 hour report sheet what was done and any abnormal symptoms. Review of the Employee Performance Forms for LVN E, LVN G, the DON and ADON A, dated 03/05/14, revealed written counselings for failure to follow appropriate policies and/or procedures resulting in harm to a resident, specifically referring to the failure to identify sensitivity and antibiotic correlation and the failure to review all documentation received from the facility upon admission, to include prior labs and [DIAGNOSES REDACTED]. The facility's current resident census report dated 03/18/14 reflected the facility had a total census of 93 residents.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one (Resident #2) of six residents reviewed for health, safety and wellness. The facility failed to review Resident #2's urine Culture and Sensitivity Report from the hospital. The facility failed to inform the physician the antibiotic, [MEDICATION NAME], that was ordered for Resident #2's UTI, would not be effective against the organism that caused the infection. After surveyor intervention, the facility obtained another urinalysis, which indicated Resident #2 had a UTI from the same organism, the infection had worsened. She received a [MEDICATION NAME] (antibiotic) injection and was ordered [MEDICATION NAME] (antibiotic) 500 mg twice a day for 10 days. These failures could affect all 93 residents by placing them at risk for continued or increased urinary infections which could result [MEDICAL CONDITION], kidney failure and even death. Findings included: Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Anxiety Disorder, Depression, and [MEDICAL CONDITION], per the most recent MDS assessment, dated 02/26/14. Her cognition was intact, and she was not suffering from any [MEDICAL CONDITION] or acute mental changes. She was also hard of hearing. Resident #2 needed the assistance of one person with bed mobility, transferring, walking in the room or corridor, dressing, toileting and personal hygiene. Resident #2 was frequently incontinent of urine and incontinent of bowel. Review of Resident #2's admission orders [REDACTED]. Resident #2 was readmitted to the nursing facility with an order for [REDACTED]. Resident #2's Care Plan, printed on 03/04/14 at 5:30 PM did not address her UTI. Review of Resident #2's hospital Urinalysis, dated 02/13/14, revealed her urine was clear, 1+ leukocytes (white blood cells) with a reference range of negative for leukocytes, white blood cells of 40 -50 with a reference range of none, and moderate bacteria. Resident #2's hospital Culture and Sensitivity Report, which resulted on 02/15/14 at 10:03 AM, revealed Escherichia Coli (a gram-negative bacillus in the human colon) in her urine, which indicated an infection. The report also reflected the Escherichia Coli was resistant to the antibiotic, [MEDICATION NAME]. The report was found in the back of Resident #2's clinical record. Review of LVN E's Nurse's Note, dated 02/15/14 at 10:45 AM, which was a late entry placed in Resident #2's clinical record on 02/15/14 at 8:03 PM, revealed a report was received from the local hospital, which indicated the resident was admitted to the hospital on [DATE] for AMS and a UTI. An interview with LVN E on 03/05/14 at approximately 2:55 PM revealed the verbal report she received from the hospital on [DATE] did include a UTI. She stated she circled the physician's orders [REDACTED]. LVN E revealed she placed all of Resident #2's hospital medical records in the back of the resident's clinical record without reviewing them. She stated she did not typically review the medical records. LVN E revealed the DON and ADON A reviewed the records. An interview with the facility's only Weekend Nursing Supervisor on 03/05/14 at approximately 2:45 PM revealed it was the Charge Nurse's responsibility to review the hospital packet of information, which accompanied the resident coming back from the hospital. She confirmed LVN E was the Charge Nurse when Resident #2 returned from the hospital on [DATE]. During the interview with the DON on 03/04/14 at 11:55 AM, she was shown the urine culture and sensitivity results from the local hospital, dated 02/15/14 at 10:03 AM, which reflected the organism was resistant to [MEDICATION NAME]. The DON was also shown Resident #2's PCP's order for [MEDICATION NAME] dated 02/15/14. The DON acknowledged they should have noticed this. She stated when tests were ordered in the hospital, the results would be received in the packet when the resident returned. The DON stated she would contact Resident #2's PCP with these findings. A telephone interview with Resident #2's PCP on 03/04/14 at 2:04 PM revealed giving an antibiotic that an infection was resistant to would not "kill the infection." She stated the facility had not contacted her about the culture and sensitivity results that reflected the [MEDICATION NAME] would be ineffective in this situation. An interview with CNA F on 03/04/14 at 2:38 PM revealed Resident #2 had been voiding a small amount of urine, an average of six times during her shift. She stated the resident had gone to the bathroom a lot more that last week. An interview with ADON A on 03/04/14 at 4:55 PM revealed she was responsible for tracking and trending infections. She stated after a resident completed the prescribed antibiotic, the resident would "fall off the log." She revealed residents with urine infections would not have routine follow-up urine tests. ADON A stated when the infection resolved, they did a follow-up to ensure the residents were symptom free. She stated symptoms of a UTI were confusion, foul smelling, dark urine, fatigue, pain and urinary frequency. Interview with Resident #2's family member was conducted on 03/04/14 at 10:20 AM. The family member expressed concern the resident was suffering from recurrent UTIs, and the family member did not know why this kept happening to the resident. An interview on 03/04/14 at approximately 4:00 PM revealed a urine specimen was obtained from Resident #2 on 03/04/14 at 3:51 PM and sent for analysis. The Urinalysis Results, dated 03/04/14 at 3:51 PM, reflected slightly cloudy urine, positive for [MEDICATION NAME], 2+ leukocytes, greater than 100 white blood cells and many bacteria, which indicated a current UTI. The Urine culture for Resident #2, dated 03/06/14 at 12:43 PM, reflected Escherichia Coli. The DON was interviewed on 03/04/14 at approximately 5:30 PM and acknowledged having contacted the PCP with the results. She stated the PCP was in house and had written an order for [REDACTED]. Resident #2's PCP's Physician's Telephone Order, dated 03/04/14 and timed at 4:53 PM, reflected [MEDICATION NAME] 1 gram Intramuscular (injection) once for a [DIAGNOSES REDACTED]. The facility's In-Service for Lab, dated 03/05/14, reflected a post test was completed by 19 staff members. Education material included urine test results and key areas to note, culture and sensitivity definition, documentation, reporting to the doctor and documenting on the 24 hour report sheet what was done and any abnormal symptoms. Review of the Employee Performance Forms for LVN E, LVN G, the DON and ADON A, dated 03/05/14, revealed written counselings for failure to follow appropriate policies and/or procedures resulting in harm, to a resident specifically referring to the failure to identify sensitivity and antibiotic correlation and the failure to review all documentation received from the facility upon admission, to include prior labs and [DIAGNOSES REDACTED]. The facility's current resident census report dated 03/18/14 reflected the facility had a total census of 93 residents.

Based on observation, interview and record review, the facility failed to ensure the necessary care and services were provided to attain maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of 11 residents reviewed. Resident #1 had a history of [REDACTED]. When Resident #1's behaviors escalated the facility failed to: 1. Implement interventions in accordance with the resident's needs. On 01/23/12 the resident's care plan was updated to include a psychiatric evaluation. The referral was never made and the evaluation never done; 2. Monitor and evaluate the response to the current plan of care. Although the resident's behaviors continued to escalate and she became a risk to herself and others, The facility did not monitor and evaluate the plan of care. Medications were not monitored and evaluated for effectiveness. A second care plan on 04/04/12 identified the resident should have a psychiatric evaluation, but it was not implemented; 3. Train the facility staff on effective management of Resident #1's behaviors. Resident #1's behavior included moving about the secured unit in a merry walker with disregard for other's safety. Resident #4 was hit by Resident #1's walker and thrown off balance but did not fall. Resident #5 was hit on the hand/wrist by the walker as Resident #1's tried to move the resident out of her way. Resident #2 and Resident #2's family member were struck by Resident #1. Resident #1's behavior also placed her at risk for abuse and/or injury by staff who did not know how to respond to the resident's behaviors. LVN P responded to Resident #1's aggression with a "reflex action" resulting in a slap to the resident's head. An Immediate Jeopardy (IJ) was identified on 05/17/12. While the IJ was removed on 05/18/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy" because all staff had not been trained, the psychiatric consult had not been completed and the facility was still monitoring the plan of removal. These facility failures affected Resident #1, which allowed uncontrolled, aggressive behaviors and placed her at risk for physical/verbal abuse, neglect and/or retaliation from the other residents, visitors, and/or staff, due to her behaviors. These facility failures resulted in Resident #1 exhibiting uncontrolled, aggressive behaviors, which could likely cause an in injury to the 28 other residents on the secured unit due to being shoved, pushed or rammed by Resident #1, which could likely cause a serious injury such as a fracture or head contusion with concussion and/or hemorrhage. Findings included: 1) Review of the quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female, admitted into the facility on [DATE], with unclear speech. She sometimes could make herself understood, however rarely understood others. The MDS assessment reflected the following: She was noted as having rejected care and had exhibited wandering behaviors in the last one to three days of the assessment; She required extensive assistance with transfers from the bed to the merry walker (an ambulation device for safety) however was listed as only needing supervision for locomotion on the unit; and she had an active [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #1 was receiving scheduled pain medication regimen, received PRN pain medications and had pain daily. The MDS assessment also reflected Resident #1 was receiving antipsychotic and antianxiety medications daily. Review of the Care Plan dated 01/23/12 for Resident #1 revealed the resident "demonstrates a history of and continued behavior of verbal aggressions." Resident was also identified as having the "potential for physically abusive behavior - hitting at caregivers or resident to resident." Approaches for care included, "Make referral for psychiatric evaluation and treatment as needed." This care plan also indicated "If problem is with roommate and cannot be resolved, move resident (Resident #1) to another room to protect (the) roommate." Review of the Care Plan dated 04/03/12 for Resident #1 revealed she was identified as having "episodes of physically abusive behavior as demonstrated by combativeness with staff and hitting another resident. Hitting, pushing, (and) scratching others." The goal for the intervention was the "resident will be prevented from hurting others every shift daily for the next 90 days" and "resident, other residents and staff will be free from injuries over the next 90 days " The approaches included: ? Approaching resident calming and unhurriedly, ? Speak in a calm voice, ? Validate resident feelings. ? Attempt to calm with conversation, ? Do not argue with resident, ? Request the intervention of a staff member who had a good relationship or successful history with the resident. ? Attempt to refocus behavior to be positive when resident is showing abusive behavior, ? Provide diversionary activity, ? Separate resident from any resident toward which aggressive behavior is demonstrated, ? Remove resident from area or source of agitation, ? Determine resident mood before placing among other residents, ? Psychiatric evaluation will be requested from the physician and responsible party if indicated, ? Family will be requested to help with interventions, ? Medications as ordered by physician. Monitor for effectiveness and side effects, ? If behavior is not resolving after all the above other methods have been tried- ? Interdisciplinary team will request meeting with responsible party for resolution of behavior or determination of appropriate action- up to and including discharge to a more appropriate facility. Review of Resident #1's entire clinical record revealed no psych consult was done. 2) Observation of the secured unit on 05/17/12 at 9:15 a.m. revealed there were locking doors on all four exits of the unit. The secured unit was located between the rest of the facility (where the rehabilitation unit was located) and the hospital. The hallway in the secured unit provided a convenient throughway for visitors, residents, hospital patients and facility/hospital staff to get from the hospital to the facility and/or from the facility to the hospital. Observation revealed almost constant foot traffic through the secured unit as residents, visitors and hospital/outpatients traveled to the rehabilitation unit of the facility, which resulted in an environment, which did not provide a structured, stable, quiet atmosphere for the residents of the secured unit. 3) Interview with LVN A on 05/17/12 at 9:45 a.m. revealed there were 29 residents on the secured unit. Staffing for the unit on 05/17/12 the 6:00 a.m. to 2:00 p.m. shift included one LVN, a unit helper, a shower aide and two CNAs. LVN A described Resident #1 as active and stated that she became agitated easily. The resident was reported to kick, bite and scratch staff. LVN A revealed they put Resident #1 into her merry walker in the morning so that she could ambulate though the unit during the day. She revealed Resident #1 was on [MEDICATION NAME] and [MEDICATION NAME] twice daily to help control behaviors. Resident #1 was also on a [MEDICATION NAME] and [MEDICATION NAME] every eight hours for pain management. Additional medication for Resident #1 used for pain and behaviors that included: ABH gel, [MEDICATION NAME] and [MEDICATION NAME]. LVN A revealed Resident #1 was not currently meeting with a psychiatrist because she was cognitively impaired. When asked if she had ever been hit by Resident #1, LVN A replied, "Oh yeah. Punched, scratched, hit, (and) kicked. We just try to stay out of her way." When asked if Resident #1 had hit another resident, LVN A replied she had not hit another resident, but she had "rammed them with her chair (merry walker)." LVN A revealed Resident #1 slept for two to three days at a time and then would stay awake for two to three days. During her "awake times" she would grow in agitation; then she would "crash again and sleep for three days." An observation of Resident #1 on 05/17/11 at 9:57 a.m. revealed she was sitting in the dining room, awake, fully dressed and sitting in her merry walker. The resident was calm and eating her breakfast, sometimes napping between bites. An interview with CNA B on 05/17/12 at 10:00 a.m. revealed she had worked in the Garden View secured unit for five months and she was familiar with Resident #1. She revealed that when Resident #1 was in a good mood there were no problems. But when she was mad she was "like a wild cat, biting, punching, clawing, kicking, (and) swinging at you." She revealed "if she is awake it will happen at least once during the day." When asked if she had ever been hit by Resident #1, she revealed, "Oh yeah." She stated she had not witnessed Resident #1 hit another resident but had seen her "swing at other residents but not make contact. She will try to run them over with her merry walker." Interview on 05/17/12 at 10:07 a.m. with CNA C revealed she worked in the secured unit Monday through Friday each week. She was familiar with Resident #1 and revealed Resident #1 "would go days asleep and then wake up." Resident #1 was sometimes sweet but would also "run over anyone in her way." She revealed Resident #1 would scratch, pinch, bite, spit and hit the staff and she was most uncooperative during ADL care. When asked what she did when a resident became aggressive, CNA C revealed she would "walk away and let then calm down. Give them a few minutes." Interview on 05/17/12 at 10:15 a.m. with the AD revealed she had worked in the facility for five years and had worked with Resident #1. She revealed Resident #1 was "agitated sometimes and has behaviors of agitation." She revealed Resident#1 was "hard to redirect" and at times was physically aggressive. The AD stated Resident #1 would "get a hold of you and not let go of you." Resident #1 was observed on 05/17/12 at 11:42 a.m. to be in an agitated state, repetitively walking between exit doors of the unit with exit seeking behaviors of trying to open the door or attempting to move through the door whenever someone entered or exited the unit. When Resident #1 was by the exit doors close to the nursing station, the staff redirected the resident away from the exit doors. Redirection was for the staff to turn the resident's merry walker away from the door and point her in another direction. No redirection was attempted when she was by the exits to the gated patio or the rehabilitation unit. One-on-one supervision was not being provided at that time. 4) Review of a facility provider investigation report, dated 12/21/11 reflected an incident involving Resident #1 hitting Resident #2 on her right arm on 12/20/11 and hitting Resident #2's family member. No injuries were noted, however Resident #2's family was concerned and "felt that her mother's safety is in question on the unit." In a statement by the ADM (attached to the provider investigation report), she documented Resident #1 was "occasionally combative with staff during care, she resists at times." Provider action taken post-investigation included Resident #2 being transferred to another facility and the staff "will continue to monitor" Resident #1 when she ambulated in her merry walker. Review of Provider Investigation Report dated 04/18/12 reflected the facility had reported an abuse incident between Resident #1 and LVN P on 04/15/12 The provider description reflected " Resident (#1) hit nurse during care; nurse out of instinct/reflex hit resident back. Neither person reportedly sustained injuries that required medical intervention." The provider response included " Employee suspended until completion of investigation, Family notified of incident with name of employee kept confidential, Family later called requesting the employee not be terminated, after they discovered who the employee is." The investigation included written statements from LVN P, Staff Q and the ADM. Interview on 05/17/12 at 9:00 a.m. with ADM revealed LVN P was immediately suspended following the incident with Resident #1 on 04/17/12 and was terminated on 04/24/12 following the investigation. LVN P admitted he had hit Resident #1 as a reflex action when she had hit him in the face "pretty hard." 5) Interview on 05/17/12 at 12:25 p.m. with the SW revealed she had scheduled a Care Plan meeting with Resident #1's family on 04/25/12, however the family had canceled and it had not been rescheduled. When asked if an interdisciplinary team had met to discuss the behaviors and possible interventions for Resident #1, the SW stated there had been no care plan meeting. 6) Interview on 05/17/12 at 12:30 p.m. with the facility's only ADON revealed they were monitoring the behaviors of Resident #1. When asked what the monitoring procedure included, she revealed the staff kept the resident close to the nursing station where they could watch her. She stated they had "put her into a merry walker to protect the other residents." Observation at 2:05 p.m. - 2:30 p.m. of Resident #1 revealed she was very mobile in her merry walker. The resident was able to stand up and move quickly down the hallways of the secured unit. The surveyor, who was using a walking pace, was unable to keep up with Resident #1 as she (the resident) moved down the hallways of the facility. The resident was moving from exit door to exit door of the secured unit, in exit seeking behaviors of grabbing the door, shaking the door, banging on the door, trying to exit whenever anyone entered or exited the unit. Staff was redirecting the resident away from the doors closest to the nursing station. Resident #1 was also observed moving rapidly down the long hallway of the secured unit when she hit Resident #4 in the back of his leg with her merry walker. Resident #4 lost his balance and stumbled, but did not fall. One-on-one supervision was not being provided with Resident #1 at this time. Four independently ambulatory residents were observed in the secured unit, one male and three females. All independently ambulatory residents were moving without an assistive device and were observed to unsteady in their gait, taking shuffling steps as they walked. 7) During an interview with the ADM on 05/17/12 at 12:25 p.m., she stated they held an inservice on 03/15/12 to train the licensed nursing staff on methods of handling difficult residents, but no inservice had been provided to train CNAs on behavior management or handling of unmanageable residents. Interview on 05/17/12 at 3:25 p.m. with CNA D revealed he had "no memory" of an inservice for CNAs on behavior modification or how to work with difficult residents. When asked if he had been given specific instructions or the care plan had been discussed on how to work with the difficult behaviors of Resident #1, he stated, "No." When asked what he did when Resident #1 displayed difficult behaviors, he revealed he tried to redirect her and/or leave her alone. Interview on 05/17/12 at 3:37 p.m. with CNA E regarding resident behaviors revealed she remembered a training on resident behaviors provided about two months ago. When asked if she had been given specific instructions or discussed the care plan on how to work with Resident #1 when she had escalating behavior, she replied, "No." Interview on 05/17/12 at 3:42 p.m. with CNA F revealed she remembered some behavior management training two months ago. When asked if she had been given instructions or discussed the care plan on how to work with Resident #1 when she had escalating behaviors, she stated, "No." She revealed Resident #1 would "sleep for two to three days and then go, go, go for two to three days." She revealed Resident #1 was physically aggressive toward staff "especially when doing routine care." When asked if a resident had the right to deny care, she revealed they did. However when asked when a residents right to deny care was secondary to the residents need to be safe, she stated "I don't know. That is a tough one." CNA F was queried regarding any assistance or training provided by the ADON, DON or ADM on determining the line between the resident ' s right to refuse care and the need for nursing to provide safety to the resident. CNA F stated she had not. Observation of Resident #1 at 4:00 p.m. - 5:15 p.m. revealed the resident's agitation was increasing. Staff was conducting occasional one-on-one supervision at that time. Resident #1 was observed hitting a CNA three times and grabbing the CNA's shirt and not letting go even when directed by staff. The staff was observed cautioning other residents to get out of the way of Resident #1 as she was rapidly moving throughout the unit and instructing Resident #1 to go around other residents. Some residents were observed moving out of the way of Resident #1. However there were many residents who did not move or acknowledge the instructions of the staff to move out of the way. Resident #1 was observed to hit Resident #5 on the right hand/wrist when Resident #5 did not get out of her way. At that time, staff attempted to redirect Resident #1 by offering her a banana, but it was only shortly effective. Resident #1 reengaged with staff by grabbing their clothing and hands. Resident #1 continued to increase in agitation with exit seeking behaviors and running in her merry walker. At that same time, the PT, who was passing through the unit to the rehabilitation unit, attempted to redirect the resident. Resident #1 grabbed both of his hands and would not release them except to hit him in the left arm repeatedly with a closed fist. The ADM stepped in to try to calm the situation and Resident #1 grabbed her hand and shirt and would not let her go. The ADM tried talking with her and assessing the situation. Resident #1 was asked if she was in pain and was heard to state "Yes." During this observation, LVN G revealed Resident #1 had been administered ABH gel and staff was now attempting to give the resident [MEDICATION NAME] suspension by mouth because the resident had reported she was in pain. After several attempts, staff was unable to get the resident to take the oral [MEDICATION NAME]. The staff tried to distract Resident #1 with food and a doll. The resident threw the doll to the floor. In an interview at that time, LVN G revealed she had not called the physician to notify her of the escalating behaviors of Resident #1 and it was not normal protocol to call the doctors when behaviors were escalating. LVN G revealed she would continue to try to get Resident #1 to take the [MEDICATION NAME] because she said she was in pain. When asked if they were going to give the [MEDICATION NAME], LVN G responded she would keep trying, but Resident #1 "had said no." 8) During an interview with ADM on 05/17/12 at 12:25 p.m., she stated the facility did not have a current policy/procedure on what staff should do when interventions were not effective and a resident's behaviors become unmanageable. Review of the In-Service Training Policy Statement dated 02/01/00 included in the facility's Abuse and Neglect policies, which provided by administration on 05/17/12 as the current policy/procedure revealed: "All employees receive periodic in-service training relative to resident rights and our facility's abuse prevention program policies and procedures." Included in the procedures was the following: "...3. Annual in-service training programs include educational sessions on such topics as: ...Dealing with aggressive or catastrophic resident behavior/reactions...." 9) On 05/17/12 at 5:55 p.m., an IJ was identified in the area of Quality of Care and Administration. At that time, the ADM was informed of the IJ situation and a Plan of Removal was requested for the IJ, which had resulted due to the facility's failure to address residents with unmanageable behaviors. 10) Interview with ADM on 05/18/12 at 11:10 a.m. revealed Resident #1 had been discharged to the emergency room for evaluation and observation. Attempts were made to admit Resident #1 into a Psychiatric Hospital, however criteria for admission was not met and Resident #1 was returned to the facility where she was placed on a one to one 24 hour supervision until a psychological evaluation could be obtained. The ADM revealed a psychological evaluation has been scheduled the following Monday on 05/21/12. Observation on 05/18/12 at 11:38 a.m. of Resident #1 revealed she was in her room, on a low bed, sleeping soundly. She was tended by a nurse who revealed Resident #1 was on continuous care nursing until after a psychological evaluation on Monday, 05/28/12. Resident #1's had two family members in the room at the time of the observation. One family member reported a medication adjustment had been made by the emergency room staff the night before and Resident #1 had awakened during the night. 11) Resident #1's Physicians Orders for October 2011 reflected an order for [REDACTED]. The current order for [MEDICATION NAME] was the January 2012 order. Review of the April 2012 consolidated Physician order [REDACTED]. a) [MEDICATION NAME]-APAP 5/500 1 by mouth every eight hours, [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg 1 by mouth twice daily (ordered on [DATE]), b) [MEDICATION NAME] 1 mg IM times 1 may repeat in 2 hours if still agitated (ordered 01/01/12), c) [MEDICATION NAME] 2 mg/ml 0.25 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), d) [MEDICATION NAME] 2 mg/ml 0.5 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), e) [MEDICATION NAME] 2 mg/ml 0.75 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), f) [MEDICATION NAME] 2 mg/ml 1 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), g) ABH gel 0.5/25/1 mg apply 1 syringe topically every 4 hours as needed for agitation (ordered on [DATE]), h) [MEDICATION NAME] 5 mg/ml give one ml IM every 12 hours as needed, and i) [MEDICATION NAME] 0.5 mg give 1 by mouth twice daily. Review of the May 2012 consolidated Physician order [REDACTED]. a) [MEDICATION NAME]-APAP 5/500 1 by mouth every eight hours, [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg 1 by mouth twice daily (ordered on [DATE]), b) [MEDICATION NAME] 1 mg IM times 1 may repeat in 2 hours if still agitated (ordered 01/01/12), c) [MEDICATION NAME] Intesol 2 mg/ml 0.5 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), d) [MEDICATION NAME] 2 mg/ml 0.75 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), and e) [MEDICATION NAME] 2 mg/ml 1 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]). Review of the April 2012 and May 2012 MAR's for Resident #1 reflected she had an order for [REDACTED]. The MAR indicated [REDACTED] Review of Resident #1's MAR for April 2012 revealed 48 scheduled doses of [MEDICATION NAME] APAP 5/500 were not administered, but during the same time period, the resident received ten doses of prn pain medication ([MEDICATION NAME]). During April 2012, the resident also had 36 missed doses of [MEDICATION NAME] and 37 missed doses of [MEDICATION NAME], but received prn doses of ABH gel (5 times), [MEDICATION NAME] (13 times) and [MEDICATION NAME] (one time) for anxiety. Review of Resident #1's MAR for May 2012 revealed 29 doses of [MEDICATION NAME] APAP were omitted between 05/01/12 - 05/17/12. During the same time period, the resident received prn pain medication five times. During May 2012 ( 05/01/12 - 05/17/12), the resident had 18 doses of [MEDICATION NAME] omitted and 18 doses of [MEDICATION NAME]. During that same time period, Resident #1 had to be given six doses of prn anxiety medications (ABH gel two times, [MEDICATION NAME] three times and [MEDICATION NAME] one time). During an interview on 05/18/12 at 3:35 p.m., the ADON was queried about the medication administration decisions for Resident #1. The ADON explained that Resident #1 was not administered the scheduled doses of medication because "she (Resident #1) was sleeping." The ADON revealed the resident would often sleep for two - three days at a time and missed her medications while she was asleep. She revealed she was unaware she had missed that many doses. 12) Review of Skin Assessments sheets revealed skin assessments had been completed on all residents in the secured until with no notations of bruises of unknown origin. Skins checks for Resident #4 and #5 were specifically reviewed and no bruising was noted to either resident. Review of the facility Incident Log dated 02/17/12 - 05/18/12 reflected there were eight bruises of unknown origin on the secured unit. Resident #1 had sustained four falls and four skin tears during that period of time. Resident #1's skin tears and bruising were attributed to her ambulation though the unit and her periods of agitation. Review of the eight incidents of bruises of unknown origin between 02/17/12 - 05/18/12 reflected investigations had been conducted and Resident #1 was not identified as the cause of the bruising in any of these reports. 13) An observation was made on 05/18/12 at 1:00 p.m. of an interdisciplinary team meeting being held with the family of Resident #1 in the facility conference room. Interview with ADM on 05/18/12 at 2:00 p.m. revealed the outcome of the interdisciplinary team meeting with the family was to provide round the clock supervision for Resident #1 until the psychological evaluation could be completed on Monday, 05/28/12. After the evaluation decisions would be make to determine if Resident #1 was appropriate for continued placement in the facility or if a 24 hour or if an on-call sitter was required for Resident #1. 14) Record review of the staffing worksheet filled out by the Staffing Coordinator reflected the secured unit was staffed with one RN from 6:00 a.m. - 2:00 p.m., with one LVN on the 6:00 - 2:00 p.m., 2:00 - 10:00 p.m. and the 10:00 p.m. - 6:00 a.m. shifts. The unit was staffed with two CNA's on the 6:00 a.m. - 2:00 p.m. and the 2:00 pm. - 10:00 p.m. shift and one CNA on the 10:00 p.m. - 6:00 a.m. shift. 15) On 05/18/12 at 4:32 p.m. the facility was notified their plan of removal was accepted. Review of the Plan of Removal revealed: "...Plan of Correction for the following Six areas as identified by the surveyor: 1. The care-plan on (Resident #1) doesn't address what to do when the resident is out of control. We need instructions for the staff. Resolution: The care-plan will be reflected to include implementation of the policy on unmanageable residents on or by May 18, 2012. The care-plan also reflects initiation of one on one care until unmanageable behavior subsides. The attached policy titled Unmanageable Residents instructs staff to notify the charge nurse and gives instruction to the charge nurse for further action. ______ (SC Program Therapist) and ______ (SC RN) will be training at 2 pm on Friday May 8th . The training will include the Unmanageable Resident policy and the other related topics address in the outline attached which include: How to protect patients rights while maintaining resident safety and when to enact the Unmanageable Resident policy A. Respecting Patient Rights B. Identifying out of control/unmanageable residents C. Identifying specific triggers to initiate the Unmanageable Resident Policy D. Initiating one on one care to ensure the safety of others (note care plans) E. Resident Rights vs. Provision of Care; Where is the line drawn between resident rights and the provision of care? a. When a resident is a danger to oneself or another resident, resident safety supersedes resident rights. b. What that means is that if one resident potentially will harm oneself or another resident due to anger, due to behaviors, due to merry chair ramming, etc. then it may be allowable for staff to inhibit that resident ' s rights in favor of creating a safe environment. c. Contact ___, ADON or ___, Social Worker with any questions. d. When would you give a medication, even when the resident refuses? e. When would you deliver peri-care, even when the resident refuses? Competence will be assessed via a post-test. Thereafter, once management has been trained by attending the 2 pm education on Friday May 18th (2012) or subsequent training given by same qualified staff, management (ADON, Wound Care Nurse, Administrator, Social Worker) will be qualified to train other employees. Once the DON is trained by the initial trainers or by an individual identified as management, he will also be able to train others. All nursing staff on all shifts (including nurse aides, nurses, unit helpers, unit secretaries and medication aides) will be inserviced by someone who is qualified to train them on these matters prior to working their next scheduled shift if they did not attend the 2 pm meeting on Friday May 18th or the meeting immediately subsequent to the 2 pm meeting (to provide for opportunity for "on duty" staff to attend without us. Nursing staff from each shift (7 am-3 pm; 3 pm-11 pm;11 pm-7 am; weekdays and weekends) will be trained prior to their next scheduled shift. Other (non-nursing) staff members (i.e. housekeeping, maintenance, dietary) will be educated by a qualified member of the staff within 14 days. Qualifications of the inservice staff: Resumes attached. Both individuals currently work in an outpatient geriatric psychiatric program. ____ (RN R) is a registered nurse with [AGE] years experience in outpatient geriatric behavioral health and previously with 3 years of MHMR nursing experience. _____(Therapist S) is an LMSW with 5 years outpatient geriatric behavioral health experience. 2. CNA's need instructions for what to do when resident is out of control. Resolution: The policy on Unmanageable Residents instructs nurse aides to notify the charge nurse and further instructs the charge nurse on action to take when a resident has become unmanageable. Additionally, the inservice referenced above will give further instruction by same qualified individuals for nurse aides and all nursing staff regarding what to do when resident is out of control, during the 2 pm inservice and immediately subsequent meeting on May 18, 2012. Nursing staff from each shift (7 am-3 pm; 3 pm-11 pm;11 pm-7 am; weekdays and weekends; full time, part time and PRN) will be trained prior to their next scheduled shift. 3. Psych Consult - The resident hit another resident in December, but care-plans in January and March say to obtain a psych consult if needed. Resolution:... Update: Resident has order from attending physician to be evaluated by psych and an appointment to be seen by ______ ( Psychiatrist) on Monday May 21st for evaluation and treatment. 4. The surveyor indicated that the resident in question hit four other residents and rammed them with her merry chair. She stated also that she uses the merry chair 'as a potential weapon'. She reportedly hit 'one of the twins'. Resolution: At present, we have spoken with every available staff member that was in the unit while the surveyor was present. The nurses didn't report any communication with the surveyor regarding any injury to any of the other residents that she observed being hit. No staff members have reported that the resident in question hit another resident today. The surveyor did mention 'one of the twins', so the nurse on duty will evaluate the twins for any injuries that might have been sustained and document outcome in the residents' charts. The resident will have one on

Based on observation, interview and record review, it was determined the Administrator and the DON failed to effectively and efficiently use its resources to intervene when one (Resident #1) of 11 residents reviewed for abuse/neglect, exhibited escalating behaviors towards facility staff, residents and residents' family members. The Administrator failed to: 1) Ensure the DON was training, supervising and monitoring staff to ensure they intervened timely and effectively when Resident #1 exhibited escalating behaviors; 2) Ensure a policy/procedure was in place for residents with escalating behaviors; and 3) Implement the facility's current policy for staff training on dealing with residents with aggressive behaviors. The DON failed to: 1) Ensure Resident #1 had a care plan, which addressed procedures to be taken by staff for unmanageable escalating behaviors; 2) Train direct care staff on the care plan and/or procedures to address escalating behaviors; 3) Train nursing staff when resident's rights become secondary to resident's safety; 4) Obtain a psych consult as outlined in Resident #1's care plans when aggressive behaviors continued; 5) Have an interdisciplinary team meeting with the family when Resident #1 aggressive behaviors continued to discuss a possible resolution, and 6) Monitor medications for Resident #1 to make sure they were given according to Physicians orders and evaluated for non-compliance outcomes. Resident #1's behaviors included moving about the secured unit in a merry walker with disregard for other's safety. Resident #4 was hit by Resident #1's walker and thrown off balance but did not fall. Resident #5 was hit on the hand/wrist by the walker as Resident #1's tried to move the resident out of her way. Resident #2 and Resident #2's family member were struck by Resident #1. LVN P responded to Resident #1's aggression with a "reflex action" resulting in a slap to the resident's head. An Immediate Jeopardy (IJ) was identified on 05/17/12. While the IJ was removed on 05/18/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm that is not immediate jeopardy" because all staff had not been trained, the psychiatric consult had not been completed and the facility was still monitoring the plan of removal. These facility failures affected Resident #1, which allowed uncontrolled, aggressive behaviors and placed her at risk for physical/verbal abuse, neglect and/or retaliation from the other residents, visitors, and/or staff, due to her behaviors. These facility failures resulted in Resident #1 exhibiting uncontrolled, aggressive behaviors, which could likely cause an in injury to the 28 other residents on the secured unit due to being shoved, pushed or rammed by Resident #1, which could likely cause a serious injury such as a fracture or head contusion with concussion and/or hemorrhage. Findings included: 1) Review of the quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female, admitted into the facility on [DATE], with unclear speech. She sometimes could make herself understood, however rarely understood others. The MDS assessment reflected the following: She was noted as having rejected care and had exhibited wandering behaviors in the last one to three days of the assessment; She required extensive assistance with transfers from the bed to the merry walker (an ambulation device for safety) however was listed as only needing supervision for locomotion on the unit; and she had an active [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #1 was receiving scheduled pain medication regimen, received PRN pain medications and had pain daily. The MDS assessment also reflected Resident #1 was receiving antipsychotic and antianxiety medications daily. Review of the Care Plan dated 01/23/12 for Resident #1 revealed the resident "demonstrates a history of and continued behavior of verbal aggressions." Resident was also identified as having the "potential for physically abusive behavior - hitting at caregivers or resident to resident." Approaches for care included, "Make referral for psychiatric evaluation and treatment as needed." This care plan also indicated "If problem is with roommate and cannot be resolved, move resident (Resident #1) to another room to protect (the) roommate." Review of the Care Plan dated 04/03/12 for Resident #1 revealed she was identified as having "episodes of physically abusive behavior as demonstrated by combativeness with staff and hitting another resident. Hitting, pushing, (and) scratching others." The goal for the intervention was the "resident will be prevented from hurting others every shift daily for the next 90 days" and "resident, other residents and staff will be free from injuries over the next 90 days " The approaches included: ? Approaching resident calming and unhurriedly, ? Speak in a calm voice, ? Validate resident feelings. ? Attempt to calm with conversation, ? Do not argue with resident, ? Request the intervention of a staff member who had a good relationship or successful history with the resident. ? Attempt to refocus behavior to be positive when resident is showing abusive behavior, ? Provide diversionary activity, ? Separate resident from any resident toward which aggressive behavior is demonstrated, ? Remove resident from area or source of agitation, ? Determine resident mood before placing among other residents, ? Psychiatric evaluation will be requested from the physician and responsible party if indicated, ? Family will be requested to help with interventions, ? Medications as ordered by physician. Monitor for effectiveness and side effects, ? If behavior is not resolving after all the above other methods have been tried- ? Interdisciplinary team will request meeting with responsible party for resolution of behavior or determination of appropriate action- up to and including discharge to a more appropriate facility. Review of Resident #1's entire clinical record revealed no psych consult was done. 2) Observation of the secured unit on 05/17/12 at 9:15 a.m. revealed there were locking doors on all four exits of the unit. The secured unit was located between the rest of the facility (where the rehabilitation unit was located) and the hospital. The hallway in the secured unit provided a convenient throughway for visitors, residents, hospital patients and facility/hospital staff to get from the hospital to the facility and/or from the facility to the hospital. Observation revealed almost constant foot traffic through the secured unit as residents, visitors and hospital/outpatients traveled to the rehabilitation unit of the facility, which resulted in an environment, which did not provide a structured, stable, quiet atmosphere for the residents of the secured unit. 3) Interview with LVN A on 05/17/12 at 9:45 a.m. revealed there were 29 residents on the secured unit. Staffing for the unit on 05/17/12 the 6:00 a.m. to 2:00 p.m. shift included one LVN, a unit helper, a shower aide and two CNAs. LVN A described Resident #1 as active and stated that she became agitated easily. The resident was reported to kick, bite and scratch staff. LVN A revealed they put Resident #1 into her merry walker in the morning so that she could ambulate though the unit during the day. She revealed Resident #1 was on [MEDICATION NAME] and [MEDICATION NAME] twice daily to help control behaviors. Resident #1 was also on a [MEDICATION NAME] and [MEDICATION NAME] every eight hours for pain management. Additional medication for Resident #1 used for pain and behaviors that included: ABH gel, [MEDICATION NAME] and [MEDICATION NAME]. LVN A revealed Resident #1 was not currently meeting with a psychiatrist because she was cognitively impaired. When asked if she had ever been hit by Resident #1, LVN A replied, "Oh yeah. Punched, scratched, hit, (and) kicked. We just try to stay out of her way." When asked if Resident #1 had hit another resident, LVN A replied she had not hit another resident, but she had "rammed them with her chair (merry walker)." LVN A revealed Resident #1 slept for two to three days at a time and then would stay awake for two to three days. During her "awake times" she would grow in agitation; then she would "crash again and sleep for three days." An observation of Resident #1 on 05/17/11 at 9:57 a.m. revealed she was sitting in the dining room, awake, fully dressed and sitting in her merry walker. The resident was calm and eating her breakfast, sometimes napping between bites. An interview with CNA B on 05/17/12 at 10:00 a.m. revealed she had worked in the Garden View secured unit for five months and she was familiar with Resident #1. She revealed that when Resident #1 was in a good mood there were no problems. But when she was mad she was "like a wild cat, biting, punching, clawing, kicking, (and) swinging at you." She revealed "if she is awake it will happen at least once during the day." When asked if she had ever been hit by Resident #1, she revealed, "Oh yeah." She stated she had not witnessed Resident #1 hit another resident but had seen her "swing at other residents but not make contact. She will try to run them over with her merry walker." Interview on 05/17/12 at 10:07 a.m. with CNA C revealed she worked in the secured unit Monday through Friday each week. She was familiar with Resident #1 and revealed Resident #1 "would go days asleep and then wake up." Resident #1 was sometimes sweet but would also "run over anyone in her way." She revealed Resident #1 would scratch, pinch, bite, spit and hit the staff and she was most uncooperative during ADL care. When asked what she did when a resident became aggressive, CNA C revealed she would "walk away and let then calm down. Give them a few minutes." Interview on 05/17/12 at 10:15 a.m. with the AD revealed she had worked in the facility for five years and had worked with Resident #1. She revealed Resident #1 was "agitated sometimes and has behaviors of agitation." She revealed Resident#1 was "hard to redirect" and at times was physically aggressive. The AD stated Resident #1 would "get a hold of you and not let go of you." Resident #1 was observed on 05/17/12 at 11:42 a.m. to be in an agitated state, repetitively walking between exit doors of the unit with exit seeking behaviors of trying to open the door or attempting to move through the door whenever someone entered or exited the unit. When Resident #1 was by the exit doors close to the nursing station, the staff redirected the resident away from the exit doors. Redirection was for the staff to turn the resident's merry walker away from the door and point her in another direction. No redirection was attempted when she was by the exits to the gated patio or the rehabilitation unit. One-on-one supervision was not being provided at that time. 4) Review of a facility provider investigation report, dated 12/21/11 reflected an incident involving Resident #1 hitting Resident #2 on her right arm on 12/20/11 and hitting Resident #2's family member. No injuries were noted, however Resident #2's family was concerned and "felt that her mother's safety is in question on the unit." In a statement by the ADM (attached to the provider investigation report), she documented Resident #1 was "occasionally combative with staff during care, she resists at times." Provider action taken post-investigation included Resident #2 being transferred to another facility and the staff "will continue to monitor" Resident #1 when she ambulated in her merry walker. Review of Provider Investigation Report dated 04/18/12 reflected the facility had reported an abuse incident between Resident #1 and LVN P on 04/15/12 The provider description reflected " Resident (#1) hit nurse during care; nurse out of instinct/reflex hit resident back. Neither person reportedly sustained injuries that required medical intervention." The provider response included " Employee suspended until completion of investigation, Family notified of incident with name of employee kept confidential, Family later called requesting the employee not be terminated, after they discovered who the employee is." The investigation included written statements from LVN P, Staff Q and the ADM. Interview on 05/17/12 at 9:00 a.m. with ADM revealed LVN P was immediately suspended following the incident with Resident #1 on 04/17/12 and was terminated on 04/24/12 following the investigation. LVN P admitted he had hit Resident #1 as a reflex action when she had hit him in the face "pretty hard." 5) Interview on 05/17/12 at 12:25 p.m. with the SW revealed she had scheduled a Care Plan meeting with Resident #1's family on 04/25/12, however the family had canceled and it had not been rescheduled. When asked if an interdisciplinary team had met to discuss the behaviors and possible interventions for Resident #1, the SW stated there had been no care plan meeting. 6) Interview on 05/17/12 at 12:30 p.m. with the facility's only ADON revealed they were monitoring the behaviors of Resident #1. When asked what the monitoring procedure included, she revealed the staff kept the resident close to the nursing station where they could watch her. She stated they had "put her into a merry walker to protect the other residents." Observation at 2:05 p.m. - 2:30 p.m. of Resident #1 revealed she was very mobile in her merry walker. The resident was able to stand up and move quickly down the hallways of the secured unit. The surveyor, who was using a walking pace, was unable to keep up with Resident #1 as she (the resident) moved down the hallways of the facility. The resident was moving from exit door to exit door of the secured unit, in exit seeking behaviors of grabbing the door, shaking the door, banging on the door, trying to exit whenever anyone entered or exited the unit. Staff was redirecting the resident away from the doors closest to the nursing station. Resident #1 was also observed moving rapidly down the long hallway of the secured unit when she hit Resident #4 in the back of his leg with her merry walker. Resident #4 lost his balance and stumbled, but did not fall. One-on-one supervision was not being provided with Resident #1 at this time. Four independently ambulatory residents were observed in the secured unit, one male and three females. All independently ambulatory residents were moving without an assistive device and were observed to unsteady in their gait, taking shuffling steps as they walked. 7) During an interview with the ADM on 05/17/12 at 12:25 p.m., she stated they held an inservice on 03/15/12 to train the licensed nursing staff on methods of handling difficult residents, but no inservice had been provided to train CNAs on behavior management or handling of unmanageable residents. Interview on 05/17/12 at 3:25 p.m. with CNA D revealed he had "no memory" of an inservice for CNAs on behavior modification or how to work with difficult residents. When asked if he had been given specific instructions or the care plan had been discussed on how to work with the difficult behaviors of Resident #1, he stated, "No." When asked what he did when Resident #1 displayed difficult behaviors, he revealed he tried to redirect her and/or leave her alone. Interview on 05/17/12 at 3:37 p.m. with CNA E regarding resident behaviors revealed she remembered a training on resident behaviors provided about two months ago. When asked if she had been given specific instructions or discussed the care plan on how to work with Resident #1 when she had escalating behavior, she replied, "No." Interview on 05/17/12 at 3:42 p.m. with CNA F revealed she remembered some behavior management training two months ago. When asked if she had been given instructions or discussed the care plan on how to work with Resident #1 when she had escalating behaviors, she stated, "No." She revealed Resident #1 would "sleep for two to three days and then go, go, go for two to three days." She revealed Resident #1 was physically aggressive toward staff "especially when doing routine care." When asked if a resident had the right to deny care, she revealed they did. However when asked when a residents right to deny care was secondary to the residents need to be safe, she stated "I don't know. That is a tough one." CNA F was queried regarding any assistance or training provided by the ADON, DON or ADM on determining the line between the resident ' s right to refuse care and the need for nursing to provide safety to the resident. CNA F stated she had not. Observation of Resident #1 at 4:00 p.m. - 5:15 p.m. revealed the resident's agitation was increasing. Staff was conducting occasional one-on-one supervision at that time. Resident #1 was observed hitting a CNA three times and grabbing the CNA's shirt and not letting go even when directed by staff. The staff was observed cautioning other residents to get out of the way of Resident #1 as she was rapidly moving throughout the unit and instructing Resident #1 to go around other residents. Some residents were observed moving out of the way of Resident #1. However there were many residents who did not move or acknowledge the instructions of the staff to move out of the way. Resident #1 was observed to hit Resident #5 on the right hand/wrist when Resident #5 did not get out of her way. At that time, staff attempted to redirect Resident #1 by offering her a banana, but it was only shortly effective. Resident #1 reengaged with staff by grabbing their clothing and hands. Resident #1 continued to increase in agitation with exit seeking behaviors and running in her merry walker. At that same time, the PT, who was passing through the unit to the rehabilitation unit, attempted to redirect the resident. Resident #1 grabbed both of his hands and would not release them except to hit him in the left arm repeatedly with a closed fist. The ADM stepped in to try to calm the situation and Resident #1 grabbed her hand and shirt and would not let her go. The ADM tried talking with her and assessing the situation. Resident #1 was asked if she was in pain and was heard to state "Yes." During this observation, LVN G revealed Resident #1 had been administered ABH gel and staff was now attempting to give the resident [MEDICATION NAME] suspension by mouth because the resident had reported she was in pain. After several attempts, staff was unable to get the resident to take the oral [MEDICATION NAME]. The staff tried to distract Resident #1 with food and a doll. The resident threw the doll to the floor. In an interview at that time, LVN G revealed she had not called the physician to notify her of the escalating behaviors of Resident #1 and it was not normal protocol to call the doctors when behaviors were escalating. LVN G revealed she would continue to try to get Resident #1 to take the [MEDICATION NAME] because she said she was in pain. When asked if they were going to give the [MEDICATION NAME], LVN G responded she would keep trying, but Resident #1 "had said no." 8) During an interview with ADM on 05/17/12 at 12:25 p.m., she stated the facility did not have a current policy/procedure on what staff should do when interventions were not effective and a resident's behaviors become unmanageable. Review of the In-Service Training Policy Statement dated 02/01/00 included in the facility's Abuse and Neglect policies, which provided by administration on 05/17/12 as the current policy/procedure revealed: "All employees receive periodic in-service training relative to resident rights and our facility's abuse prevention program policies and procedures." Included in the procedures was the following: "...3. Annual in-service training programs include educational sessions on such topics as: ...Dealing with aggressive or catastrophic resident behavior/reactions...." 9) On 05/17/12 at 5:55 p.m., an IJ was identified in the area of Quality of Care and Administration. At that time, the ADM was informed of the IJ situation and a Plan of Removal was requested for the IJ, which had resulted due to the facility's failure to address residents with unmanageable behaviors. 10) Interview with ADM on 05/18/12 at 11:10 a.m. revealed Resident #1 had been discharged to the emergency room for evaluation and observation. Attempts were made to admit Resident #1 into a Psychiatric Hospital, however criteria for admission was not met and Resident #1 was returned to the facility where she was placed on a one to one 24 hour supervision until a psychological evaluation could be obtained. The ADM revealed a psychological evaluation has been scheduled the following Monday on 05/21/12. Observation on 05/18/12 at 11:38 a.m. of Resident #1 revealed she was in her room, on a low bed, sleeping soundly. She was tended by a nurse who revealed Resident #1 was on continuous care nursing until after a psychological evaluation on Monday, 05/28/12. Resident #1's had two family members in the room at the time of the observation. One family member reported a medication adjustment had been made by the emergency room staff the night before and Resident #1 had awakened during the night. 11) Resident #1's Physicians Orders for October 2011 reflected an order for [REDACTED]. The current order for [MEDICATION NAME] was the January 2012 order. Review of the April 2012 consolidated Physician order [REDACTED]. a) [MEDICATION NAME]-APAP 5/500 1 by mouth every eight hours, [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg 1 by mouth twice daily (ordered on [DATE]), b) [MEDICATION NAME] 1 mg IM times 1 may repeat in 2 hours if still agitated (ordered 01/01/12), c) [MEDICATION NAME] 2 mg/ml 0.25 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), d) [MEDICATION NAME] 2 mg/ml 0.5 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), e) [MEDICATION NAME] 2 mg/ml 0.75 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), f) [MEDICATION NAME] 2 mg/ml 1 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), g) ABH gel 0.5/25/1 mg apply 1 syringe topically every 4 hours as needed for agitation (ordered on [DATE]), h) [MEDICATION NAME] 5 mg/ml give one ml IM every 12 hours as needed, and i) [MEDICATION NAME] 0.5 mg give 1 by mouth twice daily. Review of the May 2012 consolidated Physician order [REDACTED]. a) [MEDICATION NAME]-APAP 5/500 1 by mouth every eight hours, [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg 1 by mouth twice daily (ordered on [DATE]), b) [MEDICATION NAME] 1 mg IM times 1 may repeat in 2 hours if still agitated (ordered 01/01/12), c) [MEDICATION NAME] Intesol 2 mg/ml 0.5 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), d) [MEDICATION NAME] 2 mg/ml 0.75 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]), and e) [MEDICATION NAME] 2 mg/ml 1 cc sublingual or by mouth every 4 hours as needed for anxiety (ordered on [DATE]). Review of the April 2012 and May 2012 MAR's for Resident #1 reflected she had an order for [REDACTED]. The MAR indicated [REDACTED] Review of Resident #1's MAR for April 2012 revealed 48 scheduled doses of [MEDICATION NAME] APAP 5/500 were not administered, but during the same time period, the resident received ten doses of prn pain medication ([MEDICATION NAME]). During April 2012, the resident also had 36 missed doses of [MEDICATION NAME] and 37 missed doses of [MEDICATION NAME], but received prn doses of ABH gel (5 times), [MEDICATION NAME] (13 times) and [MEDICATION NAME] (one time) for anxiety. Review of Resident #1's MAR for May 2012 revealed 29 doses of [MEDICATION NAME] APAP were omitted between 05/01/12 - 05/17/12. During the same time period, the resident received prn pain medication five times. During May 2012 ( 05/01/12 - 05/17/12), the resident had 18 doses of [MEDICATION NAME] omitted and 18 doses of [MEDICATION NAME]. During that same time period, Resident #1 had to be given six doses of prn anxiety medications (ABH gel two times, [MEDICATION NAME] three times and [MEDICATION NAME] one time). During an interview on 05/18/12 at 3:35 p.m., the ADON was queried about the medication administration decisions for Resident #1. The ADON explained that Resident #1 was not administered the scheduled doses of medication because "she (Resident #1) was sleeping." The ADON revealed the resident would often sleep for two - three days at a time and missed her medications while she was asleep. She revealed she was unaware she had missed that many doses. 12) Review of Skin Assessments sheets revealed skin assessments had been completed on all residents in the secured until with no notations of bruises of unknown origin. Skins checks for Resident #4 and #5 were specifically reviewed and no bruising was noted to either resident. Review of the facility Incident Log dated 02/17/12 - 05/18/12 reflected there were eight bruises of unknown origin on the secured unit. Resident #1 had sustained four falls and four skin tears during that period of time. Resident #1's skin tears and bruising were attributed to her ambulation though the unit and her periods of agitation. Review of the eight incidents of bruises of unknown origin between 02/17/12 - 05/18/12 reflected investigations had been conducted and Resident #1 was not identified as the cause of the bruising in any of these reports. 13) An observation was made on 05/18/12 at 1:00 p.m. of an interdisciplinary team meeting being held with the family of Resident #1 in the facility conference room. Interview with ADM on 05/18/12 at 2:00 p.m. revealed the outcome of the interdisciplinary team meeting with the family was to provide round the clock supervision for Resident #1 until the psychological evaluation could be completed on Monday, 05/28/12. After the evaluation decisions would be make to determine if Resident #1 was appropriate for continued placement in the facility or if a 24 hour or if an on-call sitter was required for Resident #1. 14) Record review of the staffing worksheet filled out by the Staffing Coordinator reflected the secured unit was staffed with one RN from 6:00 a.m. - 2:00 p.m., with one LVN on the 6:00 - 2:00 p.m., 2:00 - 10:00 p.m. and the 10:00 p.m. - 6:00 a.m. shifts. The unit was staffed with two CNA's on the 6:00 a.m. - 2:00 p.m. and the 2:00 pm. - 10:00 p.m. shift and one CNA on the 10:00 p.m. - 6:00 a.m. shift. 15) On 05/18/12 at 4:32 p.m. the facility was notified their plan of removal was accepted. Review of the Plan of Removal revealed: "...Plan of Correction for the following Six areas as identified by the surveyor: 1. The care-plan on (Resident #1) doesn't address what to do when the resident is out of control. We need instructions for the staff. Resolution: The care-plan will be reflected to include implementation of the policy on unmanageable residents on or by May 18, 2012. The care-plan also reflects initiation of one on one care until unmanageable behavior subsides. The attached policy titled Unmanageable Residents instructs staff to notify the charge nurse and gives instruction to the charge nurse for further action. ______ (SC Program Therapist) and ______ (SC RN) will be training at 2 pm on Friday May 8th . The training will include the Unmanageable Resident policy and the other related topics address in the outline attached which include: How to protect patients rights while maintaining resident safety and when to enact the Unmanageable Resident policy A. Respecting Patient Rights B. Identifying out of control/unmanageable residents C. Identifying specific triggers to initiate the Unmanageable Resident Policy D. Initiating one on one care to ensure the safety of others (note care plans) E. Resident Rights vs. Provision of Care; Where is the line drawn between resident rights and the provision of care? a. When a resident is a danger to oneself or another resident, resident safety supersedes resident rights. b. What that means is that if one resident potentially will harm oneself or another resident due to anger, due to behaviors, due to merry chair ramming, etc. then it may be allowable for staff to inhibit that resident ' s rights in favor of creating a safe environment. c. Contact ___, ADON or ___, Social Worker with any questions. d. When would you give a medication, even when the resident refuses? e. When would you deliver peri-care, even when the resident refuses? Competence will be assessed via a post-test. Thereafter, once management has been trained by attending the 2 pm education on Friday May 18th (2012) or subsequent training given by same qualified staff, management (ADON, Wound Care Nurse, Administrator, Social Worker) will be qualified to train other employees. Once the DON is trained by the initial trainers or by an individual identified as management, he will also be able to train others. All nursing staff on all shifts (including nurse aides, nurses, unit helpers, unit secretaries and medication aides) will be inserviced by someone who is qualified to train them on these matters prior to working their next scheduled shift if they did not attend the 2 pm meeting on Friday May 18th or the meeting immediately subsequent to the 2 pm meeting (to provide for opportunity for "on duty" staff to attend without us. Nursing staff from each shift (7 am-3 pm; 3 pm-11 pm;11 pm-7 am; weekdays and weekends) will be trained prior to their next scheduled shift. Other (non-nursing) staff members (i.e. housekeeping, maintenance, dietary) will be educated by a qualified member of the staff within 14 days. Qualifications of the inservice staff: Resumes attached. Both individuals currently work in an outpatient geriatric psychiatric program. ____ (RN R) is a registered nurse with [AGE] years experience in outpatient geriatric behavioral health and previously with 3 years of MHMR nursing experience. _____(Therapist S) is an LMSW with 5 years outpatient geriatric behavioral health experience. 2. CNA's need instructions for what to do when resident is out of control. Resolution: The policy on Unmanageable Residents instructs nurse aides to notify the charge nurse and further instructs the charge nurse on action to take when a resident has become unmanageable. Additionally, the inservice referenced above will give further instruction by same qualified individuals for nurse aides and all nursing staff regarding what to do when resident is out of control, during the 2 pm inservice and immediately subsequent meeting on May 18, 2012. Nursing staff from each shift (7 am-3 pm; 3 pm-11 pm;11 pm-7 am; weekdays and weekends; full time, part time and PRN) will be trained prior to their next scheduled shift. 3. Psych Consult - The resident hit another resident in December, but care-plans in January and March say to obtain a psych consult if needed. Resolution:... Update: Resident has order from attending physician to be evaluated by psych and an appointment to be seen by ______ ( Psychiatrist) on Monday May 21st for evaluation and treatment. 4. The surveyor indicated that the resident in question hit four other residents and rammed them with her merry chair. She stated also that she uses the merry chair 'as a potential weapon'. She reportedly hit 'one of the twins'. Resolution: At present, we have spoken with every available staff member that was in the unit while the surveyor was present. The nurses didn't report any communication with the surveyor regarding any injury to any of the other residents that she observed being hit. No staff members have reported that the resident in question hit another resident today. The surveyor did mention 'one of the twins', so the nurse on duty will evaluate the twins for any injurie

Based on observation, interview and record review, it was determined the facility Administrator and DON failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 1) The ADM and the DON failed to ensure the facility was a smoke-free facility when they allowed the admission on 12/12/08 of one (Resident #12) of one resident reviewed for smoking, who was a known smoker, almost two years previously. 2) The ADM and the DON failed to train staff and implement their smoking policy/procedure. 3) The ADM and the DON failed to ensure there was a smoking assessment tool implemented, which reflected the resident's cognitive and/or physical status, and subsequently permitted unsafe and unsupervised smoking by Resident #12. 4) The ADM and the DON failed to ensure the development of a care plan, which realistically addressed and implemented interventions to ensure the safety of Resident #12 and the other 92 residents in the facility by providing supervision for the resident and control of the resident's smoking paraphernalia. An Immediate Jeopardy (IJ) was identified on 11/02/10. While the IJ was removed on 11/04/10, the facility remained out of compliance at a scope of "widespread" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still inservicing staff and monitoring implementation of the plan of removal. These failures could affect the facility's 93 residents, including Resident #12, and placed them at risk for for being exposed to a fire resulting in the potential for evacuation, injury, smoke inhalation and the need for medical treatment and hospitalization . Findings included: 1) During the survey's Entrance Conference, conducted on 11/01/10 at 9:30 a.m. with the Administrator, the surveyor provided a list of items to be provided by the facility, which included the facility's smoking policies. 2) Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] reflected Resident #12 received assistance with ADLs and required the assistance of one staff member for all transfers due to poor muscle tone and endurance. Resident #12 was independently mobile around the facility in her wheelchair. The MDS assessment reflected Resident #12's cognitive status had declined over the past 90 days. Resident #12's nursing notes dated 09/07/10 at 2:35 p.m. reflected: Resident #12 had been asked two times, not to sit in the (exit)doorway and smoke. The resident was half in and half out the door. The smoke could be smelled all the way down to the nursing station. The resident refused to put out the cigarette and shut the door. The resident wheeled further out the door and continued to smoke. The resident was reminded to only go out the front doors to smoke and not go out the doors by the time clock, because staff would not be aware the resident was outside and the resident would not be monitored. (Note: The designated smoking area was easier to get to from the doors by the time clock.) Review of Resident #12's initial Healthcare plans dated, 12/08/08 and quarterly care plan reviews from 03/08/09 through 08/23/10 revealed there was no care plan, which had been developed to address Resident #12's smoking. Resident #12's physician's progress notes dated 10/12/10 reflected the resident had no physical problems and had "severe dementia." Review of Resident #12's entire clinical record revealed the resident had not ever been assessed for safe smoking. 3) On 11/02/10 at 11:30 a.m., Resident #12 was observed trying to go outside. LVN B opened the front doors and let the resident out. Resident #12 rolled her wheelchair out, about 100 feet from the front door. This was not the approved smoking area according to facility's policy. Three surveyors were outside at that time and observed Resident #12 take cigarettes and a lighter from the purse, lighting the cigarette. LVN B returned outside to Resident #12 and placed a smoking apron on Resident #12. LVN B returned to the facility leaving the resident unsupervised. Resident #12 immediately removed the apron and stuffed it in the side of the wheelchair. At that time, the surveyor asked Resident #12 if she always wore the apron when smoking. The resident stated, "I swear to god. This is the first time I have seen this thing. What is it?" The facility's designated smoking area was observed on 11/02/10 at 11:00 a.m., located on the south side of the building. A bench had a sign on it, which reflected, "smoking area." Resident #12 was never observed smoking in this area. 4) Immediately following this observation, the surveyor alerted the ADM and the DON Resident #12 was smoking outside the building unsupervised. The ADM and DON said they would look into the surveyors' concern. The surveyor again requested the facility's smoking policies from the ADM and the DON. 5) The facility's Resident Smoking Policy, with a revision date of 11/03/07, was provided for review on 11/02/10 at 11:50 a.m. by the DON as current. The policy reflected the following: "This policy intends to curtail residents to smoke only in designated areas and only in the presence of a family/caregiver, not an employee." ..."Employees are not permitted to take a resident out to smoke, only family members/caregivers are designated to do so." ..."Residents are not permitted to keep cigarettes and/or lighters in their rooms or on their person. Cigarettes and lighters are to be kept locked up at the nurses' station and are only to be given to the resident when they are in the company of a family member/caregiver to assist the resident out to one of the designated areas." 6) On 11/02/10 at 1:10 p.m., Resident #12 was observed again smoking unsupervised outside the building. Sparks of hot ashes were observed blowing onto adjacent dry grass and the clothing of the resident when she attempted to put out her cigarette against the wall of the building. 7) On 11/02/10 at 2:30 p.m., during a meeting with the Administrator and DON, the surveyor expressed the survey team's concerns with unsupervised smoking, no smoking assessments, and failure to supervise Resident #12, a smoking resident. Specific observations related to Resident #12, who was observed twice smoking unsupervised outside the building. Sparks of fire observed blowing onto adjacent dry grass, and the clothing of Resident #12 when she attempted to put out her cigarette against the wall of the building, were discussed with the facility. During this meeting, the surveyor asked why Resident #12 was only to be supervised by a family member/caregiver and not a facility employee according to the smoking policy. The surveyor further asked why Resident #12 was not supervised after the Administrator and the DON were alerted at 11:30 a.m. that the resident needed to be supervised. There was no response from the Administrator and the DON. During the same meeting the surveyor asked if Resident #12 was a safe smoker and the DON stated, "No." During this meeting, the Administrator stated they would address this concern right away. The Administrator further stated at that time, the facility was a non-smoking facility. The ADM acknowledged the facility had admitted Resident #12, who was a known smoker, and Resident #12 was the only resident who smoked in the facility. 8) On 11/02/10 at 3:00 p.m., the surveyor observed Resident #12 sitting in her room. During this observation, the surveyor asked the resident where she stored her smoking paraphernalia. Resident #12 showed her cigarette and lighter were tucked away in her purse. 9) LVNs A, B, C, D, E and F were interviewed on 11/02/10 from 1:30 p.m., through 3:30 p.m. When questioned, all six LVN's stated they were unaware of a safe smoking assessment policy. LVNs A, B, C and D all stated individually Resident #12 went outside to smoke unsupervised "all the time," except when the family member and/or caregiver took the resident outside to smoke. LVN D stated Resident #12 had a caregiver, who came to the facility three times a week and stayed from 9:00 a.m. until 3:00 p.m. LVNs E and F stated Resident #12 went outside by herself in the late afternoon and evenings and smoked by the front door (not the designated smoking area according to facility policy). LVNs A, B and E stated the caregiver would buy Resident #12 cigarettes when she ran out and give them to her. The LVNs stated they were aware Resident #12 had the smoking items in her purse, but no one ever took they away from her. On 11/02/10 at 3:30 p.m., LVNs G, H, I and J were interviewed together and all agreed Resident #12 had smoked since her admission to the facility and she went outside, unsupervised, to smoke "all the time." LVN G stated Resident #12 did not smoke in the approved/designated smoking area. 10) An IJ was identified on 11/02/10. On 11/02/10 at 3:35 p.m., the surveyors met with the ADM and the DON and informed them of the IJ in the area of Administration. A Plan of Removal for the IJ was requested. They were further notified of the surveyors' concerns for resident safety related to the observations of unsafe smoking practices by Resident #12, the failure of facility staff to supervise the resident and the failure to ensure Resident #12 did not store her smoking paraphernalia in her room instead of at the nursing station per facility policy. 11) Review on 11/03/10 of the facility's in-services for the past 12 months revealed no documented in-services regarding smoking policies and procedures. 12) On 11/03/10 at 11:30 a.m. the surveyor queried the Administrator and the DON again about the facility being a non-smoking facility according to their policy and what provision had been given to accommodate Resident #12's smoking habit. During this interview the Administrator stated Resident #12 would be "grandfathered in" under the facility's non-smoking policy. 13) The initial Plan of Removal dated 11/02/10, revised on 11/03/10 and accepted on 11/04/10 reflected the following: Resident #12's smoking paraphernalia was removed from her possession and locked up at the nurse's station. A meeting was held with the resident's family member to inform the family member of the need to keep smoking paraphernalia locked up and for the resident to be supervised at all times when smoking. On 11/03/10, the family member was informed of the times smoking schedule set up for Resident #12 and staff supervision. A Quality Assurance meeting was held on 11/03/10 to ensure the needs and rights of Resident #12 were being met by the facility. The facility smoking policy was revised, smoking was scheduled for specific times along with staff responsible for supervising Resident #12, and a care plan was revised to address Resident #12's smoking needs. Staff members were to be provided training on the new care plan and facility smoking policy and procedure with validation of staff knowledge being accomplished by a written quiz. The Resident Smoking Policy, revised 11/03/10 (and provided by the Administrator at 2:00 PM on 11/03/10) reflected: "PURPOSE: The purpose of this policy is to provide all residents with an understanding of the ____ (facility) policy on tobacco use. This policy is designed to promote the cleanliness and quality of indoor and outdoor air and to enhance the health environment and working condition of everyone on our campus. ...This policy intends to reflect the commitment of ____ (facility) to minimize the harmful effects of tobacco use. SCOPE: This policy applies to all ____ (facility) residents and their family members/caregivers. ____ (facility) is committed to promote the health of its residents by offering assistance in cessation. POLICY: It is the policy of ____ (facility) to support a Smoke-Free Campus. All grounds and property are to be smoke-free. Residents are not permitted to smoke on facility premises or have cigarettes, lighters, or other smoking materials in the facility at any time. Prior to admission, residents and their families/caregiver will be educated on our smoking policy... GRANDFATHER CLAUSE: Any resident who is already living in this facility as of 11/3/2010 and is a current smoker will be allowed to continue to smoke only with direct supervision. The resident will have assigned times, every two hours while awake, for staff members to supervise the resident during the smoke break. The resident will only be allowed to smoke in an already designated employee smoking area. Smoking materials may not be kept in the resident's possession...." A smoking schedule was set up for every two hours from 7:00 a.m. through 9:00 p.m. with departments specified as responsible for supervising the scheduled smoke times. Staff inservicing began on 11/03/10 in regard to the new resident smoking policy with a completion date of 11/05/10. Inservices will be conducted by the ADM with a written quiz to validate the staff's understanding of the changes. Resident #12's care plan was updated 11/03/10 to reflect the changes in the smoking policy and procedure. Administrative staff will monitor beginning 11/04/10 to ensure compliance Monday through Friday. On Saturday and Sunday, the MDS Coordinator will monitor for compliance. On 11/09/10, during the facility's Quality Improvement (QI) meeting with the QI team, including the Medical Director, the smoking policy will be reviewed with further ways to monitor compliance to be developed. The QI meetings are held monthly. 14) On 11/04/10 at 10:00 a.m. and at 1:00 p.m., observations of Resident #12 revealed she was supervised by facility staff at the designated smoking times. There was no smoking paraphernalia in her room. 15) On 11/04/10 at approximately 9:00 a.m., the inservice training on the facility's newly revised "smoking policy" was reviewed with the DON. The DON stated several staff members had not been inserviced, but would receive the training on 11/05/10. 16) On 11/04/10 at 6:30 a.m., LVNs I and J were interviewed. Both LVNs stated they had received the inservice training on the newly revised smoking policy/procedure on 11/03/10 around 11:00 p.m. They were conversant with the newly revised smoking policy and aware of the measures in place for Resident #12 to smoke with supervision. LVNs A, B and D were interviewed on 11/04/10 at 10:00 a.m., and stated they had received the inservice program on the newly revised smoking policy/procedure on 11/03/10. They were conversant with the newly revised smoking policy and aware of the measures in place for Resident #12 to smoke with supervision. LVN H was interviewed on 11/04/10 at 3:00 p.m. The LVN stated he had received the inservice program on the newly revised smoking policy/procedure on 11/03/10 around 9:00 p.m. LVN H was conversant with the newly revised smoking policy and aware of the measures in place for Resident #12 to smoke with supervision. 17) On 11/04/10 at 1:30 p.m., the surveyor asked the Administrator how he thought the IJ occurred regarding the care for Resident #12. He stated, "We did not follow policy and allowed her to smoke without supervision." During this interview, the surveyor asked whether the facility had discussed smoking issues in any of their monthly Quality Assurance (QA) meetings. The Administrator said smoking had not been discussed until the survey team identified the problem. The Administrator stated during the QA meeting held on 11/04/10, the facility had discussed smoking, and he was monitoring all staff to ensure sign-in sheets were turned in according to the smoking schedule implemented for Resident #12. 18) On 11/04/10 at 1:40 p.m., the DON stated staff were kept updated on the activities of the QA meeting concerning smoking, and the new smoking policy by information provided during in-services, posted on assignment sheets, a written post-test, and on the staff sign-in sheet. During this same interview the surveyor asked the DON how she thought the IJ occurred regarding the care for Resident #12. The DON stated, "The resident was smoking by herself. We didn't have a plan in place. It was unsafe." 19) While the IJ was removed on 11/04/10, the facility remained out of compliance at a scope of "widespread" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still inservicing staff and monitoring implementation of the plan of removal. 20) The CMS-672 (Resident Census and Conditions of Residents) dated 11/02/10 and provided by the DON reflected the census was 93.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and one (Resident #12) of one resident reviewed for unsupervised smoking received adequate supervision and assistance devices to prevent accidents. Failures included: 1) Resident #12, who was an unsafe smoker, was allowed to smoke without supervision for almost two years. Resident #12 put out cigarettes on the side of the building and threw cigarette butts onto the ground. Sparks blew onto dry grass and the resident's clothing. 2) Resident #12 had cigarettes and lighter in her possession. 3) No interventions were implemented to keep Resident #12 and the rest of the residents in the facility safe when she smoked. An Immediate Jeopardy (IJ) was identified on 11/02/10. While the IJ was removed on 11/04/10, the facility remained out of compliance at a scope of "widespread" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still inservicing staff and monitoring implementation of the plan of removal. This failure could affect the facility's 93 residents, including Resident #12, and placed the residents at risk for being exposed to a fire resulting in the potential for evacuation, injury, smoke inhalation and the need for medical treatment and hospitalization . Findings: 1) Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] reflected Resident #12 received assistance with ADLs and required the assistance of one staff member for all transfers due to poor muscle tone and endurance. Resident #12 was independently mobile around the facility in her wheelchair. The MDS assessment reflected Resident #12's cognitive status had declined over the past 90 days. Review of Resident #12's initial Healthcare plans dated, 12/08/08 and quarterly care plan reviews from 03/08/09 through 08/23/10 revealed there was no care plan, which had been developed to address Resident #12's smoking. Resident #12's nursing notes dated 09/07/10 at 2:35 p.m. reflected: Resident #12 had been asked two times, not to sit in the (exit)doorway and smoke. The resident was half in and half out the door. The smoke could be smelled all the way down to the nursing station. The resident refused to put out the cigarette and shut the door. The resident wheeled further out the door and continued to smoke. The resident was reminded to only go out the front doors to smoke and not go out the doors by the time clock, because staff would not be aware the resident was outside and the resident would not be monitored. (Note: The designated smoking area was easier to get to from the door by the time clock. The resident was not smoking in the designated smoking area.) Resident #12's physician's progress notes dated 10/12/10 reflected the resident had no physical problems and had "severe dementia." Review of Resident #12's entire clinical record revealed the resident had not ever been assessed for safe smoking. 2) On 11/02/10 at 11:30 a.m., Resident #12 was observed trying to go outside. LVN B opened the front doors and let the resident out. Resident #12 rolled her wheelchair out, about 100 feet from the front door. This was not the approved smoking area according to facility's policy. Three surveyors were outside at that time and observed Resident #12 take cigarettes and a lighter from the purse, lighting the cigarette. LVN B returned outside to Resident #12 and placed a smoking apron on Resident #12. LVN B returned to the facility leaving the resident unsupervised. Resident #12 immediately removed the apron and stuffed it in the side of the wheelchair. At that time, the surveyor asked Resident #12 if she always wore the apron when smoking. The resident stated, "I swear to god. This is the first time I have seen this thing. What is it?" The facility's designated smoking area was observed on 11/02/10 at 11:00 a.m., located on the south side of the building. A bench had a sign on it, which reflected, "smoking area." Resident #12 was never observed smoking in this area. 3) On 11/02/10 at 11:45 a.m., the DON was informed by the surveyors Resident #12 was outside smoking unsupervised. The DON stated, "The Administrator will have to handle that." The DON was then asked if the resident had been assessed for safe smoking, and did the facility have a safe smoking policy. The DON responded she was not aware of what a safe smoking policy was, and the facility was a non-smoking facility. At that time, when asked further about Resident #12's smoking habits, the DON stated the family would come and take the resident out to smoke, and the resident had a caregiver three days a week, who would take the resident out to smoke. The Administrator was interviewed on 11/02/10 at 11:50 a.m. and informed about Resident #12's smoking habits. The Administrator was asked about a safe smoking policy. The Administrator informed the surveyors the facility's current smoking policy was in the admission packet. 4) Review of the facility's current smoking policy, dated 03/01/05 and revised on 11/13/07 revealed: "This policy intends to curtail residents to smoking only in designated areas and only in the presence of a family/caregiver, not an employee. ...Employees are not permitted to take a resident out to smoke, only family members/caregivers are designated to do so. ...Residents are not permitted to keep cigarettes and/or lighters in their rooms or on their person. Cigarettes and lighters are to be kept locked up at the nurses' station and are only to be given to the resident when they are in the company of a family member/caregiver to assist the resident out to one of the designated areas." 5) On 11/02/10 at 1:10 p.m., Resident #12 was observed alone and unsupervised, outside smoking. At that time, Resident #12 was interviewed by the surveyor. The resident was asked where her cigarettes and lighter were. The resident showed the surveyor the cigarettes and lighter in the purse. (Note) Resident #12 was just outside the front door, and this was not the approved smoking area. Resident #12 was asked if she knew what day and month it was, and who the President of the United States was. The resident was unable to say what day it was, but thought the month was November. Resident #12 could not say who the current President was. At that time, LVN A observed the surveyor and Resident #12 outside and came out of the facility. LVN A informed Resident #12 someone had to come outside when the resident wanted to smoke. Resident #12 responded by saying "I am very careful," and proceeded to drop ashes on the ground and stubbed the cigarette out on the side of the building. Sparks were flying all over the ground, the resident's clothing and an area with dried grass. 6) LVNs A, B, C, D, E and F were interviewed on 11/02/10 from 1:30 p.m., through 3:30 p.m. When questioned, all six LVN's stated they were unaware of a safe smoking assessment policy. LVNs A, B, C and D all stated individually Resident #12 went outside to smoke unsupervised "all the time," except when the family member and/or caregiver took the resident outside to smoke. LVN D stated Resident #12 had a caregiver, who came to the facility three times a week and stayed from 9:00 a.m. until 3:00 p.m. LVNs E and F stated Resident #12 went outside by herself in the late afternoon and evenings and smoked by the front door (not the designated smoking area). LVNs A, B and E stated the caregiver would buy Resident #12 cigarettes when she ran out and give them to her. The LVNs stated they were aware Resident #12 had the smoking items in her purse, but no one ever took they away from her. On 11/02/10 at 3:30 p.m., LVNs G, H, I and J were interviewed together and all agreed Resident #12 had smoked since her admission to the facility and she went outside, unsupervised, to smoke "all the time." 7) On 11/02/10 at 2:00 p.m., the ADM and the DON were interviewed and asked what the facility's plans were to ensure the safety of the facility residents and staff when Resident #12 was smoking. At that time, the ADM and the DON were informed by the surveyor the resident had cigarettes and a lighter in her purse, and the resident was smoking unsupervised. The surveyor reviewed Resident #12's nursing notes dated 09/07/10 at 2:35 p.m. with the ADM and the DON. (The episodes of Resident #12 being asked not to sit in the door way and smoke and to not leave by an exit door near the time clock.) During the same interview, the ADM and the DON stated they were not aware/had not been informed of the situation and did not know Resident #12 had the cigarettes and lighter in the purse. The ADM and DON stated they had talked with the SW at about noon after the surveyor had informed them about Resident #12 and her smoking. The ADM and the DON stated the SW was going to get the cigarettes and lighter from Resident #12 and give them to a family member. When asked if they thought Resident #12 was a safe smoker, both the ADM and the DON stated, "No. We don't think so." On 11/02/10 at 2:10 p.m., the SW was interviewed. The SW stated she had called and left a message with Resident #12's family member and informed them, they were going to have to take the cigarettes and lighter away from the resident. The SW stated she had not informed Resident #12's physician in regard to the smoking issue and had not yet informed the nurses, they needed to take the smoking items away from the resident. 8) Two surveyors entered Resident #12's room on 11/02/10 at 3:00 p.m., and asked the resident where she kept the cigarettes and lighter. The resident opened her purse and took out the smoking items. 9) On 11/02/10 at 3:10 p.m., the DON was observed calling the nursing station and asking LVN E to get the smoking items from Resident #12. On 11/02/10, LVN E was observed at 3:15 p.m. retrieving Resident #12's cigarettes and lighter, placing them in a bag and taking them to the nursing station. 10) An IJ was identified on 11/02/10. On 11/02/10 at 3:35 p.m., the surveyors met with the ADM and the DON and informed them of the IJ in the area of Quality of Care with Substandard Quality of Care and the extended survey. The ADM and the DON were requested for a Plan of Removal for the IJ during this meeting. 11) On 11/03/10 at 7:00 a.m., the nursing notes dated 11/02/10 at 9:30 p.m. were reviewed. The nursing notes reflected: "a lighter and a couple of broken cigarettes were found in the side of the resident's purse. The resident was very upset and began to cursing the nurse." The nursing notes reflected at 10:30 p.m., during rounds, another cigarette was found in the pocket of Resident #12's purse. The resident cussed again, ordering the nurse to give the cigarette back. The resident became physical with the staff member, grabbing her arm and trying to hit her. On 11/03/10 at 3:30 p.m., LVNs E and G were interviewed in regard to nursing notes dated 11/02/10 at 9:30 p.m. and 10:30 p.m. LVN E stated they tried to calm the resident down, explaining the cigarettes were taken away for her safety, but the resident continued to be upset, aggressive, cussing and tearful. LVNs E and G were asked if they contacted the physician in regard to the resident's increased behavior issues. They stated the physician had not been notified. LVN G further stated Resident #12 did not smoke in the approved/designated smoking area. On 11/03/10 at 8:00 a.m., the surveyor asked LVNs A, B and D if Resident #12's physician had been notified in regard to the resident's behavior issues as documented in the nursing notes the previous evening. The LVNs stated they did not know if the physician was notified, but Resident #12's caregiver would be at the facility around 9:00 a.m., and she would take the resident out to smoke. 12) On 11/03/10 at 8:00 a.m., Resident #12 was observed sitting in the recliner in her room. Resident #12 asked the surveyors, "Are you going to take me out to smoke? They took my cigarettes away. I don't have any rights. I want to move out of here and live with my ____ (family member). (He/She) will let me smoke." 13) On 11/03/10 at 8:15 a.m., the surveyor questioned LVNs B, D and E about what arrangements had been made for Resident #12 to be taken outside to smoke. The LVNs were also asked if the physician had been notified in regard to the resident's increased anxiety, agitation and smoking withdrawal symptoms. The LVNs all stated in agreement they did not know if the physician had been notified. They only knew Resident #12's smoking items had been locked up in central supply. On 11/03/10 at 9:00 a.m., Resident #12's caregiver arrived and took the resident out to smoke. 14) On 11/03/10 at 11:30 a.m., LVN C provided a new Healthcare Plan for Resident #12, dated 11/03/10. The Goal reflected: Resident will only smoke in designated smoking area. The Approach reflected: Resident will be directly supervised during the entire smoke break. 15) On 11/03/10, the DON was interviewed at 3:00 p.m., and asked if Resident #12's physician had been notified about the smoking situation. The DON stated she thought the SW was going to call the doctor. On 11/03/10, the SW was interviewed at 3:15 p.m. and stated she had spoken to the physician's nurse about the resident and the smoking situation, but she had not heard back from the physician. 16) The initial Plan of Removal dated 11/02/10, revised on 11/03/10 and accepted on 11/04/10 reflected the following: Resident #12's smoking paraphernalia was removed from her possession and locked up at the nurse's station. A meeting was held with the resident's family member to inform the family member of the need to keep smoking paraphernalia locked up and for the resident to be supervised at all times when smoking. On 11/03/10, the family member was informed of the times smoking schedule set up for Resident #12 and staff supervision. A Quality Assurance meeting was held on 11/03/10 to ensure the needs and rights of Resident #12 were being met by the facility. The facility smoking policy was revised, smoking was scheduled for specific times along with staff responsible for supervising Resident #12, and a care plan was revised to address Resident #12's smoking needs. Staff members were to be provided training on the new care plan and facility smoking policy and procedure with validation of staff knowledge being accomplished by a written quiz. The Resident Smoking Policy, revised 11/03/10 reflected: "PURPOSE: The purpose of this policy is to provide all residents with an understanding of the ____ (facility) policy on tobacco use. This policy is designed to promote the cleanliness and quality of indoor and outdoor air and to enhance the health environment and working condition of everyone on our campus. ...This policy intends to reflect the commitment of ____ (facility) to minimize the harmful effects of tobacco use. SCOPE: This policy applies to all ____ (facility) residents and their family members/caregivers. ____ (facility) is committed to promote the health of its residents by offering assistance in cessation. POLICY: It is the policy of ____ (facility) to support a Smoke-Free Campus. All grounds and property are to be smoke-free. Residents are not permitted to smoke on facility premises or have cigarettes, lighters, or other smoking materials in the facility at any time. Prior to admission, residents and their families/caregiver will be educated on our smoking policy... GRANDFATHER CLAUSE: Any resident who is already living in this facility as of 11/3/2010 and is a current smoker will be allowed to continue to smoke only with direct supervision. The resident will have assigned times, every two hours while awake, for staff members to supervise the resident during the smoke break. The resident will only be allowed to smoke in an already designated employee smoking area. Smoking materials may not be kept in the resident's possession...." A smoking schedule was set up for every two hours from 7:00 a.m. through 9:00 p.m. with departments specified as responsible for supervising the scheduled smoke times. Staff inservicing began on 11/03/10 in regard to the new resident smoking policy with a completion date of 11/05/10. Inservices will be conducted by the ADM with a written quiz to validate the staff's understanding of the changes. Resident #12's care plan was updated 11/03/10 to reflect the changes in the smoking policy and procedure. Administrative staff will monitor beginning 11/04/10 to ensure compliance Monday through Friday. On Saturday and Sunday, the MDS Coordinator will monitor for compliance. On 11/09/10, during the facility's Quality Improvement (QI) meeting with the QI team, including the Medical Director, the smoking policy will be reviewed with further ways to monitor compliance to be developed. The QI meetings are held monthly. 17) On 11/04/10 at approximately 9:00 a.m., the inservice training on the facility's newly revised "smoking policy" was reviewed with the DON. The DON stated several staff members had not been inserviced, but would receive the training on 11/05/10. 18) On 11/04/10 at 6:30 a.m., LVNs I and J were interviewed. Both LVNs stated they had received the inservice training on the newly revised smoking policy/procedure on 11/03/10 around 11:00 p.m. They were conversant with the newly revised smoking policy and aware of the measures in place for Resident #12 to smoke with supervision. LVNs A, B and D were interviewed on 11/04/10 at 10:00 a.m., and stated they had received the inservice program on the newly revised smoking policy/procedure on 11/03/10. They were conversant with the newly revised smoking policy and aware of the measures in place for Resident #12 to smoke with supervision. LVN H was interviewed on 11/04/10 at 3:00 p.m. The LVN stated he had received the inservice program on the newly revised smoking policy/procedure on 11/03/10 around 9:00 p.m. LVN H was conversant with the newly revised smoking policy and aware of the measures in place for Resident #12 to smoke with supervision. 19) On 11/03/10 at 2:20 p.m., Resident #12's caregiver was interviewed. The caregiver stated she had been informed in regard to the smoking issue and had the resident's smoking items in her pocket. The caregiver stated she had been told the resident could smoke every two hours in the designated smoking area. 20) On 11/04/10 at 8:00 a.m., the MDS Coordinator was interviewed and stated he thought Resident #12 had a previous healthcare plan about smoking. 21) On 11/04/10 at 8:30 a.m., a Health Care Plan for "Tobacco Use Disorder" dated 11/23/09 was given to the surveyor. Review of the Health Care Plan dated 11/23/09 revealed LVN C and the SW signed the care plan on 11/02/10. The Care Plan Goals/target date reflected: Resident and family will be compliant with non-smoking policy over the next 90 days. Resident will not have possession of cigarettes or lighter over the next 90 days. The Approaches reflected: Resident and family to agree to policy of Non Smoking Facility on admission. An assigned individual from administrative team will check resident's room daily for cigarettes and lighter during quality of care rounds. 22) The DON, the facility's only ADON and MDS Coordinator were interviewed on 11/04/10 at 9:00 a.m. The DON and the ADON stated on 11/02/10, they found the old Health Care Plan dated 11/23/09 on the computer. They stated they printed it and had staff members sign it. But they realized they did not have the documentation to support the 11/23/09 care plan and so devised a new Healthcare Plan. The DON stated the new Healthcare Plan, which LVN C had provided to the survey team, was put into effect on 11/03/10. On 11/04/10 the Healthcare Plan and the treatment records, dated 11/03/10 were reviewed. Resident #12 had been assigned staff members, who would supervise smoking times, and the caregiver would supervise on the days she was with the resident. The smoking times would be documented on the treatment records. 23) On 11/04/10 at 10:00 a.m. and 1:00 p.m., Resident #12 was observed outside smoking with staff supervision. 24) While the IJ was removed on 11/04/10, the facility remained out of compliance at a scope of "widespread" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still still inservicing staff and monitoring implementation of the plan of removal. 25) The CMS-672 (Resident Census and Conditions of Residents) dated 11/02/10 and provided by the DON reflected the census was 93.