Every finding on record at Glenview Health and Rehabilitation

Based on observation, interview, and review of the facility policy, the facility failed to store food in accordance with professional standards for food service safety for items not labeled or dated, as required by the policy. Observation during initial tour of the kitchen, on 06/08/2026 at 6:11 AM, revealed items in the walk-in cooler that were labeled and/or dated incorrectly. This had the potential to affect 53 of 54 residents who received meals from the kitchen.The findings include:Review of the facility policy titled 'Food storage cold,' not dated, revealed it was the center's policy to ensure that all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items would be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) food code. The Dining Services Director/Cooks ensured that all food items were stored properly in covered containers, labeled, dated, and arranged in a manner to prevent cross-contamination.Review of a document titled TCS Foods and Seven Day Labeling' dated 2024, revealed that temperature control for safety foods can grow harmful bacteria if stored or labeled incorrectly. We must label and use TCS foods within seven days from preparation to stay safe.Observation on 06/08/2026 at 6:11 AM of the walk-in cooler revealed several items with labels that did not identify the contents of the container, as well as labels with only one date. Items included a small metal container covered with aluminum foil that was labeled; however, the label did not identify the contents of the container, and only one date, 06/06/2026, was written on the label. The Dietary Manager stated pimentos were in the container. A large, clear plastic container that was half full of what appeared to be chicken. The container was dated with only one date of 06/08/2026. Additionally, the label did not identify the contents. A container half full of pimento cheese with only one date of 06/06/2026, a container covered with aluminum foil, labeled with one date of 06/08/2026, and a container of chicken noodle soup that did not identify the contents, and only one date was written on the label.During an interview with the Dietary Manager (DM) on 06/11/2026 at 3:28 PM, she stated the process for storing food items in the cooler was that items were to be stored in an airtight container, have a label on them to tell what the item was, the date it went in the cooler and the expiration date, which was seven (7) days counting the day it went into the cooler. She stated all dietary staff stored items, and that she came in and checked the coolers first thing in the morning. The DM stated items dated 06/08/2026 were probably put in the cooler on the eighth. The DM stated there would be no outcomes as their policy for stored items was seven (7) days. She stated staff had dated the items incorrectly.During an interview with the Administrator on 06/11/2026 at 5:08 PM, she stated the kitchen staff was contracted, but that she expected the Dietary Manager and the kitchen staff to follow policies and guidelines related to food storage.

Based on interview, record review, and review of the facility's policy, the facility failed to report allegations of abuse to the State Agencies for two (2) of 13 sampled residents, (Resident (R)8, and R9). The findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed 06/2025, revealed the facility was required to report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Further policy review revealed the results of all investigations were to be reported to the appropriate state agency within 5 working days of the alleged violation's initial report.1.Review of R8's Face Sheet revealed the facility admitted the resident on 11/07/2016 with diagnoses which included unspecified dementia with other behavioral disturbance, bipolar disorder, and hyperlipidemia. Review of R8's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/27/2025, revealed the facility assessed R8 as having a Brief Interview for Mental Status (BIMS) score of one (1) out of 15, indicating the resident had severe cognitive impairment. Review of the document titled Event Report, dated 06/13/2025, revealed an event description of Late entry 06/12/2025-1630 Assisted to floor due to behaviors. Further review of the document revealed the location of the fall was in the bathroom with CNA3 being a witness of the fall and there were no injuries related to the fall.Review of Progress Notes, dated 06/13/2025 through 06/15/2025, revealed that on 06/13/2025 the resident was complaining of pain in his right hand and wrist and received an x-ray. Further review of the progress notes revealed that on 06/15/2025 it was documented that the resident was up in wheelchair interacting with staff and complaining of pain to his right hand and fingers and a bruise was noted to his right index finger that appeared to be healing related to recent fall.During an interview with R8 on 01/30/2026 at 11:20 AM, he stated that he is paralyzed on his left side from a gunshot wound to the brain. He stated that he recalled the incident when a staff member pushed him out of his wheelchair onto the bathroom floor. He stated it happened a few months back but was unable to remember the staff member's name. R8 stated the staff member was a black guy. He stated that he didn't do anything wrong and the staff member pushed him out of his wheelchair onto the bathroom floor and told him, I am going to put your ass back in bed and when he picked him up off the floor, he bent his arm back and hurt his hand and wrist. R8 stated he couldn't if he had any bruises or injuries from the incident. He further stated he told every single one of the nurses about it and the staff member no longer comes in his room. During an interview with Licensed Practical Nurse (LPN)2 on 02/01/2026 at 1:28 PM, she stated that she has worked at this facility over a year on nightshift. She stated that she heard about the incident with R8, but she was not working that night. She stated that she remembered people saying that R8 threw himself on the floor and that CNA3 went in there and told him he was not going to pick him up and for him to get up on his own and that he hurt his hand. LPN2 further stated she didn't think it was ever investigated and the Director of Nursing (DON) and Administrator knew about it. During an interview with CNA3 on 02/02/2026 at 9:57 AM, he stated he recalled an incident involving R8, but he could not remember what date. He stated that he has been working at the facility for almost two years. CNA3 stated that he remembered that R8 had a care plan to be lowered to the floor and he was on the toilet. He stated that he and a trainee went in to get him off the toilet and could not lift him up, so they lowered him to the floor. He stated that he told the resident that they were going to come back in a few minutes to help him get up and he returned to assist the resident up and put him back to bed. CNA3 stated that R8 was laughing and joking at that time. He stated that the aides usually work on rotating sides of the building, and he had not been back to work on that side. CNA3 stated that he was not told that he could not work with R8 anymore and thought he had been suspended on the same day that the incident allegedly occurred. He further stated that the facility put him off work pending the investigation and he talked to the Administrator and the DON about it at the time and they told him that he could come back to work. CNA3 stated he was unaware of any injury to R8's hand and the resident did not complain of any pain. During an interview with CNA6 on 02/03/2026 at 8:53 AM, she stated that she was working on the day of 06/12/2025 and she had only been working at the facility for about 4 or 5 days. She stated that she was in orientation and was training with CNA3 on 06/12/2025. She stated that CNA3 was really mean to residents. She stated that anytime R8 would get agitated, CNA3 would put him in the floor. She stated that on that day, she walked into the resident's room and CNA3 was screaming at R8 and CNA3 was threatening to put him in the floor, and she stated that he put him in the floor in the bathroom. CNA6 stated that she told CNA3 that it was not appropriate treatment, and he walked out of the room. She stated that at that time, she and another orientee picked R8 up off the floor and put him back in bed. She stated that she told the DON at that time and the DON quit that same day.During an interview with the former DON on 02/03/2026 at 12:18 PM, she stated that she worked at this facility as the DON from December of 2024 to June of 2025. She stated that she remembered R8 and CNA3. She stated that she did not remember anyone reporting an allegation of abuse to R8. The former DON stated that when she was the DON, she expected all staff to report any allegations of abuse. She further stated that she and the Administrator would have been responsible for investigating and reporting incidents of alleged abuse. During an interview with the former Social Services Director (SSD) on 02/04/2026 at 9:00 AM, she stated that she was employed at the facility for a little over a year from October 15th, 2024, through January 9th, 2026. She stated that she remembered the incident involving R8 very well. She stated that R8 told her that CNA3 put him in the floor and threw him in the bed and hurt his wrist. The former SSD stated that she told the DON at the time and the Administrator. She stated that in a morning meeting after that, they stated that after the investigation it was determined that R8 lowered himself to the floor. She stated that CNA3 has been accused multiple times of hurting residents and that is one of the reasons why she quit her job because the allegations were not being investigated and were being swept under the rug. She stated that when an allegation of abuse was made, whoever heard about it should tell their superior and they would notify the Administrator. The former SSD stated that the entire administrative team would do an investigation after an allegation was made. She stated the admin team would be made up of the Assistant Director of Nursing (ADON), DON, the Administrator, and Social Services. She further stated she would do a questionnaire on residents with a BIMS of 8 or higher and nursing staff would do skin assessments on all the residents with a BIMS of 8 or below. She stated that anyone who knows about an allegation of abuse was supposed to report it to superiors, and the Administrator should report it to the Office of Inspector General. 2. Review of R9's Face Sheet revealed the facility admitted the resident on 06/27/2022 with diagnoses which included Alzheimer's Disease, unspecified hearing loss, and a history of falling. Review of R9's Quarterly MDS Assessment with and ARD of 11/12/2025, revealed the facility assessed R9 as having a BIMS score of nine (9) out of 15, indicating the resident had moderate cognitive impairment. Review of Progress Notes and Skin Assessments dated August of 2025 through October of 2025 revealed no documentation of a bruise or discoloration on the resident's eyes. During an interview with CNA1 on 01/30/2026 at 1:00 PM, she stated that she worked nightshift and has been employed for over a year. She stated that in September of last year, she had just come back to work after having shoulder surgery and R9 had a black eye. She stated that R9 told CNA2 and herself that CNA3 hit her in the eye. She stated that dayshift that day told her about it and that it had been reported to the DON and Administrator. CNA1 stated she could not remember the exact day or month. She stated Human Resources (HR) told her to stay out of it and that it was being taken care of. During an interview with R9 on 01/30/2026 at 2:15 PM, she stated that a black guy hit her in her left eye a few months ago. She stated that she does not know his name. R9 stated that it was on purpose, and he hit her with the back of his hand and caused a big bruise. She stated he could be mean one day and friendly the next day. R9 stated that she was told two female staff members that were sitting at her table, and she did not know who they were. She did not know who they told about it. She stated that no one came to ask her questions about it because she thinks they don't want to talk about it, and they don't want anyone to get in trouble. During an interview with LPN2 on 02/01/2026 at 1:28 PM, she stated that she has worked at this facility over a year on nightshift. She stated that for the incident involving R9, she was there that night. She stated that she was working with CNA8 and CNA3. She stated that she was at the nurse's station, and she heard a curdling scream and went to check, and she stated that she saw CNA3 coming out of a room down that hallway, but she could not tell if he was coming out of R9's room. She stated that the DON was also working that night and came down to the other end of the hall and CNA3 came back up the hall and went into R9's room and the resident was screaming that CNA3 hit her in the eye. She stated that the DON and she went in to talk to the resident and she was rubbing her left eye, and it was starting to bruise at that time. She stated that the DON told her to chart that her eye was bruised because she had been rubbing her eye. She stated that she told the DON that she was not going to chart such a thing and for her to chart it, however, she did not check to see if the DON documented anything. She stated that incident was not investigated, and she knows the abuse policy states that incidents of alleged abuse need to be reported to OIG. During an interview with CNA3 on 02/02/2026 at 9:57 AM, he stated he did not know how the incident happened involving R9. He stated that he did not remember the date of the incident, but it was sometime around September of last year. He stated that he had been in her room giving her milk and then went to use the bathroom and he heard her scream. He stated that he normally does not take care of her very much because she only wants women caregivers and two at a time and he usually just saw her in passing. He stated that he does not know when she accused him of hitting her in the eye and nothing was ever said to him about it. He stated at that time he went back to take care of his residents. He stated that he never saw her eye bruised because he just saw her in passing.During an interview with LPN3 on 02/02/2026 at 11:39 AM, she stated that she remembered R9 having a bruise on her eye and was told that she had been scratching her eye a lot and she heard that R9 accused CNA3 of hitting her in the eye. She stated that she did not remember who told her and that the incident occurred a few months back. She stated that she had abuse and neglect prevention training when she first started working here and more training on SNF Clinic, but she does not know how often she takes the course.During an interview with CNA2 on 02/03/2026 at 2:19 PM, she stated that a few months ago R9 had a black eye, but the incident happened on her night off. She stated that when she came back to work, R9 told her that CNA3 hit her in the eye with his ring. She stated that she reported it to the ADON, and she told her they were aware and that R9 had been rubbing her eye a lot. She stated that everything that ever happened had been told to them that it had been investigated and it never was.During an interview with the former social services director on 02/04/2026 at 9:00 AM, she stated that she worked here for a little over a year from October 15th, 2024, through January 9th, 2026. She stated that she remembered R9 having a bruise on her eye/cheekbone and R9 told her that CNA3 hit her in the eye, but after the investigation, the DON told her that R9 had just been rubbing her eye, so she did not think anything else of it and was told it had been investigated. During an interview with the DON on 02/04/2026 at 10:47 AM, she stated that she has been the DON since June 7th, 2025. She stated that no one has reported anything to her about the incidents involving R8 and R9. She stated that if someone reported something to her, she would have reported it to the Administrator. The DON stated she was aware that abuse was supposed to be reported within two hours. She stated that no one reported any of this to her about any of these incidents. Anytime abuse is reported, it should be reported to the Administrator because she was the abuse coordinator, then the Administrator would notify the DON to start an investigation. She stated that regional comes in and helps with investigations. She stated that they interview staff, residents that are able to be interviewed, completes skin assessments on residents with a BIMS of 7 or below. She stated that they also interviewed staff members involved that worked that hall the incident occurred on. The DON stated that the staff member would be suspended until the investigation was complete. She stated that if the alleged perpetrator was another resident, we would separate the residents. She stated that her expectation for staff if a resident alleges abuse or abuse is witnessed, they were to notify her or the Administrator immediately. The DON stated that even if a resident with a BIMS of 1 came to her with abuse allegations, she would take the allegations seriously and do an investigation. She stated that the ADON does the education and was responsible for providing abuse training to staff. She stated that staff get abuse training annually, upon hire, and as needed if there are any concerns. She stated that they have a clinical meeting every morning and she lays eyes on all residents every day and she stated that she has a good relationship with all of them. During an interview with the Administrator on 02/04/2026 at 12:00 PM, she stated she has been the Administrator since March of last year. She stated she was never informed of any of the abuse allegations for R8, and R9. She stated that she was the abuse coordinator. The Administrator stated the investigation team was composed of herself, ADON, DON, social services director, activities director, and any other staff there to assist at the time. She stated the process for investigating abuse allegations would start with determining if the staff member were still at the facility, then they would be removed from the resident's care area. They would immediately have the nurse assess the resident for skin issues and pain and would interview the resident. The Administrator stated if at that time, she did not have any concerns, she would call social services or any other manager in the facility, and we would begin a BIMS list and start checking skin and interviews as appropriate per their BIMS. She stated that they would notify legal guardians or family, notify the physician, assess residents for psychosocial issues. She stated that after all that is initiated, I would make my report to appropriate agencies within the 2-hour time frame. She stated that she would protect the residents from further abuse by educating staff and reporting the perpetrator to the abuse registry and disciplinary actions. She stated that she would also do staff interviews. She stated that anyone suspecting alleged abuse is responsible for reporting the allegations to the immediate supervisor, who then reports to the abuse coordinator or her directly. She stated that her expectations regarding the timeliness of reporting abuse are to act in the best interest of their residents and report immediately.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated to prevent further potential abuse for two (2) of 13 sampled residents, (Residents (R)8 and R9). The findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed 06/2025, revealed an immediate investigation was warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occurred. Further review of the policy revealed the facility was to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and provide complete and thorough documentation of the investigation. 1.Review of R8's Face Sheet revealed the facility admitted the resident on 11/07/2016 with diagnoses which included unspecified dementia with other behavioral disturbance, bipolar disorder, and hyperlipidemia. Review of R8's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/27/2025, revealed the facility assessed R8 as having a Brief Interview for Mental Status (BIMS) score of one (1) out of 15, indicating the resident had severe cognitive impairment. Review of the document titled Event Report, dated 06/13/2025, revealed an event description of Late entry 06/12/2025-1630 Assisted to floor due to behaviors. Further review of the document revealed the location of the fall was in the bathroom with CNA3 being a witness of the fall and there were no injuries related to the fall.Review of Progress Notes, dated 06/13/2025 through 06/15/2025, revealed that on 06/13/2025 the resident was complaining of pain in his right hand and wrist and received an x-ray. Further review of the progress notes revealed that on 06/15/2025 it was documented that the resident was up in wheelchair interacting with staff and complaining of pain to his right hand and fingers and a bruise was noted to his right index finger that appeared to be healing related to recent fall.During an interview with R8 on 01/30/2026 at 11:20 AM, he stated that he is paralyzed on his left side from a gunshot wound to the brain. He stated that he recalled the incident when a staff member pushed him out of his wheelchair onto the bathroom floor. He stated it happened a few months back but was unable to remember the staff member's name. R8 stated the staff member was a black guy. He stated that he didn't do anything wrong and the staff member pushed him out of his wheelchair onto the bathroom floor and told him, I am going to put your ass back in bed and when he picked him up off the floor, he bent his arm back and hurt his hand and wrist. R8 stated he couldn't if he had any bruises or injuries from the incident. He further stated he told every single one of the nurses about it and the staff member no longer comes in his room. During an interview with Licensed Practical Nurse (LPN)2 on 02/01/2026 at 1:28 PM, she stated that she has worked at this facility over a year on nightshift. She stated that she heard about the incident with R8, but she was not working that night. She stated that she remembered people saying that R8 threw himself on the floor and that CNA3 went in there and told him he was not going to pick him up and for him to get up on his own and that he hurt his hand. LPN2 further stated she didn't think it was ever investigated and the Director of Nursing (DON) and Administrator knew about it. During an interview with CNA3 on 02/02/2026 at 9:57 AM, he stated he recalled an incident involving R8, but he could not remember what date. He stated that he has been working at the facility for almost two years. CNA3 stated that he remembered that R8 had a care plan to be lowered to the floor and he was on the toilet. He stated that he and a trainee went in to get him off the toilet and could not lift him up, so they lowered him to the floor. He stated that he told the resident that they were going to come back in a few minutes to help him get up and he returned to assist the resident up and put him back to bed. CNA3 stated that R8 was laughing and joking at that time. He stated that the aides usually work on rotating sides of the building, and he had not been back to work on that side. CNA3 stated that he was not told that he could not work with R8 anymore and thought he had been suspended on the same day that the incident allegedly occurred. He further stated that the facility put him off work pending the investigation and he talked to the Administrator and the DON about it at the time and they told him that he could come back to work. CNA3 stated he was unaware of any injury to R8's hand and the resident did not complain of any pain. During an interview with CNA6 on 02/03/2026 at 8:53 AM, she stated that she was working on the day of 06/12/2025 and she had only been working at the facility for about 4 or 5 days. She stated that she was in orientation and was training with CNA3 on 06/12/2025. She stated that CNA3 was really mean to residents. She stated that anytime R8 would get agitated, CNA3 would put him in the floor. She stated that on that day, she walked into the resident's room and CNA3 was screaming at R8 and CNA3 was threatening to put him in the floor, and she stated that he put him in the floor in the bathroom. CNA 6 stated that she told CNA3 that it was not appropriate treatment, and he walked out of the room. She stated that at that time, she and another orientee picked R8 up off the floor and put him back in bed. She stated that she told the DON at that time and the DON quit that same day.During an interview with the former DON on 02/03/2026 at 12:18 PM, she stated that she worked at this facility as the DON from December of 2024 to June of 2025. She stated that she remembered R8 and CNA3. She stated that she did not remember anyone coming to her reporting an allegation of abuse to R8. She stated that when she was the DON, she expected all staff to report any allegations of abuse. She stated that she and the administrator would have been responsible for investigating and reporting incidents of alleged abuse. She stated that she and the administrator were responsible for providing training and/or access to training for the employees. During an interview with CNA2 on 02/03/2026 at 2:19 PM, she stated that she has been employed here for almost two years on nightshift. She stated that the only thing she knows about the incident with R8 is what R8 told her and what she heard. She stated that all staff were talking about it at that time and it was the talk of the town. She stated that R8 told her that CNA3 put him in the floor and bent his hand back. She stated that it was told to her when it happened that it had been reported to the DON. She stated that she did not remember if it was the current DON or the former DON. She stated that she has had abuse training and in services on preventing and reporting abuse. She stated that she completed these training courses on hire, this last summer, and this past weekend. She stated that it is everyone's responsibility for reporting abuse. She states that CNA's report it to the nurses, and the nurses report it to the DON and admin. She stated that abuse is to be reported immediately.During an interview with the former Social Services Director (SSD) on 02/04/2026 at 9:00 AM, she stated that she was employed at the facility for a little over a year from October 15th, 2024, through January 9th, 2026. She stated that she remembered the incident involving R8 very well. She stated that R8 told her that CNA3 put him in the floor and threw him in the bed and hurt his wrist. The former SSD stated that she told the DON at the time and the Administrator. She stated that in a morning meeting after that, they stated that after the investigation it was determined that R8 lowered himself to the floor. She stated that CNA3 has been accused multiple times of hurting residents and that is one of the reasons why she quit her job because the allegations were not being investigated and were being swept under the rug. She stated that when an allegation of abuse was made, whoever heard about it should tell their superior and they would notify the Administrator. The former SSD stated that the entire administrative team would do an investigation after an allegation was made. She stated the admin team would be made up of the Assistant Director of Nursing (ADON), DON, the Administrator, and Social Services. She further stated she would do a questionnaire on residents with a BIMS of 8 or higher and nursing staff would do skin assessments on all the residents with a BIMS of 8 or below. She stated that anyone who knows about an allegation of abuse was supposed to report it to superiors, and the Administrator should report it to the Office of Inspector General. 2. Review of R9's Face Sheet revealed the facility admitted the resident on 06/27/2022 with diagnoses which included Alzheimer's Disease, unspecified hearing loss, history of falling, and muscle weakness. Review of the Quarterly MDS Assessment with and ARD of 11/12/2025 revealed the facility assessed R9 as having a BIMS score of nine (9) out of 15, indicating the resident had moderate cognitive impairment. Review of Progress Notes and Skin Assessments from August of 2025 through October of 2025 revealed no documentation of a bruise or discoloration on the resident's eyes. During an interview with CNA1 on 01/30/2026 at 1:00 PM, she stated that she worked nightshift and has been employed for over a year. She stated that in September of last year, she had just come back to work after having shoulder surgery and R9 had a black eye. She stated that R9 told CNA2 and herself that CNA3 hit her in the eye. She stated that dayshift that day told her about it and that it had been reported to the DON and Administrator. CNA1 stated she could not remember the exact day or month. She stated Human Resources (HR) told her to stay out of it and that it was being taken care of. During an interview with R9 on 01/30/2026 at 2:15 PM, she stated that a black guy hit her in her left eye a few months ago. She stated that she does not know his name. R9 stated that it was on purpose, and he hit her with the back of his hand and caused a big bruise. She stated he could be mean one day and friendly the next day. R9 stated that she was told two female staff members that were sitting at her table, and she did not know who they were. She did not know who they told about it. She stated that no one came to ask her questions about it because she thinks they don't want to talk about it, and they don't want anyone to get in trouble. During an interview with LPN2 on 02/01/2026 at 1:28 PM, she stated that she has worked at this facility over a year on nightshift. She stated that for the incident involving R9, she was there that night. She stated that she was working with CNA8 and CNA3. She stated that she was at the nurse's station, and she heard a curdling scream and went to check, and she stated that she saw CNA3 coming out of a room down that hallway, but she could not tell if he was coming out of R9's room. She stated that the DON was also working that night and came down to the other end of the hall and CNA3 came back up the hall and went into R9's room and the resident was screaming that CNA3 hit her in the eye. She stated that the DON and she went in to talk to the resident and she was rubbing her left eye, and it was starting to bruise at that time. She stated that the DON told her to chart that her eye was bruised because she had been rubbing her eye. She stated that she told the DON that she was not going to chart such a thing and for her to chart it, however, she did not check to see if the DON documented anything. She stated that incident was not investigated, and she knows the abuse policy states that incidents of alleged abuse need to be reported to OIG. During an interview with CNA3 on 02/02/2026 at 9:57 AM, he stated he did not know how the incident happened involving R9. He stated that he did not remember the date of the incident, but it was sometime around September of last year. CNA3 stated that he normally does not take care of R9 very much because she only wants women caregivers and two at a time. He stated he usually just saw her in passing. He stated that he does not know when she accused him of hitting her in the eye and nothing was ever said to him about it. CNA3 further stated that he never saw her eye bruised because he just saw her in passing.During an interview with LPN3 on 02/02/2026 at 11:39 AM, she stated that she remembered R9 having a bruise on her eye and was told that she had been scratching her eye a lot. She stated she had heard that R9 accused CNA3 of hitting her in the eye. She stated that she did not remember who told her and that the incident occurred a few months back. During an interview with CNA2 on 02/03/2026 at 2:19 PM, she stated that a few months ago R9 had a black eye, but the incident happened on her night off. She stated that when she came back to work, R9 told her that CNA3 hit her in the eye with his ring. CNA2 stated that she reported it to the ADON, and she told her they were aware and that R9 had been rubbing her eye a lot. CNA2 further stated that everything that ever happened had been reported to them that it had been investigated and it never was.During an interview with the former Social Services Director (SSD) on 02/04/2026 at 9:00 AM, she stated that she worked at the facility for a little over a year from October 15th, 2024, through January 9th, 2026. She stated that she remembered R9 having a bruise on her eye/cheekbone and R9 told her that CNA3 hit her in the eye. She stated but after the investigation, the DON told her that R9 had just been rubbing her eye, so she did not think anything else of it and was told it had been investigated. During an interview with the DON on 02/04/2026 at 10:47 AM, she stated that she has been the DON since June 7th, 2025. She stated that no one has reported anything to her about the incidents involving R8 and R9. She stated that if someone reported something to her, she would have reported it to the Administrator. The DON stated she was aware that abuse was supposed to be reported within two hours. She stated that no one reported any of this to her about any of these incidents. Anytime abuse is reported, it should be reported to the Administrator because she was the abuse coordinator, then the Administrator would notify the DON to start an investigation. She stated that regional comes in and helps with investigations. She stated that they interview staff, residents that are able to be interviewed, completes skin assessments on residents with a BIMS of 7 or below. She stated that they also interviewed staff members involved that worked that hall the incident occurred on. The DON stated that the staff member would be suspended until the investigation was complete. She stated that if the alleged perpetrator was another resident, we would separate the residents. She stated that her expectation for staff if a resident alleges abuse or abuse is witnessed, they were to notify her or the Administrator immediately. The DON stated that even if a resident with a BIMS of 1 came to her with abuse allegations, she would take the allegations seriously and do an investigation. She stated that the ADON does the education and was responsible for providing abuse training to staff. She stated that staff get abuse training annually, upon hire, and as needed if there are any concerns. She stated that they have a clinical meeting every morning and she lays eyes on all residents every day and she stated that she has a good relationship with all of them. During an interview with the Administrator on 02/04/2026 at 12:00 PM, she stated she has been the Administrator since March of last year. She stated she was never informed of any of the abuse allegations for R8, and R9. She stated that she was the abuse coordinator. The Administrator stated the investigation team was composed of herself, ADON, DON, social services director, activities director, and any other staff there to assist at the time. She stated the process for investigating abuse allegations would start with determining if the staff member were still at the facility, then they would be removed from the resident's care area. They would immediately have the nurse assess the resident for skin issues and pain and would interview the resident. The Administrator stated if at that time, she did not have any concerns, she would call social services or any other manager in the facility, and we would begin a BIMS list and start checking skin and interviews as appropriate per their BIMS. She stated that they would notify legal guardians or family, notify the physician, assess residents for psychosocial issues. She stated that after all that is initiated, I would make my report to appropriate agencies within the 2-hour time frame. She stated that she would protect the residents from further abuse by educating staff and reporting the perpetrator to the abuse registry and disciplinary actions. She stated that she would also do staff interviews. She stated that anyone suspecting alleged abuse is responsible for reporting the allegations to the immediate supervisor, who then reports to the abuse coordinator or her directly. She stated that her expectations regarding the timeliness of reporting abuse are to act in the best interest of their residents and report immediately.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for 4 of 7 residents sampled for orthotic devices, out of the total sample of 23, (Residents (R)15, R22, R44, and R45. Additionally, the facility failed to develop the comprehensive person-centered care plan with an intervention for applying bright colored tape to R209's call light. The findings include: Review of the facility policy, Comprehensive Care Plans revised on 02/2025, revealed it was the facility's policy to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, physical, mental, and psychosocial needs. Continued review revealed the care plan was to describe any services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Per review, the care plan was also to have resident specific interventions that reflected the resident's needs. Review of the policy revealed the qualified staff responsible for carrying out the interventions were to be notified of their roles and responsibilities for carrying out the interventions initially and when changes were made. Further review revealed the comprehensive care plan was to be reviewed and revised by the interdisciplinary team (IDT) after each comprehensive and quarterly Minimum Data Set (MDS) Assessment. 1. Review of the Resident Face Sheet for R22 revealed the facility admitted the resident on 04/03/2020, with diagnoses of unspecified dementia, unspecified severity with other behavioral disturbance, drug-induced subacute dyskinesia and bipolar disorder. Review of the Annual MDS Assessment with an Assessment Reference Date (ARD) of 03/11/2025, revealed the facility had not completed a Brief Interview for Mental Status (BIMS) assessment as R22 was rarely or never understood. Review of R22's Comprehensive Care Plan dated 11/12/2024, revealed the facility had developed a focus problem for ADL-Functional status, resident required splint/brace assistance to the left hand. Continued review revealed an intervention dated 11/12/2024, to apply left resting hand splint minimum 4 hours daily to maximum of six hours daily as resident would allow. Further review revealed additional interventions to explain to the resident the splint brace schedule, correct splint/brace application and how to assess the skin, monitor for presence of pain, muscle spasm, during range of motion. Further review revealed there were no interventions for range of motion to be performed on the care plan. Observation on 06/01/2025 at 10:25 AM and 1:48 PM, of R22 revealed she was not wearing a hand splint. Observation on 06/02/2025 at 9:50 AM and 10:32 AM, revealed R22 had no hand splint in place. In addition, observation on 06/03/2025 at 10:20 AM and 1:00 PM, revealed a resting hand splint observed in a chair in the resident's room. In interview with Certified Nursing Assistant (CNA) 3 on 06/04/2025 at 9:23 AM, she stated R22's splints were on the resident's care plan which noted the splints were to be worn four to six hours daily. She reported the aides were responsible for applying (residents') splints and said she did not perform range of motion (ROM) for the resident prior to applying the splint. CNA 3 stated R22 had a hand splint that she (CNA) was supposed to put on the resident at 10:00 AM; however, the resident did not receive ROM before the application. She further stated residents not wearing their splints could make their contractures worse. 2. Review of the Resident Face Sheet R15 revealed the facility admitted the resident on 02/20/2017, with diagnoses of Alzheimer's Disease, chronic obstructive pulmonary disease and vascular dementia. Review of the Annual MDS Assessment, with an ARD of 03/28/2025, revealed had not completed a Brief Interview for Mental Status (BIMS) assessment as R15 was rarely or never understood. Review of R15's Comprehensive Care plan dated 11/12/2024, revealed the facility identified a focus for ADL's functional status, that noted the resident required splint/brace assistance to the left hand. Continued review revealed an intervention dated 11/12/2024, documenting to apply the left hand grip splint for a minimum of four hours daily to a maximum of six hours, as resident would allow. Further review revealed the goal for R15 was for the left hand to be free from injury, skin breakdown and edema. Observation on 06/01/2025 at 10:46 AM and 1:59 PM, of R15 revealed a hand splint in a mesh bag lying on the bedside table. Observation on 06/02/2025 at 10:47 AM and 1:35 PM, revealed the splint remained lying on the bedside table in a mesh bag. Additionally, observation on 06/03/2025 at 9:25 AM and 1:48 PM, revealed the splint remained lying on the bedside table. 3. Review of the Resident Face Sheet for R45 revealed the facility admitted the resident on 03/18/2024, with diagnoses that included hemiplegia, and hemiparesis following unspecified cerebrovascular disease affecting left side. Review of the Annual MDS Assessment, with an ARD of 3/26/2025, revealed the facility assessed R45 to have a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Review of the Comprehensive Care Plan dated 11/13/2024 for R45, revealed the facility identified a focus problem for ADLs, that noted the resident required splint/brace assistance to the left hand. Further review revealed an intervention dated 11/13/2024, that read to apply resting hand splint to the resident's left hand four to six hours daily. Observation of R45 on 06/04/2025 at 12:42 PM, revealed she had a resting hand splint on her left hand. In interview at the time of observation, R45 reported, today was the first time in about four months that her hand splint had been applied. She stated she did not receive range of motion (ROM) to the hand prior to the splint being applied and had discomfort when it was first applied. R45 said she wore the splint for about four hours if staff don't forget to come and take it off. She further stated Licensed Practical Nurse (LPN) 2 had to search her closet that morning to find the splint so it could be put on. The SSA Surveyor requested a policy on orthotic devices or splinting, and a policy on Restorative Nursing Services on 06/02/2025 at 2:18 PM. However, the Administrator stated the facility had no policy for Restorative Nursing Services or a policy on splinting. In interview with CNA 2 on 06/02/2025 at 12:17 PM, she stated she had been working at the facility for one month. CNA 2 said for her to view a resident's care plan she would look at the care plan in the facility's computer system. She stated the care plan would show what kind of care a resident would need. CNA 2 reported she did not apply resting hand splints to residents and guessed the nurse did that. She further stated resting hand splints should be located on the residents' care plans if a resident was supposed to wear them. In interview with CNA 4 on 06/04/2025 at 9:36 AM, she stated the CNA's were responsible for applying residents' hand splints. She reported she seldom worked on the hall she was currently assigned and therefore, did not know which residents had splints. CNA 4 further stated if a resident had splints or devices information on those should be on the resident's care plan. In interview with the MDS Coordinator on 06/04/2025 5:30 PM, she stated updating the care plan was part of her responsibility and interventions on the residents' care plans were expected to be in place and followed. She further stated staff were made aware of residents' care plan interventions by accessing the care guide on the computer. In interview with the Director of Nursing (DON) and the Administrator on 06/04/2025 at 5:52 PM, the DON stated she was new to her position and was still learning her duties. The DON stated expectations were for staff to follow what was on residents' care plans and implement them. The Administrator stated she expected staff to do whatever was in the best interest of the patient (resident) and follow their plan of care. 50153 4. Review of the Resident Face Sheet for R44 revealed the facility admitted the resident on 06/14/2024, with diagnoses that included cerebral infarction, unspecified, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R44's Quarterly MDS Assessment, with an ARD date of 03/21/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of the physician's orders dated 11/12/2024, revealed an order for R44 to have an L [left] ankle brace placed on L ankle daily to increase support, remove before bed with a start date of 11/12/2024. Continued review of the physician's orders revealed an order for R44 to have L resting hand splint to L hand 4-6 hours daily to avoid contractures to L hand and wrist with a start date of 11/12/2024. Review of R44's care plan revealed the facility identified ADLs Functional Status/Rehabilitation Potential problem dated 11/12/2024, that noted, Resident requires splint/brace assistance to left hand and ankle. Continued review revealed the interventions/approaches stated, Left resting hand splint for a minimum of 4 hours to a maximum of 6 hours as resident will allow. Apply at 10:00 and remove at HS (bedtime). Further review revealed an additional intervention/approach documented to Use left ankle brace apply in AM and remove at HS as resident will allow. Observation on 06/01/25 at 11:00 AM, revealed R44 was up in a wheelchair with no splints observed in use. Observation on 06/02/25 at 9:34 AM, revealed R44 was lying on the bed with no splints observed in use. In interview with R44 on 06/03/2025 at 1:08 PM, the resident stated he had worn the splints last week, but had not worn them on Sunday (06/01/2025) or Monday (06/02/2025). In interview with CNA 5 on 06/03/2025 at 1:10 PM, she stated R44's splints could come off at 2:00 PM and the wear time was from 10:00 AM until 2:00 PM. She further stated she was a PRN (as needed) employee at the facility. 5. Review of R209's Resident Face Sheet revealed the facility admitted the resident on 04/23/2025, with diagnoses that included Atrial Fibrillation, cognitive communication deficit, essential hypertension and heart failure. Review of R209's Admission MDS Assessment, with an ARD of 04/27/2025, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Review of R209's medical record revealed the resident sustained falls three falls since admission without major injury: on 05/06/2025 at 3:34 PM; 05/12/2025 at 7:40 PM; and 05/15/2025 at 1:00 PM. Review of R209's care plan revealed the facility identified a problem for Falls with a start date of 04/24/2025, noting the resident was at risk for falling related to weakness with a history of falls. Continued review of the care plan revealed an intervention dated 05/13/2025, that stated, apply bright color call tape to remind [R209] to call for help before self-ambulating. Observation of R209's room on 06/01/2025 at 9:22 AM; on 06/03/2025 at 11:10 AM; and on 06/04/2025 at 10:15 AM, revealed the resident had a standard call light and a touch pad call light located at bedside. Observation of the touch pad call light revealed it was white with a manufacturer-applied red symbol. Further observation revealed neither of the call lights had any brightly colored tape on them as per R209's Falls care plan intervention with the start date of 05/13/2025. In interview with the MDS Coordinator on 06/04/25 05:30 PM, she stated updating residents' care plans were part of her responsibility and the development of care plan interventions was an interdisciplinary team (IDT) effort. She said she was unsure if she had placed the intervention for brightly colored tape on R209's care plan. The MDS Coordinator reported if a resident's fall occurred on the weekend, interventions could be put on the care plan in real time by all nurses. She stated she would expect that we would follow up to see that the intervention had been put in place; however, said there was no one person responsible to follow up to ensure the intervention was in place. The MDS Coordinator stated she would expect an intervention to be in place and implemented if it was on the resident's care plan. In interview with the Assistant Director of Nursing (ADON) on 06/04/25 at 10:16 AM, she stated if an intervention for colored tape was on the resident's care plan, then one should see some the tape on the call light. She said a touch pad call light would not be substituted for the colored tape on the call light. The ADON further stated the colored tape was used to remind the resident to use the call light to call for assistance. In interview with the DON on 06/04/2025 at 5:52 PM, she stated that she would consider the touch pad as brightly colored as it had the red lettering. She said she considered a brightly colored item to be different than the item itself though. The DON reported a clinical meeting was held in the morning to review residents' falls and to review the interventions recommended to address the fall. She further stated following the morning clinical meeting, a list of items to follow up on was distributed to each nurse's station and a stand down meeting was conducted in the afternoon to follow up to ensure the items on the list were in place and completed. In interview with the Administrator on 06/04/2025 at 5:57 PM, stated she would have to consult with someone to know if a touch pad call light with red lettering was equivalent to brightly colored tape. She said at the end of the day a stand down meeting was completed with the list taken to floor staff after the morning clinical meeting to ensure the items on the list were followed up on.

Based on observation, interview, record review, and review of facility policy, the facility failed to meet professional standards of quality during medication administration for 1 of 3 sampled resident out of the 23 total sampled residents (Resident (R)51). The findings include: Review of the facility policy titled, Medication Administration, last revised date of 02/20/2025, revealed medications were to be administered as ordered by the physician and in accordance with professional standards of practice. Further review of the policy revealed the Compliance Guidelines included obtaining and recording vital signs when applicable and holding medication for vital signs outside the physician's prescribed parameters. Review of R51's Resident Face Sheet revealed the facility admitted the resident on 10/31/2024, with diagnosis that included essential hypertension, Alzheimer's disease, and chronic kidney disease. Review of the physician's orders dated 10/31/2024 revealed an order for Lisinopril 20 milligram (mg) one tablet daily which was to be held if the resident's systolic blood pressure was less than 150 mm hg (millimeters of mercury). Observation of CMT 1 administering medication for R51 on 06/03/2025 at 9:22 AM, revealed the CMT assessed R51's manual blood pressure a 132/60. Continued observation revealed CMT 1 proceeded to administer Lisinopril (blood pressure medication) 20 milligrams (mg) to R51, and returned to the medication cart to document the administration of the medication. Per observation, CMT 1 reviewed the parameters for the blood pressure and indicated the medication should not have been administered as the prescribed parameters were to hold the medication if the systolic blood pressure was less than 150. CMT 1 stated she would notify the nurse who would then contact the physician for further instructions. Review of the medication bingo card that held the Lisinopril 20 mg tablets revealed the medication was dated 5/03/2025 with 22 of 30 doses remaining on the card indicating 18 doses had been administered since 05/03/2025. Review of the Medication Administration Record (MAR) for the month of May 2025 revealed the medication was held for 10 of 31 days due to R51's blood pressure reading. However, further review of the MAR revealed the medication was administered 21 days although the maximum recorded blood pressures was 136 mm hg, which was below the 150 mm hg parameters ordered by the physician. Review of the MAR for the month of June 2025 revealed Lisinopril 20 mg was administered 06/01/2025, 06/02/2025, and 06/03/2025 with all three systolic blood pressure readings measuring less than 150 mm hg. In additional interview with CMT 1 on 06/03/2025 at 9:25 AM, she stated most of the parameters for holding blood pressure medication started at 120 mm hg. She further stated she thought that was what R51's parameters had been as well. In interview on 06/03/2025 at 9:38 AM, Licensed Practical Nurse (LPN) 1, who was assigned to R51, after being notified of the resident's blood pressure medication being administered in error, stated she would notify the physician of the error. The LPN further stated she would begin monitoring R51's blood pressure every 30 minutes and go from there. In interview on 06/03/2025 at 9:55 AM, the Assistant Director of Nursing (ADON) stated the physician had been notified. The ADON further stated a new order defining the parameters for administering R51's Lisinopril 20 mg had been changed to hold for a blood pressure less than 110/60. In interview with the Director of Nursing (DON) on 06/04/2025 at 5:45 PM, she stated usually a systolic reading of 110 was a common parameter for holding antihypertensive medication. The DON further stated she would expect staff to follow the physician's orders. In interview with the Administrator on 06/04/2025 at 5:49 PM, stated she expected staff to do whatever is in the best interest of the patient and within their nursing scope.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 of 7 residents sampled for range of motion (ROM) and orthotic devices out of the 23 total sampled residents, (Resident (R)15, R45 and R22). The finding include: In interview on 06/02/2025 at 2:18 PM, the Administrator informed the State Survey Agency (SSA) Surveyor the facility did not have a policy for splinting/orthotic devices, or for Restorative Nursing Services. 1. Review of the Resident Face Sheet for R45 revealed the facility admitted the resident on 03/18/2024, with diagnoses that included hemiplegia, and hemiparesis following unspecified cerebrovascular disease affecting the left side. Review of the Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 3/26/2025, revealed the facility assessed R45 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident had intact cognition. Review of R45's physician order dated 11/13/2024, revealed to apply a resting hand splint to the resident's left hand four to six hours daily, once a day from 7:00 AM to 7:00 PM. Observation of R45 on 06/04/2025 at 12:42 PM, revealed the resident had a left resting hand splint in place. In interview on 06/04/2025 at 12:42 PM, R45 stated 'today was the first time in about four months her hand splint had been applied. She reported ROM was not performed to the hand prior to it being applied and said she had discomfort when the splint was first applied. R45 said she wore the splint for about four hours when staff did not forget to come and take it off. She additionally stated Licensed Practical Nurse (LPN) 2 had to search in her closet that morning to locate the splint so it could be applied. 2. Review of the Resident Face Sheet revealed the facility admitted R15 on 02/20/2017, with diagnoses of vascular dementia, Alzheimer's Disease, and chronic obstructive pulmonary disease. Review of the Annual MDS Assessment with an ARD of 03/28/2025, revealed the facility was unable to perform the BIMS assessment as R15 was rarely or never understood. Review of the physician order dated 04/26/2024, revealed an order for R15 to have Physical Therapy (PT) and Occupational Therapy (OT) evaluate and treat the resident for establishment of a restorative nursing program (RNP). Review of the physician order dated 11/12/2024 and which was discontinued on 06/02/2025, revealed an order to apply left hand grip splint daily four to six hours between the hours of 7:00 AM and 7:00 PM daily. Review of the, Occupational Therapy - Evaluation and Treatment Plan, dated 09/26/2024, revealed R15 had been referred to OT due to increased right upper extremity contracture and pain in the elbow and hand. Continued review revealed R15 had functional limitations present due to the contracture. Further review revealed as a result of the contracture and pain in R15's right upper extremity, OT was to address the contracture impairment. Review of the, Occupational Therapy Discharge Summary, dated 10/24/2024, revealed OT recommended R15 wear a splint as much as tolerated. Per review, a Restorative Nursing Program (RNP) and functional maintenance were not indicated at that time. Further review revealed maintaining R15's current level of function was good with consistent staff follow through. Observation of R15 on 06/01/2025 at 10:46 AM and 1:59 PM, revealed a hand splint in a mesh bag lying on the bedside table. Observation on 06/02/2025 at 10:47 AM and 1:35 PM, revealed the splint remained on R15's bedside table in a mesh bag. Observation on 06/03/2025 at 9:25 AM and 1:48 PM, further revealed the splint continued to be lying on the bedside table. Review of a physician order dated 06/04/2025, revealed an order to, apply right hand grip splint daily for a minimum of four hours with a maximum of six hours daily. Further review of the order revealed the splint was to be placed on R15 at 10:00 AM, and remove the splint at 2:00 PM. 3. Review of the Resident Face Sheet for R22 revealed the facility admitted the resident on 04/03/2020, with diagnoses of unspecified dementia, unspecified severity with other behavioral disturbance, drug-induced subacute dyskinesia and bipolar disorder. Review of the Annual MDS Assessment with an ARD of 03/11/2025, revealed a BIMS assessment was not completed as R22 was rarely or never understood. Review of the physician's order dated 11/12/2024, revealed R22 was to wear a left resting hand splint four to six hours daily, once a day from 7:00 AM to 7:00 PM. Review of the, Occupational Therapy Evaluation and Plan of Treatment, dated 03/03/2025, revealed R22 had been referred to skilled OT services due to increased contractures requiring splinting and ROM resulting in decreased quality of life and pain. Continued review revealed R22 would benefit from skilled OT services to decrease pain and contracture and to increase the resident's overall quality of life. Further review revealed the recommendation noted, splint orthotic recommendations will be assessed and an exercise prescription was for range of motion passive to left upper extremity. Review of the OT Discharge Summary dated 04/12/2025, revealed R22's goals had been discontinued as the resident had been discharged to the hospital. Observation on 06/01/2025 at 10:25 AM and 1:48 PM, of R22 revealed the resident was not wearing a hand splint. Observation on 06/02/2025 at 9:50 AM and 10:32 AM, revealed R22 had no hand splint in place. Further observation on 06/03/2025 at 10:20 AM and 1:00 PM, revealed R22 had a resting hand splint lying on a chair in the resident's room. In interview on 06/02/2025 at 12:17 PM, Certified Nursing Assistant (CNA) 2 stated she had been at the facility for a month, and had not applied resting hand splints to residents. She said she guessed the nurse did that (applied the splints). CNA 2 further stated resting hand splint application should be located on the CNA task charting if they were to put them on residents. In interview on 06/02/2025 at 1:28 PM, Certified Medication Tech (CMT) 1 stated the nurse was responsible for applying hand splints to residents. She said she could not give specific information on splinting or on the residents who had splints, as she did not usually work the floor. In interview on 06/03/2025 at 1:08 PM, the Director of Rehabilitation (DOR), who was an Occupational Therapy Assistant (OTA), stated she had been at the facility for three years. She reported she did not know off hand which residents had orthotics (splints) and she would have to look that information up. The DOR said no residents were receiving ROM programs as the facility did not have restorative nursing services. She stated when a resident was discharged from therapy services the resident's therapy needs were turned over to the nursing staff. The DOR explained the techs and nurses received education regarding a resident's how to apply and remove any orthotic device. She further stated there was no specific time of day the orthotics had to be applied and removed; however, residents should wear them at least four to six hours or as tolerated. In interview on 06/04/2025 at 9:23 AM, CNA 3 stated the facility did not have a restorative nursing program. She stated she had been informed that morning that R22 had a hand splint she was supposed to put on at 10:00 AM, but the resident did not receive ROM on the hand. The CNA showed the State Survey Agency (SSA) Surveyor where the information on R22's splint was located in the computer. Review of the computer information revealed it showed that CNA 3 was to document the application of the splint at 10:00 AM. Further review of the computer documentation revealed R22's splint had not been documented as applied in the computer since 06/01/2025. CNA 3 further stated in interview that residents not wearing their splints could make their contractures worse. In interview on 06/04/2025 at 9:36 AM, CNA 4 stated the facility had no official restorative nursing program and no restorative nursing assistants. She stated residents received ROM during their ADL care, such as dressing. CNA 4 reported the CNAs were responsible for applying residents' hand splints. She further stated she seldom worked on the hall she was currently working on, and did not know which residents had splints. In interview on 06/04/2025 at 5:52 PM, with the Director of Nursing (DON) and the Administrator, the DON stated she was new to her position, but said her expectations were for staff to follow physician orders. She said the facility did not have restorative nursing; however, residents received ROM through walking, dressing, and transfers. The DON further stated if residents did not have their devices on and did not receive ROM, they could potentially experience a decline in mobility causing contractures. The Administrator stated she expected staff to do whatever was in the best interest of the patient (resident) and follow the physician orders. Surveyor: [NAME], [NAME]

Based on observation, interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM for 3 of 7 residents sampled for limited ROM out of the 23 total sampled residents, (Resident (R15), R22, and R45). The findings include: In interview on 06/02/2025 at 2:18 PM, the Administrator informed the State Survey Agency (SSA) the facility did not have a policy regarding Restorative Nursing Services or splinting/orthotic devices. 1. Review of the Resident Face Sheet revealed the facility admitted R45 on 03/18/2024, with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left side, and personal history of transient ischemic attack. Review of the Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 03/26/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R45 was cognitively intact. Review of the physician order for R45 dated 11/13/2024, revealed staff were to apply the resident's resting hand splint to the left hand for four to six hours daily, once a day from 7:00 AM to 7:00 PM. Observation of R45 on 06/04/2025 at 12:42 PM, revealed the resident had a left resting hand splint in place. In interview at the time of observation, R45 stated that day was the first time the hand splint had been applied in about four (4) months. She said she did not receive range of motion (ROM) from to the hand before staff put it on. The resident reported she had discomfort of the left hand when the splint was first applied. She stated she wore the splint for about four hours, when staff did not forget to come and take it off. R45 further stated Licensed Practical Nurse (LPN) 2 had to search her closet that morning to find the splint to have it put on. 2. Review of the Resident Face Sheet revealed the facility admitted R15 to the facility on [DATE], with diagnoses of Alzheimer's Disease, chronic obstructive pulmonary disease, and vascular dementia. Review of the Annual MDS Assessment with an ARD of 03/28/2025, revealed the facility had not completed the Brief Interview for Mental Status (BIMS) assessment of R15 as the resident was rarely or never understood. Review of the physician order dated 04/26/2024 for R15, revealed an order for Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat the resident for establishment of a restorative nursing program (RNP). Review of the physician order dated 11/12/2024 for R15, that was discontinued on 06/02/2025, revealed an order for staff to apply the resident's left hand grip splint daily four to six hours between the hours of 7:00 AM and 7:00 PM daily. Observation of R15 on 06/01/2025 at 10:46 AM and 1:59 PM; on 06/02/2025 at 10:47 AM and 1:35 PM; and on 06/03/2025 at 9:25 AM and 1:48 PM, revealed a hand splint in a mesh bag was lying on the bedside table. Review of the physician order dated 06/04/2025 for R15, revealed an order for staff to apply the resident's right hand grip splint daily for a minimum of four hours with a maximum of six hours daily. Further review of the order revealed the splint was to be put on at 10:00 AM, and removed at 2:00 PM. Review of the Occupational Therapy (OT) - Evaluation and Treatment Plan, dated 09/26/2024, revealed R15 had been referred to OT due to increased right upper extremity contracture and pain in the elbow and hand. Continued review revealed R15 had functional limitations present due to the contracture. Further review revealed as a result of the contracture and pain in the right upper extremity, OT was to address contracture impairment. Review of the Occupational Therapy Discharge Summary, dated 10/24/2024, revealed OT's recommendations were for the resident to wear a splint as much as tolerated. Per review, a Restorative Nursing Program (RNP) was not indicated at that time, and maintaining R15's current level of functioning was good with consistent staff follow through. 3. Review of the Resident Face Sheet revealed the facility admitted R22 on 04/03/2020, with diagnoses of dementia, unspecified severity with other behavioral disturbance, drug-induced subacute dyskinesia and bipolar disorder. Review of the Annual MDS Assessment with an ARD of 03/11/2025, revealed the facility did not complete a BIMS assessment as R22 was rarely or never understood. Review of the physician's order dated 11/12/2024 for R22 revealed an order for the resident to wear a left resting hand splint four to six hours daily, once a day from 7:00 AM to 7:00 PM. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 03/03/2025, revealed R22 had been referred to skilled OT services due to increased contractures requiring splinting and ROM resulting in decreased quality of life and pain for the resident. Continued review revealed R22 would benefit from skilled OT services to decrease pain and contracture and increase overall quality of life. Further review revealed the OT noted the splint orthotic recommendations were to be assessed and an exercise prescription for passive ROM to R22's left upper extremity. Review of the OT Discharge Summary dated 04/12/025, revealed R22's goals had been discontinued as the resident had been discharged to the hospital. Observation of R22 on 06/01/2025 at 10:25 AM and 1:48 PM, and on 06/02/2025 at 9:50 AM and 10:32 AM, revealed the resident was not wearing a hand splint. Further observation on 06/03/2025 at 10:20 AM and 1:00 PM, revealed R22 had a resting hand splint located in a chair in the resident's room. In interview with Certified Nursing Assistant (CNA) 2 on 06/02/2025 at 12:17 PM, she stated she did not apply residents' resting hand splints, and she guessed the nurse did that. She further stated resting hand splints should be on the CNA task charting if the CNAs were to put them on. In interview with Certified Medication Tech (CMT) 1 on 06/02/2025 at 1:28 PM, she stated the nurse was responsible for applying hand splints for residents. She further stated she did not usually work the floor and was unable to give specific information on which residents had splints or on applying the splints. In interview on 06/03/2025 at 1:08 PM, the Director of Rehab (DOR), who was an Occupational Therapy Assistant (OTA), stated she had been working at the facility for three years. She said she did not know off hand which residents had orthotics (splints) and she would look that information up. The DOR reported there were no residents receiving ROM programs, as the facility did not have restorative nursing services. She stated when a resident was discharged from therapy services the resident's care needs were turned over to the nursing staff. The DOR said the techs and nurses received education regarding residents' orthotic devices, such as on how to apply and remove an orthotic. She further stated there was no specific time of day the orthotics had to be applied and removed; however, residents should wear them four to six hours or as tolerated. In interview with CNA 3 on 06/04/2025 at 9:23 AM, she stated the facility did not have restorative nursing programs. She stated she had been informed that morning that R22 had a hand splint that she was supposed to put on at 10:00 AM. CNA 3 said R22 did not receive ROM though. She further stated residents not wearing their splints could cause their contractures worsen. In interview with CNA 4 on 06/04/2025 at 9:36 AM, she stated the facility did not have an official restorative nursing programs and had no restorative nursing assistants. She stated residents received ROM during their ADL care, such as dressing. CNA 4 said the CNAs were responsible for applying residents' hand splints. She further stated she seldom worked on R22's hall and did not know which residents had splints. In interview with the Director of Nursing (DON) and the Administrator on 06/04/2025 at 5:52 PM, the DON stated she was new to the position and was still learning. The DON said her expectations were for staff to follow physician orders. She stated the facility did not have restorative nursing; however, the residents received ROM through walking, dressing, and transfers. The DON further stated residents without their devices and with no ROM could potentially have a decline in mobility causing contractures. The Administrator stated she would expect staff to do whatever was in the best interest of the patient (resident) and follow the physician orders.

Based on observation, interview, and review of facility policy, the facility failed to provide a communication system that relayed the call directly to a staff member or to a centralized staff work area from toileting and bathing facilities. The findings include: Review of the facility policy titled, Call Lights: Accessibility and Timely Response, with a revision date of 08/30/2024, revealed the purpose of the policy was to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Per policy review, the call system must be accessible to the resident at each toilet and bath or shower facility and should be accessible to a resident lying on the floor. Observation of the private bathroom in resident room [ROOM NUMBER] on 06/01/2025 at 10:30 AM, revealed a walk-in shower situated to the left immediately upon entering the bathroom. Per observation, to the right, upon entry, a sink and countertop were present. Continued observation revealed parallel to the furthest wall of the bathroom and to the right corner, the toilet was installed with the call light devices installed on the wall that ran parallel to the right of the toilet. Further observation revealed the call light cord was in place and was within approximately one inch from the floor, and the distance from the call light cord to the shower was approximately five feet. Additional observation of the private bathrooms in rooms [ROOM NUMBER] revealed one call light available that was positioned next to the toilet, the same as in room [ROOM NUMBER]. Observation on 06/03/2025 at 1:10 PM, of a resident and staff accessible restroom located on the 300 hall, situated between rooms [ROOM NUMBERS], revealed the presence of a call light system installed in the wall next to the toilet. Further observation revealed however, no pull cord was attached to activate the call light. Observation of the therapy gym on 06/03/2025 at 1:08 PM, revealed the restroom located in that area, had no call light system in place in the restroom. In interview with the Director of Rehabilitation (DOR), at the time of observation, the Director stated residents were never left alone in the restroom in the therapy gym restroom as a therapy staff member was always present. In interview on 06/01/2025 at 10:27 AM, Resident (R)14 expressed concern that the call light cord did not reach the shower in the private bathroom of the room. The resident reported if someone taking a shower had a fall, they would not be able to reach the call light cord to call for help. In interview with Certified Nursing Assistant (CNA) 9 on 06/02/2025 at 11:34 AM, she stated, due to the call lights, she would remain in the room with a resident while the resident was taking a shower, so they did not fall and hurt themselves. In interview with the Assistant Director of Nursing (ADON) on 06/03/2025 at 1:12 PM, she stated that if a resident chose to shower independently and a call light was not within reach, she would probably stand outside the bathroom door to hear if in case the resident fell or called out for help. In interview with the Director of Nursing (DON) on 06/04/2025 at 6:02 PM, she stated she expected staff to know if a resident was in the shower and increase checking on the resident if the call light did not reach. In interview with the Administrator on 06/04/2025 at 6:02 PM, she stated that she would educate residents to ask for a staff member to be present (if the call light did not reach). She said she would investigate the issue further.

Based on interview, record review, and review of facility policy, it was determined the facility failed to include the resident and/or the resident's representative in the care planning process. The facility failed to either invite the resident and/or their representative or include an explanation in the resident's medical record as to why their participation in the development of the resident's care plan was not practicable. This failure affected five (Resident (R) 45, R15, R10, R43, and R48) of twenty-five (25) sampled residents. The findings include: Review of the facility policy titled, Care Planning-Resident Participation, dated 03/20/2023, revealed that the facility would discuss the plan of care with the resident and or representative at regularly scheduled care plan conferences and allow them to see the care plan initially, at routine intervals, and after significant changes. The facility would make an effort to schedule the conference at the best time of day for the resident or the resident representative. Additionally, the facility would obtain a signature from the resident and or resident representative after discussion or reviewing of the care plan. If the participation of the resident and or resident representative is determined not practicable for the development of the resident care plan, an explanation would be documented in the resident's medical record. 1. Review of R45's Facesheet in the medical record revealed the resident was admitted on [DATE], and had a durable Power of Attorney (POA) Review of most recent Minimum Data Set (MDS), a quarterly assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1/15, indicating the resident was severely cognitively impaired. Review of the Care Plan section of R45's medical record revealed no care conference notes, nor dates documenting when a care conference occurred. Consistent with R45's admitted , an admission care conference would have been expected to have occurred no later than 12/2023 and a quarterly care plan conference no later than March 2024. Further review of the Care Plan section revealed a baseline care plan was initiated on 11/21/2023, with and initial comprehensive care plan established within the first 14 days. Continued review of the care plan revealed subsequent problems and goals were identified in 12/2023 and in 03/2024. Review of R45's progress notes revealed no documentation of that the facility extended an invitation to the resident's POA to attend his care conference and participate in his care decisions. In addition, there was no documentation to explain why the resident and/or their representative was not included in the care planning process. During interview with R45's POA on 04/09/2024 at 3:24 PM, he stated he could not recall being invited to a care plan conference. The POA questioned R45's diagnoses and was unaware of possible care areas related to the resident, such as wound care. 50153 2. Review of the Admission Record revealed R15 was a long-term resident of the facility. Review of the Quarterly MDS, dated , 03/08/2024, revealed a BIMS score of 9/15, indicating R15 had moderate cognitive impairment. Progress notes review of the previous 120 days prior to 04/12/2024 revealed no evidence that the resident and/or their responsible party had been invited to attend the care plan meeting. Upon attempting to interview R15 on 04/08/2024 at 9:00 AM, the resident was in bed. The resident made eye contact but did not reply to questions when asked. 3, Record review of R48 revealed an initial admitted [DATE]. The 03/16/2024 Quarterly MDS revealed a BIMS score of 4/15, indicating severe cognitive impairment. Progress notes review of the previous 120 days prior to 04/12/2024 for R48 revealed no evidence that the resident's responsible party was invited to attend a care plan meeting. In a telephone interview with R48's Guardian on 04/09/2024 at 11:10 AM, the Guardian stated that he does not recall receiving an invitation to attend a care plan meeting. 4. Record review of R43 revealed an initial admitted [DATE]. The MDS Quarterly assessment dated [DATE] indicated a BIMS score of 3/15, indicating severe cognitive impairment. Review of the progress notes of the previous 120 days prior to 04/12/2024 revealed no evidence that the resident's responsible party was invited to attend a care plan meeting. In a telephone interview on 04/09/2024 at 11:29 AM, R43's Guardian stated that he has not received an invitation to attend a care plan meeting. 5. Record review of R10 revealed the initial admitted [DATE], The MDS Quarterly assessment dated [DATE] indicated a BIMS score of 14/15, indicating the resident is cognitively intact. Progress notes review of the previous 120 days prior to 04/12/2024 revealed no evidence that the resident and/or their representative were invited to attend a care plan meeting. In an interview with R10 on 04/11/2024 at 10:45 AM, R10 stated she did not recall being invited to a care plan meeting and has not attended any meetings. In a telephone interview with the Durable POA for R10 on 04/09/2024 at 9:05 AM, the DPOA stated that she has not received an invitation to attend a care plan meeting. During interview with the MDS Coordinator on 04/12/2024 at 5:25 PM, she stated she helps with the baseline care plan and is responsible to ensure a care plan is in place for every area triggered on the Care Area Assessments (CAA) so that staff know how to take care of the resident. The MDS Coordinator stated she is responsible to send out Primetime (facility notice) weekly for residents who are due the following week for care plan review and conference and notify staff of the planned meeting. The MDS Coordinator stated she updated care plans in real time during care plan conferences but has not documented the conference notes in the dedicated section of the record for this before. She further stated the Social Services Director (SSD) is responsible for inviting families and to document who was present, including families, in the care plan conference notes. During interview with the SSD on 04/12/2024 at 5:41 PM, she stated that normally care conferences would be documented in the medical record in the Care Conference section of the care plan. The SSD stated that she uses the BIMS score of the resident, along with the resident's actual cognitive ability, to determine who to invite to the care plan meeting. The SSD explained that residents who have a BIMS score greater than 8/15 and are cognitively intact can determine who can be invited or not from their family. She stated for residents whose BIMS score is less than 8/15, she is responsible to notify families of the date of care plan conference. The SSD indicated that if the family cannot make the typical day, she is to ask what was convenient for them, call families to invite them to the care conference, and document in a progress note if she left a message or talked to them. However, she stated, she has not been doing that. She stated it was important for families to be aware of concerns of residents' everyday wellbeing and they might have insight into things such as behavior management. Interview with the interim Director of Nursing on 04/12/2024 at 5:50 PM revealed the SSD had received education on documenting care plan conferences that day, after the survey was initiated. She stated the expectation is that care conferences are documented, and the care conference note should have documented who was present, including family. She further stated the expectation is family or POA is invited to care conferences. During interview with the Administrator on 04/12/2024 at 4:51 PM, she stated care plan conferences occurred at admission, quarterly and with significant change in a resident's condition. She indicated staff were to notify families or responsible parties, (whether by call, email, or text), of scheduled care plan conferences. She stated if family or responsible parties were not able to attend a scheduled care plan conference, then an alternate date or time was offered. When asked if there needed to be documentation in the record if attendance at the meeting was declined, the Administrator stated, It doesn't have to be, even though both the regulation and facility's own policy called for an explanation to be documented if the attendance of the resident/responsible party was not practicable.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure all drugs and biological agents were properly labeled, stored, and/or secured in accordance with accepted professional principles. Medication was not kept under lock as required. Expired medication was not discarded per policy. Medication was not completely labeled so as to identify the resident to whom it was prescribed and/or dated as required. Temperatures for medication storage were not monitored and/or maintained at a level to protect the safety/efficacy of the drugs. These failures involved two (2) of two medications rooms, two of five medication carts, and one treatment cart. The findings include: 1.Unlocked Medications: Review of the facility policy, titled Medication Storage in the Facility, dated 05/2022, revealed medications must be stored safely, securely, and properly. a. Observation on 04/08/2024 at 8:15 AM on the 200 Hall revealed Certified Medication Technician (CMT) 5 left the medication cart unlocked and unattended as the survey team entered the building for the first time. The CMT 5 was not in the line of sight of the unlocked medication cart. During interview with CMT5 on 04/08/2024 at approximately 12:15 PM, she stated she should have locked the cart before walking away. She stated it was important to lock the cart because someone could get into the cart and take out a medication that was not prescribed for them which could cause a problem. b. Observation on 04/11/2024 at 11:42 AM revealed CMT14 left the medication cart on the [NAME] Wing unattended, unlocked, and out of line of sight in the hallway. No other staff were present to provide visual supervision of the unlocked cart. During interview with CMT14 on 04/11/2024 at 11:44 AM, she stated the medication cart should be locked if she cannot see it. She stated that if the cart was not locked, someone could get into it, and it could be very bad. c. Observation on the 300 Hall on 04/08/2024 at 09:32 AM revealed an unlocked treatment cart. At this time, Licensed Practical Nurse (LPN) 1 was observed leaving a resident bathroom and returning to the unsecured cart. Interview with LPN1 at this time revealed the treatment cart was left unlocked when a resident was going to the bathroom and the LPN went in to assist. LPN1 confirmed the treatment cart was unlocked, and she should have locked it before walking off. Observation of the contents of the cart revealed that it contained creams, ointments, insulins, nebulizer treatment medications, and wound care supplies. During interview regarding securing medications with the Administrator on 04/05/2024 at 5:15 PM, she stated Generally, they [staff] are good about it. They may get distracted and lay something down but then go back to it. She stated it was her expectation that a medication cart be locked if it was not in line of sight of staff. 2. Expired Medications/Labeling Review of the facility policy, Medication Storage in the Facility, dated 05/2022, revealed medications must be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Further review of the policy revealed all medications dispensed by the pharmacy are stored in the container with the pharmacy label. The policy stated that no expired medication will be administered to a resident and all expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. a. Observation of the east side medication cart on 04/10/2024 at 4:27 PM revealed benzonatate capsule 100 milligrams (mg), labeled for Resident (R) 7 that expired 01/27/2024. Further observation revealed acetaminophen 500 mg for R40 that expired 4/07/2024. b. Observation of the west side medication cart on 04/10/24 at 4:42 PM revealed ondansetron 4 mg, labeled for R19, expired on 03/03/2024. c. Observation of the west medication storage room on 04/10/2024 at 2:08 PM revealed an opened vial of Tubersol, with an open date of 03/06/2024 (more than 30 days prior). d. Observation of the east medication storage room on 04/10/2024 at approximately 2:35 PM, revealed a vial of Arexvy, RSVPreF3 vaccine, labeled for R21, 120 micrograms (mcg), dispensed 03/22/2024. The vaccine was not open, still stored in a prescription bottle. The unsealed normal saline vial to be used for reconstitution of the vaccine was not dated. Further observation revealed Amicasin 1340 mg/250 ml bag intravenous piggyback, expired 02/23/2024. A portion of the label was no longer attached, and the resident for whom it was prescribed could not be identified. During an interview with LPN2 on 04/08/2024 at 02:08 PM, LPN2 indicated the opened vial of Tubersol should be discarded because it can only be used for up to 30 days after the open date. When asked about the use of an expired medication, LPN 2 stated that a medication could increase or decrease in strength depending on the medicine and it might not be as effective. During interview with LPN1 on 04/10/2024 at 4:27 PM, she stated that discontinued intravenous medication in the refrigerator just needs to go back to pharmacy. LPN1 stated she understood the Director of Nursing (DON) went through the refrigerator to discard expired medications. In further interview, she stated, You don't give medications that are expired because they may not be as effective. She stated that everyone who has hands in the cart should probably be looking at expiration dates. However, she added, she had not particularly been trained to do that. During interview with the Interim Director of Nursing (IDON) on 04/12/2024 at 4:06 PM, the IDON stated that it was her expectation that the nurses and CMT's dispose of expired medications. She stated she expected staff to look for expired medications if they are assigned to that cart. She stated she feels recently expired medications probably would not affect resident's health but added, We do like to keep meds in date. Expiration dates are recommendations, we would follow those as a facility. During interview regarding expired medications with the Administrator on 04/05/2024 at 5:15 PM, she stated that it was her expectation that medications are not expired on the medication carts and that weekly cart checks are completed. In continued interview, she stated medications are pulled if it's really close or the day of if there's a chance it won't be used. She indicated this was a nursing obligation to check the medications, remove expired medications from the cart, and discard the expired medications. In additional interview, she stated the floor nurses are responsible for these tasks, as well as the unit managers and Director of Nursing. 3. Storage Temperatures: Review of the facility policy, titled Medication Storage in the Facility, dated 05/2022, revealed medications must be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Per the policy, medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC). To wit, the refrigerated temperature range specified in the policy was 36 degrees Fahrenheit (F) to 46 degrees with a thermometer to allow temperature monitoring. Additional review of the policy revealed the facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day per CDC guidelines. Observation of the west medication storage room on 04/10/2024 at 2:08 PM revealed a combined refrigerator (in which medications were stored)/freezer unit. Both the refrigerator and freezer units contained thermometers. There was no temperature log labeled for recording of refrigerator temperatures. A log, labeled for the freezer, did document temperatures for the month of April 2024. However, the daily temperatures on the freezer log ranged between 23 - 28 degrees F and were not acceptable for a freezer or refrigerator. Review of the temperature log revealed it did not reflect the accepted temperature range for staff to use as a reference to determine if the unit was properly functioning. During interview on 04/10/2024 at 02:08 PM, LPN2 stated that if the refrigerator temperature was out of range, she would have to discard the medications and notify maintenance to repair the refrigerator. LPN2 stated if medications were stored out of range, medications might not be appropriate to give if the medication was too cold or too warm and it would not be safe to administer them. LPN2 stated she was not sure of the correct temperature range of the refrigerator but thought it was 32-42 degrees. Observation on 04/10/2024 at 4:05 PM revealed LPN2 was on the telephone with the Pharmacy. During interview immediately after this call, she stated the pharmacist had recommended discarding the entire stock in the west side refrigerator due to lack of confirmation of correct temperatures. During interview with the IDON on 04/12/2024 at 4:06 PM, she stated she did not know if she would be able to produce the previous three months of temperature logs requested by the survey team to verify that staff were monitoring the temperature for both compartments of the refrigerator/freezer. No such logs were provided prior to exit from the facility. The IDON further stated that upon entry of the survey team, she was asked for a blank of the temperature log for the refrigerator and there was none in place at that time. The IDON stated that it was her expectation of staff to obtain an accurate temperature of the medication storage refrigerator. During interview regarding storage temperatures with the Administrator on 04/05/2024 at 5:15 PM, she stated it depends on medications and temperatures for it. The Administrator stated that whatever the medication, it should be maintained in the proper temperature. The Administrator stated that the night shift staff was responsible to check and document the refrigerator temperature every shift. She further stated if a refrigerator temperature was out of range, it would need to be addressed, which may include maintenance, and the medications in the refrigerator would need to be determined if still in the safe range. If not, the medications would need to be discarded. She also stated the reason for the temperature not being in range would have to be addressed.

Based on observation, interview, record review, review of grievance logs, and review of the Kentucky Food Guide 2013 Food Code guidance, the facility failed to provide food that was at a palatable temperature and flavorful. Hot foods were below the acceptable levels for the point of service temperatures, while the cold food/beverages were above the acceptable temperatures for the point of service. In addition, food was bland and in need of seasoning/condiments. This failure affected three (Resident (R) 47, R62, and R36) of twenty-five (25) sampled residents out of a total census of 59 resident. In addition, this failure had the potential to affect any of the 34 residents who live on the two of three halls (200 Hall and 300 Hall) who prefer to eat in their rooms (rather than the main dining room). The findings include: 1. Review of the Admission Record revealed Resident (R) 47's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. In an interview with R47 on 04/09/2024 at 11:53 AM, she stated the food was not good. R47, who eats in her room, stated the food was bland with no flavor and sometimes cold. She further stated she received no condiments on the meal tray. She stated you have to ask for salt and pepper and most of the time they do not bring it. 2. Review of R62's Admission MDS, dated [DATE], revealed a BIMS score of 15/15, indicating the resident was cognitively intact. In an interview with R62 on 04/08/2024 at 11:22 AM, he stated, he ate meals in his room and the food was awful and most of the time it was cold. 3. A group meeting was conducted on 04/09/2024 at 2:30 PM with 18 residents the facility identified as reliable historians. During the meeting, residents voiced concerns about the food not being seasoned and hot foods being served cold. 4. a. Review of grievance logs for 01/2024 revealed R36 filed a grievance on 01/30/2024 about food being cold when it was served in the resident's room. The grievance was marked as Resolved, stating that the resident was invited to eat in the dining room and noting that the resident did not ask for her plate to be warmed. On the following day, 01/31/2024, R36 filed another grievance that the food on the tray was cold. In response, R36 was again invited to come to the dining room where, The food comes straight off the steam table and is good and hot. b. Review of the grievance log for 03/2024 revealed that six residents were listed as complaining that meals were cold when they were served in the resident's room. The response to this grievance was only addressed to one resident (R36), who was again invited to eat in the dining room (rather than her own room) and told that she that she could ask to have her plate warmed. 5. Review of the Kentucky Food Guide, 2013 Food Code guidance, revealed that at point of service, hot foods should be 135 degrees Fahrenheit (F), or greater and cold food/beverage products should be 41 F degrees or less. Observation during tray line on 04/08/2024 at 12:17 PM, revealed temperature reading obtained by the cook were as follows: turkey with orange glaze at 192 degrees F; green beans at 192 degrees F; herbed rice 188 degrees F; and egg noodles 161 degrees F. Continued observation revealed the meal was being plated on room temperature plates and no plate warmer or other device to keep food warm was observed. They food trays were then put in the 200-300 Hall cart, which was not temperature controlled. A test tray for the lunch meal was conducted on 04/08/2024 at 12:40 PM, the time that the last tray on the 200/300 Hall cart was served to a resident. A test of the food revealed the egg noodles and green beans were bland and tasted as if there was no seasoning, The turkey, noodles, green beans and rice (food to be served hot) were only warm to the taste. Temperature readings taken by dietary staff at the point of service included turkey -121 degrees F, herbed rice -124 degrees F, egg noodles - 119 degrees F; and green beans at 124 degrees F. A prepackaged cup of strawberry yogurt was at 60 degrees F; and a glass of sweet tea, with no ice in it, was 54 degrees F. The cook, who was present during the test tray process, confirmed the temperatures and stated that the food needed to be hotter. In an interview with the Interim Director of Nursing on 04/12/2024 at 5:49 PM, she stated she expected the kitchen to follow guidelines for maintaining food temperature on the tray line and at point of service. She stated regulatory requirements should always be met. In an interview with the Administrator on 04/12/2024 at 4:50 PM, she stated there were currently some concerns regarding the kitchen and food services. She stated dietary was working on things to take care of issues and residents were encouraged to come to the dining room to eat (rather than eating in their rooms).

Based on observation, interview, record review, and review of facility policy and competency documentation, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of infection for one (1) (Resident (R) 47) of six (6) residents reviewed for wounds out of a sample of twenty-five (25) residents. During wound care, one Licensed Practical Nurse (LPN) failed to utilize a barrier to lay out wound supplies and failed to change gloves and/or perform hand hygiene when indicated. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, revised on 02/21/2024, revealed that the facility would establish and 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. Review of the facility skills review (competency check-off form) for wound care, titled Clean Wound Dressing Change, revealed staff were to implement the following steps: organize the work area by protecting linens or other surfaces with a plastic bag under the affected body part, open a disposable bag to collect soiled dressing, wash hands and don gloves, remove the soiled dressing, discard the soiled dressing and gloves in the plastic bag. The nurse would then wash her hands, set up supplies on a clean field, and don gloves, apply any medications and dressings. Finally, the nurse would place all used supplies in a plastic bag, remove gloves and dispose of them in the soiled utility room, and wash hands. Review of the Admission Record revealed the facility admitted R47 on 08/24/2023 with diagnoses including peripheral vascular disease and paresthesia of the skin. (pins and needles sensation), and skin breakdown. Review of a Wound Care note, dated 04/10/2024, revealed the current treatment order for the right heel wound was to cleanse the wound with normal saline, apply Polymem Pink to the right heel, cover the wound with a dry dressing and change daily. Observation on 04/10/2024 at 2:26 PM revealed LPN1 entered R47's room. The nurse, who was not wearing gloves at the time, proceeded to pull back the sheet from the resident's lower legs/feet to see if a dressing was in place to the resident's right heel. A dressing was not secured to R47s wound and was under the resident's right heel. LPN1 then left the room and went to get wound care supplies. LPN1 reentered the room, carrying the supplies in her bare hands. LPN1 then placed the treatment supplies on R47's bed without using a barrier of any kind. Prior to starting wound care, LPN1 donned gloves without first performing hand hygiene. She then removed the soiled dressing and disposed of it in the trash. LPN1 then, without changing the soiled gloves or performing hand hygiene, cleansed the wound to the right heel, applied the ordered treatment, and covered it with a bordered gauze dressing. In an interview with LPN1 on 04/10/2024 at 2:38 PM, she stated she should have used a barrier and not used R47's bed to place the wound supplies. She confirmed she did not change her gloves after removing the soiled dressing from the right foot. She stated she should have changed her gloves and performed hand hygiene after she removed the soiled dressing. In an interview with the Interim Director of Nursing/Infection Preventionist on 04/12/2024 at 5:50 PM, she stated she expected the nurses to follow infection control policies and procedures. She stated the nurse should have changed her gloves and washed her hands before applying the clean dressing.

Based on observation, interview, record review and policy review, the facility failed to ensure one (1) of one (1) sampled residents (Resident #1) was free from abuse. On 06/21/2021, Nurse Aide (NA) #1 hit Resident #1 on the arm during a bath. The findings include: Review of the facility policy titled, Prohibiting Abuse, Neglect, Misappropriation and Exploitation, dated 11/2017, revealed the facility believed that it is each individual's right to be free from physical abuse. The policy further stated that Physical Abuse includes hitting, slapping, pinching or kicking. Record review revealed the facility admitted Resident #1 on 11/17/2020 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 quarterly Minimum Data Set (MDS) assessment dated [DATE], it revealed Resident had a Brief Interview for Mental Status (BIMS) score of 0 (zero), which indicates severe cognitive impairment. Observation of Resident #1 on 07/20/2021 at 10:45 AM revealed resident was in his/her room sitting in a chair talking with housekeeping staff. The resident had no visible signs of injury or bruising. An attempt to interview Resident #1 on 07/20/2021 at 10:50 AM was unsuccessful as the resident did not respond to questions. Review of facility investigative report dated 06/21/2021 at 3:40 PM, revealed State Registered Nurse Aide (SRNA) #3 and NA #1 were bathing Resident #1 when Resident #1 slapped NA #1 across the face. Per the investigation, NA #1 then slapped Resident #1 on the arm. NA #1 and Resident #1 were separated, NA #1 was removed from the floor, administration was made aware of incident and an investigation was initiated. Per the investigation, the facility substantiated abuse occurred. Review of incident report, dated 06/21/2021 at 3:40 PM, recorded by the Director of Nursing (DON), revealed SRNA #3 reported Resident #1 was hitting and kicking at SRNA #3 and NA #1 while staff were attempting to give the resident a shower. SRNA #3 bent over to attempt to stop Resident #1 from kicking, when she heard a smack. SRNA #3 told NA #1, who was in orientation, that we do not hit the residents and to go take a break. NA #1 was called to the conference room and was noted to be very upset. Continued review of the incident report revealed NA #1 stated she reacted to being smacked across face and put her hand up to block Resident #1 from hitting her again. Interview with SRNA #3, on 07/20/2021 at 4:00 PM, revealed Resident #1 was agitated and hitting at staff. Per the SRNA, when she and NA #1 went to undress Resident #1 to attempt to shower the resident, Resident #1 slapped NA #1. SRNA #3 stated she saw NA #1 intentionally slap Resident #1 on her arm. According to SRNA #3, NA #1 stated she did not want to work anywhere where she was going to get hit. SRNA #3 stated she then told NA#1, staff do not hit the residents and instructed her to go take a break. SRNA #3 stated she then found other staff to complete Resident #1's bath and went to report incident to the charge nurse. Interview with NA #1, on 07/20/2021 at 5:25 PM, revealed she and SRNA #3 were undressing Resident #1 to bathe him/her, when Resident #1 slapped NA #1 across the face leaving a hand print on the NA's face. NA #1 stated that she put her arm/hand up to protect herself, to stop Resident #1 from hitting her again. NA #1 stated she pushed the hand/arm of the resident to block the resident from hitting NA again Per NA #1, SRNA #3 was looking down, due to Resident #1 attempting to kick SRNA #3 and SRNA #3 was not looking at her when the blocking of Resident #1's arm took place. Interview with Resident Services Coordinator, on 7/20/2021 at 3:10 PM, revealed she completed the investigation report related to the alleged abuse to Resident #1 by NA #1. The Resident Services Coordinator further stated she was present in the second interview with SRNA #3 when the SRNA stated NA #1 intentionally hit Resident #1 on the arm and it was not done in to defend self. The Resident Service Coordinator stated the facility substantiated the the allegation of abuse based on SRNA #3 witness statement and NA #1 admitted to making contact with the resident's arm. Interview with the DON, on 07/20/2021 at 3:00 PM and 4:50 PM, revealed she was present during the interviews with SRNA #3 and NA #1 after the incident with Resident #1. The DON stated she assisted with skin assessments during the investigations and no other concerns with any other residents were noted. The DON stated the facility substantiated the allegation due to SRNA #3 stating in a second interview she saw NA #1 hit Resident #1's arm and SRNA #3 felt it was intentional. In addition, the DON further stated the statements made by NA #1 following the incident, where NA #1's immediate reaction was to state she would not work somewhere she was going to be hit. Per the DON, SRNA #3 had been on staff at facility for 4-5 years and NA #1 was still in orientation. The DON further revealed following the investigation NA #1 was terminated. Interview with the Administrator, on 07/20/2021 at 7:00 PM, revealed she was aware in the first interview with SRNA #3 following incident (related to Resident #1 and NA #1) SRNA # 3 stated she was bent over and heard a smack. During the second interview with SRNA #3, she reported she saw Resident #1 hit NA #1 and then NA #1 hit Resident #1 intentionally, not defending herself. The Administrator also stated NA #1 stated in her interview she put her arm up and made contact with Resident #1's arm, but it was to block Resident #1 from hitting NA #1 again. Per the Administrator, the allegation was substantiated by the facility and NA #1 was terminated.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide treatment and services for one (1) of one (1) sampled resident (Resident #1) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to track and trend behaviors displayed by Resident #1 in order to provide and plan person centered care. The findings include: Review of the facility policy titled, Comprehensive Care Plan Policy and Procedure, dated 11/14/2017 revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights that includes measurable objectives and time frames to the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The policy further stated the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident highest practicable, physical mental, and psychosocial well-being. The policy also stated the comprehensive care plan will be kept updated as care need changes occur. Review of the facility policy titled Assessment and Care Management of Residents diagnosed with Dementia dated 12/20/2018, revealed the facility was to ensure each resident with dementia received the care necessary to attain or maintain the highest practicable physical, mental and psychosocial well-being and to utilize his/her preferences, choices and customary routines in a person-centered approach to care delivery. The policy further stated for residents whom information cannot be obtained, and/or the resident cannot state his/her preferences, the Resident Services Coordinator, Activities Director, and the interdisciplinary Care Team would use practicable judgement in the care plan development process. Review of the facility policy titled Behavior Management Program dated 09/04/2021, revealed it was the facility objective to provide accurate documentation of all inappropriate resident behaviors. Further review revealed individualized interventions to attempt to manage inappropriate behaviors would be addressed on the resident's interdisciplinary plan of care. The policy also stated the resident's care plan would be updated with description of the inappropriate behavior and management interventions at the time of behavior occurrence. Record review revealed the facility admitted Resident #1 on 11/17/2020 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 quarterly Minimum Data Set (MDS) assessment dated [DATE], it revealed Resident had a Brief Interview for Mental Status (BIMS) score of 0 (zero), which indicated severe cognitive impairment. Observation of Resident #1, on 07/20/2021 at 10:45 AM, revealed resident was in his/her room sitting in a chair talking with housekeeping staff. The resident had no visible signs of injury or bruising. An attempt to interview Resident #1 on 07/20/2021 at 10:50 AM was unsuccessful as the resident did not respond to questions. Review of a Progress note dated 06/21/2021 at 3:00 PM, revealed the resident was sitting in a chair, cursing and had excessive grimacing present and Tylenol was administered, at 3:30 PM. Per the note at 3:30 PM, the resident was combative this AM and the aides re-approached after lunch for personal care. Review of Resident #1's care plan revealed a focus area of Alteration in mood/behavior r/t resident yells/curses, combative, easily agitated and wanders from time to time. Interventions included to: Avoid power struggles, approach resident in a calm manner. Review of facility investigative report dated 06/21/2021 at 3:40 PM, revealed State Registered Nurse Aide (SRNA) #3 and Nurse Aide (NA) #1 were bathing Resident #1 when Resident #1 slapped NA #1 across the face. NA #1 then slapped Resident #1 on the arm. NA #1 and Resident #1 were separated, NA #1 was removed from the floor, administration was made aware of incident and an investigation was initiated. Interview with SRNA #3, on 07/20/2021 at 4:00 PM, revealed Resident #1 was agitated and hitting at staff on 06/21/2021. The SRNA stated Resident #1 was more combative between 2:00 PM to 4:00 PM, and she (SRNA #3) usually attempted to bathe/shower the resident prior to that time; however, on 06/21/2021 it did not work out to provide care earlier that day. SRNA #3 further stated with residents who have agitated behaviors which are uncommon for them, care would be attempted later, but with Resident #1 the longer staff wait during the day the more combative Resident #1 becomes. SRNA #3 also stated she usually just lets Resident #1 arms move around when the resident is combative and just makes it fast. The SRNA stated on 06/21/2021, Resident #1 needed a bath. SRNA # 3 stated the nurse gave Resident #1 some medication on 06/21/2021 but it did not calm him/her. Interview with NA #1, on 07/20/2021 at 5:25 PM, revealed NA #1 and SRNA #3 were undressing Resident #1 to bathe her. NA #1 stated Resident #1 was very agitated: kicking and hitting. SRNA #3 told NA #1 to hold down the resident's arms and remove Resident #1's shirt. Per NA #1, SRNA #3 bent over to hold down Resident #1 legs due to Resident #1 kicking and to pulling Resident #1 pants off. NA #1 stated Resident #1 tolerated care better in the mornings than the afternoon. NA #1 stated the nurse caring for Resident #1 told SRNA #3 to wait to bathe Resident #1 at a different time; however, NA #1 stated the SRNA decided to bathe Resident # 1 at that time. NA #1 stated she was unsure of the name of nurse. Multiple attempts to reach the nurse documenting on Resident #1 in progress notes on 06/21/2021 were unsuccessful. Review of facility behavior monitoring sheet for the month of June 2021 revealed Resident #1 had documented behaviors of yelling/screaming on 06/09/2021 at 9:24 AM, 06/11/201 at 2:45 PM, 06/16/2021 at 9:07 AM, and on 06/21/2021 at 3:35 PM. Further review revealed the resident displayed frequent crying behaviors on 06/10/2021 at 9:57 AM and 06/11/2021 at 2:45 PM. The monitoring sheet revealed the resident displayed behaviors of rejection of care on 06/15/2021 at 6:36 PM, 06/17/2021 at 2:59 PM, and 06/20/2021 at 1:58 PM. The resident displayed behaviors of abusive language and threatening behaviors on 06/11/2021 at 2:45 PM and physically aggressive behaviors of kicking, hitting, pinching, scratching, and spitting on 06/21/2021 at 3:35 PM. Although the resident displayed increased behaviors in the afternoon/evening, there was no evidence the facility used this information to develop a person centered care plan. Interview with the Director of Nursing (DON), on 07/20/2021 at 3:00 PM and 4:50 PM, revealed she was unaware of Resident #1 tolerating hygiene care better at certain times of the day. The DON also stated the aides should have stopped attempting to shower Resident #1 due to her being combative and re-approached the resident later. Interview with MDS Coordinator, on 06/21/2021 at 5:55 PM, revealed after incidents occurred, the team meet and decided on new interventions. The MDS Coordinator further stated she was unaware of any new interventions after the incident with Resident #1, SRNA #1 and NA #1. Per the MDS Coordinator, Resident #1 was known to have history of being combative at times and she was unaware of Resident #1 tolerating and being more cooperative with care earlier in the day; however, if staff felt Resident #1 tolerated care better earlier in the day, then it should be care planned for Resident #1 to receive care earlier in the day. Interview with the Administrator, on 7/20/2021 at 7:00 PM, revealed she was unsure if staff had postponed care for Resident #1 on 06/21/2021 if it would have helped with Residents #1's behaviors. The Administrator further stated that she questioned SRNA #3 about re-approaching Resident #1 and re-attempting care later and SRNA #3 stated that Resident #1 was always like this, and Resident #1's behaviors were not different that day.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 10/24/18, revealed the kitchen had only one (1) sanitation bucket in use and the water in the sanitation bucket was visibly soiled/dirty with multiple soiled cloths in the soiled water. Review of the facility Census and Condition, dated 10/23/18, revealed fifty-five (55) of fifty-eight (58)residents received their meals from the kitchen. The findings include: Review of facility policy titled, Sanitation and Food Handling, not dated, revealed cloths used by dietary personnel must be clean and free of odors. Cleaning cloths will be kept in a small pail of sanitizing solution-minimum of 50 PPM chorine and sanitizing solution will be checked every two (2) hours for proper sanitizer levels and remade as needed. It further stated soiled cloths will be placed in a hamper. Observation of the kitchen on 10/24/18 at 11:35 AM, revealed a red sanitation bucket on sink counter with extremely soiled/visibly dirty water with multiple visibly soiled/dirty cloths in the bucket. Further observation of the Dietary Manager measuring the sanitation level in the bucket per surveyor's request, revealed a reading of no sanitation present. Interview with the Dietary Manager on 10/24/18 at 11:35 AM, revealed the sanitation bucket should have been changed due to the dirty water with dirty rags and it not measuring any sanitation present. Interview with the Dietary Manager on 10/26/18 at 1:42 PM, revealed she expected the Sanitation Bucket to be available and checked and changed every two (2) hours and more often if the water is visibly soiled.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure six (6) of seventeen (17) sampled residents (Residents #27 #32, #14, #42, #51, and #52) and one (1) unsampled resident (Resident #22) had a person-centered comprehensive care plan developed and/or implemented to meet his/her other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The facility failed to develop a Dementia Care, Care Plan for Resident #22, failed to develop a Bowel and Bladder Incontinence Care Plan for Resident #32, failed to follow Falls Careplan Interventions for Resident #52, failed to follow the Activity Care Plan interventions for Residents #27, #14, and #42, and failed to follow the Oxygen Care Plan Interventions for Resident #51. The findings include: Review of facility policy titled, Comprehensive Care Plan Policy and Procedure, revealed the purpose of the policy is to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment. It further stated the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. It also stated services that are included in the comprehensive care plan will have measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs consistent with those services. 1. Record review revealed the facility admitted Resident #22 on 05/04/16 with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #22's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of one (1) which indicated the resident was not interviewable. Further review of the MDS, revealed Resident #22 had difficulty with communicating some words and finishing thoughts along with he/she misses some part/intent of messages. Review of the Comprehensive Care Plan, last revised 03/22/18, revealed the facility did not have a Dementia Care care plan in place to guide staff on how to address this resident's Dementia Care needs. Interview with Compliance Nurse on 10/26/18 at 10:30 AM, revealed she could not find any individualized dementia care, care plans in place for Resident #22. Interview with the Social Services Director on 10/25/18 at 12:45 PM, revealed she did not see any individualized dementia care, care plans in place for Resident #22. She stated she is responsible to ensure dementia care, care plans are in place. Interview with the Director of Nursing (DON) on 10/26/18 at 11:01 AM, revealed he had not had any specific training on Dementia Care since Spring of (YEAR). He stated each resident with Dementia needs different cares that are individualized and not all residents that have dementia would have the same interventions. He further revealed staff would need to individualize each resident's cares and care plans that have dementia. He stated he would expect a dementia care, care plan to be in place and individualized for all residents with dementia for staff to know how to care for them. 2. Record review revealed the facility admitted Resident #32 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/02/18, revealed the facility assessed Resident 32's cogntion as intact with a BIMS score of fourteen (14) which indicated this resident's was interviewable. Further review of this MDS showed the facility had assessed this resident as having occasional urinary incontinence and frequent bowel incontinence. However, review of Resident #32's Comprehensive Care Plans, initiated on 12/22/17 and 12/23/17, revealed there was no incontinent care plan in place to guide staff caring for this resident. Interview with the ADON on 10/26/18 at 01:10 PM, revealed she would expect each resident who has dementia in the facility to have a individualized dementia care, plan of care in place that shows the staff how to take care of the resident. She stated any resident who is incontinent should have an incontinent care plan in place to guide staff on how to care for that resident. Interview with the DON on 10/26/18 at 11:10 AM, revealed he would expect any resident who has incontinence to have an appropriate plan of care in place with interventions to ensure each resident is getting the appropriate care. 3. Record review revealed the facility admitted Resident #52 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 09/18/18 revealed the facility assessed Resident #52's cognition as intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Review of the POS [REDACTED]. However, review of a facility incident report, dated 10/13/18, revealed Resident #52 was found, by staff, laying in the floor in his/her room alone after having been up in chair alone in room. 4. Record review revealed the facility admitted Resident #27 on 09/28/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #27's cognition as severely impaired with a BIMS score of six (6) which indicated the resident was not interviewable. Further review of the MDS assessment dated [DATE] revealed it was somewhat important to Resident #27 to attend group activities and religious services. However, review of the Resident #27's Comprehensive Care Plan, last revised 08/17/18 revealed no interventions to address the resident assessed interest in group activities and religious service. Review of the facility's Record of One-to-One Activities for (MONTH) and (MONTH) (YEAR), revealed the resident only attended group activities two (2) times during the month of (MONTH) and October. In addition, observation on 10/24/18 at 10:09 AM revealed Resident #27 was in bed while a group activity was in progress. Further observation revealed resident had lunch in bed and remained in bed throughout the remainder of the afternoon. Further review of the Comprehensive Care Plan last revised 08/17/18 revealed the resident has the need for individual activities/one-to-one visits due to memory impairment and short attention span . Interventions listed on the care plan included: provide monthly activity calendar; speak slowly and make eye contact with resident during one-to-one; visit one-to-one, read to him/her, show photos, magazines, provide music, reminiscing, puzzles. However, observation on 10/25/18 at 8:15 AM to 11:30 AM and 1:00 PM to 4:00 PM and on 10/26/18 at 8:26 AM to 11:42 AM and 1:07 PM to 4:22 PM revealed Resident #27 was out of the room wandering about the unit or sitting in the commons area, or in bed; except during lunch without meaningful activity. 5. Record review revealed the facility admitted Resident #14 on 05/22/15 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE], Section 'F', Preferences for Customary Routine and Activities, revealed the staff assessment of daily and activity preferences had not been completed. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was unable to complete the BIMS assessment due to unresponsivle state. Further review of the MDS revealed the resident required total care with all activities of daily living (ADLs) and had impaired functional range of motion to bilateral upper and lower extremities. Further, the MDS revealed the resident had [MEDICAL CONDITIONS] and Persistent Vegetative State. Review of the facility provided Activity Assessment and Resident Interest Profile completed by facility staff on 02/25/18 revealed Resident #14's previous activity was music (genre not indicated). Hobbies and Activity Preferences listed included talking books, radio, and hair cut. Review of the Comprehensive Care plan, last revised 03/06/18, revealed Resident #14 required individual activities in room due to limited time out of bed. The goal for the care plan was in room visits three (3) times a week for one-to-one activities with interventions for sensory type activities in room, music, reading, sensory stimulation; up in geri-chair as tolerated; and visit in room. However, observations on 10/24/18 from 8:22 AM to 4:37 PM, on 10/25/18 from 8:45 AM to 4:30 PM, and on 10/26/18 from 8:35 AM to 4:20 PM, revealed Resident #14 in bed, in the room, with window blinds closed, and, no music, radio, or television playing; no meaningful activity was provided. 6. Record review revealed the facility admitted Resident #42 on 09/09/16 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 07/01/18 revealed section 'F' Interview for Daily Activity Preference was not completed due to severe cognitive impairment. However, review of the Staff Assessment of Daily and Activity Preferences was completed and indicated the resident enjoyed listening to music and participation in religious activities or practices. Review of the Quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment and was not able to participate in a BIMS assessment. Further review revealed the resident required total care with all activities of daily living, he was non-ambulatory and had Dementia and [MEDICAL CONDITION]. Review of the facility provided Activity Assessment & Resident Interest Profile, completed by facility staff on 07/01/18 revealed Resident #42's previous hobbies or activities included gospel music and church and enjoyed basketball. Hobbies and Activities of interest included talking books, television, radio, church services, Bible reading. The assessment also indicated that the resident needed assistance getting to and from the activity area because he/she was bed ridden. Review of the Comprehensive Care Plan, dated 09/23/18, revealed Resident #42 had a need for some adaptations in activities due to memory loss and physical limitations. The goal for the care plan was listed as Will participate in activities of interest with assist. Interventions included were assist to and from activity area in broda chair; enjoys Church, singings, music, reading groups, visiting with family; and one-to-one activities in room. However, review of the facility's Record of One-to-One Activities for September, (YEAR), and October, (YEAR), revealed there was no documented evidence Resident #42 attended group activities. In addition, observations on 10/24/18 from 8:22 AM to 4:37 PM, on 10/25/18 from 8:45 AM to 4:30 PM, on on 10/26/18 from 8:35 AM to 4:20 PM, revealed Resident #42 either in bed or in geri chair, in the room, with window blinds closed, with no music, radio, or television playing; and no meaningful activity was provided. Interview with the Activity Director (AD) on 10/26/18 at 3:43 PM revealed the activity assistant that provided one-to-one was off work, and she had not checked to see if the one-to-one activity was being provided for Resident #27, #14 and #42, this week. She stated there was no set number for one-to-ones to be provided each week. The AD revealed she updated the care plans quarterly and as needed, and stated the activity care plans need to be more detailed and person centered. The AD stated she expected the activity team to follow the care plans as written. 7. Record review revealed the facility admitted Resident #51 on 10/24/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #51's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. Further review of the MDS revealed the resident was receiving oxygen (O2). Review of the physician's orders [REDACTED].>Review of the Comprehensive Care Plan for At Risk for cardiac alteration related to [DIAGNOSES REDACTED].#51 was up in the wheel chair, sitting at the dining room table and was not wearing O2. Per surveyor request, LPN #1 checked the resident's O2 level and the resident's Oxygen saturation (SaO2) level was ninety-three percent (93%) (normal for resident) on room air. Interview with the Assistant Director of Nursing (ADON) on 10/26/18 at 12:54 PM, revealed she would expect all interventions to be followed by all staff. Interview with the Director of Nursing (DON) on 10/26/18 at 9:13 AM revealed staff needed to follow the nursing care plan.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure activities meet the needs of three (3) of seventeen (17) severely cognitively impaired resident (Resident #27, #14, and #42). The facility failed to provide appropriate, ongoing activities for Residents #27, #14, and #42 as assessed. The findings included: Review of the facility's policy titled Activities, not dated, revealed the facility must provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of the resident. Activities refer to any endeavor, other than routine (activities of daily living) ADL's, in which a resident participates that is intended to enhance their sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include but are not limited to activities to promote self-esteem, pleasure, comfort, education, creativity, success, and independence. (Minimum Data Set) MDS identifies residents interests and needs. Care Plans identifies interest, preferences, strengths, abilities and any issues, concerns, problems, or needs affecting resident involvement in activities. The Activity Director is responsible for directing the development, implementation, supervision and on-going evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment and ensuring the care plan goals and interventions are individualized to match skills, abilities, and interest of each resident. Directing the activity program includes scheduling of activities, individual and groups, implementation of programs, monitoring the response to the programs to determine if the activities meet the need of the resident and making revisions if necessary. One-on-one activities may include reading, music, reminisce, games, manicures, massages, looking through photos, television, animal therapy, take outside, sensory type activities (sight, smell, taste, touch, hearing). 1. Record review revealed the facility admitted Resident #27 on 09/28/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #27's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Resident #27 required limited assistance with mobility and transfers. Review of the Annual MDS dated [DATE] section 'F', Preferences for Customary Routine and Activities, revealed it was very important to the resident to go outside to get fresh air when the weather is good; and it was somewhat important to listen to music, have pet visits through animal therapy, attend group activities, and attend religious services. Review of the Comprehensive Care Plan, last revised 08/17/18 revealed Resident #27 has the need for individual activities/one-to-one visits due to memory impairment and short attention span even though it is somewhat important to the resident to attend group activities and religious services. The goal of the care plan was for the resident to receive three (3) or more one-to-one visits per week, looking at photos, magazines, reading, music, and reminiscing. Interventions listed on the care plan included: provide monthly activity calendar; speak slowly and make eye contact with resident during one-to-one; visit one-to-one, read to him/her, show photos, magazines, provide music, reminiscing, puzzles. Review of the facility's Record of One-to-One Activities for September, (YEAR), revealed Resident #27 received one-to-one activities only two (2) times per week for two (2) week which did not meet the resident's goal. Further review revealed these activities only included sitting with the resident and talking; reading to the resident; walked the resident to her room or around the facility and providing a snack to the resident. Music was provided only one (1) time during September. Further review of the Record of One-to-One Activities for October, (YEAR), revealed the resident received one-to-one activities two (2) times per week for three (3) weeks of (MONTH) which did not meet the resident's goal. Further review revealed the one-to-one activities included reading to the resident; assisting the resident to his/her room; held the resident's hand and talked with. Further review revealed the resident only attended group activities two (2) times during the month of (MONTH) and (MONTH) even though he/she was assessed as it being somewhat important to attend group activities and religious activities. In addition, observation on 10/24/18 at 10:09 AM revealed Resident #27 was in bed while a group activity was in progress. Further observation revealed resident had lunch in bed and remained in bed throughout the remainder of the afternoon. Observation on 10/25/18 at 8:15 AM to 11:30 AM and 1:00 PM to 4:00 PM and on 10/26/18 at 8:26 AM to 11:42 AM and 1:07 PM to 4:22 PM, revealed Resident #27 was out of the room wandering about the unit or sitting in the commons area, except during lunch without meaningful activity. 2. Record review revealed the facility admitted Resident #14 on 05/22/15 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE], Section 'F', Preferences for Customary Routine and Activities, revealed the staff assessment of daily and activity preferences had not been completed. Review of the Quarterly MDS assessment dated [DATE] revealed the resident required total care with all activities of daily living (ADLs) and had impaired functional range of motion to bilateral upper and lower extremities. Further, the MDS revealed the resident had [MEDICAL CONDITIONS] and Persistent Vegetative State. Review of the facility provided Activity Assessment & Resident Interest Profile completed by facility staff on 02/25/18 revealed Resident #14's previous activity was music (genre not indicated). Hobbies and Activity Preferences listed included talking books, radio, and hair cut. Review of the Comprehensive Care plan, last revised 03/06/18, revealed Resident #14 required Individual activities in room due to limited time out of bed. The goal for the care plan was in room visits three (3) times a week for one-to-one activities. Interventions included: Observe and document any responses; Sensory type activities in room, music, reading, sensory stimulation; Up in geri-chair as tolerated; visit in room. Review of the facility's Record of One-to-One Activities for September, (YEAR), revealed Resident #14 received one-to-one activity two (2) times each week of (MONTH) except the last week which did not meet the resident's goal of three (3) times a week. Further review revealed these activities consisted of read to the resident and rubbed his/her hand or head; music and radio. Review of the Record of One-to-One Activities for October, (YEAR), revealed the resident received one-to-one activity two (2) times during one week which did not meet the resident's goal of three (3) time a week. Observations on 10/24/18 from 8:22 AM to 4:37 PM, on 10/25/18 from 8:45 AM to 4:30 PM, and on 10/26/18 from 8:35 AM to 4:20 PM revealed Resident #14 in bed, in the room, window blinds were closed, no music, radio, or television was playing, no meaningful activity was provided. 3. Record review revealed the facility admitted Resident #42 on 09/09/16 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed section 'F' Interview for Daily Activity Preference was not completed due to severe cognitive impairment. However, the Staff Assessment of Daily and Activity Preferences was completed and indicated the resident enjoyed listening to music and participation in religious activities or practices. Review of the facility provided Activity Assessment & Resident Interest Profile, completed by facility staff on 07/01/18 listed Resident #42's previous hobbies or activities included gospel music and church and enjoyed basketball. Hobbies and Activities of interest included talking books, television, radio, church services, Bible reading. The assessment also indicated that the resident needed assistance getting to and from the activity area because he/she was bed ridden. Review of the Quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment and was not able to participate in a BIMS assessment. Further review revealed the resident required total care with all activities of daily living, he was non-ambulatory and had Dementia and [MEDICAL CONDITION]. Review of the Comprehensive Care Plan, dated 09/23/18, revealed Resident #42 had a need for some adaptations in activities due to memory loss and physical limitations. The goal for the care plan was listed as Will participate in activities of interest with assist. Interventions included were to assist to and from activity area in broda chair; Enjoys Church, singings, music, reading groups, visiting with family; and one-to-one activities in room. Review of the facility's Record of One-to-One Activities for (MONTH) (YEAR), and October, (YEAR), revealed one-to-one activities were provided two (2) to three (3) times per week during both months. The activities listed included music, read to the resident, pat or rub hand, radio or music. There was no documented evidence Resident #42 attended group activities to include religious activities or religious music. Observations on 10/24/18 from 8:22 AM to 4:37 PM, on 10/25/18 from 8:45 AM to 4:30 PM, and on 10/26/18 from 8:35 AM to 4:20 PM, revealed Resident #42 either in bed or in geri chair, in the room, window blinds were closed, no music, radio, or television was playing, no meaningful activity was provided. Interview with Activity Assistant #1 on 10/26/18 at 3:29 PM revealed she assesses the residents for social aspects of activities and usually provides group activities. She stated the activity department tried to provide one-to-one activities three (3) to four (4) times per week for fifteen to twenty (15 to 20) minutes. She revealed she did not feel this was adequate for the residents as they needed more interaction. She stated there was another Activity Assistant other than her who usually provided the one-to-one activities, but she was off work this week. Interview with the Activity Director (AD) on 10/26/18 at 3:43 PM revealed the activity assistant that provided one-to-one was off work and she had not checked to see if one-to-one activity was being provided to Residents #27, #14, and #42 this week. She stated there was no set number for one-to-one to be provided each week. The AD stated she would like the staff to provide one-to-one activities three (3) times per week for 15 to 20 minutes per visit. The AD revealed she updates the care plans quarterly and as needed, and stated the activity care plans need to be more detailed and person centered. The AD further stated the expectation for the activity team is to have interaction with every resident every day to let the resident know that they are loved. The AD revealed she could not answer as to why Resident #14 and Resident #42 had not received any activity or interaction this week. She stated she needed to be more alert to the happenings and activities that are provided. Interview with the Administrator on 10/26/18 at 4:18 PM revealed she expected the activity department to provide activities to all residents, especially those that are bed bound and unable to get out of their rooms.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure a resident who displays or is diagnosed with [REDACTED].#27) and for two (2) unsampled residents (Residents #22 and #25). Record review revealed no documented evidence the facility had developed and implemented person-centered care plans that included and supported the dementia care needs, identified in the comprehensive assessment for a resident with the [DIAGNOSES REDACTED]. The findings include: Interview with facility's Compliance Nurse on 10/25/18 01:14 PM, revealed the facility follows the federal regulations for guidance and did not have a specific 'Dementia Care' policy. 1. Record review revealed the facility admitted Resident #22 on 05/04/16 with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #22's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of one (1) which indicated the resident was not interviewable. Further review of the MDS, revealed Resident #22 had difficulty with communicating some words and finishing thoughts along with he/she misses some part/intent of messages. Review of the Comprehensive Care Plan, last revised on 03/22/18, revealed the facility did not have a Dementia Care, care plan in place to guide staff on how to address this resident's Dementia Care needs. 2. Record review revealed the facility admitted Resident #25 on 03/04/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #25's cognition as severely impaired with a BIMS score of two (2) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had verbal and physical behaviors directed toward others and rejects care one (1) to three (3) days during the look-back period; requires limited to extensive care for all activities of daily living; and had Non-Alzheimer's dementia. Review of the Comprehensive Care Plans, last revised 07/02/18, revealed the facility did not have a Dementia Care, care plan in place to guide staff on how to address Resident #25's Dementia Care needs. 3. Record review revealed the facility admitted Resident #27 on 09/28/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #27's cognition as severely impaired with a BIMS score of six (6) which indicated the resident was not interviewable. Further review of the MDS revealed the resident had behaviors not directed at others one (1) to three (3) days during the look back period and had [MEDICAL CONDITION]. Review of the Comprehensive Care Plans, last revised 03/27/18, revealed the facility did not have a Dementia Care, care plan in place to guide staff on how to address Resident #27's Dementia Care needs. Interview with facility's Compliance Nurse on 10/25/18 1:14 PM, revealed she could not find any evidence Resident #22 had any individualized dementia care in place or care planned. She further stated the facility follows the federal regulations for guidance and did not have a specific dementia care policy. Interview with the Social Services Director on 10/25/18 at 12:45 PM, revealed she had not seen a individualized dementia care plan for the residents who have dementia. She stated she is responsible for the dementia care along with the minimum data set coordinator. Interview with facility's Compliance Nurse on 10/26/18 at 10:30 AM, revealed the facility did not have a specific Dementia Care policy and have not done any individualized dementia care for the residents with Dementia diagnoses. Interview with the Assistant Director of Nursing (ADON) on 10/26/18 at 01:10 PM, revealed she would expect each resident with dementia who is in the facility to have an individualized dementia plan of care that shows the staff how to take care of the resident. Interview with the Director of Nursing on 10/26/18 at 11:01 AM, revealed he had not had any specific Dementia training since spring of (YEAR). He stated each dementia resident needed different care that is individualized due to not all residents that have dementia would have the same interventions. He revealed the facility needed to individualize each resident's care and care plans that have dementia. He stated he expected a dementia care, care plan to be in place and individualized for all residents with dementia so staff know how to care for them. He further stated he did not find any evidence Resident #22 was getting any individualized dementia care.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure a copy of the resident's executed advance directive was maintained in the resident's medical record readily retrievable by any facility staff for one (1) of seventeen (17) sampled residents (Resident #27). The findings include: Review of the facility policy Advance Directives, not dated, revealed a resident's choice about advanced directives will be respected. Should the resident indicate that he or she has issued advance directives about his or her care and treatment, the facility will require that a copy of such directives be included in the medical record. Record review revealed the facility admitted Resident #27 on 09/28/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/02/18 revealed the facility assessed Resident #27's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Review of the facility Advance Directive Acknowledgement completed on admission and dated 09/28/15 revealed a check-marked box next to the statement, I have executed an Advance Directive. However, a copy of the Resident #27's advance directive was not in the medical record. Interview with the Social Services Director (SSD) on 10/26/18 at 1:24 PM revealed Resident #27 did, in fact, have an Advanced Directive (AD), but it was not on the chart. The SSD found the Advance Directive in her office. Further interview with the SSD on 10/26/18 at 1:31 PM revealed upon admission, the advance directive acknowledgment is completed and if the resident has executed an advance directive, a copy is obtained and placed on the resident's chart. The SSD stated she was not employed by the facility when Resident #27 was admitted , so she was not aware there was not a copy of the AD on the chart. The SSD stated, in the future, the AD will be placed on the residents' charts upon admission. Interview with the Director of Nursing (DON) on 10/26/18 at 1:35 PM revealed any time a resident is admitted and has executed an advance directive, it is expected that the AD be place on the chart for staff to have immediate access to that document.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of seventeen (17) sampled residents (Resident #52). Resident #52 was care planned to not be left unattended in chair after a fall on 09/19/18; however, staff failed to ensure the resident was not left unattended in room on 10/13/18, and the resident fell again and sustained a laceration to the left eye. The findings included: Review of the facility policy titled, Resident Incident/Accident Policy, last updated 06/15/18 revealed it is the policy of the facility to attempt to provide a safe environment free of accidents with proactive, preventative care interventions. Record review revealed the facility admitted Resident #52 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 09/18/18 revealed the facility assessed Resident #52's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. In addition, the resident was assessed to be nonambulatory and frequently incontinent of urine. However, review of the facility's admission 'Fall Risk Assessment' for Resident #52, dated 09/11/18, revealed this resident was assessed as ambulatory and continent and was assessed to be at modrate risk for falls. Review of the facility incident report, dated 09/19/18, revealed Resident #52 fell out of his/her chair in his/her room while a therapy staff member was in the room. The resident stated he/she was reaching for something, but didn't know what it was and fell out of the chair. Further review of this incident report, revealed this resident was assessed and had a small cut and knot above the right eye and this resident was transported to the hospital. The immediate intervention put in place was for this resident to be in the observation of staff when he/she was up in a chair. Review of the POS [REDACTED]. Review of the facility incident report, dated 10/13/18, revealed Resident #52 was found,by staff, laying in the floor in his/her room alone. The resident had been in hi/her chair in room prior to fall. The resident stated he/she was reaching for something and bent too far. Further review of this incident report, revealed this resident was assessed and had a laceration to the left brow and this resident was transported to the hospital. The immediate intervention put in place after this fall was for this resident to not be up in chair in room alone, even though the prior intervention after the fall on 09/19/18 was for this resident to be in the observation of staff when he/she is up in a chair. Interview with the Assistant Director of Nursing (ADON) on 10/26/18 at 12:54 PM, revealed it was required for staff to assess for a root cause of all falls. She stated it was a requirement to ensure an intervention was put in place for each resident's fall that occurs and if a resident has an additional fall it would not be appropriate to use the same intervention from the previous fall. She stated she would expect all new interventions to be appropriate and be care planned. She stated she would expect the care plans to be followed by all staff to ensure adequate supervision. Interview with the Director of Nursing (DON) on 10/26/18 at 11:17 AM, revealed he would expect staff to ensure an immediate appropriate intervention was put in place for all resident falls and staff care plan those interventions. He stated he would expect staff to follow the care plans and implement the care plan interventions. He also stated he would expect facility assessments, such as falls risk assessment, to be accurate and reflect the residents' true status.

Based on interviews and record reviews, it was determined the facility failed to ensure services provided or arranged by the facility met professional standards of quality, related to medication administration, which affected three residents, (#1, #2 and #3) in the selected sample of three. During a medication pass, on 01/28/11, approximately 8:30 AM until 11:30 AM, three Certified Medication Technicians failed to follow acceptable Standard of Practice for medication administration (Five Rights),which resulted in the hospitalization of one resident (#1), due to adverse effects of the medication error. Resident #1's heart rate and blood pressure decreased to a dangerous level, requiring hospitalization . The facility failed to provide supervision to ensure medications were prepared and administered in accordance with acceptable standards of practice, resulting in additional medication errors for two residents (#2 and #3). Two CMT's prepared medication for the residents. One CMT prepared the medication and the second CMT administered the medication. Resident #2 received Resident #5's medication, to include cardiac and hypertensive medications, which presented a high risk for adverse effects for Resident #2. The facility failed to ensure that CMT #1 documented she had administered medication for Resident #3 timely. CMT #3 administered Resident #3's medication for the second time, resulting in the resident receiving twice as much of the medication as prescribed. Medications included a blood thinner and a drug to lower the blood sugar, which presented a high risk for adverse effect for Resident #3. The facility's failure to ensure medications were administered in accordance with acceptable professional standards of quality, resulted in multiple medication errors affecting Resident #1, #2 and #3 placing the residents at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified and the facility notified, on 02/04/11. Findings include: Review of the "Lippincott Nursing Drug Guide" revealed, "Ensuring that the drug being administered is the correct dose of the correct drug at the correct time, and is being given to the correct patient, by the correct route, is standard of nursing practice". Additionally, the standard includes recording the delivery of the correct drug and dosage, correct route, correct time to the correct patient. A review of the facility's investigation, dated 01/31/11 revealed three medication errors were made during an 8:30 AM -9:30 AM medication pass, on 01/28/11. 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of clinical record to include the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview with Resident #1's family member, on 02/03/11 at 12:00 noon, revealed the resident had received [MEDICATION NAME] prior to admission to the facility and the drug caused the resident's heart rate to "bottom out". An interview with CMT #1, on 02/03/11 at 12:00 PM, revealed she administered medication, which included the drug [MEDICATION NAME] (lowers the blood pressure) 90 milligrams (mg) two tablets, which was prescribed for Resident #4, to Resident #1 on 01/28/11, during the 8:30 AM to 9:30 AM medication pass. CMT #1 stated she did not verify the resident's identity prior to the administration of the medication. The CMT stated she entered the resident's room and "assumed" Resident #4 was the resident lying on a bed. After she administered the medication, she realized she gave the medication to the wrong resident and reported the error to the nurse immediately. An interview with Licensed Practical Nurse (LPN) #1, on 02/02/11 at 12:00 PM, revealed CMT #1 reported she had given Resident #4's 9:30 AM medications to Resident #1, at approximately 8:50 AM. She immediately assessed Resident #1 and reviewed Resident #1's allergies [REDACTED]. LPN #1 stated she called the physician and notified him of the medication error and resident's allergy to [MEDICATION NAME]. An order was received to monitor the resident's vital signs every 15 minutes. A review of the Resident #1's vital signs revealed the resident's blood pressure was 122/48 and heart rate was 88 at 8:50 AM. A review of the Nurse's Notes, dated 01/28/11 at 10:10 AM, revealed the resident's heart rate decreased to 58 (normal 64-74) and the resident's blood pressure decreased to 80/40 (normal 120's/60's). LPN#1 stated the physician was called and the resident was transferred to the hospital and was admitted . A review of the hospital records and interview with the Physician/Hospitalist (physician who cared for the resident while in the hospital), on 02/03/11 at 4:00 PM, revealed the resident's blood pressure medication was withheld and Resident #1 was placed in a monitor bed so his/her heart rate could be monitored closely. The physician stated there was a chance the resident's heart rate could have fallen enough to cause the resident to require resuscitation. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview with CMT #1, CMT #2 and CMT #3, on 02/02/11 at 12:25 PM and on 02/03/11 at 10:00 AM and at 12:00 noon, revealed the three CMT's worked together to complete the medication pass. CMT #1 prepared medications, which were administered to the residents by CMT #2 and CMT #3. At a point in the process, LPN #2 approached the CMT's, during the medication pass, and told CMT #1 to take a break, which left CMT #2 and CMT #3. At that time, CMT #2 "pulled up" the medication and CMT #3 administered the medication to the residents. During the process, CMT #2 handed CMT #3 a medicine cup containing medication with a blue paper, which indicated the medication belonged to Resident #5. However, CMT #3 stated she "thought" CMT #2 told her the medication was for Resident #2 and she administered the medication, belonging to Resident #5, to Resident #2. On return to the cart, CMT #2 gave her the next medicine cup and told her the medication was for Resident #2. The CMT's realized, at that time, a second error had occurred as they had administered Resident #5's medications to Resident #2. A review of Resident #5's MAR, dated January 2011, revealed the following medications [MEDICATION NAME] (heart medication) 0.25 micrograms (mcg.), [MEDICATION NAME] (lowers blood pressure) 20 mg. and Klor Kon (Potassium)10 mill Equivalents (meq) were administered to Resident #2 in error. An interview with LPN #2, on 02/02/11 at 1:00 PM, revealed Resident #2's physician was notified and orders were received to monitor the resident's vital signs. Interviews with CMT #2 and CMT #3 revealed they were aware the CMT who prepared the medication should also administer the medication; however, they thought it would be faster if one of them prepared the medication and the other gave the medication. On 02/02/11 at 12:00 noon and at 1:00 PM, interviews with LPN #1 and LPN #2, who were responsible for the supervision of the CMT's, revealed they did not identify that the CMT's were not following acceptable standards of practice for medication administration. An interview with the Assistant Director of Nursing (DON) and LPN #2 on 02/02/11 at 11:05 AM and 1:00 PM, revealed CMT #2 and #3 immediately reported the medication error and how it happened; however, they did not identify the CMT's were not administering the medications in accordance with acceptable standards of practice. Further interview with CMT #2 and CMT #3, on 02/02/11 at 10:00 AM and at 12:25 PM, revealed after they reported the medication error to the DON and LPN #2, which affected Resident #2, they resumed the medication pass, utilizing the same techniques used which resulted in the medication error. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interviews with CMT #2 and CMT #3, on 02/02/11 at 02/02/11 at 2:25 PM and on 02/03/11 at 10:00 AM revealed after completing the medication pass, the CMT's reviewed the MARs and discovered a third medication error had occurred for Resident #3. On MAR indicated [REDACTED]. Further review of the MAR, revealed Resident #3 received [MEDICATION NAME] (blood thinner) 75 mg., Aspirin 81 mg. (blood thinner) and [MEDICATION NAME] (lowers the blood sugar) 5 mg. twice. An interview with LPN #2, on 02/02/11 at 1:00 PM, revealed Resident #3's physician was notified and orders were received to monitor the resident's vital signs and blood sugars every 15 minutes. A review of the vital sign and blood sugar flow sheet, dated 01/28/11, revealed Resident #2 had no adverse effects. An acceptable Allegation of Compliance was received on 02/10/11 and detailed as follows: On 01/28/11, CMT #1 immediately reported a medication error to LPN #1. LPN #1 immediately reported incident to DON and ADON. Facility began monitoring resident. LPN #1 immediately contacted attending physician office and spoke with ARNP. Facility received order to send to ER at hospital. ADON spoke with Administrator and ADON was asked to immediately relieve CMT #1 of her duties. Contacted OIG, DCBS, Medical Director, owner, and pharmacy on 01/28/11, regarding medication error. Employee reprimands were done on day of incident. Immediate in-servicing was initiated by ADON, followed up by Administrator on evening of 01/28/11. Administrator performed walking in-services throughout facility regarding events that occurred earlier in the day. Administrator discussed with employees on duty that a medication error had occurred due to CMT's not following standards of practice during medication administration and by not following facility policy and procedure NP- . Discussed poor judgement used by CMT's when they deviated from standards of practice and by not following policy & procedure (NP- ). Explained to staff what employees failed to do and then reviewed what they should have done according to standards of practice and facility policy (NP- ). Administrator repeated walking in-service with staff on duty for 7-3 and 3-11 shifts on 01/29/11 (See attached exhibit A-1). Follow up in-servicing was performed by staff development for CMT's involved in errors on 02/01/11. Further in-servicing was completed with licensed nursing staff and CMT's from pharmacy on 02/04/11. Resident #1 did not receive any medication or treatment at the local hospital to counteract the medication he had received in error and had no adverse effect related to the medication error. He was placed in observation for [MEDICAL CONDITION]. He was admitted to hospital on [DATE] for [DIAGNOSES REDACTED]. 4. (1) Date the IJ was removed? 02/05/11 (2) A. What caused the IJ? CMT's made medication error despite repeated training on policy and procedure of facility regarding resident identification and standards of practice for medication delivery. CMT # 1 administered medications to the wrong resident when she failed to follow facility policy and procedure on identification of resident. CMT # 2 and CMT # 3 caused medication errors to occur when they did not follow facility policy & procedure and current standards of practice. (2) B. What residents/patients are impacted by the IJ? Residents #1, #2 and #3. All residents have the potential to be impacted. (2) C. What staff is involved in IJ? CMT's #1, #2 and #3. All licensed nurses and CMT's have the potential to be impacted. (2) D. What area of the facility are impacted by the IJ? Entire facility has the potential to be impacted by the IJ. (3) Detail how the IJ will be prevented from recurring to this resident/patient, and to other residents/patients. This may include the following, but is not limited to: A. Investigation to determine the cause of the IJ 01/28/11 - Reviewed facility Medication Administration Policy and procedures regarding medication administration, policy number NP- . Review completed by ADON. Administrator instructed ADON to complete review of pictures on MARS. 02/01/11 - Medication Administration Policy & Procedure (NP- ) reviewed with addendum added for staff to ask resident "What is your name?" before administering medications. 02/04/11 - Camera in business office made available to nursing staff at all times. B-1 In-service training: content, staff attending, implementation of 01/28/2011. Proper identification of resident prior to treatment or medication administration by ADON; Persons trained licensed nurses and CMT's. 02/01/11 - 5 Rights of Medication Administration and general medication guidelines, conducted by Staff Development LPN to CMT's #2 and #3. 02/04/11 - Medication Administration inservice completed by LPN Med Care Pharmacy Consultant. In-service included IJ deficiencies, correct policies and procedures identification process. Persons included licensed nurses and CMT's. 02/04/11 - All staff in-serviced in person or via telephone before returning to work on IJ deficiencies. 02/04/11 - Management Team in-serviced on audit process. Management team consists of: DON, ADON, Administrator, Admissions/Social Services, Activities, Staff Development/HR, MDS Coordinator, Dietary Manager, Environmental Director, Maintenance Director and Medical Records. B-2 - Disciplinary actions: LPN #1 on 01/28/11 CMT #1 on 01/28/11 with suspension CMT #2 on 01/28/11 CMT #3 on 01/28/11 LPN #3 on 02/04/11 C-2 - Monitoring/Tracking System: A. Resident Identification through Photograph, Policy and Procedure. Admitting nurse to obtain photograph and place on MAR indicated What is your name?" Medical Records or designee monitor resident identification (photograph) daily Monday thru Friday, RN supervisor to monitor on weekends. Staff development to monitor weekly, DON to audit daily and weekly audit form. CMT is supervised by licensed nurse. Licensed nurse is supervised by ADON and DON. DON is supervised by Administrator. Medical Records is supervised by DON. Staff Development is supervised by Administrator. CMT's supervised by licensed nurses performing daily shift rounds. Monitoring: Audit review by QA committee on a monthly basis for 12 months. B. Medication, Administration of: Oral administration, etc. policy and procedure. Staff development/designee audit med pass process weekly. Pharmacy performs monthly medication pass audit. Weekly and monthly audits monitored by DON. Audit reviewed by QA committee monthly for 12 months. C. Root Cause Analysis Policy and Procedure All departments submit as needed to administrator. Audit reviewed thru QA process monthly for 12 months. D. Development/Revision of Assessment Tools Root cause analysis report form. 01/28/11 - Resident Identification and Med pass audit process was developed, concerning formal auditing of both processes. Root Cause Analysis performed to ensure compliance according to federal and stare guidelines and policies and procedures of facility. Analysis to record problem and identify the cause of the problem. Lists actions taken to reduce risk of a future occurrence. Dept. managers will be initiating root cause analysis and Administrator will review and submit at monthly QA meeting. 01/31/11 - Formal auditing procedures initiated ensuring resident ID on MAR's and name plates on resident doors and med pass performed according to standards of practice and policies and procedures of facility. During the partial extended survey on 02/11/11, verification of the removal of Immediate Jeopardy was completed as follows: Interviews with RN #1, LPN #1, CMT #2 and CMT #4 on 02/11/11 at 1:30 PM, 3:30 PM, 4:50 PM and 5:05 PM revealed they were educated on the five rights and professional standards of practice of medication administration. A review of the February 2011 schedule revealed two staff was scheduled to administer medication (one on each hall). A review of the facility's policy and procedure for Medication Administration revealed an addendum was added for staff to ask the resident their name, prior to administering the medication and the person who initiates the medication pass should complete the medication pass for that resident. Observation of a medication pass on 02/11/11 at 12:50 PM revealed one staff was administering the medication to include looking at the residents' pictures with the MARs, asking the resident their name and initialing the MAR, after the medication was administered. Interviews with RN #1, LPN #1 and LPN #2 on 02/11/11 at 12:50 PM, 4:50 PM and 5:05 PM revealed the admitting nurse was responsible for taking the resident's picture and ensuring the picture was placed with the resident's MAR. Observation of the business office on 02/11/11 at 3:55 PM revealed the camera was kept on a stand so staff would have access to it at all times. Observation of the MARs on 02/11/11 at 12:50 PM revealed pictures were with the MAR for each resident. Interview with the Housekeeping Supervisor on 02/11/11 at 3:30 PM revealed she was responsible for placing the resident's name on the doors for new admissions and when a resident was moved to another room. Observations revealed all residents' names were on their bedroom doors. Interviews Staff Development LPN, Medical Records, ADON and the DON on 02/11/11 ar 4:05 PM, 4:08 PM, 4:10 PM and 4:15 PM revealed they were educated on the audit process put in place to ensure pictures of residents were with the Medication Administration Records (MAR), residents' names were on the doors and staff were administering medications according to professional standards of practice. A review of the daily and weekly audits revealed the audits were conducted to ensure the resident pictures were with the MAR, resident names were on the doors and staff was administering medications according to the five rights and professional standards of practice. A review of the inservice training, dated 02/04/11 at 3:00 PM and 5:00 PM revealed the Pharmacy Nurse Consultant educated all licensed staff and Certified Nurse Technicians on medication administration to include the five rights ( right resident, right medication, right time, right dose and right route) and documentation. A review of the inservice training, dated 02/04/11 at 4:00 PM, revealed members of the Management Team were educated on the audit process and root cause analysis. Based on the above observations, interviews and review of records, it was determined the Immediate Jeopardy was removed, effective 02/05/11, as alleged in the AoC with the scope and severity lowered to a "E" based on the need for the facility to continue to evaluate the implementation of changes and quality assurance activities.

Based on interviews and record reviews, it was determined the facility failed to ensure three residents (#1, #2, & #3), in the selected sample of three, were free of any significant medication errors. The facility failed to ensure staff was following nursing standards of practice as it relates to medication administration. The facility failed to ensure resident identification systems were implemented and effective on 01/28/11. CMT #1 administered Resident #4's medications to Resident #1, which included [MEDICATION NAME] (calcium channel blocker), a medication for which Resident #1 had a known allergy. The resident's heart rate decreased to the low 30s (normal 64/74) for which the resident required hospitalization and cardiac monitoring. On 01/28/11, CMT #2 and CMT #3 failed to follow standards of practice related medication administration as they both participated in the administration of Resident #5's medication to the wrong resident (#2), which included cardiac medication, antihypertensives and a potassium supplement. Additionally, CMT #1 failed to document on the MAR timely after administration of medications. This failure resulted in another CMT administering a second dose to Resident #3, which included blood thinners and an antidiabetic medication. The facility's failure to ensure Resident #1 was not administered a contraindicated medication and failure to ensure repeated medication errors were not made without intervention placed Resident #1, #2 and #3 at risk for serious injury, harm, impairment or death. Immediate Jeopardy and substandard quality of care (SQC) was identified on 02/04/11. Findings include: Refer to F281 Based on interviews and record reviews, it was determined the facility failed to ensure three Certified Medication Technicians (CMT) administered medications to three resident (#1, #2 and #3) in accordance with professional standards of quality, during a medication pass, on 01/28/11. The facility failed to ensure staff administered medications in accordance with the "Five Rights" and the facility's established policy related to identification of the residents prior to administration of medications. A review of the policy and procedure entitled, "Medication Administration of: Oral Administration" (undated), revealed the person administering medication must check the drug label three times, during preparation of each medication. The identity of the resident must be validated prior to administering any drug, by checking the resident's ID picture and verifying the resident's name by calling the resident's name. Review of the "Lippincott Nursing Drug Guide" revealed, "Ensuring that the drug being administered is the correct dose of the correct drug at the correct time, and is being given to the correct patient, by the correct route, is standard of nursing practice". Additionally, the standard includes recording the delivery of the correct drug and dosage, correct route, correct time to the correct patient. 1. Record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident #1's chart and January 2011 MAR, revealed [MEDICATION NAME] was listed as an allergy. An interview with Resident #1's family member, on 02/03/11 at 12:00 noon, revealed the resident had received [MEDICATION NAME], prior to admission to the facility, and it had caused the resident's heart rate to "bottom out". An interview with the Administrator, on 02/03/11 at 11:05 AM, and review of the facility's investigation, dated 01/31/11, revealed CMT #1 administered Resident #4's 9:30 AM medications to Resident #1 on 01/28/11. A review of the "Resident Abuse Investigation Report, dated 01/31/11, revealed the medication error was reported by CMT #1 on 01/28/11 at approximately 9:00 AM. The report indicated the resident experienced an adverse effect as a result of the error, which was documented as a decrease in blood pressure and pulse. The report revealed Resident #1 was allergic to the drug recieved ([MEDICATION NAME]) and was transferred to the hospital emergency room . The investigative report did not reveal the root cause of the error and/or any corrective actions taken by the facility to prevent a recurrence. Interview with CMT #1, on date 02/03/11 at 12:00 noon, revealed Resident #4 had been admitted during her days off and there were no identification pictures on the MAR for Resident #1 and Resident #4, at the time the medication error occurred. She stated she entered the resident's room and "assumed" the resident lying on a bed in the room was Resident #4. After she administered the medication, she observed a urinal hanging on the other resident's bed labeled with the name of Resident #4. At that time, she realized she had given Resident #1, medication prescribed for Resident #4. She reported the error to the nurse immediately. A review of Resident #4's January 2011 Medication Administration Record (MAR), revealed Resident #1 received [MEDICATION NAME] (antihypertensive) 90 milligrams (mg) two tablets. An interview with Licensed Practical Nurse (LPN) #1, on 02/02/11 at 12:00 PM, revealed Resident #1's physician was made aware of the medication error and an order was received to monitor the resident's vital signs every 15 minutes. A review of the Nurse's Notes, dated 01/28/11 at 10:10 AM, revealed the resident's heart rate was 58 (normal 64-74) and the resident's blood pressure was 80/40 (normal 120's/60's). The physician was called and the facility transferred the resident to the hospital. A review of the hospital records and interview with the Hospitalist (physician who cared for the resident while in hospital), on 02/03/11 at 4:00 PM, revealed the resident's blood pressure medication was withheld and Resident #1 was placed in a monitor bed so his/her heart rate could be monitored closely. The Hospitalist stated there was a chance the resident's heart rate could have fallen enough to cause the resident to require resuscitation. Interviews with the Director of Nursing (DON) on 02/03/11 at 2:00 PM revealed the facility did not follow acceptable standards of practice for medication administration when the CMT did not validate the resident's identity prior to medication administration. 2. A record review revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. An interview with the Administrator, on 02/03/11 at 11:05 AM, and review of the facility's investigation, dated 01/31/11, revealed Resident #3 received his/her 9:30 AM medications twice, on 01/28/11. A review of the "Resident Abuse Investigation Report, dated 01/31/11, revealed the medication error was reported by CMT #2 on 01/28/11 at approximately12:00 noon. The report indicated the resident's physician was called with an order received to monitor the resident. The investigative report did not reveal the root cause of the error and/or any corrective actions taken by the facility to prevent a recurrence. Interviews with CMT #2 and CMT #3 on 02/02/11 at 12:25 PM and 02/03/11 at 10:00 AM revealed CMT #1 had failed to initial Resident #3's MAR to indicate the medicines had been given. They revealed when they opened the MAR and there were no initials in the boxes for 01/28/11, they pulled up the medicine and administered it. A review of the January 2011 MAR, revealed Resident #3 received [MEDICATION NAME] (blood thinner) 75 mg. every day, Aspirin 81 mg. every day (blood thinner) and [MEDICATION NAME] (lowers the blood sugar) 5 mg. every morning. An interview with LPN #2, on 02/02/11 at 1:00 PM, revealed Resident #3's physician was called with orders received to monitor the resident's blood sugars every 15 minutes to ensure the double dose of the antidiabetic did not cause the resident's blood sugar to drop too low. A review of the vital sign and blood sugar flow sheet, dated 01/28/11, revealed Resident #2 had no adverse effects. 3. A record review revealed Resident #2 was admitted to the facility, on 08/20/10, with [DIAGNOSES REDACTED]. An interview with the Administrator, on 02/03/11 at 11:05 AM, and review of the facility's investigation, dated 01/31/11, revealed Resident #2 was given Resident #5's medications during the 9:30 AM medication pass on 01/28/11. A review of the "Resident Abuse Investigation Report, dated 01/31/11, revealed the medication error was reported by CMT #2 and CMT #3 01/28/11 at approximately11:00 AM. The report indicated the resident's physician was called with an order received to monitor the resident. The investigative report did not reveal the root cause of the error and/or any corrective actions taken by the facility to prevent a recurrence. Interviews with CMT #2 and CMT #3, on 02/02/11 at 12:55 PM and 02/03/11 at 10:00 AM revealed during the administration pass CMT #2 "pulled up" the medication and CMT #3 administered the medication to the residents. During the process, CMT #2 handed CMT #3 a medicine cup containing medication with a blue paper, which indicated the medication belonged to Resident #5. However, CMT #3 stated she "thought" CMT #2 told her the medication was for Resident #2 and she administered the medication, belonging to Resident #5, to Resident #2. On return to the cart, CMT #2 gave her the next medicine cup and told her the medication was for Resident #2. The CMT's realized, at that time, a second error had occurred as they had administered Resident #5's medications to Resident #2. A review of Resident #5's January 2011 MAR, revealed Resident #2 received [MEDICATION NAME] (cardiac medication) 0.25 micrograms (mcg.) every day, [MEDICATION NAME] ( lowers blood pressure) 20 mg. every day and Klor Kon (Potassium)10 milliEquivalents (meq) every day. An interview with LPN #2, on 02/02/11 at 1:00 PM, revealed Resident #2's physician was called with orders received to monitor the resident's vital signs every 15 minutes to ensure the resident's blood pressure and heart rate did not drop too low. A review of the vital sign flow sheet, dated 01/28/11, revealed the resident had no adverse effects. Interview with the Director of Nursing on 02/03/11 at 2:00 PM revealed the CMTs did not follow acceptable standards of practice regarding validation of the resident's identity and did not follow the established policy and procedure for medication administration in regard to providing a complete report prior to assuming responsibility for the medication pass and also in regard to the process of preparation and administration of medication by the same individual. Staff responsible for the supervision of the medication administration did not identify the CMTs failure to follow acceptable practices and did not intervene to correct the problem and prevent a recurrence. An acceptable Allegation of Compliance was received on 02/10/11 and detailed as follows: On 01/28/11, CMT #1 immediately reported medication error to LPN #1. LPN #1 immediately reported incident to DON and ADON. Facility began monitoring resident. LPN #1 immediately contacted attending physician office and spoke with ARNP. Facility received order to send to ER at hospital. ADON spoke with Administrator and ADON was asked to immediately relieve CMT #1 of her duties. Contacted OIG, DCBS, Medical Director, owner, and pharmacy on 01/28/11, regarding medication error. Employee reprimands were done on day of incident. Immediate in-servicing was initiated by ADON, followed up by Administrator on evening of 01/28/11. Administrator performed walking in-services throughout facility regarding events that occurred earlier in the day. Administrator discussed with employees on duty that a medication error had occurred due to CMT's not following standards of practice during medication administration and by not following facility policy and procedure NP- . Discussed poor judgement sued by CMT's when they deviated from standards of practice and by not following policy & procedure (NP- ). Explained to staff what employees failed to do and then reviewed what they should have done according to standards of practice and facility policy (NP- ). Administrator repeated walking in-service with staff on duty for 7-3 and 3-11 shifts on 01/29/11 (See attached exhibit A-1). Follow up in-servicing was performed by staff development for CMT's involved in errors on 02/01/11. Further in-servicing was completed with licensed nursing staff and CMT's from pharmacy on 02/04/11. Resident #1 did not receive any medication or treatment at the local hospital to counteract the medication he had received in error and had no adverse effect related to the medication error. He was placed in observation for [MEDICAL CONDITION]. He was admitted to hospital on [DATE] for [DIAGNOSES REDACTED]. 4. (1) Date the IJ was removed? 02/05/11 (2) A. What caused the IJ? CMT's made medication error despite repeated training on policy and procedure of facility regarding resident identification and standards of practice for medication delivery. CMT # 1 administered medications to the wrong resident when she failed to follow facility policy and procedure on identification of resident. CMT # 2 and CMT # 3 caused medication errors to occur when they did not follow facility policy & procedure and current standards of practice. (2) B. What residents/patients are impacted by the IJ? Residents #1, #2 and #3. All residents have the potential to be impacted. (2) C. What staff is involved in IJ? CMT's #1, #2 and #3. All licensed nurses and CMT's have the potential to be impacted. (2) D. What area of the facility are impacted by the IJ? Entire facility has the potential to be impacted by the IJ. (3) Detail how the IJ will be prevented from recurring to this resident/patient, and to other residents/patients. This may include the following, but is not limited to: A. Investigation to determine the cause of the IJ 01/28/11 - Reviewed facility Medication Administration Policy and procedures regarding medication administration, policy number NP- . Review completed by ADON. Administrator instructed ADON to complete review of pictures on MARS. 02/01/11 - Medication Administration Policy & Procedure (NP- ) reviewed with addendum added for staff to ask resident "What is your name?" before administering medications. 02/04/11 - Camera in business office made available to nursing staff at all times. B-1 In-service training: content, staff attending, implementation of 01/28/2011. Proper identification of resident prior to treatment or medication administration by ADON; Persons trained licensed nurses and CMT's. 02/01/11 - 5 Rights of Medication Administration and general medication guidelines, conducted by Staff Development LPN to CMT's #2 and #3. 02/04/11 - Medication Administration inservice completed by LPN Med Care Pharmacy Consultant. In-service included IJ deficiencies, correct policies and procedures identification process. Persons included licensed nurses and CMT's. 02/04/11 - All staff in-serviced in person or via telephone before returning to work on IJ deficiencies. 02/04/11 - Management Team in-serviced on audit process. Management team consists of: DON, ADON, Administrator, Admissions/Social Services, Activities, Staff Development/HR, MDS Coordinator, Dietary Manager, Environmental Director, Maintenance Director and Medical Records. B-2 - Disciplinary actions: LPN #1 on 01/28/11 CMT #1 on 01/28/11 with suspension CMT #2 on 01/28/11 CMT #3 on 01/28/11 LPN #3 on 02/04/11 C-2 - Monitoring/Tracking System: A. Resident Identification through Photograph, Policy and Procedure. Admitting nurse to obtain photograph and place on MAR on day of admission. Nurse or CMT will ensure identification prior to completing a medication administration by reviewing name plate on door, reviewing photograph and by asking resident "What is your name?" Medical Records or designee monitor resident identification (photograph) daily Monday thru Friday, RN supervisor to monitor on weekends. Staff development to monitor weekly, DON to audit daily and weekly audit form. CMT is supervised by licensed nurse. Licensed nurse is supervised by ADON and DON. DON is supervised by Administrator. Medical Records is supervised by DON. Staff Development is supervised by Administrator. CMT's supervised by licensed nurses performing daily shift rounds. Monitoring: Audit review by QA committee on a monthly basis for 12 months. B. Medication, Administration of: Oral administration, etc. policy and procedure. Staff development/designee audit med pass process weekly. Pharmacy performs monthly medication pass audit. Weekly and monthly audits monitored by DON. Audit reviewed by QA committee monthly for 12 months. C. Root Cause Analysis Policy and Procedure All departments submit as needed to administrator. Audit reviewed thru QA process monthly for 12 months. D. Development/Revision of Assessment Tools Root cause analysis report form. 01/28/11 - Resident Identification and Med pass audit process was developed, concerning formal auditing of both processes. Root Cause Analysis performed to ensure compliance according to federal and stare guidelines and policies and procedures of facility. Analysis to record problem and identify the cause of the problem. Lists actions taken to reduce risk of a future occurrence. Dept. managers will be initiating root cause analysis and Administrator will review and submit at monthly QA meeting. 01/31/11 - Formal auditing procedures initiated ensuring resident ID on MAR's and name plates on resident doors and med pass performed according to standards of practice and policies and procedures of facility. During the partial extended survey on 02/11/11, verification of the removal of Immediate Jeopardy was completed as follows: Interviews with RN #1, LPN #1 and CMT #2 on 02/11/11 at 1:30 PM, 4:50 PM and 5:05 PM revealed they were educated on the five rights and professional standards of practice of medication administration. A review of the February 2011 schedule revealed two staff was scheduled to administer medication (one on each hall). A review of the facility's policy and procedure for Medication Administration revealed an addendum was added for staff to ask the resident their name, prior to administering the medication and the person who initiates the medication pass should complete the medication pass for that resident. Observation of a medication pass on 02/11/11 at 12:50 PM revealed one staff was administering the medication to include looking at the residents' pictures with the MARs, asking the resident their name and initialing the MAR, after the medication was administered. Interviews with RN #1, LPN #1 and LPN #2 on 02/11/11 at 12:50 PM, 4:50 PM and 5:05 PM revealed the admitting nurse was responsible for taking the resident's picture and ensuring the picture was placed with the resident's MAR. Observation of the business office on 02/11/11 at 3:55 PM revealed the camera was kept on a stand so staff would have access to it at all times. Observation of the MARs on 02/11/11 at 12:50 PM revealed pictures were with the MAR for each resident. Interview with the Housekeeping Supervisor on02/11/11 at 3:30 PM revealed she was responsible for placing the resident's name on the doors for new admissions and when a resident was moved to another room. Observations revealed all residents' names were on their bedroom doors. Interviews Staff Development LPN, Medical Records, ADON and DON on 02/11/11 ar 4:05 PM, 4:08 PM, 4:10 PM and 4:15 PM revealed they were educated on the audit process put in place to ensure pictures of residents were with the Medication Administration Records (MAR), residents' names were on the doors and staff were administering medications according to professional standards of practice. A review of the daily and weekly audits revealed the audits were conducted to ensure the resident pictures were with the MAR, resident names were on the doors and staff was administering medications according to the five rights and professional standards of practice. A review of the inservice training, dated 02/04/11at 3:00 PM and 5: 00 PM revealed the Pharmacy Nurse Consultant educated all licensed staff and Certified Nurse Technicians on medication administration to include the five rights ( right resident, right medication, right time, right dose and right route) and documentaion. A review of the inservice training, dated 02/04/11 at 4:00 PM, revealed members of the Management Team were educated on the audit process and root cause analysis. Based on the above observations, interviews and review of records, it was determined the Immediate Jeopardy was removed, effective 02/05/11, as alleged in the AoC with the scope and severity lowered to a "E" based on the need for the facility to continue to evaluate the implementation of changes and quality assurance activities.

Based on observation, interviews and record review, it was determined the facility Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, related to provision of care in accordance with acceptable Standards of Quality, assurance of the freedom of significant medication errors and maintenance of the clinical records. Administration failed to ensure appropriate nursing supervision was provided to three CMTs (#1, #2 and #3) who failed to administer medication in accordance with acceptable nursing standards of practice. Additionally, the facility failed to ensure the resident identification systems were implemented and effective. Furthermore, the facility failed to identify through their investigation the root cause of the medication errors. These failures resulted in three residents having medication administration errors, one of which was significant, on 01/28/11. The facility's failure to ensure Resident #1 was not administered a contraindicated medication and failure to ensure repeated medication errors were not made without intervention placed Resident #1, #2 and #3 at risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified and the facility notified, on 02/04/11. Findings include: Reference to F281, F333 and F514. 1. The facility failed to ensure services provided or arranged by the facility met professional standards of quality, related to medication administration, which affected three residents, (#1, #2 and #3) in the selected sample of three. During a medication pass, on 01/28/11, at approximately 8:30 AM until 11:30 AM, three Certified Medication Technicians failed to follow acceptable Standard of Practice for medication administration (Five Rights),which resulted in the hospitalization of one resident (#1), due to adverse effects of the medication error. Resident #1's heart rate and blood pressure decreased to a dangerous level, requiring hospitalization . The facility failed to provide supervision to ensure medications were prepared and administered in accordance with acceptable standards of practice, resulting in additional medication errors for two residents (#2 and #3). Two CMTs prepared medication for the residents. One CMT prepared the medication and the second CMT administered the medication. Resident #2 received Resident #5's medication, to include cardiac and hypertensive medications, which presented a high risk for adverse effects for Resident #2. The facility failed to ensure that CMT #1 documented she had administered medication for Resident #3 timely. CMT #3 administered Resident #3's medication for the second time, resulting in the resident receiving twice as much of the medication as prescribed. Medications included a blood thinner and a drug to lower the blood sugar, which presented a high risk for adverse effect for Resident #3. 2. The facility failed to ensure three residents (#1, #2, & #3), in the selected sample of three, were free of any significant medication errors. The facility failed to ensure staff was following nursing standards of practice as it relates to medication administration. The facility failed to ensure resident identification systems were implemented and effective on 01/28/11. CMT #1 administered Resident #4's medications to Resident #1, which included [MEDICATION NAME] (calcium channel blocker), a medication for which Resident #1 had a known allergy. The resident's heart rate decreased to the low 30s (normal 64/74) for which the resident required hospitalization and cardiac monitoring. On 01/28/11, CMT #2 and CMT #3 failed to follow standards of practice related medication administration as they both participated in the administration of Resident #5's medication to the wrong resident (#2), which included cardiac medication, antihypertensives and a potassium supplement. Additionally, CMT #1 failed to document on the MAR indicated [REDACTED]. 3. The facility failed to ensure the clinical records for three residents (#1, #2 & #3), in the selected sample of three, were complete and accurate. An interview with the Administrator on 02/03/11 at 2:05 PM revealed she was not at the facility at the time the medication errors occurred. She stated the Licensed staff had called and made her aware of the errors. She sent CMT #1 home pending an investigation of the incident. She revealed during her investigation of the errors she had identified CMT #1 had not recognized Resident #1 and there were to many hands on the medication cart. She revealed she talked to the nurses on duty that night and on Saturday so she could make sure they knew what had happened. She stated it was her understanding after talking to the DON the photographs were with the MARs. She stated inservices were not completed with all licensed staff and CMTs because she looked at the errors as individuals making mistakes. An acceptable Allegation of Compliance was received on 02/10/11 and detailed as follows: On 01/28/11, CMT #1 immediately reported medication error to LPN #1. LPN #1 immediately reported incident to DON and ADON. Facility began monitoring resident. LPN #1 immediately contacted attending physician office and spoke with ARNP. Facility received order to send to ER at hospital. ADON spoke with Administrator and ADON was asked to immediately relieve CMT #1 of her duties. Contacted OIG, DCBS, Medical Director, owner, and pharmacy on 01/28/11, regarding medication error. Employee reprimands were done on day of incident. Immediate in-servicing was initiated by ADON, followed up by Administrator on evening of 01/28/11. Administrator performed walking in-services throughout facility regarding events that occurred earlier in the day. Administrator discussed with employees on duty that a medication error had occurred due to CMT's not following standards of practice during medication administration and by not following facility policy and procedure NP- . Discussed poor judgement sued by CMT's when they deviated from standards of practice and by not following policy & procedure (NP- ). Explained to staff what employees failed to do and then reviewed what they should have done according to standards of practice and facility policy (NP- ). Administrator repeated walking in-service with staff on duty for 7-3 and 3-11 shifts on 01/29/11 (See attached exhibit A-1). Follow up in-servicing was performed by staff development for CMT's involved in errors on 02/01/11. Further in-servicing was completed with licensed nursing staff and CMT's from pharmacy on 02/04/11. Resident #1 did not receive any medication or treatment at the local hospital to counteract the medication he had received in error and had no adverse effect related to the medication error. He was placed in observation for [MEDICAL CONDITION]. He was admitted to hospital on [DATE] for [DIAGNOSES REDACTED]. 4. (1) Date the IJ was removed? 02/05/11 (2) A. What caused the IJ? CMT's made medication error despite repeated training on policy and procedure of facility regarding resident identification and standards of practice for medication delivery. CMT # 1 administered medications to the wrong resident when she failed to follow facility policy and procedure on identification of resident. CMT # 2 and CMT # 3 caused medication errors to occur when they did not follow facility policy & procedure and current standards of practice. (2) B. What residents/patients are impacted by the IJ? Residents #1, #2 and #3. All residents have the potential to be impacted. (2) C. What staff is involved in IJ? CMT's #1, #2 and #3. All licensed nurses and CMT's have the potential to be impacted. (2) D. What area of the facility are impacted by the IJ? Entire facility has the potential to be impacted by the IJ. (3) Detail how the IJ will be prevented from recurring to this resident/patient, and to other residents/patients. This may include the following, but is not limited to: A. Investigation to determine the cause of the IJ 01/28/11 - Reviewed facility Medication Administration Policy and procedures regarding medication administration, policy number NP- . Review completed by ADON. Administrator instructed ADON to complete review of pictures on MARS. 02/01/11 - Medication Administration Policy & Procedure (NP- ) reviewed with addendum added for staff to ask resident "What is your name?" before administering medications. 02/04/11 - Camera in business office made available to nursing staff at all times. B-1 In-service training: content, staff attending, implementation of 01/28/2011. Proper identification of resident prior to treatment or medication administration by ADON; Persons trained licensed nurses and CMT's. 02/01/11 - 5 Rights of Medication Administration and general medication guidelines, conducted by Staff Development LPN to CMT's #2 and #3. 02/04/11 - Medication Administration inservice completed by LPN Med Care Pharmacy Consultant. In-service included IJ deficiencies, correct policies and procedures identification process. Persons included licensed nurses and CMT's. 02/04/11 - All staff in-serviced in person or via telephone before returning to work on IJ deficiencies. 02/04/11 - Management Team in-serviced on audit process. Management team consists of: DON, ADON, Administrator, Admissions/Social Services, Activities, Staff Development/HR, MDS Coordinator, Dietary Manager, Environmental Director, Maintenance Director and Medical Records. B-2 - Disciplinary actions: LPN #1 on 01/28/11 CMT #1 on 01/28/11 with suspension CMT #2 on 01/28/11 CMT #3 on 01/28/11 LPN #3 on 02/04/11 C-2 - Monitoring/Tracking System: A. Resident Identification through Photograph, Policy and Procedure. Admitting nurse to obtain photograph and place on MAR indicated What is your name?" Medical Records or designee monitor resident identification (photograph) daily Monday thru Friday, RN supervisor to monitor on weekends. Staff development to monitor weekly, DON to audit daily and weekly audit form. CMT is supervised by licensed nurse. Licensed nurse is supervised by ADON and DON. DON is supervised by Administrator. Medical Records is supervised by DON. Staff Development is supervised by Administrator. CMT's supervised by licensed nurses performing daily shift rounds. Monitoring: Audit review by QA committee on a monthly basis for 12 months. B. Medication, Administration of: Oral administration, etc. policy and procedure. Staff development/designee audit med pass process weekly. Pharmacy performs monthly medication pass audit. Weekly and monthly audits monitored by DON. Audit reviewed by QA committee monthly for 12 months. C. Root Cause Analysis Policy and Procedure All departments submit as needed to administrator. Audit reviewed thru QA process monthly for 12 months. D. Development/Revision of Assessment Tools Root cause analysis report form. 01/28/11 - Resident Identification and Med pass audit process was developed, concerning formal auditing of both processes. Root Cause Analysis performed to ensure compliance according to federal and stare guidelines and policies and procedures of facility. Analysis to record problem and identify the cause of the problem. Lists actions taken to reduce risk of a future occurrence. Dept. managers will be initiating root cause analysis and Administrator will review and submit at monthly QA meeting. 01/31/11 - Formal auditing procedures initiated ensuring resident ID on MAR's and name plates on resident doors and med pass performed according to standards of practice and policies and procedures of facility. During the partial extended survey on 02/11/11, verification of the removal of Immediate Jeopardy was completed as follows: Interviews with RN #1, LPN #1 and CMT #2 on 02/11/11 at 1:30 PM, 4:50 PM and 5:05 PM revealed they were educated on the five rights and professional standards of practice of medication administration. A review of the February 2011 schedule revealed two staff was scheduled to administer medication (one on each hall). A review of the facility's policy and procedure for Medication Administration revealed an addendum was added for staff to ask the resident their name, prior to administering the medication and the person who initiates the medication pass should complete the medication pass for that resident. Observation of a medication pass on 02/11/11 at 12:50 PM revealed one staff was administering the medication to include looking at the residents' pictures with the MARs, asking the resident their name and initialing the MAR, after the medication was administered. Interviews with RN #1, LPN #1 and LPN #2 on 02/11/11 at 12:50 PM, 4:50 PM and 5:05 PM revealed the admitting nurse was responsible for taking the resident's picture and ensuring the picture was placed with the resident's MAR. Observation of the business office on 02/11/11 at 3:55 PM revealed the camera was kept on a stand so staff would have access to it at all times. Observation of the MARs on 02/11/11 at 12:50 PM revealed pictures were with the MAR for each resident. Interview with the Housekeeping Supervisor on 02/11/11 at 3:30 PM revealed she was responsible for placing the resident's name on the doors for new admissions and when a resident was moved to another room. Observations revealed all residents' names were on their bedroom doors. Interviews Staff Development LPN, Medical Records, ADON and DON on 02/11/11 ar 4:05 PM, 4:08 PM, 4:10 PM and 4:15 PM revealed they were educated on the audit process put in place to ensure pictures of residents were with the Medication Administration Records (MAR), residents' names were on the doors and staff were administering medications according to professional standards of practice. A review of the daily and weekly audits revealed the audits were conducted to ensure the resident pictures were with the MAR, resident names were on the doors and staff was administering medications according to the five rights and professional standards of practice. A review of the inservice training, dated 02/04/11 at 3:00 PM and 5: 00 PM revealed the Pharmacy Nurse Consultant educated all licensed staff and Certified Nurse Technicians on medication administration to include the five rights ( right resident, right medication, right time, right dose and right route) and documentation. A review of the inservice training, dated 02/04/11 at 4:00 PM, revealed members of the Management Team were educated on the audit process and root cause analysis. Based on the above observations, interviews and review of records, it was determined the Immediate Jeopardy was removed, effective 02/05/11, as alleged in the AoC with the scope and severity lowered to a "E" based on the need for the facility to continue to evaluate the implementation of changes and quality assurance activities.