Every finding on record at Golden Age Nursing Home

Based on staff interviews, record review, and facility policy review, the facility failed to ensure that allegations of abuse and misappropriation were reported immediately to the State Agency within required timeframes. This deficient practice was identified for two (2) of seven (7) residents reviewed for reporting of allegations (Residents #1 and #4). Findings include: Review of the facility policy titled, “Abuse, Neglect, Exploitation” (revised August 2018), revealed: “Response and Reporting of Abuse, Neglect, and Exploitation .13 .ensure all alleged violations involving abuse, neglect, are reported immediately, but no later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse or result in bodily injury, and no later than 24 hours if the events do not involve abuse or bodily injury. Allegations involving licensed staff will be reported to the appropriate licensing authority.” Resident #1 – Misappropriation of PropertyDuring an interview with the Administrator (ADM) on 9/3/25 at 8:40AM regarding a facility-reported incident, she confirmed that on 6/27/25 Resident #1 reported her cell phone missing. Staff used the resident's iPad to track the phone, which pinged at the address of Housekeeper #1. She stated video footage showed Housekeeper #1 entering Resident #1's room at 1:27 PM, discarding the phone case, concealing the phone in her bra, and leaving the room. The Administrator confirmed police were notified the same day, Housekeeper #1 was terminated, and the housekeeper was later arrested. However, she acknowledged that the State Agency was not notified until 6/30/25, when the final report was submitted. She confirmed the allegation should have been reported immediately on 6/27/25 once misappropriation was substantiated. Record review of the “admission Record” revealed Resident #1 was admitted on [DATE] with a diagnosis of polyneuropathy. Record review of the Brief Interview for Mental Status (BIMS) dated 6/7/25 revealed a score of 15, indicating the resident was cognitively intact. Resident #4 – Alleged AbuseDuring an interview with the Director of Nursing (DON) on 9/2/25 at 2:47 PM regarding a facility-reported incident, she confirmed that an alleged incident of verbal/physical abuse occurred on 7/13/25 at approximately 6:00 PM involving Resident #4. She stated she was not notified until 7/14/25 when she found a note under her office door. She confirmed staff should have immediately reported the allegation to her or the ADM. She also confirmed she did not report the allegation to the State Agency until 7/14/25, after receiving the note. The DON further stated that the purpose of immediate reporting of all allegations of abuse or misappropriation is to ensure resident safety and allow for a timely investigation. Record review of a written statement provided by Licensed Practical Nurse (LPN) #1 revealed that on 7/13/25 a Certified Nursing Assistant (CNA) orientee #2 gave her a note regarding the allegation. She stated she handed the note to the House Supervisor, Registered Nurse (RN) #1, who instructed her to place it under the DON's door for the next morning. Record review of a written statement from RN #1 dated 7/15/25 confirmed she read the note and instructed LPN #1 to leave it under the DON's door. Record review of an in-service dated 7/14/25 revealed both LPN #1 and RN #1 attended training on immediately reporting allegations of abuse. The in-service emphasized: “Abuse must be reported to MSDH within two hours by Administration. … Remember to always report any suspicion of abuse and neglect immediately. … When in doubt, report it.” Record review of the “admission Record” revealed Resident #4 was admitted on [DATE] with a diagnosis of dementia, unspecified severity with agitation. Record review of the BIMS dated 5/9/25 revealed a score of 99, indicating the resident was rarely/never understood.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's grievances related to missing property were investigated and resolved. This deficient practice was identified for three (3) of seven (7) residents reviewed for grievances (Residents #1, #2, and #3) Findings include: Review of the facility policy titled, Resident and Family Grievances, dated April 2017, revealed: “The facility will make prompt efforts to resolve grievances… The written decision will include a minimum: a summary of the pertinent findings or conclusions regarding the resident's concerns… any corrective action as a result of the grievance.” Resident #1Record review of a Missing Item Report Form dated 6/27/25 documented Resident #1's iPhone with a pink case as missing. The follow-up/results section was blank. In an interview with the Administrator (ADM) on 9/3/25 at 8:40 AM, she confirmed Resident #1 reported her phone missing on 6/27/25. Staff tracked it with her iPad, which pinged at Housekeeper #1's address. Video footage showed Housekeeper #1 entering Resident #1's room at 1:27 PM, discarding the phone case, concealing the phone in her bra, and leaving the room. Police were notified the same day, and the housekeeper was terminated and later arrested. She confirmed the facility did not reimburse or replace the phone. In an interview with Resident #1 on 9/3/25 at 9:20 AM, she stated she spoke to her daughter on her phone at 11:30 AM, dozed off after lunch, and woke to find it missing. She stated she reported it to staff, who tracked it and confirmed the location. She stated she was told the housekeeper was fired but the facility never reimbursed or replaced the phone, and her daughter purchased one for her. Record review of the “admission Record” revealed Resident #1 was admitted on [DATE]. Record review of a Brief Interview for Mental Status (BIMS) for Resident #1 dated 6/7/25 revealed a score of 15 indicating the resident was cognitively intact. Resident #2Record review of a Missing Item Report Form dated 6/11/25 documented Resident #2's red iPhone 11 as missing. The follow-up/results section was blank. During an interview with Resident #2 on 9/3/25 at 12:10 PM, he stated he reported his phone missing in June, staff searched but never found it, and “it doesn't seem like I will be getting another one.” During an interview with Resident #2's representative on 7/2/25 at 4:00 PM, she confirmed she was notified of the missing phone but stated the facility never offered reimbursement or replacement. Record review of the “admission Record” revealed Resident #2 was admitted on [DATE]. Record review of a BIMS for Resident #2 dated 8/14/25 revealed a score of 12 indicating the resident was moderately cognitively impaired. Resident #3Record review of a Missing Item Report Form dated 6/5/25 documented Resident #3's black iPhone 16 as missing. The follow-up/results section was blank. During an interview with Certified Nursing Assistant (CNA) #1 on 9/3/25 at 12:00 PM, she stated she reported Resident #3's phone missing after it was not located. She confirmed the resident used it regularly, but it had not been replaced. In an interview with the ADM on 9/4/25 at 8:35 AM, she confirmed the cell phones for Residents #1, #2, and #3 were never located or replaced. She stated she reviewed video footage of Residents #2 and #3's rooms but could not substantiate misappropriation. During an interview with the Social Worker on 9/4/25 at 8:40 AM, she confirmed she searched for the phones of Residents #1, #2, and #3 but did not find them. She stated all three residents used their cell phones regularly and kept them within reach. She also confirmed the Missing Item Reports for all three residents contained no documentation of a resolution. Record review of the “admission Record” revealed Resident #3 was admitted on [DATE]. Record review of the BIMS dated 7/22/25 revealed a score of 11, indicating Resident #3 was moderately cognitively impaired.

Based on resident and staff interviews, record review and facility policy review, the facility failed to ensure residents were free from misappropriation of property for one (1) of four (4) residents reviewed (Resident #1). Findings include: Review of the facility policy titled, “Abuse, Neglect, Exploitation,” revised August 2018, revealed: “Each resident has the right to be free from . misappropriation of property .Misappropriation of Resident Property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings without the resident's consent . An interview on 9/3/25 at 8:40 AM with the Administrator (ADM) revealed that Resident #1 had reported her phone missing on 6/27/25. She confirmed that a facility-reported incident dated 6/27/25 had been completed regarding the reported missing phone, staff used the resident's iPad to track the phone, which pinged at the address of Housekeeper #1. She further stated video footage showed Housekeeper #1 entering Resident #1's room at 1:27 PM, discarding the phone case, concealing the phone in her bra, and leaving the room. The Administrator confirmed that police were notified the same day, that Housekeeper #1 was terminated on 6/27/25, and that the housekeeper was later arrested. She acknowledged the facility did not reimburse or replace the resident's stolen phone. Review of a payroll change form confirmed Housekeeper #1's termination on 6/27/25 related to “stealing resident property.” During an interview with Resident #1 on 9/3/25 at 9:20 AM, she stated that on 6/27/25 she spoke to her daughter on the phone around 11:30 AM. After lunch she dozed off, and upon waking her cell phone was missing. She stated she always kept it nearby in case her family called. She reported the loss to staff who used her iPad to locate it. She stated the police came and confirmed her phone was taken, and she was later informed the housekeeper was fired. Resident #1 stated, however, the facility did not replace her phone, and her daughter had to buy her a new one. Review of the “admission Record” revealed Resident #1 was admitted on [DATE]. Review of the Brief Interview for Mental Status (BIMS) dated 6/7/25 revealed a score of 15, indicating the resident was cognitively intact.

Based on staff interviews, record reviews, and facility policy reviews, the facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for three (3) of twenty-one sampled residents. Residents #18, #54, and #81. Findings include: Record review of the facility policy titled, Conducting an Accurate Resident Assessment, dated 6/2023, revealed, The purpose of this policy is to assure that all residents receive an accurate assessment of relevant care areas . Accurate assessments addressing each resident's status, needs, strengths, and areas of decline must be conducted by qualified staff that are knowledgeable about the resident and correctly document information about the resident's status. Resident #18 Record review of Resident #18's Order Summary Report revealed an Admit to (Proper Name) Hospice order dated 7/15/2024. Record review of Resident #18's MDS with an Assessment Reference Date (ARD) of 10-18-2024 revealed in Section O-K1 that hospice care was coded No. During an interview on 11/19/24 at 1:30 PM, the MDS Coordinator confirmed that Resident #18 is receiving hospice services and that the MDS assessment for 10/18/24 had not been coded correctly. She revealed that it is important that the MDS assessments are correct, because it is supposed to reflect the residents plan of care. In an interview on 11/19/24 at 1:40 PM, the Director of Nurses (DON) confirmed that hospice should have been marked on the MDS assessment for Resident #18. She said that error could affect the residents' care and is also a financial issue. She confirmed that the MDS assessment from 10/18/24 did not represent an accurate assessment of the resident. A record review of Resident #18's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's Disease and Anxiety Disorder. Resident #54 A record review of an Unwitnessed Fall dated 8/10/2024 revealed that Resident #54 was found on the floor in his room .Fracture of one of the lateral mid left ribs suspected Fractures of left seventh and eighth ribs . Record review of Resident #54's MDS with an ARD of 10-07-2024 revealed in Section J-Health Conditions. J1800 that the resident had no falls since admission or reentry or the prior assessment. An interview on 11/19/24 at 1:00 PM, the Administrator (ADM) confirmed that she was aware that Resident #54 had a fall with an injury and any falls that a resident has should be coded on their MDS. An interview on 11/19/24 at 1:45 PM, the MDS Coordinator confirmed that she was aware that Resident #54 had a fall on 8/10/24. She revealed that Section J1800 was not accurately checked, revealing that the resident had a fall. She revealed it must have been overlooked in error. A record review of Resident #54's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease and a recent medical diagnosis on 8/10/24 of Multiple Fractures of Ribs, left side. 47158 Resident #81 Record review of the Discharge-Return Not Anticipated MDS with an ARD of 10/17/24 for Resident #81 revealed Discharge Status was coded as Short-Term General Hospital. Record review of Progress Notes for Resident #81, dated 10/17/24 revealed Resident discharged to home. An interview with the MDS nurse on 11/20/24 at 10:40 AM confirmed that Resident #81 was discharged home and the MDS assessment was coded incorrectly. She stated that she is usually notified by Social Services of the resident's discharge location, but it must have fallen through the cracks. Record review of the Admission Record revealed the facility admitted Resident #81 on 9/13/24 with a diagnosis of Acquired Absence of Right Leg Above Knee.

Based on staff interviews and record reviews, the facility failed to implement interventions to maintain nutritional status for one (1) of eight (8) residents reviewed for nutritional status. Resident # 20. Findings include: A typed statement on company letter head dated 11/20/24 and signed by the Director of Nursing (DON) revealed that the facility did not have a policy related to following the Registered Dietitian's (RD) recommendations. A record review of the Registered Dietitian Assessment Summary for Resident #20, dated 10/16/24, revealed a weight loss of -2.4 percent (%) in 30 days and -6.5% over 180 days, with weight documented below normal limits for the resident's height. The nutrition diagnosis noted Increased needs related to skin breakdown. The recommended interventions included: Zinc 220 milligrams (mg) once daily for 14 days, Vitamin C 500 mg once daily, and Pro-Stat Advanced Wound Care 30 milliliters (ml) once daily. The goals indicated were to achieve weight stability and meet nutritional needs for wound healing. The recommendations were signed and approved by the Nurse Practitioner (NP) on 10/18/24. A record review of the Order Summary with active orders as of 10/1/2024, for Resident #20 revealed no new orders reflecting the RD recommendations dated 10/16/24. A record review of the Monthly Weight Report for Resident #20 revealed: 5/2024 weight 116.0 pounds (Lbs.), 6/2024 weight 114.0 Lbs., 7/2024 weight 114.6 Lbs., 8/2024 weight 112.5 Lbs. , 9/2024 weight 109.2 Lbs., 10/2024 weight 106.6 Lbs., and 11/2024 weight 103.0 Lbs. During an interview with the DON on 11/19/24 at 12:45 PM, she confirmed that she had received the RD's recommendations and forwarded them to the NP for review. She stated that the NP typically indicates approval on the form, which is then sent to the floor nurse to initiate the orders. She retains a copy to follow up and ensure the recommendations are implemented. However, the DON acknowledged that the RD recommendations dated 10/16/24 for Resident #20 were not initiated, despite the NP's approval. She was unsure why the recommendations were not followed. The DON agreed that failure to implement the RD recommendations could result in further weight loss and delayed wound healing. Record review of the Admission Record revealed that the facility admitted Resident #20 on 10/17/19 with diagnoses that included Vitamin Deficiency and Benign Neoplasm of Meninges.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow nursing standards of practice as evidenced by administering a resident's medication by the wrong route for eight (8) of 38 medication opportunities observed. Resident #30 Findings Include: Cross Reference F759 Review of the facility policy titled, Medication Administration -General Guidelines unrevised, revealed under, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices . Also revealed under, A. Preparation . 4) Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away .B. Administration .2) Medications are administered in accordance with written orders of the prescriber . On 11/20/24 at 7:45 AM, an observation during medication pass, with Licensed Practical Nurse (LPN) #1 revealed, she crushed and administered the following medications to Resident #30 via percutaneous endoscopic gastrostomy (PEG) tube: 1. Fenofibrate (lowers cholesterol)160 milligrams (mg) 1 tablet 2. Apixaban (blood thinner) 2.5 milligrams (mg) 1 tablet 3. Atorvastatin (lowers cholesterol) 20 milligrams (mg) 1 tablet 4. Carvedilol (lowers blood pressure) 6.25 milligrams (mg) 1 tablet 5. Ascorbic Acid (immune support) 500 milligrams (mg)/5 milliliters (ml) 5 milliliters 6. Allopurinol (gout) 100 milligrams (mg) 1 tablet 7. Potassium ER (potassium supplement) 20 milliequivalents (MEQ) 1 tablet 8. Multivitamin liquid (vitamin supplement) 15 milliliters (ml) Record review of the November 2024 Medication Administration Record (MAR) for Resident #30 revealed the following orders, Allopurinol tablet 100 mg (milligrams) give 1 tablet by mouth in the morning, Apixaban oral tablet 2.5 mg (milligrams) give 1 tablet by mouth every morning and at bedtime, Atorvastatin Calcium oral tablet 20 mg (milligrams) give 1 tablet by mouth in the morning, Carvedilol tablet 6.25 mg (milligrams) give 1 tablet by mouth every morning and at bedtime, Fenofibrate oral tablet 160 mg (milligrams) give 1 tablet by mouth one time a day, Multivitamin Oral Liquid give 15 ml (milliliters) by mouth in the morning, Potassium Chloride ER oral tablet extended release give 1 tablet by mouth in the morning, Ascorbic Acid 500 mg (milligrams) give 5 ml (milliliters) by mouth in the morning. An interview with LPN #1 on 11/20/24 at 8:40 AM, revealed she had reviewed Resident #30's MAR and confirmed she gave the resident's medication by the wrong route. LPN #1 revealed she was fixated on giving the right medication and dosage and did not read the rest of the order. She confirmed that she did not follow the nursing principles on the 5 (five) rights of medication administration. She confirmed giving the medication by the wrong route was a medication error. On 11/20/24 at 8:50 AM, an interview with the Director of Nursing (DON) revealed, her expectations were for the nurses to follow the physician orders and the 5 (five) rights of medication administration to prevent potential errors. Record review of the Admission Record revealed the facility admitted Resident #30 on 11/9/24 with medical diagnoses that included Cerebral Infarction and Gastrostomy Status.

Based on staff interviews and record review, the facility failed to ensure an as-needed (PRN) psychotropic medication had a stop date for two (2) of five (5) residents reviewed for unnecessary medications. Resident #18 and Resident #49 Findings include: A typed statement on company letterhead revealed that the facility does not have a policy for Ativan/Lorazepam order stop dates and was signed by the Director of Nurses (DON), dated [DATE]. Resident #18 Record review of the Order Summary Report for Resident #18 revealed an order dated 7/23/2024, Ativan Oral Tablet 1 mg (Lorazepam) Give 1 tablet by mouth every 6 (six) hours as needed with no stop date. During an interview on 11/19/24 at 12:30 PM, Registered Nurse (RN) #2 confirmed that Resident #18 had an order for Ativan one milligram (mg) every 6 hours as needed. She revealed the resident has had to take it several times and confirmed that there was no stop date for the Ativan. An interview on 11/20/24 at 10:03 AM, with the facility's Pharmacy Consultant revealed he was aware that a PRN psychotropic medication needed a stop date, had recommended it, but was not sure why there wasn't one. Record review of the October 2024 Interdisciplinary Psych Dashboard revealed Resident #18 with an order for Ativan 1 mg Q6H (every 6 hours) PRN and the pharmacy consultant recommendation of . PRN psychotropic orders require a 14 day stop order and resident must be evaluated prior to continuing. A record review of Resident #18's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's Disease and Anxiety Disorder. 47157 Resident #49 Record review of the Order Summary Report for Resident #49 revealed an order dated 8/9/24 for Lorazepam Tab 0.5 MG (1) one tablet orally every 4 (four) hours as needed for Terminal Agitation related to Restlessness and agitation with no stop date. Record review Interdisciplinary Psych (psychotropic) Dashboard for October 2024, revealed, Pharmacist Comments for Resident #49: PRN psychotropic orders require a 14-day stop order and resident must be evaluated prior to continuing . In an interview with Licensed Practical Nurse #1 on 11/19/24 at 12:50 PM, she revealed Resident #49 did not have a stop date for the PRN Lorazepam and does have to take it sometimes. In an interview with the Director of Nursing on 11/19/24 at 1:00 PM, she revealed that she was aware that PRN Lorazepam required a stop date and confirmed that she was unaware that Resident #18 and Resident #49 did not have a stop date on their Lorazepam. She then revealed the purpose of the PRN medication requiring a stop date was to assess the residents' need to continue the PRN psychotropic medication. She then stated that Residents #18 and #49 were on hospice services and thought that might be the reason the medication had no stop date. A phone interview with the Hospice Nurse on 11/19/24 at 2:33 PM revealed she was unaware that the as needed Lorazepam required a stop date. Record review of the Admission Record revealed the facility admitted Resident #49 on 12/05/2019 with diagnoses of Restlessness, Agitation and Anxiety Disorder.

Based on observation, staff interview, record review, and facility policy review, the facility failed to use enhanced barrier precautions (EBP) during wound care for one (1) of five (5) resident direct care opportunities during the survey. Resident #59 Findings Include: Review of the facility policy titled, Enhanced Barrier Precautions with a revision date of 5/24 revealed under, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .2. Initiation of Enhanced Barrier Precautions: An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers . Record review of Resident #59's Wound Evaluation dated 11/13/24 revealed, Pressure -Stage 3 Sacrum with measurements of 3 centimeters (cm) length, 1.95 centimeters (cm) width, and 0.2 centimeters (cm) deepest point. Record review of the November 2024 Treatment Administration Record (TAR), for Resident #59 revealed, an order dated 10/31/24, Clean sacrum stage II pressure injury daily and PRN (as needed) with WW (wound wash) and pat dry. Apply collagen and cover with border gauze until resolved. One time a day related to pressure ulcer stage 3. An observation of wound care on 11/20/24 at 9:21 AM, with Registered Nurse (RN) #1 and Nurse Practitioner (NP) #1 revealed, they entered Resident #59's room and did not apply a gown for EBP. NP #1 assisted with wound care by turning the resident onto her side while RN #1 performed the wound care. Further observation revealed, there was not a sign posted to indicate the resident was on enhanced barrier precautions (EBP). An interview with RN #1 on 11/20/24 at 10:28 AM confirmed she did not apply a gown for Resident #59's wound care. RN #1 revealed she was familiar with EBP but did not practice it on wounds unless they were draining. She revealed the purpose of practicing EBP was to protect the residents from bacteria that they could be exposed to and explained that it made sense to wear a gown. An interview with NP #1 on 11/20/24 at 11:10 AM, revealed she had not been made aware they must use EBP with pressure wounds. An interview with the Director of Nursing (DON) on 11/20/24 at 1:43 PM, revealed they had not received any guidance on using EBP with wounds unless the wound was draining. She confirmed the purpose was to protect the residents from infection. Record review of the Admission Record revealed the facility admitted Resident #59 on 1/10/24 with medical diagnoses that included Alzheimer's Disease and Pressure Ulcer of Other Site, Stage 3.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was not five (5) percent (%) or greater for eight (8) of 38 medication opportunities. The medication error rate was 21.05%. Resident #30 Findings Include: Cross Reference F658 Review of the facility policy titled, Medication Administration -General Guidelines unrevised, revealed under, A. Preparation . 4) Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away .B. Administration .2) Medications are administered in accordance with written orders of the prescriber . An observation during medication pass, on 11/20/24 at 7:45 AM, with Licensed Practical Nurse (LPN) #1 revealed, she crushed and administered the following medications to Resident #30 via percutaneous endoscopic gastrostomy (PEG) tube: 1. Fenofibrate (lowers cholesterol)160 milligrams (mg) 1 tablet 2. Apixaban (blood thinner) 2.5 milligrams (mg) 1 tablet 3. Atorvastatin (lowers cholesterol) 20 milligrams (mg) 1 tablet 4. Carvedilol (lowers blood pressure) 6.25 milligrams (mg) 1 tablet 5. Ascorbic Acid (immune support) 500 milligrams (mg)/5 milliliters (ml) 5 milliliters 6. Allopurinol (gout) 100 milligrams (mg) 1 tablet 7. Potassium ER (potassium supplement) 20 milliequivalents (MEQ) 1 tablet 8. Multivitamin liquid (vitamin supplement) 15 milliliters (ml) Record review of the November 2024 Medication Administration Record (MAR) for Resident #30 revealed the following orders, Allopurinol tablet 100 mg (milligrams) give 1 tablet by mouth in the morning, Apixaban oral tablet 2.5 mg (milligrams) give 1 tablet by mouth every morning and at bedtime, Atorvastatin Calcium oral tablet 20 mg (milligrams) give 1 tablet by mouth in the morning, Carvedilol tablet 6.25 mg (milligrams) give 1 tablet by mouth every morning and at bedtime, Fenofibrate oral tablet 160 mg (milligrams) give 1 tablet by mouth one time a day, Multivitamin Oral Liquid give 15 ml (milliliters) by mouth in the morning, Potassium Chloride ER oral tablet extended release give 1 tablet by mouth in the morning, Ascorbic Acid 500 mg (milligrams) give 5 ml (milliliters) by mouth in the morning. On 11/20/24 at 8:40 AM an interview with LPN #1 revealed she reviewed Resident #30's MAR and confirmed she gave the medication by the wrong route. LPN #1 revealed she did not read the entire order. She confirmed this was medication errors. An interview with the Director of Nursing (DON) on 11/20/24 at 8:50 AM revealed, Resident #30 had a recent order change from PEG medication administration to by mouth and she expected the nurses to follow the physician orders and the 5 rights of medication administration to prevent potential errors. Record review of the Admission Record revealed the facility admitted Resident #30 on 11/9/24 with medical diagnoses that included Cerebral Infarction and Gastrostomy Status.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, freezers, and dry storage room were dated, labeled, and discarded by the expiration date for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled Storing: Food and Equipment with no revision date revealed under Policy .Team members must store food in a manner that ensures quality, freshness and safeguards against foodborne illness . This review revealed under Label .Items to label .Ensure all food items are labeled. Be especially cautious to label all food items that are , not kept in their original containers, including condiments (e.g., salad dressing, ketchup, etc. Label information: Each label must contain the following information Product name (or a common name or identifying description), use-by-date, date the product was prepared or opened. And under Storage; General Rule: Follow the Use-by-Date, generally, food should be discarded or used by the use-by date. That food should be discarded or used by the use-by date, which is the last date the manufacturer recommends use of the food. For foods that do not have a use-by date or do not have any identified quality issues, the Food Storage Chart can be used as a general suggestion for the average recommended length of storage time from the sell-by date to help preserve quality. An observation and interview on [DATE] at 10:25 AM, of the walk-In refrigerator with the Assistant Dietary Manager revealed a large container of mustard with an opened date of [DATE] and a best by [DATE], four (4) large containers of sour cream with an open date of [DATE] and best by date of [DATE], an opened zip lock bag of bacon with no label. An interview at this time with the Assistant Dietary Manager confirmed that the large container of mustard and four (4) large containers of sour cream were expired, and the unlabeled and unzipped bag of bacon should be discarded and not used. She stated that the mustard, sour cream, and bacon would be served to all residents that receive food. She stated that she has no idea when the bacon was cooked. She revealed that all foods that are expired should be disposed of, and all opened food should be labeled with a date to prevent the resident's from getting sick. An observation and interview with the Assistant Dietary Manager on [DATE] at 10:40 AM, of the walk-in freezer revealed a package of opened corn chowder. The Assistant Dietary Manager confirmed that the open corn chowder should be discarded since it had been opened. An observation and interview on [DATE] at 10:50 AM, with the Assistant Dietary Manager of the dry food storage revealed an unopened package of tortilla shells with a best by date of [DATE]. An interview at this time with the Assistant Dietary Manager revealed the tortilla shells are used for soft shell tacos as an alternate food choice for residents, confirmed they were expired and should have been disposed of. An interview with the Dietary Manager on [DATE] at 09:00 AM, revealed that food supply is received twice a week and kitchen staff are supposed to rotate items and dispose of expired items at that time with the Assistant Dietary Manager checking behind them to make sure this is completed. She stated that opened food is supposed to be labeled and the labels should include the open date. She confirmed that the mustard, sour cream, bacon, and corn chowder would have been used for all residents that receive food. She stated that the tortilla shells were used to make soft shell tacos and should have been disposed of when the food shipment came in and staff were rotating food according to dates. When the State Agent asked what the cooked bacon that was found in an unzipped bag and not labeled was used for, she revealed the staff use it to season vegetables and soups, but it should have been zipped and labeled. She confirmed that the mustard, sour cream, corn chowder, bacon and tortilla shells should have been disposed of. When asked what could happen if the expired or unlabeled foods were served to residents, she confirmed that it could have caused the residents to be sick. 44804

Based on staff interview ,record review, and facility policy review, the facility failed to accurately code antipsychotic medication for two (2) of 18 Minimum Data Set (MDS) assessments reviewed. Resident #61 and #62. Findings include: Review of the facility policy titled, Resident Assessment Instrument, revised 12/2010, revealed, .Policy Interpretation and Implementation .3. The purpose of the assessment is to describe the resident's capability to perform life functions and to identify significant impairments in in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning .7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign each document attesting to the accuracy of such information . Resident #61 A record review of Resident #61's Section N-Medications of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/10/2023, revealed N0410A: antipsychotic-number of days received seven (7) .N0450A-Resident received antipsychotic medications coded zero (0)-antipsychotics were not administered .N0450B: (GDR) gradual dose reduction attempted , N0450C: Date of last attempted GDR, N0450D: physician documented GDR, N0450E: Date physician documented GDR ,N2001: Drug regimen review ,N2003: Medication follow-up, and N2005: Medication intervention were not answered. A record review of Resident # 61's Electronic Medication Administration Record (E-MAR) for May 2023 revealed that he received an antipsychotic medication, Haloperidol 5 mg (milligrams), for seven (7) days during the assessment reference period of 5/04/23 through 5/10/23. An interview with the MDS Coordinator on 7/26/23 at 3:45 PM, she revealed she coded N0450A under Section N of the MDS dated [DATE] incorrectly, revealing that because she coded section N0450A incorrectly she was not prompted to answer the questions regarding gradual dose reduction and drug regimen review and confirmed she should have answered all of the questions and confirmed Resident #61 did receive antipsychotic medications for seven days during the look back period. Record review of Resident #61's Facesheet revealed that the resident was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder and Schizoaffective Disorder. Record review of the Minimum Data Set (MDS) Section C with an ARD on 5/10/23, revealed that Resident # 61 had a Brief Interview of Mental Status (BIMS) score of 4 which indicated that he was severely cognitively impaired. Section N revealed Resident # 61 received antipsychotic medications seven days during the look back period. 47158 Resident #62 A record review of Resident #62's quarterly MDS with an ARD of 6/26/2023, revealed in Section N, Item N0410A: medications received: Days: antipsychotic was coded as five (5), but N0450A: Resident received antipshychotic medications was coded zero (0) No-Antipsychotics were not received. A record review of Resident # 62's E-MAR Administration Record revealed that she received an antipsychotic medication, Risperdal 0.5 mg, for six (6) days during the assessment reference period of 6/20/23 through 6/26/23. An interview with Minimum Data Set Nurse (MDS) on 7/26/23 at 3:50 PM, she verified that failure to code the Antipsychotic Medication Review correctly could lead to residents missing gradual dose reductions and increase risk for side effects that can affect their health. Review of Resident # 62's Facesheet revealed that she was admitted to the facility on [DATE], with diagnoses that include Unspecified dementia, Unspecified severity, with agitation, Personal history of other mental and behavioral disorders, Dementia .with psychotic disturbance, and Alzheimer's Disease.

Based on observations, resident and staff interview, record review and facility policy review the facility failed to implement a care plan for removing facial hair on a resident that was dependent on staff for Activities of Daily Living (ADL) [Resident #28], and failed to develop a care plan for positioning of right arm and positioning of a urine catheter bag [Resident #228] for three (3) of 18 care plans reviewed. Findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 2/2017, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #28 Record review of Resident #28's care plans revealed a care plan with a problem onset date of 04/26/2019 that indicated that Resident #28 requires assistance with ADL's (Activities of Daily Living). Approaches include Provide assist with all ADLs .Wax or pluck facial hair - do not shave . An observation on 07/24/23 at 03:53 PM revealed that Resident #28 had dark hair approximately 1/8 of an inch long above her lip with a patch of black hair 1/8 of an inch wide and long on either side of her mouth and black hair stubble approximately 1/8 inch long covering her chin. An observation on 07/25/23 at 09:13 AM, revealed that the hair above Resident #28's lips and on her chin remained as it was yesterday. An interview on 7/25/23 at 4:00 PM with the Administrator and the Director of Nurses (DON), they confirmed that her care plan said do not shave, but the resident had agreed to being shaved in the past and while they were waiting on the wax strips to come in, they should have at least shaved in order to remove the hair from the resident's face. Record review of Resident #28's Facesheet revealed the resident was admitted to the facility on ,d+[DATE] with medical diagnoses that included Hemiplegia, unspecified affecting right dominant side and Dysphagia, oropharyngeal phase. Record review of Resident #28's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident is moderately cognitively impaired and in Section G that the resident needed extensive assistance with personal hygiene and total dependence with bathing. Resident #228 Urinary Catheter An observation, on 07/25/23 at 03:25 PM revealed Resident #228 lying in bed positioned on his back. The State Agency (SA) was unable to locate the resident's Foley (urinary) catheter on either side of the bed. An observation and interview on 7/25/23 at 3:27 PM, with Licensed Practical Nurse (LPN)#1 revealed Resident #228's Foley catheter bag was laying on the bed beside the resident's right knee. LPN #1 confirmed the catheter bag should not be in the bed with the resident. LPN #1 stated that the catheter bag should be hanging on the bedside to prevent urine from backing up into the urethra and causing an infection. An interview, on 7/26/23 at 10:20 PM with Licensed Practical Nurse (LPN) #2 revealed she develops care plans. She confirmed that she failed to care plan that Resident #228's Foley catheter should be kept below the level of the bladder. She stated that was important because if the catheter is not below the level of the bladder, urine can back up and could cause pain or infection. An interview, with the DON on 7/26/23 at 10:30 AM, revealed Resident #228's care plan should have included position of the catheter bag, it is in their policy. 39807 Resident #228 Positioning Record review of Resident #228's care plans revealed there was no care plan regarding the need to position the resident's right arm. On 07/24/23 at 10:30 AM, observation revealed Resident #228 was sitting up in his geriatric chair with his right arm hanging down beside the chair. On 07/24/23 at 11:30 AM, Resident # 228 was observed sitting up in his geriatric chair with his right arm hanging down beside his chair. The Speech Therapist walked up to his chair and picked up his arm and repositioned it. On 07/26/23 at 1:26 PM, observation revealed Resident #228 sitting up in his geriatric chair with his right arm hanging down beside his chair. On 07/26/23 at 01:45 PM, in an interview with Resident # 228 he stated that he can move his arm around and he can put his arm down but cannot pick it back up and doesn't want it to stay hanging down. Resident #228 stated that he would like them to find something to keep it from falling off the side of the chair. An interview on 07/26/23 at 01:50 PM with LPN #2 confirmed that there was not a care plan for positioning for Resident #228. She stated that therapy has not talked to her about positioning for Resident #228 while up in the geriatric chair. . An interview on 07/27/23 at 09:07 AM with Director of Nursing (DON), confirmed that there was no care plan for positioning Resident #228's right arm and that there should be a care plan in place for this. Review of the facility Facesheet revealed Resident #228 was admitted to the facility on [DATE] with diagnoses that included Paraplegia, Fusion of spine cervical region, Benign Prostatic Hyperplasia, and Retention of Urine, unspecified. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #228 was cognitively intact. 44804

Based on observations, staff and resident interview, record review and facility policy review the facility failed to remove facial hair on a resident that was dependent on staff for their Activities of Daily Living (ADL) for one (1) of 18 resident's reviewed for ADL's. Resident #28. Findings Include: Review of the facility policy titled, ADL Basic Care with a revision date of 4/25/17 revealed, A. All residents are given or are assisted with their bathing, showering or bed bath . An observation on 07/24/23 at 3:53 PM, revealed that Resident #28 had dark hair approximately 1/8 of an inch long above her lip with a patch of black hair 1/8 of an inch wide and long on either side of her mouth and black hair stubble approximately 1/8 inch long covering her chin. An observation on 07/25/23 at 09:13 AM, revealed that the hair above Resident #28's lips and on her chin remained as it was yesterday. An interview on 7/25/23 at 12:40 PM, with Certified Nurse Assistant (CNA) #2 revealed that female facial shaving is a part of the resident's bath and confirmed that Resident #28 had facial hair above her lip and on her chin. She stated that she thinks the resident goes to the beauty shop to get the facial hair waxed, but she is not sure the last time she went. An interview and observation on 7/25/23 at 1:10 PM, with Licensed Practical Nurse (LPN) #1 confirmed that female resident's facial hair should be removed unless they refuse. LPN #1 confirmed that Resident #28 had facial hair above her lip and on her chin. When the State Agent ask the resident if she wanted her facial hair removed by shaving the resident answered one finger for yes and agreed that 2 fingers would have meant no. An interview on 7/25/23 at 3:40 PM, with the facility Beautician revealed she does not like to use the hot wax on Resident #28, because it is so harmful on her skin. She revealed it has been at least 2 months since she had waxed Resident #28's facial hair. An interview on 7/25/23 at 4:00 PM, with the Administrator and the Director of Nurses (DON) revealed they had been in the process of ordering some wax strips that were not so hot and hard on her skin. She confirmed the resident had agreed to being shaved in the past and while they were waiting on the wax strips to come in, we should have at least shaved in order to remove the hair from the resident's face. Record review of Resident #28's Facesheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia, unspecified affecting right dominant side and Dysphagia, oropharyngeal phase. Record review of Resident #28's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident is moderately cognitively impaired and in Section G that the resident needed extensive assistance with personal hygiene and total dependence with bathing.

Based on observations, resident and staff interview, record review and facility policy review, the facility failed to provide treatment and care to address a resident's positioning needs that were in accordance with professional standards of practice for one (1) of (18) residents reviewed on sample. Findings include: A review of the facility policy titled, Positioning in Chair , undated, revealed, STANDARD Residents are positioned to maintain correct body alignment when seated in a chair .POLICY .Special seating-positioning needs are provided .Recliner .2. Center head and shoulders against the backrest of chair, maintaining alignment with hips . An observation on 07/24/23 at 10:30 AM, revealed Resident #228 was sitting up in his geriatric chair with his right arm hanging down beside the chair. An observation on 07/24/23 at 11:30 AM, revealed Resident # 228 was sitting up in his geriatric chair with his right arm hanging down beside his chair. The Speech Therapist walked up to his chair and picked up his arm and repositioned it. An observation on 07/24/23 at 11:56 AM and again at 2:48 PM, revealed Resident #228 sitting up in his geriatric chair with his right arm hanging down beside his chair. An observation on 07/26/23 at 1:26 PM, revealed Resident #228 sitting up in his geriatric chair with his right arm hanging down beside his chair. Licensed Practical Nurse (LPN) #3 walked up and talked to Resident # 228 and did not pick his arm up and place it back in his geriatric chair. An interview on 07/26/23 at 1:36 PM, with LPN #3, confirmed that she should have repositioned the resident's arm and that it should not be hanging down. An interview on 07/26/23 at 1:38 PM, with Certified Occupational Therapy Assistant (COTA) revealed that they have been working with Resident #228 and his hand splints. She stated that they have been looking at his positioning in the chair but other than a sling they really aren't sure what they would use. She stated they didn't want to use a sling because he has use of the right elbow and can move his arm around, that he just can't lift it back up to put back in the chair if it falls to the side of the chair. She stated that they have worked on educating the resident to tell the staff when he needs his arm picked back up. An interview on 07/26/23 at 01:45 PM, with Resident # 228 he stated that he can move his arm around and he can put his arm down but cannot pick it back up and doesn't want it to stay hanging down. Resident #228 stated that he would like them to find something to keep it from falling off the side of the chair. An interview on 07/26/23 at 1:47 PM, with LPN #3 stated that she had not received any education from therapy on putting the residents' arm back up on the geriatric chair or positioning. An interview on 07/26/23 at 2:50 PM, with the Director of Nursing (DON) confirmed that Resident #228's arm should not be hanging down and that it could cause swelling. A record review of the facility Facesheet for Resident #228 revealed that he admitted to the facility on [DATE] with diagnoses that included Cervical disc disorder with myelopathy, unspecified cervical region, Paraplegia unspecified, and Fusion of spine cervical region. A record review of Resident #228's Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 07/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact.

Based on observation, staff interview, record review and facility policy review the facility failed to maintain a urinary catheter drainage bag below the bladder to prevent the potential of infection for one (1) of two (2) residents with a urinary catheter in the facility. Resident #228 Findings include: Review of the facility policy titled, Catheterization, dated 11/2022, revealed, .Procedure . Indwelling (FOLEY) Catheters .#6 Drainage bag should hang below bladder level at all times. An observation on 07/25/23 at 3:25 PM, revealed Resident #228 lying in bed positioned on his back. The State Agency (SA) was unable to locate the resident's Foley (urinary) catheter on either side of the bed. An observation and interview on 7/25/23 at 3:27 PM, with Licensed Practical Nurse (LPN) #1 revealed Resident #228's Foley catheter bag was laying on the bed beside the resident's right knee. LPN #1 confirmed the catheter bag should not be in the bed with the resident. LPN #1 stated that the catheter bag should be hanging on the bedside to prevent urine from backing up into the urethra and causing an infection. An interview on 7/26/23 at 9:35 AM, with the Director of Nursing (DON) revealed she was aware of the incident with Resident #228's catheter bag being left in the bed yesterday. She stated that she could not imagine why that happened. She stated that the staff knows to hang it on the bedside. The DON stated that leaving the catheter on the bed can cause urine to back up and lead to infection. An interview on 7/26/23 at 1:30 PM, with Certified Nursing Assistant (CNA) #1 revealed that she knows she is supposed to make sure the catheter bag is below the bladder. She stated that she usually does, but yesterday she was busy and just forgot. She stated the bag should be below the bladder, so urine won't flow back into the bladder and cause infection. Record review of the Physician Orders for the month of July 2023 revealed orders dated 7/14/23, Foley catheter 16 French (F) with 10 cubic centimeter (cc) bulb -- Change monthly and as needed (prn). Review of the facility Facesheet revealed Resident #228 was admitted to the facility on [DATE] with diagnoses that included Paraplegia, Benign Prostatic Hyperplasia, and Retention of Urine, unspecified. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #228 was cognitively intact.

Based on staff interview, record and policy review the facility failed to ensure residents were free from unnecessary medications as evidenced by no documented monitoring for side effects of psychotropic medications for two (2) of five (5) residents reviewed for unnecessary medications. Resident #61 and Resident #62. Findings include Review of the facility policy titled, Use of Psychotropic Drugs, with a revised date of 4/2017, revealed .Procedure .13. The facility will monitor for general, cardiovascular, metabolic, and neurological adverse consequences of antipsychotic drug use . Resident #61 A record review of the Physician Orders for July 2023 for Resident #61, revealed Haloperidol 5 mg (milligrams) give 1/2 tablet (2.5 mg) by mouth at bedtime for schizoaffective disorder and Seroquel 25 mg one tablet by mouth daily at 7 pm Record review of Resident # 61's E-MAR (Electronic Administration Record) Administration Record for July 2023, revealed there was no monitoring for side effects of psychotropic drugs documented. A review of Resident # 61's Progress Notes for July 2023 revealed no documentation of monitoring for side effects of psychotropic drugs. Record review of Resident #61's Facesheet revealed that the resident was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder and Schizoaffective Disorder. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 5/10/23, revealed Resident # 61 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated he was severely cognitively impaired. Section N revealed Resident # 61 received antipsychotic medications seven days during the look back period. Resident #62 A record review of Resident # 62's July 2023 Physician Orders revealed an order dated 6/27/23 Risperdal 0.5 milligrams (mg) tablet. Give one tab (tablet) PO (by mouth) QD (daily) x (times) 1 week . Rexulti 0.5 mg tablet. Give one tab PO QD x 1 week .Rexulti 1 mg tablet. Give one tab PO QD x 1 week .with a start date of 7/6/23, and Rexulti 2 mg tablet. Give one tab PO QD .with a start date of 7/13/23 . Record review of Resident # 62's E-MAR Administration Record for July 2023 revealed there was no documentation of monitoring for side effects for the use of psychotropic medications. Review of Resident # 62's Facesheet revealed that she was admitted to the facility on [DATE], with diagnoses that included Unspecified dementia, unspecified severity, with agitation, Personal history of other mental and behavioral disorders, and Dementia with psychotic disturbance and Alzheimer's Disease. Record review of Resident # 62's MDS with an ARD of 6/26/2023 revealed a BIMS score of eight (8), which indicated the resident has moderate cognitive impairment. An interview with the DON on 7/26/23 at 9:22 AM, confirmed that there was no documentation of monitoring for side effects of psychotropic medications and verified that neither Resident #61 or Resident #62 was monitored for side effects. The DON verified that failure to monitor for side effects could result in staff missing negative side effects in residents on psychotropic medications. The DON confirmed there should have been monitoring in place. 47158

Based on staff interview, record review, and facility policy review, the facility failed to notify the Responsible Party (RP) of bed hold for five (5) of five (5) residents reviewed for hospitalization ; Resident #2, Resident #16, Resident #55, Resident #126, and Resident #130. Findings include: Record review of the facility's Notification To Responsible Party policy, with a revised date of 1/12/05, revealed the RP will be notified for all Resident's MD appointments, tests, outside therapy, admissions, and/or discharges to any outside facility. Notify family member and/or RP when any of the following occurs: Admit and/or discharge to any outside facility (Hospital, Senior Care Unit, etc.) Resident #55 Record review revealed Resident #55 was transferred to the Wound Care Center on 9/19/18, and sent to hospital from there with [MEDICAL CONDITION]. The physician and RP were notified of the transfer. Resident returned with a new Percutaneous Endoscopic Gastrostomy (PEG) tube. There was no written bed hold notice provided/documented. Resident #2 Record review revealed Resident left on 1/28/19, to an appointment with the wound clinic, and was transferred from the wound clinic to the ER due to low blood pressure. Resident #2 returned to the facility on [DATE]. There was no documentation that the RP was provided written notice of the transfer. Record review of the nurse's notes do not reveal the RP being notified of the transfer. The surveyor attempted to call the RP (daughter), but there was no answer and the number did not have a voice mail message available. Record review of Resident #2's nurse's notes revealed on 1/28/19 at 1:07 PM, the resident went for an appointment via the ambulance service, to the Wound Care Center. The nurse's note, dated 2/5/19, revealed the resident returned to the facility from the hospital stay. There is not documentation of the Responsible Party being notified of the transfer by phone or written notice of a bed hold. Resident #16 Record review revealed Resident #16 was transferred to the hospital on [DATE], for evaluation of shortness of breath per ambulance. The resident's RP was notified of status and the transfer to hospital. No written notice of bed hold was found in chart. Resident #126 Record review revealed Resident #126 was hospitalized [DATE] through 01/17/2019, for Geri-Psych evaluation and treatment. The RP was notified of transfer and condition. Care plan in place with interventions to prevent transfer. No notification of a written bed hold policy was provided. Resident #130 Record review revealed Resident #130 discharged to the hospital on [DATE], related to complaint of chest pain and Shortness of Breath (SOB). The Resident and family decided to release the bed on discharge. The RP was notified per nurse's notes, of transfer and condition, but no written bed hold to the RP was provided. On 02/11/19 at 2:15 PM, an interview with the DON and the Administrator revealed they were unaware of the regulation that the facility should send a hand written note to the RP of the transfer and the reason why the Resident was transferred. The DON revealed they call the RP when a resident is transferred to the hospital, but do not send a letter. On 2/12/19 at 9:18 AM, interview with the Director of Social Services revealed a bed hold policy/notification is not sent to the RP or the hospital when the resident is transferred to the hospital. On 02/12/19 at 11:25 AM, interview with the Administrator, revealed the facility had never notified the Responsible Party in writing of the bed hold. She stated their practice has been to notify by phone only.

Based on staff interview, record review, and facility policy review, the facility failed to obtain a Level II evaluation after a new [DIAGNOSES REDACTED].#67. Findings include: Record review revealed Resident #67 was not reviewed for referral for a Level II and mental health evaluation, related to new [DIAGNOSES REDACTED]. Interview on 02/11/2019 at 10:00 AM, with the Social Services Representative, confirmed that an updated PASARR had not been completed, related to new [DIAGNOSES REDACTED].#67. The Social Services Representative stated that the purpose of an updated PASARR is to see if a resident needs additional services and to know how to care for the resident. Interview with the Director of Nursing, on 02/11/2019 at 1:05 PM, confirmed that a new evaluation was important in caring for a resident with new mental illness diagnoses. Interview on 02/11/2019 at 1:10 PM, with the Administrator, confirmed that it is Social Service's responsibility to complete the PASARR as needed, and submit them timely. The Administrator stated that responsible staff was sent to in-services on completion of the PASARR.

Based on staff interview, record review, and facility policy review the facility failed to notify the Responsible Party (RP) of Resident #2's transfer to the hospital, for one (1) of five (5) residents reviewed for hospitalization , Resident #2. Findings include: Record review of the facility's Notification To Responsible Party policy, revised 1/12/05, revealed the Responsible Party (RP) will be notified for all Resident's MD appointments, tests, outside therapy, admissions, and/or discharges to any outside facility. Notify family member and/or Responsible Party when any of the following occurs: Admit and/or discharge to any outside facility (Hospital, Senior Care Unit, etc.) Record review revealed the facility transferred Resident #2 to the hospital on [DATE]. Resident #2 left on 1/28/19 to an appointment with the wound clinic and was transferred from the wound clinic to the emergency room (ER) due to low blood pressure. Resident #2 returned to the facility on [DATE]. On 02/11/19 at 2:15 PM, an interview with the Director of Nursing (DON) and the Administrator revealed they were unaware of the regulation that the facility should send a hand written note to the RP of the transfer and the reason why they were transferred. The DON revealed they call the RP when a resident is transferred to the hospital, but do not send a letter. Record review of the nurses notes do not reveal the RP was notified of the transfer for Resident #2 on 1/28/19. The surveyor attempted to call the RP (daughter) but there was no answer and the number did not have a voice mail message available. On 2/12/19 at 9:18 AM, interview with the Director of Social Services revealed a bed hold policy/notification is not sent to the RP or the hospital at the time of transfer to the hospital. Record review of Resident #2's nurse's notes revealed on 1/28/19 at 1:07 PM, the resident went on Leave of Absence (LOA) for an appointment via (Ambulance service) to the Wound Care Center. On 1/28/19 at 10:32 PM, a Nurse's note revealed the nurse called the hospital to check on the resident and was told she was still in the back awaiting lab results. On 1/28/19 at 10:30 PM, a nurse's note revealed the nurse called the hospital to get an update on the resident's status and was informed that her nurse did not have any information and she would call when the ER Nurse gets an update. The next nurse's note was on 2/5/19, when the resident returned to the facility from the hospital stay. There is not documentation the RP was notified of the transfer by phone or written notice.

Based on observation, staff interview, and facility policy review, the facility failed to properly clean a blood glucose meter, per manufacture recommendations and facility policy, for one (1) of three (3) blood glucose fingerstick procedures observed. Resident #63 Findings include: Review of the facility's Infection Control Program policy, dated 11/19/10, revealed, Policy: The Infection Control Program will be as follows: Designed to provide a safe, sanitary & comfortable environment. Designed to help prevent the development and transmission of disease and infection. Review of the facility's Glucometer policy, dated 9/17/10, revealed: Procedure for cleaning/disinfecting Glucometer: Clean/Disinfect Glucometer before & after each use as follows: 1. Using Super Sani-Cloth Germicidal Wipe. 2. Use gloves while cleaning. 3. Place clean paper towel in drawer of med cart. 4. Wipe meter before & after each use. 5. Place clean meter on the clean paper towel. 6. Allow meter to air dry for at least two (2) minutes after cleaning. 7. ALWAYS wear gloves while handling Sani-Cloth wipe. 8. Each medication cart has two (2) meters. 9. Dispose of Sani-Cloth wipe & gloves in trash can. 10. Wipe hands after removing gloves. Review of the Assure Prism multi Blood Glucose Monitoring System's Manufacturer's Recommendations revealed the cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter. Manufacturer: Professional Disposables International, Inc. (PDI) Super Sani-Cloth Germicidal Disposable Wipe. Cleaning and Disinfecting Procedures: NOTE: Do not get fluids inside the meter through the test strip port, data port or battery compartment. Never immerse the meter or hold it under running water because it will damage the meter. Two (2) disposable wipes will be needed for each cleaning and disinfecting procedure; one (1) wipe for cleaning and a second wipe for disinfecting. During an observation of a blood glucose finger stick procedure, on 02/12/19, 10:56 AM, for Resident #63, LPN #1 cleaned the glucometer (Assure Prism Multi Blood Glucose Meter) with PDI Sani Hands Instant hand sanitizing wipes , wiped down the meter and let dry two (2)-three (3) minutes . The Antiseptic hand sanitizer was 70% Alcohol and LPN #1 stated this was approved for use on equipment. On 02/12/19 at 2:01 PM, interview with LPN #1 revealed, I used the wrong wipe, I was supposed to use the purple wipe. She stated she floated from hall to hall and worked wherever she was needed. She stated, I did go back and clean the meter with the Super Sani Wipe, after I realized I had used the wrong wipe. On 02/12/19 at 1:30 PM, interview with RN #1, part-time nurse, stated, I don't know their policy. She picked up a PPI Sani wipe container and stated, This is what I've been using to clean it. Wipe down real good, let it sit three (3)-five (5) minutes to dry real good. I orientated one (1) time in (MONTH) for one (1) day and then they gave me the keys to the cart. On 02/12/19 at 11:25 AM, interview with LPN #2, revealed she used the Super-Sani-Cloth to clean and disinfect the Glucometer. On 2/12/19 at 4:00 PM, interview with the Director of Nursing (DON) confirmed that the Glucometer should be cleaned with the Super Sani-Cloth and not the Sani Hands wipe. She stated that this is an infection control problem. 25 residents with a [DIAGNOSES REDACTED]. None were noted/documented to have a blood borne infection.

Based on record review, policy and procedure review and interview, the facility failed to follow the care plan to provide the care for one (1) of five residents reviewed (Resident #1) as outlined in her care plan, as evidenced by Resident #1, who was transferred by one (1) Certified Nursing Assistant (CNA) and was care planned for a two (2) person assist transfer in a Vander lift. Resident fell from the lift on on 10/25/17, and experienced a fractured Right Femur. Findings include: Review of the facility's, Total Care Plan, policy/procedure, revised 11/30/06, revealed the Interdisciplinary Care Plan will Identify problems that affect the Resident and his/her care needs and Identify the interventions related to the specific problems. The care plan will be maintained. Review of the Nurse Aide Care Plan (NACP) Form and Verification of Daily Resident Care Form, revised 6/16/11, revealed The Nurse Aide Care Plan Form will be personalized by circling areas in black ink. The Verification of daily Resident Care Form will be reviewed daily every shift by the primary CNA for the Resident. CNAs are to familiarize themselves with the NACP before care is given. Failure to follow the NACP can result in suspension and/or termination. Review of Resident #1's Nurse Aide Care Plan dated 3/8/17, has -Mechanical Lift Vander and total lift circled. (The policy required two (2) person assist with the Vander lift). Review of Resident #1's Nursing Care Plan, initiated 8/10/15, revealed: Perform all transfers with use of Vander lift with two (2) staff. Interview with Resident #1 at 5:30 PM on 11/15/17, revealed her stating only one (1) CNA was using the swing lift and she slid out of the sling. The Resident stated she had pain after that but didn't recall if she told anyone. She is unable to identify the CNA by name that was with her when she slid out of the lift. Review of the facility's written report, dated 10/31/17, revealed Resident #1 reported falling from the lift when CNA #1 transferred her with the use of a lift by herself. Resident #1 sustained a fracture o the right femur. CNA #1 admitted to not reviewing the residents care plan prior to transferring the resident with a lift, knew she was supposed to and stated, I don't know why I just didn't. The report noted that CNA #1 failed to follow the policy/procedure and as a result the resident was injured. CNA #1 was terminated because she knew to follow the care plan and did not. The 10/26/17 X-ray of Resident #1's right leg, dated 10/26/17, revealed Fracture of distal femur in the supracondylar region with minimal impaction. Fracture is predominantly seen along the medial aspect. [MEDICAL CONDITION] arthritis. [MEDICAL CONDITION], Joint effusion. Record Review of Resident #1's Lift/Transfer/Assistance assessment dated [DATE], revealed that she was assessed to be transferred with a Vander lift with the assist of two (2) staff members. An interview with the Director of Nurses (DON) on 11/16/17 at 3:10 PM, revealed The Activities Daily Living (ADL) Care Plan info is based off of the admit assessments and risk assessments. The assessments let us know what ADL's are required. That is updated every 90 days and as needed. The ADL's are kept behind the nurses desk. Interview with the Director of Nurses (DON) on 11/15/17 at 5:00 PM, revealed her investigation revealed that CNA #1 attempted a Vander lift with Resident #1 without assist of another staff member, thus she did not follow the care plan. Resident #1 fell out of the lift. She was sent out on 10/26/17, for an evaluation and X-ray that revealed a fractured Right femur. Review of personnel records and the facility's written report, revealed CNA #1's employment has been terminated by the facility as a result of the facility investigation and failure to follow the CNA care plan. Multiple attempts to contact CNA #1 were unsuccessful during survey. Interview with CNA #2 on 11/16/17 at 2:30 PM, revealed CNA #1 busted through the door of the room she was in and said I need you right now (in Resident #1's room). CNA #2 stated she went in the room saw Resident #1 sitting on the floor between the bathroom door and room door and a Vander lift beside the resident. (CNA #2's written statement, dated 10/17/17, revealed she told CNA #1 she should have waited until she was in the room to transfer the resident.) CNA #2 stated that CNA #1 said she was just trying to get the resident to the bed. CNA #2 stated they were trained on using two (2) people with the lift and the care guides (NACP) were behind the nurse's desk to know which lift to use with the resident. Review of Resident #1's medical record revealed an admission date of [DATE], with the [DIAGNOSES REDACTED]. She does have a history of prior fractures. Review of Resident #1's Quarterly Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of 10/24/17, revealed her Brief Interview for Mental Status (BIMS) was a 15, an MDS with an ARD on 11/3/17, revealed a BIMS of 14, and a BIMS, conducted on 11/16/17, scored scored 15, all meaning the resident had no cognitive impairment. Both MDS documents indicated Resident #1 required total assistance with two (2) persons for transfer.

Based on record review, interview and policy/procedure review, the facility failed to provide the adequate supervision and assistive devices necessary for one (1) of five (5) Residents reviewed, Resident #1, as evidenced by on 10/25/17, Certified Nurses Assistant (CNA) #1 attempted to transfer Resident #1, using a Vander (full body total lift), without getting assistance from another staff member, as required per assessment. Resident #1 slid out of the lift during the attempted transfer, landed on the floor and fractured her right distal femur, which required surgical intervention. Resident #1 was assessed and care-planned for a Vander total lift with two (2) persons for transfers. Findings include: Policy/procedure review of the facility's Modified Lifting Policy last revised 9/2017, revealed: Staff will follow the documented lifting protocol deemed appropriate for each Resident and Two (2) people will be present when using a lift on each Resident. Review of the facility's investigation revealed that during the 3:00 PM - 11:00 PM shift on10/25/17, Resident #1 was transferred by CNA #1 using a Vander total lift. CNA #1 did not wait for staff assistance and attempted the transfer by herself. Resident #1 came out of the sling and landed on the floor. CNA #1 then left the resident on the floor to get assistance from CNA # 2. The two (2) CNA's put Resident #1 back into the bed and did not alert a nurse to the incident. Further review of the facility's investigation revealed a hand-written, signed statement by CNA#1, stating that she and CNA #2 used the lift to put Resident #1 in the bed. She does not mention a fall or slide from the Vander total lift. CNA #2 refuted CNA #1's statement and reported that she walked into the room, after CNA #1 summoned her, and Resident #1 was on the floor and the Vander lift was bedside the resident. CNA #2 stated that she told CNA #1 she should have waited until she was in the room to transfer Resident #1. Resident #1's statement was that only one (1) CNA, identified by the resident as CNA #1, had transferred her with the lift and she had slid out of the sling during the transfer. Review of Resident #1's X-ray report of the right leg, dated 10/26/17, revealed: Fracture of distal femur in the supracondylar region with minimal impaction. Fracture is predominantly seen along the medial aspect. Degenerative arthritis. Osteoporosis. Joint effusion. Review of the hospital record, revealed Resident #1 had an open reduction-internal fixation of the right femur surgical procedure on 10/27/17. Record Review of Resident #1's Lift/Transfer/Assistance Aassessment dated [DATE], revealed that she was assessed to be transferred with a Vander lift with the assist of two (2) staff members. Review of the care plan also revealed she had a nursing care plan in place for two (2) person assistance with the use of the Vander lift. During an interview, on 11/15/17 at 5:00 PM, the Director of Nurses (DON) stated her investigation revealed that CNA #1 attempted a Vander lift transfer with Resident #1 without assistance of another staff member. Resident #1 fell out of the lift. She was sent out on 10/26/17, for an evaluation and X-ray that revealed a fractured Right femur. The DON stated that CNA #1 wrote a statement that she and CNA #2 used the lift to transfer the resident but does not mention a fall. Both CNA's were suspended. The DON stated that CNA #2 came into her office the next day saying she was not going to lie for anyone and was going to tell her what happened. The DON stated the written statement of CNA #2 recorded that she came in the room and the resident was already in the floor and the lift was beside the resident. The written statement also documented that CNA #2 told CNA #1 she should have waited until she was there to transfer the resident. The DON stated she had not been able to contact CNA #1 since she left the facility after giving her written, signed statement on 10/26/17, and that CNA #1's employment has been terminated by the facility as a result of the facility investigation. Multiple attempts to contact CNA #1 were unsuccessful by the surveyor. Review of CNA #1's written statement, not dated, revealed the CNA, after supper on 10/25/17, went to Resident #1's room to prepare her for bed. The resident asked to go to the bathroom, and CNA #1's statement documented she wasn't sure if the resident was allowed to sit on the toilet, so she went and asked another CNA (CNA #2), who said no, so she and CNA #2 used the lift and put the resident to bed. There was no mention of the resident on the floor or that an incident had occurred. Interview with Resident #1, on 11/15/17 at 5:30 PM, revealed she was alert and cognitive. Resident #1 stated that one (1) CNA used the swing lift and she slid out of the sling. Resident #1 stated she had pain after that and was unable to recall if she told anyone. Interview with Registered Nurse #1 (RN) on 11/16/17 at 11:10 AM, revealed Resident #1 was complaining of pain on 10/26/17, and her right knee was slightly swollen. She also stated that the resident had said she fell after supper the night before. The resident was sent out for an evaluation and X-ray. RN #1 stated she called CNA #1, who said she did take Resident #1 to the bathroom by herself, but didn't mention the lift. RN #1 stated CNA #2 was also interviewed and her statement was that she came into Resident #1's room and saw the resident on the floor with the Vander lift in the room and a Vera (sit-to-stand) sling, which was not supposed to be used with the Vander lift. RN #1 stated CNA #2 indicated that CNA #1 wanted her to say there had been no fall for Resident #1. RN #1 stated that staff are taught to use two (2) people with the Vera or Vander lift. Interview with CNA #2 on 11/16/17 at 2:30 PM, revealed it was after supper on 10/16/17, while picking up dinner trays, she was in the hall helping a resident to the bathroom. She stated that CNA #1 came and asked if she could help her with Resident #1. She stated she told CNA #1 that she would be there after she took her resident to the bathroom. CNA #2 stated that CNA#1 busted through the door and said I need you right now. CNA #2 stated she went to Resident #1's room and saw the resident sitting on the floor between the bathroom door and room door. She stated that she saw the Vander lift beside the resident. CNA #2 stated she told CNA#1 to go get a nurse and CNA #1 replied she was going to get in trouble, she was just trying to get the resident in the bed. She never said she was using the lift. CNA #2 stated that Resident #1 didn't say anything until they started getting her back in the bed, using the Vander lift, then she complained of pain in her leg. She didn't say which leg. CNA #2 stated that she told CNA #1 several times she needed to report this to the nurse. CNA #2 stated the very next morning she got a call to come talk to the DON. She stated that she and CNA #1 were waiting to talk to the DON and she picked up a piece of paper, CNA #1's written statement, which didn't document the truth about the incident. CNA #2 stated she read the statement and looked at CNA #1 and said, You know I can't lie for you, right?,to which CNA #1 responded, Oh well, I'm going to have to look for another job. Interview with Licensed Practical Nurse #1 on 11/20/17 at 12:45 PM, revealed she did see Resident #1 for the last time on 10/25/17 at approximately 9:00 PM. The resident was in bed with no complaints. Resident #1 did not mention a fall. LPN #1 says she never was told of a fall or incident during the shift. Review of Resident #1's medical record revealed the facility admitted the resident on 8/10/15, with [DIAGNOSES REDACTED]. She does have a history of prior fractures. Review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/24/17, revealed her Brief Interview for Mental Status (BIMS) score was a 15, meaning no cognitive impairment. A second BIMS was performed on 11/16/17, during the complaint survey, which also scored 15. The MDS documented that Resident #1 required total assistance with transfers with the assistance of two (2) people.

Based on observation, record review, staff interview and facility policy/procedure review, the facility failed to ensure that two (2) of 10 residents reviewed, Resident #2 and Resident #3, received the goods and services necessary to avoid physical harm as evidenced by during observation of a skin assessment performed by the Assistant Director of Nurses on 8/3/12 at 2:40 p.m., an unstageable pressure sore was discovered on Resident #2's left plantar surface of the foot and Resident #3 having an amputation of left hand pinky finger due to erosion of pinky finger nail into palm bed. A complaint investigation, with a partially extended survey, was conducted from 8/1/12 to 8/7/12. During the investigation, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. A partially extended survey was conducted on 8/3/12 through 8/7/12. It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12. The facility submitted an Allegation of Compliance 8/4/12 at 6:30 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 8/7/12 at 12:00 p.m. and is considered ongoing. Findings include: Cross reference to F-309 and F-314 for the facility's failure to ensure Resident #2 and Resident #3 received the treatment and services necessary to avoid physical harm. Resident #2 Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #2's cognitive status was severely impaired. Observation of a skin assessment on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses for Resident #2 revealed on the left foot plantar surface an enlarged area near outside of left big toe joint. The area was dark and dry with peeling skin. Interview on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses revealed "That left foot area looks unstageable. It looks like eschar on that foot. It appears to be an unstageable pressure sore. The nurse who does the weekly body audit and CNA's (Certified Nurse Aides) that provide skin care should have found this. Let me go and get the nurse to get MD (physician) orders for it. We don't have any orders for that area." Interview on 8/3/12 at 3:00 p.m. with the Assistant Director of Nurses (ADON) revealed wound on left plantar foot of Resident #2 was " unstageable, 4LX3.6W, 0 (no) Depth, 100 % brown black eschar, periwound flesh color, intact edges. 0 (no) drainage. The plan is call MD (physician), family, and start wound treatment." The ADON was asked if this type wound would happen overnight, and the ADON stated, "No, this didn't happen overnight." Interview on 8/4/12 at 11:40 a.m. with Licensed Practical Nurse #4 revealed " I was the treatment nurse on July 25 for Yellow Unit. I did do (name of Resident #2)'s skin assessment that day. I do not recall any pressure sores, stageable or unstageable on her at all. I signed the electronic TAR (treatment administration record). I did all my skin assessments that day during my shift." Interview on 8/6/12 at 1:35 p.m. with Licensed Practical Nurse #5 revealed, "I'm really not exactly sure when I did my last skin assessment on (name of Resident #2)." Interview on 8/6/12 at 1:50 p.m. with Licensed Practical Nurse #6 revealed "I do skin assessments weekly on every patient. I work yellow unit. When I do skin assessments, I initial it in the computer. I do the skin assessments as assigned. (Name of Resident #2) is high risk for pressure sores." Resident #3 Record review revealed that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, indicating Resident #3's cognitive status was severely impaired. Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." Review of the POS [REDACTED]. Review of the Pre-Operative [DIAGNOSES REDACTED]. Review of the POS Same, circumferential abscess small finger with necrosis of flexor tendon, subcutaneous tissue and bone extending into palmar aspect of the hand with ulcerated open wound in the palm secondary to digital flexion contractures with nail erosion into the palm and flexion contractures of the long and ring finger... Operation: 1. Irrigation and debridement of digital abscess and amputation of left small finger. 2. Percutaneous flexor tendon tenotomy and manipulation of long and ring fingers." Review of physician's orders [REDACTED]." *Review of handwritten physician's orders [REDACTED]. In December 2011 and January 2012, orders were handwritten on the Treatment Administration Records. In January 2012, the handwritten order was typed into the computer with the start date 12/3/12 instead of 12/3/11; therefore, restorative treatment was not begun until 2/1/12 to Resident #3's bilateral hands due to the order was on hold based on the computer input error. Review of the restorative treatment administrative record (TAR) from February 2012 through June 2012 revealed there was no documented evidence that Restorative treatment was provided to the bilateral hands of Resident #3. Review of the July 2012 Restorative TAR noted initials from 7/18/12 through 7/21/12 noted restorative treatment orders were followed. There are stars on each area where staff should initial that treatment was done from February 2012 through June 2012. Beginning in July 2012, there were handwritten x's through each blank until 7/17/12. From 7/17/12 through 7/21/12, there were initials.

Based on record review, observation, staff interview and policy review, the facility failed to provide the necessary care and services needed to attain and or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for one (1) of 10 residents reviewed. *Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." (Resident #3). It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12 and was removed on 08/20/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrrective actions implemented by the facility have been able to demonstrate removal of the immediate jeopardy. The validation of the Allegation of Compliance (AoC) was accomplished through observation, staff interview, record review, and in-service review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings include: Record review revealed that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, indicating Resident #3's cognitive status was severely impaired. Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." Review of the POS [REDACTED]. Review of the Pre-Operative [DIAGNOSES REDACTED]. Review of the POS Same, circumferential abscess small finger with necrosis of flexor tendon, subcutaneous tissue and bone extending into palmar aspect of the hand with ulcerated open wound in the palm secondary to digital flexion contractures with nail erosion into the palm and flexion contractures of the long and ring finger... Operation: 1. Irrigation and debridement of digital abscess and amputation of left small finger. 2. Percutaneous flexor tendon tenotomy and manipulation of long and ring fingers." Review of physician's orders [REDACTED]." Review of the restorative treatment administrative record (TAR) from February 2012 through June 2012 revealed there was no documented evidence that Restorative treatment was provided to the bilateral hands of Resident #3. Review of the July 2012 Restorative TAR noted initials from 7/18/12 through 7/21/12 noted restorative treatment orders were followed. There are stars on each area where staff should initial that treatment was done from February 2012 through June 2012. Beginning in July 2012, there were handwritten x's through each blank until 7/17/12. From 7/17/12 through 7/21/12, there were initials. Review of Resident #3's care plan for "Limited ROM (range of motion)/weakness to bilateral fingers/wrist & (and) bilateral lower extremities" with an onset date of 12/03/11 revealed the goal to "maintain strength/ROM" and the approach was "ROM to bilateral fingers/wrist 5 days a week on 7-3 shift for 15 minutes." Interview on 8/2/12 at 10:10 a.m. with the Assistant Director of Nurses revealed, "There is not a set policy that says a nurse has to go and lay eyes on or observe (restorative) treatment. (Name of Resident #3) was on restorative for ROM (range of motion) to hands and lower extremities. It's the treatment nurse or medication nurse that does nail care. Nail care is not on a MAR (medication administration record) or TAR (treatment administration record). It's on an as needed basis. The stars on the Rehab/Restorative care TAR mean the treatment was blocked out and not scheduled to be done. In June it was x'd out by the computer. In July it was x'd out by staff. Resident #3 had ROM on fingers and wrist 5 days a week ordered. It can be any 5 days of the week then she went into the hospital 7/22/12." Interview on 8/2/12 at 1:05 p.m. with Certified Nurse Aide #1 revealed, "When we first got the orders, I did them but when the stars were on the Restorative TAR (treatment administration record) I thought the orders had been dc'd (discontinued) so I stopped it. I did not ask a nurse about it. I did wonder why the order kept showing up but I thought it was dc'd because the stars blocked the space where I would initial. So I didn't do the treatment." Interview on 8/3/12 at 8:45 a.m. with Certified Nurse Aide (CNA) #1 revealed when asked if she ever had a nurse come and watch her perform restorative on residents, CNA #1 stated, "No, mam. At times a nurse will ask me questions like how a resident is doing. Therapy doesn't ask. I tell the nurse if they have met their goal, we discuss it and if the goal is met, the resident will be dc'd (discontinued)." Interview on 8/3/12 at 9:15 a.m. with Certified Nurse Aide (CNA) #3 revealed "I've never had a nurse follow me and observe restorative treatments. They've never asked me about patients meeting goals. I've done this off and on for 2 years." Interview on 8/3/12 at 10:40 a.m. with Certified Nurse Aide #2 revealed, "On July 16 (2012), I gave her a bath. LPN (Licensed Practical Nurse) #7 said to wash her hand cause (because) there was dried blood on the side. I couldn't open her hand up to wash it cause it's so tight. The hand was not red or swollen. The only thing I saw was a small amount of dried blood on the side near her pinky finger. When in the shower, I called LPN #7 into the room to make sure that hand was what she was talking about. LPN #7 looked at it and said yes. I washed it the best I could. LPN #7 told me when I took Resident #3 back to her room to try and get a palm guard on or at least a towel in her hand. I've never used a palm guard. So I tried the towel. I told LPN #7 that I couldn't get the towel in her hand cause it was so tight. Resident #3's hand was a clenched fist. I had Resident #3 again Saturday and Sunday, July 21 and 22 (2012). I gave her a bed bath Saturday morning. Her hand was still tight but the hand wasn't swollen or red. On Sunday, I went down to her room about 9:30 or 10:00 a.m. I didn't see the hand swollen or red. It was still clenched tight. I didn't cut her/his nails that week. I don't remember if they were long or short. Close to 2:00 p.m., after lunch, I went to do my last rounds. That's when I saw her hand was swollen. It was red, light red, still clenched in a fist. I called the nurse's station. LPN #1 came to Resident #3's room. LPN #1 opened the hand so I could clean it. It wasn't opened all the way, but opened it enough to wash it. With the way LPN #1 was holding the hand open, I couldn't get a good look at it. I washed it and LPN #1 helped me put a gown on her. I saw no blood or pus on the wash rag or in the water." Interview on 8/7/12 at 3:05 p.m. with Licensed Practical Nurse #7 revealed, "I did go to CNA (Certified Nurse Aide) #2 and tell her to give Resident #3 a bath and wash her hand. The hand was sweaty. I didn't see any blood. It wasn't red or swollen, I'm not sure of the date. I went in after the bath and put her palm guards in. She had an old skin tear on top of right hand, no open area seen on left palm." Interview on 8/3/12 at 11:25 a.m. with Licensed Practical Nurse #1 revealed, "CNA (Certified Nurse Aide) #2 called the nurse's station and asked me to come look at Resident #3's hand. I wasn't assigned that hall that week so I hadn't seen her in a week. Her pinky was swollen, her hand was clenched. Her ring finger was swollen. Both fingers were hot and red. The top of the hand was warm to the wrist and pink, not red. It looked like a very small amount of dried serous drainage from small splits of each finger joint on her pinky. I picked her hand up, stretched out her fingers as far as I could. I told CNA #2 to get me a towel with warm soapy water. I saw nothing when I stretched out her fingers. There was no odor. Her long finger had a nail that was soft and would bend. I cut that nail. I didn't cut the pinky nail. It wasn't long. Her palm wasn't swollen. It did not have an open area. I was looking for open areas cause (because) it was so swollen. I just knew I'd see something cause the fingers were so swollen. I saw nothing. She did have a temp (temperature). She wasn't moaning. She didn't react when I stretched out her fingers and washed her hand. Before I even got the vital signs, I called for the charge nurse (name of RN #4). RN #4 said to start the transfer process. We got her out fast. The only open areas were the joints of her pinky and they were just cracks. I washed her palm and there was nothing on the towel. I pulled the pinky away from the palm. When I read the operative report, I couldn't believe it. I saw nothing like that." Interview on 8/6/12 at 11:00 a.m. with Registered Nurse #4, via the phone, revealed, "I went into Resident #3's room to assess her hand. It was cherry red with 4 plus [MEDICAL CONDITION]. I was scared to touch it. It was very hot. I didn't want to open her hand because I didn't know if there was a fracture and I didn't want to cause any further damage. I didn't see any drainage. Resident #3 was moaning. I immediately called her doctor and got an ambulance. I didn't see the fingernail unless I lifted her finger. I didn't move it." Record review revealed that Resident #3's medical doctor was notified and ordered the transfer to the local hospital for evaluation and treatment. Resident #3 was transferred to the hospital on [DATE] at 2:55 p.m. by ambulance. Interview on 8/7/12 at 10:30 a.m. with the Resident #3's physician, who is also the Medical Director, regarding if the orders for range of motion had been followed, could it have prevented the nail growing into the palm revealed, the physician stated, "It might not have occurred if range of motion was done..." Review of the facility's "Restorative Nursing Programs" policy, revised 2/11/05, revealed, "All residents will be evaluated for participation in Restorative Nursing Programs following admission. Participation in Restorative Programs will be reflected in the Resident Plan of Care ...4. Provide follow-up evaluation every 30 days by Charge Nurse while the resident remains on the program. 5. Resident Plan of Care will be updated appropriately ..." The following information is quoted from the facility's AoC as follows: F 309 (1) Resident #3 On 7/22/12, Resident #3 was admitted to the hospital related to [MEDICAL CONDITION], redness, and warmth in left hand and wrist. Resident #3 was diagnosed with [REDACTED]. Resident #3's left small finger was amputated on 7/23/12. Resident #3 was discharged from the facility on 7/31/12. The two Certified Nurse Assistants (CNAs) responsible for the Restorative care on Resident #3 received employee counseling by the Registered Nurse supervisor on Yellow Wing. The counseling was done on 8/01/12 and addressed the range of motion that was ordered on Resident #3 and following physician's order [REDACTED]. Copies of the counseling forms for the 2 Restorative CNAs are included. (2) All Residents have the potential to be affected by the failure to provide the necessary care and services needed to attain and/or maintain the highest practicable physical well being in Accordance with the comprehensive assessment and plan of care. On 8/01/12, a visual check of hands, fingernails, and skin integrity of the hands was done on all Residents in the facility. The visual checks were done by the Director of Nursing, the Assistant Director of Nursing, 2 Registered Nurses and 2 Licensed Practical Nurses. The Residents hands were checked for contractures, skin problems, cleanliness of hands, and fingernails. No new contractures and no new skin problems were identified. Several Residents did need nail care which was provided on 8/01/12. Documentation of the checks were given to the surveyor at that time. Body audits were done on 8/02/12 on all Residents except for three (3) Residents that were in the hospital, one (1) Resident that was on therapeutic leave, and five (5) Residents that refused after two (2) attempts to do the audits. On 8/06/12, five (5) Practical Nurses began reviewing all physician orders. The orders were reviewed for accuracy of content. All hand written orders were entered into the computer. The orders were compared to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurse Practitioner assisted with the review. The Registered Nurse Charge Nurses compared the orders to the Activities of Daily Living (ADL) Care Plans. The Minimum Data Set (MDS) Nurses reviewed the Comprehensive Care Plans to ensure all pertinent orders had been addressed on the total care plan. The process concluded on 8/13/12 when all orders had been reviewed. On 8/06/12, the Registered Nurse Charge Nurses reviewed the Residents who receive Restorative Care. The Certified Nurse Assistants (CNA) were observed while performing the Restorative Care to ensure that the CNAs are following the Restorative orders. On 8/09/12 and 8/10/12, the three (3) Registered Nurse Charge Nurses did body audits on the Residents during the Resident ' s bath. No new problems identified during these body audits. (3) An in-service was done by the Director of Nursing on 8/01/12, with the Registered Nurses and Licensed Practical Nurses who worked Yellow Wing and provided care for Resident #3 from 7/19/12 until the Resident was transferred to the hospital. The in-service covered assessments, reporting changes, documentation and following physician's order [REDACTED]. A copy of the in-service with the Yellow Wing Nurses is included. In addition, all nurses have been inserviced on skin assessments, reporting changes, documentation and following physician's order [REDACTED]. The facility initiated a new policy addressing contractures on 8/09/12. The policy addressed the care of the contractured extremity as well as devices to be used as ordered. A copy of the Contracture Policy is included. Weekly body audits are being done by the Licensed Nurse on all Residents that will permit the audit to be done. The weekly body audits will be documented on the Weekly Body Audit form. A copy of the Weekly Body Audit form is included. The facility revised the Pressure Ulcer Policies and Protocols on 8/17/12. The policies revised include Daily Evaluation of Pressure Ulcer Policy, Pressure Ulcers Classification Policy, Pressure Ulcer Risk Assessment Policy and Daily Evaluation of Pressure Ulcer Policy. Protocols revised include Braden Scale Assessment Scale Protocol and Pressure Ulcer Protocol. The Pressure Ulcer Protocol addresses guidelines for preventive measures to be initiated for Residents assessed at high risk on the Braden Scale. All Resident assessed at high risk now have a total body audit twice weekly. The Licensed Practical Nurses and Registered Nurses were inserviced on the revised policies and protocols. Copies of the revised policies and protocols are included. A copy of the in-service addressing the revised policies is included. An in-service was done on 8/02/12, by the Assistant Director of Nursing addressing Restorative Procedure covering the Restorative Program policy, documentation, reporting changes in skin integrity, and communication between the Restorative Certified Nurse and the Charge Nurse. The in-service was attended by the Registered Nurses, the Licensed Practical Nurses, and the Certified Nurse Assistants. A copy of the in-service addressing the Restorative Program is included. An in-service for the Registered Nurses, the Licensed Practical Nurses and Certified Nurse Assistants, was conducted on 8/03/12 by the Assistant Director of Nursing. The in-service addressed skin assessments, weekly body audits, nail care, documentation and notification of the physician. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing skin assessments is included. On 8/03/12, an in-service was done by the Registered Nurse Staff Development addressing neglect. The in-service was presented to the nursing staff including Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants (CNA). Any nurse or CNA who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing neglect is included. An in-service was done on 8/06/12 and 8/07/12, by the Assistant Director of Nursing addressing following physician's order [REDACTED]. The in-service was attended by Registered Nurses and Licensed Practical Nurses. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing following the physician's order [REDACTED]. On 8/7/12, an in-service was conducted by a Certified Mental Health Therapist who is the Director of Silver Services at the local regional mental health center addressing abuse, neglect and stress management. The in-service was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, dietary personnel, housekeeping and laundry personnel, maintenance personnel, office personnel and administrative staff. A copy of the in-service addressing abuse and neglect is included. An in-service was done on 8/07/12 by the Registered Nurse Staff Development addressing nail assessments and nail care to be done weekly as a part of the weekly body audit. The Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants attended the in-service. A copy of the in-service addressing nail assessments and nail care is included. An in-service was done on 8/08/12 by the Nurse Consultant to the Registered Nurses and Licensed Practical Nurses who were working on 8/08/12 on 7-3 shift. The in-service addressed following physician's order [REDACTED]. A copy of the in-service by the Nurse Consultant is included. An in-service addressing basic Restorative Technique was presented by the Therapy Company to the Registered Nurses, Licensed Practical Nurses and Certified Nurse Assistants. The in-service was done on 8/10/12 and on 8/14/12. A copy of the in-service by the Therapy Company is included. An in-service was done by the Nurse Practitioner for the Registered Nurses and Licensed Practical Nurses on 8/13/12. The in-service addressed Systemic Body Audits of the Resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION], obtaining orders for treatments needed. A copy of the in-service by the Nurse Practitioner is included. An in-service for the Certified Nurse Assistants was done by the Nurse Practitioner on 8/15/12, addressing alteration of normal skin, types of [MEDICAL CONDITION] , reporting changes, following physician's order [REDACTED]. A copy of the in-service by the Nurse Practitioner is included. (4) The weekly body audits will be monitored by the Registered Nurse (RN) Charge Nurses on each unit. The Charge Nurses will review and sign the weekly body audit form. A copy of the Weekly Body Audit form is included. The Registered Nurse Charge Nurses monitor the Restorative Program by observing the Restorative Certified Nurse Assistant performing Restorative Care on each Resident requiring Restorative treatment. The monitoring on each Resident in Restorative will be done at least weekly. Daily, Monday through Friday, except holidays, the Registered Nurse Charge Nurses review all new orders that were received the prior day. On Monday, the orders that were received on Friday and on the week-end are reviewed. The orders taken on holidays are reviewed the next working day. The Charge Nurses check the accuracy of the order and check to ensure that the order was transcribed to the appropriate documentation form (Medication Administration Record, [REDACTED]. Any discrepancies noted are corrected by the Charge Nurses. The review is given to the appropriate Minimum Data Set (MDS)/Care Plan Nurse. The MDS Nurse also checks for accuracy and addresses on the care plan if needed. The MDS then gives the order review to the Director of Nursing. The Director of Nursing takes appropriate action for the incorrect orders that were noted. The Director of Nursing maintains the daily reviews in a file. Any discrepancies noted are presented to the monthly Quality Assurance Committee meeting for review. The facility called an emergency Quality Assurance Committee meeting on 8/03/12 to address the Immediate Jeopardy issues. The Quality Assurance Committee met again on 8/09/12, to discuss the plan of correction needed. The Quality Assurance Committee members attending this meeting included the Medical Director, the Administrator, The Director of Nursing, the Assistant Director of Nursing, the Nurse Practitioner, and the Quality Assurance Nurses. Any problems noted by continued monitoring will be presented to the Quality Assurance Committee as needed. The facility feels the Immediate Jeopardy has been removed as of 8/20/12." The validation of the AoC was accomplished through observation, staff interview, record review, and in-service review. Observation of six (6) skin assessments and five (5) restorative treatments verified that the facility has implemented a more through skin assessment and restorative program as indicated in the Allegation of compliance (AOC). Interviews with 16 Certified Nurses Aides (CNA), 10 Licensed Practical Nurses (LPN) and five (5) Registered Nurses (RN) verified that in-services had been done with staff regarding skin assessments, range of motion, pressure ulcers, following doctor orders and abuse/neglect. The staff interviewed were able to give details to each in-service. Review of the six (6) sampled resident records verified that skin assessments were documented, restorative treatments were observed weekly by the RN Charge nurses, care plans and doctor orders were followed as indicated in the AOC. Record review confirmed that two (2) restorative CNAs were counseled on 8/1/12 addressing Range of Motion and following physician's orders [REDACTED]. Policy/Procedure review for pressure ulcers and contractures did indicate changes in the policy/procedure as noted in the AoC. Review of in-services verified that the LPNs and RNs on the Yellow wing were in-serviced on 8/1/12 covering assessments, reporting changes, documentation and following physician's orders [REDACTED]. On 8/2/12 an in-service addressing the restorative procedure covering the Restorative Program policy, documentation and reporting changes in skin integrity and communication between the Restorative Certified Nurse and the Charge Nurse. This in-service was attended by Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. On 8/3/12, an in-service for the Registered Nurses, Licensed Practical Nurses and Certified Nurses Aides addressing skin assessments, weekly body audits, nail care, documentation and notification of the physician was done. "Any nurse who did not attend the in-service will not be allowed to work until in-serviced." An in-service on 8/6/12 and 8/7/12 covered following physician's orders [REDACTED]. This in-service was attended by RN's and LPN's and "any nurse who did not attend the in-service will not be allowed to work until in-serviced." On 8/7/12, an in-service for abuse/neglect and stress management was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, Dietary Personnel, Housekeeping and Laundry Personnel, Maintenance Personnel, Office Personnel and Administrative Staff. An in-service was done on 8/7/12 addressing nail assessment and nail care to be done weekly as part of the weekly body audit. RN's, LPN's and CNA's attended this in-service. An in-service on 8/8/12 to RN's and LPN's working on 8/8/12 on the 7-3 shift was done addressing following physician's orders [REDACTED]. On 8/10/12 and 8/14/12 an in-service was done addressing basic Restorative Technique. RNs, LPNs and CNAs attended this in-service. An in-service on 8/13/12 addressed systemic body audits of the resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION] and obtaining orders for treatments needed was given for RN's and LPN's. On 8/15/12 an in-service was given addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's orders [REDACTED]. In-service record review and employee roster verification confirmed these in-services listed above. Based on the facility's corrective actions that were validated by observation, staff interview, record review, and in-service review, the Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee.

Based on observation, record review, staff interview and facility policy/procedure review, the facility failed to ensure that two (2) of 10 residents reviewed, Resident #2 and Resident #3, received the goods and services necessary to avoid physical harm as evidenced by during observation of a skin assessment performed by the Assistant Director of Nurses on 8/3/12 at 2:40 p.m., an unstageable pressure sore was discovered on Resident #2's left plantar surface of the foot and Resident #3 having an amputation of left hand pinky finger due to erosion of pinky finger nail into palm bed. It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12 and was removed on 08/20/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrrective actions implemented by the facility have been able to demonstrate removal of the immediate jeopardy. The validation of the Allegation of Compliance (AoC) was accomplished through observation, staff interview, and record review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings include: Cross reference to F-309 and F-314 for the facility's failure to ensure Resident #2 and Resident #3 received the treatment and services necessary to avoid physical harm. Resident #2 Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #2's cognitive status was severely impaired. Observation of a skin assessment on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses for Resident #2 revealed on the left foot plantar surface an enlarged area near outside of left big toe joint. The area was dark and dry with peeling skin. Interview on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses revealed "That left foot area looks unstageable. It looks like eschar on that foot. It appears to be an unstageable pressure sore. The nurse who does the weekly body audit and CNA's (Certified Nurse Aides) that provide skin care should have found this. Let me go and get the nurse to get MD (physician) orders for it. We don't have any orders for that area." Interview on 8/3/12 at 3:00 p.m. with the Assistant Director of Nurses (ADON) revealed wound on left plantar foot of Resident #2 was " unstageable, 4LX3.6W, 0 (no) Depth, 100 % brown black eschar, periwound flesh color, intact edges. 0 (no) drainage. The plan is call MD (physician), family, and start wound treatment." The ADON was asked if this type wound would happen overnight, and the ADON stated, "No, this didn't happen overnight." Interview on 8/4/12 at 11:40 a.m. with Licensed Practical Nurse #4 revealed " I was the treatment nurse on July 25 for Yellow Unit. I did do (name of Resident #2)'s skin assessment that day. I do not recall any pressure sores, stageable or unstageable on her at all. I signed the electronic TAR (treatment administration record). I did all my skin assessments that day during my shift." Interview on 8/6/12 at 1:35 p.m. with Licensed Practical Nurse #5 revealed, "I'm really not exactly sure when I did my last skin assessment on (name of Resident #2)." Interview on 8/6/12 at 1:50 p.m. with Licensed Practical Nurse #6 revealed "I do skin assessments weekly on every patient. I work yellow unit. When I do skin assessments, I initial it in the computer. I do the skin assessments as assigned. (Name of Resident #2) is high risk for pressure sores." Resident #3 Record review revealed that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, indicating Resident #3's cognitive status was severely impaired. Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." Review of the POS [REDACTED]. Review of the Pre-Operative [DIAGNOSES REDACTED]. Review of the POS Same, circumferential abscess small finger with necrosis of flexor tendon, subcutaneous tissue and bone extending into palmar aspect of the hand with ulcerated open wound in the palm secondary to digital flexion contractures with nail erosion into the palm and flexion contractures of the long and ring finger... Operation: 1. Irrigation and debridement of digital abscess and amputation of left small finger. 2. Percutaneous flexor tendon tenotomy and manipulation of long and ring fingers." Review of physician's orders [REDACTED]." *Review of handwritten physician's orders [REDACTED]. In December 2011 and January 2012, orders were handwritten on the Treatment Administration Records. In January 2012, the handwritten order was typed into the computer with the start date 12/3/12 instead of 12/3/11; therefore, restorative treatment was not begun until 2/1/12 to Resident #3's bilateral hands due to the order was on hold based on the computer input error. Review of the restorative treatment administrative record (TAR) from February 2012 through June 2012 revealed there was no documented evidence that Restorative treatment was provided to the bilateral hands of Resident #3. Review of the July 2012 Restorative TAR noted initials from 7/18/12 through 7/21/12 noted restorative treatment orders were followed. There are stars on each area where staff should initial that treatment was done from February 2012 through June 2012. Beginning in July 2012, there were handwritten x's through each blank until 7/17/12. From 7/17/12 through 7/21/12, there were initials. The facility's Allegation of Compliance included corrective actions as follows: "Resident #2 The Nurse Practitioner was notified of the area on Resident #2's left foot on 8/02/12. The Nurse Practitioner checked Resident #2's foot and gave treatment orders for the area. The treatment was initiated on Resident #2 on 8/02/12. [MEDICATION NAME] was applied every shift as ordered. A copy of the treatment order for Resident #2 is included. A copy of the Treatment Record reflecting the treatment on 8/02/12 is included. The physician was notified on 8/03/12, concerning the unstageable area on the left plantar surface of Resident #2's foot and the treatment that was ordered by the Nurse Practitioner on 8/02/12. The area on Resident #2's foot was assessed by the Director of Nursing, the Nurse Consultant and the Registered Nurse Charge Nurse on the unit on 8/15/12. The dry black skin is not present at this time. The area presents as a callous. The Nurse Practitioner assessed the area on 8/15/12 and diagnosed the area as a callous. The Nurse Practitioner detailed the assessment in a progress note dated 8/15/12. A copy of the progress note by the Nurse Practitioner is included. Resident #3 On 7/22/12, Resident #3 was admitted to the hospital related to [MEDICAL CONDITION], redness, and warmth in left hand and wrist. Resident #3 was diagnosed with [REDACTED]. Resident #3's left small finger was amputated on 7/23/12. Resident #3 was discharged from the facility on 7/31/12. The two Certified Nurse Assistants (CNAs) responsible for the Restorative care on Resident #3 received employee counseling by the Registered Nurse supervisor on Yellow Wing. The counseling was done on 8/01/12 and addressed the range of motion that was ordered on Resident #3 and following physician's order [REDACTED]. (2) All Residents have the potential to be affected by the failure to provide the necessary care and services needed to attain and/or maintain the highest practicable physical well being in Accordance with the comprehensive assessment and plan of care. On 8/01/12, a visual check of hands, fingernails, and skin integrity of the hands was done on all Residents in the facility. The visual checks were done by the Director of Nursing, the Assistant Director of Nursing, 2 Registered Nurses and 2 Licensed Practical Nurses. The Residents hands were checked for contractures, skin problems, cleanliness of hands, and fingernails. No new contractures and no new skin problems were identified. Several Residents did need nail care which was provided on 8/01/12. Documentation of the checks were given to the surveyor at that time. Body audits were done on 8/02/12 on all Residents except for three (3) Residents that were in the hospital, one (1) Resident that was on therapeutic leave, and five (5) Residents that refused after two (2) attempts to do the audits. On 8/06/12, five (5) Practical Nurses began reviewing all physician orders. The orders were reviewed for accuracy of content. All hand written orders were entered into the computer. The orders were compared to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurse Practitioner assisted with the review. The Registered Nurse Charge Nurses compared the orders to the Activities of Daily Living (ADL) Care Plans. The Minimum Data Set (MDS) Nurses reviewed the Comprehensive Care Plans to ensure all pertinent orders had been addressed on the total care plan. The process concluded on 8/13/12 when all orders had been reviewed. On 8/06/12, the Registered Nurse Charge Nurses reviewed the Residents who receive Restorative Care. The Certified Nurse Assistants (CNA) were observed while performing the Restorative Care to ensure that the CNAs are following the Restorative orders. On 8/09/12 and 8/10/12, the three (3) Registered Nurse Charge Nurses did body audits on the Residents during the Resident ' s bath. No new problems identified during these body audits. (3) An in-service was done by the Director of Nursing on 8/01/12, with the Registered Nurses and Licensed Practical Nurses who worked Yellow Wing and provided care for Resident #3 from 7/19/12 until the Resident was transferred to the hospital. The in-service covered assessments, reporting changes, documentation and following physician's order [REDACTED]. A copy of the in-service with the Yellow Wing Nurses is included. In addition all nurses have been inserviced on skin assessment, reporting changes, documentation and following physician's order [REDACTED]. The facility initiated a new policy addressing contractures on 8/09/12. The policy addressed the care of the contractured extremity as well as devices to be used as ordered. A copy of the Contracture Policy is included. Weekly body audits are being done by the Licensed Nurse on all Residents that will permit the audit to be done. The weekly body audits will be documented on the Weekly Body Audit form. A copy of the Weekly Body Audit form is included. The facility revised the Pressure Ulcer Policies and Protocols on 8/17/12. The policies revised include Daily Evaluation of Pressure Ulcer Policy, Pressure Ulcers Classification Policy, Pressure Ulcer Risk Assessment Policy and Daily Evaluation of Pressure Ulcer Policy. Protocols revised include Braden Scale Assessment Scale Protocol and Pressure Ulcer Protocol. The Pressure Ulcer Protocol addresses guidelines for preventive measures to be initiated for Residents assessed at high risk on the Braden Scale. All Resident assessed at high risk now have a total body audit twice weekly. The Licensed Practical Nurses and Registered Nurses were inserviced on the revised policies and protocols. Copies of the revised policies and protocols are included. A copy of the in-service addressing the revised policies is included. An in-service was done on 8/02/12, by the Assistant Director of Nursing addressing Restorative Procedure covering the Restorative Program policy, documentation, reporting changes in skin integrity, and communication between the Restorative Certified Nurse and the Charge Nurse. The in-service was attended by the Registered Nurses, the Licensed Practical Nurses, and the Certified Nurse Assistants. A copy of the in-service addressing the Restorative Program is included. An in-service for the Registered Nurses, the Licensed Practical Nurses and Certified Nurse Assistants, was conducted on 8/03/12 by the Assistant Director of Nursing. The in-service addressed skin assessments, weekly body audits, nail care, documentation and notification of the physician. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing skin assessments is included. On 8/03/12, an in-service was done by the Registered Nurse Staff Development addressing neglect. The in-service was presented to the nursing staff including Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants (CNA). Any nurse or CNA who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing neglect is included. An in-service was done on 8/06/12 and 8/07/12, by the Assistant Director of Nursing addressing following physician's order [REDACTED]. The in-service was attended by Registered Nurses and Licensed Practical Nurses. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing following the physician's order [REDACTED]. On 8/7/12, an in-service was conducted by a Certified Mental Health Therapist who is the Director of Silver Services at the local regional mental health center addressing abuse, neglect and stress management. The in-service was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, dietary personnel, housekeeping and laundry personnel, maintenance personnel, office personnel and administrative staff. A copy of the in-service addressing abuse and neglect is included. An in-service was done on 8/07/12 by the Registered Nurse Staff Development addressing nail assessments and nail care to be done weekly as a part of the weekly body audit. The Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants attended the in-service. A copy of the in-service addressing nail assessments and nail care is included. An in-service was done on 8/08/12 by the Nurse Consultant to the Registered Nurses and Licensed Practical Nurses who were working on 8/08/12 on 7-3 shift. The in-service addressed following physician 's orders , falsification of documentation, body audits and pressure sores. A copy of the in-service by the Nurse Consultant is included. An in-service addressing basic Restorative Technique was presented by the Therapy Company to the Registered Nurses, Licensed Practical Nurses and Certified Nurse Assistants. The in-service was done on 8/10/12 and on 8/14/12. A copy of the in-service by the Therapy Company is included. An in-service was done by the Nurse Practitioner for the Registered Nurses and Licensed Practical Nurses on 8/13/12. The in-service addressed Systemic Body Audits of the Resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION], obtaining orders for treatments needed. A copy of the in-service by the Nurse Practitioner is included. An in-service for the Certified Nurse Assistants was done by the Nurse Practitioner on 8/15/12, addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's order [REDACTED]. A copy of the in-service by the Nurse Practitioner is included. (4) The weekly body audits will be monitored by the Registered Nurse (RN) Charge Nurses on each unit. The Charge Nurses will review and sign the weekly body audit form. A copy of the Weekly Body Audit form is included. The Registered Nurse Charge Nurses monitor the Restorative Program by observing the Restorative Certified Nurse Assistant performing Restorative Care on each Resident requiring Restorative treatment. The monitoring on each Resident in Restorative will be done at least weekly. The weekly monitoring will be documented on the Restorative Notes. Daily, Monday through Friday, except holidays, the Registered Nurse Charge Nurses review all new orders that were received the prior day. On Monday, the orders that were received on Friday and on the week-end are reviewed. The orders taken on holidays are reviewed the next working day. The Charge Nurses check the accuracy of the order and check to ensure that the order was transcribed to the appropriate documentation form (Medication Administration Record, [REDACTED]. Any discrepancies noted are corrected by the Charge Nurses. The review is given to the appropriate Minimum Data Set (MDS)/Care Plan Nurse. The MDS Nurse also checks for accuracy and addresses on the care plan if needed. The MDS then gives the order review to the Director of Nursing. The Director of Nursing takes appropriate action for the incorrect orders that were noted. The Director of Nursing maintains the daily reviews in a file. Any discrepancies noted are presented to the monthly Quality Assurance Committee meeting for review. The facility called an emergency Quality Assurance Committee meeting on 8/03/12 to address the Immediate Jeopardy issues. The Quality Assurance Committee met again on 8/09/12, to discuss the plan of correction needed. The Quality Assurance Committee members attending this meeting included the Medical Director, the Administrator, The Director of Nursing, the Assistant Director of Nursing, the Nurse Practitioner, and the Quality Assurance Nurses. Any problems noted by continued monitoring will be presented to the Quality Assurance Committee as needed. The facility feels the Immediate Jeopardy has been removed as of 8/20/12." The facility's corrective actions were verified by observation, interviews, record reviews, policy/procedure reviews and review of in-services. Observation of six (6) skin assessments and five (5) restorative treatments verified that the facility has implemented a more thorough skin assessment and restorative program as indicated in the Allegation of compliance (AoC). Interviews with 16 Certified Nurses Aides (CNAs), 10 Licensed Practical Nurses (LPNs) and five (5) Registered Nurses (RNs) verified that in-services had been conducted with staff regarding skin assessments, range of motion, pressure ulcers, following physician's orders [REDACTED]. Review of the six (6) sampled resident records verified that skin assessments were documented, restorative treatments were observed weekly by the RN Charge nurses, care plans and that physician's orders [REDACTED]. Record review confirmed that two (2) restorative CNAs were counseled on 8/1/12 addressing Range of Motion and following physician's orders [REDACTED]. Policy/Procedure review for pressure ulcers and contractures did indicate changes in the policy/procedure as noted in the AoC. Review of in-services verified that the LPNs and RNs on the Yellow wing were in-serviced on 8/1/12 covering assessments, reporting changes, documentation and following physician's orders [REDACTED]. On 8/2/12 an in-service addressing the restorative procedure covering the Restorative Program policy, documentation and reporting changes in skin integrity and communication between the Restorative Certified Nurse and the Charge Nurse. This in-service was attended by Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. On 8/3/12, an in-service for the RNs, LPNs and CNAs addressing skin assessments, weekly body audits, nail care, documentation and notification of the physician were conducted. "Any nurse who did not attend the in-service will not be allowed to work until in-serviced." An in-service on 8/6/12 and 8/7/12 covered following physician's orders [REDACTED]. This in-service was attended by RNs and LPNs and "any nurse who did not attend the in-service will not be allowed to work until in-serviced." On 8/7/12, an in-service for abuse/neglect and stress management was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, Dietary Personnel, Housekeeping and Laundry Personnel, Maintenance Personnel, Office Personnel and Administrative Staff. An in-service was conducted on 8/7/12 addressing nail assessment and nail care to be done weekly as part of the weekly body audit. RNs, LPNs and CNAs attended this in-service. An in-service on 8/8/12 to RNs and LPNs working on 8/8/12 on the 7-3 shift was done addressing following physician's orders [REDACTED]. On 8/10/12 and 8/14/12 an in-service was done addressing basic Restorative Technique. RNs, LPNs and CNAs attended this in-service. An in-service on 8/13/12 addressed systemic body audits of the resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION] and obtaining orders for treatments needed was given for RNs and LPNs. On 8/15/12 an in-service was given addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's orders [REDACTED]. In-service record review and employee roster verification confirmed these aforementioned in-services had been conducted. Based on the facility's corrective actions that were validated by observation, staff interview, and record review, the Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee.

Based on observation, staff interview, record review and policy review, the facility failed to ensure that one (1) of 10 residents reviewed received the necessary treatment to ensure the prevention of new pressure sores as evidenced by during observation of a skin assessment performed by the Assistant Director of Nurses on 8/3/12 at 2:40 p.m., an unstageable pressure sore was discovered on the left plantar surface of the foot (Resident #2). A complaint investigation, with a partially extended survey, was conducted from 8/1/12 to 8/7/12. During the investigation, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. A partially extended survey was conducted on 8/3/12 through 8/7/12. It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12. The facility submitted an Allegation of Compliance 8/4/12 at 6:30 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 8/7/12 at 12:00 p.m. and is considered ongoing. Findings include: Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #2's cognitive status was severely impaired. Observation of a skin assessment on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses for Resident #2 revealed on the left foot plantar surface an enlarged area near outside of left big toe joint. The area was dark and dry with peeling skin. Interview on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses revealed "That left foot area looks unstageable. It looks like eschar on that foot. It appears to be an unstageable pressure sore. The nurse who does the weekly body audit and CNA's (Certified Nurse Aides) that provide skin care should have found this. Let me go and get the nurse to get MD (physician) orders for it. We don't have any orders for that area." Interview on 8/3/12 at 3:00 p.m. with the Assistant Director of Nurses (ADON) revealed wound on left plantar foot of Resident #2 was "unstageable, 4LX3.6W, 0 (no) Depth, 100 % brown black eschar, periwound flesh color, intact edges. 0 (no) drainage. The plan is call MD (physician), family, and start wound treatment." The ADON was asked if this type wound would happen overnight, and the ADON stated, "No, this didn't happen overnight." Interview on 8/4/12 at 11:40 a.m. with Licensed Practical Nurse #4 revealed "I was the treatment nurse on July 25 for Yellow Unit. I did do (name of Resident #2)'s skin assessment that day. I do not recall any pressure sores, stageable or unstageable on her at all. I signed the electronic TAR (treatment administration record). I did all my skin assessments that day during my shift." Interview on 8/6/12 at 1:35 p.m. with Licensed Practical Nurse #5 revealed, "I'm really not exactly sure when I did my last skin assessment on (name of Resident #2)." Interview on 8/6/12 at 1:50 p.m. with Licensed Practical Nurse #6 revealed "I do skin assessments weekly on every patient. I work yellow unit. When I do skin assessments, I initial it in the computer. I do the skin assessments as assigned. (Name of Resident #2) is high risk for pressure sores." Observation during record review on 8/2/12 at 2:15 p.m. revealed that the medication administration records (MARs) and treatment administration records (TARs) were not initial by nurses as being completed beginning on 7/23/12 through 8/2/12. Interview with the facility's Internet Technology (IT) Technician, via the phone, on 8/2/12 at 4:30 p.m. revealed, "The facility has permanently lost all MARs (medication administration records), TARs (treatment administration records) and other electronic records for all residents from 7/23/12 to today (8/2/12). The records are gone. The backup was corrupted." Review of Resident #2's "E-TAR" (electronic-treatment administration record) for July 2012 revealed a body audit was due 7/25/12. This area was blank. There were no initials indicating that body audits had been performed. The previous audit was done on 7/18/12 and was initialed by the nurse. The next body audit performed and initialed was by the Assistant Director of Nurses on 8/2/12 at 2:40 p.m. There was not a handwritten TAR available until 8/2/12 at 2:45 p.m. Review of the facility's "Pressure Ulcer Protocol" policy, dated 9/10/10, revealed "A pressure ulcer is a localized injury to the skin &/or (and/or) underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear &/or friction... Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) &/or eschar (tan, brown, or black) in the wound bed. Until enough slough &/or eschar is removed to expose the base of the wound, the true depth, & therefore stage, cannot be determined..." Review of the facility's "Electronic Charting Policy", dated 4/1/10, revealed, "The following will be electronically documented: Physicians Orders, CNA (Certified Nurse Aide) documentation, MARs (medication administration records), Documentation of PRN (as needed) medications, TARs (treatment administration records), ADL (activities of daily living) records, I&O (input and output) records. "The procedure is "physician's orders [REDACTED]. Hard copies of records will be maintained at nurses (nurse's) desk in the event the computer crashes: MARs, TARs, ADL record, Food Intake Sheet. Hard copies will be only be used if computer crashes."

Based on observation, staff interview, record review and policy review, the facility failed to ensure that one (1) of 10 residents reviewed received the necessary treatment to ensure the prevention of new pressure sores as evidenced by during observation of a skin assessment performed by the Assistant Director of Nurses on 8/3/12 at 2:40 p.m., an unstageable pressure sore was discovered on the left plantar surface of the foot (Resident #2). It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12 and was removed on 08/20/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrrective actions implemented by the facility have been able to demonstrate removal of the immediate jeopardy. The validation of the Allegation of Compliance (AoC) was accomplished through observation, staff interview, record review, and in-service review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings include: Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #2's cognitive status was severely impaired. Observation of a skin assessment on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses for Resident #2 revealed on the left foot plantar surface an enlarged area near outside of left big toe joint. The area was dark and dry with peeling skin. Interview on 8/3/12 at 2:40 p.m. with the Assistant Director of Nurses revealed "That left foot area looks unstageable. It looks like eschar on that foot. It appears to be an unstageable pressure sore. The nurse who does the weekly body audit and CNA's (Certified Nurse Aides) that provide skin care should have found this. Let me go and get the nurse to get MD (physician) orders for it. We don't have any orders for that area." Interview on 8/3/12 at 3:00 p.m. with the Assistant Director of Nurses (ADON) revealed wound on left plantar foot of Resident #2 was "unstageable, 4LX3.6W, 0 (no) Depth, 100 % brown black eschar, periwound flesh color, intact edges. 0 (no) drainage. The plan is call MD (physician), family, and start wound treatment." The ADON was asked if this type wound would happen overnight, and the ADON stated, "No, this didn't happen overnight." Interview on 8/4/12 at 11:40 a.m. with Licensed Practical Nurse #4 revealed "I was the treatment nurse on July 25 for Yellow Unit. I did do (name of Resident #2)'s skin assessment that day. I do not recall any pressure sores, stageable or unstageable on her at all. I signed the electronic TAR (treatment administration record). I did all my skin assessments that day during my shift." Interview on 8/6/12 at 1:35 p.m. with Licensed Practical Nurse #5 revealed, "I'm really not exactly sure when I did my last skin assessment on (name of Resident #2)." Interview on 8/6/12 at 1:50 p.m. with Licensed Practical Nurse #6 revealed "I do skin assessments weekly on every patient. I work yellow unit. When I do skin assessments, I initial it in the computer. I do the skin assessments as assigned. (Name of Resident #2) is high risk for pressure sores." Observation during record review on 8/2/12 at 2:15 p.m. revealed that the medication administration records (MARs) and treatment administration records (TARs) were not initial by nurses as being completed beginning on 7/23/12 through 8/2/12. Interview with the facility's Internet Technology (IT) Technician, via the phone, on 8/2/12 at 4:30 p.m. revealed, "The facility has permanently lost all MARs (medication administration records), TARs (treatment administration records) and other electronic records for all residents from 7/23/12 to today (8/2/12). The records are gone. The backup was corrupted." Review of Resident #2's "E-TAR" (electronic-treatment administration record) for July 2012 revealed a body audit was due 7/25/12. This area was blank. There were no initials indicating that body audits had been performed. The previous audit was done on 7/18/12 and was initialed by the nurse. The next body audit performed and initialed was by the Assistant Director of Nurses on 8/2/12 at 2:40 p.m. There was not a handwritten TAR available until 8/2/12 at 2:45 p.m. Review of the facility's "Pressure Ulcer Protocol" policy, dated 9/10/10, revealed "A pressure ulcer is a localized injury to the skin &/or (and/or) underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear &/or friction... Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) &/or eschar (tan, brown, or black) in the wound bed. Until enough slough &/or eschar is removed to expose the base of the wound, the true depth, & therefore stage, cannot be determined..." Review of the facility's "Electronic Charting Policy", dated 4/1/10, revealed, "The following will be electronically documented: Physicians Orders, CNA (Certified Nurse Aide) documentation, MARs (medication administration records), Documentation of PRN (as needed) medications, TARs (treatment administration records), ADL (activities of daily living) records, I&O (input and output) records. "The procedure is "physician's orders [REDACTED]. Hard copies of records will be maintained at nurses (nurse's) desk in the event the computer crashes: MARs, TARs, ADL record, Food Intake Sheet. Hard copies will be only be used if computer crashes." The following information is quoted from the facility's AoC: "F 314 (1) Resident #2 The Nurse Practitioner was notified of the area on Resident #2's left foot on 8/02/12. The Nurse Practitioner checked Resident #2's foot and gave treatment orders for the area. The treatment was initiated on Resident #2 on 8/02/12. [MEDICATION NAME] was applied every shift as ordered. A copy of the treatment order for Resident #2 is included. A copy of the Treatment Record reflecting the treatment on 8/02/12 is included. The physician was notified on 8/03/12, concerning the unstageable area on the left plantar surface of Resident #2's foot and the treatment that was ordered by the Nurse Practitioner on 8/02/12. The area on Resident #2's foot was assessed by the Director of Nursing, the Nurse Consultant and the Registered Nurse Charge Nurse on the unit on 8/15/12. The dry black skin is not present at this time. The area presents as a callous. The Nurse Practitioner assessed the area on 8/15/12 and diagnosed the area as a callous. The Nurse Practitioner detailed the assessment in a progress note dated 8/15/12. A copy of the progress note by the Nurse Practitioner is included. (2) All Residents have the potential to be affected by the failure to ensure the necessary treatment to ensure the prevention of new pressure sores. A Braden Scale Assessment tool has been completed on all Residents to determine the risk factor for the development of pressure sores. Body audits were done on 8/02/12 on all Residents except for three (3) Residents that were in the hospital, one (1) Resident that was on therapeutic leave, and five (5) Residents that refused after two (2) attempts to do the audits. (3) An in-service for the Registered Nurses, the Licensed Practical Nurses and Certified Nurse Assistants, was conducted on 8/03/12 by the Assistant Director of Nursing. The in-service addressed skin assessments, weekly body audits, nail care, documentation and notification of the physician. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing skin assessments is included. Weekly body audits are being done by the Licensed Nurse on all Residents that will permit the audit to be done. The weekly body audits will be documented on the Weekly Body Audit form. A copy of the Weekly Body Audit form is included. The facility revised the Pressure Ulcer Policies and Protocols on 8/17/12. The policies revised include Daily Evaluation of Pressure Ulcer Policy, Pressure Ulcers Classification Policy, Pressure Ulcer Risk Assessment Policy and Daily Evaluation of Pressure Ulcer Policy. Protocols revised include Braden Scale Assessment Scale Protocol and Pressure Ulcer Protocol. The Pressure Ulcer Protocol addresses guidelines for preventive measures to be initiated for Residents assessed at high risk on the Braden Scale. All Resident assessed at high risk now have a total body audit twice weekly. The Licensed Practical Nurses and Registered Nurses were inserviced on the revised policies and protocols. Copies of the revised policies and protocols are included. A copy of the in-service addressing the revised policies is included. An in-service was done by the Nurse Practitioner for the Registered Nurses and Licensed Practical Nurses on 8/13/12. The in-service addressed Systemic Body Audits of the Resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION], obtaining orders for treatments needed. A copy of the in-service by the Nurse Practitioner is included. An in-service for the Certified Nurse Assistants was done by the Nurse Practitioner on 8/15/12, addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's order [REDACTED]. A copy of the in-service by the Nurse Practitioner is included. (4) The weekly body audits will be monitored by the Registered Nurse (RN) Charge Nurses on each unit. The Charge Nurses will review and sign the weekly body audit form. A copy of the Weekly Body Audit form is included. The Quality Assurance Committee met on 8/09/12, to discuss the plan of correction needed. The Quality Assurance Committee members attending this meeting included the Medical Director, the Administrator, The Director of Nursing, the Assistant Director of Nursing, the Nurse Practitioner, and the Quality Assurance Nurses. Any problems noted by continued monitoring will be presented to the Quality Assurance Committee as needed. The facility feels the Immediate Jeopardy has been removed as of 8/20/12." The validation of the AoC was accomplished through observation, staff interview, record review, and in-service review. Observation of six (6) skin assessments and five (5) restorative treatments verified that the facility has implemented a more through skin assessment and restorative program as indicated in the Allegation of compliance (AOC). Interviews with 16 Certified Nurses Aides (CNA), 10 Licensed Practical Nurses (LPN) and five (5) Registered Nurses (RN) verified that in-services had been done with staff regarding skin assessments, range of motion, pressure ulcers, following doctor orders and abuse/neglect. The staff interviewed were able to give details to each in-service. Review of the six (6) sampled resident records verified that skin assessments were documented, restorative treatments were observed weekly by the RN Charge nurses, care plans and doctor orders were followed as indicated in the AOC. Record review confirmed that two (2) restorative CNAs were counseled on 8/1/12 addressing Range of Motion and following physician's orders [REDACTED]. Policy/Procedure review for pressure ulcers and contractures did indicate changes in the policy/procedure as noted in the AOC. Review of in-services verified that the LPNs and RNs on the Yellow wing were in-serviced on 8/1/12 covering assessments, reporting changes, documentation and following physician's orders [REDACTED]. On 8/2/12 an in-service addressing the restorative procedure covering the Restorative Program policy, documentation and reporting changes in skin integrity and communication between the Restorative Certified Nurse and the Charge Nurse. This in-service was attended by Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. On 8/3/12, an in-service for the Registered Nurses, Licensed Practical Nurses and Certified Nurses Aides addressing skin assessments, weekly body audits, nail care, documentation and notification of the physician was done. "Any nurse who did not attend the in-service will not be allowed to work until in-serviced." An in-service on 8/6/12 and 8/7/12 covered following physician's orders [REDACTED]. This in-service was attended by RNs and LPNs and "any nurse who did not attend the in-service will not be allowed to work until in-serviced." On 8/7/12, an in-service for abuse/neglect and stress management was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, Dietary Personnel, Housekeeping and Laundry Personnel, Maintenance Personnel, Office Personnel and Administrative Staff. An in-service was done on 8/7/12 addressing nail assessment and nail care to be done weekly as part of the weekly body audit. RNs, LPNs and CNAs attended this in-service. An in-service on 8/8/12 to RNs and LPNs working on 8/8/12 on the 7-3 shift was done addressing following physician's orders [REDACTED]. On 8/10/12 and 8/14/12 an in-service was done addressing basic Restorative Technique. RN's, LPNs and CNAs attended this in-service. An in-service on 8/13/12 addressed systemic body audits of the resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION] and obtaining orders for treatments needed was given for RN's and LPN's. On 8/15/12 an in-service was given addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's orders [REDACTED]. In-service record review and employee roster verification confirmed these in-services listed above. Based on the facility's corrective actions that were validated by observation, staff interview, record review, and in-service review, the Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee.

Based on record review, observation, staff interview and policy review, the facility failed to provide the necessary care and services needed to attain and or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for one (1) of 10 residents reviewed. *Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." A complaint investigation, with a partially extended survey, was conducted from 8/1/12 to 8/7/12. During the investigation, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. A partially extended survey was conducted on 8/3/12 through 8/7/12. It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12. The facility submitted an Allegation of Compliance 8/4/12 at 6:30 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 8/7/12 at 12:00 p.m. and is considered ongoing. Findings include: Record review revealed that Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 3, indicating Resident #3's cognitive status was severely impaired. Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." Review of the POS [REDACTED]. Review of the Pre-Operative [DIAGNOSES REDACTED]. Review of the POS Same, circumferential abscess small finger with necrosis of flexor tendon, subcutaneous tissue and bone extending into palmar aspect of the hand with ulcerated open wound in the palm secondary to digital flexion contractures with nail erosion into the palm and flexion contractures of the long and ring finger... Operation: 1. Irrigation and debridement of digital abscess and amputation of left small finger. 2. Percutaneous flexor tendon tenotomy and manipulation of long and ring fingers." Review of physician's orders [REDACTED]." Review of the restorative treatment administrative record (TAR) from February 2012 through June 2012 revealed there was no documented evidence that Restorative treatment was provided to the bilateral hands of Resident #3. Review of the July 2012 Restorative TAR noted initials from 7/18/12 through 7/21/12 noted restorative treatment orders were followed. There are stars on each area where staff should initial that treatment was done from February 2012 through June 2012. Beginning in July 2012, there were handwritten x's through each blank until 7/17/12. From 7/17/12 through 7/21/12, there were initials. Review of Resident #3's care plan for "Limited ROM (range of motion)/weakness to bilateral fingers/wrist & (and) bilateral lower extremities" with an onset date of 12/03/11 revealed the goal to "maintain strength/ROM" and the approach was "ROM to bilateral fingers/wrist 5 days a week on 7-3 shift for 15 minutes." Interview on 8/2/12 at 10:10 a.m. with the Assistant Director of Nurses revealed, "There is not a set policy that says a nurse has to go and lay eyes on or observe (restorative) treatment. (Name of Resident #3) was on restorative for ROM (range of motion) to hands and lower extremities. It's the treatment nurse or medication nurse that does nail care. Nail care is not on a MAR (medication administration record) or TAR (treatment administration record). It's on an as needed basis. The stars on the Rehab/Restorative care TAR mean the treatment was blocked out and not scheduled to be done. In June it was x'd out by the computer. In July it was x'd out by staff. Resident #3 had ROM on fingers and wrist 5 days a week ordered. It can be any 5 days of the week then she went into the hospital 7/22/12." Interview on 8/2/12 at 1:05 p.m. with Certified Nurse Aide #1 revealed, "When we first got the orders, I did them but when the stars were on the Restorative TAR (treatment administration record) I thought the orders had been dc'd (discontinued) so I stopped it. I did not ask a nurse about it. I did wonder why the order kept showing up but I thought it was dc'd because the stars blocked the space where I would initial. So I didn't do the treatment." Interview on 8/3/12 at 8:45 a.m. with Certified Nurse Aide (CNA) #1 revealed when asked if she ever had a nurse come and watch her perform restorative on residents, CNA #1 stated, "No, mam. At times a nurse will ask me questions like how a resident is doing. Therapy doesn't ask. I tell the nurse if they have met their goal, we discuss it and if the goal is met, the resident will be dc'd (discontinued)." Interview on 8/3/12 at 9:15 a.m. with Certified Nurse Aide (CNA) #3 revealed "I've never had a nurse follow me and observe restorative treatments. They've never asked me about patients meeting goals. I've done this off and on for 2 years." Interview on 8/3/12 at 10:40 a.m. with Certified Nurse Aide #2 revealed, "On July 16 (2012), I gave her a bath. LPN (Licensed Practical Nurse) #7 said to wash her hand cause (because) there was dried blood on the side. I couldn't open her hand up to wash it cause it's so tight. The hand was not red or swollen. The only thing I saw was a small amount of dried blood on the side near her pinky finger. When in the shower, I called LPN #7 into the room to make sure that hand was what she was talking about. LPN #7 looked at it and said yes. I washed it the best I could. LPN #7 told me when I took Resident #3 back to her room to try and get a palm guard on or at least a towel in her hand. I've never used a palm guard. So I tried the towel. I told LPN #7 that I couldn't get the towel in her hand cause it was so tight. Resident #3's hand was a clenched fist. I had Resident #3 again Saturday and Sunday, July 21 and 22 (2012). I gave her a bed bath Saturday morning. Her hand was still tight but the hand wasn't swollen or red. On Sunday, I went down to her room about 9:30 or 10:00 a.m. I didn't see the hand swollen or red. It was still clenched tight. I didn't cut her/his nails that week. I don't remember if they were long or short. Close to 2:00 p.m., after lunch, I went to do my last rounds. That's when I saw her hand was swollen. It was red, light red, still clenched in a fist. I called the nurse's station. LPN #1 came to Resident #3's room. LPN #1 opened the hand so I could clean it. It wasn't opened all the way, but opened it enough to wash it. With the way LPN #1 was holding the hand open, I couldn't get a good look at it. I washed it and LPN #1 helped me put a gown on her. I saw no blood or pus on the wash rag or in the water." Interview on 8/7/12 at 3:05 p.m. with Licensed Practical Nurse #7 revealed, "I did go to CNA (Certified Nurse Aide) #2 and tell her to give Resident #3 a bath and wash her hand. The hand was sweaty. I didn't see any blood. It wasn't red or swollen, I'm not sure of the date. I went in after the bath and put her palm guards in. She had an old skin tear on top of right hand, no open area seen on left palm." Interview on 8/3/12 at 11:25 a.m. with Licensed Practical Nurse #1 revealed, "CNA (Certified Nurse Aide) #2 called the nurse's station and asked me to come look at Resident #3's hand. I wasn't assigned that hall that week so I hadn't seen her in a week. Her pinky was swollen, her hand was clenched. Her ring finger was swollen. Both fingers were hot and red. The top of the hand was warm to the wrist and pink, not red. It looked like a very small amount of dried serous drainage from small splits of each finger joint on her pinky. I picked her hand up, stretched out her fingers as far as I could. I told CNA #2 to get me a towel with warm soapy water. I saw nothing when I stretched out her fingers. There was no odor. Her long finger had a nail that was soft and would bend. I cut that nail. I didn't cut the pinky nail. It wasn't long. Her palm wasn't swollen. It did not have an open area. I was looking for open areas cause (because) it was so swollen. I just knew I'd see something cause the fingers were so swollen. I saw nothing. She did have a temp (temperature). She wasn't moaning. She didn't react when I stretched out her fingers and washed her hand. Before I even got the vital signs, I called for the charge nurse (name of RN #4). RN #4 said to start the transfer process. We got her out fast. The only open areas were the joints of her pinky and they were just cracks. I washed her palm and there was nothing on the towel. I pulled the pinky away from the palm. When I read the operative report, I couldn't believe it. I saw nothing like that." Interview on 8/6/12 at 11:00 a.m. with Registered Nurse #4, via the phone, revealed, "I went into Resident #3's room to assess her hand. It was cherry red with 4 plus [MEDICAL CONDITION]. I was scared to touch it. It was very hot. I didn't want to open her hand because I didn't know if there was a fracture and I didn't want to cause any further damage. I didn't see any drainage. Resident #3 was moaning. I immediately called her doctor and got an ambulance. I didn't see the fingernail unless I lifted her finger. I didn't move it." Record review revealed that Resident #3's medical doctor was notified and ordered the transfer to the local hospital for evaluation and treatment. Resident #3 was transferred to the hospital on [DATE] at 2:55 p.m. by ambulance. Interview on 8/7/12 at 10:30 a.m. with the Resident #3's physician, who is also the Medical Director, regarding if the orders for range of motion had been followed, could it have prevented the nail growing into the palm revealed, the physician stated, "It might not have occurred if range of motion was done..." Review of the facility's "Restorative Nursing Programs" policy, revised 2/11/05, revealed, "All residents will be evaluated for participation in Restorative Nursing Programs following admission. Participation in Restorative Programs will be reflected in the Resident Plan of Care ...4. Provide follow-up evaluation every 30 days by Charge Nurse while the resident remains on the program. 5. Resident Plan of Care will be updated appropriately ..."

Based on record review, observation, staff interview and policy review, the facility failed to provide the necessary care and services needed to attain and or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for one (1) of 10 residents reviewed. *Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." A complaint investigation was conducted from 8/1/12 to 8/4/12, 8/7/12. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at his time. The Immediate Jeopardy was determined to begin on 7/22/12. The facility submitted an Allegation of Compliance 8/4/12 at 6:30 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 8/7/12 at 12:00 p.m. and is considered ongoing. Findings include: Cross refer to F-309 for failure of the facility to follow the resident's care plan for restorative care. Review of Resident #3's care plan for "Limited ROM (range of motion)/weakness to bilateral fingers/wrist & (and) bilateral lower extremities" with an onset date of 12/03/11 revealed the goal to "maintain strength/ROM" and the approach was "ROM to bilateral fingers/wrist 5 days a week on 7-3 shift for 15 minutes." Review of the facility's "Restorative Nursing Programs" policy, revised 2/11/05, revealed, "All residents will be evaluated for participation in Restorative Nursing Programs following admission. Participation in Restorative Programs will be reflected in the Resident Plan of Care ...4. Provide follow-up evaluation every 30 days by Charge Nurse while the resident remains on the program. 5. Resident Plan of Care will be updated appropriately ..."

Based on record review, observation, staff interview and policy review, the facility failed to follow follow the physician's orders to provide the necessary care and services needed to attain and or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for one (1) of 10 residents reviewed. *Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." (Resident #3). It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12 and was removed on 08/20/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrrective actions implemented by the facility have been able to demonstrate removal of the immediate jeopardy. The validation of the Allegation of Compliance (AoC) was accomplished through observation, staff interview, and record review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings include: Cross refer to F-309 for the failure of the facility to follow physician's orders. Review of physician's orders from January 1, 2012 through July 31, 2012 revealed an order, dated 12/03/11, for "Restorative to see for Range of Motion (ROM) to bilateral fingers/wrist 5 days a week on 7-3 shift for 15 minutes related to bilateral contracters." Review of the restorative treatment administrative record (TAR) from February 2012 through June 2012 revealed there was no documented evidence that Restorative treatment was provided to the bilateral hands of Resident #3. Review of the July 2012 Restorative TAR noted initials from 7/18/12 through 7/21/12 noted restorative treatment orders were followed. There are stars on each area where staff should initial that treatment was done from February 2012 through June 2012. Beginning in July 2012, there were handwritten x's through each blank until 7/17/12. From 7/17/12 through 7/21/12, there were initials. The following information was submitted in the facility's credible Allegation of Compliance and is quoted as follows: "F-281 Cross Refer to F 309 (1) Resident #3 On 7/22/12, Resident #3 was admitted to the hospital related to [MEDICAL CONDITION], redness, and warmth in left hand and wrist. Resident #3 was diagnosed with [REDACTED]. Resident #3's left small finger was amputated on 7/23/12. Resident #3 was discharged from the facility on 7/31/12. The two Certified Nurse Assistants (CNAs) responsible for the Restorative care on Resident #3 received employee counseling by the Registered Nurse supervisor on Yellow Wing. The counseling was done on 8/01/12 and addressed the range of motion that was ordered on Resident #3 and following physician ' s orders. Copies of the counseling forms for the 2 Restorative CNAs are included. (2) All Residents have the potential to be affected by the failure to follow physician's orders. On 8/01/12, a visual check of hands, fingernails, and skin integrity of the hands was done on all Residents in the facility. The visual checks were done by the Director of Nursing, the Assistant Director of Nursing, 2 Registered Nurses and 2 Licensed Practical Nurses. The Residents hands were checked for contractures, skin problems, cleanliness of hands, and fingernails. No new contractures and no new skin problems were identified. Several Residents did need nail care which was provided on 8/01/12. Documentation of the checks were given to the surveyor at that time. Body audits were done on 8/02/12 on all Residents except for three (3) Residents that were in the hospital, one (1) Resident that was on therapeutic leave, and five (5) Residents that refused after two (2) attempts to do the audits. On 8/06/12, five (5) Practical Nurses began reviewing all physician orders. The orders were reviewed for accuracy of content. All hand written orders were entered into the computer. The orders were compared to the Medication Administration Record [REDACTED]. The Nurse Practitioner assisted with the review. The Registered Nurse Charge Nurses compared the orders to the Activities of Daily Living (ADL) Care Plans. The Minimum Data Set (MDS) Nurses reviewed the Comprehensive Care Plans to ensure all pertinent orders had been addressed on the total care plan. The process concluded on 8/13/12 when all orders had been reviewed. On 8/06/12, the Registered Nurse Charge Nurses reviewed the Residents who receive Restorative Care. The Certified Nurse Assistants (CNA) were observed while performing the Restorative Care to ensure that the CNAs are following the Restorative orders. On 8/09/12 and 8/10/12, the three (3) Registered Nurse Charge Nurses did body audits on the Residents during the Resident ' s bath. No new problems identified during these body audits. (3) An in-service was done by the Director of Nursing on 8/01/12, with the Registered Nurses and Licensed Practical Nurses who worked Yellow Wing and provided care for Resident #3 from 7/19/12 until the Resident was transferred to the hospital. The in-service covered assessments, reporting changes, documentation and following physician's orders. A copy of the in-service with the Yellow Wing Nurses is included. In addition, all nurses have been inserviced on skin assessments, reporting changes, documentation and following physician ' s orders The facility initiated a new policy addressing contractures on 8/09/12. The policy addressed the care of the contractured extremity as well as devices to be used as ordered. A copy of the Contracture Policy is included. Weekly body audits are being done by the Licensed Nurse on all Residents that will permit the audit to be done. The weekly body audits will be documented on the Weekly Body Audit form. A copy of the Weekly Body Audit form is included. The facility revised the Pressure Ulcer Policies and Protocols on 8/17/12. The policies revised include Daily Evaluation of Pressure Ulcer Policy, Pressure Ulcers Classification Policy, Pressure Ulcer Risk Assessment Policy and Daily Evaluation of Pressure Ulcer Policy. Protocols revised include Braden Scale Assessment Scale Protocol and Pressure Ulcer Protocol. The Pressure Ulcer Protocol addresses guidelines for preventive measures to be initiated for Residents assessed at high risk on the Braden Scale. All Resident assessed at high risk now have a total body audit twice weekly. The Licensed Practical Nurses and Registered Nurses were inserviced on the revised policies and protocols. Copies of the revised policies and protocols are included. A copy of the in-service addressing the revised policies is included. An in-service was done on 8/02/12, by the Assistant Director of Nursing addressing Restorative Procedure covering the Restorative Program policy, documentation, reporting changes in skin integrity, and communication between the Restorative Certified Nurse and the Charge Nurse. The in-service was attended by the Registered Nurses, the Licensed Practical Nurses, and the Certified Nurse Assistants. A copy of the in-service addressing the Restorative Program is included. An in-service for the Registered Nurses, the Licensed Practical Nurses and Certified Nurse Assistants, was conducted on 8/03/12 by the Assistant Director of Nursing. The in-service addressed skin assessments, weekly body audits, nail care, documentation and notification of the physician. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing skin assessments is included. On 8/03/12, an in-service was done by the Registered Nurse Staff Development addressing neglect. The in-service was presented to the nursing staff including Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants (CNA). Any nurse or CNA who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing neglect is included. An in-service was done on 8/06/12 and 8/07/12, by the Assistant Director of Nursing addressing following physician ' s orders, computer printed orders, and auditing the orders each month. The in-service was attended by Registered Nurses and Licensed Practical Nurses. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing following the physician ' s orders is included. On 8/7/12, an in-service was conducted by a Certified Mental Health Therapist who is the Director of Silver Services at the local regional mental health center addressing abuse, neglect and stress management. The in-service was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, dietary personnel, housekeeping and laundry personnel, maintenance personnel, office personnel and administrative staff. A copy of the in-service addressing abuse and neglect is included. An in-service was done on 8/07/12 by the Registered Nurse Staff Development addressing nail assessments and nail care to be done weekly as a part of the weekly body audit. The Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants attended the in-service. A copy of the in-service addressing nail assessments and nail care is included. An in-service was done on 8/08/12 by the Nurse Consultant to the Registered Nurses and Licensed Practical Nurses who were working on 8/08/12 on 7-3 shift. The in-service addressed following physician ' s orders , falsification of documentation, body audits and pressure sores. A copy of the in-service by the Nurse Consultant is included. An in-service addressing basic Restorative Technique was presented by the Therapy Company to the Registered Nurses, Licensed Practical Nurses and Certified Nurse Assistants. The in-service was done on 8/10/12 and on 8/14/12. A copy of the in-service by the Therapy Company is included. An in-service was done by the Nurse Practitioner for the Registered Nurses and Licensed Practical Nurses on 8/13/12. The in-service addressed Systemic Body Audits of the Resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION], obtaining orders for treatments needed. A copy of the in-service by the Nurse Practitioner is included. An in-service for the Certified Nurse Assistants was done by the Nurse Practitioner on 8/15/12, addressing alteration of normal skin, types of [MEDICAL CONDITION] , reporting changes, following physician ' s orders, false documentation and failure to provide proper care to the Residents. A copy of the in-service by the Nurse Practitioner is included. (4) The weekly body audits will be monitored by the Registered Nurse (RN) Charge Nurses on each unit. The Charge Nurses will review and sign the weekly body audit form. A copy of the Weekly Body Audit form is included. The Registered Nurse Charge Nurses monitor the Restorative Program by observing the Restorative Certified Nurse Assistant performing Restorative Care on each Resident requiring Restorative treatment. The monitoring on each Resident in Restorative will be done at least weekly. Daily, Monday through Friday, except holidays, the Registered Nurse Charge Nurses review all new orders that were received the prior day. On Monday, the orders that were received on Friday and on the week-end are reviewed. The orders taken on holidays are reviewed the next working day. The Charge Nurses check the accuracy of the order and check to ensure that the order was transcribed to the appropriate documentation form (Medication Administration Record, [REDACTED]. Any discrepancies noted are corrected by the Charge Nurses. The review is given to the appropriate Minimum Data Set (MDS)/Care Plan Nurse. The MDS Nurse also checks for accuracy and addresses on the care plan if needed. The MDS then gives the order review to the Director of Nursing. The Director of Nursing takes appropriate action for the incorrect orders that were noted. The Director of Nursing maintains the daily reviews in a file. Any discrepancies noted are presented to the monthly Quality Assurance Committee meeting for review. The facility called an emergency Quality Assurance Committee meeting on 8/03/12 to address the Immediate Jeopardy issues. The Quality Assurance Committee met again on 8/09/12, to discuss the plan of correction needed. The Quality Assurance Committee members attending this meeting included the Medical Director, the Administrator, The Director of Nursing, the Assistant Director of Nursing, the Nurse Practitioner, and the Quality Assurance Nurses. Any problems noted by continued monitoring will be presented to the Quality Assurance Committee as needed. The facility feels the Immediate Jeopardy has been removed as of 8/20/12." The validation of the Allegation of Compliance (AoC) was accomplished through observation, staff interview, record review, and in-service review Observation of six (6) skin assessments and five (5) restorative treatments verified that the facility has implemented a more through skin assessment and restorative program as indicated in the Allegation of compliance (AOC). Interviews with 16 Certified Nurses Aides (CNA), 10 Licensed Practical Nurses (LPN) and five (5) Registered Nurses (RN) verified that in-services had been done with staff regarding skin assessments, range of motion, pressure ulcers, following doctor orders and abuse/neglect. The staff interviewed were able to give details to each in-service. Review of the six (6) sampled resident records verified that skin assessments were documented, restorative treatments were observed weekly by the RN Charge nurses, care plans and doctor orders were followed as indicated in the AOC. Record review confirmed that two (2) restorative CNAs were counseled on 8/1/12 addressing Range of Motion and following physician's orders. Policy/Procedure review for pressure ulcers and contractures did indicate changes in the policy/procedure as noted in the AoC. Review of in-services verified that the LPNs and RNs on the Yellow wing were in-serviced on 8/1/12 covering assessments, reporting changes, documentation and following physician's orders. On 8/17/12, the licensed practical nurses and registered were in-serviced on the revised policies and procedures regarding Pressure Ulcers. On 8/2/12 an in-service addressing the restorative procedure covering the Restorative Program policy, documentation and reporting changes in skin integrity and communication between the Restorative Certified Nurse and the Charge Nurse. This in-service was attended by Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. On 8/3/12, an in-service for the Registered Nurses, Licensed Practical Nurses and Certified Nurses Aides addressing skin assessments, weekly body audits, nail care, documentation and notification of the physician was done. "Any nurse who did not attend the in-service will not be allowed to work until in-serviced." An in-service on 8/6/12 and 8/7/12 covered following physician's orders, computer printed orders and auditing the order each month. This in-service was attended by RNs and LPNs and "any nurse who did not attend the in-service will not be allowed to work until in-serviced." On 8/7/12, an in-service for abuse/neglect and stress management was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, Dietary Personnel, Housekeeping and Laundry Personnel, Maintenance Personnel, Office Personnel and Administrative Staff. An in-service was done on 8/7/12 addressing nail assessment and nail care to be done weekly as part of the weekly body audit. RNs, LPNs and CNAs attended this in-service. An in-service on 8/8/12 to RNs and LPN's working on 8/8/12 on the 7-3 shift was done addressing following physician's orders, falsification of documentation, body audits and pressure sores. On 8/10/12 and 8/14/12 an in-service was done addressing basic Restorative Technique. RNs, LPNs and CNAs attended this in-service. An in-service on 8/13/12 addressed systemic body audits of the resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION] and obtaining orders for treatments needed was given for RNs and LPNs. On 8/15/12 an in-service was given addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's orders, false documentation and failure to provide proper care to the resident to CNAs. In-service record review and employee roster verification confirmed these in-services listed above. Based on the facility's corrective actions that were validated by observation, staff interview, record review, and in-service review the Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee.

Based on record review, observation, staff interview and policy review, the facility failed to follow follow the physician's orders to provide the necessary care and services needed to attain and or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for one (1) of 10 residents reviewed. *Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." A complaint investigation, with a partially extended survey, was conducted from 8/1/12 to 8/7/12. During the investigation, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. A partially extended survey was conducted on 8/3/12 through 8/7/12. It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12. The facility submitted an Allegation of Compliance 8/4/12 at 6:30 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 8/7/12 at 12:00 p.m. and is considered ongoing. Findings include: Cross refer to F-309 for the failure of the facility to follow physician's orders. Review of physician's orders from January 1, 2012 through July 31, 2012 revealed an order, dated 12/03/11, for "Restorative to see for Range of Motion (ROM) to bilateral fingers/wrist 5 days a week on 7-3 shift for 15 minutes related to bilateral contracters." Review of the restorative treatment administrative record (TAR) from February 2012 through June 2012 revealed there was no documented evidence that Restorative treatment was provided to the bilateral hands of Resident #3. Review of the July 2012 Restorative TAR noted initials from 7/18/12 through 7/21/12 noted restorative treatment orders were followed. There are stars on each area where staff should initial that treatment was done from February 2012 through June 2012. Beginning in July 2012, there were handwritten x's through each blank until 7/17/12. From 7/17/12 through 7/21/12, there were initials.

Based on record review, observation, staff interview and policy review, the facility failed to provide the necessary care and services needed to attain and or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for one (1) of 10 residents reviewed. *Review of nurse's notes, dated 7/22/12 at 2:30 p.m., revealed Registered Nurse #4 documented "[MEDICAL CONDITION] noted to left (L) hand and wrist. Area is cherry red and warm to touch. Subj s/s (subject signs/symptoms) of pain noted by moaning." It was determined that an Immediate Jeopardy was identified on 8/3/12 at 10:30 a.m. and the Administrator and Director of Nurses were notified at this time. The Immediate Jeopardy was determined to begin on 7/22/12 and was removed on 08/20/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrrective actions implemented by the facility have been able to demonstrate removal of the immediate jeopardy. The validation of the Allegation of Compliance (AoC) was accomplished through observation, staff interview, record review, and in-service review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings include: Cross refer to F-309 for failure of the facility to follow the resident's care plan for restorative care. Review of Resident #3's care plan for "Limited ROM (range of motion)/weakness to bilateral fingers/wrist & (and) bilateral lower extremities" with an onset date of 12/03/11 revealed the goal to "maintain strength/ROM" and the approach was "ROM to bilateral fingers/wrist 5 days a week on 7-3 shift for 15 minutes." Review of the facility's "Restorative Nursing Programs" policy, revised 2/11/05, revealed, "All residents will be evaluated for participation in Restorative Nursing Programs following admission. Participation in Restorative Programs will be reflected in the Resident Plan of Care ...4. Provide follow-up evaluation every 30 days by Charge Nurse while the resident remains on the program. 5. Resident Plan of Care will be updated appropriately ..." The following information was submitted in the faciltiy's AOC and is quoted as follows: "F 279 Cross Refer to F 309 (1) Resident #2 The Nurse Practitioner was notified of the area on Resident #2's left foot on 8/02/12. The Nurse Practitioner checked Resident #2's foot and gave treatment orders for the area. The treatment was initiated on Resident #2 on 8/02/12. [MEDICATION NAME] was applied every shift as ordered. A copy of the treatment order for Resident #2 is included. A copy of the Treatment Record reflecting the treatment on 8/02/12 is included. The physician was notified on 8/03/12, concerning the unstageable area on the left plantar surface of Resident #2's foot and the treatment that was ordered by the Nurse Practitioner on 8/02/12. The area on Resident #2's foot was assessed by the Director of Nursing, the Nurse Consultant and the Registered Nurse Charge Nurse on the unit on 8/15/12. The dry black skin is not present at this time. The area presents as a callous. The Nurse Practitioner assessed the area on 8/15/12 and diagnosed the area as a callous. The Nurse Practitioner detailed the assessment in a progress note dated 8/15/12. A copy of the progress note by the Nurse Practitioner is included. Resident #3 On 7/22/12, Resident #3 was admitted to the hospital related to [MEDICAL CONDITION], redness, and warmth in left hand and wrist. Resident #3 was diagnosed with [REDACTED]. Resident #3's left small finger was amputated on 7/23/12. Resident #3 was discharged from the facility on 7/31/12. The two Certified Nurse Assistants (CNAs) responsible for the Restorative care on Resident #3 received employee counseling by the Registered Nurse supervisor on Yellow Wing. The counseling was done on 8/01/12 and addressed the range of motion that was ordered on Resident #3 and following physician's order [REDACTED]. Copies of the counseling forms for the 2 Restorative CNAs are included. (2) All Residents have the potential to be affected by the failure to follow the Residents plan of care. On 8/01/12, a visual check of hands, fingernails, and skin integrity of the hands was done on all Residents in the facility. The visual checks were done by the Director of Nursing, the Assistant Director of Nursing, 2 Registered Nurses and 2 Licensed Practical Nurses. The Residents hands were checked for contractures, skin problems, cleanliness of hands, and fingernails. No new contractures and no new skin problems were identified. Several Residents did need nail care which was provided on 8/01/12. Documentation of the checks were given to the surveyor at that time. Body audits were done on 8/02/12 on all Residents except for three (3) Residents that were in the hospital, one (1) Resident that was on therapeutic leave, and five (5) Residents that refused after two (2) attempts to do the audits. On 8/06/12, five (5) Practical Nurses began reviewing all physician orders. The orders were reviewed for accuracy of content. All hand written orders were entered into the computer. The orders were compared to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurse Practitioner assisted with the review. The Registered Nurse Charge Nurses compared the orders to the Activities of Daily Living (ADL) Care Plans. The Minimum Data Set (MDS) Nurses reviewed the Comprehensive Care Plans to ensure all pertinent orders had been addressed on the total care plan. The process concluded on 8/13/12 when all orders had been reviewed. On 8/06/12, the Registered Nurse Charge Nurses reviewed the Residents who receive Restorative Care. The Certified Nurse Assistants (CNA) were observed while performing the Restorative Care to ensure that the CNAs are following the Restorative orders. On 8/09/12 and 8/10/12, the three (3) Registered Nurse Charge Nurses did body audits on the Residents during the Resident ' s bath. No new problems identified during these body audits. (3) An in-service was done by the Director of Nursing on 8/01/12, with the Registered Nurses and Licensed Practical Nurses who worked Yellow Wing and provided care for Resident #3 from 7/19/12 until the Resident was transferred to the hospital. The in-service covered assessments, reporting changes, documentation and following physician's order [REDACTED]. A copy of the in-service with the Yellow Wing Nurses is included. In addition, all nurses have been inserviced on skin assessments, reporting changes, documentation and following physician's order [REDACTED]. The facility initiated a new policy addressing contractures on 8/09/12. The policy addressed the care of the contractured extremity as well as devices to be used as ordered. A copy of the Contracture Policy is included. Weekly body audits are being done by the Licensed Nurse on all Residents that will permit the audit to be done. The weekly body audits will be documented on the Weekly Body Audit form. A copy of the Weekly Body Audit form is included. The facility revised the Pressure Ulcer Policies and Protocols on 8/17/12. The policies revised include Daily Evaluation of Pressure Ulcer Policy, Pressure Ulcers Classification Policy, Pressure Ulcer Risk Assessment Policy and Daily Evaluation of Pressure Ulcer Policy. Protocols revised include Braden Scale Assessment Scale Protocol and Pressure Ulcer Protocol. The Pressure Ulcer Protocol addresses guidelines for preventive measures to be initiated for Residents assessed at high risk on the Braden Scale. All Resident assessed at high risk now have a total body audit twice weekly. The Licensed Practical Nurses and Registered Nurses were inserviced on the revised policies and protocols. Copies of the revised policies and protocols are included. A copy of the in-service addressing the revised policies is included. An in-service was done on 8/02/12, by the Assistant Director of Nursing addressing Restorative Procedure covering the Restorative Program policy, documentation, reporting changes in skin integrity, and communication between the Restorative Certified Nurse and the Charge Nurse. The in-service was attended by the Registered Nurses, the Licensed Practical Nurses, and the Certified Nurse Assistants. A copy of the in-service addressing the Restorative Program is included. An in-service for the Registered Nurses, the Licensed Practical Nurses and Certified Nurse Assistants, was conducted on 8/03/12 by the Assistant Director of Nursing. The in-service addressed skin assessments, weekly body audits, nail care, documentation and notification of the physician. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing skin assessments is included. On 8/03/12, an in-service was done by the Registered Nurse Staff Development addressing neglect. The in-service was presented to the nursing staff including Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants (CNA). Any nurse or CNA who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing neglect is included. An in-service was done on 8/06/12 and 8/07/12, by the Assistant Director of Nursing addressing following physician's order [REDACTED]. The in-service was attended by Registered Nurses and Licensed Practical Nurses. Any nurse who did not attend the in-service will not be allowed to work until in-serviced. A copy of the in-service addressing following the physician's order [REDACTED]. On 8/7/12, an in-service was conducted by a Certified Mental Health Therapist who is the Director of Silver Services at the local regional mental health center addressing abuse, neglect and stress management. The in-service was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, dietary personnel, housekeeping and laundry personnel, maintenance personnel, office personnel and administrative staff. A copy of the in-service addressing abuse and neglect is included. An in-service was done on 8/07/12 by the Registered Nurse Staff Development addressing nail assessments and nail care to be done weekly as a part of the weekly body audit. The Registered Nurses, Licensed Practical Nurses and the Certified Nurse Assistants attended the in-service. A copy of the in-service addressing nail assessments and nail care is included. An in-service was done on 8/08/12 by the Nurse Consultant to the Registered Nurses and Licensed Practical Nurses who were working on 8/08/12 on 7-3 shift. The in-service addressed following physician's order [REDACTED]. A copy of the in-service by the Nurse Consultant is included. An in-service addressing basic Restorative Technique was presented by the Therapy Company to the Registered Nurses, Licensed Practical Nurses and Certified Nurse Assistants. The in-service was done on 8/10/12 and on 8/14/12. A copy of the in-service by the Therapy Company is included. An in-service was done by the Nurse Practitioner for the Registered Nurses and Licensed Practical Nurses on 8/13/12. The in-service addressed Systemic Body Audits of the Resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION], obtaining orders for treatments needed. A copy of the in-service by the Nurse Practitioner is included. An in-service for the Certified Nurse Assistants was done by the Nurse Practitioner on 8/15/12, addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's order [REDACTED]. A copy of the in-service by the Nurse Practitioner is included. (4) The weekly body audits will be monitored by the Registered Nurse (RN) Charge Nurses on each unit. The Charge Nurses will review and sign the weekly body audit form. A copy of the Weekly Body Audit form is included. The Registered Nurse Charge Nurses monitor the Restorative Program by observing the Restorative Certified Nurse Assistant performing Restorative Care on each Resident requiring Restorative treatment. The monitoring on each Resident in Restorative will be done at least weekly. Daily, Monday through Friday, except holidays, the Registered Nurse Charge Nurses review all new orders that were received the prior day. On Monday, the orders that were received on Friday and on the week-end are reviewed. The orders taken on holidays are reviewed the next working day. The Charge Nurses check the accuracy of the order and check to ensure that the order was transcribed to the appropriate documentation form (Medication Administration Record, [REDACTED]. Any discrepancies noted are corrected by the Charge Nurses. The review is given to the appropriate Minimum Data Set (MDS)/Care Plan Nurse. The MDS Nurse also checks for accuracy and addresses on the care plan if needed. The MDS then gives the order review to the Director of Nursing. The Director of Nursing takes appropriate action for the incorrect orders that were noted. The Director of Nursing maintains the daily reviews in a file. Any discrepancies noted are presented to the monthly Quality Assurance Committee meeting for review. The facility called an emergency Quality Assurance Committee meeting on 8/03/12 to address the Immediate Jeopardy issues. The Quality Assurance Committee met again on 8/09/12, to discuss the plan of correction needed. The Quality Assurance Committee members attending this meeting included the Medical Director, the Administrator, The Director of Nursing, the Assistant Director of Nursing, the Nurse Practitioner, and the Quality Assurance Nurses. Any problems noted by continued monitoring will be presented to the Quality Assurance Committee as needed. The facility feels the Immediate Jeopardy has been removed as of 8/20/12." The validation of the Allegation of Compliance (AoC) was accomplished through observation, staff interview, record review, and in-service review. Observation of six (6) skin assessments and five (5) restorative treatments verified that the facility has implemented a more through skin assessment and restorative program as indicated in the Allegation of compliance (AOC). Interviews with 16 Certified Nurses Aides (CNAs), 10 Licensed Practical Nurses (LPNs) and five (5) Registered Nurses (RNs) verified that in-services had been done with staff regarding skin assessments, range of motion, pressure ulcers, following doctor orders and abuse/neglect. The staff interviewed were able to give details to each in-service. Review of the six (6) sampled resident records verified that skin assessments were documented, restorative treatments were observed weekly by the RN Charge nurses, care plans and doctor orders were followed as indicated in the AOC. Record review confirmed that two (2) restorative CNAs were counseled on 8/1/12 addressing Range of Motion and following physician's orders [REDACTED]. Policy/Procedure review for pressure ulcers and contractures did indicate changes in the policy/procedure as noted in the AOC. Review of in-services verified that the LPNs and RNs on the Yellow wing were in-serviced on 8/1/12 covering assessments, reporting changes, documentation and following physician's orders [REDACTED]. On 8/2/12 an in-service addressing the restorative procedure covering the Restorative Program policy, documentation and reporting changes in skin integrity and communication between the Restorative Certified Nurse and the Charge Nurse. This in-service was attended by Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. On 8/3/12, an in-service for the Registered Nurses, Licensed Practical Nurses and Certified Nurses Aides addressing skin assessments, weekly body audits, nail care, documentation and notification of the physician was done. "Any nurse who did not attend the in-service will not be allowed to work until in-serviced." An in-service on 8/6/12 and 8/7/12 covered following physician's orders [REDACTED]. This in-service was attended by RNs and LPNs and "any nurse who did not attend the in-service will not be allowed to work until in-serviced." On 8/7/12, an in-service for abuse/neglect and stress management was presented to all staff including Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, Social Services, Activities, Dietary Personnel, Housekeeping and Laundry Personnel, Maintenance Personnel, Office Personnel and Administrative Staff. An in-service was done on 8/7/12 addressing nail assessment and nail care to be done weekly as part of the weekly body audit. RNs, LPNs and CNAs attended this in-service. An in-service on 8/8/12 to RNs and LPNs working on 8/8/12 on the 7-3 shift was done addressing following physician's orders [REDACTED]. On 8/10/12 and 8/14/12 an in-service was done addressing basic Restorative Technique. RNs, LPNs and CNAs attended this in-service. An in-service on 8/13/12 addressed systemic body audits of the resident, documentation of the body audits, documentation of [MEDICAL CONDITION], review of proper notification of [MEDICAL CONDITION] and obtaining orders for treatments needed was given for RNs and LPNs. On 8/15/12 an in-service was given addressing alteration of normal skin, types of [MEDICAL CONDITION], reporting changes, following physician's orders [REDACTED]. In-service record review and employee roster verification confirmed these in-services listed above. Based on the facility's corrective actions that were validated by observation, staff interview, record review, an in-service review, the Immediate Jeopardy was determined to be removed on 08/20/12. The facility remained out of compliance at a Scope and Severity of "D", isolated deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the faciltiy's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee.

CI MS # Part1 Based on observation, interview, record review and policy review the facility failed to ensure accurate procedures for dispensing, administration, reconciliation and documentation of narcotics for 11 of 15 residents reviewed who received pain medications, Residents #4, #11, #13, #14, #15, #16, #17, #18, #19, #20 and #21. Interview with Resident #15, #16 and #17 revealed that they did not receive pain medication that was signed out for them by LPN #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. There were documentation discrepancies in the narcotic records noted for 10 residents, Resident #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21 which included narcotics that were signed out and not documented on the Medication Administration Record and discrepancies in the times that narcotics were administered. The facility's failure to ensure that accurate procedures for dispensing, administering, reconciliation and documentation of narcotics was identified as an Immediate Jeopardy (IJ) on 3/15/12. The IJ began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the IJ on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to a " D " level which constitutes no actual harm with potential for more than minimal harm. Findings include: Cross refer to F224 for the facilities failure to ensure accurate procedures for dispensing, administration and documentation of narcotics and narcotic records for 11 of 15 residents as evidenced by no documentation on the Medication Administration Record for narcotics that were signed out for Resident #14, #15, #16, #17, #18, and #20; Residents #15, #16, and #17 denial of receiving medication that was signed out; and detail Administration Reports with discrepancies of when the actual narcotics were administered to Resident #4, #13, #14, #18, #19 and #21. There were also patterns on the Individual Sedative Records where LPN #1 and LPN #2 signed out narcotics to residents who normally didn ' t receive them. Credible Allegation of Compliance: "This is to serve as the credible allegation of compliance (AOC) for the incident involving Licensed Practical Nurse (LPN) #1 as reported to the State Board of Nursing on January 5, 2012, Licensed Practical Nurse (LPN) #2 as investigated by Attorney General (AG) Investigator #1 and Attorney General (AG) Investigator #2 on March 8, 2012 and March 9, 2012, and Licensed Practical Nurse (LPN) #3 as investigated on March 12, 2012. Director of Nursing (DON) received a report on 1/3/12 that LPN #1, was signing out narcotics on the sedative record but not documenting the medication on the medication administration record (MAR) when administered or the nurses notes, five (5) Residents were identified with discrepancies in narcotic administration/documentation by LPN #1. Those Residents identified were Resident #15, Resident #16, Resident #17, Resident #18 and Resident #20. On 1/3/12, a urine drug screen was done on LPN #1 at 3:45 PM. The drug screen was positive for Amphetamine, Benzodiazepine, Opiate and Oxycodone. LPN #1 had a prescription for Hydrocodone dated 11/15/11 for 40 pills with no refill. LPN #1 could not explain the positive drug screen. LPN #1 stated she was not aware that she needed to chart the medication on the MAR. LPN #1 was placed on suspension and ultimately terminated on 2/1/12 for failing drug test and for suspect for possible misappropriation of Resident property. On 1/4/12 the DON informed the Administrator and the Pharmacy Consultant of the possible problem with the narcotic documentation. Resident #18 and Resident #20 were not interviewable. On 1/4/12, Resident #15, Resident #16, and Resident #17 were interviewed by LPN #2 and LPN #4 concerning pain medication administration. Resident #15 and Resident #17 said they had not received the narcotic medications. Resident #16 said she had only taken one of the "strong pain pills" lately and had slept all day after taking the pill. The Quality Assurance Nurse, LPN #3 conducted a spot check on 1/5/12 on all 6 medications carts to review the documentation of PRN narcotic medications and no other problems were reported to the DON at that time. At approximately 11 AM, on 1/5/12, the DON called the State Board of Nursing and left a message. On 1/6/2012 at 9 AM, the Director of Nursing contacted the Board of Nursing Investigator #1 at the State Board of Nursing and reported the possible problem with the narcotics and supplied all the information requested b the State Board of Nursing. Board of Nursing Investigator #1 informed the DON that he would notify the appropriate entities. The DON asked the Board of Nursing Investigator #1 if she needed to report to any other agency and was told no, he would do that. The DON informed the Administrator of the conversation with the State Board of Nursing. On 2/1/12, LPN #1 was terminated from employment with the facility for failing drug test. Incident of LPN #1 signing out narcotic medications but not documenting medications was given was not reported to the State department of Health or Attorney General's office at that time. The State Department of Health was notified on 3/15/12 by the Administrator that LPN #1 was signing out narcotics on the Individual Sedative Record but no documentation that the medication was administered to the Resident and she failed her drug test. On Thursday, March 8, 2012, AG Investigator #1 presented himself at the facility and talked with the Administrator and Assistant Administrator regarding an anonymous complaint that had been registered against LPN #2. The facility had no prior knowledge of an incident involving LPN #2. He produced several documents which were not reviewable by the Administrator or Assistant Administrator. AG Investigator #1 did not share with us how he intended to conduct the investigation so we made ourselves available. On 3/8/12 at approximately 2 PM, the DON reviewed ten (10) Resident narcotic records that AG Investigator #1 requested. Six (6) Residents were identified with discrepancies of narcotic administration/documentation by LPN #2. Residents identified were Resident #4, Resident #13, Resident #14, Resident #18, Resident #19 and Resident #21. AG Investigator #2 arrived on Friday 3/9/12 to assist AG Investigator #1. About mid afternoon on 3/9/12, AG Investigator #1 contacted the Administrator and asked if he, the Director of Nursing or Assistant Administrator could come to the conference room. LPN #2 had signed a written confession that she had taken some of the controlled drugs that were in question regarding the investigation. The Residents identified in the written confession from LPN #2 were Resident #4, Resident #13, Resident #14 and Resident #11. Due to the cognitive status of these Residents, interview of the Residents was not possible. At that time, both AG Investigator #1 and #2 left the room and only the Administrator and Assistant Administrator and LPN #2 were in the room. The Administrator asked LPN #2 why did she take the medications and LPN #2 stated she worked long hours and her legs and back hurt. On 3/9/12 LPN #2 was informed that she was terminated for misappropriation of Resident medication. AG Investigator #1 and #2 returned to the Administrator ' s office along with the DON and Assistant Administrator and stated that LPN #2 said LPN #3 had charted omitted PRN controlled drugs several weeks after they were given for LPN #2. The DON said she would suspend LPN #3 and contact the Board of Nursing. The Board of Nursing was contacted by the DON on 3/9/12 at approximately 4:30 PM to report LPN #2 for misappropriation of Resident Medication and for LPN #3 for falsification of documentation. The State Department of Health was notified on 3/14/12 by the Administrator that LPN #2 had confessed to misappropriation of Resident property and LPN #3 for falsification of documentation. On Monday, 3/12/12 the DON and Assistant Director of Nursing talked to LPN #3. LPN #3 admitted to documenting the administration of PRN pain meds for LPN #2. She stated she observed the omissions during a routine audit in January, 2012. This information of charting omissions was not presented to the DON, ADON, or Administrator prior to this statement being given. State Board of Nursing Investigator #2 interviewed LPN #3 on 3/12/12. On Tuesday, 3/13/12, the Administrator conducted a meeting of all employees to review whistle blower protect and suspicion of abuse/false claims, and Resident Abuse. His presentation included billing for services that are intended for Resident ' s, and misappropriation of Resident property including taking medication or supplied intended for Residents. No employee will be allowed to work until they have been inserviced on Resident Abuse. On Wednesday, 3/14/12, the Administrator spoke with AG Investigator #1 at approximately 9:05 AM. The purpose of this contact was to ask him if he had concluded his investigation and if he had any additional information to share. He replied that he had pretty much concluded the investigation and that no additional information was available. LPN #3 was terminated on 3/15/12 for falsification of documentation. On 3/14/12, beginning at 3:30 PM the Pain Assessments were reviewed by the RN supervisors on each wing on the Residents requiring Loratab, Ultram, Ultracet, and Lorcet. There was a total of 32 Residents reviewed with seven (7) Residents on Yellow Wing, 15 on Blue Wing and 10 on Orange Wing. The pain assessments were reviewed and signed. No problems were identified with the pain assessments. On 3/14/12 the DON, RN #1, LPN #5, LPN #6, LPN #7, LPN #8 reviewed the January through March 2012 Individual Sedative Records for 32 Residents requiring Ultram, Ultracet, Lortab and Lorcet. The Individual Sedative Records were matched with the MAR for accurate documentation and the detail summary of the MAR was reviewed for timely documentation and explanation for PRN administration of these drugs. There were no further discrepancies noted in the reviews. An inservice was initiated for all employees on 3/14/12 by Social Worker #1, Social Worker #2, and Assistant Director of Nursing on Misappropriation of Resident Property. The inservice included a definition of misappropriation of Resident property, reporting of misappropriation of Resident property, examples of misappropriation of Resident property, including medication, examples of abuse and exploitation. No Licensed Practical Nurse and Registered Nurse will be allowed to work until they have all been inserviced. On 3/14/12, an inservice was initiated by Information Technologist for all computer users. The inservice instructed all computer users that passwords would be changed 3/15/12 upon login and that each employee will set their own password and passwords are not to be shared. On 3/14/12, an inservice was initiated by the Information Technologist and ADON for all Licensed Practical Nurses and Registered Nurses. The inservice stated any Nurse who fails to document PRN medication within a 24 hour time frame must report the omission to their immediate supervisor as well as the DON/ADON. The Nurse making the omission must justify the reason why the omission occurred to the DON/ADON. The omission will be logged and reviewed by the DON/ADON before the Nurse is allowed to document the administration of the PRN on the Medication Administration Record and Detail Sheet. Any suspicion or allegation of misappropriation of Resident medications will be reported to the DON and Administrator when discovered. No LPN or RN will be allowed to work until they have been inserviced. Any suspicions or allegations will be reported to the State Department of Health, Attorney General's Office and State Board of Nursing. A random audit was conducted by the DON on 3/15/12 of five (5) Residents which include Resident A, Resident B, Resident C, Resident #10 and Resident #2. These Residents received narcotic medication on 3/14/12. Resident A and Resident B are alert and oriented and were interviewed b the DON to ensure that they had received their medications. The audit was to ensure individual sedative reports matched the MAR. There were no discrepancies in the review. Quality Assurance Committee met March 15, 2012 at 1:30 PM. Committee members consisted on Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, MDS Coordinator, Medicare Nurse, Quality Assurance Nurse, Assistant Administrator and the Medical Director was contacted via telephone. The committee was made aware of the misappropriation of Resident medications and the termination of employees involved and the actions taken to prevent the recurrence of the incident through random weekly audits of Individual Sedative Records compared to the Medication Administration Record. The members were told that all pain assessments had been updated for Residents with PRN medication orders and that Individual Sedative Records had been reviewed for accuracy against the Medication Administration Record. Members were told that all licensed nursing staff were inserviced regarding omissions of PRN medications and changing of passwords for computer users. Any misappropriation of Resident property will be reported to the proper authorities including the State Department of Health and the Attorney General's office." Verification of the AoC: Random interviews with nursing staff were conducted on 3/16/12 and 3/17/12 to ensure and verify that they had been inserviced on misappropriation of resident property, specifically for narcotic/medication, narcotic documentation, abuse, neglect, and sharing of passwords for computer usage and procedures that they would follow to notify administration of suspected drug diversion and/or documentation discrepancies. Observation and interview on 3/15/12 and 3/16/12 revealed that the narcotic counts were correct on each wing. Review of a Memo from the Information Technologist dated 3/12/12 revealed that staff was not to share their password with anyone. Review of documented in-services revealed that staff had been trained on Fraud and Abuse and Suspicion of Abuse/False Claims Review on 3/13/12. Review of documented in-services revealed that staff had been trained on Computer Usage; Misappropriation of Resident ' s property, medicine, money and consequences; Passcodes and monitoring medications; and Recognizing and reporting suspicious drug activity on 3/14/12. These in-services were also performed to staff via phone or before their next shift. Review of random audits performed on 3/15/12 and interview with the DON on 3/17/12 revealed no issues in documentation of the narcotics. Review of narcotic sheets and random interviews with residents who had received narcotics on 3/17/12 revealed no discrepancies. Interview with the Information Technologist on 3/16/12 verified that he had in-serviced nursing staff on setting new passwords and not to share with anyone. Review of the sign in sheet and agenda dated 3/15/12 revealed that the QA committee had met and discussed the narcotic misappropriation and documentation issues. Interview with the Medical Director on 3/16/12 at 1:45 p.m. verified that he had participated in the QA meeting on 3/15/12 and discussed the narcotic issues. Review of personnel files for LPN #1, LPN #2 and LPN #3 verified that they had been terminated by the facility for misappropriation and/or documentation issues and for LPN #1's failure of a urine drug screen without proper prescriptions for all medications. Part2 Based on interview, record review and policy review the facility failed to ensure that narcotics were signed out on the Individual Sedative Record at the time the narcotic was administered. The facility also failed to ensure that the "Controlled Drugs-Count Record" was documented consistently each shift after narcotic count for three (3) of three (3) nursing wings. Findings include: Orange Wing: Interview with LPN #11 on 3/15/12 at 4:40 p.m. revealed that the narcotics that were administered during medication pass were not documented in the narcotic book until after the whole medication pass was complete. Blue Wing: Interview with LPN #12 on 3/16/12 at 11:10 a.m. revealed that she had started today putting the sign out sheets for narcotics on the medication carts. Further interview with LPN #12 on 3/16/12 at 12:15 p.m. revealed that prior to today, the narcotic sign out books were in the medication room and the narcotics would be signed out after completion of the medication pass. LPN #12 stated that she would document that the narcotic was given in the computer, write it down on a piece of paper and then sign out on the narcotic sedative record when medication pass was completed. LPN #2 stated that if a PRN was given that she would sign it out as it was given if not during the regular medication pass. LPN #12 stated that she occasionally may forget to sign the count sheet but always counted narcotics coming on and going off the shift. Interview with RN #3 on 3/16/12 at 10:40 a.m. revealed that the nurses had been routinely giving a narcotic and documenting in the computer and then after the whole medication pass was over they would document on the narcotic sign out sheet. RN #3 stated that there was room for error because the sign out book was not right there to see when the last time a narcotic was signed out if it wasn't by chance documented in the computer. Review of the policy/procedures taken from the Blue Wing with RN #3 revealed: "Chart controlled drugs immediately on record provided for that purpose". RN #3 stated that would mean on the Individual Sedative Record. Yellow Wing: Interview with LPN #4 on 3/16/12 at 11:35 a.m. revealed that they were keeping the narcotic sign out book in the medication room and after all of the medication pass was complete then she would sign out all of the narcotics that she'd given. LPN #4 stated that starting this morning they were to chart on the EMAR and sign out the narcotic when it was given. Further interview with LPN #4 on 3/17/12 at 12:20 p.m. revealed that she might occasionally forget to sign the narcotic count sheet but that she counted every time she got/gave up the keys and had no discrepancies in the counts. Observation revealed that the narcotic sign out book was on the cart. Interview with the Pharmacy Consultant on 3/16/17 at 2:05 p.m. revealed that she had been concerned that the medication carts weren't big enough to put the narcotic book on the cart. The Pharmacy Consultant stated that the process had been for the nurse to punch out the narcotic and give it, document in the computer and then after the medication pass was over they would go sign out in the narcotic book. The Pharmacy Consultant stated that she didn't know that it was a big problem as long as they had signed out in the narcotic book and the counts had been okay. The Pharmacy Consultant stated that she had been looking for ways to put the book on the cart with some method such as clips or chains. Review of the Controlled Drug Count Sheet revealed omissions of nurse's signing that the count was done for the following times/dates: Orange Wing: "B" Cart: 3/11/12 ....11/7 "Nurse On" 3/12/12 ....11-7 "Nurse Off" 3/15/12 ....3-11 "Nurse On" "Split" Cart: 3/5/12 ....3-11 "Nurse On" 3/5/12 ....3-11 "Nurse Off" 3/5/12 ....11-7 "Nurse On" 3/6/12 ....11-7 "Nurse Off" 3/6/12 ....3-11 "Nurse On" 3/6/12 ....3-11 "Nurse Off" 3/6/12 .....11-7 "Nurse On" 3/7/12 ....11-7 "Nurse Off" 3/7/12 ....7-3 "Nurse On" 3/7/12 ....7-3 "Nurse Off" 3/7/12 ....3-11 "Nurse On" 3/7/12 ....3-11 "Nurse Off" 3/8/12 ....7-3 "Nurse On" 3/8/12 ....7-3 "Nurse Off" 3/8/12 ....3-11 "Nurse On" 3/8/12 ....3-11 "Nurse Off" 3/9/12 ....3-11 "Nurse On" 3/9/12 ....3-11 "Nurse Off" 3/11/12 ...11-7 "Nurse On" 3/13/12 ....11-7 "Nurse Off" 3/15/12 ....3-11 "Nurse On" Blue Wing: "Split Cart": 3/16/12 ....7-3 "Nurse On" "B" Cart" 3/16/12 ....7-3 "Nurse On" Yellow Wing: "A Cart" 3/1/12 ...3-11 "Nurse Off" "Split Cart" 3/7/12 ...3-11 "Nurse Off" 3/8/12 ...3-11 "Nurse Off" 3/12/12..7-3 "Nurse On" "B Cart" 3/6/12 ...11-7 "Nurse Off" 3/13/12 ...3-11 "Nurse On" 3/13/12 ...3-11 "Nurse Off" 3/14/12 ...7-3 "Nurse Off" 3/14/12 ...11-7 "Nurse On" 3/15/12 ...11-7 "Nurse Off" 3/16/12 ...7-3 "Nurse On" Interview with the Director of Nursing (DON) on 3/15/12 at 6:20 p.m. revealed that nurses should document their narcotic counts when they come on and when they go off on all shifts. When shown the "Controlled Drugs-Count Record" for the Orange Wing with many omissions, especially on the "Split Cart", the DON stated that there weren't always three (3) nurses and the "Split" cart wasn't always used and medications were either kept in the medication room or put on the other carts. The DON agreed that the count should still be documented or either a statement that the cart wasn't used that shift. The DON stated that counts were done each shift and cards were counted each shift and that there hadn't been any discrepancies in the counts that she had been made aware of. The DON stated that the oncoming nurse was not supposed to take the keys unless the count was correct. Further interview with the DON on 3/16/12 at 11:50 a.m. revealed that the Consultant Pharmacist had brought to her attention last week that there needed to be a way of putting the narcotic sign out book on the medication carts the Attorney General's office representative had mentioned it to the Consultant Pharmacist last week. The DON stated that the Consultant Pharmacist had said she would look into it and then left on vacation. The DON stated that as of today the narcotic sign out books were on the medication carts and the nurses were signing out as they give the medications. Interview with RN #2 on 3/15/12 at 6:35 p.m. revealed that she did see the nurse's counting narcotics each morning that she was here but that she did not check the narcotic book to make sure that they documented. RN #2 stated that there had been no discrepancies that she was aware of and that the nurse would not accept the keys if the counts were wrong. RN #2 stated that the narcotic sign out book had typically been kept in the medication room and nurses would sign out any narcotics given after the medication pass was completed. RN #2 agreed that narcotics should be signed out when given. Review of the facility's policy "Medications-Administration" provided by RN #3 on 3/16/12 at 10:40 a.m., revealed: "Chart controlled drugs immediately on record provided for that purpose". Review of the "Narcotics" policy provided by the DON on 3/15/12 at 6:30 p.m., revealed under the "Procedure" section: "2. Each narcotic administered will be documented on the Sedative Record and the patient's MAR. This procedure will ensure that all doses are accounted for. 3. A Controlled Drug Count Form is in the front of each narcotic binder. At the change of each shift, each narcotic must be counted and match totals on the Sedative Record. The "signing on" and "signing off" nurse signature is verification of responsibility and accuracy of count."

CI MS # Part1 Based on observation, interview, record review and policy review the facility failed to ensure accurate procedures for dispensing, administration, reconciliation and documentation of narcotics for 11 of 15 residents reviewed who received pain medications, Residents #4, #11, #13, #14, #15, #16, #17, #18, #19, #20 and #21. Interview with Resident #15, #16 and #17 revealed that they did not receive pain medication that was signed out for them by LPN #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. There were documentation discrepancies in the narcotic records noted for 10 residents, Resident #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21 which included narcotics that were signed out and not documented on the Medication Administration Record and discrepancies in the times that narcotics were administered. The facility's failure to ensure that an accurate procedure for dispensing, administering, reconciliation and documentation of narcotics was identified as an Immediate Jeopardy (IJ) on 3/15/12. The IJ began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the IJ on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to an "E" level which constitutes no actual harm with potential for more than minimal harm. Findings include: Cross refer to F224 for the facility's failure to ensure accurate procedures for dispensing, administration and documentation of narcotics and narcotic records for 11 of 15 residents as evidenced by no documentation on the Medication Administration Record for narcotics that were signed out for Resident #14, #15, #16, #17, #18, and #20; Residents #15, #16, and #17 denial of receiving medication that was signed out; and detail Administration Reports with discrepancies of when the actual narcotics were administered to Resident #4, #13, #14, #18, #19 and #21. There were also patterns on the Individual Sedative Records where LPN #1 and LPN #2 signed out narcotics to residents who normally didn't receive them. Credible Allegation of Compliance: "This is to serve as the credible allegation of compliance (AOC) for the incident involving Licensed Practical Nurse (LPN) #1 as reported to the State Board of Nursing on January 5, 2012, Licensed Practical Nurse (LPN) #2 as investigated by Attorney General (AG) Investigator #1 and Attorney General (AG) Investigator #2 on March 8, 2012 and March 9, 2012, and Licensed Practical Nurse (LPN) #3 as investigated on March 12, 2012. Director of Nursing (DON) received a report on 1/3/12 that LPN #1, was signing out narcotics on the sedative record but not documenting the medication on the medication administration record (MAR) when administered or the nurses notes, five (5) Residents were identified with discrepancies in narcotic administration/documentation by LPN #1. Those Residents identified were Resident #15, Resident #16, Resident #17, Resident #18 and Resident #20. On 1/3/12, a urine drug screen was done on LPN #1 at 3:45 PM. The drug screen was positive for Amphetamine, Benzodiazepine, Opiate and Oxycodone. LPN #1 had a prescription for Hydrocodone dated 11/15/11 for 40 pills with no refill. LPN #1 could not explain the positive drug screen. LPN #1 stated she was not aware that she needed to chart the medication on the MAR. LPN #1 was placed on suspension and ultimately terminated on 2/1/12 for failing drug test and for suspect for possible misappropriation of Resident property. On 1/4/12 the DON informed the Administrator and the Pharmacy Consultant of the possible problem with the narcotic documentation. Resident #18 and Resident #20 were not interviewable. On 1/4/12, Resident #15, Resident #16, and Resident #17 were interviewed by LPN #2 and LPN #4 concerning pain medication administration. Resident #15 and Resident #17 said they had not received the narcotic medications. Resident #16 said she had only taken one of the "strong pain pills" lately and had slept all day after taking the pill. The Quality Assurance Nurse, LPN #3 conducted a spot check on 1/5/12 on all 6 medications carts to review the documentation of PRN narcotic medications and no other problems were reported to the DON at that time. At approximately 11 AM, on 1/5/12, the DON called the State Board of Nursing and left a message. On 1/6/2012 at 9 AM, the Director of Nursing contacted the Board of Nursing Investigator #1 at the State Board of Nursing and reported the possible problem with the narcotics and supplied all the information requested by the State Board of Nursing. Board of Nursing Investigator #1 informed the DON that he would notify the appropriate entities. The DON asked the Board of Nursing Investigator #1 if she needed to report to any other agency and was told no, he would do that. The DON informed the Administrator of the conversation with the State Board of Nursing. On 2/1/12, LPN #1 was terminated from employment with the facility for failing drug test. Incident of LPN #1 signing out narcotic medications but not documenting medications was given was not reported to the State department of Health or Attorney General's office at that time. The State Department of Health was notified on 3/15/12 by the Administrator that LPN #1 was signing out narcotics on the Individual Sedative Record but no documentation that the medication was administered to the Resident and she failed her drug test. On Thursday, March 8, 2012, AG Investigator #1 presented himself at the facility and talked with the Administrator and Assistant Administrator regarding an anonymous complaint that had been registered against LPN #2. The facility had no prior knowledge of an incident involving LPN #2. He produced several documents which were not reviewable by the Administrator or Assistant Administrator. AG Investigator #1 did not share with us how he intended to conduct the investigation so we made ourselves available. On 3/8/12 at approximately 2 PM, the DON reviewed ten (10) Resident narcotic records that AG Investigator #1 requested. Six (6) Residents were identified with discrepancies of narcotic administration/documentation by LPN #2. Residents identified were Resident #4, Resident #13, Resident #14, Resident #18, Resident #19 and Resident #21. AG Investigator #2 arrived on Friday 3/9/12 to assist AG Investigator #1. About mid afternoon on 3/9/12, AG Investigator #1 contacted the Administrator and asked if he, the Director of Nursing or Assistant Administrator could come to the conference room. LPN #2 had signed a written confession that she had taken some of the controlled drugs that were in question regarding the investigation. The Residents identified in the written confession from LPN #2 were Resident #4, Resident #13, Resident #14 and Resident #11. Due to the cognitive status of these Residents, interview of the Residents was not possible. At that time, both AG Investigator #1 and #2 left the room and only the Administrator and Assistant Administrator and LPN #2 were in the room. The Administrator asked LPN #2 why did she take the medications and LPN #2 stated she worked long hours and her legs and back hurt. On 3/9/12 LPN #2 was informed that she was terminated for misappropriation of Resident medication. AG Investigator #1 and #2 returned to the Administrator's office along with the DON and Assistant Administrator and stated that LPN #2 said LPN #3 had charted omitted PRN controlled drugs several weeks after they were given for LPN #2. The DON said she would suspend LPN #3 and contact the Board of Nursing. The Board of Nursing was contacted by the DON on 3/9/12 at approximately 4:30 PM to report LPN #2 for misappropriation of Resident Medication and for LPN #3 for falsification of documentation. The State Department of Health was notified on 3/14/12 by the Administrator that LPN #2 had confessed to misappropriation of Resident property and LPN #3 for falsification of documentation. On Monday, 3/12/12 the DON and Assistant Director of Nursing talked to LPN #3. LPN #3 admitted to documenting the administration of PRN pain meds for LPN #2. She stated she observed the omissions during a routine audit in January, 2012. This information of charting omissions was not presented to the DON, ADON, or Administrator prior to this statement being given. State Board of Nursing Investigator #2 interviewed LPN #3 on 3/12/12. On Tuesday, 3/13/12, the Administrator conducted a meeting of all employees to review whistle blower protect and suspicion of abuse/false claims, and Resident Abuse. His presentation included billing for services that are intended for Resident's, and misappropriation of Resident property including taking medication or supplied intended for Residents. No employee will be allowed to work until they have been in-serviced on Resident Abuse. On Wednesday, 3/14/12, the Administrator spoke with AG Investigator #1 at approximately 9:05 AM. The purpose of this contact was to ask him if he had concluded his investigation and if he had any additional information to share. He replied that he had pretty much concluded the investigation and that no additional information was available. LPN #3 was terminated on 3/15/12 for falsification of documentation. On 3/14/12, beginning at 3:30 PM the Pain Assessments were reviewed by the RN supervisors on each wing on the Residents requiring Lortab, Ultram, Ultracet, and Lorcet. There was a total of 32 Residents reviewed with seven (7) Residents on Yellow Wing, 15 on Blue Wing and 10 on Orange Wing. The pain assessments were reviewed and signed. No problems were identified with the pain assessments. On 3/14/12 the DON, RN #1, LPN #5, LPN #6, LPN #7, LPN #8 reviewed the January through March 2012 Individual Sedative Records for 32 Residents requiring Ultram, Ultracet, Lortab and Lorcet. The Individual Sedative Records were matched with the MAR for accurate documentation and the detail summary of the MAR was reviewed for timely documentation and explanation for PRN administration of these drugs. There were no further discrepancies noted in the reviews. An inservice was initiated for all employees on 3/14/12 by Social Worker #1, Social Worker #2, and Assistant Director of Nursing on Misappropriation of Resident Property. The in-service included a definition of misappropriation of Resident property, reporting of misappropriation of Resident property, examples of misappropriation of Resident property, including medication, examples of abuse and exploitation. No Licensed Practical Nurse and Registered Nurse will be allowed to work until they have all been in-serviced. On 3/14/12, an inservice was initiated by Information Technologist for all computer users. The in-service instructed all computer users that passwords would be changed 3/15/12 upon login and that each employee will set their own password and passwords are not to be shared. On 3/14/12, an inservice was initiated by the Information Technologist and ADON for all Licensed Practical Nurses and Registered Nurses. The in-service stated any Nurse who fails to document PRN medication within a 24 hour time frame must report the omission to their immediate supervisor as well as the DON/ADON. The Nurse making the omission must justify the reason why the omission occurred to the DON/ADON. The omission will be logged and reviewed by the DON/ADON before the Nurse is allowed to document the administration of the PRN on the Medication Administration Record and Detail Sheet. Any suspicion or allegation of misappropriation of Resident medications will be reported to the DON and Administrator when discovered. No LPN or RN will be allowed to work until they have been in-serviced. Any suspicions or allegations will be reported to the State Department of Health, Attorney General's Office and State Board of Nursing. A random audit was conducted by the DON on 3/15/12 of five (5) Residents which include Resident A, Resident B, Resident C, Resident #10 and Resident #2. These Residents received narcotic medication on 3/14/12. Resident A and Resident B are alert and oriented and were interviewed by the DON to ensure that they had received their medications. The audit was to ensure individual sedative reports matched the MAR. There were no discrepancies in the review. Quality Assurance Committee met March 15, 2012 at 1:30 PM. Committee members consisted on Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, MDS Coordinator, Medicare Nurse, Quality Assurance Nurse, Assistant Administrator and the Medical Director was contacted via telephone. The committee was made aware of the misappropriation of Resident medications and the termination of employees involved and the actions taken to prevent the recurrence of the incident through random weekly audits of Individual Sedative Records compared to the Medication Administration Record. The members were told that all pain assessments had been updated for Residents with PRN medication orders and that Individual Sedative Records had been reviewed for accuracy against the Medication Administration Record. Members were told that all licensed nursing staff were in-serviced regarding omissions of PRN medications and changing of passwords for computer users. Any misappropriation of Resident property will be reported to the proper authorities including the State Department of Health and the Attorney General's office." Verification of the AoC: Random interviews with nursing staff were conducted on 3/16/12 and 3/17/12 to ensure and verify that they had been in-serviced on misappropriation of resident property, specifically for narcotic/medication, narcotic documentation, abuse, neglect, and sharing of passwords for computer usage and procedures that they would follow to notify administration of suspected drug diversion and/or documentation discrepancies. Observation and interview on 3/15/12 and 3/16/12 revealed that the narcotic counts were correct on each wing. Review of a Memo from the Information Technologist dated 3/14/12 revealed that staff was not to share their password with anyone. Review of documented in-services revealed that staff had been trained on Fraud and Abuse and Suspicion of Abuse/False Claims Review on 3/13/12. Review of documented in-services revealed that staff had been trained on Computer Usage; Misappropriation of Resident's property, medicine, money and consequences; Passcodes and monitoring medications; and Recognizing and reporting suspicious drug activity on 3/14/12. These in-services were also performed to staff via phone or before their next shift. Review of random audits performed on 3/15/12 and interview with the DON on 3/17/12 revealed no issues in documentation of the narcotics. Review of narcotic sheets and random interviews with residents who had received narcotics on 3/17/12 revealed no discrepancies. Interview with the Information Technologist on 3/16/12 verified that he had in-serviced nursing staff on setting new passwords and not to share with anyone. Review of the sign in sheet and agenda dated 3/15/12 revealed that the QA committee had met and discussed the narcotic misappropriation and documentation issues. Interview with the Medical Director on 3/16/12 at 1:45 p.m. verified that he had participated in the QA meeting on 3/15/12 and discussed the narcotic issues. Review of personnel files for LPN #1, LPN #2 and LPN #3 verified that they had been terminated by the facility for misappropriation and/or documentation issues and for LPN #1's failure of a urine drug screen without proper prescriptions for all medications. Part2 Based on interview, record review and policy review, the facility failed to ensure that narcotics were signed out on the Individual Sedative Record at the time the narcotic was administered. The facility also failed to ensure that the "Controlled Drugs-Count Record" was documented consistently each shift after narcotic count for three (3) of three (3) nursing wings. Findings include: Orange Wing: Interview with LPN #11 on 3/15/12 at 4:40 p.m. revealed that the narcotics that were administered during medication pass were not documented in the narcotic book until after the whole medication pass was complete. Blue Wing: Interview with Licensed Practical Nurse (LPN) #12 on 3/16/12 at 11:10 a.m. revealed that she had started today putting the sign out sheets for narcotics on the medication carts. Interview with LPN #12 on 3/16/12 at 12:15 p.m. revealed that prior to today, the narcotic sign out books were in the medication room and the narcotics would be signed out after completion of the medication pass. LPN #12 stated that she would document that the narcotic was given in the computer, write it down on a piece of paper and then sign out on the narcotic sedative record when medication pass was completed. LPN #2 stated that if a PRN (as needed) was given that she would sign it out as it was given if not during the regular medication pass. LPN #12 stated that she occasionally may forget to sign the count sheet but always counted narcotics coming on and going off the shift. Interview with Registered Nurse (RN) #3 on 3/16/12 at 10:40 a.m. revealed that the nurses had been routinely giving a narcotic and documenting in the computer and then after the whole medication pass was over they would document on the narcotic sign out sheet. RN #3 stated that there was room for error because the sign out book was not right there to see when the last time a narcotic was signed out if it wasn't by chance documented in the computer. Review of the policy/procedures taken from the Blue Wing with RN #3 revealed: "Chart controlled drugs immediately on record provided for that purpose." RN #3 stated that would mean on the Individual Sedative Record. Yellow Wing: Interview with Licensed Practical Nurse (LPN) #4 on 3/16/12 at 11:35 a.m. revealed that they were keeping the narcotic sign out book in the medication room and after all of the medication pass was complete then she would sign out all of the narcotics that she'd given. LPN #4 stated that starting this morning they were to chart on the EMAR and sign out the narcotic when it was given. Interview with LPN #4 on 3/17/12 at 12:20 p.m. revealed that she might occasionally forget to sign the narcotic count sheet but that she counted every time she got/gave up the keys and had no discrepancies in the counts. Observation revealed that the narcotic sign out book was on the cart. Interview with the Pharmacy Consultant on 3/16/17 at 2:05 p.m. revealed that she had been concerned that the medication carts weren't big enough to put the narcotic book on the cart. The Pharmacy Consultant stated that the process had been for the nurse to punch out the narcotic and give it, document in the computer and then after the medication pass was over they would go sign out in the narcotic book. The Pharmacy Consultant stated that she didn't know that it was a big problem as long as they had signed out in the narcotic book and the counts had been okay. The Pharmacy Consultant stated that she had been looking for ways to put the book on the cart with some method such as clips or chains. Review of the Controlled Drug Count Sheet revealed omissions of nurse's signing that the count was done for the following times/dates: Orange Wing: "B" Cart on: 3/11/12 - 11/7 "Name of Nurse On"; 3/12/12 - 11-7 "Name of Nurse Off"; 3/15/12 - 3-11 "Name of Nurse On". "Split" Cart: 3/5/12 - 3-11 "Name of Nurse On"; 3/5/12 - 3-11 "Name of Nurse Off"; 3/5/12 - 11-7 "Name of Nurse On"; 3/6/12 - 11-7 "Name of Nurse Off"; 3/6/12 - 3-11 "Name of Nurse On"; 3/6/12 - 3-11 "Name of Nurse Off"; 3/6/12 - 11-7 "Name of Nurse On"; 3/7/12 - 11-7 "Name of Nurse Off"; 3/7/12 - 7-3 "Name of Nurse On"; 3/7/12 - 7-3 "Name of Nurse Off"; 3/7/12 - 3-11 "Name of Nurse On"; 3/7/12 - 3-11 "Name of Nurse Off"; 3/8/12 - 7-3 "Name of Nurse On"; 3/8/12 - 7-3 "Name of Nurse Off"; 3/8/12 - 3-11 "Name of Nurse On"; 3/8/12 - 3-11 "Name of Nurse Off"; 3/9/12 - 3-11 "Name of Nurse On"; 3/9/12 - 3-11 "Name of Nurse Off"; 3/11/12 - 11-7 "Name of Nurse On"; 3/13/12 - 11-7 "Name of Nurse Off"; 3/15/12 - 3-11 "Name of Nurse On". Blue Wing: "Split Cart": 3/16/12 - 7-3 " Name of Nurse On". "B" Cart" 3/16/12 - 7-3 "Name of Nurse On"; Yellow Wing: "A Cart" 3/1/12 - 3-11 "Name of Nurse Off". "Split " Cart: 3/7/12 - 3-11 "Name of Nurse Off"; 3/8/12 - 3-11 "Name of Nurse Off"; 3/12/12- 7-3 "Name of Nurse On". "B Cart" 3/6/12 - 11-7 "Name of Nurse Off"; 3/13/12 - 3-11 "Name of Nurse On"; 3/13/12 - 3-11 "Name of Nurse Off"; 3/14/12 - 7-3 "Name of Nurse Off"; 3/14/12 - 11-7 "Name of Nurse On"; 3/15/12 - 11-7 "Name of Nurse Off", and 3/16/12 - 7-3 "Name of Nurse On". Interview with the Director of Nurses (DON) on 3/15/12 at 6:20 p.m. revealed that nurses should document their narcotic counts when they come on and when they go off on all shifts. When shown the "Controlled Drugs-Count Record" for the Orange Wing with many omissions, especially on the "Split Cart", the DON stated that there weren't always three (3) nurses and the "Split" cart wasn't always used and medications were either kept in the medication room or put on the other carts. The DON agreed that the count should still be documented or either a statement that the cart wasn't used that shift. The DON stated that counts were done each shift and cards were counted each shift and that there hadn't been any discrepancies in the counts that she had been made aware of. The DON stated that the oncoming nurse was not supposed to take the keys unless the count was correct. Interview with the DON on 3/16/12 at 11:50 a.m. revealed that the Consultant Pharmacist had brought to her attention last week that there needed to be a way of putting the narcotic sign out book on the medication carts the Attorney General's office representative had mentioned it to the Consultant Pharmacist last week. The DON stated that the Consultant Pharmacist had said she would look into it and then left on vacation. The DON stated that as of today the narcotic sign out books were on the medication carts and the nurses were signing out as they give the medications. Interview with Registered Nurse (RN) #2 on 3/15/12 at 6:35 p.m. revealed that she did see the nurse's counting narcotics each morning that she was here but that she did not check the narcotic book to make sure that they documented. RN #2 stated that there had been no discrepancies that she was aware of and that the nurse would not accept the keys if the counts were wrong. RN #2 stated that the narcotic sign out book had typically been kept in the medication room and nurses would sign out any narcotics given after the medication pass was completed. RN #2 agreed that narcotics should be signed out when given. Review of the home's "Medications-Administration" policy, dated 7/1/97, provided by Registered Nurse #3 on 3/16/12 at 10:40 a.m., revealed: "Chart controlled drugs immediately on record provided for that purpose." Review of the home's "Narcotics" policy, revised 10/25/00, provided by the DON on 3/15/12 at 6:30 p.m., noted: " ... Procedure: ... 2. Each narcotic administered will be documented on the Sedative Record and the patient's MAR (Medication Administration Record). This procedure will ensure that all doses are accounted for. 3. A Controlled Drug Count Form is in the front of each narcotic binder. At the change of each shift, each narcotic must be counted and match totals on the Sedative Record. The "signing on" and "signing off" nurse signature is verification of responsibility and accuracy of count."

CI MS # Part1 Based on observation, interview, record review and policy review the facility failed to ensure accurate procedures for dispensing, administration, reconciliation and documentation of narcotics for 11 of 15 residents reviewed who received pain medications, Residents #4, #11, #13, #14, #15, #16, #17, #18, #19, #20 and #21. Interview with Resident #15, #16 and #17 revealed that they did not receive pain medication that was signed out for them by LPN #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. There were documentation discrepancies in the narcotic records noted for 10 residents, Resident #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21 which included narcotics that were signed out and not documented on the Medication Administration Record and discrepancies in the times that narcotics were administered. The facility's failure to ensure that an accurate procedure for dispensing, administering, reconciliation and documentation of narcotics was identified as an Immediate Jeopardy (IJ) on 3/15/12. The IJ began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the IJ on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to a " D " level which constitutes no actual harm with potential for more than minimal harm. Findings include: Cross refer to F224 for the facilities failure to ensure accurate procedures for dispensing, administration and documentation of narcotics and narcotic records for 11 of 15 residents as evidenced by no documentation on the Medication Administration Record for narcotics that were signed out for Resident #14, #15, #16, #17, #18, and #20; Residents #15, #16, and #17 denial of receiving medication that was signed out; and detail Administration Reports with discrepancies of when the actual narcotics were administered to Resident #4, #13, #14, #18, #19 and #21. There were also patterns on the Individual Sedative Records where LPN #1 and LPN #2 signed out narcotics to residents who normally didn't receive them. Credible Allegation of Compliance: "This is to serve as the credible allegation of compliance (AOC) for the incident involving Licensed Practical Nurse (LPN) #1 as reported to the State Board of Nursing on January 5, 2012, Licensed Practical Nurse (LPN) #2 as investigated by Attorney General (AG) Investigator #1 and Attorney General (AG) Investigator #2 on March 8, 2012 and March 9, 2012, and Licensed Practical Nurse (LPN) #3 as investigated on March 12, 2012. Director of Nursing (DON) received a report on 1/3/12 that LPN #1, was signing out narcotics on the sedative record but not documenting the medication on the medication administration record (MAR) when administered or the nurses notes, five (5) Residents were identified with discrepancies in narcotic administration/documentation by LPN #1. Those Residents identified were Resident #15, Resident #16, Resident #17, Resident #18 and Resident #20. On 1/3/12, a urine drug screen was done on LPN #1 at 3:45 PM. The drug screen was positive for Amphetamine, Benzodiazepine, Opiate and Oxycodone. LPN #1 had a prescription for Hydrocodone dated 11/15/11 for 40 pills with no refill. LPN #1 could not explain the positive drug screen. LPN #1 stated she was not aware that she needed to chart the medication on the MAR. LPN #1 was placed on suspension and ultimately terminated on 2/1/12 for failing drug test and for suspect for possible misappropriation of Resident property. On 1/4/12 the DON informed the Administrator and the Pharmacy Consultant of the possible problem with the narcotic documentation. Resident #18 and Resident #20 were not interviewable. On 1/4/12, Resident #15, Resident #16, and Resident #17 were interviewed by LPN #2 and LPN #4 concerning pain medication administration. Resident #15 and Resident #17 said they had not received the narcotic medications. Resident #16 said she had only taken one of the "strong pain pills" lately and had slept all day after taking the pill. The Quality Assurance Nurse, LPN #3 conducted a spot check on 1/5/12 on all 6 medications carts to review the documentation of PRN narcotic medications and no other problems were reported to the DON at that time. At approximately 11 AM, on 1/5/12, the DON called the State Board of Nursing and left a message. On 1/6/2012 at 9 AM, the Director of Nursing contacted the Board of Nursing Investigator #1 at the State Board of Nursing and reported the possible problem with the narcotics and supplied all the information requested b the State Board of Nursing. Board of Nursing Investigator #1 informed the DON that he would notify the appropriate entities. The DON asked the Board of Nursing Investigator #1 if she needed to report to any other agency and was told no, he would do that. The DON informed the Administrator of the conversation with the State Board of Nursing. On 2/1/12, LPN #1 was terminated from employment with the facility for failing drug test. Incident of LPN #1 signing out narcotic medications but not documenting medications was given was not reported to the State department of Health or Attorney General's office at that time. The State Department of Health was notified on 3/15/12 by the Administrator that LPN #1 was signing out narcotics on the Individual Sedative Record but no documentation that the medication was administered to the Resident and she failed her drug test. On Thursday, March 8, 2012, AG Investigator #1 presented himself at the facility and talked with the Administrator and Assistant Administrator regarding an anonymous complaint that had been registered against LPN #2. The facility had no prior knowledge of an incident involving LPN #2. He produced several documents which were not reviewable by the Administrator or Assistant Administrator. AG Investigator #1 did not share with us how he intended to conduct the investigation so we made ourselves available. On 3/8/12 at approximately 2 PM, the DON reviewed ten (10) Resident narcotic records that AG Investigator #1 requested. Six (6) Residents were identified with discrepancies of narcotic administration/documentation by LPN #2. Residents identified were Resident #4, Resident #13, Resident #14, Resident #18, Resident #19 and Resident #21. AG Investigator #2 arrived on Friday 3/9/12 to assist AG Investigator #1. About mid afternoon on 3/9/12, AG Investigator #1 contacted the Administrator and asked if he, the Director of Nursing or Assistant Administrator could come to the conference room. LPN #2 had signed a written confession that she had taken some of the controlled drugs that were in question regarding the investigation. The Residents identified in the written confession from LPN #2 were Resident #4, Resident #13, Resident #14 and Resident #11. Due to the cognitive status of these Residents, interview of the Residents was not possible. At that time, both AG Investigator #1 and #2 left the room and only the Administrator and Assistant Administrator and LPN #2 were in the room. The Administrator asked LPN #2 why did she take the medications and LPN #2 stated she worked long hours and her legs and back hurt. On 3/9/12 LPN #2 was informed that she was terminated for misappropriation of Resident medication. AG Investigator #1 and #2 returned to the Administrator ' s office along with the DON and Assistant Administrator and stated that LPN #2 said LPN #3 had charted omitted PRN controlled drugs several weeks after they were given for LPN #2. The DON said she would suspend LPN #3 and contact the Board of Nursing. The Board of Nursing was contacted by the DON on 3/9/12 at approximately 4:30 PM to report LPN #2 for misappropriation of Resident Medication and for LPN #3 for falsification of documentation. The State Department of Health was notified on 3/14/12 by the Administrator that LPN #2 had confessed to misappropriation of Resident property and LPN #3 for falsification of documentation. On Monday, 3/12/12 the DON and Assistant Director of Nursing talked to LPN #3. LPN #3 admitted to documenting the administration of PRN pain meds for LPN #2. She stated she observed the omissions during a routine audit in January, 2012. This information of charting omissions was not presented to the DON, ADON, or Administrator prior to this statement being given. State Board of Nursing Investigator #2 interviewed LPN #3 on 3/12/12. On Tuesday, 3/13/12, the Administrator conducted a meeting of all employees to review whistle blower protect and suspicion of abuse/false claims, and Resident Abuse. His presentation included billing for services that are intended for Resident ' s, and misappropriation of Resident property including taking medication or supplied intended for Residents. No employee will be allowed to work until they have been in-serviced on Resident Abuse. On Wednesday, 3/14/12, the Administrator spoke with AG Investigator #1 at approximately 9:05 AM. The purpose of this contact was to ask him if he had concluded his investigation and if he had any additional information to share. He replied that he had pretty much concluded the investigation and that no additional information was available. LPN #3 was terminated on 3/15/12 for falsification of documentation. On 3/14/12, beginning at 3:30 PM the Pain Assessments were reviewed by the RN supervisors on each wing on the Residents requiring Lortab, Ultram, Ultracet, and Lorcet. There was a total of 32 Residents reviewed with seven (7) Residents on Yellow Wing, 15 on Blue Wing and 10 on Orange Wing. The pain assessments were reviewed and signed. No problems were identified with the pain assessments. On 3/14/12 the DON, RN #1, LPN #5, LPN #6, LPN #7, LPN #8 reviewed the January through March 2012 Individual Sedative Records for 32 Residents requiring Ultram, Ultracet, Lortab and Lorcet. The Individual Sedative Records were matched with the MAR for accurate documentation and the detail summary of the MAR was reviewed for timely documentation and explanation for PRN administration of these drugs. There were no further discrepancies noted in the reviews. An in-service was initiated for all employees on 3/14/12 by Social Worker #1, Social Worker #2, and Assistant Director of Nursing on Misappropriation of Resident Property. The in-service included a definition of misappropriation of Resident property, reporting of misappropriation of Resident property, examples of misappropriation of Resident property, including medication, examples of abuse and exploitation. No Licensed Practical Nurse and Registered Nurse will be allowed to work until they have all been in-serviced. On 3/14/12, an in-service was initiated by Information Technologist for all computer users. The in-service instructed all computer users that passwords would be changed 3/15/12 upon login and that each employee will set their own password and passwords are not to be shared. On 3/14/12, an in-service was initiated by the Information Technologist and ADON for all Licensed Practical Nurses and Registered Nurses. The in-service stated any Nurse who fails to document PRN medication within a 24 hour time frame must report the omission to their immediate supervisor as well as the DON/ADON. The Nurse making the omission must justify the reason why the omission occurred to the DON/ADON. The omission will be logged and reviewed by the DON/ADON before the Nurse is allowed to document the administration of the PRN on the Medication Administration Record and Detail Sheet. Any suspicion or allegation of misappropriation of Resident medications will be reported to the DON and Administrator when discovered. No LPN or RN will be allowed to work until they have been in-serviced. Any suspicions or allegations will be reported to the State Department of Health, Attorney General's Office and State Board of Nursing. A random audit was conducted by the DON on 3/15/12 of five (5) Residents which include Resident A, Resident B, Resident C, Resident #10 and Resident #2. These Residents received narcotic medication on 3/14/12. Resident A and Resident B are alert and oriented and were interviewed b the DON to ensure that they had received their medications. The audit was to ensure individual sedative reports matched the MAR. There were no discrepancies in the review. Quality Assurance Committee met March 15, 2012 at 1:30 PM. Committee members consisted on Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, MDS Coordinator, Medicare Nurse, Quality Assurance Nurse, Assistant Administrator and the Medical Director was contacted via telephone. The committee was made aware of the misappropriation of Resident medications and the termination of employees involved and the actions taken to prevent the recurrence of the incident through random weekly audits of Individual Sedative Records compared to the Medication Administration Record. The members were told that all pain assessments had been updated for Residents with PRN medication orders and that Individual Sedative Records had been reviewed for accuracy against the Medication Administration Record. Members were told that all licensed nursing staff were in-serviced regarding omissions of PRN medications and changing of passwords for computer users. Any misappropriation of Resident property will be reported to the proper authorities including the State Department of Health and the Attorney General's office." Verification of the AoC: Random interviews with nursing staff were conducted on 3/16/12 and 3/17/12 to ensure and verify that they had been inserviced on misappropriation of resident property, specifically for narcotic/medication, narcotic documentation, abuse, neglect, and sharing of passwords for computer usage and procedures that they would follow to notify administration of suspected drug diversion and/or documentation discrepancies. Observation and interview on 3/15/12 and 3/16/12 revealed that the narcotic counts were correct on each wing. Review of a Memo from the Information Technologist dated 3/12/12 revealed that staff was not to share their password with anyone. Review of documented in-services revealed that staff had been trained on Fraud and Abuse and Suspicion of Abuse/False Claims Review on 3/13/12. Review of documented in-services revealed that staff had been trained on Computer Usage; Misappropriation of Resident ' s property, medicine, money and consequences; Passcodes and monitoring medications; and Recognizing and reporting suspicious drug activity on 3/14/12. These in-services were also performed to staff via phone or before their next shift. Review of random audits performed on 3/15/12 and interview with the DON on 3/17/12 revealed no issues in documentation of the narcotics. Review of narcotic sheets and random interviews with residents who had received narcotics on 3/17/12 revealed no discrepancies. Interview with the Information Technologist on 3/16/12 verified that he had in-serviced nursing staff on setting new passwords and not to share with anyone. Review of the sign in sheet and agenda dated 3/15/12 revealed that the QA committee had met and discussed the narcotic misappropriation and documentation issues. Interview with the Medical Director on 3/16/12 at 1:45 p.m. verified that he had participated in the QA meeting on 3/15/12 and discussed the narcotic issues. Review of personnel files for LPN #1, LPN #2 and LPN #3 verified that they had been terminated by the facility for misappropriation and/or documentation issues and for LPN #1's failure of a urine drug screen without proper prescriptions for all medications. Part2 Based on interview, record review and policy review, the facility failed to ensure that narcotics were signed out on the Individual Sedative Record at the time the narcotic was administered. The facility also failed to ensure that the "Controlled Drugs-Count Record" was documented consistently each shift after narcotic count for three (3) of three (3) nursing wings. Findings include: Orange Wing: Interview with LPN #11 on 3/15/12 at 4:40 p.m. revealed that the narcotics that were administered during medication pass were not documented in the narcotic book until after the whole medication pass was complete. Blue Wing: Interview with Licensed Practical Nurse (LPN) #12 on 3/16/12 at 11:10 a.m. revealed that she had started today putting the sign out sheets for narcotics on the medication carts. Interview with LPN #12 on 3/16/12 at 12:15 p.m. revealed that prior to today, the narcotic sign out books were in the medication room and the narcotics would be signed out after completion of the medication pass. LPN #12 stated that she would document that the narcotic was given in the computer, write it down on a piece of paper and then sign out on the narcotic sedative record when medication pass was completed. LPN #2 stated that if a PRN (as needed) was given that she would sign it out as it was given if not during the regular medication pass. LPN #12 stated that she occasionally may forget to sign the count sheet but always counted narcotics coming on and going off the shift. Interview with Registered Nurse (RN) #3 on 3/16/12 at 10:40 a.m. revealed that the nurses had been routinely giving a narcotic and documenting in the computer and then after the whole medication pass was over they would document on the narcotic sign out sheet. RN #3 stated that there was room for error because the sign out book was not right there to see when the last time a narcotic was signed out if it wasn't by chance documented in the computer. Review of the policy/procedures taken from the Blue Wing with RN #3 revealed: "Chart controlled drugs immediately on record provided for that purpose." RN #3 stated that would mean on the Individual Sedative Record. Yellow Wing: Interview with Licensed Practical Nurse (LPN) #4 on 3/16/12 at 11:35 a.m. revealed that they were keeping the narcotic sign out book in the medication room and after all of the medication pass was complete then she would sign out all of the narcotics that she'd given. LPN #4 stated that starting this morning they were to chart on the EMAR and sign out the narcotic when it was given. Interview with LPN #4 on 3/17/12 at 12:20 p.m. revealed that she might occasionally forget to sign the narcotic count sheet but that she counted every time she got/gave up the keys and had no discrepancies in the counts. Observation revealed that the narcotic sign out book was on the cart. Interview with the Pharmacy Consultant on 3/16/17 at 2:05 p.m. revealed that she had been concerned that the medication carts weren't big enough to put the narcotic book on the cart. The Pharmacy Consultant stated that the process had been for the nurse to punch out the narcotic and give it, document in the computer and then after the medication pass was over they would go sign out in the narcotic book. The Pharmacy Consultant stated that she didn't know that it was a big problem as long as they had signed out in the narcotic book and the counts had been okay. The Pharmacy Consultant stated that she had been looking for ways to put the book on the cart with some method such as clips or chains. Review of the Controlled Drug Count Sheet revealed omissions of nurse's signing that the count was done for the following times/dates: Orange Wing: "B" Cart on: 3/11/12 - 11/7 "Name of Nurse On"; 3/12/12 - 11-7 "Name of Nurse Off"; 3/15/12 - 3-11 "Name of Nurse On". "Split" Cart: 3/5/12 - 3-11 "Name of Nurse On"; 3/5/12 - 3-11 "Name of Nurse Off"; 3/5/12 - 11-7 "Name of Nurse On"; 3/6/12 - 11-7 "Name of Nurse Off"; 3/6/12 - 3-11 "Name of Nurse On"; 3/6/12 - 3-11 "Name of Nurse Off"; 3/6/12 - 11-7 "Name of Nurse On"; 3/7/12 - 11-7 "Name of Nurse Off"; 3/7/12 - 7-3 "Name of Nurse On"; 3/7/12 - 7-3 "Name of Nurse Off"; 3/7/12 - 3-11 "Name of Nurse On"; 3/7/12 - 3-11 "Name of Nurse Off"; 3/8/12 - 7-3 "Name of Nurse On"; 3/8/12 - 7-3 "Name of Nurse Off"; 3/8/12 - 3-11 "Name of Nurse On"; 3/8/12 - 3-11 "Name of Nurse Off"; 3/9/12 - 3-11 "Name of Nurse On"; 3/9/12 - 3-11 "Name of Nurse Off"; 3/11/12 - 11-7 "Name of Nurse On"; 3/13/12 - 11-7 "Name of Nurse Off"; 3/15/12 - 3-11 "Name of Nurse On". Blue Wing: "Split Cart": 3/16/12 - 7-3 " Name of Nurse On". "B" Cart" 3/16/12 - 7-3 "Name of Nurse On"; Yellow Wing: "A Cart" 3/1/12 - 3-11 "Name of Nurse Off". "Split " Cart: 3/7/12 - 3-11 "Name of Nurse Off"; 3/8/12 - 3-11 "Name of Nurse Off"; 3/12/12- 7-3 "Name of Nurse On". "B Cart" 3/6/12 - 11-7 "Name of Nurse Off"; 3/13/12 - 3-11 "Name of Nurse On"; 3/13/12 - 3-11 "Name of Nurse Off"; 3/14/12 - 7-3 "Name of Nurse Off"; 3/14/12 - 11-7 "Name of Nurse On"; 3/15/12 - 11-7 "Name of Nurse Off", and 3/16/12 - 7-3 "Name of Nurse On". Interview with the Director of Nurses (DON) on 3/15/12 at 6:20 p.m. revealed that nurses should document their narcotic counts when they come on and when they go off on all shifts. When shown the "Controlled Drugs-Count Record" for the Orange Wing with many omissions, especially on the "Split Cart", the DON stated that there weren't always three (3) nurses and the "Split" cart wasn't always used and medications were either kept in the medication room or put on the other carts. The DON agreed that the count should still be documented or either a statement that the cart wasn't used that shift. The DON stated that counts were done each shift and cards were counted each shift and that there hadn't been any discrepancies in the counts that she had been made aware of. The DON stated that the oncoming nurse was not supposed to take the keys unless the count was correct. Interview with the DON on 3/16/12 at 11:50 a.m. revealed that the Consultant Pharmacist had brought to her attention last week that there needed to be a way of putting the narcotic sign out book on the medication carts the Attorney General's office representative had mentioned it to the Consultant Pharmacist last week. The DON stated that the Consultant Pharmacist had said she would look into it and then left on vacation. The DON stated that as of today the narcotic sign out books were on the medication carts and the nurses were signing out as they give the medications. Interview with Registered Nurse (RN) #2 on 3/15/12 at 6:35 p.m. revealed that she did see the nurse's counting narcotics each morning that she was here but that she did not check the narcotic book to make sure that they documented. RN #2 stated that there had been no discrepancies that she was aware of and that the nurse would not accept the keys if the counts were wrong. RN #2 stated that the narcotic sign out book had typically been kept in the medication room and nurses would sign out any narcotics given after the medication pass was completed. RN #2 agreed that narcotics should be signed out when given. Review of the home's "Medications-Administration" policy, dated 7/1/97, provided by Registered Nurse #3 on 3/16/12 at 10:40 a.m., revealed: "Chart controlled drugs immediately on record provided for that purpose." Review of the home's "Narcotics" policy, revised 10/25/00, provided by the DON on 3/15/12 at 6:30 p.m., noted: " ... Procedure: ... 2. Each narcotic administered will be documented on the Sedative Record and the patient's MAR (Medication Administration Record). This procedure will ensure that all doses are accounted for. 3. A Controlled Drug Count Form is in the front of each narcotic binder. At the change of each shift, each narcotic must be counted and match totals on the Sedative Record. The "signing on" and "signing off" nurse signature is verification of responsibility and accuracy of count."

CI MS Based on observation, interview, record review and policy review the facility failed to effectively use its resources to ensure that misappropriation of narcotics did not occur for seven (7) of 15 residents reviewed who had pain medication ordered, Residents #4, #11, #13, #14, #15, #16, #17 and for narcotic documentation discrepancies for 10 of 15 residents reviewed who had pain medications ordered, Residents #4, #13, #14, #15, #16, #17, #18, #19, #20 and #21. Interview with Resident #15, #16 and #17 revealed that they did not receive pain medication that was signed out for them by LPN #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. Discrepancies in the narcotic records included narcotics that were signed out but not documented on the Medication Administration Record and false documentation of times that narcotics were administered by LPN #3. There were no adverse effects or increased pain noted for these residents. The facility's failure to effectively utilize their resources to ensure that misappropriation of narcotics and inaccurate documentation of narcotic records did not occur was identified as an Immediate Jeopardy (IJ) on 3/15/12. The IJ began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the IJ on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to a " D " level which constitutes no actual harm with potential for more than minimal harm. Cross refer to F224 for the facilityss failure to ensure that misappropriation of narcotics did not occur for Residents #4, #11, #13, #14, #15, #16, and #17 as evidenced by Resident #15, #16 and #17 not receiving narcotics that were signed out for them by LPN #1 and LPN #2 admitted to signing out narcotics for Residents #4, #11, #13 and #14; and for discrepancies in documentation for Residents #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21 that included signing out narcotics without documentation on the Medication Administration Record or nurse;s notes and false documentation of the times that medication was administered. Credible Allegation of Compliance: "This is to serve as the credible allegation of compliance (AOC) for the incident involving Licensed Practical Nurse (LPN) #1 as reported to the State Board of Nursing on January 5, 2012, Licensed Practical Nurse (LPN) #2 as investigated by Attorney General (AG) Investigator #1 and Attorney General (AG) Investigator #2 on March 8, 2012 and March 9, 2012, and Licensed Practical Nurse (LPN) #3 as investigated on March 12, 2012. Director of Nursing (DON) received a report on 1/3/12 that LPN #1, was signing out narcotics on the sedative record but not documenting the medication on the medication administration record (MAR) when administered or the nurses notes, five (5) Residents were identified with discrepancies in narcotic administration/documentation by LPN #1. Those Residents identified were Resident #15, Resident #16, Resident #17, Resident #18 and Resident #20. On 1/3/12, a urine drug screen was done on LPN #1 at 3:45 PM. The drug screen was positive for [MEDICATION NAME], Benzodiazepine, Opiate and [MEDICATION NAME]. LPN #1 had a prescription for [MEDICATION NAME] dated 11/15/11 for 40 pills with no refill. LPN #1 could not explain the positive drug screen. LPN #1 stated she was not aware that she needed to chart the medication on the MAR. LPN #1 was placed on suspension and ultimately terminated on 2/1/12 for failing drug test and for suspect for possible misappropriation of Resident property. On 1/4/12 the DON informed the Administrator and the Pharmacy Consultant of the possible problem with the narcotic documentation. Resident #18 and Resident #20 were not interviewable. On 1/4/12, Resident #15, Resident #16, and Resident #17 were interviewed by LPN #2 and LPN #4 concerning pain medication administration. Resident #15 and Resident #17 said they had not received the narcotic medications. Resident #16 said she had only taken one of the "strong pain pills" lately and had slept all day after taking the pill. The Quality Assurance Nurse, LPN #3 conducted a spot check on 1/5/12 on all 6 medications carts to review the documentation of PRN narcotic medications and no other problems were reported to the DON at that time. At approximately 11 AM, on 1/5/12, the DON called the State Board of Nursing and left a message. On 1/6/2012 at 9 AM, the Director of Nursing contacted the Board of Nursing Investigator #1 at the State Board of Nursing and reported the possible problem with the narcotics and supplied all the information requested b the State Board of Nursing. Board of Nursing Investigator #1 informed the DON that he would notify the appropriate entities. The DON asked the Board of Nursing Investigator #1 if she needed to report to any other agency and was told no, he would do that. The DON informed the Administrator of the conversation with the State Board of Nursing. On 2/1/12, LPN #1 was terminated from employment with the facility for failing drug test. Incident of LPN #1 signing out narcotic medications but not documenting medications was given was not reported to the State department of Health or Attorney General's office at that time. The State Department of Health was notified on 3/15/12 by the Administrator that LPN #1 was signing out narcotics on the Individual Sedative Record but no documentation that the medication was administered to the Resident and she failed her drug test. On Thursday, March 8, 2012, AG Investigator #1 presented himself at the facility and talked with the Administrator and Assistant Administrator regarding an anonymous complaint that had been registered against LPN #2. The facility had no prior knowledge of an incident involving LPN #2. He produced several documents which were not reviewable by the Administrator or Assistant Administrator. AG Investigator #1 did not share with us how he intended to conduct the investigation so we made ourselves available. On 3/8/12 at approximately 2 PM, the DON reviewed ten (10) Resident narcotic records that AG Investigator #1 requested. Six (6) Residents were identified with discrepancies of narcotic administration/documentation by LPN #2. Residents identified were Resident #4, Resident #13, Resident #14, Resident #18, Resident #19 and Resident #21. AG Investigator #2 arrived on Friday 3/9/12 to assist AG Investigator #1. About mid afternoon on 3/9/12, AG Investigator #1 contacted the Administrator and asked if he, the Director of Nursing or Assistant Administrator could come to the conference room. LPN #2 had signed a written confession that she had taken some of the controlled drugs that were in question regarding the investigation. The Residents identified in the written confession from LPN #2 were Resident #4, Resident #13, Resident #14 and Resident #11. Due to the cognitive status of these Residents, interview of the Residents was not possible. At that time, both AG Investigator #1 and #2 left the room and only the Administrator and Assistant Administrator and LPN #2 were in the room. The Administrator asked LPN #2 why did she take the medications and LPN #2 stated she worked long hours and her legs and back hurt. On 3/9/12 LPN #2 was informed that she was terminated for misappropriation of Resident medication. AG Investigator #1 and #2 returned to the Administrator ' s office along with the DON and Assistant Administrator and stated that LPN #2 said LPN #3 had charted omitted PRN controlled drugs several weeks after they were given for LPN #2. The DON said she would suspend LPN #3 and contact the Board of Nursing. The Board of Nursing was contacted by the DON on 3/9/12 at approximately 4:30 PM to report LPN #2 for misappropriation of Resident Medication and for LPN #3 for falsification of documentation. The State Department of Health was notified on 3/14/12 by the Administrator that LPN #2 had confessed to misappropriation of Resident property and LPN #3 for falsification of documentation. On Monday, 3/12/12 the DON and Assistant Director of Nursing talked to LPN #3. LPN #3 admitted to documenting the administration of PRN pain meds for LPN #2. She stated she observed the omissions during a routine audit in January, 2012. This information of charting omissions was not presented to the DON, ADON, or Administrator prior to this statement being given. State Board of Nursing Investigator #2 interviewed LPN #3 on 3/12/12. On Tuesday, 3/13/12, the Administrator conducted a meeting of all employees to review [MEDICATION NAME] blower protect and suspicion of abuse/false claims, and Resident Abuse. His presentation included billing for services that are intended for Resident ' s, and misappropriation of Resident property including taking medication or supplied intended for Residents. No employee will be allowed to work until they have been inserviced on Resident Abuse. On Wednesday, 3/14/12, the Administrator spoke with AG Investigator #1 at approximately 9:05 AM. The purpose of this contact was to ask him if he had concluded his investigation and if he had any additional information to share. He replied that he had pretty much concluded the investigation and that no additional information was available. LPN #3 was terminated on 3/15/12 for falsification of documentation. On 3/14/12, beginning at 3:30 PM the Pain Assessments were reviewed by the RN supervisors on each wing on the Residents requiring Loratab, [MEDICATION NAME], and [MEDICATION NAME]. There was a total of 32 Residents reviewed with seven (7) Residents on Yellow Wing, 15 on Blue Wing and 10 on Orange Wing. The pain assessments were reviewed and signed. No problems were identified with the pain assessments. On 3/14/12 the DON, RN #1, LPN #5, LPN #6, LPN #7, LPN #8 reviewed the January through March 2012 Individual Sedative Records for 32 Residents requiring [MEDICATION NAME] and [MEDICATION NAME]. The Individual Sedative Records were matched with the MAR for accurate documentation and the detail summary of the MAR was reviewed for timely documentation and explanation for PRN administration of these drugs. There were no further discrepancies noted in the reviews. An inservice was initiated for all employees on 3/14/12 by Social Worker #1, Social Worker #2, and Assistant Director of Nursing on Misappropriation of Resident Property. The inservice included a definition of misappropriation of Resident property, reporting of misappropriation of Resident property, examples of misappropriation of Resident property, including medication, examples of abuse and exploitation. No Licensed Practical Nurse and Registered Nurse will be allowed to work until they have all been inserviced. On 3/14/12, an inservice was initiated by Information Technologist for all computer users. The inservice instructed all computer users that passwords would be changed 3/15/12 upon login and that each employee will set their own password and passwords are not to be shared. On 3/14/12, an inservice was initiated by the Information Technologist and ADON for all Licensed Practical Nurses and Registered Nurses. The inservice stated any Nurse who fails to document PRN medication within a 24 hour time frame must report the omission to their immediate supervisor as well as the DON/ADON. The Nurse making the omission must justify the reason why the omission occurred to the DON/ADON. The omission will be logged and reviewed by the DON/ADON before the Nurse is allowed to document the administration of the PRN on the Medication Administration Record and Detail Sheet. Any suspicion or allegation of misappropriation of Resident medications will be reported to the DON and Administrator when discovered. No LPN or RN will be allowed to work until they have been inserviced. Any suspicions or allegations will be reported to the State Department of Health, Attorney General's Office and State Board of Nursing. A random audit was conducted by the DON on 3/15/12 of five (5) Residents which include Resident A, Resident B, Resident C, Resident #10 and Resident #2. These Residents received narcotic medication on 3/14/12. Resident A and Resident B are alert and oriented and were interviewed b the DON to ensure that they had received their medications. The audit was to ensure individual sedative reports matched the MAR. There were no discrepancies in the review. Quality Assurance Committee met March 15, 2012 at 1:30 PM. Committee members consisted on Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, MDS Coordinator, Medicare Nurse, Quality Assurance Nurse, Assistant Administrator and the Medical Director was contacted via telephone. The committee was made aware of the misappropriation of Resident medications and the termination of employees involved and the actions taken to prevent the recurrence of the incident through random weekly audits of Individual Sedative Records compared to the Medication Administration Record. The members were told that all pain assessments had been updated for Residents with PRN medication orders and that Individual Sedative Records had been reviewed for accuracy against the Medication Administration Record. Members were told that all licensed nursing staff were inserviced regarding omissions of PRN medications and changing of passwords for computer users. Any misappropriation of Resident property will be reported to the proper authorities including the State Department of Health and the Attorney General's office." Verification of the AoC: Random interviews with nursing staff were conducted on 3/16/12 and 3/17/12 to ensure and verify that they had been inserviced on misappropriation of resident property, specifically for narcotic/medication, narcotic documentation, abuse, neglect, and sharing of passwords for computer usage and procedures that they would follow to notify administration of suspected drug diversion and/or documentation discrepancies. Observation and interview on 3/15/12 and 3/16/12 revealed that the narcotic counts were correct on each wing. Review of a Memo from the Information Technologist dated 3/12/12 revealed that staff was not to share their password with anyone. Review of documented in-services revealed that staff had been trained on Fraud and Abuse and Suspicion of Abuse/False Claims Review on 3/13/12. Review of documented in-services revealed that staff had been trained on Computer Usage; Misappropriation of Resident ' s property, medicine, money and consequences; Passcodes and monitoring medications; and Recognizing and reporting suspicious drug activity on 3/14/12. These in-services were also performed to staff via phone or before their next shift. Review of random audits performed on 3/15/12 and interview with the DON on 3/17/12 revealed no issues in documentation of the narcotics. Review of narcotic sheets and random interviews with residents who had received narcotics on 3/17/12 revealed no discrepancies. Interview with the Information Technologist on 3/16/12 verified that he had in-serviced nursing staff on setting new passwords and not to share with anyone. Review of the sign in sheet and agenda dated 3/15/12 revealed that the QA committee had met and discussed the narcotic misappropriation and documentation issues. Interview with the Medical Director on 3/16/12 at 1:45 p.m. verified that he had participated in the QA meeting on 3/15/12 and discussed the narcotic issues. Review of personnel files for LPN #1, LPN #2 and LPN #3 verified that they had been terminated by the facility for misappropriation and/or documentation issues and for LPN #1's failure of a urine drug screen without proper prescriptions for all medications.

CI MS Based on observation, interview, record review and policy review the facility failed to effectively use its resources to ensure that misappropriation of narcotics did not occur for seven (7) of 15 residents reviewed who had pain medication ordered, Residents #4, #11, #13, #14, #15, #16, #17 and for narcotic documentation discrepancies for 10 of 15 residents reviewed who had pain medications ordered, Residents #4, #13, #14, #15, #16, #17, #18, #19, #20 and #21. Interview with Resident #15, #16 and #17 revealed that they did not receive pain medication that was signed out for them by LPN #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. Discrepancies in the narcotic records included narcotics that were signed out but not documented on the Medication Administration Record and false documentation of times that narcotics were administered by LPN #3. There were no adverse effects or increased pain noted for these residents. The facility's failure to effectively utilize their resources to ensure that misappropriation of narcotics and inaccurate documentation of narcotic records did not occur was identified as an Immediate Jeopardy (IJ) on 3/15/12. The IJ began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the IJ on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to a "D" level which constitutes no actual harm with potential for more than minimal harm. Cross refer to F224 for the facility ' s failure to ensure that misappropriation of narcotics did not occur for Residents #4, #11, #13, #14, #15, #16, and #17 as evidenced by Resident #15, #16 and #17 not receiving narcotics that were signed out for them by LPN #1 and LPN #2 admitted to signing out narcotics for Residents #4, #11, #13 and #14; and for discrepancies in documentation for Residents #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21 that included signing out narcotics without documentation on the Medication Administration Record or nurse;s notes and false documentation of the times that medication was administered. Credible Allegation of Compliance: "This is to serve as the credible allegation of compliance (AOC) for the incident involving Licensed Practical Nurse (LPN) #1 as reported to the State Board of Nursing on January 5, 2012, Licensed Practical Nurse (LPN) #2 as investigated by Attorney General (AG) Investigator #1 and Attorney General (AG) Investigator #2 on March 8, 2012 and March 9, 2012, and Licensed Practical Nurse (LPN) #3 as investigated on March 12, 2012. Director of Nursing (DON) received a report on 1/3/12 that LPN #1, was signing out narcotics on the sedative record but not documenting the medication on the medication administration record (MAR) when administered or the nurses notes, five (5) Residents were identified with discrepancies in narcotic administration/documentation by LPN #1. Those Residents identified were Resident #15, Resident #16, Resident #17, Resident #18 and Resident #20. On 1/3/12, a urine drug screen was done on LPN #1 at 3:45 PM. The drug screen was positive for [MEDICATION NAME], Benzodiazepine, Opiate and [MEDICATION NAME]. LPN #1 had a prescription for [MEDICATION NAME] dated 11/15/11 for 40 pills with no refill. LPN #1 could not explain the positive drug screen. LPN #1 stated she was not aware that she needed to chart the medication on the MAR. LPN #1 was placed on suspension and ultimately terminated on 2/1/12 for failing drug test and for suspect for possible misappropriation of Resident property. On 1/4/12 the DON informed the Administrator and the Pharmacy Consultant of the possible problem with the narcotic documentation. Resident #18 and Resident #20 were not interviewable. On 1/4/12, Resident #15, Resident #16, and Resident #17 were interviewed by LPN #2 and LPN #4 concerning pain medication administration. Resident #15 and Resident #17 said they had not received the narcotic medications. Resident #16 said she had only taken one of the "strong pain pills" lately and had slept all day after taking the pill. The Quality Assurance Nurse, LPN #3 conducted a spot check on 1/5/12 on all 6 medications carts to review the documentation of PRN narcotic medications and no other problems were reported to the DON at that time. At approximately 11 AM, on 1/5/12, the DON called the State Board of Nursing and left a message. On 1/6/2012 at 9 AM, the Director of Nursing contacted the Board of Nursing Investigator #1 at the State Board of Nursing and reported the possible problem with the narcotics and supplied all the information requested b the State Board of Nursing. Board of Nursing Investigator #1 informed the DON that he would notify the appropriate entities. The DON asked the Board of Nursing Investigator #1 if she needed to report to any other agency and was told no, he would do that. The DON informed the Administrator of the conversation with the State Board of Nursing. On 2/1/12, LPN #1 was terminated from employment with the facility for failing drug test. Incident of LPN #1 signing out narcotic medications but not documenting medications was given was not reported to the State department of Health or Attorney General's office at that time. The State Department of Health was notified on 3/15/12 by the Administrator that LPN #1 was signing out narcotics on the Individual Sedative Record but no documentation that the medication was administered to the Resident and she failed her drug test. On Thursday, March 8, 2012, AG Investigator #1 presented himself at the facility and talked with the Administrator and Assistant Administrator regarding an anonymous complaint that had been registered against LPN #2. The facility had no prior knowledge of an incident involving LPN #2. He produced several documents which were not reviewable by the Administrator or Assistant Administrator. AG Investigator #1 did not share with us how he intended to conduct the investigation so we made ourselves available. On 3/8/12 at approximately 2 PM, the DON reviewed ten (10) Resident narcotic records that AG Investigator #1 requested. Six (6) Residents were identified with discrepancies of narcotic administration/documentation by LPN #2. Residents identified were Resident #4, Resident #13, Resident #14, Resident #18, Resident #19 and Resident #21. AG Investigator #2 arrived on Friday 3/9/12 to assist AG Investigator #1. About mid afternoon on 3/9/12, AG Investigator #1 contacted the Administrator and asked if he, the Director of Nursing or Assistant Administrator could come to the conference room. LPN #2 had signed a written confession that she had taken some of the controlled drugs that were in question regarding the investigation. The Residents identified in the written confession from LPN #2 were Resident #4, Resident #13, Resident #14 and Resident #11. Due to the cognitive status of these Residents, interview of the Residents was not possible. At that time, both AG Investigator #1 and #2 left the room and only the Administrator and Assistant Administrator and LPN #2 were in the room. The Administrator asked LPN #2 why did she take the medications and LPN #2 stated she worked long hours and her legs and back hurt. On 3/9/12 LPN #2 was informed that she was terminated for misappropriation of Resident medication. AG Investigator #1 and #2 returned to the Administrator ' s office along with the DON and Assistant Administrator and stated that LPN #2 said LPN #3 had charted omitted PRN controlled drugs several weeks after they were given for LPN #2. The DON said she would suspend LPN #3 and contact the Board of Nursing. The Board of Nursing was contacted by the DON on 3/9/12 at approximately 4:30 PM to report LPN #2 for misappropriation of Resident Medication and for LPN #3 for falsification of documentation. The State Department of Health was notified on 3/14/12 by the Administrator that LPN #2 had confessed to misappropriation of Resident property and LPN #3 for falsification of documentation. On Monday, 3/12/12 the DON and Assistant Director of Nursing talked to LPN #3. LPN #3 admitted to documenting the administration of PRN pain meds for LPN #2. She stated she observed the omissions during a routine audit in January, 2012. This information of charting omissions was not presented to the DON, ADON, or Administrator prior to this statement being given. State Board of Nursing Investigator #2 interviewed LPN #3 on 3/12/12. On Tuesday, 3/13/12, the Administrator conducted a meeting of all employees to review [MEDICATION NAME] blower protect and suspicion of abuse/false claims, and Resident Abuse. His presentation included billing for services that are intended for Resident ' s, and misappropriation of Resident property including taking medication or supplied intended for Residents. No employee will be allowed to work until they have been inserviced on Resident Abuse. On Wednesday, 3/14/12, the Administrator spoke with AG Investigator #1 at approximately 9:05 AM. The purpose of this contact was to ask him if he had concluded his investigation and if he had any additional information to share. He replied that he had pretty much concluded the investigation and that no additional information was available. LPN #3 was terminated on 3/15/12 for falsification of documentation. On 3/14/12, beginning at 3:30 PM the Pain Assessments were reviewed by the RN supervisors on each wing on the Residents requiring Loratab, [MEDICATION NAME], and [MEDICATION NAME]. There was a total of 32 Residents reviewed with seven (7) Residents on Yellow Wing, 15 on Blue Wing and 10 on Orange Wing. The pain assessments were reviewed and signed. No problems were identified with the pain assessments. On 3/14/12 the DON, RN #1, LPN #5, LPN #6, LPN #7, LPN #8 reviewed the January through March 2012 Individual Sedative Records for 32 Residents requiring [MEDICATION NAME] and [MEDICATION NAME]. The Individual Sedative Records were matched with the MAR for accurate documentation and the detail summary of the MAR was reviewed for timely documentation and explanation for PRN administration of these drugs. There were no further discrepancies noted in the reviews. An inservice was initiated for all employees on 3/14/12 by Social Worker #1, Social Worker #2, and Assistant Director of Nursing on Misappropriation of Resident Property. The inservice included a definition of misappropriation of Resident property, reporting of misappropriation of Resident property, examples of misappropriation of Resident property, including medication, examples of abuse and exploitation. No Licensed Practical Nurse and Registered Nurse will be allowed to work until they have all been inserviced. On 3/14/12, an inservice was initiated by Information Technologist for all computer users. The inservice instructed all computer users that passwords would be changed 3/15/12 upon login and that each employee will set their own password and passwords are not to be shared. On 3/14/12, an inservice was initiated by the Information Technologist and ADON for all Licensed Practical Nurses and Registered Nurses. The inservice stated any Nurse who fails to document PRN medication within a 24 hour time frame must report the omission to their immediate supervisor as well as the DON/ADON. The Nurse making the omission must justify the reason why the omission occurred to the DON/ADON. The omission will be logged and reviewed by the DON/ADON before the Nurse is allowed to document the administration of the PRN on the Medication Administration Record and Detail Sheet. Any suspicion or allegation of misappropriation of Resident medications will be reported to the DON and Administrator when discovered. No LPN or RN will be allowed to work until they have been inserviced. Any suspicions or allegations will be reported to the State Department of Health, Attorney General's Office and State Board of Nursing. A random audit was conducted by the DON on 3/15/12 of five (5) Residents which include Resident A, Resident B, Resident C, Resident #10 and Resident #2. These Residents received narcotic medication on 3/14/12. Resident A and Resident B are alert and oriented and were interviewed b the DON to ensure that they had received their medications. The audit was to ensure individual sedative reports matched the MAR. There were no discrepancies in the review. Quality Assurance Committee met March 15, 2012 at 1:30 PM. Committee members consisted on Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, MDS Coordinator, Medicare Nurse, Quality Assurance Nurse, Assistant Administrator and the Medical Director was contacted via telephone. The committee was made aware of the misappropriation of Resident medications and the termination of employees involved and the actions taken to prevent the recurrence of the incident through random weekly audits of Individual Sedative Records compared to the Medication Administration Record. The members were told that all pain assessments had been updated for Residents with PRN medication orders and that Individual Sedative Records had been reviewed for accuracy against the Medication Administration Record. Members were told that all licensed nursing staff were inserviced regarding omissions of PRN medications and changing of passwords for computer users. Any misappropriation of Resident property will be reported to the proper authorities including the State Department of Health and the Attorney General's office." Verification of the AoC: Random interviews with nursing staff were conducted on 3/16/12 and 3/17/12 to ensure and verify that they had been inserviced on misappropriation of resident property, specifically for narcotic/medication, narcotic documentation, abuse, neglect, and sharing of passwords for computer usage and procedures that they would follow to notify administration of suspected drug diversion and/or documentation discrepancies. Observation and interview on 3/15/12 and 3/16/12 revealed that the narcotic counts were correct on each wing. Review of a Memo from the Information Technologist dated 3/12/12 revealed that staff was not to share their password with anyone. Review of documented in-services revealed that staff had been trained on Fraud and Abuse and Suspicion of Abuse/False Claims Review on 3/13/12. Review of documented in-services revealed that staff had been trained on Computer Usage; Misappropriation of Resident's property, medicine, money and consequences; Passcodes and monitoring medications; and Recognizing and reporting suspicious drug activity on 3/14/12. These in-services were also performed to staff via phone or before their next shift. Review of random audits performed on 3/15/12 and interview with the DON on 3/17/12 revealed no issues in documentation of the narcotics. Review of narcotic sheets and random interviews with residents who had received narcotics on 3/17/12 revealed no discrepancies. Interview with the Information Technologist on 3/16/12 verified that he had in-serviced nursing staff on setting new passwords and not to share with anyone. Review of the sign in sheet and agenda dated 3/15/12 revealed that the QA committee had met and discussed the narcotic misappropriation and documentation issues. Interview with the Medical Director on 3/16/12 at 1:45 p.m. verified that he had participated in the QA meeting on 3/15/12 and discussed the narcotic issues. Review of personnel files for LPN #1, LPN #2 and LPN #3 verified that they had been terminated by the facility for misappropriation and/or documentation issues and for LPN #1's failure of a urine drug screen without proper prescriptions for all medications.

CI MS # Part 1: Based on observation, interview, record review and policy review the facility failed to ensure that misappropriation of narcotics did not occur for seven (7) of 15 residents reviewed who received pain medications (Residents #4, #11, #13, #14, #15, #16, and #17). Resident #15, #16 and #17 stated that they did not receive pain medication that was signed out for them by Licensed Practical Nurse (LPN) #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. There were documentation discrepancies in the narcotic records noted for 10 residents (Resident #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21) with a pattern of LPN #1 and LPN #2 signing out narcotics. LPN #3 admitted to falsely documenting narcotics on some of the Medication Administration Records for LPN #2. The facility failed to report the misappropriation of medications by LPN #1 when the Director of Nursing was notified on 1/3/12 to the Attorney General's office and the Mississippi State Department of Health (MSDH). There were no documented in-services that included Misappropriation of resident's property/narcotics or narcotic documentation and no routine narcotic audits were performed after a random audit was completed by LPN #3, who was the LPN who falsified narcotic documentation for LPN #2, on 1/5/12 to ensure that any further problems existed after 1/3/12. The facility failed to report LPN #2 and the falsification of Records by LPN #3 to the MSDH when they were notified on 3/8/12 during the Attorney General's office visit and did not initiate in-services for misappropriation and documentation until 3/13/12. There were no adverse effects noted for these residents but the potential existed for them to not receive their pain medication as needed. The positive drug test for LPN #1 with a suspicion of misappropriation of resident medications and the confession of LPN #2 of taking resident's pain medication for personal use along with the lack of implementation of measures to ensure that no further problems of misappropriation existed was identified as an Immediate Jeopardy (IJ) on 3/15/12. The IJ began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the Immediate Jeopardy on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings include: Part 1: Interview with the Director of Nurses (DON) on 3/14/12 at 9:30 a.m. revealed that the Attorney General's (AG) office had been at the facility the week prior (3/8/12) on an anonymous compliant. The DON stated that Licensed Practical Nurse (LPN) #2 had admitted to stealing narcotics and was terminated. The DON stated that LPN #3 had been given a password by LPN #2 and had falsely documented medications for LPN #2 in the computer for medications that had been signed out but not documented and was on suspension pending the completion of the investigation which was still ongoing. The DON stated that the incident had not been reported to the Mississippi State Department of Health (MSDH) at this time unless the Administrator had reported the incidents. (Incident reported by the Administrator on 3/14/12). Interview with the DON on 3/14/12 at 2:05 p.m. confirmed that LPN #1 had a positive drug test and that several residents had been interviewed about medications that LPN #1 had signed out for them but they had not received. Interview with the Director of Nurses (DON) on 3/16/12 at 8:15 a.m. revealed that she had been informed on 1/3/12 that LPN #1 had been signing out narcotics on the "Sedative Record" but not documenting on the Medication Administration Record (MAR) or the nurse's notes. The DON stated that three (3) alert and oriented residents (Resident #15, #16, and #17) had narcotics signed out and reported that they had not received them. The DON stated that there had been some other residents with discrepancies but were not cognitive for interview. The DON stated that LPN #1 was given a drug screen on 1/3/12 that showed positive for Opioids, [MEDICATION NAME], and Benzodiazepines. The DON stated that LPN #1 only presented a prescription for [MEDICATION NAME]. The DON stated that LPN #1 did not admit to taking the residents narcotics and had only said that she was not aware of having to sign the narcotics on the MAR and had thought signing out on the Sedative Record was enough. The DON stated that LPN #1 was terminated for a positive drug screen and reason to suspicion of taking resident narcotics due to documentation. The DON stated that she had the Quality Assurance (QA) nurse, LPN #3 do some audits (1/5/12) of the PRN (as needed) narcotic medications and LPN #3 had reported that there were no further problems. (LPN #3 was the nurse who had falsely documented for LPN #2). The DON verified that no further audits of the narcotic records had been done since January (1/5/12) until the AG's office came to the facility on [DATE]. There were no verified in-services that had been done about misappropriation or narcotic documentation after the incident that was reported for LPN #1 on 1/3/12. The DON stated that the Board of Nursing had been notified but the AG's office nor the Mississippi State Department of Health (MSDH) had been notified at the time of the incident with LPN #1's positive drug screen. (The facility reported LPN #1's incident of discrepancies in documentation and positive drug screen to the MSDH on 3/15/12). Review of a written report to the Mississippi State Department of Health dated 3/15/12 by the Administrator, revealed that Licensed Practical Nurse (LPN) #1 had failed a drug test on 1/3/12 and placed on suspension during an investigation. Findings include that she was charting on the Individual Sedative Record and not on the Medication Administration Record or in the Nurse's Notes. It was suspicious when she signed out controlled drugs on the Individual Sedative Record for three Residents that can tell you if they are given their medications and they stated that they didn't get the medication. LPN #1 was terminated on 2/1/12 for failing the drug screen and was reported to the Board of Nursing on 1/5/12. On March 8-9, 2012, representatives from the Attorney General's office came to investigate LPN #1. Incident for Licensed Practical Nurse #1 reported to the Director of Nurses on 1/3/12: Review of "Personnel File Notes" documented by the DON for Licensed Practical Nurse (LPN) #1 on 1/3/12 revealed the following information: it was reported that LPN #1 was signing out narcotics only on the Sedative record and not putting documentation on the MAR or nurse's notes. It was discovered that three (3) residents (not named, but documented interviews from Resident #15, #16 and #17) had medicines signed out and the residents had not asked for narcotics but for Tylenol only. A drug test was performed on LPN #1 on 1/3/12 which showed positive for [MEDICATION NAME], Benzodiazepines, Opiate and [MEDICATION NAME]. LPN #1 had a prescription for only [MEDICATION NAME] dated 11/15/11 and could not offer an explanation of the other drugs. LPN #1 was asked about signing out narcotics and not documenting and the three (3) resident's reports of not getting the medications that she'd signed out and that it looked suspicious. LPN #1 reported that she had given the medication and said that she was not aware of the need to sign out the narcotics on the MAR and that signing out on the sedative record was her way of charting. LPN was placed off the schedule until the investigation was complete (1/3/12). A message was left for the Board of Nursing (BON) on 1/5/12 at 11:00 a.m. Review of another "Personnel File Notes" documented by the DON for LPN #1dated 1/6/12 revealed that contact was made with the Board of Nursing and information that was requested was faxed. The DON documented that she had asked if she needed to call anyone else and the representative from the BON said he would notify the other entities. Documentation on 2/1/12 revealed no word from LPN #1 and that she was being terminated. Review of "Personnel File Notes" for LPN #1 dated 3/8/12 revealed that AG #1 was at the facility to get information and was given copies of what had been given to the Board of Nursing. When asked why she had not called the AG's office she reported to AG #1 that the Board of Nursing personnel had told her that he would notify the others. Resident #15: Observation and interview with Resident #15 on 3/16/12 at 1:05 p.m. revealed that Resident #15 was alert and oriented to person, place and time and denied pain. Resident #15 stated that she had not taken anything stronger than a Tylenol in a long time and had recalled facility staff asking her about this before several months ago. Record review revealed that Resident #15 moved into the home on 2/16/07 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated that Resident #15 was cognitively intact. Review of Section J of this MDS documented that Resident #15 had no pain. Review of Resident #15's printed December 2011 physician's orders [REDACTED]. Review of an "Individual Sedative Record" for Resident #15 revealed the following dates/times that Hydro/Apap ([MEDICATION NAME]) 5/325 mg was signed out by LPN #1 and no documentation of administration on the Medication Administration record (MAR), detail report for the MAR, or nurse's notes: 11/25/11 at 8:00 p.m.; 11/30/11 at 8:30 (not identified for a.m. or p.m.); 12/1/11 at 9:00 p.m.; 12/6/11 at 8:30 p.m., 12/7/11 at 9:00 p.m., 12/8/11 at 4:00 p.m. and 10:00 p.m.; 12/9/11 at 9:00 p.m.; 12/10/11 at 4:00 p.m. and 10:35 p.m.; 12/11/11 at 4:15 (not identifed for a.m. or p.m.) and 10:30 (not identified for a.m. of p.m.); 12/24/11 ....3:30 p.m. and 10:00 p.m., and 1/2/12 .....3:30 p.m. and 10:15 p.m. Review of Resident #15's current Individual Sedative Record, Medication Administration Records and nurse's notes revealed no documentation that Resident #15 has received [MEDICATION NAME] since 1/2/12. Review of a pain assessment for Resident #15 dated 4/6/11 revealed that she had no complaint of pain or discomfort at this time. Updates to the pain assessment on 8/12/11, 11/3/11, 2/20/11 and 3/14/11 revealed no changes. Review of a written statement taken from Resident #15 by LPN #4 on 12/29/11, revealed that she had not taken anything but Tylenol for awhile, that she had recalled taking some of her pain medication in September when she had sciatica. Interview with Licensed Practical Nurse (LPN) #4 on 3/16/12 at 1:10 p.m. confirmed that she had looked at the Medication Admihistration Records and had seen where [MEDICATION NAME] had been signed out by LPN #1 for residents who didn't normally take the medication a lot. LPN #4 stated that Resident #15 had reported not taking strong pain medicine, only took it for sciatica very seldom. LPN #4 stated that she had reported her findings to the DON on 1/5/12. Resident #16: Observation and interview with Resident #16 on 3/16/12 at 1:00 p.m. revealed that Resident #16 was alert and oriented to person, place and time and denied pain. Resident #16 stated that she occasionally took Tylenol for neck pain and nothing stronger because she didn't like the "strong stuff." Resident #16 stated that she had not had a strong pain pill in a long time and that she had been asked about this before, and had told them the same thing. Review of Resident #16's medical record revealed that she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's most recent MDS with an ARD of 2/14/12 revealed that she was cognitively intact with a BIMS score of 15. The MDS was documented that Resident #16 had occasional pain. Review of Resident #16's printed December 2011 physician's orders [REDACTED]. Review of Resident #16's Individual Sedative Record revealed the following dates and times that LPN #1 signed out [MEDICATION NAME] 10 without documentation of administration on the Medication Administration Record (MAR), detail report for the MAR or the nurse's note with exception of one (1) dose documented in the nurse's notes on 11/25/11 for 7:45 p.m. (signed out on 11/25/11 at 3:50 p.m. and 10:15 p.m. and the detail report for the MAR and the MAR documents the administration of [MEDICATION NAME] on 11/25/11 at 6:10 p.m.). There was no documentation of administration on the Medication Administration Record (MAR), detail report for the MAR, or nurse's notes on: 11/25/11 at 3:50 p.m. and 10:50 p.m.; 11/30/11 at 3:30 p.m. and 9:50 p.m.; 12/7/11 at 3:45 p.m. and 10:15 p.m.; 12/8/11 at 4:00 p.m. and 8:50 p.m.; 12/9/11 at 6:00 p.m.; 12/10/11 at 4:00 p.m. and 9:00 p.m.; 12/11/11 at 3:30 p.m. and 8:00 p.m.; 12/17/11 at 5:30 p.m.; 12/24/11 at 3:30 p.m. and 8:30 p.m., and 1/2/12 at 3:30 p.m. and 8:30 p.m. Review of Resident #16's current Individual Sedative Record revealed that [MEDICATION NAME] 10/500 had been signed out on 1/15/12 with documentation on the Medication Administration Record. There was no further documentation that Resident #16 received [MEDICATION NAME] since that time. Review of Resident #16's Pain assessment dated [DATE] revealed that the current pain meds were effective. The Pain Assessment upated 4/11/09 revealed that Resident #16 denied pain. Updates to the pain assessment for Resident #16 dated 5/11/11, 8/9/11, 2/20/12, and 3/14/12 revealed no changes to the pain assessment. Review of a written statement dated 12/29/11 by LPN #4 revealed that Resident #16 had reported taking only one (1) of her strong pain pills recently and she had slept all day. "I ask for Tylenol for pain." Interview with LPN #4 on 3/16/12 at 1:10 p.m. confirmed that she had looked at the MARs and had seen where [MEDICATION NAME] had been signed out by LPN #1 for residents who didn't normally take the medication a lot. LPN #4 stated that Resident #16 had reported not taking strong pain medicine in a long time and the last one made her sleep all day. LPN #4 stated that LPN #1 had signed out a lot of pain medication in a row for Resident #16. LPN #4 stated that she had reported her findings to the DON on 1/5/12. Resident #17: Observation and interview with Resident #17 on 3/16/12 at 12:40 p.m. revealed that he was alert and oriented to person, place and time and denied pain. Resident #17 stated that he had not received any pain medication other than Tylenol twice daily. Resident #17 stated that he had told someone (at facility) and that if he needed something for pain that he would get it if he asked for it. Resident #17 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's most recent MDS with ARD 1/31/12 revealed that he was cognitively intact with a BIMS score of 14. The MDS had documentation that Resident #17 had no pain. Review of Resident #17's printed December 2011 physician's order [REDACTED]. He also had an order for [REDACTED]. Review of the Individual Sedative Record for Resident #17 revealed the following dates and times that [MEDICATION NAME]/APAP 7.5/650 mg ([MEDICATION NAME] Plus) was signed out by LPN #1 with no documentation of administration on the MAR, detail report for the MAR or nurse's notes: 12/25/11 ....4:15 p.m. 12/26/11 ....3:50 p.m. Review of Resident #17's current Individual Sedative Record and MAR reveals no documentation that the resident has received [MEDICATION NAME] since 12/16/11. Review of a written statement documented by LPN #2 on 1/6/12, revealed that Resident #17 stated that he had not taken any [MEDICATION NAME] in a long time. An attempt to interview LPN #2 was made on 3/14/12 at 2:15 p.m. without success. Review of a Pain Assessment for Resident #17 dated 1/25/10 revealed no complaint of pain at that time with updates 8/6/11, 11/6/11, 2/3/12 and 3/14/12 that revealed no change. Resident #18: Observation and interview with Resident #18 on 3/16/12 at 12:41 p.m. revealed that he had no response and his eyes were closed. [MEDICATION NAME] 1.2 at 65cc/hr/pump was infusing via feeding tube. There were no signs/symptoms of pain for Resident #18. Interview with RN #3 on 3/16/12 at 12:42 p.m. revealed that Resident #18 was not cognitive and that he usually complained of no pain and the [MEDICATION NAME] had been discontinued. Resident #18 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's most recent MDS with an ARD of 3/12/12 revealed that he was severely cognitively impaired with long and short term memory deficits. The MDS had documentation of staff assessment with indicators of pain observed one (1)-two (2) days. Review of a physician's order [REDACTED]. Review of Resident #18 ' s Individual Sedative Record revealed that [MEDICATION NAME] 5/500 mg was signed out by LPN #1 on the following dates and times without documentation of administration on the MAR or nurse ' s notes: 12/25/11 ....4:30 p.m. and 8:40 p.m. 12/26/11 ....3:45 p.m. and 8:15 p.m. Review of Resident #18 ' s current Individual Sedative Record and MAR revealed no [MEDICATION NAME] had been signed out since 12/26/11 and the order had been discontinued on 3/5/12. Review of a Pain assessment dated [DATE] for Resident #18 revealed no pain. Current pain medication listed Tylenol every four (4) hours prn pain/fever. 1/6/11 [MEDICATION NAME] 5/500 every four hours prn pain was added to the pain medication list. Updates to the pain assessment on 8/7/11, 11/8/11, and 2/12/12 revealed no changes. An update on 3/5/12 revealed that Resident #18 complained of no pain or discomfort. Resident #20: Observation and interview with Resident #20 on 3/16/12 at 1:03 p.m. revealed that her eyes were closed with the head of the bed elevated. There were no signs or symptoms that Resident #20 had any pain. Interview with LPN #4 on 3/16/12 at 1:10 p.m. revealed that Resident #20 didn ' t talk and that she slept all of the time and was not cognitive and didn ' t usually get pain medication. LPN #4 stated that she had looked one day and they had been a lot of [MEDICATION NAME] signed out for residents who didn ' t usually take pain medication and that Resident #20 was one of the residents. LPN #4 stated that Resident #4 periodically received Tylenol for pain. Resident #20 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #20 ' s most recent MDS with an ARD of 12/21/11 revealed that she had severe cognitive impairment with long and short term memory problems. She was coded for indicators of pain possible three (3) to four (4) days. Review of Resident #20 ' s printed December 2011 physician's order [REDACTED]. Resident #20 also had orders for Tylenol 325 mg every four (4) hours PRN pain. Review of Resident #20 ' s Individual Sedative Record revealed that [MEDICATION NAME] 5 mg was signed out for the following dates and times by LPN #1 without documentation of administration on the MAR or the nurse ' s notes: 12/1/11 ....5:00 p.m. 12/6/11 ....6:00 p.m. 12/7/11 ....4:00 p.m. and 9:00 p.m. 12/8/11 ....3:45 p.m. and 8:15 p.m. 12/9/11 ....4:00 p.m. 12/10/11 ...4:30 p.m. 12/16/11 ...9:00 p.m. Review of Resident #20 ' s current Individual Sedative Record, MAR, and Nurse ' s notes reveal no documentation of receiving [MEDICATION NAME] since 12/16/11. Review of a Pain assessment dated [DATE] and 3/14/12 revealed no complaint of pain and no signs and symptoms of pain noted. Interview with RN #3, Unit Manager (UM) on 3/16/12 at 10:40 a.m. revealed that she had not routinely had a set pattern of checking narcotic records or looking to see if one nurse was signing out any more than another. RN #3 stated that she had not checked MARs for narcotic documentation. RN #3 stated that no one had ever come to her with suspicion of any nurse diverting narcotics except for LPN #1 in January 2012 and that was turned over to the DON. RN #3 stated that she thought since LPN #1 was no longer here that it was solved. RN #3 stated that Resident #17, who was alert and oriented, had said that he had not received pain medication in a long time and LPN #1 had signed out that she had given pain medication to Resident #17. Interview with LPN #1 on 3/16/12 at 7:40 p.m. revealed that she denied diverting narcotics from the facility for personal use. LPN #1 stated that she did have some documentation issues and had not grasped the PRN documentation in the computer. LPN #1 stated that when she gave narcotics that she did sign them out and thought that it had been okay. LPN #1 stated that she had been trained to document on the MAR but just had not grasped the way to document well in the computer. LPN #1 stated that if she signed out the medication that she had given it and didn ' t know why residents would say that they didn ' t receive it. LPN #1 stated that she had been drug tested at the facility and was told that she had tested positive but didn ' t know what for. LPN #1 stated that she had provided a prescription for some pain medications that she had been taking. LPN #1 stated that she had been fired for a positive drug test and narcotic documentation. Incident for LPN #2 that was reported to the facility by the AG Representative 3/8/12: Review of a " Personnel Action " form for LPN #2 dated 3/9/12 documented by the DON, revealed that on 3/9/12 LPN #2 admitted to using the resident ' s (no name) [MEDICATION NAME] for her own use. This was brought forward by the investigator from the Attorney General ' s Investigator whose investigation was conducted on 3/8/12 and 3/9/12. LPN #2 was terminated. BON was contacted and to pick up records on 3/12/11. Review of a signed statement from LPN #2 dated 3/9/12 and witnessed by AG Investigators, #1 and #2, revealed the following: "I (LPN #2) took some [MEDICATION NAME] from the following patients (Resident #11, Resident #4, Resident #13, & Resident #14) on different occasions-some of the pain meds that is documented on the drug sheets were actually given to the residents. I did take some of the pills myself R/T (related to) legs, feet and lower back pain especially when I worked more than 1 shift. I would ask my patients on a dly (daily) basis if they were hurting if they were I would give them a pill-if not it was an opportunity that I could take it. When I say take it I mean I consumed it myself. I would sign them out in the computer and then on the narcotic sheets-sometimes I would forget to put it in the computer and I would go back at a later date and put it in the computer-not all of the ones I put in the computer at a later time were pills I consumed myself-these were some times that I gave (error) the pills to the patients and forgot to sign them off in the computer. If my patient said they were hurting I gave them their pain meds. All of this has occurred over the past couple of months-approx less than 50 [MEDICATION NAME] but more than 20 have been consumed by myself over the past couple of months." Review of a report signed by the Administrator and dated 3/14/12 revealed that AG Investigators #1 was in the facility on 3/8/12 and 3/9/12 conducting an investigation concerning an anonymous report that LPN #2 had inappropriate entries in the medical record regarding the use of controlled drugs, namely [MEDICATION NAME]. AG Investigated #1 informed the Administrator and Assistant Administrator on 3/9/12 that LPN #2 had admitted to taking [MEDICATION NAME] and LPN #2 was informed of termination at that time. During the investigation AG Investigator #1 and #2 stated that LPN #3 was involved in a cover up of the entries made on the MAR and LPN #3 was suspended until the investigation was complete. The BON was contacted on 3/9/12. It was documented that the incident with LPN #2 was not reported sooner than 3/14/12 due to the investigation being conducted by the AG office. An attempt to interview LPN #2 was made on 3/14/12 at 2:15 p.m. without success. The following Residents were identified by LPN #2 as residents that she took medication from: Resident #4, Resident #11, Resident #13 and Resident #14. Resident #4: Observation and interview with Resident #4 on 3/15/12 at 6:00 p.m. revealed that she was in the bed being fed by staff and consumed 100 percent of the meal. Observation and interview with Resident #4 on 3/16/12 at 12:45 p.m. revealed that she was alert and oriented to person only and had no complaint of pain. Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's MDS with an ARD of 2/17/12 revealed that she had severe cognitive impairment with a BIMS score of 5. A score of 0-5 is indicative of severe impairment. Section J of the MDS documented that Resident #4 had rarely complained of mild pain. Review of Resident #4's printed December 2011 physician's orders [REDACTED]. Review of Resident #4's Individual Sedative Record revealed that [MEDICATION NAME] Plus was signed out by LPN #2 on the following dates/times and documented as administered on the MAR for the dates signed out, but documented incorrectly on the Administration Record (detail report): 12/13/11 ...1:00 p.m. (documented on detail report 1/8/12 at 1:57 p.m.) 12/14/11 ...10:00 a.m. (documented on detail report 1/8/12 at 1:58 p.m.) 12/18/11 ...9:00 a.m. (documented on detail report 1/8/12 at 1:59 p.m.) 12/19/11 ...8:15 a.m. (documented on detail report 1/8/12 at 1:59 p.m.) 12/20/11 ...8:30 a.m. (documented on detail report 1/8/12 at 2:00 p.m.) 12/21/11 ...8:45 a.m. (documented on detail report 1/8/12 at 2:01 p.m.) 12/22/11 ...8:30 a.m. (documented on detail report 1/8/12 at 2:08 p.m.) Further review of Resident #4's Individual Sedative Record revealed that [MEDICATION NAME] Plus was signed out on 12/25/11 at 4:15 p.m. and 8:30 p.m. and again on 12/26/11 at 3:45 p.m. and 7:50 p.m. by LPN #1 and not documented on the December 2011 MAR. Review of an updated pain assessment for Resident #4 on 3/14/12 revealed that she complained of some pain in both ears. Resident receives Tylenol PRN. There has been no [MEDICATION NAME] documented for Resident #4 since 2/4/12. Resident #11: Observation and interview with Resident #11 on 3/15/12 at 5:45 p.m. revealed that he stated "doing pretty good right now, they give me something if I ' m hurting". Further interview and observation of Resident #11 on 3/16/12 at 12:55 p.m. revealed that he was alert and oriented to person and denied complaint of pain. Resident #11 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's most recent MDS with an ARD 2/28/12 revealed that he had severe cognitive impairment with a BIMS score of 5. A score of 0-7 indicates severe impairment. Review of section J of the MDS revealed that Resident #11 had occasional moderate pain. Review of Resident #11's updated Pain Assessment on 3/14/12 revealed no changes in the assessment. Review of Resident #11's printed January 2012 orders and current physician's orders [REDACTED]. Review of Resident #11's Individual Sedative Record revealed that LPN #2 was the only nurse to sign out [MEDICATION NAME] Plus from 10/30/11-3/3/12 which included a total of 22 doses. (LPN #2 signed a documented confession of taking this resident's [MEDICATION NAME]). The doses were documented on the MAR and detail record of the Administration Record at the same time as on the Individual Sedative Record. The following dates/times were documented: 10/30/11 ...4:00 p.m. 10/31/11 ...8:15 a.m. and 3:45 p.m. 11/1/11 ....9:00 a.m. 11/2/11 ....8:30 a.m. 11/3/11 ....8:35 a.m. 11/9/11 ....8:30 a.m. 11/10/11 ...8:45 a.m. 11/11/11 ...8:30 a.m 11/28/11 ...9:00 a.m. 12/1/11 ....8:45 a.m. 12/2/11 ....9:00 a.m. 12/3/11 ....8:30 a.m. 12/4/11 ....8:45 a.m. 12/6/11 ....8:15 a.m. 12/27/11 ...9:00 a.m. 12/28/11 ...8:30 a.m. 12/29/11 ...9:00 a.m. 12/30/11 ...8:45 a.m. 1/5/12 .....8:45 a.m. 1/7/12 .....8:30 a.m. 3/3/12 ....5:00 p.m. Resident #13: Observation and interview with Resident #13 on 3/15/12 at 5:50 p.m. revealed no verbal response and contractures to bilateral lower extremities. Resident #13 was smiling. No complaint of signs of pain. Resident #13 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's MDS with an ARD of 12/14/11 and a MDS with an ARD of 3/14/12 revealed that Resident #13 had severe cognitive impairment with long and short term memory problems. Section J of the MDS documented no pain for Resident #13. Review of a Pain Assessment updated on 3/14/12 revealed that Resident #13 had no complaint of pain. Review of Resident #13's printed physician's orders [REDACTED]. Review of Resident #13's Individual Sedative Record revealed that LPN #2 had signed out nine (9) doses of [MEDICATION NAME] from 12/1/11-12/30/11 and was the only nurse to sign out the [MEDICATION NAME] for December 2011. All doses were documented on the MAR for the times that the [MEDICATION NAME] was signed out but review of the Administration Record "detail report" revealed that the dose signed out for 12/29/11 at 8:30 a.m. was documented on 1/8/12 at 1:43 p.m. There was no documentation in the nurse's notes that Resident #13 had pain medication. The following dates/times for [MEDICATION NAME] were documented on the Individual Sedative Record for Resident #13 by LPN #2: 12/1/11 ...8:15 a.m. 12/2/11 ...8:30 a.m. 12/3/11 ...8:20 a.m. 12/4/11 ...8:15 a.m. 12/6/11 ...8:15 a.m. 12/27/11..8:15 a.m. 12/28/11..8:05 a.m. 12/29/11..8:30 a.m. (Documented on the detail report on 1/8/12 at 1:43 p.m.) 12/30/11..8:25 a.m. There was no further documentation after 12/30/11 that Resident #13 received [MEDICATION NAME]. Resident #14: Observation and interview with Resident #14 on 3/15/12 at 5:40 p.m. revealed that she was fed by staff, was confused and her speech was slurred. Further observation on 3/16/12 at 12:50 p.m. revealed that Resident #14 was up in a geri-chair with no verbal response and no signs/symptoms of pain. Resident #14 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's MDS with an ARD of 12/21/11 revealed that she had severe cognitive impairment with long and short term memory problems. Section J revealed no complaint of pain. Review of an updated Pain assessment dated [DATE] revealed no changes for pain. Review of Resident #14 's printed December 2011 physician's orders [REDACTED]. Review of an Individual Sedative Record for Resident #14 revealed that [MEDICATION NAME] was signed out for the following dates and times by LPN #2 with all doses documented on the MAR but with discrepancies in the "Detail Report" of the Administration Record: 12/18/11 ...8:30 a.m. (Detail report documented 1/5/12 at 2:50 p.m.) 12/19/11 ...8:30 a.m. (Detail report documented 1/5/12 at 2:51 p.m.) 12/20/11 ...8:30 a.m. (Detail report documented 1/5/12 at 2:52 p.m.) 12/21/11 ...8:30 a.m. (Detail report documented 1/5/12 at 2:52 p.m.) 12/22/11 ...8:30 a.m. (Detail report documented 1/5/12 at 2:53 pXX

Based on record review, staff interview and policy review, the facility failed to report an allegation of abuse reported by a resident to a staff member to the appropriate state agencies for one (1) of six (6) residents reviewed (Resident #18). Findings include: Resident #18 Record review revealed that Resident #18 moved into the home on 6/14/06 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 11 which indicated that Resident #18 ' s cognitive status was moderately impaired. Record review revealed that Resident #18 stated in a complaint on 8/12/11 that a CNA (Certified Nurse Aide) pulled him around his neck last night while the CNA was turning him. Review of a Complaint form, dated 12/6/11, revealed that Resident #18 reported to the 7 - 3 staff that someone on 11 - 7 shift screamed at him last night. Review of a Complaint, dated 1/5/12, revealed Resident #18 complained that a nurse yelled at him last night and was upset with him. Interview on 2/9/12 at 12:00 noon with the Director of Nurses revealed: "No I didn't call it in. I investigated and didn't substantiate it, so, I didn't call it in." Interview on 2/10/12 at 12:05 p.m. with the Administrator revealed, "I didn't call those in because they weren't substantiated. We call in incidents and accidents but, we didn't call those in."

CI MS # Part 1: Based on observation, interview, record review and policy review the facility failed to ensure that misappropriation of narcotics did not occur for seven (7) of 15 residents reviewed who received pain medications (Residents #4, #11, #13, #14, #15, #16, and #17). Resident #15, #16 and #17 stated that they did not receive pain medication that was signed out for them by Licensed Practical Nurse (LPN) #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. There were documentation discrepancies in the narcotic records noted for 10 residents (Resident #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21) with a pattern of LPN #1 and LPN #2 signing out narcotics. LPN #3 admitted to falsely documenting narcotics on some of the Medication Administration Records for LPN #2. The facility failed to report the misappropriation of medications by LPN #1 when the Director of Nursing was notified on 1/3/12 to the Attorney General's office and the Mississippi State Department of Health (MSDH). There were no documented in-services that included Misappropriation of resident's property/narcotics or narcotic documentation and no routine narcotic audits were performed after a random audit was completed by LPN #3, who was the LPN who falsified narcotic documentation for LPN #2, on 1/5/12 to ensure that any further problems existed after 1/3/12. The facility failed to report LPN #2 and the falsification of Records by LPN #3 to the MSDH when they were notified on 3/8/12 during the Attorney General's office visit and did not initiate in-services for misappropriation and documentation until 3/13/12. There were no adverse effects noted for these residents but the potential existed for them to not receive their pain medication as needed. The positive drug test for LPN #1 with a suspicion of misappropriation of resident medications and the confession of LPN #2 of taking resident's pain medication for personal use along with the lack of implementation of measures to ensure that no further problems of misappropriation existed was identified as an Immediate Jeopardy on 3/15/12. The Immediate Jeopardy began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the Immediate Jeopardy on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to a "D" level which constitutes no actual harm with potential for more than minimal harm. Findings include: Part 1: Interview with the Director of Nurses (DON) on 3/14/12 at 9:30 a.m. revealed that the Attorney General's (AG) office had been at the facility the week prior (3/8/12) on an anonymous compliant. The DON stated that Licensed Practical Nurse (LPN) #2 had admitted to stealing narcotics and was terminated. The DON stated that LPN #3 had been given a password by LPN #2 and had falsely documented medications for LPN #2 in the computer for medications that had been signed out but not documented and was on suspension pending the completion of the investigation which was still ongoing. The DON stated that the incident had not been reported to the Mississippi State Department of Health (MSDH) at this time unless the Administrator had reported the incidents. (Incident reported by the Administrator on 3/14/12). Interview with the DON on 3/14/12 at 2:05 p.m. confirmed that LPN #1 had a positive drug test and that several residents had been interviewed about medications that LPN #1 had signed out for them but they had not received. Interview with the Director of Nurses (DON) on 3/16/12 at 8:15 a.m. revealed that she had been informed on 1/3/12 that LPN #1 had been signing out narcotics on the "Sedative Record" but not documenting on the Medication Administration Record (MAR) or the nurse's notes. The DON stated that three (3) alert and oriented residents (Resident #15, #16, and #17) had narcotics signed out and reported that they had not received them. The DON stated that there had been some other residents with discrepancies but were not cognitive for interview. The DON stated that LPN #1 was given a drug screen on 1/3/12 that showed positive for Opioids, [MEDICATION NAME], and Benzodiazepines. The DON stated that LPN #1 only presented a prescription for [MEDICATION NAME]. The DON stated that LPN #1 did not admit to taking the residents narcotics and had only said that she was not aware of having to sign the narcotics on the MAR and had thought signing out on the Sedative Record was enough. The DON stated that LPN #1 was terminated for a positive drug screen and reason to suspicion of taking resident narcotics due to documentation. The DON stated that she had the Quality Assurance (QA) nurse, LPN #3 do some audits (1/5/12) of the PRN (as needed) narcotic medications and LPN #3 had reported that there were no further problems. (LPN #3 was the nurse who had falsely documented for LPN #2). The DON verified that no further audits of the narcotic records had been done since January (1/5/12) until the AG's office came to the facility on [DATE]. There were no verified in-services that had been done about misappropriation or narcotic documentation after the incident that was reported for LPN #1 on 1/3/12. The DON stated that the Board of Nursing had been notified but the AG's office nor the Mississippi State Department of Health (MSDH) had been notified at the time of the incident with LPN #1's positive drug screen. (The facility reported LPN #1's incident of discrepancies in documentation and positive drug screen to the MSDH on 3/15/12). Review of a written report to the Mississippi State Department of Health dated 3/15/12 by the Administrator, revealed that Licensed Practical Nurse (LPN) #1 had failed a drug test on 1/3/12 and placed on suspension during an investigation. Findings include that she was charting on the Individual Sedative Record and not on the Medication Administration Record or in the Nurse's Notes. It was suspicious when she signed out controlled drugs on the Individual Sedative Record for three Residents that can tell you if they are given their medications and they stated that they didn't get the medication. LPN #1 was terminated on 2/1/12 for failing the drug screen and was reported to the Board of Nursing on 1/5/12. On March 8-9, 2012, representatives from the Attorney General's office came to investigate LPN #1. Incident for Licensed Practical Nurse #1 reported to the Director of Nurses on 1/3/12: Review of "Personnel File Notes" documented by the DON for Licensed Practical Nurse (LPN) #1 on 1/3/12 revealed the following information: it was reported that LPN #1 was signing out narcotics only on the Sedative record and not putting documentation on the MAR or nurse's notes. It was discovered that three (3) residents (not named, but documented interviews from Resident #15, #16 and #17) had medicines signed out and the residents had not asked for narcotics but for Tylenol only. A drug test was performed on LPN #1 on 1/3/12 which showed positive for [MEDICATION NAME], Benzodiazepines, Opiate and [MEDICATION NAME]. LPN #1 had a prescription for only [MEDICATION NAME] dated 11/15/11 and could not offer an explanation of the other drugs. LPN #1 was asked about signing out narcotics and not documenting and the three (3) resident's reports of not getting the medications that she'd signed out and that it looked suspicious. LPN #1 reported that she had given the medication and said that she was not aware of the need to sign out the narcotics on the MAR and that signing out on the sedative record was her way of charting. LPN was placed off the schedule until the investigation was complete (1/3/12). A message was left for the Board of Nursing (BON) on 1/5/12 at 11:00 a.m. Review of another "Personnel File Notes" documented by the DON for LPN #1 dated 1/6/12 revealed that contact was made with the Board of Nursing and information that was requested was faxed. The DON documented that she had asked if she needed to call anyone else and the representative from the BON said he would notify the other entities. Documentation on 2/1/12 revealed no word from LPN #1 and that she was being terminated. Review of "Personnel File Notes" for LPN #1 dated 3/8/12 revealed that AG #1 was at the facility to get information and was given copies of what had been given to the Board of Nursing. When asked why she had not called the AG's office she reported to AG #1 that the Board of Nursing personnel had told her that he would notify the others. Resident #15: Observation and interview with Resident #15 on 3/16/12 at 1:05 p.m. revealed that Resident #15 was alert and oriented to person, place and time and denied pain. Resident #15 stated that she had not taken anything stronger than a Tylenol in a long time and had recalled facility staff asking her about this before several months ago. Record review revealed that Resident #15 moved into the home on 2/16/07 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated that Resident #15 was cognitively intact. Review of Section J of this MDS documented that Resident #15 had no pain. Review of Resident #15's printed December 2011 physician's orders [REDACTED]. Review of an "Individual Sedative Record" for Resident #15 revealed the following dates/times that Hydro/APP ([MEDICATION NAME]) 5/325 mg was signed out by LPN #1 and no documentation of administration on the Medication Administration record (MAR), detail report for the MAR, or nurse's notes on 11/25/11 at 8:00 p.m.; 11/30/11 at 8:30 (not identified for a.m. or p.m.); 12/1/11 at 9:00 p.m.; 12/6/11 at 8:30 p.m., 12/7/11 at 9:00 p.m., 12/8/11 at 4:00 p.m. and 10:00 p.m.; 12/9/11 at 9:00 p.m.; 12/10/11 at 4:00 p.m. and 10:35 p.m.; 12/11/11 at 4:15 (not identified for a.m. or p.m.) and 10:30 (not identified for a.m. of p.m.); 12/24/11 ....3:30 p.m. and 10:00 p.m., and 1/2/12 .....3:30 p.m. and 10:15 p.m. Review of Resident #15's current Individual Sedative Record, Medication Administration Records and nurse's notes revealed no documentation that Resident #15 has received [MEDICATION NAME] since 1/2/12. Review of a pain assessment for Resident #15 dated 4/6/11 revealed that she had no complaint of pain or discomfort at this time. Updates to the pain assessment on 8/12/11, 11/3/11, 2/20/11 and 3/14/11 revealed no changes. Review of a written statement taken from Resident #15 by LPN #4 on 12/29/11, revealed that she had not taken anything but Tylenol for awhile, that she had recalled taking some of her pain medication in September when she had sciatica. Interview with Licensed Practical Nurse (LPN) #4 on 3/16/12 at 1:10 p.m. confirmed that she had looked at the Medication Administration Records and had seen where [MEDICATION NAME] had been signed out by LPN #1 for residents who didn't normally take the medication a lot. LPN #4 stated that Resident #15 had reported not taking strong pain medicine, only took it for sciatica very seldom. LPN #4 stated that she had reported her findings to the DON on 1/5/12. Resident #16: Observation and interview with Resident #16 on 3/16/12 at 1:00 p.m. revealed that Resident #16 was alert and oriented to person, place and time and denied pain. Resident #16 stated that she occasionally took Tylenol for neck pain and nothing stronger because she didn't like the "strong stuff." Resident #16 stated that she had not had a strong pain pill in a long time and that she had been asked about this before, and had told them the same thing. Record review revealed that Resident #16 moved into the home on 7/12/05 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #16 was cognitive intact. Review of Section J of the MDS documented that Resident #16 had occasional pain. Review of Resident #16's printed December 2011 physician's orders [REDACTED]. Review of Resident #16's Individual Sedative Record revealed the following dates and times that LPN #1 signed out [MEDICATION NAME] 10 without documentation of administration on the Medication Administration Record (MAR), detail report for the MAR or the nurse's note with exception of one (1) dose documented in the nurse's notes on 11/25/11 for 7:45 p.m. (signed out on 11/25/11 at 3:50 p.m. and 10:15 p.m. and the detail report for the MAR and the MAR documents the administration of [MEDICATION NAME] on 11/25/11 at 6:10 p.m.). There was no documentation of administration on the Medication Administration Record (MAR), detail report for the MAR, or nurse's notes on: 11/25/11 at 3:50 p.m. and 10:50 p.m.; 11/30/11 at 3:30 p.m. and 9:50 p.m.; 12/7/11 at 3:45 p.m. and 10:15 p.m.; 12/8/11 at 4:00 p.m. and 8:50 p.m.; 12/9/11 at 6:00 p.m.; 12/10/11 at 4:00 p.m. and 9:00 p.m.; 12/11/11 at 3:30 p.m. and 8:00 p.m.; 12/17/11 at 5:30 p.m.; 12/24/11 at 3:30 p.m. and 8:30 p.m., and 1/2/12 at 3:30 p.m. and 8:30 p.m. Review of Resident #16's current Individual Sedative Record revealed that [MEDICATION NAME] 10/500 had been signed out on 1/15/12 with documentation on the Medication Administration Record. There was no further documentation that Resident #16 received [MEDICATION NAME] since 1/15/12. Review of Resident #16's Pain assessment dated [DATE] revealed that the current pain medications were effective. The Pain Assessment updated 4/11/09 revealed that Resident #16 denied pain. Updates to the pain assessment for Resident #16 dated 5/11/11, 8/9/11, 2/20/12, and 3/14/12 revealed no changes to the pain assessment. Review of a written statement dated 12/29/11 by Licensed Practical Nurse #4 revealed that Resident #16 had reported taking only one (1) of her strong pain pills recently and she had slept all day. "I ask for Tylenol for pain." Interview with Licensed Practical Nurse (LPN) #4 on 3/16/12 at 1:10 p.m. confirmed that she had looked at the Medication Administration Records and had seen where [MEDICATION NAME] had been signed out by LPN #1 for residents who didn't normally take the medication a lot. LPN #4 stated that Resident #16 had reported not taking strong pain medicine in a long time and the last one made her sleep all day. LPN #4 stated that LPN #1 had signed out a lot of pain medication in a row for Resident #16. LPN #4 stated that she had reported her findings to the Director of Nurses on 1/5/12. Resident #17: Observation and interview with Resident #17 on 3/16/12 at 12:40 p.m. revealed that Resident #17 was alert and oriented to person, place and time and denied pain. Resident #17 stated that he had not received any pain medication other than Tylenol twice daily. Resident #17 stated that he had told someone (at facility) and that if he needed something for pain that he would get it if he asked for it. Record review revealed that Resident #17 moved into the home on 1/25/10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated that Resident #17 was cognitively intact. Review of Section J of this MDS documented that Resident #17 had no pain. Review of Resident #17's printed December 2011 physician's orders [REDACTED]. Resident #17 had an order, dated 8/22/11, for Tylenol Arthritis caplets twice daily. Review of the Individual Sedative Record for Resident #17 revealed the following dates and times that [MEDICATION NAME]/APP 7.5/650 mg ([MEDICATION NAME] Plus) was signed out by Licensed Practical Nurse #1 with no documentation of administration on the Medication Administration Record (MAR), detail report for the MAR or nurse's notes on 12/25/11 at 4:15 p.m. and 12/26/11 at 3:50 p.m. Review of Resident #17's current Individual Sedative Record and the Medication Administration Record revealed there was no documentation that Resident #17 had received [MEDICATION NAME] since 12/16/11. Review of a written statement documented by Licensed Practical Nurse (LPN) #2 on 1/6/12, revealed that Resident #17 stated that he had not taken any [MEDICATION NAME] in a long time. An attempt to interview LPN #2 was made on 3/14/12 at 2:15 p.m. by telephone without success. Review of a Pain Assessment for Resident #17 dated 1/25/10 revealed no complaint of pain at that time with updates 8/6/11, 11/6/11, 2/3/12 and 3/14/12 that revealed no change. Resident #18: Observation and interview with Resident #18 on 3/16/12 at 12:41 p.m. revealed that Resident #18 had no response and his eyes were closed. [MEDICATION NAME] 1.2 at 65cc/hr/pump was infusing via feeding tube. There were no signs/symptoms of pain for Resident #18. Interview with Registered Nurse #3 on 3/16/12 at 12:42 p.m. revealed that Resident #18 was not cognitive and that he usually complained of no pain and the [MEDICATION NAME] had been discontinued. Record review revealed that Resident #18 moved into the home on 5/28/10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #18 was severely cognitively impaired with long and short term memory deficits. Review of Section J of this MDS documented that Resident #18 had pain observed one (1) - two (2) days per week. Review of a January 2012 physician's orders [REDACTED]. Review of Resident #18's Individual Sedative Record revealed that [MEDICATION NAME] 5/500 mg (milligrams) was signed out by Licensed Practical Nurse #1 on the following dates and times without documentation of administration on the Medication Administration Record or nurse's notes on 12/25/11 at 4:30 p.m. and 8:40 p.m., and 12/26/11 at 3:45 p.m. and 8:15 p.m. Review of Resident #18's current Individual Sedative Record and the Medication Administration Record revealed [MEDICATION NAME] had not been signed out since 12/26/11, and the order had been discontinued on 3/5/12. Review of a Pain assessment dated [DATE] for Resident #18 revealed no pain. Current pain medication listed Tylenol every four (4) hours PRN pain/fever. 1/6/11 [MEDICATION NAME] 5/500 every four (4) hours PRN (as needed) pain was added to the pain medication list. Updates to the pain assessment on 8/7/11, 11/8/11, and 2/12/12 revealed no changes. An update on 3/5/12 revealed that Resident #18 complained of no pain or discomfort. Resident #20: Observation and interview with Resident #20 on 3/16/12 at 1:03 p.m. revealed that Resident #20's eyes were closed with the head of the bed elevated. There were no signs or symptoms that Resident #20 had any pain. Interview with LPN #4 on 3/16/12 at 1:10 p.m. revealed that Resident #20 didn't talk and that she slept all of the time and was not cognitive and didn't usually get pain medication. LPN #4 stated that she had looked one day and they had been a lot of [MEDICATION NAME] signed out for residents who didn't usually take pain medication and that Resident #20 was one of the residents. LPN #4 stated that Resident #4 periodically received Tylenol for pain. Record review revealed that Resident #20 moved into the home on 11/17/08 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed that she had severe cognitive impairment with long and short term memory problems. Review of Section J of this MDS documented that Resident #20 had pain possible three (3) to four (4) days. Review of Resident #20's printed December 2011 physician's orders [REDACTED]. Resident #20 also had orders for Tylenol 325 mg every four (4) hours PRN pain. Review of Resident #20's Individual Sedative Record revealed that [MEDICATION NAME] 5 mg (milligrams) was signed out for the following dates and times by Licensed Practical Nurse #1 without documentation of administration on the Medication Administration Record or the nurse's notes on 12/1/11 at 5:00 p.m.; 12/6/11 at 6:00 p.m.; 12/7/11 at 4:00 p.m. and 9:00 p.m.; 12/8/11 at 3:45 p.m. and 8:15 p.m.; 12/9/11 at 4:00 p.m.; 12/10/11 at 4:30 p.m., and 12/16/11 at 9:00 p.m. Review of Resident #20's current Individual Sedative Record, the Medication Administration Record, and nurse's notes revealed there was no documentation the Resident #20 received [MEDICATION NAME] since 12/16/11. Review of a Pain assessment dated [DATE] and 3/14/12 revealed no complaint of pain and no signs and symptoms of pain noted. Interview with Registered Nurse (RN) #3, the Unit Manager, on 3/16/12 at 10:40 a.m. revealed that she had not routinely had a set pattern of checking narcotic records or looking to see if one nurse was signing out any more than another. RN #3 stated that she had not checked Medication Administration Records for narcotic documentation. RN #3 stated that no one had ever come to her with suspicion of any nurse diverting narcotics except for Licensed Practical Nurse (LPN) #1 in January 2012 and that was turned over to the Director of Nurses. RN #3 stated that she thought since LPN #1 was no longer here that it was solved. RN #3 stated that Resident #17, who was alert and oriented, had said that he had not received pain medication in a long time and LPN #1 had signed out that she had given pain medication to Resident #17. Interview with Licensed Practical Nurse (LPN) #1 on 3/16/12 at 7:40 p.m. revealed that she denied diverting narcotics from the facility for personal use. LPN #1 stated that she did have some documentation issues and had not grasped the PRN (as needed) documentation in the computer. LPN #1 stated that when she gave narcotics that she did sign them out and thought that it had been okay. LPN #1 stated that she had been trained to document on the Medication Administration Record but just had not grasped the way to document well in the computer. LPN #1 stated that if she signed out the medication that she had given it and didn't know why residents would say that they didn't receive it. LPN #1 stated that she had been drug tested at the facility and was told that she had tested positive but didn't know what for. LPN #1 stated that she had provided a prescription for some pain medications that she had been taking. LPN #1 stated that she had been fired for a positive drug test and narcotic documentation. Incident for Licensed Practical Nurse #2 that was reported to the facility by the Attorney General Representative on 3/8/12: Review of a "Personnel Action" form for Licensed Practical Nurse (LPN) #2 dated 3/9/12 documented by the Director of Nurses, revealed that on 3/9/12 LPN #2 admitted to using the resident's (no name) [MEDICATION NAME] for her own use. This was brought forward by the investigator from the Attorney General's Investigator whose investigation was conducted on 3/8/12 and 3/9/12. LPN #2 was terminated. The Board of Nursing was contacted and to pick up records on 3/12/11. Review of a signed statement from Licensed Practical Nurse (LPN) #2, dated 3/9/12 and witnessed by the Attorney General Investigators #1 and #2, revealed the following: "I (LPN #2) took some [MEDICATION NAME] from the following patients (Resident #11, Resident #4, Resident #13, & Resident #14) on different occasions-some of the pain meds that is documented on the drug sheets were actually given to the residents. I did take some of the pills myself R/T (related to) legs, feet and lower back pain especially when I worked more than 1 shift. I would ask my patients on a dly (daily) basis if they were hurting if they were I would give them a pill-if not it was an opportunity that I could take it. When I say take it I mean I consumed it myself. I would sign them out in the computer and then on the narcotic sheets-sometimes I would forget to put it in the computer and I would go back at a later date and put it in the computer-not all of the ones I put in the computer at a later time were pills I consumed myself-these were some times that I gave (error) the pills to the patients and forgot to sign them off in the computer. If my patient said they were hurting I gave them their pain meds. All of this has occurred over the past couple of months-approx (approximately) less than 50 [MEDICATION NAME] but more than 20 have been consumed by myself over the past couple of months." Review of a report signed by the Administrator and dated 3/14/12 revealed that AG (Attorney General) Investigator #1 was in the facility on 3/8/12 and 3/9/12 conducting an investigation concerning an anonymous report that LPN (Licensed Practical Nurse) #2 had inappropriate entries in the medical record regarding the use of controlled drugs, namely [MEDICATION NAME]. AG Investigator #1 informed the Administrator and Assistant Administrator on 3/9/12 that LPN #2 had admitted to taking [MEDICATION NAME] and LPN #2 was informed of termination at that time. During the investigation AG Investigators #1 and #2 stated that LPN #3 was involved in a cover up of the entries made on the MAR (Medication Administration Record) and LPN #3 was suspended until the investigation was complete. The BON (Board of Nursing) was contacted on 3/9/12. It was documented that the incident with LPN #2 was not reported sooner than 3/14/12 due to the investigation being conducted by the AG office. An attempt to interview Licensed Practical Nurse #2 was made on 3/14/12 at 2:15 p.m. without success. The following residents were identified by Licensed Practical Nurse #2 as residents that she took medication from: Resident #4, Resident #11, Resident #13 and Resident #14. Resident #4: Observation and interview with Resident #4 on 3/15/12 at 6:00 p.m. revealed that Resident #4 was in the bed being fed by staff and consumed 100 percent of the meal. Observation and interview with Resident #4 on 3/16/12 at 12:45 p.m. revealed that she was alert and oriented to person only and had no complaint of pain. Record review revealed that Resident #4 moved into the hoe on 10/26/04 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 5, which indicated that Resident #4 ' s cognitive status was severely impaired. Review of Section J of this MDS documented that Resident #4 had rarely complained of mild pain. Review of Resident #4's printed December 2011 physician's orders [REDACTED]. Review of Resident #4's Individual Sedative Record revealed that [MEDICATION NAME] Plus was signed out by Licensed Practical Nurse #2 on the following dates/times and documented as administered on the Medication Administration Record for the dates signed out, but documented incorrectly on the Administration Record (detail report) on 12/13/11 at 1:00 p.m. (documented on detail report 1/8/12 at 1:57 p.m.); 12/14/11 at 10:00 a.m. (documented on detail report 1/8/12 at 1:58 p.m.); 12/18/11 at 9:00 a.m. (documented on detail report 1/8/12 at 1:59 p.m.); 12/19/11 at 8:15 a.m. (documented on detail report 1/8/12 at 1:59 p.m.); 12/20/11 at.8:30 a.m. (documented on detail report 1/8/12 at 2:00 p.m.); 12/21/11 at 8:45 a.m. (documented on detail report 1/8/12 at 2:01 p.m.), and 12/22/11 at 8:30 a.m. (documented on detail report 1/8/12 at 2:08 p.m.). Review of Resident #4's Individual Sedative Record revealed that [MEDICATION NAME] Plus was signed out on 12/25/11 at 4:15 p.m. and 8:30 p.m. and again on 12/26/11 at 3:45 p.m. and 7:50 p.m. by Licensed Practical Nurse #1 and was not documented on the December 2011 Medication Administration Record. Review of an updated pain assessment for Resident #4 on 3/14/12 revealed that she complained of some pain in both ears. Resident receives Tylenol PRN (as needed). There was no documentation that [MEDICATION NAME] had been signed out for Resident #4 since 2/4/12. Resident #11: Observation and interview with Resident #11 on 3/15/12 at 5:45 p.m. revealed that Resident #11 stated "Doing pretty good right now, they give me something, if I'm hurting." Interview and observation of Resident #11 on 3/16/12 at 12:55 p.m. revealed that Resident #11 was alert and oriented to person and denied complaint of pain. Record review revealed that Resident #11 moved into the home on 2/8/08 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 5, which indicated that Resident #11 ' s cognitive status was severely impaired. Review of section J of the MDS revealed that Resident #11 had occasional moderate pain. Review of Resident #11's updated Pain Assessment on 3/14/12 revealed there were no changes in the assessment. Review of Resident #11's printed January 2012 orders and current physician's orders [REDACTED]. Review of Resident #11's Individual Sedative Record revealed that Licensed Practical Nurse (LPN) #2 was the only nurse to sign out [MEDICATION NAME] Plus from 10/30/11 through 3/3/12 which included a total of 22 doses. (LPN #2 signed a documented confession of taking Resident #11's [MEDICATION NAME]). The doses were documented on the Medication Adinistration Record and detail record of the Administration Record at the same time as on the Individual Sedative Record. The following dates/times were documented on 10/30/11 at 4:00 p.m.; 10/31/11 at 8:15 a.m. and 3:45 p.m.; 11/1/11 at 9:00 a.m.; 11/2/11 at 8:30 a.m., 11/3/11 at 8:35 a.m.; 11/9/11 at 8:30 a.m.; 11/10/11 at 8:45 a.m.; 11/11/11 at 8:30 a.m.; 11/28/11 at 9:00 a.m.; 12/1/11 at 8:45 a.m.; 12/2/11 at 9:00 a.m.; 12/3/11 at 8:30 a.m.; 12/4/11 at 8:45 a.m.; 12/6/11 at 8:15 a.m.; 12/27/11 at 9:00 a.m.; 12/28/11 at 8:30 a.m.; 12/29/11 at 9:00 a.m.; 12/30/11 at 8:45 a.m.; 1/5/12 at 8:45 a.m.; 1/7/12 at 8:30 a.m., and 3/3/12 at 5:00 p.m. Resident #13: Observation and interview with Resident #13 on 3/15/12 at 5:50 p.m. revealed there was no verbal response, and contractures to bilateral lower extremities. Resident #13 was smiling and did not exhibit of signs of pain. Record review revealed that Resident #13 moved into the home on 6/22/81 with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS), dated [DATE] and 3/14/12, revealed that Resident #13 had severe cognitive impairment with long and short term memory problems. Review of Section J of the MDS documented no pain for Resident #13. Review of a Pain Assessment updated on 3/14/12 revealed that Resident #13 had no complaint of pain. Review of Resident #13's printed December 2011 physician's orders [REDACTED]. Review of Resident #13's Individual Sedative Record revealed that LPN #2 had signed out nine (9) doses of [MEDICATION NAME] from 12/1/11-12/30/11 and was the only nurse to sign out the [MEDICATION NAME] for December 2011. All doses were documented on the MAR for the times that the [MEDICATION NAME] was signed out but review of the Administration Record "detail report" revealed that the dose signed out for 12/29/11 at 8:30 a.m. was documented on 1/8/12 at 1:43 p.m. There was no documentation in the nurse's notes that Resident #13 had pain medication. The following dates/times for [MEDICATION NAME] were documented on the Individual Sedative Record for Resident #13 by Licensed Practical Nurse #2 on 12/1/11 at 8:15 a.m.; 12/2/11 at 8:30 a.m.; 12/3/11 ...8:20 a.m.; 12/4/11 at 8:15 a.m.; 12/6/11 at 8:15 a.m.; 1

CI MS # Based on interview, record review and policy review, the facility failed to ensure that a facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. This was evident by ensuring resident's were not neglected for one (1) of six (6) residents reviewed, Resident #4. Resident #4 had orders for Resuscitation and facility staff, Licensed Practical Nurse (LPN) #1 failed to provide Cardiopulmonary Resuscitation (CPR) when she found Resident #4 unresponsive and without vital signs at 12:45 a.m. on [DATE]. Resident #4 was pronounced dead by the Coroner on [DATE] at 1:10 a.m. The facility failed to ensure that standards of practice and physician's orders [REDACTED]. The facility failed to implement facility policy and procedure "Abuse", "Incidents- Incident Occurrence", "Full Code" and "Full Codes-No Codes" thereby not providing CPR on full code residents who were unresponsive and without vital signs. Facility staff, LPN #1 practiced nursing beyond the authorized scope of the license as evidenced by failing to provide Resident #4 with CPR. The Administrator and the Director of Nursing (DON) was notified on [DATE] that CPR was not performed on a full code resident, Resident #4. The facility administration failed to thoroughly investigate and report the incident of neglect to the appropriate state agencies as required. The facility's failure to ensure that the facility must be administered in a manner that enable it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident was deemed an Immediate Jeopardy (IJ) on [DATE] at 1:20 p.m. The Immediate Jeopardy was determined to begin on [DATE] and was removed on [DATE]. The Director of Nursing and the Administrator were notified of the Immediate Jeopardy on [DATE] at 1:35 p.m. The facility provided a Credible Allegation of Compliance (AoC) on [DATE]. Based on the facility's implementation of corrective actions and an acceptable Credible Allegation of Compliance, the Immediate Jeopardy was removed as of [DATE] and lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) Committee. Findings Include: Cross refer to F-224 for the facility's failure to provide CPR to Resident #4, who had orders to Resuscitate, when the resident was found without responsiveness and no vital signs. Cross refer to F-281 for the facility's failure to ensure that Standards of Practice and physician's orders [REDACTED].#1 not initiating CPR. Credible Allegation of Compliance: "On [DATE], at 12:45 AM, Licensed Practical Nurse (LPN) #1 was called to the room of Resident #4 by Certified Nursing Assistant (CNA) #1 and found the skin of Resident #4 to be cold and ashy in color with no vital signs which LPN #1 documented in the Nurses Notes. CNA #1 was not certified in CPR, therefore did not initiate CPR. Responsible Party (RP) of Resident #4 was notified on [DATE] at 1:00 AM of death of Resident #4. Cardiopulmonary Resuscitation (CPR) was not performed as ordered by the physician. Resident #4 had a code status of resuscitate. LPN #1 failed to follow physician orders [REDACTED]. On [DATE] at 12:30 PM, during a Utilization Review Meeting, the Medical Director, who is also the Primary Physician for Resident #4, was informed of the failure of LPN #1 to follow Doctor's orders for Resident #4. The Administrator reviewed the chart of Resident #4 on [DATE] at approximately 7:30 AM. A list of all Residents who had died in the facility from [DATE] to [DATE] was reviewed on [DATE] at approximately 7:30 AM by the Administrator and the Director of Nurses. Of the 7 deaths in the facility, only one Resident had a code status of resuscitate which was Resident #4. There were no unusual circumstances to indicate any of other 6 Residents who died in the facility were the result of failure to follow physician orders [REDACTED].#1 to follow Doctor's order for the code status of Resident #4 when discovered with no vital signs on [DATE] at 12:45 AM. The Administrator, Director of Nurses and Director of Medical Records reviewed the code status of all Residents at 7:30 AM on [DATE]. It was determined that 67 Residents out of 172 had a code status of resuscitate. The Administrator notified the Attorney General's office on February 1, 2012 at 3:30 PM of the failure of LPN #1 to follow physician orders [REDACTED]. The Board of Nursing was notified on February 1, 2012 at 2:55 PM by the DON, of the failure of LPN #1 to follow physician orders [REDACTED]. On [DATE] at 3:20 PM, the ADON, Charge Nurse #1, Charge Nurse #2, Charge Nurse #3, LPN #2, LPN #3 and LPN #4 reviewed all 172 charts to ensure that the code status was on the physician orders, ID bracelet and code status list at the nurses station. The ID bracelets were observed for placement on Residents. This was completed by 6:30 PM on [DATE]. An inservice was initiated on [DATE] at 3:20 PM by the Assistant Director of Nurses for all Licensed Practical Nurses and Registered Nurses regarding following physician orders [REDACTED]. No LPN or RN will be allowed to work until they have been inserviced. No staff other than RN's or LPN's are required to be certified in CPR at this facility. LPN #1 was suspended [DATE] pending termination for failure to follow physician orders [REDACTED]. LPN #1 was terminated on [DATE] for failure to follow physician orders [REDACTED]. Quality Assurance Committee met February 1, 2012 at 3:00 PM with the following members present; Quality Assurance Director, Licensed Social Worker, Licensed Activity Director, Quality Assurance Nurse, Administrator, Certified Food Service Manager, Medical Director, Minimum Data Set Coordinator, Family Nurse Practitioner, Assistant Director of Nurses, Director of Maintenance, Laundry Director, Director of Nurses, and Assistant Administrator. Committee members were made aware of the allegation of non-compliance of the failure of LPN #1 to follow Doctor's orders for code status of Resident #4. Members were told that all licensed staff would be inserviced regarding following physician orders [REDACTED]. There were also informed that the Resident identification bracelet was to be worn by Residents at all times and that the code status would be reflected on the bracelet. A list of all Residents who have code status of resuscitate is kept at each nurses station for reference. An official report was made to the Mississippi State Department of Health by the Administrator on [DATE] at 12:47 PM of the incident of the failure of LPN #1 to follow physician orders [REDACTED]. Verification of the AoC: Random interviews with Administrative Staff, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) and observations of random medical records, resident arm bands and lists of resident code status at the nursing stations were conducted on [DATE] and [DATE]. These interviews and rounds were conducted to verify that RNs and LPNs knew the proper procedure of when to administer Cardiopulmonary Resuscitation (CPR) and to confirm that all licensed nurses had been inserviced on Code Status, Neglect, following physician's orders [REDACTED]. The nurses also confirmed that they had been in-serviced on Code Status/CPR, following physician's orders [REDACTED]. Interviews confirmed that staff knew to start CPR if a resident had an order to resuscitate and the resident was found to be without response and no vital signs. Random review of the medical records, resident arm bands and a list of residents with their code status on [DATE] confirmed that all matched the order for the residents' code status. Observation of random residents on [DATE] revealed that they had arm bands with their designated code status. Review of in-service records confirmed that in-services were initiated on [DATE] at 3:20 p.m. by the Assistant Director of Nurses on following the code status in every case as indicated in the chart, initiating CPR any time a resident was found with no vital signs or not breathing and there was an order for [REDACTED]. [REDACTED]. After verification of the facility's corrective action through observation, staff interviews and in-service review, the Immediate Jeopardy was removed and the scope and severity was lowered on [DATE] to a "D" level, which constituted no actual harm with the potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) Committee.

CI MS # Part 1: Based on observation, interview, record review and policy review the facility failed to ensure that misappropriation of narcotics did not occur for seven (7) of 15 residents reviewed who received pain medications (Residents #4, #11, #13, #14, #15, #16, and #17). Resident #15, #16 and #17 stated that they did not receive pain medication that was signed out for them by Licensed Practical Nurse (LPN) #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. There were documentation discrepancies in the narcotic records noted for 10 residents (Resident #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21) with a pattern of LPN #1 and LPN #2 signing out narcotics. LPN #3 admitted to falsely documenting narcotics on some of the Medication Administration Records for LPN #2. The facility failed to report the misappropriation of medications by LPN #1 when the Director of Nursing was notified on 1/3/12 to the Attorney General's office and the Mississippi State Department of Health (MSDH). There were no documented in-services that included Misappropriation of resident's property/narcotics or narcotic documentation and no routine narcotic audits were performed after a random audit was completed by LPN #3, who was the LPN who falsified narcotic documentation for LPN #2, on 1/5/12 to ensure that any further problems existed after 1/3/12. The facility failed to report LPN #2 and the falsification of Records by LPN #3 to the MSDH when they were notified on 3/8/12 during the Attorney General's office visit and did not initiate in-services for misappropriation and documentation until 3/13/12. There were no adverse effects noted for these residents but the potential existed for them to not receive their pain medication as needed. The positive drug test for LPN #1 with a suspicion of misappropriation of resident medications and the confession of LPN #2 of taking resident's pain medication for personal use along with the lack of implementation of measures to ensure that no further problems of misappropriation existed was identified as an Immediate Jeopardy on 3/15/12. The Immediate Jeopardy began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the Immediate Jeopardy on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to an "E" level which constitutes no actual harm with potential for more than minimal harm. Findings include: Part 1: Interview with the Director of Nurses (DON) on 3/14/12 at 9:30 a.m. revealed that the Attorney General's (AG) office had been at the facility the week prior (3/8/12) on an anonymous compliant. The DON stated that Licensed Practical Nurse (LPN) #2 had admitted to stealing narcotics and was terminated. The DON stated that LPN #3 had been given a password by LPN #2 and had falsely documented medications for LPN #2 in the computer for medications that had been signed out but not documented and was on suspension pending the completion of the investigation which was still ongoing. The DON stated that the incident had not been reported to the Mississippi State Department of Health (MSDH) at this time unless the Administrator had reported the incidents. (Incident reported by the Administrator on 3/14/12). Interview with the DON on 3/14/12 at 2:05 p.m. confirmed that LPN #1 had a positive drug test and that several residents had been interviewed about medications that LPN #1 had signed out for them but they had not received. Interview with the Director of Nurses (DON) on 3/16/12 at 8:15 a.m. revealed that she had been informed on 1/3/12 that LPN #1 had been signing out narcotics on the "Sedative Record" but not documenting on the Medication Administration Record (MAR) or the nurse's notes. The DON stated that three (3) alert and oriented residents (Resident #15, #16, and #17) had narcotics signed out and reported that they had not received them. The DON stated that there had been some other residents with discrepancies but were not cognitive for interview. The DON stated that LPN #1 was given a drug screen on 1/3/12 that showed positive for Opioids, [MEDICATION NAME], and Benzodiazepines. The DON stated that LPN #1 only presented a prescription for [MEDICATION NAME]. The DON stated that LPN #1 did not admit to taking the residents narcotics and had only said that she was not aware of having to sign the narcotics on the MAR and had thought signing out on the Sedative Record was enough. The DON stated that LPN #1 was terminated for a positive drug screen and reason to suspicion of taking resident narcotics due to documentation. The DON stated that she had the Quality Assurance (QA) nurse, LPN #3 do some audits (1/5/12) of the PRN (as needed) narcotic medications and LPN #3 had reported that there were no further problems. (LPN #3 was the nurse who had falsely documented for LPN #2). The DON verified that no further audits of the narcotic records had been done since January (1/5/12) until the AG's office came to the facility on [DATE]. There were no verified in-services that had been done about misappropriation or narcotic documentation after the incident that was reported for LPN #1 on 1/3/12. The DON stated that the Board of Nursing had been notified but the AG's office nor the Mississippi State Department of Health (MSDH) had been notified at the time of the incident with LPN #1's positive drug screen. (The facility reported LPN #1's incident of discrepancies in documentation and positive drug screen to the MSDH on 3/15/12). Review of a written report to the Mississippi State Department of Health dated 3/15/12 by the Administrator, revealed that Licensed Practical Nurse (LPN) #1 had failed a drug test on 1/3/12 and placed on suspension during an investigation. Findings include that she was charting on the Individual Sedative Record and not on the Medication Administration Record or in the Nurse's Notes. It was suspicious when she signed out controlled drugs on the Individual Sedative Record for three Residents that can tell you if they are given their medications and they stated that they didn't get the medication. LPN #1 was terminated on 2/1/12 for failing the drug screen and was reported to the Board of Nursing on 1/5/12. On March 8-9, 2012, representatives from the Attorney General's office came to investigate LPN #1. Incident for Licensed Practical Nurse #1 reported to the Director of Nurses on 1/3/12: Review of "Personnel File Notes" documented by the DON for Licensed Practical Nurse (LPN) #1 on 1/3/12 revealed the following information: it was reported that LPN #1 was signing out narcotics only on the Sedative record and not putting documentation on the MAR or nurse's notes. It was discovered that three (3) residents (not named, but documented interviews from Resident #15, #16 and #17) had medicines signed out and the residents had not asked for narcotics but for Tylenol only. A drug test was performed on LPN #1 on 1/3/12 which showed positive for [MEDICATION NAME], Benzodiazepines, Opiate and [MEDICATION NAME]. LPN #1 had a prescription for only [MEDICATION NAME] dated 11/15/11 and could not offer an explanation of the other drugs. LPN #1 was asked about signing out narcotics and not documenting and the three (3) resident's reports of not getting the medications that she'd signed out and that it looked suspicious. LPN #1 reported that she had given the medication and said that she was not aware of the need to sign out the narcotics on the MAR and that signing out on the sedative record was her way of charting. LPN was placed off the schedule until the investigation was complete (1/3/12). A message was left for the Board of Nursing (BON) on 1/5/12 at 11:00 a.m. Review of another "Personnel File Notes" documented by the DON for LPN #1 dated 1/6/12 revealed that contact was made with the Board of Nursing and information that was requested was faxed. The DON documented that she had asked if she needed to call anyone else and the representative from the BON said he would notify the other entities. Documentation on 2/1/12 revealed no word from LPN #1 and that she was being terminated. Review of "Personnel File Notes" for LPN #1 dated 3/8/12 revealed that AG #1 was at the facility to get information and was given copies of what had been given to the Board of Nursing. When asked why she had not called the AG's office she reported to AG #1 that the Board of Nursing personnel had told her that he would notify the others. Resident #15: Observation and interview with Resident #15 on 3/16/12 at 1:05 p.m. revealed that Resident #15 was alert and oriented to person, place and time and denied pain. Resident #15 stated that she had not taken anything stronger than a Tylenol in a long time and had recalled facility staff asking her about this before several months ago. Record review revealed that Resident #15 moved into the home on 2/16/07 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated that Resident #15 was cognitively intact. Review of Section J of this MDS documented that Resident #15 had no pain. Review of Resident #15's printed December 2011 physician's orders [REDACTED]. Review of an "Individual Sedative Record" for Resident #15 revealed the following dates/times that Hydro/APP ([MEDICATION NAME]) 5/325 mg was signed out by LPN #1 and no documentation of administration on the Medication Administration record (MAR), detail report for the MAR, or nurse's notes on 11/25/11 at 8:00 p.m.; 11/30/11 at 8:30 (not identified for a.m. or p.m.); 12/1/11 at 9:00 p.m.; 12/6/11 at 8:30 p.m., 12/7/11 at 9:00 p.m., 12/8/11 at 4:00 p.m. and 10:00 p.m.; 12/9/11 at 9:00 p.m.; 12/10/11 at 4:00 p.m. and 10:35 p.m.; 12/11/11 at 4:15 (not identified for a.m. or p.m.) and 10:30 (not identified for a.m. of p.m.); 12/24/11 ....3:30 p.m. and 10:00 p.m., and 1/2/12 .....3:30 p.m. and 10:15 p.m. Review of Resident #15's current Individual Sedative Record, Medication Administration Records and nurse's notes revealed no documentation that Resident #15 has received [MEDICATION NAME] since 1/2/12. Review of a pain assessment for Resident #15 dated 4/6/11 revealed that she had no complaint of pain or discomfort at this time. Updates to the pain assessment on 8/12/11, 11/3/11, 2/20/11 and 3/14/11 revealed no changes. Review of a written statement taken from Resident #15 by LPN #4 on 12/29/11, revealed that she had not taken anything but Tylenol for awhile, that she had recalled taking some of her pain medication in September when she had sciatica. Interview with Licensed Practical Nurse (LPN) #4 on 3/16/12 at 1:10 p.m. confirmed that she had looked at the Medication Administration Records and had seen where [MEDICATION NAME] had been signed out by LPN #1 for residents who didn't normally take the medication a lot. LPN #4 stated that Resident #15 had reported not taking strong pain medicine, only took it for sciatica very seldom. LPN #4 stated that she had reported her findings to the DON on 1/5/12. Resident #16: Observation and interview with Resident #16 on 3/16/12 at 1:00 p.m. revealed that Resident #16 was alert and oriented to person, place and time and denied pain. Resident #16 stated that she occasionally took Tylenol for neck pain and nothing stronger because she didn't like the "strong stuff." Resident #16 stated that she had not had a strong pain pill in a long time and that she had been asked about this before, and had told them the same thing. Record review revealed that Resident #16 moved into the home on 7/12/05 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #16 was cognitive intact. Review of Section J of the MDS documented that Resident #16 had occasional pain. Review of Resident #16's printed December 2011 physician's orders [REDACTED]. Review of Resident #16's Individual Sedative Record revealed the following dates and times that LPN #1 signed out [MEDICATION NAME] 10 without documentation of administration on the Medication Administration Record (MAR), detail report for the MAR or the nurse's note with exception of one (1) dose documented in the nurse's notes on 11/25/11 for 7:45 p.m. (signed out on 11/25/11 at 3:50 p.m. and 10:15 p.m. and the detail report for the MAR and the MAR documents the administration of [MEDICATION NAME] on 11/25/11 at 6:10 p.m.). There was no documentation of administration on the Medication Administration Record (MAR), detail report for the MAR, or nurse's notes on: 11/25/11 at 3:50 p.m. and 10:50 p.m.; 11/30/11 at 3:30 p.m. and 9:50 p.m.; 12/7/11 at 3:45 p.m. and 10:15 p.m.; 12/8/11 at 4:00 p.m. and 8:50 p.m.; 12/9/11 at 6:00 p.m.; 12/10/11 at 4:00 p.m. and 9:00 p.m.; 12/11/11 at 3:30 p.m. and 8:00 p.m.; 12/17/11 at 5:30 p.m.; 12/24/11 at 3:30 p.m. and 8:30 p.m., and 1/2/12 at 3:30 p.m. and 8:30 p.m. Review of Resident #16's current Individual Sedative Record revealed that [MEDICATION NAME] 10/500 had been signed out on 1/15/12 with documentation on the Medication Administration Record. There was no further documentation that Resident #16 received [MEDICATION NAME] since 1/15/12. Review of Resident #16's Pain assessment dated [DATE] revealed that the current pain medications were effective. The Pain Assessment updated 4/11/09 revealed that Resident #16 denied pain. Updates to the pain assessment for Resident #16 dated 5/11/11, 8/9/11, 2/20/12, and 3/14/12 revealed no changes to the pain assessment. Review of a written statement dated 12/29/11 by Licensed Practical Nurse #4 revealed that Resident #16 had reported taking only one (1) of her strong pain pills recently and she had slept all day. "I ask for Tylenol for pain." Interview with Licensed Practical Nurse (LPN) #4 on 3/16/12 at 1:10 p.m. confirmed that she had looked at the Medication Administration Records and had seen where [MEDICATION NAME] had been signed out by LPN #1 for residents who didn't normally take the medication a lot. LPN #4 stated that Resident #16 had reported not taking strong pain medicine in a long time and the last one made her sleep all day. LPN #4 stated that LPN #1 had signed out a lot of pain medication in a row for Resident #16. LPN #4 stated that she had reported her findings to the Director of Nurses on 1/5/12. Resident #17: Observation and interview with Resident #17 on 3/16/12 at 12:40 p.m. revealed that Resident #17 was alert and oriented to person, place and time and denied pain. Resident #17 stated that he had not received any pain medication other than Tylenol twice daily. Resident #17 stated that he had told someone (at facility) and that if he needed something for pain that he would get it if he asked for it. Record review revealed that Resident #17 moved into the home on 1/25/10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 14, which indicated that Resident #17 was cognitively intact. Review of Section J of this MDS documented that Resident #17 had no pain. Review of Resident #17's printed December 2011 physician's orders [REDACTED]. Resident #17 had an order, dated 8/22/11, for Tylenol Arthritis caplets twice daily. Review of the Individual Sedative Record for Resident #17 revealed the following dates and times that [MEDICATION NAME]/APP 7.5/650 mg ([MEDICATION NAME] Plus) was signed out by Licensed Practical Nurse #1 with no documentation of administration on the Medication Administration Record (MAR), detail report for the MAR or nurse's notes on 12/25/11 at 4:15 p.m. and 12/26/11 at 3:50 p.m. Review of Resident #17's current Individual Sedative Record and the Medication Administration Record revealed there was no documentation that Resident #17 had received [MEDICATION NAME] since 12/16/11. Review of a written statement documented by Licensed Practical Nurse (LPN) #2 on 1/6/12, revealed that Resident #17 stated that he had not taken any [MEDICATION NAME] in a long time. An attempt to interview LPN #2 was made on 3/14/12 at 2:15 p.m. by telephone without success. Review of a Pain Assessment for Resident #17 dated 1/25/10 revealed no complaint of pain at that time with updates 8/6/11, 11/6/11, 2/3/12 and 3/14/12 that revealed no change. Interview with Registered Nurse (RN) #3, the Unit Manager, on 3/16/12 at 10:40 a.m. revealed RN #3 stated that Resident #17, who was alert and oriented, had said that he had not received pain medication in a long time and LPN #1 had signed out that she had given pain medication to Resident #17. Resident #18: Observation and interview with Resident #18 on 3/16/12 at 12:41 p.m. revealed that Resident #18 had no response and his eyes were closed. [MEDICATION NAME] 1.2 at 65cc/hr/pump was infusing via feeding tube. There were no signs/symptoms of pain for Resident #18. Interview with Registered Nurse #3 on 3/16/12 at 12:42 p.m. revealed that Resident #18 was not cognitive and that he usually complained of no pain and the [MEDICATION NAME] had been discontinued. Record review revealed that Resident #18 moved into the home on 5/28/10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #18 was severely cognitively impaired with long and short term memory deficits. Review of Section J of this MDS documented that Resident #18 had pain observed one (1) - two (2) days per week. Section J was completed by Licensed Practical Nurse #6. Review of a January 2012 physician's orders [REDACTED]. Review of Resident #18's Individual Sedative Record revealed that [MEDICATION NAME] 5/500 mg (milligrams) was signed out by Licensed Practical Nurse #1 on the following dates and times without documentation of administration on the Medication Administration Record or nurse's notes on 12/25/11 at 4:30 p.m. and 8:40 p.m., and 12/26/11 at 3:45 p.m. and 8:15 p.m. Review of Resident #18's current Individual Sedative Record and the Medication Administration Record revealed [MEDICATION NAME] had not been signed out since 12/26/11, and the order had been discontinued on 3/5/12. Review of a Pain assessment dated 5/*28*/10 and updated *2/2/12* for Resident #18 revealed no pain. Current pain medication listed Tylenol every four (4) hours PRN pain/fever. 1/6/11 [MEDICATION NAME] 5/500 every four (4) hours PRN (as needed) pain was added to the pain medication list. Updates to the pain assessment on 8/7/11, 11/8/11, and 2/12/12 revealed no changes. An update on 3/5/12 revealed that Resident #18 complained of no pain or discomfort. Resident #20: Observation and interview with Resident #20 on 3/16/12 at 1:03 p.m. revealed that Resident #20's eyes were closed with the head of the bed elevated. There were no signs or symptoms that Resident #20 had any pain. Interview with LPN #4 on 3/16/12 at 1:10 p.m. revealed that Resident #20 didn't talk and that she slept all of the time and was not cognitive and didn't usually get pain medication. LPN #4 stated that she had looked one day and they had been a lot of [MEDICATION NAME] signed out for residents who didn't usually take pain medication and that Resident #20 was one of the residents. LPN #4 stated that Resident #*20* periodically received Tylenol for pain. Record review revealed that Resident #20 moved into the home on 11/17/08 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed that she had severe cognitive impairment with long and short term memory problems. Review of Section J of this MDS documented that Resident #20 had pain possible three (3) to four (4) days. Review of Resident #20's printed December 2011 physician's orders [REDACTED]. Resident #20 also had orders for Tylenol 325 mg every four (4) hours PRN pain. Review of Resident #20's Individual Sedative Record revealed that [MEDICATION NAME] 5 mg (milligrams) was signed out for the following dates and times by Licensed Practical Nurse #1 without documentation of administration on the Medication Administration Record or the nurse's notes on 12/1/11 at 5:00 p.m.; 12/6/11 at 6:00 p.m.; 12/7/11 at 4:00 p.m. and 9:00 p.m.; 12/8/11 at 3:45 p.m. and 8:15 p.m.; 12/9/11 at 4:00 p.m.; 12/10/11 at 4:30 p.m., and 12/16/11 at 9:00 p.m. Review of Resident #20's current Individual Sedative Record, the Medication Administration Record, and nurse's notes revealed there was no documentation the Resident #20 received [MEDICATION NAME] since 12/16/11. Review of a Pain assessment dated [DATE] and 3/14/12 revealed no complaint of pain and no signs and symptoms of pain noted. Interview with Registered Nurse (RN) #3, the Unit Manager, on 3/16/12 at 10:40 a.m. revealed that she had not routinely had a set pattern of checking narcotic records or looking to see if one nurse was signing out any more than another. RN #3 stated that she had not checked Medication Administration Records for narcotic documentation. RN #3 stated that no one had ever come to her with suspicion of any nurse diverting narcotics except for Licensed Practical Nurse (LPN) #1 in January 2012 and that was turned over to the Director of Nurses. RN #3 stated that she thought since LPN #1 was no longer here that it was solved. Interview with Licensed Practical Nurse (LPN) #1 on 3/16/12 at 7:40 p.m. revealed that she denied diverting narcotics from the facility for personal use. LPN #1 stated that she did have some documentation issues and had not grasped the PRN (as needed) documentation in the computer. LPN #1 stated that when she gave narcotics that she did sign them out and thought that it had been okay. LPN #1 stated that she had been trained to document on the Medication Administration Record but just had not grasped the way to document well in the computer. LPN #1 stated that if she signed out the medication that she had given it and didn't know why residents would say that they didn't receive it. LPN #1 stated that she had been drug tested at the facility and was told that she had tested positive but didn't know what for. LPN #1 stated that she had provided a prescription for some pain medications that she had been taking. LPN #1 stated that she had been fired for a positive drug test and narcotic documentation. Incident for Licensed Practical Nurse #2 that was reported to the facility by the Attorney General Representative on 3/8/12: Review of a "Personnel Action" form for Licensed Practical Nurse (LPN) #2 dated 3/9/12 documented by the Director of Nurses, revealed that on 3/9/12 LPN #2 admitted to using the resident's (no name) [MEDICATION NAME] for her own use. This was brought forward by the investigator from the Attorney General's Investigator whose investigation was conducted on 3/8/12 and 3/9/12. LPN #2 was terminated. The Board of Nursing was contacted and to pick up records on 3/12/11. Review of a signed statement from Licensed Practical Nurse (LPN) #2, dated 3/9/12 and witnessed by the Attorney General Investigators #1 and #2, revealed the following: "I (LPN #2) took some [MEDICATION NAME] from the following patients (Resident #11, Resident #4, Resident #13, & Resident #14) on different occasions-some of the pain meds that is documented on the drug sheets were actually given to the residents. I did take some of the pills myself R/T (related to) legs, feet and lower back pain especially when I worked more than 1 shift. I would ask my patients on a dly (daily) basis if they were hurting if they were I would give them a pill-if not it was an opportunity that I could take it. When I say take it I mean I consumed it myself. I would sign them out in the computer and then on the narcotic sheets-sometimes I would forget to put it in the computer and I would go back at a later date and put it in the computer-not all of the ones I put in the computer at a later time were pills I consumed myself-these were some times that I gave (error) the pills to the patients and forgot to sign them off in the computer. If my patient said they were hurting I gave them their pain meds. All of this has occurred over the past couple of months-approx (approximately) less than 50 [MEDICATION NAME] but more than 20 have been consumed by myself over the past couple of months." Review of a report signed by the Administrator and dated 3/14/12 revealed that AG (Attorney General) Investigator #1 was in the facility on 3/8/12 and 3/9/12 conducting an investigation concerning an anonymous report that LPN (Licensed Practical Nurse) #2 had inappropriate entries in the medical record regarding the use of controlled drugs, namely [MEDICATION NAME]. AG Investigator #1 informed the Administrator and Assistant Administrator on 3/9/12 that LPN #2 had admitted to taking [MEDICATION NAME] and LPN #2 was informed of termination at that time. During the investigation AG Investigators #1 and #2 stated that LPN #3 was involved in a cover up of the entries made on the MAR (Medication Administration Record) and LPN #3 was suspended until the investigation was complete. The BON (Board of Nursing) was contacted on 3/9/12. It was documented that the incident with LPN #2 was not reported sooner than 3/14/12 due to the investigation being conducted by the AG office. An attempt to interview Licensed Practical Nurse #2 was made on 3/14/12 at 2:15 p.m. without success. The following residents were identified by Licensed Practical Nurse #2 as residents that she took medication from: Resident #4, Resident #11, Resident #13 and Resident #14. Resident #4: Observation and interview with Resident #4 on 3/15/12 at 6:00 p.m. revealed that Resident #4 was in the bed being fed by staff and consumed 100 percent of the meal. Observation and interview with Resident #4 on 3/16/12 at 12:45 p.m. revealed that she was alert and oriented to person only and had no complaint of pain. Record review revealed that Resident #4 moved into the home on 10/26/04 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 5, which indicated that Resident #4's cognitive status was severely impaired. Review of Section J of this MDS documented that Resident #4 had rarely complained of mild pain. Review of Resident #4's printed December 2011 physician's orders [REDACTED]. Review of Resident #4's Individual Sedative Record revealed that [MEDICATION NAME] Plus was signed out by Licensed Practical Nurse #2 on the following dates/times and documented as administered on the Medication Administration Record for the dates signed out, but documented incorrectly on the Administration Record (detail report) on 12/13/11 at 1:00 p.m. (documented on detail report 1/8/12 at 1:57 p.m.); 12/14/11 at 10:00 a.m. (documented on detail report 1/8/12 at 1:58 p.m.); 12/18/11 at 9:00 a.m. (documented on detail report 1/8/12 at 1:59 p.m.); 12/19/11 at 8:15 a.m. (documented on detail report 1/8/12 at 1:59 p.m.); 12/20/11 at. 8:30 a.m. (documented on detail report 1/8/12 at 2:00 p.m.); 12/21/11 at 8:45 a.m. (documented on detail report 1/8/12 at 2:01 p.m.), and 12/22/11 at 8:30 a.m. (documented on detail report 1/8/12 at 2:08 p.m.). Review of Resident #4's Individual Sedative Record revealed that [MEDICATION NAME] Plus was signed out on 12/25/11 at 4:15 p.m. and 8:30 p.m. and again on 12/26/11 at 3:45 p.m. and 7:50 p.m. by Licensed Practical Nurse #1 and was not documented on the December 2011 Medication Administration Record. Review of an updated pain assessment for Resident #4 on 3/14/12 revealed that she complained of some pain in both ears. Resident receives Tylenol PRN (as needed). There was no documentation that [MEDICATION NAME] had been signed out for Resident #4 since 2/4/12. Resident #11: Observation and interview with Resident #11 on 3/15/12 at 5:45 p.m. revealed that Resident #11 stated "Doing pretty good right now, they give me something, if I'm hurting." Interview and observation of Resident #11 on 3/16/12 at 12:55 p.m. revealed that Resident #11 was alert and oriented to person and denied complaint of pain. Record review revealed that Resident #11 moved into the home on 2/8/08 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 5, which indicated that Resident #11's cognitive status was severely impaired. Review of section J of the MDS revealed that Resident #11 had occasional moderate pain. Review of Resident #11's updated Pain Assessment on 3/14/12 revealed there were no changes in the assessment. Review of Resident #11's printed January 2012 orders and current physician's orders [REDACTED]. Review of Resident #11's Individual Sedative Record revealed that Licensed Practical Nurse (LPN) #2 was the only nurse to sign out [MEDICATION NAME] Plus from 10/30/11 through 3/3/12 which included a total of 22 doses. (LPN #2 signed a documented confession of taking Resident #11's [MEDICATION NAME]). The doses were documented on the Medication Administration Record and detail record of the Administration Record at the same time as on the Individual Sedative Record. The following dates/times were documented on 10/30/11 at 4:00 p.m.; 10/31/11 at 8:15 a.m. and 3:45 p.m.; 11/1/11 at 9:00 a.m.; 11/2/11 at 8:30 a.m., 11/3/11 at 8:35 a.m.; 11/9/11 at 8:30 a.m.; 11/10/11 at 8:45 a.m.; 11/11/11 at 8:30 a.m.; 11/28/11 at 9:00 a.m.; 12/1/11 at 8:45 a.m.; 12/2/11 at 9:00 a.m.; 12/3/11 at 8:30 a.m.; 12/4/11 at 8:45 a.m.; 12/6/11 at 8:15 a.m.; 12/27/11 at 9:00 a.m.; 12/28/11 at 8:30 a.m.; 12/29/11 at 9:00 a.m.; 12/30/11 at 8:45 a.m.; 1/5/12 at 8:45 a.m.; 1/7/12 at 8:30 a.m., and 3/3/12 at 5:00 p.m. Resident #13: Observation and interview with Resident #13 on 3/15/12 at 5:50 p.m. revealed there was no verbal response, and contractures to bilateral lower extremities. Resident #13 was smiling and did not exhibit of signs of pain. Record review revealed that Resident #13 moved into the home on 6/22/81 with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS), dated [DATE] and 3/14/12, revealed that Resident #13 had severe cognitive impairment with long and short term memory problems. Review of Section J of the MDS documented no pain for Resident #13. Review of a Pain Assessment updated on 3/14/12 revealed that Resident #13 had no complaint of pain. Review of Resident #13's printed December 2011 physician's orders [REDACTED]. Review of Resident #13's Individual Sedative Record revealed that LPN #2 had signed out nine (9) doses of [MEDICATION NAME] from 12/1/11-12/30/11 and was the only nurse to sign out the [MEDICATION NAME] for December 2011. All doses were documented on the MAR for the times that the [MEDICATION NAME] was signed out but review of the Administration Record "detail report" revealed that the dose signed out for 12/29/11 at 8:30 a.m. was documented on 1/8/12 at 1:43 p.m. There was no documentation in the nurse's notes that Resident #13 had pain medication. The following dates/times for [MEDICATION NAME] were documented on the Individual Sedative R

CI MS Based on observation, interview, record review and policy review the facility failed to effectively use its resources to ensure that misappropriation of narcotics did not occur for seven (7) of 15 residents reviewed who had pain medication ordered, Residents #4, #11, #13, #14, #15, #16, #17 and for narcotic documentation discrepancies for 10 of 15 residents reviewed who had pain medications ordered, Residents #4, #13, #14, #15, #16, #17, #18, #19, #20 and #21. Interview with Resident #15, #16 and #17 revealed that they did not receive pain medication that was signed out for them by LPN #1. LPN #2 admitted to not giving pain medication that was signed out for Residents #4, #11, #13 and #14. Discrepancies in the narcotic records included narcotics that were signed out but not documented on the Medication Administration Record and false documentation of times that narcotics were administered by LPN #3. There were no adverse effects or increased pain noted for these residents. The facility's failure to effectively utilize their resources to ensure that misappropriation of narcotics and inaccurate documentation of narcotic records did not occur was identified as an Immediate Jeopardy (IJ) on 3/15/12. The IJ began on 1/3/12 and was determined to be removed on 3/17/12. The Administrator was notified of the IJ on 3/16/12 at 12:00 noon. The facility provided a credible Allegation of Compliance (AoC) on 3/16/12. Based on the facility's implementation of corrective actions the Immediate Jeopardy was removed and the scope and severity was lowered on 3/17/12 to an "E" level which constitutes no actual harm with potential for more than minimal harm. Cross refer to F224 for the facility's failure to ensure that misappropriation of narcotics did not occur for Residents #4, #11, #13, #14, #15, #16, and #17 as evidenced by Resident #15, #16 and #17 not receiving narcotics that were signed out for them by LPN #1 and LPN #2 admitted to signing out narcotics for Residents #4, #11, #13 and #14; and for discrepancies in documentation for Residents #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21 that included signing out narcotics without documentation on the Medication Administration Record or nurse's notes and false documentation of the times that medication was administered. Credible Allegation of Compliance: "This is to serve as the credible allegation of compliance (AOC) for the incident involving Licensed Practical Nurse (LPN) #1 as reported to the State Board of Nursing on January 5, 2012, Licensed Practical Nurse (LPN) #2 as investigated by Attorney General (AG) Investigator #1 and Attorney General (AG) Investigator #2 on March 8, 2012 and March 9, 2012, and Licensed Practical Nurse (LPN) #3 as investigated on March 12, 2012. Director of Nursing (DON) received a report on 1/3/12 that LPN #1, was signing out narcotics on the sedative record but not documenting the medication on the medication administration record (MAR) when administered or the nurses notes, five (5) Residents were identified with discrepancies in narcotic administration/documentation by LPN #1. Those Residents identified were Resident #15, Resident #16, Resident #17, Resident #18 and Resident #20. On 1/3/12, a urine drug screen was done on LPN #1 at 3:45 PM. The drug screen was positive for [MEDICATION NAME], Benzodiazepine, Opiate and [MEDICATION NAME]. LPN #1 had a prescription for [MEDICATION NAME] dated 11/15/11 for 40 pills with no refill. LPN #1 could not explain the positive drug screen. LPN #1 stated she was not aware that she needed to chart the medication on the MAR. LPN #1 was placed on suspension and ultimately terminated on 2/1/12 for failing drug test and for suspect for possible misappropriation of Resident property. On 1/4/12 the DON informed the Administrator and the Pharmacy Consultant of the possible problem with the narcotic documentation. Resident #18 and Resident #20 were not interviewable. On 1/4/12, Resident #15, Resident #16, and Resident #17 were interviewed by LPN #2 and LPN #4 concerning pain medication administration. Resident #15 and Resident #17 said they had not received the narcotic medications. Resident #16 said she had only taken one of the "strong pain pills" lately and had slept all day after taking the pill. The Quality Assurance Nurse, LPN #3 conducted a spot check on 1/5/12 on all 6 medications carts to review the documentation of PRN narcotic medications and no other problems were reported to the DON at that time. At approximately 11 AM, on 1/5/12, the DON called the State Board of Nursing and left a message. On 1/6/2012 at 9 AM, the Director of Nursing contacted the Board of Nursing Investigator #1 at the State Board of Nursing and reported the possible problem with the narcotics and supplied all the information requested by the State Board of Nursing. Board of Nursing Investigator #1 informed the DON that he would notify the appropriate entities. The DON asked the Board of Nursing Investigator #1 if she needed to report to any other agency and was told no, he would do that. The DON informed the Administrator of the conversation with the State Board of Nursing. On 2/1/12, LPN #1 was terminated from employment with the facility for failing drug test. Incident of LPN #1 signing out narcotic medications but not documenting medications was given was not reported to the State department of Health or Attorney General's office at that time. The State Department of Health was notified on 3/15/12 by the Administrator that LPN #1 was signing out narcotics on the Individual Sedative Record but no documentation that the medication was administered to the Resident and she failed her drug test. On Thursday, March 8, 2012, AG Investigator #1 presented himself at the facility and talked with the Administrator and Assistant Administrator regarding an anonymous complaint that had been registered against LPN #2. The facility had no prior knowledge of an incident involving LPN #2. He produced several documents which were not reviewable by the Administrator or Assistant Administrator. AG Investigator #1 did not share with us how he intended to conduct the investigation so we made ourselves available. On 3/8/12 at approximately 2 PM, the DON reviewed ten (10) Resident narcotic records that AG Investigator #1 requested. Six (6) Residents were identified with discrepancies of narcotic administration/documentation by LPN #2. Residents identified were Resident #4, Resident #13, Resident #14, Resident #18, Resident #19 and Resident #21. AG Investigator #2 arrived on Friday 3/9/12 to assist AG Investigator #1. About mid afternoon on 3/9/12, AG Investigator #1 contacted the Administrator and asked if he, the Director of Nursing or Assistant Administrator could come to the conference room. LPN #2 had signed a written confession that she had taken some of the controlled drugs that were in question regarding the investigation. The Residents identified in the written confession from LPN #2 were Resident #4, Resident #13, Resident #14 and Resident #11. Due to the cognitive status of these Residents, interview of the Residents was not possible. At that time, both AG Investigator #1 and #2 left the room and only the Administrator and Assistant Administrator and LPN #2 were in the room. The Administrator asked LPN #2 why did she take the medications and LPN #2 stated she worked long hours and her legs and back hurt. On 3/9/12 LPN #2 was informed that she was terminated for misappropriation of Resident medication. AG Investigator #1 and #2 returned to the Administrator's office along with the DON and Assistant Administrator and stated that LPN #2 said LPN #3 had charted omitted PRN controlled drugs several weeks after they were given for LPN #2. The DON said she would suspend LPN #3 and contact the Board of Nursing. The Board of Nursing was contacted by the DON on 3/9/12 at approximately 4:30 PM to report LPN #2 for misappropriation of Resident Medication and for LPN #3 for falsification of documentation. The State Department of Health was notified on 3/14/12 by the Administrator that LPN #2 had confessed to misappropriation of Resident property and LPN #3 for falsification of documentation. On Monday, 3/12/12 the DON and Assistant Director of Nursing talked to LPN #3. LPN #3 admitted to documenting the administration of PRN pain meds for LPN #2. She stated she observed the omissions during a routine audit in January, 2012. This information of charting omissions was not presented to the DON, ADON, or Administrator prior to this statement being given. State Board of Nursing Investigator #2 interviewed LPN #3 on 3/12/12. On Tuesday, 3/13/12, the Administrator conducted a meeting of all employees to review [MEDICATION NAME] blower protect and suspicion of abuse/false claims, and Resident Abuse. His presentation included billing for services that are intended for Resident's, and misappropriation of Resident property including taking medication or supplied intended for Residents. No employee will be allowed to work until they have been inserviced on Resident Abuse. On Wednesday, 3/14/12, the Administrator spoke with AG Investigator #1 at approximately 9:05 AM. The purpose of this contact was to ask him if he had concluded his investigation and if he had any additional information to share. He replied that he had pretty much concluded the investigation and that no additional information was available. LPN #3 was terminated on 3/15/12 for falsification of documentation. On 3/14/12, beginning at 3:30 PM the Pain Assessments were reviewed by the RN supervisors on each wing on the Residents requiring Loratab, [MEDICATION NAME], and [MEDICATION NAME]. There was a total of 32 Residents reviewed with seven (7) Residents on Yellow Wing, 15 on Blue Wing and 10 on Orange Wing. The pain assessments were reviewed and signed. No problems were identified with the pain assessments. On 3/14/12 the DON, RN #1, LPN #5, LPN #6, LPN #7, LPN #8 reviewed the January through March 2012 Individual Sedative Records for 32 Residents requiring [MEDICATION NAME] and [MEDICATION NAME]. The Individual Sedative Records were matched with the MAR for accurate documentation and the detail summary of the MAR was reviewed for timely documentation and explanation for PRN administration of these drugs. There were no further discrepancies noted in the reviews. An inservice was initiated for all employees on 3/14/12 by Social Worker #1, Social Worker #2, and Assistant Director of Nursing on Misappropriation of Resident Property. The inservice included a definition of misappropriation of Resident property, reporting of misappropriation of Resident property, examples of misappropriation of Resident property, including medication, examples of abuse and exploitation. No Licensed Practical Nurse and Registered Nurse will be allowed to work until they have all been inserviced. On 3/14/12, an inservice was initiated by Information Technologist for all computer users. The inservice instructed all computer users that passwords would be changed 3/15/12 upon login and that each employee will set their own password and passwords are not to be shared. On 3/14/12, an inservice was initiated by the Information Technologist and ADON for all Licensed Practical Nurses and Registered Nurses. The inservice stated any Nurse who fails to document PRN medication within a 24 hour time frame must report the omission to their immediate supervisor as well as the DON/ADON. The Nurse making the omission must justify the reason why the omission occurred to the DON/ADON. The omission will be logged and reviewed by the DON/ADON before the Nurse is allowed to document the administration of the PRN on the Medication Administration Record and Detail Sheet. Any suspicion or allegation of misappropriation of Resident medications will be reported to the DON and Administrator when discovered. No LPN or RN will be allowed to work until they have been inserviced. Any suspicions or allegations will be reported to the State Department of Health, Attorney General's Office and State Board of Nursing. A random audit was conducted by the DON on 3/15/12 of five (5) Residents which include Resident A, Resident B, Resident C, Resident #10 and Resident #2. These Residents received narcotic medication on 3/14/12. Resident A and Resident B are alert and oriented and were interviewed by the DON to ensure that they had received their medications. The audit was to ensure individual sedative reports matched the MAR. There were no discrepancies in the review. Quality Assurance Committee met March 15, 2012 at 1:30 PM. Committee members consisted on Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, MDS Coordinator, Medicare Nurse, Quality Assurance Nurse, Assistant Administrator and the Medical Director was contacted via telephone. The committee was made aware of the misappropriation of Resident medications and the termination of employees involved and the actions taken to prevent the recurrence of the incident through random weekly audits of Individual Sedative Records compared to the Medication Administration Record. The members were told that all pain assessments had been updated for Residents with PRN medication orders and that Individual Sedative Records had been reviewed for accuracy against the Medication Administration Record. Members were told that all licensed nursing staff were inserviced regarding omissions of PRN medications and changing of passwords for computer users. Any misappropriation of Resident property will be reported to the proper authorities including the State Department of Health and the Attorney General's office." Verification of the AoC: Random interviews with nursing staff were conducted on 3/16/12 and 3/17/12 to ensure and verify that they had been inserviced on misappropriation of resident property, specifically for narcotic/medication, narcotic documentation, abuse, neglect, and sharing of passwords for computer usage and procedures that they would follow to notify administration of suspected drug diversion and/or documentation discrepancies. Observation and interview on 3/15/12 and 3/16/12 revealed that the narcotic counts were correct on each wing. Review of a Memo from the Information Technologist dated 3/12/12 revealed that staff was not to share their password with anyone. Review of documented in-services revealed that staff had been trained on Fraud and Abuse and Suspicion of Abuse/False Claims Review on 3/13/12. Review of documented in-services revealed that staff had been trained on Computer Usage; Misappropriation of Resident's property, medicine, money and consequences; Passcodes and monitoring medications; and Recognizing and reporting suspicious drug activity on 3/14/12. These in-services were also performed to staff via phone or before their next shift. Review of random audits performed on 3/15/12 and interview with the DON on 3/17/12 revealed no issues in documentation of the narcotics. Review of narcotic sheets and random interviews with residents who had received narcotics on 3/17/12 revealed no discrepancies. Interview with the Information Technologist on 3/16/12 verified that he had in-serviced nursing staff on setting new passwords and not to share with anyone. Review of the sign in sheet and agenda dated 3/15/12 revealed that the QA committee had met and discussed the narcotic misappropriation and documentation issues. Interview with the Medical Director on 3/16/12 at 1:45 p.m. verified that he had participated in the QA meeting on 3/15/12 and discussed the narcotic issues. Review of personnel files for LPN #1, LPN #2 and LPN #3 verified that they had been terminated by the facility for misappropriation and/or documentation issues and for LPN #1's failure of a urine drug screen without proper prescriptions for all medications.

Based on observation, interview, record review and policy review the facility failed to ensure that physician's orders and/or care plans were followed for two (2) of seven (7) residents reviewed for following physician's orders. Resident #6 had orders for [MEDICATION NAME] every other hour of sleep (QOHS) and was given the medication at 4:30 p.m. on 3/15/12. Resident #8 was on a 1200 cubic centimeter (cc) daily fluid restriction and the Intake was not monitored or a total of fluid in a 24 hour period documented to ensure that the fluid intake was being met and not to exceed 1200 cc/day. Findings include: Resident #6: Observation and interview with Resident #6 on 3/14/12 at 12:52 revealed that Resident #6 was alert and oriented to person and answered simple questions. Resident #6 was not sure of the date/time or place. Resident #6 had no complaints. Record review revealed that Resident #6 moved into the home on 10/26/07 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], a Brief Interview for Mental Status score of 8, which indicated that Resident #6's cognitive status was moderately impaired. Review of Resident #6's printed March 2012 physician's orders revealed on order, dated 10/5/11, for [MEDICATION NAME] 1 (one) milligram (mg) every other night for [MEDICAL CONDITION]. Review of an "Individual Sedative Record" for Resident #6 revealed that [MEDICATION NAME] 1 (one) mg (milligram) was signed out on 3/15/12 at 4:30 p.m. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"detail report" Administration Record was documented at 5:16 p.m. that [MEDICATION NAME] 1 (one) mg (milligram) that was scheduled at 8:30 p.m. was administered early by accident and med error was in progress. Interview with Licensed Practical Nurse (LPN) #11 on 3/15/12 at 4:30 p.m. revealed that she had given Resident #6 [MEDICATION NAME] one (1) milligram (mg) at 4:40 p.m. that was ordered for 8:30 p.m. and that was considered a medication error that she would report to the supervisor. Review of the home's "Medication, Administering of General Rules and Reminders" policy, dated 7/1/97, provided by Registered Nurse (RN) #3 on 3/16/12 at 10:40 a.m. noted: " ... 5. The nurse will read the label with the residents name, check the M.A.R. sheet and prepare the medications as ordered ..." Resident #8: Observation and interview with Resident #8 on 3/14/12 at 1:05 p.m. revealed that Resident #8 had just returned from [MEDICAL TREATMENT] and was alert and oriented to person, place and knew that it was either the 13th or 14th of March 2012. Resident #8 stated that she was on fluid restriction due to [MEDICAL TREATMENT] and that she usually only drank what they brought her, that she hardly ever drank from her water pitcher. There was a water pitcher in Resident #8's room. Record review revealed that Resident #8 moved into the home on 10/29/09 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 10, which indicated that Resident #8's cognitive status was moderately impaired. Review of the March 2012 physician's orders revealed an order, dated 2/28/12, for 1200 cc fluid restriction. Review of orders, dated 2/29/12, revealed that Resident #8 fluid restrictions was not to exceed 100 cc liquids per medication pass on 7-3 and 3-11 shift and fluids not to exceed 60 cc on 11-7 shift. Resident #8 received [MEDICAL TREATMENT] three (3) days weekly. Review of a "Medical Nutrition Therapy LTC Assessment" dated 2/28/12 revealed that the Registered Dietician documented that Resident #8 received [MEDICAL TREATMENT] three (3) days per week and the dietician at [MEDICAL TREATMENT] had recommended 1200 cc every 24 hours. An order was received on 2/29/12 for the 1200 cc fluid restriction. Dietary was to provide resident with four (4) ounces (oz) of fluid with each meal and Nepro between meals, this will provide resident with 840 cc and nursing to provide 360 cc fluid every 24 hours to be divided between medication pass. Review of the care plan, dated 10/29/09 and updated 2/28/12, revealed that Resident #8 was to have 1200 cc fluid restriction. One of the approaches on Resident #8's care plan was to monitor Intake and Output (I&O). Review of Resident #8's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was documentation that fluids did not exceed 100 cc per medication pass for 7-3 and 3-11 shift and not to exceed 60 cc on the 11-7 shift on the MAR but no amount of fluid was documented. Review of the "Meals Report-Food & Fluid Intake" record revealed that Resident #8's fluid intake in a 24 hour period ranged from 570 cc totals on 3/1/12 to 1260 cc on 3/8/12. Review of the home's plan of correction for the annual survey of 2/10/12 revealed that the Charge Nurse would monitor intake and amounts on each shift and that intake and output would be documented in the computer. There was no evidence that this was being done. Interview with Registered Nurse (RN) #4 on 3/14/12 at 9:50 a.m. revealed that fluid intake was documented by the nurses and the Certified Nurse Aides (CNAs) in the computer. RN #4 stated that she didn't know if they totaled anywhere other than what the CNAs documented. When asked how it was determined if the residents who had fluid restriction were getting the correct amounts if not totaled her reply was "Guess you can't." Interview with the Assistant DON (ADON) on 3/15/12 at 6:30 p.m. verified that there were no fluid totals for Resident #8 each shift or a 24 hour total. The ADON stated that it could not be determined exactly what the nurse's had given so it could not be determined if Resident #8 was getting what was ordered for 1200 cc fluid/24 hours. The ADON agreed that on some days that Resident #8 had exceeded her 1200 cc/day by CNA documentation and that the physician orders had not been followed. The ADON stated that the care plan had not been followed for monitoring Resident #8's Intake & Output. Interview with the Director of Nurses and the Registered Nurse Consultant on 3/17/12 at 12:10 p.m. revealed that the plan of correction for annual survey had not been followed for monitoring intake and output. Review of the home's "Intake and Output" policy, revised 4/1/10, did not address maintaining daily totals.

CI MS # Based on interview, record review and policy review, the facility failed to ensure that standards of practice and physician's orders were followed for one (1) of six (6) residents reviewed, Resident #4. This was evidenced by failure of facility staff (LPN #1) to provide Cardiopulmonary Resuscitation (CPR) as ordered by the physician on [DATE] for a resident (Resident #4) who was found unresponsive and with no vital signs. Resident #4 was pronounced dead by the Coroner on [DATE]. The facility failed to implement facility policy and procedure "Abuse", "Incidents- Incident Occurrence", "Full Code" and "Full Codes-No Codes" thereby not providing CPR on full code residents who were unresponsive and without vital signs. LPN #1 practiced nursing beyond the authorized scope of the license as evidenced by failing to provide Resident #4 with CPR. The facility's failure to ensure that Standards of Practice and physician's orders were followed for Resident #4 by LPN #1 not initiating CPR by was deemed an Immediate Jeopardy (IJ) on [DATE] at 1:20 p.m. The Immediate Jeopardy was determined to begin on [DATE] and was removed on [DATE]. The Director of Nursing and the Administrator were notified of the Immediate Jeopardy on [DATE] at 1:35 p.m. The facility provided a Credible Allegation of Compliance (AoC) on [DATE]. Based on the facility's implementation of corrective actions and an acceptable Credible Allegation of Compliance, the Immediate Jeopardy was removed as of [DATE] and lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) Committee. Findings Include: Cross refer to F-224 for the facility's failure to provide CPR to Resident #4, who had orders to Resuscitate, when the resident was found without responsiveness and no vital signs. Credible Allegation of Compliance: "On [DATE], at 12:45 AM, Licensed Practical Nurse (LPN) #1 was called to the room of Resident #4 by Certified Nursing Assistant (CNA) #1 and found the skin of Resident #4 to be cold and ashy in color with no vital signs which LPN #1 documented in the Nurses Notes. CNA #1 was not certified in CPR, therefore did not initiate CPR. Responsible Party (RP) of Resident #4 was notified on [DATE] at 1:00 AM of death of Resident #4. Cardiopulmonary Resuscitation (CPR) was not performed as ordered by the physician. Resident #4 had a code status of resuscitate. LPN #1 failed to follow physician orders to provide CPR on Resident #4 on [DATE] at 12:45 AM. On [DATE] at 12:30 PM, during a Utilization Review Meeting, the Medical Director, who is also the Primary Physician for Resident #4, was informed of the failure of LPN #1 to follow Doctor's orders for Resident #4. The Administrator reviewed the chart of Resident #4 on [DATE] at approximately 7:30 AM. A list of all Residents who had died in the facility from [DATE] to [DATE] was reviewed on [DATE] at approximately 7:30 AM by the Administrator and the Director of Nurses. Of the 7 deaths in the facility, only one Resident had a code status of resuscitate which was Resident #4. There were no unusual circumstances to indicate any of other 6 Residents who died in the facility were the result of failure to follow physician orders and the care plan. It was during this review that questions arose regarding failure of LPN #1 to follow Doctor's order for the code status of Resident #4 when discovered with no vital signs on [DATE] at 12:45 AM. The Administrator, Director of Nurses and Director of Medical Records reviewed the code status of all Residents at 7:30 AM on [DATE]. It was determined that 67 Residents out of 172 had a code status of resuscitate. The Administrator notified the Attorney General's office on February 1, 2012 at 3:30 PM of the failure of LPN #1 to follow physician orders for Resident #4 for resuscitation. The Board of Nursing was notified on February 1, 2012 at 2:55 PM by the DON, of the failure of LPN #1 to follow physician orders for Resident #4 for resuscitation. On [DATE] at 3:20 PM, the ADON, Charge Nurse #1, Charge Nurse #2, Charge Nurse #3, LPN #2, LPN #3 and LPN #4 reviewed all 172 charts to ensure that the code status was on the physician orders, ID bracelet and code status list at the nurses station. The ID bracelets were observed for placement on Residents. This was completed by 6:30 PM on [DATE]. An inservice was initiated on [DATE] at 3:20 PM by the Assistant Director of Nurses for all Licensed Practical Nurses and Registered Nurses regarding following physician orders for the following: the code status will be followed in every case as indicated in the chart; CPR must be initiated and continued until told to discontinue by a physician any time a Resident is found with no vital signs or not breathing that has an order for [REDACTED]. No LPN or RN will be allowed to work until they have been inserviced. No staff other than RN's or LPN's are required to be certified in CPR at this facility. LPN #1 was suspended [DATE] pending termination for failure to follow physician orders by no following the resuscitation order for Resident #4. LPN #1 was terminated on [DATE] for failure to follow physician orders for Resident #4. Quality Assurance Committee met February 1, 2012 at 3:00 PM with the following members present; Quality Assurance Director, Licensed Social Worker, Licensed Activity Director, Quality Assurance Nurse, Administrator, Certified Food Service Manager, Medical Director, Minimum Data Set Coordinator, Family Nurse Practitioner, Assistant Director of Nurses, Director of Maintenance, Laundry Director, Director of Nurses, and Assistant Administrator. Committee members were made aware of the allegation of non-compliance of the failure of LPN #1 to follow Doctor's orders for code status of Resident #4. Members were told that all licensed staff would be inserviced regarding following physician orders before they would be allowed to return to work. There were also informed that the Resident identification bracelet was to be worn by Residents at all times and that the code status would be reflected on the bracelet. A list of all Residents who have code status of resuscitate is kept at each nurses station for reference. An official report was made to the Mississippi State Department of Health by the Administrator on [DATE] at 12:47 PM of the incident of the failure of LPN #1 to follow physician orders for Resident #4." Verification of the AoC: Random interviews with Administrative Staff, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) and observations of random medical records, resident arm bands and lists of resident code status at the nursing stations were conducted on [DATE] and [DATE] . These interviews and rounds were conducted to verify that RNs and LPNs knew the proper procedure of when to administer Cardiopulmonary Resuscitation (CPR) and to confirm that all licensed nurses had been inserviced on Code Status, Neglect, following physician's orders and CPR. The licensed nurses confirmed that CPR was initiated on any resident who was found unresponsive, not breathing and without vital signs if there was an order to Resuscitate. The nurses also confirmed that they had been in-serviced on Code Status/CPR, following physician's orders, abuse/neglect, and documentation. Interviews confirmed that staff knew to start CPR if a resident had an order to resuscitate and the resident was found to be without response and no vital signs. Random review of the medical records, resident arm bands and a list of residents with their code status on [DATE] confirmed that all matched the order for the residents' code status. Observation of random residents on [DATE] revealed that they had arm bands with their designated code status. Review of in-service records confirmed that in-services were initiated on [DATE] at 3:20 p.m. by the Assistant Director of Nurses on following the code status in every case as indicated in the chart, initiating CPR any time a resident was found with no vital signs or not breathing and there was an order for [REDACTED]. for resuscitation and actions of in-service of staff, identification bracelets to be worn by residents with reflection of code status and a list to be kept at the nurses station with reflection of resident code status. After verification of the facility's corrective action through observation, staff interviews and in-service review, the Immediate Jeopardy was removed and the scope and severity was lowered on [DATE] to a "D" level, which constituted no actual harm with the potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) Committee.

CI MS # Based on interview, record review and policy review, the facility failed to ensure that resident's were not neglected for one (1) of six (6) residents reviewed, Resident #4. Resident #4 had orders for Resuscitation and facility staff, Licensed Practical Nurse (LPN) #1 failed to provide Cardiopulmonary Resuscitation (CPR) when she found Resident #4 unresponsive and without vital signs at 12:45 a.m. on [DATE]. Resident #4 was pronounced dead by the Coroner on [DATE] at 1:10 a.m. The facility failed to implement facility policy and procedure "Abuse", "Incidents- Incident Occurrence", "Full Code" and "Full Codes-No Codes" thereby not providing CPR on full code residents who were unresponsive and without vital signs. LPN #1 practiced nursing beyond the authorized scope of the license as evidenced by failing to provide Resident #4 with CPR. The facility's failure to ensure that Resident #4 was not neglected by the failure of LPN #1 to initiate CPR was deemed an Immediate Jeopardy (IJ) on [DATE] at 1:20 p.m. . The Immediate Jeopardy was determined to begin on [DATE] and was removed on [DATE]. The Director of Nursing and the Administrator were notified of the Immediate Jeopardy on [DATE] at 1:35 p.m. The facility provided a Credible Allegation of Compliance (AoC) on [DATE]. Based on the facility's implementation of corrective actions and an acceptable Credible Allegation of Compliance, the Immediate Jeopardy was removed as of [DATE] and lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) Committee. Findings Include: An anonymous report was received at the State Agency (SA) on [DATE] that revealed on [DATE], Resident #4 allegedly died because LPN #1 failed to perform CPR (Cardiopulmonary Resuscitation) and that Resident #4 was a full code. Observation of Resident #4 was not conducted. Resident #4 expired on [DATE]. Review of Resident #4's medical record revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed that she was cognitive with a Brief Interview for Mental Status (BIMS) of 11. A score of ,[DATE] is indicative of a moderate cognitive impairment status. Resident #4 required extensive assistance of one (1) to two (2) persons for her activities of daily living. Review of Resident #4's [DATE] physician's orders revealed an Advanced Directive: Resuscitate order since [DATE]. Review of an "Advance Directives Individual Instruction for Health Care Decision" dated [DATE], revealed that Resident #4 had a Resuscitation Agreement on file that was signed by Resident #4's Responsible Party (RP). The Advanced Directive indicated: "Please attempt Resuscitation if loss of vital signs occurs." Review of letters from the facility's Social Services department dated [DATE] and [DATE] in regards to a care conference for Resident #4, documented that a Resuscitative Agreement was in Resident #4's file. Review of a "Departmental Note" dated [DATE] at 3:04 p.m. revealed that Resident #4 had a Resuscitative Agreement on file. Review of a "Departmental Note" dated [DATE] at 4:27 p.m. revealed that Resident #4 had a No Code Agreement in her file. (This was confirmed to be in error by the Licensed Social Worker on [DATE] and should have been a Resuscitative Agreement as indicated by the letter in regards to the care conference on [DATE] and [DATE].) Review of Resident #4's care plans, which were updated [DATE], revealed: "Nursing Alert: Resuscitate" at the top of every care plan page. The [DATE] "E-MAR (electronic medication administration record) and the [DATE] E-TAR (electronic treatment administration record) also had "Nursing Alert: Resuscitation" documented on each page. Review of a "Nurse's Note" dated [DATE] at 12:45 a.m. that was documented by LPN #1, revealed that she was summoned to Resident #4's room per CNA (Certified Nursing Assistant (CNA #1)). Resident #4 was unresponsive, skin cold to touch, no vital signs detected, color ashy. Attempts were made to contact Resident #4's physician with no answer or return call. Coroner was notified to come and pronounce Resident #4. Documentation of the Nurse's Note on [DATE] at 1:00 a.m. revealed that the Coroner pronounced Resident #4 and LPN #1 notified Resident #4's Responsible Party (RP) of the events. There was no documented evidence that an attempt was made to initiate CPR for Resident #4 when she was found by LPN #1 to be unresponsive and without vital signs. Review of a "Certificate of Death" dated [DATE] at 1:10 a.m. revealed that Resident #4 was pronounced dead by the coroner with the immediate cause of death listed as Heart Failure, [MEDICAL CONDITION] and Hypertension. Interview with LPN #1 on [DATE] at 12:00 noon, revealed that she was called to Resident #4's room by CNA #1 who said that she thought the resident was dead. LPN #1 stated that this was around 12:45 a.m. ([DATE]). LPN #1 stated that the CNAs do live checks when they first come in (11:00 p.m.) and that CNA #3 stated that Resident #4 looked like she was sleeping at that check. LPN #1 stated that she went to Resident #4's room and saw her in the bed with a little bit of white foamy froth and bubbles at the side of her mouth. LPN #1 stated that Resident #4's extremities were cold but not stiff. LPN #1 stated that she felt for a carotid pulse and the carotid pulse was absent and that she couldn't feel any breath from Resident #4 on her cheek when she checked. LPN #1 stated that Resident #4 had no response and that she did not attempt a blood pressure. LPN #1 stated that she had attempted to call the physician but that he had not called back. LPN #1 stated that she knew that Resident #4 had orders to resuscitate because she had pulled the chart to make sure. LPN #1 stated that she did not start CPR because the resident's extremities were so cold. LPN #1 stated that she had been certified in CPR. LPN #1 stated that she had not called the other nurse's on duty to come and look at Resident #4, that she did call and ask one nurse to unlock the gate so that the Coroner could get there. LPN #1 stated that she guessed that she'd made a mistake, but felt that since Resident #4 was cold that she had not started CPR, because she wouldn't want someone beating on her chest if she wasn't going to make it. LPN #1 stated that she made the decision not to initiate CPR. LPN #1 stated that she had called the Director of Nurses (DON) that morning ([DATE]) before leaving work to let her know that Resident #4 had expired, that Resident #4 was a code status but that she (LPN #1) had not performed CPR because Resident #4 was cold and had no vital signs. LPN #1 stated that she had meant no ill intent by not starting the CPR for Resident #4, but had simply thought that doing CPR was futile on Resident #4. Interview with CNA #1 on [DATE] at 6:58 a.m. revealed that she had gotten to Resident #4's room around 12:45 a.m. ([DATE]) and knocked on the door with no answer. CNA #1 stated that Resident #4 was pale, foam at the mouth and no response so she went and got LPN #1. CNA #1 stated that LPN #1 came to Resident #4's room and checked Resident #4 for a pulse and said "she's gone". CNA #1 stated that Resident #4 had soiled herself a little and LPN #1 had told her and CNA #2 to clean Resident #4 up and they did. CNA #1 stated that Resident #4's back was still kind of warm when they turned her over and her face was cooler. CNA #1 stated that the Coroner and the family came to the facility. CNA #1 stated that LPN #1 had not asked her to call the other wings for help. CNA #1 stated that she was not currently certified in CPR. Interview with CNA #2 on [DATE] at 8:10 a.m. revealed that she had been told by LPN #1 that Resident #4 had passed ([DATE]) and to help clean her up. CNA #2 stated that she assisted CNA #1 to clean bowel movement (BM) from Resident #4. CNA #2 stated that Resident #4's body was cool-lukewarm and had foamy stuff at her mouth, white foamy bubbles. CNA #2 stated that she had not been asked to call the other stations for assistance. CNA #2 stated that while cleaning Resident #4, they had to turn her over and that when she picked up her right arm that it was not stiff, that it dropped readily. CNA #2 stated that Resident #4 was a dark skinned lady and that she had not really noticed any color change at that time. Interview with CNA #3 on [DATE] at 10:05 a.m. revealed that she had passed out ice around 11:30 p.m. ([DATE]) and Resident #4 was asleep and looked like that she was breathing normally. CNA #3 stated that when she had completed rounds on her hall that LPN #1 told her that Resident #4 had passed. Interview with CNA #4 on [DATE] at 4:15 p.m. revealed that she had seen Resident #4 on the ,[DATE] shift ([DATE]) around 10:,[DATE]:30 p.m. when she provided incontinent care and had given her water before leaving the room. CNA #4 stated that Resident #4 had not had any complaints. Interview with LPN #6 on [DATE] at 6:45 a.m., revealed that she had worked ([DATE]) the night that Resident #4 expired and that there were four (4) nurses in the building. LPN #6 stated that she had not been called by LPN #1 and did not even know that Resident #4 had expired until the family came to the building. LPN #6 stated that if a resident was a full code that she would not have a choice but to initiate CPR even if the resident was cold because she did not feel that not doing CPR was her choice to make. LPN #6 stated that LPN #1 had told her that she had not started CPR on Resident #4 because the resident's arms and legs were cold. Interview with LPN #5 on [DATE] at 7:20 a.m. revealed that he would always do CPR if the resident was a code status and that if there was an order to resuscitate, then CPR had to be started. LPN #5 stated that he was working the night the Resident #4 expired ([DATE]) and that LPN #1 had called his station to have security unlock the gate for the Coroner. LPN #5 stated that LPN #1 had not asked for assistance with Resident #4. Interview with the DON on [DATE] at 7:50 a.m. revealed that LPN #1 had reported that when she went in to check Resident #4 between 12:30 a.m. and 12:45 a.m. ([DATE]) that the resident was cold and had no vital signs. The DON stated that LPN #1 had not told her if she (LPN #1) had attempted CPR and that she (DON) had not asked her (LPN#1) whether she (LPN#1) had called anyone else or not. The DON stated that normally if a resident was a resuscitative status that CPR would be initiated but again, LPN #1 had told her that Resident #4 was cold when Resident #4 was found. The DON stated that Resident #4 was a Resuscitate status (full code) resident. Further interview with the DON on [DATE] at 9:25 a.m. revealed that LPN #1 had called her between 6:30 a.m. and 6:45 a.m. on [DATE] and reported that Resident #4 had expired, that she (LPN #1) had been called to Resident #4's room and Resident #4 was cold with no vital signs. The DON stated that LPN #1 had attempted to call the physician with no answer so she (LPN#1) then notified the Coroner. The DON stated that LPN #1 never said that the Coroner indicated that a code should have been done. The DON stated that she had discussed with the Medical Director who was also Resident #4's primary physician, the fact that CPR was not done because LPN #1 had found the resident cold with no vital signs. The DON stated that the Medical Director did not address the issue of CPR not being done for Resident #4 by LPN #1 (after the fact) but had stated "she did what she needed to do". The DON stated that she didn't think that anything needed to be done at that time because the physician had said what was done was okay. The DON stated that she had not looked at the situation as neglect at that time, but that she did know that physician orders were to be followed and that LPN #1 had not followed them for Resident #4. The DON stated that she had begun an investigation after the Administrator had received notification from the Department of Health about deaths in the facility ([DATE]) and had not completed the entire investigation. Interview with the Medical Director (MD), who was also Resident #4's primary physician, on [DATE] at 10:30 a.m. revealed that he was informed of Resident #4's death and the fact that the LPN had not started CPR during a meeting ([DATE]). The MD stated that the nurse had found the resident cold and didn't start CPR and in retrospect that she should have started CPR if there was an order for [REDACTED].#4 but agreed that the nurse should have followed the order. The MD stated that the nurse did what she thought was right at the time and didn't think about any legal ramifications. The MD stated that a Quality Assurance meeting had been held ([DATE]) about the incident with Resident #4 and that in-services were started about following the physician's orders and making sure the code status was documented and followed. Interview with the Administrator on [DATE] at 7:40 a.m. revealed that he had reviewed Resident #4's chart himself and had read in the nurse's notes where the resident was cold when she was found. The Administrator stated that even though Resident #4 had an order for [REDACTED].#4 other than the nurse's notes and chart, but had reviewed everything and didn't think that LPN #1 was neglectful at the time for not starting CPR on Resident #4. Further interview with the Administrator on [DATE] at 3:45 p.m. revealed that he had not seen the event with Resident #4 as neglectful at the time that the event had occurred because he had reviewed the chart, talked with the physician and ambulance service, but could now see where not doing CPR on a full code resident could be classified as neglect for LPN #1 not performing CPR on Resident #4. The Administrator stated that LPN #1 should have performed CPR on Resident #4. The Administrator stated that he had started an investigation into the incident but agreed that the investigation had not all been documented or completed and that he had not notified the Board of Nursing or the Attorney General's office until [DATE]. Interview with the Family Nurse Practitioner (FNP) on [DATE] at 9:15 a.m. revealed that if a resident has a code status to resuscitate, then the nurses job was to follow the order and initiate CPR until the ambulance staff or physician arrives to take over or tell them to stop. The FNP stated that if a nurse found a resident unresponsive with no vital signs that CPR should be initiated if there was an order to resuscitate, even if the body was cold or even in rigor mortis. The FNP stated that she was aware that Resident #4 had orders to resuscitate and that CPR had not been initiated. The FNP stated that the decision was not within the scope of practice for the nurse (LPN) to make to not follow the physician's orders and that CPR should have been started on Resident #4. Interview with the Coroner on [DATE] at 9:00 a.m. revealed that she had been called to the facility about Resident #4's death ([DATE]). The Coroner stated that she had asked LPN #1 what Resident #4's code status was and was told that she was a full code. The Coroner stated that she had asked LPN #1 why CPR was not done and LPN #1 told her that Resident #4 was cold/dead. The Coroner stated that she informed LPN #1 that the decision was not her choice to make, that if a resident was a code status and had an order to resuscitate, then CPR had to be initiated. The Coroner stated that the statement didn't matter if the doctor said LPN #1's inaction was okay after the event, that if there was an order, then CPR was to be done. The Coroner stated that she had told LPN #1 to call the DON and let her know of the events. The Coroner stated that LPN #1 should have started CPR on Resident #4, that the outcome would probably not have been any different but that not doing CPR was not LPN #1's decision to make. Interview with the Licensed Social Worker (LSW) on [DATE] at 8:50 a.m. revealed that it was part of the admission process was to ask the resident/family if they want a no code or resuscitation agreement. The LSW stated that Resident #4's RP had signed the Resuscitation Agreement for Resident #4 on [DATE]. The LSW stated that the Resuscitation Agreement was documented in the physician's order. The LSW stated that Resuscitation was also documented at the top of Resident #4's care plan as a nursing alert. The LSW stated that she had made a mistake on the [DATE] Departmental Note about Resident #4's code status agreement because Resident #4's code status remained as Resuscitate as evidenced by the care plan letter dated [DATE] for the care plan conference. The LSW stated that no family had contacted her about a change in the code status and that it had just been an error on her part, Resident #4 had orders for Resuscitation in effect on [DATE]. Review of the facility's policy "Abuse" with a revised date of [DATE], revealed: "It is the policy of Golden Age, Inc. that all residents be free from verbal, sexual, physical, and mental abuse; free from corporal punishment, involuntary seclusion, mistreatment, neglect, and misappropriation of resident property. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, or volunteers, staff or other agencies serving the resident, family members or legal guardian, friends, or other individuals." Further documented in the policy: "Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of a "Full Code" policy with a revised date of [DATE], revealed under the "Policy" section: "Code 99 to the designated area will be announced on the intercom system. CPR will be administered to any Resident who has a signed resuscitative agreement." Under the "Procedure" section: "1. Assess Resident ie; choking, not breathing, cyanotic. 2. Clear the airway ie; secretions, food or vomitus. 3. Call CODE 99 to area/room on intercom. 4. Gather CPR equipment: a. Ambu Bag b. Back Board c. Suction Machine & Suction Cannula d. Other CPR Supplies 5. Place Resident in supine position. 6. Place back board under Resident. 7. Begin CPR. 8. Call 911. 9. Notify physician and family. 10. Continue CPR until EMT's arrive. 11. Document in nursing notes the sequence of events." Review of a "Full Codes-No Codes" policy with a revised date of [DATE], revealed "As a matter of understanding, full code means that in the event resuscitation is required, CPR will be administered by Golden Age Staff until the ambulance Paramedics/EMT's arrive...". Review of the facility policy "Incidents- Incident Occurrence" dated revised ,[DATE] revealed "Policy: Incidents occurring in Golden Age, Inc. to Residents, visitors or employees will be reported immediately and an Incident Report completed and forwarded to the Q & A Coordinator. QA Nurse will have DON sign and QA Nurse will forward forms to Administrator. All incidents will be recorded in a log book indicating code and severity. Reporting: It is important to note that the definition of an "incident" encompasses a vast scope of occurrences &/or any serious or life threatening injuries. Accurate reporting & investigating is crucial to our system and provides us with a mechanism to identify and address problems, prevent events which may be harmful to our residents/visitors, and improve interdepartmental communication. Reporting to state will follow the same procedure as the facility's reporting requirements under the abuse policy. Procedure: 1. Assess for injury & document findings on incident report & Nurses's Notes (If Resident). 4. Document in Nurses Notes details of accident. 5. Contact Family or Responsible Party. 6. Contact Physician and document any orders and comments made. 11. if the attending physician is not available, notify MD on call and if on call MD is unavailable, call medical director. 12. If unable to reach primary MD, on call MD, and medical director - call DON. 13. Notify Administrator & DON immediately of any serious or life threatening injuries, abuse, neglect, &/or any Resident on Resident incidents, staff on Resident." Review of the MS Board of Nursing "Administrative Code" dated ,[DATE] revealed "Part 2820 Chapter 1: Denial, Revocation, Suspension of License. Rule 1.2 Unprofessional Conduct Defined. Unprofessional conduct shall include but not be limited to the following: D. [MEDICATION NAME] nursing beyond the authorized scope of the license or directing others to practice beyond their authorized scope; E. failure to maintain medical records in a professional manner: 2) Failure to make intelligible essential entries; K. Assuming duties and responsibilities in the practice of nursing when competency has not been established or maintained; T. Failing to immediately report facts known regarding a nurse who fails to render care in accordance with current standards of practice or illegal practice of any licensed nurse. X. Failure to safeguard the patient's rights and dignity; Y. Intentionally or negligently causing or allowing others to physically, sexually, emotionally or verbally abuse a patient. Part 2830 Chapter 2: Functions of the Licensed Practical Nurse. Rule 2.2 Responsibility. The LPN shall be responsible for: B. [MEDICATION NAME] within the scope of practice as established by the board and according to generally accepted standards of practice. Rule 2.4 Provision of Care. The LPN performs the following functions in any area of the health care facility: Assist the RN in the planning, implementation and evaluation of nursing care by: 4) Respecting the rights of patients by not intentionally or negligently causing or allowing others to physically, sexually, emotionally or verbally abuse a patient; and C. Observing, recording and reporting to the appropriate person the signs and symptoms which may be indicative of change in the patient's condition. The LPN shall not perform nursing assessments on patients. D. Performing nursing procedures for which the LPN has the necessary degree of skill and judgment." Credible Allegation of Compliance: "On [DATE], at 12:45 AM, Licensed Practical Nurse (LPN) #1 was called to the room of Resident #4 by Certified Nursing Assistant (CNA) #1 and found the skin of Resident #4 to be cold and ashy in color with no vital signs which LPN #1 documented in the Nurses Notes. CNA #1 was not certified in CPR, therefore did not initiate CPR. Responsible Party (RP) of Resident #4 was notified on [DATE] at 1:00 AM of death of Resident #4. Cardiopulmonary Resuscitation (CPR) was not performed as ordered by the physician. Resident #4 had a code status of resuscitate. LPN #1 failed to follow physician orders to provide CPR on Resident #4 on [DATE] at 12:45 AM. On [DATE] at 12:30 PM, during a Utilization Review Meeting, the Medical Director, who is also the Primary Physician for Resident #4, was informed of the failure of LPN #1 to follow Doctor's orders for Resident #4. The Administrator reviewed the chart of Resident #4 on [DATE] at approximately 7:30 AM. A list of all Residents who had died in the facility from [DATE] to [DATE] was reviewed on [DATE] at approximately 7:30 AM by the Administrator and the Director of Nurses. Of the 7 deaths in the facility, only one Resident had a code status of resuscitate which was Resident #4. There were no unusual circumstances to indicate any of other 6 Residents who died in the facility were the result of failure to follow physician orders and the care plan. It was during this review that questions arose regarding failure of LPN #1 to follow Doctor's order for the code status of Resident #4 when discovered with no vital signs on [DATE] at 12:45 AM. The Administrator, Director of Nurses and Director of Medical Records reviewed the code status of all Residents at 7:30 AM on [DATE]. It was determined that 67 Residents out of 172 had a code status of resuscitate. The Administrator notified the Attorney General's office on February 1, 2012 at 3:30 PM of the failure of LPN #1 to follow physician orders for Resident #4 for resuscitation. The Board of Nursing was notified on February 1, 2012 at 2:55 PM by the DON, of the failure of LPN #1 to follow physician orders for Resident #4 for resuscitation. On [DATE] at 3:20 PM, the ADON, Charge Nurse #1, Charge Nurse #2, Charge Nurse #3, LPN #2, LPN #3 and LPN #4 reviewed all 172 charts to ensure that the code status was on the physician orders, ID bracelet and code status list at the nurses station. The ID bracelets were observed for placement on Residents. This was completed by 6:30 PM on [DATE]. An in-service was initiated on [DATE] at 3:20 PM by the Assistant Director of Nurses for all Licensed Practical Nurses and Registered Nurses regarding following physician orders for the following: the code status will be followed in every case as indicated in the chart; CPR must be initiated and continued until told to discontinue by a physician any time a Resident is found with no vital signs or not breathing that has an order for [REDACTED]. No LPN or RN will be allowed to work until they have been in-serviced. No staff other than RN's or LPN's are required to be certified in CPR at this facility. LPN #1 was suspended [DATE] pending termination for failure to follow physician orders by no following the resuscitation order for Resident #4. LPN #1 was terminated on [DATE] for failure to follow physician orders for Resident #4. Quality Assurance Committee met February 1, 2012 at 3:00 PM with the following members present; Quality Assurance Director, Licensed Social Worker, Licensed Activity Director, Quality Assurance Nurse, Administrator, Certified Food Service Manager, Medical Director, Minimum Data Set Coordinator, Family Nurse Practitioner, Assistant Director of Nurses, Director of Maintenance, Laundry Director, Director of Nurses, and Assistant Administrator. Committee members were made aware of the allegation of non-compliance of the failure of LPN #1 to follow Doctor's orders for code status of Resident #4. Members were told that all licensed staff would be inserviced regarding following physician orders before they would be allowed to return to work. There were also informed that the Resident identification bracelet was to be worn by Residents at all times and that the code status would be reflected on the bracelet. A list of all Residents who have code status of resuscitate is kept at each nurses station for reference. An official report was made to the Mississippi State Department of Health by the Administrator on [DATE] at 12:47 PM of the incident of the failure of LPN #1 to follow physician orders for Resident #4." Verification of the AoC: Random interviews with Administrative Staff, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) and observations of random medical records, resident arm bands and lists of resident code status at the nursing stations were conducted on [DATE] and [DATE]. These interviews and rounds were conducted to verify that RNs and LPNs knew the proper procedure of when to administer Cardiopulmonary Resuscitation (CPR) and to confirm that all licensed nurses had been inserviced on Code Status, Neglect, following physician's orders and CPR. The licensed nurses confirmed that CPR was initiated on any resident who was found unresponsive, not breathing and without vital signs if there was an order to Resuscitate. The nurses also confirmed that they had been in-serviced on Code Status/CPR, following physician's orders, abuse/neglect, and documentation. Interviews confirmed that staff knew to start CPR if a resident had an order to resuscitate and the resident was found to be without response and no vital signs. Random review of the medical records, resident arm bands and a list of residents with their code status on [DATE] confirmed that all matched the order for the residents' code status. Observation of random residents on [DATE] revealed that they had arm bands with their designated code status. Review of in-service records confirmed that in-services were initiated on [DATE] at 3:20 p.m. by the Assistant Director of Nurses on following the code status in every case as indicated in the chart, initiating CPR any time a resident was found with no vital signs or not breathing and there was an order for [REDACTED]. for resuscitation and actions of in-service of staff, identification bracelets to be worn by residents with reflection of code status and a list to be kept at the nurses station with reflection of resident code status. After verification of the facility's corrective action through observation, staff interviews and in-service review, the Immediate Jeopardy was removed and the scope and severity was lowered on [DATE] to a "D" level which is no actual harm with the potential for more than minimal harm. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated for effectiveness by the facility's Quality Assurance (QA) Committee.

CI MS #9851 CI MS #9856 Based on observation, record review, policy review and staff interview, the facility failed to ensure that the status of Resident #2 was assessed by the facility. This was evidenced by no documentation that the intake and output goals were met, assessed and addressed by the facility. Resident #2 was admitted to the hospital with [REDACTED].#2). Findings Include: Resident #2 Observation of Resident #2 was conducted on 11/3/11 at 2:00 p.m. and noted the Resident to be sitting in a wheelchair near the nurses desk. Resident #2 had his eyes closed. Observation of Resident #2 was conducted on 11/4/11 at 8:45 a.m. and revealed him in the bed being fed by staff. Resident #2 did not speak. Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/11 revealed that Resident #2 had a Cognitive Skills for Daily Decision Making code of two (2) which was defined as "Moderately impaired-decisions poor;cues/supervision given". The code for Eating, which included eating and drinking, was 3/2 which was defined as "Extensive assistance", "one person physical assist". Review of a "Medical Nutrition Therapy Flow Sheet" for Resident #2 with documentation dated 7/6/11 revealed "Res.(Resident) receives diuretic therapy and is @ (at) risk for dehydration. Nursing to encourage extra fluid intake." Review of a document with a section titled "Estimated Nutritional Needs" dated 1/19/11 at 1:34 p.m. revealed a section titled "Fluid 1850-2265 ml/Day Problem: Inadequate oral food/beverage intake. Etiology: Recent hospitalization /decline in overall status. [DIAGNOSES REDACTED].(admitted ) to (name of hospital) on 1-13-11 and returned 1-16-11 c dx of [MEDICAL CONDITION], dehydration and [MEDICAL CONDITION]. Nursing states Res. is holding food in his mouth. He is refusing to wear his dentures @ meal time. He has had a significant amt (amount) of wt (weight) loss in a month. Res has been referred to SLP (Speech Language Pathologist) for screen/evaluation." Review of "Nurses Notes" dated 9/23/11 revealed "Hydration fair. Will encourage more po (by mouth) fluids". Review of a document with a section titled "Estimated Nutritional Needs" dated 10/31/11 revealed "Fluid 1788-2145 ml (milliliters)/Day. Problem: Inadequate oral food/beverage intake. Signs & Symptoms: Poor po intake-Recent hospitalization for dehydration. [DIAGNOSES REDACTED]." Review of the facility E-MAR (Electronic Medical Administration Record) for October 2011 revealed a section titled "Encourage Fluid Intake" with checkmarks noted at 12:00 a.m., 8:00 a.m., and 4:00 p.m. with no amount documented at the checked times. Review of a document titled "Meals Report-Food & Fluid Intake" revealed that on none of the dates documented did Resident #2 meet the goals of 1850 -2265 ml/Day as recommended by the Dietician. The total of fluids documented was as followed: 10/14/11 1080 cc 10/15/11 1200 cc 10/16/11 720 cc. Interview with Certified Nursing Assistant (CNA) #1 on 11/4/11 at 9:30 a.m. revealed that on the weekend before October 17, 2011 when Resident #2 was admitted to the hospital she had provided care for him. CNA #1 stated that on that weekend (of 10/17/11) Resident #2 could not stand. Resident #2 could normally help to transfer himself to the bedside commode but on that weekend he could not help to transfer himself, which was unusual. Resident #2 did not eat much, which was also unusual because he usually had a good appetite. CNA #1 stated that Resident #2's condition was reported to the nurse and the nurse came and took his vital signs. Interview with Licensed Practical Nurse (LPN) #1 on 11/4/11 at 10:00 a.m. revealed that she did not normally work the unit where Resident #2 resided. LPN #1 revealed that Resident #2's sister came to the nurses station and wanted to know what was wrong with her brother because Resident #2 would not talk to her which was unusual. LPN #1 stated that Resident #2's sister wanted her to give out the contact number for the residents daughter. LPN #1 stated she could not do that. Resident #2's sister then stated that she wanted her brother, Resident #2, sent to the hospital because he did not seem to be acting right. LPN #1 stated that she took Resident #2's vital signs and did not see the need to send him to the hospital. "I checked vital signs to be sure no fever. I did not see anything wrong with him. I see daughter (of Resident #2) here every now and then but did not see her that weekend." LPN #1 also stated that she did not call the family of Resident #2 to report that his sister was at the facility and concerned about his condition. LPN #1 stated that she would not call the family unless Resident #2 was running a fever or was short of breath. LPN #1 stated again that Resident #2's sister wanted him sent to the hospital and that the sister comes everyday and "name (Resident #2's sister) at bottom of list means we can tell her vs (vital signs) and how doing but she can't make health care decisions. She wanted him sent to hospital. She come every day. I would assume she would know if something was wrong. He was talking to me. I never called daughter to tell her that the sister was concerned about him." LPN #1 confirmed that she did not call the Doctor or the Registered Nurse (RN) Supervisor who was on another unit. She stated that she looked at the chart of Resident #2, his vital signs were okay and she did not need to send him to the hospital. LPN #1 stated that the visit and the conversation with Resident #2's sister occurred on Saturday October 15, 2011. Review of Resident #2's nurses notes revealed no entry from 10/06/11 until 10/17/11. 10/17/11 at 9:00 a.m. nurses note revealed "resident noted to be lethargic-decreased appitite (appetite)-unable to hold teeth in mouth-MD (Medical Doctor) made aware-new orders noted for CBC (Complete Blood Count), UA (Urinalysis) C/S (Culture and Sensitivity) if pus, CXR (Chest X-ray) PA/LAT (Posterior/Anterior and Lateral). (R) rales, BIG 8- V/s 107/75 (Blood Pressure), 82 (pulse), 18 (respirations) 96 6 (temperature)". (name of daughter) made aware". 10/17/11 at 2:45 p.m. nurses note revealed "new order noted to send to (name of hospital) for direct admit (to) the services of Dr. (name) for UTI (Urinary Tract Infection) and abnormal labs." 10/19/11 at 1:45 p.m. nurses note revealed "Late entry for 10/15/11. Resident's sister (name) came up to the desk stating that this resident did not look right. Resident's vital signs were BP 117/80, P 66, R 20, T 97.8. O 2 Sat (oxygen saturation) was 90% (percent). Vital signs were within normal range as is O 2 sat. No resp (respiratory) distress noted. No c/o (complaints of) pain noted. No c/o SOB (shortness of breath) noted. Resident requested to go to bed. Assisted to bed x 2 CNA's. (name of sister) standing at the nurses station. This nurses note further stated that Resident #2's daughter "needed to come and check on him cause he don't look right. (name of sister) was informed that we would keep a check on this resident." The interview continued with LPN #1 on 11/4/11 at 10:0 a.m. LPN #1 stated that a late entry was put in Resident #2's medical record because the family had made a complaint. LPN #1 stated that if vital signs were normal there would not be an entry made in the medical record. LPN #1 stated that Resident #2 was at risk for dehydration and that they were not getting Intake and Output for him. "CNA's document and will tell us (nurses) if did not eat. No one reported that he did not eat." Interview with the Director of Nursing (DON) on 11/4/11 at 12:20 p.m. confirmed that there was no documented evidence on the 24 hour nursing report related to Resident #2 on the weekend of October 15th and 16th of 2011. The DON stated that on Monday (11/17/11) that Resident #2 was not "looking good -not responding" and that the Nurse Practitioner would be contacted to check on him. Review of Resident #2's "history and physical examination Chief Complaint: Patient sent from nursing home for UTI (Urinary Tract Infection) and dehydration. Summary: This is an [AGE] year old male who has been in the nursing home and noted to be unresponsive for the past 24-48 hours and he has not been eating or drinking well. They did some lab work today and noted to have URI and his sodium level was elevated at 178 and the patient is now sent as a direct admit for treatment of [REDACTED]. Laboratory Data: The labs done earlier from the nursing home today shows that his sodium is 174 with BUN (Blood Urea Nitrogen) of 60 and creatinine of 1.8 and potassium of 4.2, osmolality 373. WBC (White Blood Cells) 6.3 with a hemoglobin 15.8. Urine shows [MEDICATION NAME] positive, 3+ leukocytes and trace protein and blood is trace with 4+ bacteruria. Impression: [MEDICAL CONDITION] with UTI, altered mental status secondary [MEDICAL CONDITION], dehydration." Interview with the Director of Nursing (DON) on 11/4/11 at 11:15 a.m. revealed that Resident #2 was care planned for "at risk for dehydration" and that the Registered Dietician (RD) recommendations for fluids was 1933-2319 cc of fluid per day. The CNA's document the amount of fluids consumed in the computer and that amount should be looked at to see if getting what he needs." The Medication Nurse or the Charge Nurse should review those totals daily. The DON stated that Resident #2's sister comes to visit him often and would recognize changes in him and that LPN #1 should have called Resident #2's daughter when his sister reported that something was wrong. The DON stated that Resident #2's sister cannot request that he be sent to the hospital but if his daughter had been present and requested that Resident #2 be sent to the hospital then he would have been sent. Review of the facility policy "Change in Condition" with a revision date of 11/24/08 revealed: "Policy: The attending physician will be notified for changes in condition on any resident." "Procedure: In the event of a change in condition , the Resident's physician is notified and orders will be carried out by the appropriate personnel. If the attending physician is not available, the Nursing Home notified the physician on -call or the Medical Director. The Resident's next of kin or responsible party is notified of emergency situations. Arrangements for transportation will be made with family, nursing home vehicle or (Name) Ambulance Service as emergency situation warrants. Documentation will be entered into the Nurses Notes and in the unit day communication book. ALL personnel on the unit will be made aware of the Resident's condition during the shift as well as the on-coming shift personnel. *Remember-if in doubt call MD."

CI MS #9851 CI MS #9856 Based on observation, record review, policy review and staff interview, the facility failed to ensure that the hydration status of Resident #2 was assessed by the facility. This was evidenced by no documentation that the intake and output goals were met, assessed and addressed by the facility. Resident #2 was admitted to the hospital with [REDACTED].#2). Findings Include: Resident #2 Observation of Resident #2 was conducted on 11/3/11 at 2:00 p.m. and noted the Resident to be sitting in a wheelchair near the nurses desk. Resident #2 had his eyes closed. Observation of Resident #2 was conducted on 11/4/11 at 8:45 a.m. and revealed him in the bed being fed by staff. Resident #2 did not speak. Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/11 revealed that Resident #2 had a Cognitive Skills for Daily Decision Making code of two (2) which was defined as "Moderately impaired-decisions poor;cues/supervision given". The code for Eating, which included eating and drinking, was 3/2 which was defined as "Extensive assistance", "one person physical assist". Review of a "Medical Nutrition Therapy Flow Sheet" for Resident #2 with documentation dated 7/6/11 revealed "Res.(Resident) receives diuretic therapy and is @ (at) risk for dehydration. Nursing to encourage extra fluid intake." Review of a document with a section titled "Estimated Nutritional Needs" dated 1/19/11 at 1:34 p.m. revealed a section titled "Fluid 1850-2265 ml/Day Problem: Inadequate oral food/beverage intake. Etiology: Recent hospitalization /decline in overall status. [DIAGNOSES REDACTED].(admitted ) to (name of hospital) on 1-13-11 and returned 1-16-11 c dx of [MEDICAL CONDITION], dehydration and [MEDICAL CONDITION]. Nursing states Res. is holding food in his mouth. He is refusing to wear his dentures @ meal time. He has had a significant amt (amount) of wt (weight) loss in a month. Res has been referred to SLP (Speech Language Pathologist) for screen/evaluation." Review of "Nurses Notes" dated 9/23/11 revealed "Hydration fair. Will encourage more po (by mouth) fluids". Review of a document with a section titled "Estimated Nutritional Needs" dated 10/31/11 revealed "Fluid 1788-2145 ml (milliliters)/Day. Problem: Inadequate oral food/beverage intake. Signs & Symptoms: Poor po intake-Recent hospitalization for dehydration. [DIAGNOSES REDACTED]." Review of the facility E-MAR (Electronic Medical Administration Record) for October 2011 revealed a section titled "Encourage Fluid Intake" with checkmarks noted at 12:00 a.m., 8:00 a.m., and 4:00 p.m. with no amount documented at the checked times. Review of a document titled "Meals Report-Food & Fluid Intake" revealed that on none of the dates documented did Resident #2 meet the goals of 1850 -2265 ml/Day as recommended by the Dietician. The total of fluids documented was as followed: 10/14/11 1080 cc 10/15/11 1200 cc 10/16/11 720 cc. Interview with Certified Nursing Assistant (CNA) #1 on 11/4/11 at 9:30 a.m. revealed that on the weekend before October 17, 2011 when Resident #2 was admitted to the hospital she had provided care for him. CNA #1 stated that on that weekend (of 10/17/11) Resident #2 could not stand. Resident #2 could normally help to transfer himself to the bedside commode but on that weekend he could not help to transfer himself, which was unusual. Resident #2 did not eat much, which was also unusual because he usually had a good appetite. CNA #1 stated that Resident #2's condition was reported to the nurse and the nurse came and took his vital signs. Interview with Licensed Practical Nurse (LPN) #1 on 11/4/11 at 10:00 a.m. revealed that she did not normally work the unit where Resident #2 resided. LPN #1 revealed that Resident #2's sister came to the nurses station and wanted to know what was wrong with her brother because Resident #2 would not talk to her which was unusual. LPN #1 stated that Resident #2's sister wanted her to give out the contact number for the residents daughter. LPN #1 stated she could not do that. Resident #2's sister then stated that she wanted her brother, Resident #2, sent to the hospital because he did not seem to be acting right. LPN #1 stated that she took Resident #2's vital signs and did not see the need to send him to the hospital. "I checked vital signs to be sure no fever. I did not see anything wrong with him. I see daughter (of Resident #2) here every now and then but did not see her that weekend." LPN #1 also stated that she did not call the family of Resident #2 to report that his sister was at the facility and concerned about his condition. LPN #1 stated that she would not call the family unless Resident #2 was running a fever or was short of breath. LPN #1 stated again that Resident #2's sister wanted him sent to the hospital and that the sister comes everyday and "name (Resident #2's sister) at bottom of list means we can tell her vs (vital signs) and how doing but she can't make health care decisions. She wanted him sent to hospital. She come every day. I would assume she would know if something was wrong. He was talking to me. I never called daughter to tell her that the sister was concerned about him." LPN #1 confirmed that she did not call the Doctor or the Registered Nurse (RN) Supervisor who was on another unit. She stated that she looked at the chart of Resident #2, his vital signs were okay and she did not need to send him to the hospital. LPN #1 stated that the visit and the conversation with Resident #2's sister occurred on Saturday October 15, 2011. Review of Resident #2's nurses notes revealed no entry from 10/06/11 until 10/17/11. 10/17/11 at 9:00 a.m. nurses note revealed "resident noted to be lethargic-decreased appitite (appetite)-unable to hold teeth in mouth-MD (Medical Doctor) made aware-new orders noted for CBC (Complete Blood Count), UA (Urinalysis) C/S (Culture and Sensitivity) if pus, CXR (Chest X-ray) PA/LAT (Posterior/Anterior and Lateral). (R) rales, BIG 8- V/s 107/75 (Blood Pressure), 82 (pulse), 18 (respirations) 96 6 (temperature)". (name of daughter) made aware". 10/17/11 at 2:45 p.m. nurses note revealed "new order noted to send to (name of hospital) for direct admit (to) the services of Dr. (name) for UTI (Urinary Tract Infection) and abnormal labs." 10/19/11 at 1:45 p.m. nurses note revealed "Late entry for 10/15/11. Resident's sister (name) came up to the desk stating that this resident did not look right. Resident's vital signs were BP 117/80, P 66, R 20, T 97.8. O 2 Sat (oxygen saturation) was 90% (percent). Vital signs were within normal range as is O 2 sat. No resp (respiratory) distress noted. No c/o (complaints of) pain noted. No c/o SOB (shortness of breath) noted. Resident requested to go to bed. Assisted to bed x 2 CNA's. (name of sister) standing at the nurses station. This nurses note further stated that Resident #2's daughter "needed to come and check on him cause he don't look right. (name of sister) was informed that we would keep a check on this resident." The interview continued with LPN #1 on 11/4/11 at 10:0 a.m. LPN #1 stated that a late entry was put in Resident #2's medical record because the family had made a complaint. LPN #1 stated that if vital signs were normal there would not be an entry made in the medical record. LPN #1 stated that Resident #2 was at risk for dehydration and that they were not getting Intake and Output for him. "CNA's document and will tell us (nurses) if did not eat. No one reported that he did not eat." Review of Resident #2's "history and physical examination Chief Complaint: Patient sent from nursing home for UTI (Urinary Tract Infection) and dehydration. Summary: This is an [AGE] year old male who has been in the nursing home and noted to be unresponsive for the past 24-48 hours and he has not been eating or drinking well. They did some lab work today and noted to have URI and his sodium level was elevated at 178 and the patient is now sent as a direct admit for treatment of [REDACTED]. Laboratory Data: The labs done earlier from the nursing home today shows that his sodium is 174 with BUN (Blood Urea Nitrogen) of 60 and creatinine of 1.8 and potassium of 4.2, osmolality 373. WBC (White Blood Cells) 6.3 with a hemoglobin 15.8. Urine shows [MEDICATION NAME] positive, 3+ leukocytes and trace protein and blood is trace with 4+ bacteruria. Impression: [MEDICAL CONDITION] with UTI, altered mental status secondary [MEDICAL CONDITION], dehydration." Interview with the Director of Nursing (DON) on 11/4/11 at 11:15 a.m. revealed that Resident #2 was care planned for "at risk for dehydration" and that the Registered Dietician (RD) recommendations for fluids was 1933-2319 cc of fluid per day. The CNA's document the amount of fluids consumed in the computer and that amount should be looked at to see if getting what he needs." The Medication Nurse or the Charge Nurse should review those totals daily. The DON stated that Resident #2's sister comes to visit him often and would recognize changes in him and that LPN #1 should have called Resident #2's daughter when his sister reported that something was wrong. The DON stated that Resident #2's sister cannot request that he be sent to the hospital but if his daughter had been present and requested that Resident #2 be sent to the hospital then he would have been sent. Review of the facility policy "Change in Condition" with a revision date of 11/24/08 revealed: "Policy: The attending physician will be notified for changes in condition on any resident." "Procedure: In the event of a change in condition , the Resident's physician is notified and orders will be carried out by the appropriate personnel. If the attending physician is not available, the Nursing Home notified the physician on -call or the Medical Director. The Resident's next of kin or responsible party is notified of emergency situations. Arrangements for transportation will be made with family, nursing home vehicle or (Name) Ambulance Service as emergency situation warrants. Documentation will be entered into the Nurses Notes and in the unit day communication book. ALL personnel on the unit will be made aware of the Resident's condition during the shift as well as the on-coming shift personnel. *Remember-if in doubt call MD."