Every finding on record at Golden Age of Welsh, LLC

Based on observations, interviews, and policy and procedure reviews, the facility failed to: 1. Maintain a clean and sanitary kitchen to prevent cross contamination and the likelihood of foodborne illnesses;2. Store food in accordance with professional standards for food service safety; and3. Wear an appropriate hair restraint. This had the potential to effect the 85 residents who ate meals prepared from the facility's kitchen in a census of 86 residents. Findings:Review of the facility's policy, Sanitization, with a last review date of 03/24/2025, revealed the following in part: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. Review of the facility's policy, Date Marking for Food Safety, with a last review date of 03/24/2025, revealed the following in part: Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety. Policy Explanation and Compliance Guidelines for Staffing: 2.The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. Review of the facility's policy, Dietary Employee Personal Hygiene, with a last review date of 02/25/2025, revealed the following in part: Policy: It is the policy of the facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. 4. Hair Restraints. a. All dietary staff must wear hair restraints to prevent hair from contacting food. Review of Evening [NAME] Cleaning List posted on the wall in the kitchen revealed in part: Saturday- Fryer. An initial tour of the kitchen was conducted on 07/28/2025 at 08:38 a.m. with S2DM (Dietary Manager) which revealed the following: General: 1. 2 Fryers with a large amount of food residue on the inside surface and dark grease containing a large amount of food residue. 2.Warming cabinet with dried food residue and crumbs on the bottom and side surfaces, as well as the grated shelving. 3.S3COOK observed without a hair covering for his mustache. Dry Storage 1.Milk crate on the floor with dried white residue. 2.Storage container labeled Saltines without a lid, empty, with a large amount of crumbs on the bottom surface. Cooler 1.5 prepared containers of fruit juice sealed with saran wrap, not dated. 2.2 prepared containers of punch sealed with saran wrap, not dated. 3. 7 prepared containers of tea sealed with saran wrap, not dated. 4. 1 prepared container of pear sealed with saran wrap, not dated. 5.1 prepared container of milk sealed with saran wrap, not dated. 6. 4 prepared containers of lemon pie filling sealed with saran wrap, not dated. 7.3 half gallons cartons of [NAME] reduced fat milk with expiration dates of 07/21/2025. 8. 1 prepared container of orange dressing sealed with saran wrap, not dated. 9. 4 prepared cups of pie sealed with saran wrap, not dated. On 07/28/2025 at 11:40 a.m., a further observation of a double shelved rolling cart containing clean dish covers and clean trays was observed with crumbs and food debris on the top and bottom shelves. On 07/28/2025 at 4:10 p.m., an interview was conducted with S2DM. She confirmed the observations of the tour. She stated that the warming cabinet and the double shelved rolling cart should be cleaned after every meal. She also stated that the last time the fryer was used was on Friday 07/25/2025 when fish were fried. She confirmed that the fryer should have been cleaned two days prior on Saturday 07/26/2025, by the evening cook, per the Evening [NAME] Cleaning Schedule. She further confirmed that S3COOK should have been wearing a restraint to cover his mustache. She further confirmed that items in the cooler should have been dated per facility policy.

Based on record review and interviews, the facility failed to ensure individual financial records were provided to the resident through quarterly statements for 1 (Resident #67) out of 2 (Resident #4 and Resident #67) residents investigated for personal funds.Findings:A review of facility's policy titled, Resident Personal Funds, with an implemented date of 01/28/2025, indicated the following: Accounting and Records, 3. The individual financial record must be available to the residents through quarterly statements.A review of Resident #67's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.A review of Resident #67's admission Record under Contacts section revealed Resident #67's name, contact type: Responsible Party (RP), and relationship: self.On 07/30/2025 at 10:56 a.m., an interview was conducted with Resident #67. Resident #67 stated she did not receive quarterly statements for her personal funds account.On 07/30/2025 at 9:17 a.m., an interview was conducted with S6OM (Office Manager). S6OM stated financial statements for personal funds accounts were sent out quarterly. She stated if a resident is his or her own RP then the statement is given to the resident, if not, the statement is mailed to the resident's RP. S6OM could not provide any documentation or evidence that quarterly statements were given to residents or that quarterly statements were mailed to resident's RP.On 07/30/2025 at 12:20 p.m., an interview was conducted with S7RF (Resident Funds). S7RF confirmed Resident #67 had a financial account at the facility. S7RF also confirmed that if a resident is his or her own RP, the resident would receive the quarterly statement. S7RF could not provide documentation or evidence that Resident #67 received quarterly financial statements.

Based on record review and interviews, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were administered in the appropriate time frame for 1 (#22) resident out of a final sample of 44 residents. Findings:A review of the facility's policy titled, Medication Administration with a last review date of 02/28/2025, read in part: Medications are administered by licensed nurses, who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy also indicated general guidelines, Administer within 60 minutes prior to or after scheduled time.A review of Resident #22's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included, in part, Major Depressive Disorder, Generalized Anxiety Disorder, Insomnia, Hyperlipidemia, and Essential (Primary) Hypertension.A review of Resident #22's Annual MDS (Minimum Data Set) dated 05/19/2025 revealed she had a BIMS (Brief Interview for Mental Status) of 15, indicating her cognition was intact.On 07/28/2025 at 9:00 a.m., an interview was conducted with Resident #22. She stated her medications at nighttime were administered to her late by S4LPN.A review of Resident #22's Order Summary Report revealed the following scheduled night medications were to be administered at 8:00 p.m. every night: 1. Lorazepam oral tablet 0.5 mg (milligram)2. Melatonin oral tablet 10 mg 3. Buspirone HCl (hydrochloride) oral tablet 5 mg4. Trazadone HCl oral tablet 50 mg 5. Gabapentin oral tablet 600 mg6. Simvastatin oral tablet 40 mg7. Labetalol HCl oral tablet 200 mg 8. Potassium Chloride ER (extended release) oral tablet 20 mEq (milliequivalent) A review of Resident #22's Medication Administration Audit Report revealed the following night medications were administered on 07/21/2025 between 10:42 p.m. and 10:43 p.m. by S4LPN (Licensed Practical Nurse):1. Lorazepam oral tablet 0.5 mg (milligram)2. Melatonin oral tablet 10 mg 3. Buspirone HCl (hydrochloride) oral tablet 5 mg4. Trazadone HCl oral tablet 50 mg 5. Gabapentin oral tablet 600 mg6. Simvastatin oral tablet 40 mg7. Labetalol HCl oral tablet 200 mg 8. Potassium Chloride ER (extended release) oral tablet 20 mEq (milliequivalent) A review of Resident #22's Medication Administration Audit Report revealed the following night medications were administered on 07/22/2025 between 10:55 p.m. and 10:56 p.m. by S4LPN: 1. Lorazepam oral tablet 0.5 mg (milligram)2. Melatonin oral tablet 10 mg 3. Buspirone HCl (hydrochloride) oral tablet 5 mg4. Trazadone HCl oral tablet 50 mg 5. Gabapentin oral tablet 600 mg6. Simvastatin oral tablet 40 mg7. Potassium Chloride ER (extended release) oral tablet 20 mEq (milliequivalent) A review of Resident #22's Medication Administration Audit Report revealed the following night medications were administered on 07/27/2025 at 9:45 p.m. by S4LPN: 1. Lorazepam oral tablet 0.5 mg (milligram)2. Melatonin oral tablet 10 mg 3. Potassium Chloride ER (extended release) oral tablet 20 mEq (milliequivalent) 4. Trazadone HCl oral tablet 50 mg 5. Simvastatin oral tablet 40 mg6. Labetalol HCl oral tablet 200 mg On 07/30/2025 at 11:10 a.m., a follow-up interview was conducted with Resident #22. She reported her nighttime medications, which included medications to help her sleep due to insomnia, were administered to her late at night, at around 11:00 p.m. On 07/30/2025 at 11:20 a.m., an interview with S5ADON (Assistant Director of Nursing) confirmed that nurses are to administer medications 1 hour before or 1 hour after the scheduled time. On 07/30/2025 at 11:40 a.m., a phone interview was conducted with S4LPN. She stated nighttime medications were scheduled for 8:00 p.m. She stated she had a time frame of 1 hour before and 1 hour after the scheduled time to administer medications. She stated that sometimes she was late on administering medications if there was a fall, behavior, or computer issues. She stated that when she was late on administering medications, she did not notify administration the following day. S4LPN stated that Resident #22 stated to her, I'm getting my medications late at almost midnight, and S4LPN asked her who was giving her medications late. The resident stated to her, I'm talking about you giving me my medications late. S4LPN confirmed there were days in July 2025 when Resident #22's medications were administered late. On 07/30/2025 at 11:57 a.m., an interview was conducted with S1DON (Director of Nursing). She confirmed nurses have 1 hour before the scheduled time and 1 hour after the scheduled time to administer medication for all shifts. A record review was conducted with S1DON, who confirmed Resident #22 received her night medications late on 07/21/2025, 07/22/2025, and 07/27/2025, and not in the appropriate time frame per policy nor accepted professional standards.

Based on observation, record review and interview, the facility failed to ensure the accurate administering of a medication for 1 (#17) out of 4 (#17, #38, #68, #71) residents observed during the administration of medications. Findings: Review of the facility's policy titled Medication Administration with an implementation date of 02/28/2025 read in part: . 10.) Ensure that the six rights of medication administration are followed: a. right resident b. right drug c. right dosage d. right route e. right time f. right documentation. Review of Resident #17's EMR (Electronic Medical Record) revealed an admission date of 08/31/2020 with diagnoses that included in part, Hypertensive Retinopathy Right Eye.Review of Resident #17's current Physician's Orders for July 2025 revealed an order for Prolensa Ophthalmic Solution (eye drop) instill 1 drop in the right eye one time a day for Hypertensive Retinopathy. On 07/29/2025 at 7:25 a.m., an observation was made of S8LPN (Licensed Practical Nurse) during medication administration. S8LPN was observed administering Resident #17's Prolensa eye drops to both eyes instead of to the right eye only as ordered. On 07/30/2025 at 1:30 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON confirmed Resident #17's Prolensa eye drops should have only been administered to her right eye as ordered.

Based on observations, record review, interviews and policy review, the facility failed to ensure pain management was provided to resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (#16) out of 5 (#15, #16, #22, #40, and #44) sampled residents receiving pain medication. The facility failed to: 1. provide pain medication upon complaints of pain nor offer non-pharmacologic interventions; and 2. follow up with the physician and/or pharmacy after the physician reported he was sending a pain medication order to the pharmacy. This deficient practice resulted in actual harm for Resident #16 beginning on 07/14/2024 at 10:02 a.m. when the resident reported she was in pain was not provided any medication nor offered non-pharmacological interventions for pain relief. On 07/15/2024, S6LPN (Licensed Practical Nurse) called S15DR to report the resident's pain and stated that he would send something to the pharmacy as soon as possible, however, no order was received by the pharmacy. On 07/16/2024 at 10:37 a.m., Resident #16 refused Physical Therapy because of continued pain and was not provided any pain relieving medication nor offered non-pharmacological interventions. On 07/17/2024 at 9:08 a.m., Resident #16 stated I am tired of hurting and the doctor still hasn't sent anything stronger than Tylenol to help with my back pain. The resident was sent to the ER (emergency room ) on 07/17/2024 at 9:41 a.m. for low back pain. Findings: On 07/17/2024, a review of the facility's policy titled Pain Management with a last reviewed date of 01/2024 read in part, Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: . c. Manage or prevent pain . 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: . d. Facial expressions (e.g. grimacing .) Pain Management and Treatment: 1. Based upon evaluation, the facility in collaboration with the attending physician/prescriber . prevent or manage each individual resident's pain . 6. Non-pharmacological interventions . 7. H. Facility will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen . Review of Resident #16's health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Pain, Idiopathic Peripheral Autonomic Neuropathy, Transient Cerebral Ischemic Attack, Neurologic Neglect Syndrome and Chronic Pain Due To Trauma. Review of Resident #16's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating her cognition was intact. Section J Health Conditions: A. Received scheduled pain medication regimen? Coded 0. No. Review of Resident #16's physician's orders revealed an order dated 07/10/2024 that read in part, . PT (Physical Therapy) to tx (treat) 3 times a week for 8 weeks . Further review of orders revealed an order dated 04/13/2024 that read, Tylenol Extra Strength Oral Tablet 500 mg (milligram) (Acetaminophen) Give 2 tablets by mouth every 6 hours as needed for pain. Review of Resident #16's comprehensive care plan with a focus that read in part, The resident has a potential for pain r/t (related to): chronic physical disability . neurologic neglect . neuropathy with a goal that read, the resident will not have an interruption in normal activities d/t (due to) pain . with interventions that read in part, administer analgesia medications as ordered/requested, anticipate the residents need for pain relief and respond immediately to any complaint of pain, attempt non pharmacological pain relief techniques . document technique and effectiveness, observe and report changes in . sleep patterns Review of Resident #18's form titled Weights and Vitals Summary read in part, pain level documented on 07/14/2024 at 10:02 a.m. was rated a 5 out of 10 (pain scale from rated from 1-10 with 1 being the least and 10 being the most), further review revealed a pain level documented on 07/16/2024 at 10:37 a.m. was rated a 5 out of 10. Review of Resident #18's MAR (Medication Administration Record) from July 2024 failed to reveal administration of Tylenol Extra Strength Oral Tablet 500 mg on 07/14/2024 at 10:02 a.m. for pain rated 5 out of 10, and before this she was last given Tylenol on 07/13/2024 at 7:20 p.m. On 07/16/2024 at 10:37 a.m. when the resident reported pain rated 5 out 10 Tylenol was not administered, and before this was last given Tylenol on 07/15/2024 at 4:10 a.m. Review of Resident #18's progress notes failed to reveal non-pharmacological interventions were provided on 07/14/2024 at 10:02 a.m. and 07/16/2024 at 10:37 a.m. when the resident reported pain. On 07/15/2024 9:48 a.m., an observation was made of Resident #16. She was lying sideways on the bed and facial grimacing was noted. Upon interview, she complained of pain rated as a 10 out of 10 to left sided sciatica radiating down her left leg. She stated she has been feeling this pain since last week and all that she has received from nursing was Prednisone (steroid). She stated that she has notified nursing staff that the Prednisone is not working and she needs something else to help with her pain. She stated she had not received anything else to help with her pain. Review of progress note by S6LPN dated 07/15/2024 at 4:25 p.m. read, S6LPN spoke to S15DR's (Physician) nurse. S15DR's nurse stated that she sent a note to S15DR concerning resident's back pain. S15DR stated he would be sending something to the pharmacy ASAP (as soon as possible). Don't go to hospital until she tries what S15DR is sending. Further review of progress notes failed to reveal any documentation that S6LPN nor any other facility staff followed-up with the pharmacy or S15DR when no new pain medication was received for Resident #16. On 07/17/2024 at 8:55 a.m., a follow-up observation was made of Resident #16. She was lying sideways on the bed with facial grimacing noted. On 07/17/2024 8:55 a.m., a second interview with Resident #16. She rated her pain as a 10 out of 10 (worst pain possible) to the left side of the back down her left leg stating it was sciatica pain. She stated she has been having this pain for over 1 week now. She stated she received Prednisone during the day and Tylenol at times but none of these medications have worked. She stated she notified nursing staff that the medications were not working. She further stated I've been begging for something for pain. Review of progress note by S10LPN dated 7/17/1024 at 9:08 a.m. read, Called to room by resident, states I am tired of hurting and the doctor still hasn't sent anything stronger than Tylenol to help with my back pain. Pain 6/10. Refused any pain medication intervention at this time .(ambulance) called for transportation .09:30 a.m. transported to (hospital) in stable condition. Review of Resident #16's form titled Transfer Form dated 07/17/2024 completed by S10LPN read in part, . reason for transfer: Resident . going to hospital ER (emergency room ) for low back pain . On 07/17/24 at 9:19 a.m. an interview was conducted with S10LPN. S10LPN stated resident has been in pain for about 1 week now. She stated the resident went to S15DR's for a rash and back pain on 07/09/2024 she was told by S15DR it was sciatica pain and to take OTC (over the counter) medication such as Tylenol. S10LPN stated communication was sent to S15DR about resident requesting something else for pain besides Tylenol on 07/13/2024 at around 10:15 a.m., but she was unable to provide any documented evidence of that communication. S10LPN confirmed she did not follow up with S15DR about prescribing the resident something else for pain after she communicated with him on 07/13/2024. S10LPN stated she worked again on 07/14/2024. On 07/14/2024 she had not heard back from S15DR about Resident #16's request to prescribe something else for pain nor did she attempt to call S15DR again. She confirmed she could have followed up with S16MD (Medical Director) of Resident #16's request for stronger pain medication. S10LPN stated based off her documentation in the EHR (Electronic Health Record) the resident reported 5 out of 10 on 07/14/2024 and she did not administer Tylenol as ordered to her on that shift and she stated she did not offer Resident #16 Tylenol. Four attempts were made to contact S6LPN via phone on 07/17/2024 at 10:17 a.m., 10:36 a.m., 11:40 a.m., and 2:47 p.m. S6LPN failed to return any phone calls and was unable to be interviewed. Four attempts were made to contact S13LPN on 07/17/2024 at 10:21 a.m., 12:10 p.m., 1:21 p.m., and 2:46 p.m. S13LPN failed to return any phone calls and was unable to be interviewed. On 07/17/2024 at 11:42 a.m. an interview was conducted with S12LPN. S12LPN confirmed that Resident #16 was in pain last night and was given Tylenol. She stated Resident #16 didn't sleep well last night and slept off and on. S12LPN confirmed the resident had been complaining of sciatica pain since last week. She stated she had not reached out to S15DR regarding the resident's pain because other staff had already. She stated she had not received any other updates from S15DR or nursing staff in report regarding resident's pain medication. She stated she had no provided non-pharmacological pain relief interventions to the resident. On 07/17/2024 at 12:30 p.m., an interview with S19PM (Pharmacy Manager). S19PM stated he reviewed resident #16's medications from February 2024 to 07/17/2024 and there were no new orders of pain medication. On 07/17/2024 at 12:37 p.m., attempted to call S15DR (Physician) per his answering system his office is closed on Wednesday's. On 07/17/2024 3:41 p.m., an interview with S3RDON (Registered Nurse, Regional Director of Nursing). She stated On 07/09/2024 Resident #16 went to an appointment with S15DR, new orders were implemented for resident to start PT. Phone call interview was conducted at this time with S20TD (Therapy Director) and S3RDON. S20TD stated the first therapy evaluation for Resident #16 was done on 07/10/2024. S20TD stated Resident #16 was unable to participate in therapy on 07/16/2024 due to her verbalizing that she could not get out of bed due to pain. He communicated to S6LPN that resident refused therapy due to pain. The resident's documented pain levels were then reviewed with S3RDON. She confirmed on 07/14/2024 at 10:02 a.m. and 07/16/2024 at 10:37 a.m. Resident #16 rated her pain at a 5 out of 10 and no Tylenol was administered and non-pharmacological interventions were not done nor documented. S3RDON then reviewed S6LPN's progress note dated 07/15/2024 that stated she had called S15DR regarding the resident's request for more effective pain medication. S3RDON confirmed that there was no follow up completed by the nurse. S3RDON confirmed that the staff should have followed up regarding Resident #16's pain with S15DR or S16MD on 07/15/2024 and 07/16/2024 and staff did not. She confirmed Resident #16 was sent to the emergency room today due to her pain. Review of Discharge Hospital Records dated 07/17/2024 read in part, . diagnosis hip pain bilateral, sciatica of right side, neuropathy. Medications given: Decadron, Demerol, and Phenergan. Start taking: Flexeril (muscle relaxant) and Tramadol (opioid analgesic). Resident #16 returned to the facility on [DATE] at 03:11 p.m.

Based on record review, policy review and interviews, the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident council meetings and failed to demonstrate the facility's response for such grievances. Findings: On 07/17/2024, a review of the facility's policy titled Resident and Family Grievances with a last reviewed date of 01/2024 read in part, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . Policy Explanation and Compliance Guidelines: . 8. Grievances may be voiced in following forums: . d. complaint during resident or family council meetings . 10. Procedure: . d. The grievance official will take steps to resolve the grievance, and report information about the grievance, and those actions on the grievance form . e. The grievance official, or designee, will keep the resident appropriately appraised of progress towards resolution of the grievances . A review of the Resident Council Meeting Minutes was conducted and revealed notes by (Activity Director) for April 2024 - July 2024 with the different complaints voiced by the residents. However there was no evidence that the complaints were reviewed and initiated nor that attempts were made to resolve the voiced grievances. A review of the facility's grievance logs from April 2024 - July 2024 failed to include the complaints addressed during the monthly Resident Council Meeting Minutes. Resident #11 was identified in the complaints on the Resident Council Meeting Minutes. Review of Resident #11's Annual MDS (Minimum Data Set) dated 04/11/2024 revealed the Brief Interview for Mental Status (BIMS) score of 13, indicating her cognition was intact. On 07/15/2024 at 1:15 p.m., an interview was conducted with Resident #11 who reported she attended monthly Resident Council meetings regularly. Resident #11 reported S5AD (Activity Director) was present at the meetings and was responsible for documenting the voiced complaints. Resident #11 also reported residents were not being notified of any follow ups or resolutions regarding their complaints. On 07/15/2024 at 1:34 p.m., an interview was conducted with S5AD. S5AD confirmed she was the designated staff who sat in on the monthly Resident Council meetings. A review of the Resident Council Meeting Minutes from April 2024 - July 2024 was reviewed with S5AD and she explained she had given a copy of all complaints voiced to the administrative staff during the daily morning huddle meetings. S5AD confirmed that grievances voiced in the resident council meetings were not filed nor included with the other facility grievances. On 07/17/2024 at 8:22 a.m., an interview was conducted with S4SSD (Social Service Director). She stated that her responsibility at the facility was to file grievances and complete investigations which included the efforts made by the facility to resolve the filed grievances. She verified that she received the resident council meeting minutes during the daily morning huddle meetings. S4SSD reviewed the resident council meeting minutes and confirmed there was documentation of the grievances voiced by the residents. S4SSD further confirmed that she should have started a Resident Council Meeting Minutes grievance for the complaints from April 2024 - July 2024 and she did not.

Based on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status by failing to accurately code the Minimum Data Set (MDS) assessment for medications received for 1 (#44) of 38 residents reviewed in the initial pool. Findings: Review of Resident #44's electronic health record revealed she was admitted on [DATE] with diagnoses that included: Morbid Obesity, Bipolar Disorder, and Spondylosis with Radiculopathy. A review of the Quarterly MDS with an Assessment Reference Date (ARD) of 05/31/2023 for Resident #44 revealed, Section N: Medications received failed to include opioid use. A review of the Medication Administration Record (MAR) for May 2024 revealed the resident received an opioid for the entire month. On 07/17/2024 at 10:00 a.m., a concurrent record review and interview was conducted with S14RN (Registered Nurse). S14RN reviewed Resident #44's May 2024 MAR and confirmed she received an opioid for the whole month of May 2024. S14RN then viewed Resident #44's quarterly assessment for 05/31/2024 and confirmed that the resident was coded inaccurately for opioid use.

Based on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 ( #10) of 4 (#10, #54, #63, #61) residents investigated for PASARR in a final sample of 38 residents. Findings: Resident #10 Review of Resident #10's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Bipolar Disorder and Major Depressive Disorder. Further review of Resident #10's records revealed no evidence that a new review or a Level II PASRR had been submitted to the appropriate state-designated authority with those psychiatric diagnoses identified on the request. On 07/16/2024 at 8:29 a.m., an interview was conducted with S3RDON. She reviewed Resident #10's Level I Pre-admission screening with completed date of 02/28/2023. S3RDON confirmed Section III #1 was answered with no diagnoses checked. S3RDON then reviewed the resident's diagnoses list and confirmed the resident had the diagnoses of Bipolar Disorder and Major Depressive Order since admit on 03/01/2023. S3RDON confirmed a request for level II should have been resubmitted indicating the resident had a diagnosis of Bipolar disorder and Major Depressive disorder. On 07/16/24 at 9:36 a.m., during an interview S4SSD reported the Notice of Medical Certification was resubmitted for continued stay on 05/30/2023, and where indicated on page 1 nothing was checked that indicated mental illness was known or suspected. S4SS then confirmed the resident had both qualifying diagnoses of Bipolar Disorder and Major Depressive Disorder. She confirmed those diagnoses should have been identified on the continued stay form when it was submitted but were not.

Based on record review and interview, the facility failed to develop a comprehensive resident centered care plan for 1 (#33) out of 38 final sampled residents by failing to update the care plan to reflect the resident's code status. Findings: On [DATE], a review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives with a last reviewed date of ,d+[DATE] read in part, Policy: It is policy of this facility to support and facilitate a resident's right to request, refused and/or discontinue medical or surgical treatment to formulate an advance directive . Policy Explanation and Compliance Guidelines: . 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process . 9. Any decisions making regarding the resident's choices will be documented in the resident's medical record . Review of Resident #33's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Heart Failure, Hypersomnia, and Traumatic Brain Injury. A review of Resident #19's Electronic Health Record (EHR) revealed a physician's order dated [DATE] that read DNR (Do Not Resuscitate). A review of the resident's medical record revealed the form titled, Louisiana Physician Orders for Scope of Treatment (LaPOST) signed by the physician and dated [DATE]. Section A. Cardiopulmonary Resuscitation (CPR) had a check mark next to DNR/Do Not Attempt Resuscitation. Further review of Section B. Medical Interventions had a check mark next to comfort focused treatment. Further review of all areas in the EHR and hard chart revealed Resident #33 was a DNR. A review of Resident # 19's care plan revealed in part in part, the resident is a Full Code. On [DATE] at 3:02 p.m., a record review and interview was conducted with S7MDS/LPN (Minimum Data Set/Licensed Practical Nurse). S7MDS/LPN confirmed the care plan read the resident was a full code. S7MDS/LPN confirmed the physician's order written on [DATE] read DNR (Do not resuscitate). S2ADON also confirmed Resident #19's record revealed the LaPOST form that indicated the resident had a DNR status with comfort focused treatment and was signed on [DATE]. She confirmed the resident's code status was not accurately documented in the resident's care plan.

Based on observations, record review and interviews the facility failed to properly store respiratory equipment for 2 (#18 and #75) out of 2 (#18 and #75) residents investigated for respiratory care. Findings: On 07/17/2024, a review of the facility's policy titled Oxygen Administration with a last reviewed date of 01/2024 read in part . Policy Explanation and Compliance Guidelines: . 8. Oxygen tubing is to be bagged at bedside when not is use . 10. Types of delivery systems included: . e. Bi-level Positive Airway Pressure (BiPAP) Mask . g. Aerosol Generating Device . Resident #18 Review of Resident #18's health record revealed that he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease, Heart Failure, Obstructive Sleep Apnea, and Respiratory Failure. Review of Resident #18's most recent Admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 13, indicating her cognition was intact. Section O: Special Treatments, Procedures and Programs was checked for oxygen therapy. Review of Resident #18's physician's orders revealed an order dated 05/06/2024 that read, ensure oxygen tubing, oxygen masks, BiPAP/CPAP masks are in respiratory bags when not in use. On 07/15/2024 at 9:27 a.m., an observation was conducted in Resident #18's room. Resident #18's BiPAP mask was hanging over her recliner, not in use, open to air and not stored in a respiratory bag. On 07/15/2024 at 10:24 a.m., a second observation was conducted in Resident #18's room. Resident #18's BiPAP mask was hanging over her recliner, not in use, open to air and not stored in a respiratory bag. On 07/15/2024 at 11:30 a.m., a third observation was conducted in Resident #18's room. Resident #18's BiPAP mask was hanging over her recliner, not in use, open to air and not stored in a respiratory bag. On 07/15/2024 at 11:55 a.m., an observation and interview was conducted with S6LPN (Licensed Practical Nurse). S6LPN confirmed that Resident #9's BiPAP mask was hanging over her recliner, not in use and open to air. She stated the resident was at doctor's appointment today and her BiPAP mask should have been stored in a respiratory bag. On 07/17/2024 at 8:41 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Preventionist). S2DON confirms when BiPAP masks are not in use it should be stored in a respiratory bag. 47251 Resident #75 Findings: Resident #75 was admitted to the facility 01/05/2022 with diagnoses that included, but not limited to, Acute and Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. Review of Resident #75's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/29/2024 revealed a BIMS (Brief Interview for Mental Status) of 15, indicating he was cognitively intact. Review of Resident #75 current physician's orders read: Arformoterol Tartrate Inhalation Nebulization Solution 2 ml (milliliters), Inhale orally via nebulizer two times a day. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 3mg/3ml (milligram/milliliter) 3 ml inhale orally via nebulizer every 4 hours as needed for wheezing/shortness of breath. Sodium Chloride Inhalation Nebulization Solution 3% 1 vial inhale orally via nebulizer two times a day. Further review of Resident #75's physician's orders revealed an order that read: Ensure oxygen tubing, oxygen masks, are in respiratory bags when not in use. On 07/15/2024 at 09:00 a.m., an observation was made of Resident #75's nebulizer mask lying open to air on his bedside table, not in a bag. On 07/15/2024 at 09:45 a.m., a second observation and interview was made with S15LPN (Licensed Practical Nurse) and she confirmed that the nebulizer mask was open to air and not stored properly. Also present for interview was S16CNA (Certified Nursing Assistant) and she confirmed that she had placed Resident #75's nebulizer mask on the bedside table and had not stored it properly.

Based on observations, interviews, record review and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S8CNA (Certified Nursing Assistant) and S9CNA wore proper PPE (Personal Protective Equipment) while proving care for 1 (#33) out of 2 (#29 and #33) sampled residents reviewed for peg tube care. Findings: On 07/17/2024, a review of the facility's policy titled, Enhanced Barrier Precautions with a last reviewed date of 04/01/2024 read in part, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-dry resistant organisms that employs targeted gown and gloves use during high contact resident care activities . Policy Explanation and Compliance Guidelines: . 3. Implementation of Enhanced Barrier Precautions: . b. PPE for enhanced barrier precautions is only necessary when performing high contact activities . 4. High-contact resident care activities include: . f. changing briefs . Review of Resident #33's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Gastrostomy Status, Disturbances of Salivary Secretion, and Gastro-Esophageal Reflux Disease. Review of Resident #33's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was blank, indicating she was unable to participate during this assessment. Section H: Bladder and Bowel was checked for always incontinent of bowel and bladder. Section K: Swallowing/Nutritional Status was checked for feeding tube. Review of Resident #33's physician's orders revealed an order dated 04/01/2024 that read, Enhanced Barrier Precautions gown and gloves worn for high-contact care activities. On 07/16/2024 at 2:40 p.m., an observation was made of Resident's #33's name outside of her door, next to her name was a sign which stated Enhanced Barrier Precautions. On 07/16/2024 at 2:42 p.m., an observation was made of two staff members with an incontinent brief and gloves in their hands walking into Resident #33's room and closing the door behind them. They were observed with no gown in their hands nor did they don a gown before entering into Resident #33's room. There was a PPE station noted next to the resident's door stocked with gown and gloves. On 07/16/2024 at 2:56 p.m. an interview was conducted with S8CNA. S8CNA stated she went into Resident #33's room to change the resident's brief due to it being soiled. She confirmed the resident was on EBP and she did not wear gowns before providing resident care and should have. On 07/16/2024 at 2:57 p.m., an interview with S9CNA. S9CNA stated that she went into Resident #33's room to change the resident's brief due to it being soiled. She confirmed the resident was on EBP due to her peg tube. She confirmed that PPE supplies are on the outside of Resident #33's room readily available, but she did not wear a gown while proving resident care. On 07/17/2024 8:42 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Preventionist). S2DON stated she was one of the IP's for the facility. She confirmed if a resident was on EBP, a gown and gloves must be donned when proving high contact activities such as changing a resident's brief.

Based on record review and interview, the facility failed to provide annual nurse aide training of abuse, neglect and exploitation for 1 (S2ACNA) (Agency Certified Nursing Assistant) out of 1 (S2ACNA) Agency CNA personnel record reviewed. Findings: Review of the facility's policy titled, Abuse, Neglect and Exploitation, read in part: Employee Training: A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation . A review of S2CNA's personnel record revealed that he did not receive the required annual training for Abuse, Neglect, and Exploitation. The personnel record contained abuse, neglect policy training dated 04/02/2019, which was the last documented training. On 11/07/2023 at 12:10 p.m., an interview was conducted with S1OM (Office Manager). S1OM confirmed that S2ACNA had not received the required annual training for Abuse, Neglect and Exploitation. On 11/07/2023 at 1:15 p.m., an interview was conducted with S6DON, she confirmed S2ACNA did not have the required in-service training for Abuse, Neglect and Exploitation.

Based on record review and interview, the facility failed to provide nurse aide training of at least 12 hours a year for 1 (S2ACNA) (Agency Certified Nursing Assistant) out of 4 (S2ACNA, S3CNA [Certified Nursing Assistant], S4CNA, S5CNA) CNAs whose personnel records were reviewed. Findings: A review of S2CNA's personnel record revealed that he did not receive the required training in Dementia Care, Behavioral Health, Communication or and Resident Rights. Further review revealed the training for Abuse, Neglect, Exploitation and Infection Control were dated 04/02/2019. On 11/07/2023 at 12:10 p.m., an interview was conducted with S1OM (Office Manager). S1OM confirmed that S2ACNA did not receive the required yearly training of at least 12 hours a year in Dementia Care, Behavioral Health, Communication, Resident Rights, Abuse, Neglect, Exploitation, and Infection Control. She also confirmed that the trainings should have been completed before S2ACNA started working at the facility.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of anticoagulants for 1 (#45) of 32 sampled residents whose records were reviewed. The deficient practice has the potential to affect a facility census of 89 residents. Findings: A review of resident #45's medical record revealed a Quarterly MDS with an ARD (Assessment Reference Date) of 03/02/2023, read in part . Section N. Medications . indicate the number of days the resident received the following medication by pharmacological classification, not how it is used, during the last 7 days E. Anticoagulant . Coded for 7 days. Further review of resident #45's electronic medication administration record for February 2023 through March 2023, and Physician's orders from February 2023 through March of 2023 revealed no evidence of an anticoagulant being administered or ordered. On 06/06/2023, during an interview S4MDS and S5MDS nurses verified that resident #45's MDS with ARD date of 03/02/2023 was coded for receiving 7 days of an anticoagulant. They both reviewed Resident #45's electronic medical record and confirmed that Resident #45 did not receive any anticoagulants during the 7 day observation period of the MDS and stated the MDS was incorrectly coded.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards for 1 (#10) of 32 sampled residents. This deficient practice was evident when facility staff failed to ensure respiratory equipment was properly stored for Resident #10. The deficient practice has the potential to affect 13 residents receiving respiratory treatment out of a total census of 89 residents. Findings: On 06/06/2023 at 8:49 a.m. and on 06/07/2023 at 2:00 p.m., a request was made for S2DON (Director of Nursing) to provide the facility's policy regarding storage of resident's respiratory equipment. By time of exit on 06/07/2023, the facility failed to provide requested policy. Review of Resident #10's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Acute Respiratory Failure with Hypercapnia, and Dyspnea. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating his cognition was moderately impaired. Section O-Special Treatments, Procedures, and Programs revealed the resident required use of BiPAP (Bilevel Positive Airway Pressure) non-invasive mechanical ventilator while a resident. Review of resident's comprehensive care plan revealed on 03/31/2023 resident at risk for SOB (shortness of breath) while lying flat with intervention to wear BiPAP per MD (doctor of medicine) orders. Review of the resident's physician's orders revealed an order entry dated 03/31/2023 BiPAP to be worn at bed time and when napping. Observation on 06/05/2023 at 7:45 a.m., revealed Resident #10's BiPAP mask was next to his bed on a side table, not stored in a plastic bag and open to air. A follow up observation on 06/06/2023 at 8:46 a.m., revealed Resident #10's BiPAP mask was next to his bed on a side table, not stored in a plastic bag and open to air. On 06/06/2023 at 8:49 a.m., an interview was conducted with S2DON who confirmed that when a resident's BiPAP mask was not in use, the mask must be stored in a bag. On 06/06/2023 at 9:00 a.m., an interview and observation was conducted with S3ADON (Assistant Director of Nursing) who observed Resident #10's BiPAP next to his bed on a side table, not stored in a plastic bag and open to air. S3ADON confirmed the BiPAP mask was not stored in a bag and open to air.

Based on observation and interview, the facility failed to maintain proper labeling and storage of all medications as evidenced by loose unlabeled pills found in a drawer in 1 (Medication Cart B) of 2 medication carts (B and C) reviewed. This had the potential to affect a census of 89 residents. Findings: Review of the providers Medication Storage Policy read in part .All medications housed on our premises will be stored sufficient to ensure proper sanitation, light, moisture control, segregation, and security. On 06/07/2023 at 8:10 a.m., an observation of Medication Cart B conducted with S6LPN revealed two loose tablet pills at the bottom of the cart's second medication drawer. There was one orange colored round pill and one white round pill. S6LPN nor surveyor were able to see any visible markings to identify them nor access them from that position in the drawer. S6LPN confirmed the nurses are required to either administer or discard all medications that are popped out of their blister packs and should never leave loose medication in the carts. On 06/07/2023 at 09:25 a.m., S2DON confirmed that pills should not be loose in the bottom of the medication cart drawer.

Based on observation, interview and record review the facility failed to assess 3 (#5, R1 and R3) out of a total of 13 (#1, #2, #3, #4, #5, R1, R2, R3, R4, R5, R6, R7 and R8) sampled residents for self-administration of medication. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine that this practice is clinically appropriate. Findings: Review of the facility's policy and procedure titled Self-Administration of Medications revealed in part, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Families are informed at admission to not bring medications into the facility . Resident #5 Resident #5 was admitted on [DATE] with diagnoses that included Major depressive disorder, Metabolic encephalopathy, Dysphagia, and Gastro esophageal reflux disease. On 04/24/2023 at 11:15 a.m., an observation of Resident #5's room was conducted. Upon approaching the room, the resident's rolling table was observed with 3 small clear medication cups lined up in a row. The first clear cup contained a white colored pudding and small pieces of medication could be seen mixed within the pudding. The second clear cup contained a pale pink colored liquid, and the third clear cup contained a darker colored pink liquid. An immediate interview was conducted with the resident, who confirmed that the three clear cups on his rolling table were his noon medications. The resident stated the nurse left them there for him to take. On 04/24/2023 at 11:17 a.m., an observation and interview was conducted with S3ADON (Assistant Director of Nursing) who confirmed that the nurse should not have left the resident's medication on the rolling table. She also confirmed that the resident did not have a self-administered medication assessment. On 04/24/2023 at 12:00 p.m., an interview was conducted with S5LPN (License Practical Nurse) who stated that she left the resident's medications on the bedside table because she was talking with the resident about watermelon, and while she was talking she stepped out of the room for something and then got distracted by another staff member who needed her assistance. S5LPN confirmed that she should not have left the medication at Resident #5's bedside. 44269 Resident R1 Resident R1 was admitted to the facility on [DATE] with diagnoses that included in part, Dysphagia Following Cerebral Infarction, Chronic Obstructive Pulmonary Disorder, Gastro-Esophageal Reflux Disease Without Esophagitis and Unspecified Osteoarthritis. On 04/24/2023 at 12:15 p.m., an observation was made of Resident R1 laying in her bed watching television. Upon entering the room, an observation was made of a clear plastic bottle labeled Tums Chewables that was located on the resident's bedside table. The bottle was observed with half of the chewables in it and the resident stated one of her children brought that to her a while back because she sometimes has reflux after eating. Further observation of the resident's room revealed Icy Hot 1.5 ounce bottle located on the night stand drawer to the left of the resident's bed. On 04/24/2023 at 12:32 p.m., an interview was conducted with S2DON (Director of Nursing) who reported residents were able to self- administer medications when one of the nurses completed an assessment that identified a resident as safe to self- administer. S2DON stated there were currently no residents in the facility who self- administer medications. S2DON accompanied surveyor to Resident R1's room and confirmed the presence of the Tums and Icy Hot bottles in the room. S2DON confirmed Resident R1 was not assessed to self-administer her medications and the medications should not have been left at the resident's bedside.

Based on records reviewed and interviews, the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 2 (#2 and #4) out of 8 (#1, #2, #3, #4, #5, R1, R2, & R3) sampled residents. The facility census was 90. Findings: Review of the facility's policy titled Resident Grievance/Complaint Procedures read in part . A resident, his or her representative (sponsor), family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents .1. Obtain a Resident Grievance Complaint Form. 2. Answer all questions on the forms . 4. Give the completed form to the SSD or his/her designee .5. Within 5 working days of the date you filed the grievance, a written summary of the results of the investigation will be available .7. It is the policy of this facility to assist you in filing a grievance or complaint . Resident #2 Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses in part: Unspecified Dementia Moderate with Anxiety, Psychotic Disorder with Delusions, Major Depressive Disorder and Recurrent Severe with Psychotic Symptoms. Review of facility's Grievance Logs from November 2022 to April 2023 revealed no grievance was filed for Resident #2. On 04/25/2023 at 3:42 p.m., an interview was conducted with S2DON (Director of Nursing) who stated Resident #2's family had voiced concerns about care and services. S2DON confirmed there was no documentation completed for addressing the concerns voiced by Resident #2's family. On 04/25/2023 at 5:00 p.m., an interview was conducted with S1ADM (Administrator). S1ADM confirmed he had multiple meetings with Resident #2's family but had not documented the family's voiced concerns. Resident #4 Resident #4 was admitted to the facility on [DATE] with diagnoses in part: Other Sequalae of Cerebral Infarction, Abnormal Posture, Difficulty in Walking, Other lack of Coordination, Muscle Weakness, Muscle Wasting and Atrophy, Diverticulosis of intestine without perforation or abscess with bleeding. Review of Resident #4's April 2023 Progress Notes revealed a late entry on 04/13/2023 at 10:52 a.m. by S3ADON: Resident's family members entered facility stating if they didn't speak to someone right now they will be calling state and an attorney immediately. Facility had not received any calls from family prior to arrival. Meeting held with S7SSD (Social Services Director) and S10MDS (Minimum Data Set Licensed Practical Nurse). Family members stated they are very unhappy with facility regarding the care mother has been receiving and she HAS HAD ENOUGH! States that her mother informed them both of some bruising to her arms and chest area and is questioning why neither of them were ever called and informed of this . Review of facility's Grievance Logs from November 2022 to April 2023 revealed no grievance was filed for Resident #4. On 04/25/2023 at 8:40 a.m., an interview was conducted with S2DON, and S3ADON. S2DON confirmed that a meeting was held on 04/13/2023 with the resident's family members and staff members S3ADON, S7SSD, S10MDS and S11CNA (Certified Nursing Assistant). S3ADON stated that the resident's family members voiced they were very angry about not being informed of their mother's care. On 04/25/2023 at 1:06 p.m., an interview and review of grievance policy was conducted with S7SSD. She confirmed Resident #2 and #4's names were not on the grievance list because she did not file any grievance for them. S7SSD confirmed that a grievance should have been filed after Resident #2 and #4's family voiced their concerns.

Based on observation, interview and record review, the facility failed to honor and accommodate food preferences for 1 (#R4) out of 1 residents reviewed for food. Findings: On 04/25/2023 at 11:39 a.m., an interview was conducted with #R4. She stated that she was enjoying her lunch but that she did not like mashed potatoes. On 04/25/2023 at 11:40 a.m., an observation of #R4's meal tray was conducted. She was served finely chopped hamburger steak, green peas, bread with a brown gravy on top, mashed potato with gravy. A review of #R4's meal ticket revealed that she disliked mashed potatoes. On 04/25/2023 at 11:45 a.m., an interview and observation was conducted with S6DM (Dietary Manager). S6DM stated that the kitchen staff on the serving line should not only serve a resident the correct meal but they should also make sure they honor the residents' likes and dislikes. At that time, an observation was conducted with S6DM of #R4's meal ticket and meal tray. S6DM confirmed that the resident was served mashed potatoes and her meal ticket indicated that one of her dislikes was mashed potatoes. S6DM confirmed that according to #R4's meal ticket, she should not have been served mashed potatoes.

Based on record reviews and interview, the facility failed to ensure residents' quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for 5 (#1, 2, 3, 6, 80) out of 40 sampled residents. This deficient practice has the potential to affect a census of 88. Findings: A review of Resident #1's quarterly MDS revealed an assessment reference date (ARD) of 2/25/22. The assessment had a complete by date of 3/11/22. The status of the MDS was in progress indicating the assessment was incomplete. A review of Resident #2's quarterly MDS revealed an assessment reference date (ARD) of 3/4/22. The assessment had a complete by date of 3/18/22. The status of the MDS was in progress indicating the assessment was incomplete. A review of Resident #3's quarterly MDS revealed an assessment reference date (ARD) of 4/6/22. The assessment had a complete by date of 4/20/22. The status of the MDS was in progress indicating the assessment was incomplete. A review of Resident #6's quarterly MDS revealed an assessment reference date (ARD) of 3/25/22. The assessment had a complete by date of 4/8/22. The status of the MDS was in progress indicating the assessment was incomplete. A review of Resident #80's quarterly MDS revealed an assessment reference date (ARD) of 3/29/22. The assessment had a complete by date of 4/12/22. The status of the MDS was in progress indicating the assessment was incomplete. On 4/20/2022 at 10:20 am, S2 MDS confirmed the above residents' quarterly assessments were not completed within the required time frame.

Based on interview and record review, the facility failed to provide services that meet professional standards of quality as evidenced by the Registered Nurse failing to accurately evaluate a resident's skin as having pressure ulcers which led to the facility's failure to implement further services to promote healing and to avoid further pressure to the pressure ulcer areas. This deficient practice resulted in actual harm for 1 (#3) of 4 (#1, #3, #4, #5) residents reviewed for pressure ulcers out of a total of 83 reported census clients when Resident #3 developed DTIs (Deep Tissue Injuries) to his left heel, left ankle, and left dorsal foot in the facility and were not discovered by the facility. He was admitted to the hospital on [DATE] with DTIs to his left heel, Left ankle, and a Stage II to his right elbow. He returned to the facility and was not evaluated as having pressure wounds and so the resident was not placed on nutritional therapy or heel floating measures to prevent the progression of the pressure ulcers. He was as admitted to the hospital again on 11/2/14 and, upon admission, was assessed as having the following wounds: Unstagable wound with black eschar on his left heel that measured 7cmx5cm which was debrided to the fat pad of his heel, left lateral malleoli (ankle) Stage III 2.5x2cm, left great toe Stage II which measured 0.5x0.5cm, left ventral foot/ankle wound that measured 5.5cmx9cm., mid-back blister that was opened which measured 2cmx1cm, and a new Stage II wound/skin tear to his left calf which measured 2cmx1cm. Resident was experiencing pain at the left lateral malleoli with bone exposure. Findings: A review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standards, Part XLVII. Nurses: Subpart 2. Registered Nurses revealed 3901. A. The Louisiana State Board of Nursing recognizes that assessment, planning, intervention evaluation teaching, and supervision ate the major responsibilities of the registered nurse in the practice of nursing. The standards of nursing practice provide a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a registered nurse in conjunction with other licensed of unlicensed personnel ... B. The standards are based on the premise that the registered nurse is responsible for and accountable to the individual for the quality of nursing care he or she receives. Documentation must reflect the quality of care. 3093. Standard Number 1: Collection and Recording Individual's Health Status. A. Data concerning an individual ' s health status must be systematically and continuously collected, recorded and communicated in order to determine nursing care needs ... Resident #3 was admitted to the facility on [DATE] from another nursing home. His [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The facility's policy titled Admitting the Resident read "...Documentation. The following information should be recorded in the resident's medical record: ... 3. All assessment data (e.g., bruises, rashes, sores, etc.) observed during the procedure on admission and every 7 days thereafter. ...Reporting. 1. Notify the supervisor and the Attending Physician of any wounds that the resident may have that may need to be treated ...." The facility's policy titled Guidelines for Charting and Documentation read "...Nursing Summaries and/or Assessments. When charting nursing summaries or making assessments, include (as they may apply) the following information: ... 14. Skin-Hair-Scalp-Nails: ...Be descriptive of [MEDICAL CONDITIONS]; etc. Include locations, size, depth, color, amount, consistency, odor of drainage, and status of tissue and surrounding area ..." A review of the care plan revealed that Resident #3 was identified as at risk for skin breakdown on 8/21/4 related health issues that included PEG (Percutaneous Endoscopic Gastrostomy), [MEDICAL CONDITIONS], Diabetes Mellitus, [MEDICAL CONDITION], and Limited Mobility. Approaches were for the nurse to perform a full weekly skin evaluation, CNA (Certified Nursing Assistant) was to monitor skin daily and report changes to the nurse, to apply preventative treatment as ordered, assist as needed to turn and reposition at least every 2 hours, and a pressure reducing mattress. The care plan was updated on 9/10/14 for a problem of right sided facial swelling and again on 10/15/14 for an open blister to the top of his left hand. Further review of the care plan revealed scheduled care tasks with approaches that included AM/PM care, resident turned and repositioned at least every 2 hours, and stop and watch any new changes with resident. Further review of the care plan failed to reveal any issues with wounds on his left foot, failed to reveal any approaches for floating the heels to prevent pressure ulcers to the heels, and failed to reveal nutritional approaches for wound healing. A review of the eTARs (Electronic Treatment Administration Record), and departmental notes for the dates ranging from 8/21/14 to 11/2/14 revealed that Resident #3 had a healed Stage II pressure ulcer to his left dorsal foot upon admission to the facility on [DATE]. On 8/22/14, the skin assessment was documented on the eTAR as "intact" by S3TxNurse, although he did have a [MEDICAL CONDITION] and a PEG (Percutaneous Endoscopic Gastrostomy). On 8/29/14 there was no documentation on the eTAR by S8LPN of whether the skin was intact or not intact and there was no description in the nurse's notes of skin issues. On 9/5/14, 9/12/14, 9/19/14, 9/26/14, and 10/3/14 the skin assessment was documented on the eTAR as "not intact" by S3TxNurse and there was no description of the skin issues in the nurse's notes. A review of the departmental notes revealed that on 10/7/14 Resident #3 was found unresponsive and was sent to the ER (emergency room ) at HOSP1. He was then transferred to HOSP2 on the same day, after he was stable. A review of the nurse's notes from HOSP2 on 10/8/14 at 7:00 a.m. revealed "Wound: left heel DTI (Deep Tissue Injury) 2"x1" , Left ankle DTI 2"x2" , Right elbow pressure ulcer Stage II, 1"x1." Clean all wounds with Shur-clens, covered left foot with [MEDICATION NAME] dressing and 4x4 wrapped by Kerlix. Right elbow covered by [MEDICATION NAME] foam." Further review of HOSP2's nurse's notes on 10/8/14 at 4:40 p.m., revealed "Left dorsal foot 5 x 9 DTI, Left great toe 0.3 x 0.2 DTI, Left heel 5.5 x 4 DTI, Left ankle 2 x 2 DTI. Cleansed with Shur-Clens, covered with [MEDICATION NAME] dressing. admitted with multiple DTIs to Lt (left) foot. Cleansed all affected areas and dried well. Lt great toe left OTA (Open To Air). Aqualcel dressing applied to Lt heel Wrapped Lt foot with kerlix and secured with tape. Elevated Lt foot off of bed surfaces with pillow." Further review of HOSP2's nurse's notes dated 10/13/14 at 6:07 p.m. revealed that Resident #3's pressure wounds were as follows: "Left heel 5cm, Left dorsal foot 5x8, left ankle 2x2. DTI to left heel measured larger than last assessment. DTI to left dorsal foot presenting with scant serous drainage. Left lateral ankle wound unchanged. Cleansed all wounds. Covered dorsal foot wound with [MEDICATION NAME]. Wrapped foot with kerlix. Floated heel off bed." Further review of the nurse's notes from HOSP2 revealed that Resident #3 was discharged on [DATE] to return to the nursing home. The last description of the pressure wounds were on 10/15/14 at 7:00 a.m. as follows: "Left heel 2x1, left ankle 2x2, right arm 1x1, cleaned left heel and ankle with normal saline and covered with adaptive dressing and 4x4, protective pads wrap with kerlix. Right forearm, covered with adaptive dressing. Covered with [MEDICATION NAME] foam. Tolerated well." A review of the statement of Medical Status from HOSP2 dated 10/15/14 revealed that Resident #3 had wounds on his left heel and left ankle. A review of the physician's order [REDACTED].#3 was ordered the same treatment as before his hospitalization for his left ankle which was to apply a bordered foam dressing to his left ankle every day as a preventive measure. Further review failed to reveal orders for floating the heels for pressure relief and failed to reveal additional nutritional measures for wound healing. A review of the facility's nurse's notes by S2DON revealed that Resident #3 returned to the nursing home on10/15/14. S2DON documented that he presented with a blister on the top of his left hand. Further review failed to reveal any other descriptions of his skin assessment. On 10/17/14, the skin assessment was documented on the eTAR as "not intact" by S3TxNurse and there was no description of any skin issues in the nurse's notes. Review of the departmental notes revealed that Resident #3 was sent to HOSP1 on 10/22/14 then was transported to HOSP2 on the same day after he was stabilized. A review of the Admitting History and Physical dated 10/22/14 by HOSP2 revealed a Stage 1 on the sacrum approximately 2cm, and a dressed Stage 3 on the dorsum of the left foot. A review of the Discharge Summary from HOSP2 dated 10/29/14 revealed that Resident #3 was admitted to the hospital on [DATE] with a left heel stage III decubitus heel ulcer measuring 3cm x 3cm with black eschar. Further review of HOSP2's progress notes dated 10/26/14 revealed Resident #3's foot ulcer was causing pain. A review of the nurse's notes dated 10/29/14 at 6:15 p.m. by S8LPN revealed that Resident #3 was discharged from HOSP2 and re-entered the nursing home in stable condition. Further review of the eTAR and nurse's notes of 10/29/14 failed to reveal that a skin assessment was conducted by S8LPN or the RN, S2DON, upon re-entry into the facility. On 10/30/14 at 1:20 p.m., S3TxNurse documented that the skin was not intact related to the stoma at the PEG site. S3TxNurse documented that preventative measures and ongoing treatment to the left foot was noted at that time. Further review failed to reveal a description of his skin issues to include his [MEDICAL CONDITION], left great toe, left heel, left ankle, and left dorsal foot. On 10/31/14, the skin assessment was documented by S2DON on the eTAR as not intact and there was no description of the wounds/skin issues in the nurse's notes since he returned to the facility on [DATE]. A review of the nurse's notes on 11/2/14 at 6:43 a.m. by S11LPN revealed that Resident #3 was sent to the ER at HOSP1 for evaluation and treatment. A review of HOSP1's Initial Physical assessment dated [DATE] at 1:17 p.m. revealed "skin condition: see skin assessment and documentation below. Pt. (patient) arrived with numerous decubitus ulcers, pics. (pictures) taken. Stage III and Stage IV treatment: Consult Physical therapy, wet to dry dressing applied to all stage 3 and 4 wounds. Unstageable wound treatment: Wound cannot be staged at this time, consult physical therapy, Left heel." A review of the HOSP1 progress notes dated 11/3/14 at 7:45 a.m. revealed: "Subjective data: Pt. alert and reports pain. Left foot with multiple wounds. Objective: Left foot dressing removed. Wounds as follows: L (left) great toe stage II 0.5cm x 0.5cm. Left lateral malleoli stage III 2.5 x 2 cm. Left heel unstageable 7 cm x 5 cm. L (left) ventral foot/ankle 5.5 cm x 9 cm. Right buttocks and Left buttocks wounds stage II resolved. Mid back blister open 2cm x 1cm. New stage II wound /skin tear to left lateral calf 2 cm x 1 cm. All wounds to LLE (left lower extremity) cleansed with [MEDICATION NAME] and NS (normal saline), rinsed with NS and patted dry. Sharps debridement to L heel to remove eschar and dressed with santyl and wet to dry and cut ABD (abdominal) pad. Ventral foot Left dressed with santyl and wet to dry 4 x 4. Left lateral foot wound dressed with wet to dry. Left lateral calf dressed with [MEDICATION NAME]. All dressings secured with kerlix and floated. Assessment: Pt's healing potential is diminished. He tolerated wound care fair. Tenderness to lateral malleoli. Debridement of all eschar tissue to heel tolerated well. Santyl should continue to debride necrotic tissue remaining." A review of HOSP1's progress note dated 11/4/14 at 8:00 a.m. revealed: "Assessment: Fat pad exposed on Left heel with poor circulation. Patient only complains of pain at lateral malleoli with bone exposure at this wound site. Continue with santyl today to decrease necrotic tissue but santyl may not be necessary for much longer depending on progression of necrosis." On 11/13/14 at 11:20 a.m., an interview was conducted with S3TxNurse. She stated that when residents were first admitted to the facility and when they returned from a hospital admission, the RN (Registered Nurse) DON (Director of Nursing) did skin assessments and documented their findings and then she proceeded with weekly skin inspections and treatments from that point on. She stated that Resident #3 had a healed stage II wound on the top of his left foot when he was admitted to the facility. S3TxNurse stated that he had a contracted left foot which tended to put pressure on the outside of his left ankle. She stated that they applied foam dressing to the top of his left foot at the healed stage II site as a preventive measure. She stated that in late September 2014, the healed Stage II on top of his left foot changed. She stated that the color became darker and that the skin loosened on the top of the wound like it was a blister that popped but the skin stayed on. She stated that she also found that Resident #3 had a new spot on his left heel that was dark and mushy and was about the size of a quarter in late September 2014. She stated that she was not responsible for measuring and staging wounds and told S2DON about the wounds because he was responsible for staging. She stated that she continued to apply the foam dressing to the top of his left foot and wrap the foot in kerlix as a preventative measure as was previously ordered. She reviewed the wound documentation on the eTARs (Electronic Treatment Administration Record) and nurse's notes and verified that she did not document any of the findings she had regarding the new skin issues for Resident #3. She reviewed the documentation that she wrote on 11/30/14 which read "preventive measures and ongoing treatment to left foot noted at this time." She stated that she meant that she was continuing with the same treatment that Resident #3 had before which was to apply a bordered foam to his left dorsal foot. She stated that she was responsible for conducting weekly skin audits and that she was supposed to document all areas of skin that were not intact including the wounds, [MEDICAL CONDITION], and PEG tube site. S3TxNurse and confirmed that she failed to document her findings for Resident #3 to include all skin issues on 9/5/24, 9/12/14, 9/19/14, 9/26/14, 10/4/14, 10/17/14, and 10/30/14. During an interview with S2DON on 11/13/14 at 12:00 p.m., he reviewed Resident #3's record and confirmed that weekly skin assessments with documentation was not present in the record as ordered and care planned. He stated that when Resident #3 was admitted , he had a healed Stage II pressure ulcer on the top of his left foot and that they applied a foam dressing as a protective measure. He stated that Resident #3 never had any other skin issues or pressure ulcers during the course of his stay at the facility from 8/21/14-11/2/14 with the exception of a blister on his left hand which he was admitted with when he returned from the hospital on [DATE]. When told of S3TxNurse's statement that she found a dark spot on Resident #3's left heel and that the wound on top of his foot had changed in late September 2014 and that she reported it to him, he stated that when he assessed the resident he did not have those same findings.

Based on interview and record review, the facility failed to ensure a resident did not develop a pressure ulcer and received the necessary care and services to promote healing by failing to accurately assess a resident ' s skin and by failing to revise the plan of care to provide additional pressure relief measures/interventions to avoid further pressure to the pressure ulcer areas. This deficient practice resulted in actual harm for 1 (#3) of 4 (#1, #3, #4, #5) residents reviewed for pressure ulcers out of a total of 83 reported census clients when Resident #3 developed DTIs (Deep Tissue Injuries) to his left heel, left ankle, and left dorsal foot in the facility and were not discovered by the facility. He was admitted to the hospital on [DATE] with DTIs to his left heel, Left ankle, and a Stage II to his right elbow. He returned to the facility and was not evaluated as having pressure wounds and so the resident was not placed on nutritional therapy or heel floating measures to prevent the progression of the pressure ulcers. He was as admitted to the hospital again on 11/2/14 and, upon admission, was assessed as having the following wounds: Unstagable wound with black eschar on his left heel that measured 7cmx5cm which was debrided to the fat pad of his heel, left lateral malleoli (ankle) Stage III 2.5x2cm, left great toe Stage II which measured 0.5x0.5cm, left ventral foot/ankle wound that measured 5.5cmx9cm., mid-back blister that was opened which measured 2cmx1cm, and a new Stage II wound/skin tear to his left calf which measured 2cmx1cm. Resident was experiencing pain at the left lateral malleoli with bone exposure. Findings: Resident #3 was admitted to the facility on [DATE] from another nursing home. His [DIAGNOSES REDACTED]. A review of the physician's order [REDACTED]. The facility ' s policy titled Admitting the Resident read " ...Documentation. The following information should be recorded in the resident ' s medical record: ... 3. All assessment data (e.g., bruises, rashes, sores, etc.) observed during the procedure on admission and every 7 days thereafter. ...Reporting. 1. Notify the supervisor and the Attending Physician of any wounds that the resident may have that may need to be treated .... " The facility ' s policy titled Guidelines for Charting and Documentation read " ...Nursing Summaries and/or Assessments. When charting nursing summaries or making assessments, include (as they may apply) the following information: ... 14. Skin-Hair-Scalp-Nails: ...Be descriptive of [MEDICAL CONDITIONS]; etc. Include locations, size, depth, color, amount, consistency, odor of drainage, and status of tissue and surrounding area ... " A review of the care plan revealed that Resident #3 was identified as at risk for skin breakdown on 8/21/4 related health issues that included PEG (Percutaneous Endoscopic Gastrostomy), [MEDICAL CONDITIONS], Diabetes Mellitus, [MEDICAL CONDITION], and Limited Mobility. Approaches were for the nurse to perform a full weekly skin evaluation, CNA (Certified Nursing Assistant) was to monitor skin daily and report changes to the nurse, to apply preventative treatment as ordered, assist as needed to turn and reposition at least every 2 hours, and a pressure reducing mattress. The care plan was updated on 9/10/14 for a problem of right sided facial swelling and again on 10/15/14 for an open blister to the top of his left hand. Further review of the care plan revealed scheduled care tasks with approaches that included AM/PM care, resident turned and repositioned at least every 2 hours, and stop and watch any new changes with resident. Further review of the care plan failed to reveal any issues with wounds on his left foot, failed to reveal any approaches for floating the heels to prevent pressure ulcers to the heels, and failed to reveal nutritional approaches for wound healing. A review of the eTARs (Electronic Treatment Administration Record), and departmental notes for the dates ranging from 8/21/14 to 11/2/14 revealed that Resident #3 had a healed Stage II pressure ulcer to his left dorsal foot upon admission to the facility on [DATE]. On 8/22/14, the skin assessment was documented on the eTAR as " intact " by S3TxNurse, although he did have a [MEDICAL CONDITION] and a PEG (Percutaneous Endoscopic Gastrostomy). On 8/29/14 there was no documentation on the eTAR by S8LPN of whether the skin was intact or not intact and there was no description in the nurse ' s notes of skin issues. On 9/5/14, 9/12/14, 9/19/14, 9/26/14, and 10/3/14 the skin assessment was documented on the eTAR as " not intact " by S3TxNurse and there was no description of the skin issues in the nurse ' s notes. A review of the departmental notes revealed that on 10/7/14 Resident #3 was found unresponsive and was sent to the ER (emergency room ) at HOSP1. He was then transferred to HOSP2 on the same day, after he was stable. A review of the nurse ' s notes from HOSP2 on 10/8/14 at 7:00 a.m. revealed " Wound: left heel DTI (Deep Tissue Injury) 2 " x 1 " , Left ankle DTI 2 " x 2 " , Right elbow pressure ulcer Stage II, 1 " x 1 " . Clean all wounds with Shur-clens, covered left foot with [MEDICATION NAME] dressing and 4 x 4 wrapped by Kerlix. Right elbow covered by [MEDICATION NAME] foam. " Further review of HOSP2 ' s nurse ' s notes on 10/8/14 at 4:40 p.m., revealed " Left dorsal foot 5 x 9 DTI, Left great toe 0.3 x 0.2 DTI, Left heel 5.5 x 4 DTI, Left ankle 2 x 2 DTI. Cleansed with Shur-Clens, covered with [MEDICATION NAME] dressing. admitted with multiple DTIs to Lt (left) foot. Cleansed all affected areas and dried well. Lt great toe left OTA (Open To Air). Aqualcel dressing applied to Lt heel Wrapped Lt foot with kerlix and secured with tape. Elevated Lt foot off of bed surfaces with pillow. " Further review of HOSP2 ' s nurse ' s notes dated 10/13/14 at 6:07 p.m. revealed that Resident #3 ' s pressure wounds were as follows: " Left heel 5cm, Left dorsal foot 5x8, left ankle 2x2. DTI to left heel measured larger than last assessment. DTI to left dorsal foot presenting with scant serous drainage. Left lateral ankle wound unchanged. Cleansed all wounds. Covered dorsal foot wound with [MEDICATION NAME]. Wrapped foot with kerlix. Floated heel off bed. " Further review of the nurse ' s notes from HOSP2 revealed that Resident #3 was discharged on [DATE] to return to the nursing home. The last description of the pressure wounds were on 10/15/14 at 7:00 a.m. as follows: " Left heel 2x1, left ankle 2x2, right arm 1x1, cleaned left heel and ankle with normal saline and covered with adaptive dressing and 4x4, protective pads wrap with kerlix. Right forearm, covered with adaptive dressing. Covered with [MEDICATION NAME] foam. Tolerated well " A review of the statement of Medical Status from HOSP2 dated 10/15/14 revealed that Resident #3 had wounds on his left heel and left ankle. A review of the physician's order [REDACTED].#3 was ordered the same treatment as before his hospitalization for his left ankle which was to apply a bordered foam dressing to his left ankle every day as a preventive measure. Further review failed to reveal orders for floating the heels for pressure relief and failed to reveal additional nutritional measures for wound healing. A review of the facility ' s nurse ' s notes by S2DON revealed that Resident #3 returned to the nursing home on10/15/14. S2DON documented that he presented with a blister on the top of his left hand. Further review failed to reveal any other descriptions of his skin assessment. On 10/17/14, the skin assessment was documented on the eTAR as " not intact " by S3TxNurse and there was no description of any skin issues in the nurse ' s notes. Review of the departmental notes revealed that Resident #3 was sent to HOSP1 on 10/22/14 then was transported to HOSP2 on the same day after he was stabilized. A review of the Admitting History and Physical dated 10/22/14 by HOSP2 revealed stage 1 on sacrum approximately 2cm, and a dressed Stage 3 on dorsum of left foot. A review of the Discharge Summary from HOSP2 dated 10/29/14 revealed that Resident #3 was admitted to the hospital on [DATE] with a left heel stage III decubitus heel ulcer measuring 3cm x 3 cm with black eschar. Further review of HOSP2 ' s progress notes dated 10/26/14 revealed Resident #3 ' s foot ulcer was causing pain. A review of the nurse ' s notes dated 10/29/14 at 6:15 p.m. by S8LPN revealed that Resident #3 was discharged from HOSP2 and re-entered the nursing home in stable condition. Further review of the eTAR and nurse ' s notes of 10/29/14 failed to reveal that a skin assessment was conducted by S8LPN or the RN, S2DON, upon re-entry into the facility. On 10/30/14 at 1:20 p.m., S3TxNurse documented that the skin was not intact related to the stoma at the PEG site. S3TxNurse documented that preventative measures and ongoing treatment to the left foot was noted at that time. Further review failed to reveal a description of his skin issues to include his [MEDICAL CONDITION], left great toe, left heel, left ankle, and left dorsal foot. On 10/31/14, the skin assessment was documented by S2DON on the eTAR as not intact and there was no description of the wounds/skin issues in the nurse ' s notes since he returned to the facility on [DATE]. A review of the nurse ' s notes on 11/2/14 at 6:43 a.m. by S11LPN revealed that Resident #3 was sent to the ER at HOSP1 for evaluation and treatment. A review of HOSP1 ' s Initial Physical assessment dated [DATE] at 1:17 p.m. revealed " skin condition: see skin assessment and documentation below. Pt. (patient) arrived with numerous decubitus ulcers, pics. (pictures) taken. Stage III and Stage IV treatment: Consult Physical therapy, wet to dry dressing applied to all stage 3 and 4 wounds. Unstageable wound treatment: Wound cannot be staged at this time, consult physical therapy, Left heel. " A review of the HOSP1 progress notes dated 11/3/14 at 7:45 a.m. revealed: " Subjective data: Pt. alert and reports pain. Left foot with multiple wounds. Objective: Left foot dressing removed. Wounds as follows: L (left) great toe stage II 0.5cm x 0.5cm. Left lateral malleoli stage III 2.5 x 2 cm. Left heel unstageable 7 cm x 5 cm. L (left) ventral foot/ankle 5.5 cm x 9 cm. Right buttocks and Left buttocks wounds stage II resolved. Mid back blister open 2cm x 1cm. New stage II wound /skin tear to left lateral calf 2 cm x 1 cm. All wounds to LLE (left lower extremity) cleansed with [MEDICATION NAME] and NS (normal saline), rinsed with NS and patted dry. Sharps debridement to L heel to remove eschar and dressed with santyl and wet to dry and cut ABD (abdominal) pad. Ventral foot Left dressed with santyl and wet to dry 4 x 4. Left lateral foot wound dressed with wet to dry. Left lateral calf dressed with [MEDICATION NAME]. All dressings secured with kerlix and floated. Assessment: Pt ' s healing potential is diminished. He tolerated wound care fair. Tenderness to lateral malleoli. Debridement of all eschar tissue to heel tolerated well. Santyl should continue to debride necrotic tissue remaining. " A review of HOSP1 ' s progress note dated 11/4/14 at 8:00 a.m. revealed: " Assessment: Fat pad exposed on Left heel with poor circulation. Patient only complains of pain at lateral malleoli with bone exposure at this wound site. Continue with santyl today to decrease necrotic tissue but santyl may not be necessary for much longer depending on progression of necrosis. " On 11/13/14 at 11:20 a.m., an interview was conducted with S3TxNurse. She stated that when residents were first admitted to the facility and when they returned from a hospital admission, the RN (Registered Nurse) DON (Director of Nursing) did skin assessments and documented their findings and then she proceeded with weekly skin inspections and treatments from that point on. She stated that Resident #3 had a healed stage II wound on the top of his left foot when he was admitted to the facility. S3TxNurse stated that he had a contracted left foot which tended to put pressure on the outside of his left ankle. She stated that they applied foam dressing to the top of his left foot at the healed stage II site as a preventive measure. She stated that in late September 2014, the healed Stage II on top of his left foot changed. She stated that the color became darker and that the skin loosened on the top of the wound like it was a blister that popped but the skin stayed on. She stated that she also found that Resident #3 had a new spot on his left heel that was dark and mushy and was about the size of a quarter in late September 2014. She stated that she was not responsible for measuring and staging wounds and told S2DON about the wounds because he was responsible for staging. She stated that she continued to apply the foam dressing to the top of his left foot and wrap the foot in kerlix as a preventative measure as was previously ordered. She reviewed the wound documentation on the eTARs (Electronic Treatment Administration Record) and nurse ' s notes and verified that she did not document any of the findings she had regarding the new skin issues for Resident #3. She reviewed the documentation that she wrote on 11/30/14 which read " preventive measures and ongoing treatment to left foot noted at this time. " She stated that she meant that she was continuing with the same treatment that Resident #3 had before which was to apply a bordered foam to his left dorsal foot. She stated that she was responsible for conducting weekly skin audits and that she was supposed to document all areas of skin that were not intact including the wounds, [MEDICAL CONDITION], and PEG tube site. S3TxNurse and confirmed that she failed to document her findings for Resident #3 to include all skin issues on 9/5/24, 9/12/14, 9/19/14, 9/26/14, 10/4/14, 10/17/14, and 10/30/14. During an interview with S2DON on 11/13/14 at 12:00 p.m., he reviewed Resident #3 ' s record and confirmed that weekly skin assessments with documentation was not present in the record as ordered and care planned. He stated that when Resident #3 was admitted , he had a healed Stage II pressure ulcer on the top of his left foot and that they applied a foam dressing as a protective measure. He stated that Resident #3 never had any other skin issues or pressure ulcers during the course of his stay at the facility from 8/21/14- 11/2/14 with the exception of a blister on his left hand which he was admitted with when he returned from the hospital on [DATE]. When told of S3TxNurse ' s statement that she found a dark spot on Resident #3 ' s left heel and that the wound on top of his foot had changed in late September 2014 and that she reported it to him, he stated that when he assessed the resident he did not have those same findings.

Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Record review of the printed Nurses Notes revealed the following documentation: Late Entry Nurses Notes dated 11/25/12 at 2:50 p.m. revealed received call from Dr......, New Order Noted: U/A (Urinalysis) with C&S (Culture & Sensitivity) [MEDICATION NAME] 1 gm (gram) IM (intramuscular) QD (every day) x 3 days. Late Entry Nurses Notes 11/25/12 at 1:30 p.m. UA collected via indwelling cath. Specimen sent to ... Lab. Will F/U. (follow up) initial Dose [MEDICATION NAME] 1 gm IM administered at this time, resident tolerated well, will continue to monitor effectiveness. Record review of the MAR revealed the following documentation: [MEDICATION NAME] 1 gm IM QD x 3 days 11/25/12 Time Code: 1530 Initial was noted, but there was no documentation of the site of administration of the medication for the initial dose. Record review of the Physician ' s Telephone Orders dated 11/25/12 at 2:50 p.m. revealed the following: U/A with C&S; [MEDICATION NAME] 1 gm IM QD x 3 days. Record review of the Microbiology: Ordered - 11/25/12 1552 Collected - 11/25/12 1510 Received - 11/25/12 1553 Resulted - 11/28/12 0611 Verified - 11/28/12 0611. Record review of the facility ' s Policy and Procedure for Documentation of Medication Administration revealed the following: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason (s) why a medication was withheld, not administered, or refused (as applicable); and f. Signature and title of the person administering the medication. In an interview on 11/28/12 at 1:20 p.m. with S3, RN/ADON she confirmed that the time of the event was the time in the late entry. She stated that the time and date above the late entry,was the time that the note was entered into the computer. She revealed that the time the note is entered cannot be changed. S3, RN/ADON indicated that the written order was received 11/25/12 at 2:50 p.m. and the specimen was collected at 3:10 p.m. and the specimen was received at the hospital 11/25/12 at 3:53 p.m. She disclosed that the time documented was a mistake for collection of the specimen and administration of the [MEDICATION NAME] was not at 1:30 p.m. She added that she did not have any other documentation by the nurse of where the [MEDICATION NAME] injection was given. S3, RN/ADON confirmed that the nurse did not follow the policy and procedure for administering the medication

Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Record review of the printed Nurses Notes revealed the following documentation: Late Entry Nurses Notes dated 11/25/12 at 2:50 p.m. revealed received call from Dr......, New Order Noted: U/A (Urinalysis) with C&S (Culture & Sensitivity) [MEDICATION NAME] 1 gm (gram) IM (intramuscular) QD (every day) x 3 days. Late Entry Nurses Notes 11/25/12 at 1:30 p.m. UA collected via indwelling cath. Specimen sent to ... Lab. Will F/U. (follow up) initial Dose [MEDICATION NAME] 1 gm IM administered at this time, resident tolerated well, will continue to monitor effectiveness. Record review of the MAR revealed the following documentation: [MEDICATION NAME] 1 gm IM QD x 3 days 11/25/12 Time Code: 1530 Initial was noted, but there was no documentation of the site of administration of the medication for the initial dose. Record review of the Physician ' s Telephone Orders dated 11/25/12 at 2:50 p.m. revealed the following: U/A with C&S; [MEDICATION NAME] 1 gm IM QD x 3 days. Record review of the Microbiology: Ordered - 11/25/12 1552 Collected - 11/25/12 1510 Received - 11/25/12 1553 Resulted - 11/28/12 0611 Verified - 11/28/12 0611. Record review of the facility ' s Policy and Procedure for Documentation of Medication Administration revealed the following: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason (s) why a medication was withheld, not administered, or refused (as applicable); and f. Signature and title of the person administering the medication. In an interview on 11/28/12 at 1:20 p.m. with S3, RN/ADON she confirmed that the time of the event was the time in the late entry. She stated that the time and date above the late entry,was the time that the note was entered into the computer. She revealed that the time the note is entered cannot be changed. S3, RN/ADON indicated that the written order was received 11/25/12 at 2:50 p.m. and the specimen was collected at 3:10 p.m. and the specimen was received at the hospital 11/25/12 at 3:53 p.m. She disclosed that the time documented was a mistake for collection of the specimen and administration of the [MEDICATION NAME] was not at 1:30 p.m. She added that she did not have any other documentation by the nurse of where the [MEDICATION NAME] injection was given. S3, RN/ADON confirmed that the nurse did not follow the policy and procedure for administering the medication

Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Record review of the printed Nurses Notes revealed the following documentation: Late Entry Nurses Notes dated 11/25/12 at 2:50 p.m. revealed received call from Dr......, New Order Noted: U/A (Urinalysis) with C&S (Culture & Sensitivity) [MEDICATION NAME] 1 gm (gram) IM (intramuscular) QD (every day) x 3 days. Late Entry Nurses Notes 11/25/12 at 1:30 p.m. UA collected via indwelling cath. Specimen sent to ... Lab. Will F/U. (follow up) initial Dose [MEDICATION NAME] 1 gm IM administered at this time, resident tolerated well, will continue to monitor effectiveness. Record review of the MAR revealed the following documentation: [MEDICATION NAME] 1 gm IM QD x 3 days 11/25/12 Time Code: 1530 Initial was noted, but there was no documentation of the site of administration of the medication for the initial dose. Record review of the Physician ' s Telephone Orders dated 11/25/12 at 2:50 p.m. revealed the following: U/A with C&S; [MEDICATION NAME] 1 gm IM QD x 3 days. Record review of the Microbiology: Ordered - 11/25/12 1552 Collected - 11/25/12 1510 Received - 11/25/12 1553 Resulted - 11/28/12 0611 Verified - 11/28/12 0611. Record review of the facility ' s Policy and Procedure for Documentation of Medication Administration revealed the following: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason (s) why a medication was withheld, not administered, or refused (as applicable); and f. Signature and title of the person administering the medication. In an interview on 11/28/12 at 1:20 p.m. with S3, RN/ADON she confirmed that the time of the event was the time in the late entry. She stated that the time and date above the late entry,was the time that the note was entered into the computer. She revealed that the time the note is entered cannot be changed. S3, RN/ADON indicated that the written order was received 11/25/12 at 2:50 p.m. and the specimen was collected at 3:10 p.m. and the specimen was received at the hospital 11/25/12 at 3:53 p.m. She disclosed that the time documented was a mistake for collection of the specimen and administration of the [MEDICATION NAME] was not at 1:30 p.m. She added that she did not have any other documentation by the nurse of where the [MEDICATION NAME] injection was given. S3, RN/ADON confirmed that the nurse did not follow the policy and procedure for administering the medication

Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them.

Based on record review and interview, the facility failed to ensure that there were sufficent nursing staff on duty to ensure residents received the required care and services in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Ensure the Director of Nursing (DON) verify that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 4. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was lifted when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on today. Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." On 11/26/12 at 3:00 pm, S2 DON was interviewed and asked what she put in place to correct the system failure of not verifying the nursing license for S13LPN? She stated that she will now call state board and check the site of the compliance department to see if there has been any action placed against the license of the employee. When asked who will be responsible to do this, she stated the ADON but confirmed that this was not in the facility ' s policy but that she would be changing the policy. The facility's policy was that the Director of Nursing would verify licensure. When asked for the documentation of the QA of this incident, S2DON stated that she did not have any documentation of the QA or procedure that was put into place after facility found out that the nurse did not have a license verification in her personnel file. S2DON stated she did not put anything in writing and that there was no policy and procedure to address the verification of licenses when she is not at work. The facility ' s policy and procedure for nursing verification of licensures was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. S13LPN's personnel chart was reviewed and revealed Medication Deviation Report Form for F21 dated 9/30/12. On the form it was documented that the resident did not receive [MEDICATION NAME] .5 mg po BID - 8:00 am dose and [MEDICATION NAME] 5/500 po QID - 12:00 noon dose was not given. These medications were not administered by S13LPN while she was on duty. The Medication Deviation Report Form for F20 was reviewed and revealed that she did not received her [MEDICATION NAME] .5 mg po TID the 8:00 am dose and [MEDICATION NAME] 75 mg po BID the 8:00 am dose. These medications were not administered to the residents by S13LPN while she was on duty on 9/30/12. This was confirmed by the facility during a random narcotic count of S13LPN's medication cart after the nurse was relieved of her duties.

Based on record review and interview, the facility failed to ensure that there were sufficent nursing staff on duty to ensure residents received the required care and services in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Ensure the Director of Nursing (DON) verify that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 4. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was lifted when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on today. Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." On 11/26/12 at 3:00 pm, S2 DON was interviewed and asked what she put in place to correct the system failure of not verifying the nursing license for S13LPN? She stated that she will now call state board and check the site of the compliance department to see if there has been any action placed against the license of the employee. When asked who will be responsible to do this, she stated the ADON but confirmed that this was not in the facility ' s policy but that she would be changing the policy. The facility's policy was that the Director of Nursing would verify licensure. When asked for the documentation of the QA of this incident, S2DON stated that she did not have any documentation of the QA or procedure that was put into place after facility found out that the nurse did not have a license verification in her personnel file. S2DON stated she did not put anything in writing and that there was no policy and procedure to address the verification of licenses when she is not at work. The facility ' s policy and procedure for nursing verification of licensures was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. S13LPN's personnel chart was reviewed and revealed Medication Deviation Report Form for F21 dated 9/30/12. On the form it was documented that the resident did not receive [MEDICATION NAME] .5 mg po BID - 8:00 am dose and [MEDICATION NAME] 5/500 po QID - 12:00 noon dose was not given. These medications were not administered by S13LPN while she was on duty. The Medication Deviation Report Form for F20 was reviewed and revealed that she did not received her [MEDICATION NAME] .5 mg po TID the 8:00 am dose and [MEDICATION NAME] 75 mg po BID the 8:00 am dose. These medications were not administered to the residents by S13LPN while she was on duty on 9/30/12. This was confirmed by the facility during a random narcotic count of S13LPN's medication cart after the nurse was relieved of her duties.

Based on record review and interview, the facility's administration failed to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to: Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12 by failing to ensure: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. . 6. Failed to protect and thoroughly investigate the complaint of a cognitively impaired resident inappropriately touched by another resident and failling to complete an Incident Report. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Review of the clinical record revealed that resident F1 was a 92 y/o white male with the following Diagnosis: [REDACTED]. Review of the MDS Minimum Data Set assessment dated [DATE] of F1 ' s Cognitive Pattern Section revealed that the resident had a BIMS (Brief Interview Memory Score) summary score of 8, moderately impaired. Review of the clinical record of F5 revealed the following Diagnosis: [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] of F5 ' s Cognitive Pattern Section revealed that the resident had a BIMS summary score of 5, severe impairement. Record review of the Activity Progress Notes revealed the following documentation: 9/28/12 Today during remember when RAD (Resident Activity Director), reeducated residents that if they see someone touch someone else in a wrong way that they need to report the situation to someone immediately. F6 stated she saw F1 the day before yesterday come to the feeders table and touch on F5. F6 said she hollered at him to leave her alone and he went on his way. F7 also reported that he was touching on F5 a while back in the vestibule area where she sits. F7 went and scared him away from her. I asked if they reported this to anyone and residents both stated, " no " RAD informed them that they need to report a situation like this as soon as it happens and not to wait. Further review of the notes that was written by the Activity Director revealed the following documentation: On 9/28/12 (Activity) was having an activity with residents and a couple of them stated that F1 was inappropriately touching a female resident in hallway and in dining room. She then reported it to department heads. It was discussed that he needed to be redirected. SSD (Social Service Director) questioned F1 about inappropriately touching a female and he denied it and said I will speak to Mr. (NAME REDACTED) .....because they are making things up about him. SSD continued to explain to him that he is not to touch anyone male or female. He kept saying, whoever said that is trying to get him in trouble. He then returned to therapy. Review of the Social Progress Notes revealed the following documentation: 10/3/12 F1 was told by SSD that he was not allowed on hall 500. He was upset, but agreed to the stipulation. 10/16/12 During a birthday party on Station A, F1 would approach a female resident a couple of time try to get her attention, by touching her shoulder. He was re-directed by the Activity Director and was told if he continued to go near her or touch her, he would be sent to his room until after party. Activity Director & staff monitored both residents and no other problems occurred. 10/26/12 F1 was found going down 600 and was re-directed. He did state why? And it was explained to him and he stated he never did anything to anyone. He said he wanted to go visit his female friend on the hall, SSD explained, It was not possible and he could not go on hall 600 either. 10/29/12 SSD call F1 contact ( ... ....) to let her know he touched a female inappropriately and was unable to go on hall 500 or 600. He has been re-directed several times by staff. SSD explained he will say & is his girl friend or sometimes denies knowing her. SSD explained that if he does it again, we will send him to a psych facility. Resident F1:Review of F1's Care Plan revealed the following: Problem Onset 9/13/12: Potential for Psychosocial well being altered r/t behavior r/t cognitive deficits r/t does not want daughter called with new orders " I don ' t want my daughter bothered " r/t refuses to keep neb in bag r/t takes things that don ' t belong to him. 9/28/12 Resident reported witnessing F1 touching on a female resident. 10/16/12 touching female resident Goal & Target date: Will attain and maintain psychosocial health and well being as evidenced by all needs being met and continue physical functioning 12/10/12 Will indicate understanding by answering appropriately 12/10/12 Approaches: Orient daily and prn; Encourage to express needs and feelings; Interact with resident as often as possible; Involve resident in all planning of care; Medicate as ordered; Monitor effectiveness of medication if not effective MD will be notified; Observe for expressions of Depression or loneliness; Encourage to attend activity of choice; Reality orientation during walking hours, do not support confusion, open blinds during the day; Plays cards, enjoy music, reads, views TV, attends rosary and mass, courtyard visit when weather permits; Allow space for resident and friend for games; History of being caught eating coco butter lotion, redirected. 9/28/12 SSD redirected resident; 10/3/12 SSD informed resident he was not allowed down hall 500 d/t reports given on 9/28/12 per other resident staff informed monitor resident; 10/16/12 redirected per staff easily Continue to monitor. Record review of the facility 's Policy and Procedure for Accidents and Incidents - Investigating and Reporting revealed the following: Policy Statement - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy interpretation and Implementation: 1. The attending nurse, department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be include on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name (s) of witnesses and their accounts of the accident or incident; f. The injured person ' s account of the accident or incident; g. The time the injured person ' s Attending Physician was notified, as well as the time the time the physician responded and his or her instructions; h. The date/time the injured person ' s family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. The attending nurse, department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. The Director of Nursing shall ensure that the Administrator reviews Report of Incident/Accident form for each occurrence. In an interview on 11/20/12 at 8:40 a.m. with F1 he was asked how he gets around in his wheelchair. He stated that he has the walker but it is easier to get around in his wheelchair. He indicated that he can go anywhere in the facility except on the other side. He disclosed that they told him he cannot go on the other side because of rules and regulations. In an interview on 11/20/12 at 9:09 a.m. with S11, CNA revealed that F1 gets around in his wheelchair and he does not need assistance to propel himself. She disclosed that the resident was not allowed on the 400 and 500 halls. She stated that she did not know why he was restricted from those halls. Interview on 11/20/12 at 12:00 p.m. with S5, SSD revealed that she receives the incident reports from whom ever notice or if family reports. She stated that the reports are given to her and she gives them to the department to take care of the issue or she may handle them herself. She indicated that abuse issues are handled by the Administrator, DON, or herself. In an interview on 11/20/12 at 12:35 p.m. with S6, Activity Director revealed that she remember the incident with resident F1 on 10/16/12 and she documented it in her notes. She stated that the resident was at the activity and he was on one end of the room and when he went to the bathroom he saw F5 and he reached out to touch the resident. She indicated that she reported the incident to the SSD. She disclosed that she did not complete an Incident Report. She stated that this was looked at the last time the state surveyors were here. She revealed that F5 was cognitively impaired and does not know what is going on. In a further interview on 11/20/12 at 12:50 p.m. with the SSD she stated that resident F1 was informed of the reason that he was not allowed on the 500 and 600 halls and he at times would be confused but had accepted his restrictions. She confirmed that the incident that occurred was not documented on an Incident Report. She revealed that she documented in her notes and there were notes in the Activity Progress Notes. She indicated that they conducted two meetings to discuss the issue. She added that they put into place to keep the resident off the 500 and 600 halls. In an interview on 11/20/12 at 2:20 p.m. with S2, RN/DON revealed that F1 cannot come on the 500 and 600 halls. She stated that F1 thinks that F5 is his girlfriend or wife. She indicated that F5 sat in a certain area on the 500 hall and F1 is not allowed to come back to the area. She disclosed that is what was put into place to protect that resident. She confirmed that an Incident Report was no completed. In an interview on 11/20/12 at 2:37 p.m. with S7, PT revealed that F1 was initially being escorted to the Physical Therapy department, then the resident began coming to the therapy department on his own. She stated that they then started seeing the resident in his room or they would bring him outside. In an interview on 11/20/12 at 3:05 p.m. with S9, LPN/MDS revealed that resident F1 was not allowed on the 500 and 600 Halls. She stated that the Care Plan did not reflect that the resident was not allowed on the 600 Hall. She indicated that resident F1 was attending Physical Therapy and he would go to the Nurses Station A and the nurses would call for PT and they would come and escort the resident back to PT and they will bring him back to his room. She disclosed that Physical Therapy was then seeing F1 in his room. She indicated that these were interventions, but the care plan did not reflect those interventions. She revealed that F1 was discussed in meetings.

Based on record review and interview, the facility's administration failed to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to: Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12 by failing to ensure: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. . 6. Failed to protect and thoroughly investigate the complaint of a cognitively impaired resident inappropriately touched by another resident and failling to complete an Incident Report. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Review of the clinical record revealed that resident F1 was a 92 y/o white male with the following Diagnosis: [REDACTED]. Review of the MDS Minimum Data Set assessment dated [DATE] of F1 ' s Cognitive Pattern Section revealed that the resident had a BIMS (Brief Interview Memory Score) summary score of 8, moderately impaired. Review of the clinical record of F5 revealed the following Diagnosis: [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] of F5 ' s Cognitive Pattern Section revealed that the resident had a BIMS summary score of 5, severe impairement. Record review of the Activity Progress Notes revealed the following documentation: 9/28/12 Today during remember when RAD (Resident Activity Director), reeducated residents that if they see someone touch someone else in a wrong way that they need to report the situation to someone immediately. F6 stated she saw F1 the day before yesterday come to the feeders table and touch on F5. F6 said she hollered at him to leave her alone and he went on his way. F7 also reported that he was touching on F5 a while back in the vestibule area where she sits. F7 went and scared him away from her. I asked if they reported this to anyone and residents both stated, " no " RAD informed them that they need to report a situation like this as soon as it happens and not to wait. Further review of the notes that was written by the Activity Director revealed the following documentation: On 9/28/12 (Activity) was having an activity with residents and a couple of them stated that F1 was inappropriately touching a female resident in hallway and in dining room. She then reported it to department heads. It was discussed that he needed to be redirected. SSD (Social Service Director) questioned F1 about inappropriately touching a female and he denied it and said I will speak to Mr. (NAME REDACTED) .....because they are making things up about him. SSD continued to explain to him that he is not to touch anyone male or female. He kept saying, whoever said that is trying to get him in trouble. He then returned to therapy. Review of the Social Progress Notes revealed the following documentation: 10/3/12 F1 was told by SSD that he was not allowed on hall 500. He was upset, but agreed to the stipulation. 10/16/12 During a birthday party on Station A, F1 would approach a female resident a couple of time try to get her attention, by touching her shoulder. He was re-directed by the Activity Director and was told if he continued to go near her or touch her, he would be sent to his room until after party. Activity Director & staff monitored both residents and no other problems occurred. 10/26/12 F1 was found going down 600 and was re-directed. He did state why? And it was explained to him and he stated he never did anything to anyone. He said he wanted to go visit his female friend on the hall, SSD explained, It was not possible and he could not go on hall 600 either. 10/29/12 SSD call F1 contact ( ... ....) to let her know he touched a female inappropriately and was unable to go on hall 500 or 600. He has been re-directed several times by staff. SSD explained he will say & is his girl friend or sometimes denies knowing her. SSD explained that if he does it again, we will send him to a psych facility. Resident F1:Review of F1's Care Plan revealed the following: Problem Onset 9/13/12: Potential for Psychosocial well being altered r/t behavior r/t cognitive deficits r/t does not want daughter called with new orders " I don ' t want my daughter bothered " r/t refuses to keep neb in bag r/t takes things that don ' t belong to him. 9/28/12 Resident reported witnessing F1 touching on a female resident. 10/16/12 touching female resident Goal & Target date: Will attain and maintain psychosocial health and well being as evidenced by all needs being met and continue physical functioning 12/10/12 Will indicate understanding by answering appropriately 12/10/12 Approaches: Orient daily and prn; Encourage to express needs and feelings; Interact with resident as often as possible; Involve resident in all planning of care; Medicate as ordered; Monitor effectiveness of medication if not effective MD will be notified; Observe for expressions of Depression or loneliness; Encourage to attend activity of choice; Reality orientation during walking hours, do not support confusion, open blinds during the day; Plays cards, enjoy music, reads, views TV, attends rosary and mass, courtyard visit when weather permits; Allow space for resident and friend for games; History of being caught eating coco butter lotion, redirected. 9/28/12 SSD redirected resident; 10/3/12 SSD informed resident he was not allowed down hall 500 d/t reports given on 9/28/12 per other resident staff informed monitor resident; 10/16/12 redirected per staff easily Continue to monitor. Record review of the facility 's Policy and Procedure for Accidents and Incidents - Investigating and Reporting revealed the following: Policy Statement - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy interpretation and Implementation: 1. The attending nurse, department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be include on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name (s) of witnesses and their accounts of the accident or incident; f. The injured person ' s account of the accident or incident; g. The time the injured person ' s Attending Physician was notified, as well as the time the time the physician responded and his or her instructions; h. The date/time the injured person ' s family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. The attending nurse, department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. The Director of Nursing shall ensure that the Administrator reviews Report of Incident/Accident form for each occurrence. In an interview on 11/20/12 at 8:40 a.m. with F1 he was asked how he gets around in his wheelchair. He stated that he has the walker but it is easier to get around in his wheelchair. He indicated that he can go anywhere in the facility except on the other side. He disclosed that they told him he cannot go on the other side because of rules and regulations. In an interview on 11/20/12 at 9:09 a.m. with S11, CNA revealed that F1 gets around in his wheelchair and he does not need assistance to propel himself. She disclosed that the resident was not allowed on the 400 and 500 halls. She stated that she did not know why he was restricted from those halls. Interview on 11/20/12 at 12:00 p.m. with S5, SSD revealed that she receives the incident reports from whom ever notice or if family reports. She stated that the reports are given to her and she gives them to the department to take care of the issue or she may handle them herself. She indicated that abuse issues are handled by the Administrator, DON, or herself. In an interview on 11/20/12 at 12:35 p.m. with S6, Activity Director revealed that she remember the incident with resident F1 on 10/16/12 and she documented it in her notes. She stated that the resident was at the activity and he was on one end of the room and when he went to the bathroom he saw F5 and he reached out to touch the resident. She indicated that she reported the incident to the SSD. She disclosed that she did not complete an Incident Report. She stated that this was looked at the last time the state surveyors were here. She revealed that F5 was cognitively impaired and does not know what is going on. In a further interview on 11/20/12 at 12:50 p.m. with the SSD she stated that resident F1 was informed of the reason that he was not allowed on the 500 and 600 halls and he at times would be confused but had accepted his restrictions. She confirmed that the incident that occurred was not documented on an Incident Report. She revealed that she documented in her notes and there were notes in the Activity Progress Notes. She indicated that they conducted two meetings to discuss the issue. She added that they put into place to keep the resident off the 500 and 600 halls. In an interview on 11/20/12 at 2:20 p.m. with S2, RN/DON revealed that F1 cannot come on the 500 and 600 halls. She stated that F1 thinks that F5 is his girlfriend or wife. She indicated that F5 sat in a certain area on the 500 hall and F1 is not allowed to come back to the area. She disclosed that is what was put into place to protect that resident. She confirmed that an Incident Report was no completed. In an interview on 11/20/12 at 2:37 p.m. with S7, PT revealed that F1 was initially being escorted to the Physical Therapy department, then the resident began coming to the therapy department on his own. She stated that they then started seeing the resident in his room or they would bring him outside. In an interview on 11/20/12 at 3:05 p.m. with S9, LPN/MDS revealed that resident F1 was not allowed on the 500 and 600 Halls. She stated that the Care Plan did not reflect that the resident was not allowed on the 600 Hall. She indicated that resident F1 was attending Physical Therapy and he would go to the Nurses Station A and the nurses would call for PT and they would come and escort the resident back to PT and they will bring him back to his room. She disclosed that Physical Therapy was then seeing F1 in his room. She indicated that these were interventions, but the care plan did not reflect those interventions. She revealed that F1 was discussed in meetings. Surveyor: Gee, Vanessa A.

Based on observations, record review, and staff interview, the facility failed to provide an effective Quality Assurance and Quality Improvement program by failing to identify that the facility: 1. Had a back-up system in place to specify who would address the issue of license verification when the Director Of Nursing was not on duty in the facility. The facility did not have documentation of QA and what was placed into affect concerning verification of licensed staff after the incident on 9/30/12 occurred in which S13LPN was allowed to perform resident care without a valid license. S13LPN was employed with the facility from 7/25/12 to 9/30/12 when she was relieved of her duties after working impaired. 2. A system in place to ensure the facility's policy and procedures were followed prior to hiring an LPN who was to provide care to facility residents on 2 halls. Policy required: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. 3. Failed to have a system in place that investigated resident's complaints concerning the incident that occurred on 9/28/12 when a female cognitively impaired resident (F5) was touched inappropriately by a male resident (F1). This incident was reported to the facility's activity staff by the residents in the facility that witnessed the incident and the facility had no documentation of the investigation of the incident. Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until on 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 p.m. An interview with the S2DON on 11/26/12 at 12:16 p.m. was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a siezure. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 p.m. , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 a.m.- 10 p.m..) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 p.m. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 p.m., a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on today. Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 p.m., an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. On 11/26/12 at 3:00 p.m., S2 DON was interviewed and asked what she put in place to correct the system failure of not verifying the nursing license for S13LPN? She stated that she will now call state board and check the site of the compliance department to see if there has been any action placed against the license of the employee. When asked who will be responsible to do this, she stated the ADON but confirmed that this was not in the facility ' s policy but that she would be changing the policy. The facility's policy was that the Director of Nursing would verify licensure. When asked for the documentation of the QA of this incident, S2DON stated that she did not have any documentation of the QA or procedure that was put into place after facility found out that the nurse did not have a license verification in her personnel file. S2DON stated she did not put anything in writing and that there was no policy and procedure to address the verification of licenses when she is not at work. S13LPN's personnel chart was reviewed and revealed Medication Deviation Report Form for F21 dated 9/30/12. On the form it was documented that the resident did not receive [MEDICATION NAME] .5 mg po BID - 8:00 am dose and [MEDICATION NAME] 5/500 po QID - 12:00 noon dose was not given. These medication was not administered by S13LPN while she was on duty. The Medication Deviation Report Form for F20 was reviewed and revealed that she did not received her [MEDICATION NAME] .5 mg po TID the 8:00 am dose and [MEDICATION NAME] 75 mg po BID the 8:00 am dose. These medications were not administered to the residents by S13LPN while she was on duty. This was confirmed by the facility during a random narcotic count of S13LPN's medication cart after the nurse was relieved of her duties. 2. Review of the clinical record revealed that resident F1 was a 92 y/o white male with the following Diagnosis: [REDACTED]. Review of the MDS Minimum Data Set assessment dated [DATE] of F1 ' s Cognitive Pattern Section revealed that the resident had a BIMS (Brief Interview Memory Score) summary score of 8, moderately impaired. Review of the clinical record of F5 revealed the following Diagnosis: [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] of F5 ' s Cognitive Pattern Section revealed that the resident had a BIMS summary score of 5, severe impairement. Record review of the Activity Progress Notes revealed the following documentation: 9/28/12 Today during remember when RAD (Resident Activity Director), reeducated residents that if they see someone touch someone else in a wrong way that they need to report the situation to someone immediately. F6 stated she saw F1 the day before yesterday come to the feeders table and touch on F5. F6 said she hollered at him to leave her alone and he went on his way. F7 also reported that he was touching on F5 a while back in the vestibule area where she sits. F7 went and scared him away from her. I asked if they reported this to anyone and residents both stated, " no " RAD informed them that they need to report a situation like this as soon as it happens and not to wait. Further review of the notes that was written by the Activity Director revealed the following documentation: On 9/28/12 (Activity) was having an activity with residents and a couple of them stated that F1 was inappropriately touching a female resident in hallway and in dining room. She then reported it to department heads. It was discussed that he needed to be redirected. SSD (Social Service Director) questioned F1 about inappropriately touching a female and he denied it and said I will speak to Mr. (NAME REDACTED) .....because they are making things up about him. SSD continued to explain to him that he is not to touch anyone male or female. He kept saying, whoever said that is trying to get him in trouble. He then returned to therapy. Review of the Social Progress Notes revealed the following documentation: 10/3/12 F1 was told by SSD that he was not allowed on hall 500. He was upset, but agreed to the stipulation. 10/16/12 During a birthday party on Station A, F1 would approach a female resident a couple of time try to get her attention, by touching her shoulder. He was re-directed by the Activity Director and was told if he continued to go near her or touch her, he would be sent to his room until after party. Activity Director & staff monitored both residents and no other problems occurred. 10/26/12 F1 was found going down 600 and was re-directed. He did state why? And it was explained to him and he stated he never did anything to anyone. He said he wanted to go visit his female friend on the hall, SSD explained, It was not possible and he could not go on hall 600 either. 10/29/12 SSD call F1 contact ( ... ....) to let her know he touched a female inappropriately and was unable to go on hall 500 or 600. He has been re-directed several times by staff. SSD explained he will say & is his girl friend or sometimes denies knowing her. SSD explained that if he does it again, we will send him to a psych facility. Resident F1:Review of F1's Care Plan revealed the following: Problem Onset 9/13/12: Potential for Psychosocial well being altered r/t behavior r/t cognitive deficits r/t does not want daughter called with new orders " I don ' t want my daughter bothered " r/t refuses to keep neb in bag r/t takes things that don ' t belong to him. 9/28/12 Resident reported witnessing F1 touching on a female resident. 10/16/12 touching female resident Goal & Target date: Will attain and maintain psychosocial health and well being as evidenced by all needs being met and continue physical functioning 12/10/12 Will indicate understanding by answering appropriately 12/10/12 Approaches: Orient daily and prn; Encourage to express needs and feelings; Interact with resident as often as possible; Involve resident in all planning of care; Medicate as ordered; Monitor effectiveness of medication if not effective MD will be notified; Observe for expressions of Depression or loneliness; Encourage to attend activity of choice; Reality orientation during walking hours, do not support confusion, open blinds during the day; Plays cards, enjoy music, reads, views TV, attends rosary and mass, courtyard visit when weather permits; Allow space for resident and friend for games; History of being caught eating coco butter lotion, redirected. 9/28/12 SSD redirected resident; 10/3/12 SSD informed resident he was not allowed down hall 500 d/t reports given on 9/28/12 per other resident staff informed monitor resident; 10/16/12 redirected per staff easily Continue to monitor. Record review of the facility 's Policy and Procedure for Accidents and Incidents - Investigating and Reporting revealed the following: Policy Statement - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy interpretation and Implementation: 1. The attending nurse, department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be include on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name (s) of witnesses and their accounts of the accident or incident; f. The injured person ' s account of the accident or incident; g. The time the injured person ' s Attending Physician was notified, as well as the time the time the physician responded and his or her instructions; h. The date/time the injured person ' s family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. The attending nurse, department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. The Director of Nursing shall ensure that the Administrator reviews Report of Incident/Accident form for each occurrence. In an interview on 11/20/12 at 8:40 a.m. with F1 he was asked how he gets around in his wheelchair. He stated that he has the walker but it is easier to get around in his wheelchair. He indicated that he can go anywhere in the facility except on the other side. He disclosed that they told him he cannot go on the other side because of rules and regulations. In an interview on 11/20/12 at 9:09 a.m. with S11, CNA revealed that F1 gets around in his wheelchair and he does not need assistance to propel himself. She disclosed that the resident was not allowed on the 400 and 500 halls. She stated that she did not know why he was restricted from those halls. Interview on 11/20/12 at 12:00 p.m. with S5, SSD revealed that she receives the incident reports from whom ever notice or if family reports. She stated that the reports are given to her and she gives them to the department to take care of the issue or she may handle them herself. She indicated that abuse issues are handled by the Administrator, DON, or herself. In an interview on 11/20/12 at 12:35 p.m. with S6, Activity Director revealed that she remember the incident with resident F1 on 10/16/12 and she documented it in her notes. She stated that the resident was at the activity and he was on one end of the room and when he went to the bathroom he saw F5 and he reached out to touch the resident. She indicated that she reported the incident to the SSD. She disclosed that she did not complete an Incident Report. She stated that this was looked at the last time the state surveyors were here. She revealed that F5 was cognitively impaired and does not know what is going on. In a further interview on 11/20/12 at 12:50 p.m. with the SSD she stated that resident F1 was informed of the reason that he was not allowed on the 500 and 600 halls and he at times would be confused but had accepted his restrictions. She confirmed that the incident that occurred was not documented on an Incident Report. She revealed that she documented in her notes and there were notes in the Activity Progress Notes. She indicated that they conducted two meetings to discuss the issue. She added that they put into place to keep the resident off the 500 and 600 halls. In an interview on 11/20/12 at 2:20 p.m. with S2, RN/DON revealed that F1 cannot come on the 500 and 600 halls. She stated that F1 thinks that F5 is his girlfriend or wife. She indicated that F5 sat in a certain area on the 500 hall and F1 is not allowed to come back to the area. She disclosed that is what was put into place to protect that resident. She confirmed that an Incident Report was no completed. In an interview on 11/20/12 at 2:37 p.m. with S7, PT revealed that F1 was initially being escorted to the Physical Therapy department, then the resident began coming to the therapy department on his own. She stated that they then started seeing the resident in his room or they would bring him outside. In an interview on 11/20/12 at 3:05 p.m. with S9, LPN/MDS revealed that resident F1 was not allowed on the 500 and 600 Halls. She stated that the Care Plan did not reflect that the resident was not allowed on the 600 Hall. She indicated that resident F1 was attending Physical Therapy and he would go to the Nurses Station A and the nurses would call for PT and they would come and escort the resident back to PT and they will bring him back to his room. She disclosed that Physical Therapy was then seeing F1 in his room. She indicated that these were interventions, but the care plan did not reflect those interventions. She revealed that F1 was discussed in meetings.

2 Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR. Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds. The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Record review of the printed Nurses Notes revealed the following documentation: Late Entry Nurses Notes dated 11/25/12 at 2:50 p.m. revealed received call from Dr., New Order Noted: U/A (Urinalysis) with C&S (Culture & Sensitivity) [MEDICATION NAME] 1 gm (gram) IM (intramuscular) QD (every day) x 3 days. Late Entry Nurses Notes 11/25/12 at 1:30 p.m. UA collected via indwelling cath. Specimen sent to . Lab. Will F/U. (follow up) initial Dose [MEDICATION NAME] 1 gm IM administered at this time, resident tolerated well, will continue to monitor effectiveness. Record review of the MAR revealed the following documentation: [MEDICATION NAME] 1 gm IM QD x 3 days 11/25/12 Time Code: 1530 Initial was noted, but there was no documentation of the site of administration of the medication for the initial dose. Record review of the Physician ' s Telephone Orders dated 11/25/12 at 2:50 p.m. revealed the following: U/A with C&S; [MEDICATION NAME] 1 gm IM QD x 3 days. Record review of the Microbiology: Ordered - 11/25/12 1552 Collected - 11/25/12 1510 Received - 11/25/12 1553 Resulted - 11/28/12 0611 Verified - 11/28/12 0611. Record review of the facility ' s Policy and Procedure for Documentation of Medication Administration revealed the following: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason (s) why a medication was withheld, not administered, or refused (as applicable); and f. Signature and title of the person administering the medication. In an interview on 11/28/12 at 1:20 p.m. with S3, RN/ADON she confirmed that the time of the event was the time in the late entry. She stated that the time and date above the late entry,was the time that the note was entered into the computer. She revealed that the time the note is entered cannot be changed. S3, RN/ADON indicated that the written order was received 11/25/12 at 2:50 p.m. and the specimen was collected at 3:10 p.m. and the specimen was received at the hospital 11/25/12 at 3:53 p.m. She disclosed that the time documented was a mistake for collection of the specimen and administration of the [MEDICATION NAME] was not at 1:30 p.m. She added that she did not have any other documentation by the nurse of where the [MEDICATION NAME] injection was given. S3, RN/ADON confirmed that the nurse did not follow the policy and procedure for administering the medication

2 Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR. Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds. The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Record review of the printed Nurses Notes revealed the following documentation: Late Entry Nurses Notes dated 11/25/12 at 2:50 p.m. revealed received call from Dr., New Order Noted: U/A (Urinalysis) with C&S (Culture & Sensitivity) [MEDICATION NAME] 1 gm (gram) IM (intramuscular) QD (every day) x 3 days. Late Entry Nurses Notes 11/25/12 at 1:30 p.m. UA collected via indwelling cath. Specimen sent to . Lab. Will F/U. (follow up) initial Dose [MEDICATION NAME] 1 gm IM administered at this time, resident tolerated well, will continue to monitor effectiveness. Record review of the MAR revealed the following documentation: [MEDICATION NAME] 1 gm IM QD x 3 days 11/25/12 Time Code: 1530 Initial was noted, but there was no documentation of the site of administration of the medication for the initial dose. Record review of the Physician ' s Telephone Orders dated 11/25/12 at 2:50 p.m. revealed the following: U/A with C&S; [MEDICATION NAME] 1 gm IM QD x 3 days. Record review of the Microbiology: Ordered - 11/25/12 1552 Collected - 11/25/12 1510 Received - 11/25/12 1553 Resulted - 11/28/12 0611 Verified - 11/28/12 0611. Record review of the facility ' s Policy and Procedure for Documentation of Medication Administration revealed the following: Policy Statement: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason (s) why a medication was withheld, not administered, or refused (as applicable); and f. Signature and title of the person administering the medication. In an interview on 11/28/12 at 1:20 p.m. with S3, RN/ADON she confirmed that the time of the event was the time in the late entry. She stated that the time and date above the late entry,was the time that the note was entered into the computer. She revealed that the time the note is entered cannot be changed. S3, RN/ADON indicated that the written order was received 11/25/12 at 2:50 p.m. and the specimen was collected at 3:10 p.m. and the specimen was received at the hospital 11/25/12 at 3:53 p.m. She disclosed that the time documented was a mistake for collection of the specimen and administration of the [MEDICATION NAME] was not at 1:30 p.m. She added that she did not have any other documentation by the nurse of where the [MEDICATION NAME] injection was given. S3, RN/ADON confirmed that the nurse did not follow the policy and procedure for administering the medication

Based on observation, record review and interview, the facility failed to ensure that a resident received necessary care and services to attain the highest practicable physical, mental and psychosocial well-being by 1. failing to ensure that documentation of skin tears was done and 1. failing to ensure coordination of care between the Hospice agency and the facility, related to care provided to skin tears, was provided to a resident for 1 of 10 residents receiving Hospice services in a facility where 92 residents resided. #6 Findings: Resident #6: The resident was admitted to the facility on [DATE]. His current [DIAGNOSES REDACTED]. His MDS assessment dated [DATE] revealed that he had partial loss of his right arm, right leg and both feet and complete loss of his left hand and arm. Resident #6 required total assistance with all of his ADLs. His BIMS score on his current MDS was a 5 (scored from 0-15 with 15 being the highest score). Resident #6 was admitted to Hospice on 5-10-12 with a [DIAGNOSES REDACTED]. Review of the Hospice POC dated 8-22-12 revealed that #6 was eating well and his pain was described as better with no break thru pain noted. His pressure sore risk assessment dated [DATE] revealed him to be scored at a 14 (12 or less representing high risk). The assessment went on to reveal that friction and shear was scored as #1 = Problem = requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. Resident #6 was currently receiving daily wound care to his multiple skin tears. Observation of #6's wound care was done with #S5LPN (the new wound care nurse) on 10-15-12 at 2:20 p.m. The wound care nurse preceded to care for #6's skin tear areas. She stated the skin tears were cleaned and bandaged on Monday, Wednesday and Friday of each week. On #6's left forearm was 2 bandaged areas. The nurse removed the first bandage then preceded to remove a bandage just below the first one. At this time she stated that she was unaware of the second bandage to his forearm. #S5 stated she was not aware of this skin tear. She stated she thought it was there on Friday (when she last did the wound care), however, there was no documentation of this skin tear. She stated that sometimes Hospice put bandages on #6's skin tears and would not tell the nurse or not document anything about the skin tear. Then #S5 found another bandage located above #6's right wrist. When the bandage on #6's right wrist was removed, there was a skin bread approximately the size of a dime and the skin was red with small amount of drainage. S5 stated this skin tear and bandage was not there on Friday when she did wound care. She stated this must have happened over the weekend but there was no documentation to reflect the new skin tear. S5 then measured the skin tear as [MEDICAL CONDITION]. with the wound bed being red and wet. She then cleaned the area with NS, applied TAO and dressing. She stated she would document this skin tear area and send an order to #6's physician. She again stated that Hospice often bandaged skin tear areas without informing the facility's nurses. During an interview held with #S5LPN (wound care nurse) on 10-16-12 at 10:10 a.m., she stated, after checking, the area to resident's right wrist (skin tear) was not documented because the Hospice nurse probably found and bandaged. Stated Hospice nurses' often did this in the past. Stated to her knowledge, there was no documentation done by the Hospice nurse. At 10:30 a.m., S5 stated she reviewed the Hospice binder and there was no documentation for the resident on Friday and no documentation that a bandage was placed on his right wrist. She also stated that any skin tears should be documented on the TARS however, after checking, stated there was no documentation about the skin tear to #6's right wrist or left forearm. During an interview with #S2DON on 10-16-12 at 11 a.m. She stated there was a problem with Hospice coming in and finding things about the residents and not documenting or reporting to the facility nurses. She stated she was the new as DON at the facility and has not yet met with the 3 Hospice personnel. She stated that she did recognize that a lack of communication with Hospice agencies did exist and that she had not addressed this problem.

Based on record review and interview, the facility failed to ensure that each resident receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Ensure the Director of Nursing (DON) verify that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was lifted when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. This failed practice had the potential to affect all of the residents on the 100 and 300 halls, where S13LPN was assigned to work. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on today. Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." On 11/26/12 at 3:00 pm, S2 DON was interviewed and asked what she put in place to correct the system failure of not verifying the nursing license for S13LPN? She stated that she will now call state board and check the site of the compliance department to see if there has been any action placed against the license of the employee. When asked who will be responsible to do this, she stated the ADON but confirmed that this was not in the facility ' s policy but that she would be changing the policy. The facility's policy was that the Director of Nursing would verify licensure. When asked for the documentation of the QA of this incident, S2DON stated that she did not have any documentation of the QA or procedure that was put into place after facility found out that the nurse did not have a license verification in her personnel file. S2DON stated she did not put anything in writing and that there was no policy and procedure to address the verification of licenses when she is not at work. The facility ' s policy and procedure for nursing verification of licensures was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. S13LPN's personnel chart was reviewed and revealed Medication Deviation Report Form for F21 dated 9/30/12. On the form it was documented that the resident did not receive [MEDICATION NAME] .5 mg po BID - 8:00 am dose and [MEDICATION NAME] 5/500 po QID - 12:00 noon dose was not given. These medications were not administered by S13LPN while she was on duty. The Medication Deviation Report Form for F20 was reviewed and revealed that she did not received her [MEDICATION NAME] .5 mg po TID the 8:00 am dose and [MEDICATION NAME] 75 mg po BID the 8:00 am dose. These medications were not administered to the residents by S13LPN while she was on duty on 9/30/12. This was confirmed by the facility during a random narcotic count of S13LPN's medication cart after the nurse was relieved of her duties.

2 Based on record review and interview, the facility failed to ensure that there were sufficent nursing staff on duty to ensure residents received the required care and services in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Ensure the Director of Nursing (DON) verify that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 4. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was lifted when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR. Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on today. Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds. On 11/26/12 at 3:00 pm, S2 DON was interviewed and asked what she put in place to correct the system failure of not verifying the nursing license for S13LPN? She stated that she will now call state board and check the site of the compliance department to see if there has been any action placed against the license of the employee. When asked who will be responsible to do this, she stated the ADON but confirmed that this was not in the facility ' s policy but that she would be changing the policy. The facility's policy was that the Director of Nursing would verify licensure. When asked for the documentation of the QA of this incident, S2DON stated that she did not have any documentation of the QA or procedure that was put into place after facility found out that the nurse did not have a license verification in her personnel file. S2DON stated she did not put anything in writing and that there was no policy and procedure to address the verification of licenses when she is not at work. The facility ' s policy and procedure for nursing verification of licensures was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. S13LPN's personnel chart was reviewed and revealed Medication Deviation Report Form for F21 dated 9/30/12. On the form it was documented that the resident did not receive [MEDICATION NAME] .5 mg po BID - 8:00 am dose and [MEDICATION NAME] 5/500 po QID - 12:00 noon dose was not given. These medications were not administered by S13LPN while she was on duty. The Medication Deviation Report Form for F20 was reviewed and revealed that she did not received her [MEDICATION NAME] .5 mg po TID the 8:00 am dose and [MEDICATION NAME] 75 mg po BID the 8:00 am dose. These medications were not administered to the residents by S13LPN while she was on duty on 9/30/12. This was confirmed by the facility during a random narcotic count of S13LPN's medication cart after the nurse was relieved of her duties.

2 Based on record review and interview, the facility's administration failed to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to: Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12 by failing to ensure: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. 6. Failed to protect and thoroughly investigate the complaint of a cognitively impaired resident inappropriately touched by another resident and failling to complete an Incident Report. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR. Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds. The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them. 4. Review of the clinical record revealed that resident F1 was a 92 y/o white male with the following Diagnosis: [REDACTED]. Review of the MDS Minimum Data Set assessment dated [DATE] of F1 ' s Cognitive Pattern Section revealed that the resident had a BIMS (Brief Interview Memory Score) summary score of 8, moderately impaired. Review of the clinical record of F5 revealed the following Diagnosis: [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] of F5 ' s Cognitive Pattern Section revealed that the resident had a BIMS summary score of 5, severe impairement. Record review of the Activity Progress Notes revealed the following documentation: 9/28/12 Today during remember when RAD (Resident Activity Director), reeducated residents that if they see someone touch someone else in a wrong way that they need to report the situation to someone immediately. F6 stated she saw F1 the day before yesterday come to the feeders table and touch on F5. F6 said she hollered at him to leave her alone and he went on his way. F7 also reported that he was touching on F5 a while back in the vestibule area where she sits. F7 went and scared him away from her. I asked if they reported this to anyone and residents both stated, no RAD informed them that they need to report a situation like this as soon as it happens and not to wait. Further review of the notes that was written by the Activity Director revealed the following documentation: On 9/28/12 (Activity) was having an activity with residents and a couple of them stated that F1 was inappropriately touching a female resident in hallway and in dining room. She then reported it to department heads. It was discussed that he needed to be redirected. SSD (Social Service Director) questioned F1 about inappropriately touching a female and he denied it and said I will speak to Mr. (NAME REDACTED) .because they are making things up about him. SSD continued to explain to him that he is not to touch anyone male or female. He kept saying, whoever said that is trying to get him in trouble. He then returned to therapy. Review of the Social Progress Notes revealed the following documentation: 10/3/12 F1 was told by SSD that he was not allowed on hall 500. He was upset, but agreed to the stipulation. 10/16/12 During a birthday party on Station A, F1 would approach a female resident a couple of time try to get her attention, by touching her shoulder. He was re-directed by the Activity Director and was told if he continued to go near her or touch her, he would be sent to his room until after party. Activity Director & staff monitored both residents and no other problems occurred. 10/26/12 F1 was found going down 600 and was re-directed. He did state why? And it was explained to him and he stated he never did anything to anyone. He said he wanted to go visit his female friend on the hall, SSD explained, It was not possible and he could not go on hall 600 either. 10/29/12 SSD call F1 contact ( .) to let her know he touched a female inappropriately and was unable to go on hall 500 or 600. He has been re-directed several times by staff. SSD explained he will say & is his girl friend or sometimes denies knowing her. SSD explained that if he does it again, we will send him to a psych facility. Resident F1:Review of F1's Care Plan revealed the following: Problem Onset 9/13/12: Potential for Psychosocial well being altered r/t behavior r/t cognitive deficits r/t does not want daughter called with new orders I don ' t want my daughter bothered r/t refuses to keep neb in bag r/t takes things that don ' t belong to him. 9/28/12 Resident reported witnessing F1 touching on a female resident. 10/16/12 touching female resident Goal & Target date: Will attain and maintain psychosocial health and well being as evidenced by all needs being met and continue physical functioning 12/10/12 Will indicate understanding by answering appropriately 12/10/12 Approaches: Orient daily and prn; Encourage to express needs and feelings; Interact with resident as often as possible; Involve resident in all planning of care; Medicate as ordered; Monitor effectiveness of medication if not effective MD will be notified; Observe for expressions of Depression or loneliness; Encourage to attend activity of choice; Reality orientation during walking hours, do not support confusion, open blinds during the day; Plays cards, enjoy music, reads, views TV, attends rosary and mass, courtyard visit when weather permits; Allow space for resident and friend for games; History of being caught eating coco butter lotion, redirected. 9/28/12 SSD redirected resident; 10/3/12 SSD informed resident he was not allowed down hall 500 d/t reports given on 9/28/12 per other resident staff informed monitor resident; 10/16/12 redirected per staff easily Continue to monitor. Record review of the facility 's Policy and Procedure for Accidents and Incidents - Investigating and Reporting revealed the following: Policy Statement - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy interpretation and Implementation: 1. The attending nurse, department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be include on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name (s) of witnesses and their accounts of the accident or incident; f. The injured person ' s account of the accident or incident; g. The time the injured person ' s Attending Physician was notified, as well as the time the time the physician responded and his or her instructions; h. The date/time the injured person ' s family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. The attending nurse, department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. The Director of Nursing shall ensure that the Administrator reviews Report of Incident/Accident form for each occurrence. In an interview on 11/20/12 at 8:40 a.m. with F1 he was asked how he gets around in his wheelchair. He stated that he has the walker but it is easier to get around in his wheelchair. He indicated that he can go anywhere in the facility except on the other side. He disclosed that they told him he cannot go on the other side because of rules and regulations. In an interview on 11/20/12 at 9:09 a.m. with S11, CNA revealed that F1 gets around in his wheelchair and he does not need assistance to propel himself. She disclosed that the resident was not allowed on the 400 and 500 halls. She stated that she did not know why he was restricted from those halls. Interview on 11/20/12 at 12:00 p.m. with S5, SSD revealed that she receives the incident reports from whom ever notice or if family reports. She stated that the reports are given to her and she gives them to the department to take care of the issue or she may handle them herself. She indicated that abuse issues are handled by the Administrator, DON, or herself. In an interview on 11/20/12 at 12:35 p.m. with S6, Activity Director revealed that she remember the incident with resident F1 on 10/16/12 and she documented it in her notes. She stated that the resident was at the activity and he was on one end of the room and when he went to the bathroom he saw F5 and he reached out to touch the resident. She indicated that she reported the incident to the SSD. She disclosed that she did not complete an Incident Report. She stated that this was looked at the last time the state surveyors were here. She revealed that F5 was cognitively impaired and does not know what is going on. In a further interview on 11/20/12 at 12:50 p.m. with the SSD she stated that resident F1 was informed of the reason that he was not allowed on the 500 and 600 halls and he at times would be confused but had accepted his restrictions. She confirmed that the incident that occurred was not documented on an Incident Report. She revealed that she documented in her notes and there were notes in the Activity Progress Notes. She indicated that they conducted two meetings to discuss the issue. She added that they put into place to keep the resident off the 500 and 600 halls. In an interview on 11/20/12 at 2:20 p.m. with S2, RN/DON revealed that F1 cannot come on the 500 and 600 halls. She stated that F1 thinks that F5 is his girlfriend or wife. She indicated that F5 sat in a certain area on the 500 hall and F1 is not allowed to come back to the area. She disclosed that is what was put into place to protect that resident. She confirmed that an Incident Report was no completed. In an interview on 11/20/12 at 2:37 p.m. with S7, PT revealed that F1 was initially being escorted to the Physical Therapy department, then the resident began coming to the therapy department on his own. She stated that they then started seeing the resident in his room or they would bring him outside. In an interview on 11/20/12 at 3:05 p.m. with S9, LPN/MDS revealed that resident F1 was not allowed on the 500 and 600 Halls. She stated that the Care Plan did not reflect that the resident was not allowed on the 600 Hall. She indicated that resident F1 was attending Physical Therapy and he would go to the Nurses Station A and the nurses would call for PT and they would come and escort the resident back to PT and they will bring him back to his room. She disclosed that Physical Therapy was then seeing F1 in his room. She indicated that these were interventions, but the care plan did not reflect those interventions. She revealed that F1 was discussed in meetings.

2 Based on observations, record review, and staff interview, the facility failed to provide an effective Quality Assurance and Quality Improvement program by failing to identify that the facility: 1. Had a back-up system in place to specify who would address the issue of license verification when the Director Of Nursing was not on duty in the facility. The facility did not have documentation of QA and what was placed into affect concerning verification of licensed staff after the incident on 9/30/12 occurred in which S13LPN was allowed to perform resident care without a valid license. S13LPN was employed with the facility from 7/25/12 to 9/30/12 when she was relieved of her duties after working impaired. 2. A system in place to ensure the facility's policy and procedures were followed prior to hiring an LPN who was to provide care to facility residents on 2 halls. Policy required: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. 3. Failed to have a system in place that investigated resident's complaints concerning the incident that occurred on 9/28/12 when a female cognitively impaired resident (F5) was touched inappropriately by a male resident (F1). This incident was reported to the facility's activity staff by the residents in the facility that witnessed the incident and the facility had no documentation of the investigation of the incident. Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until on 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 p.m. An interview with the S2DON on 11/26/12 at 12:16 p.m. was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a siezure. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 p.m. , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 a.m.- 10 p.m.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR. Drug screen results were received 10/2/12 at 4:15 p.m. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 p.m., a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on today. Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 p.m., an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds. The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. On 11/26/12 at 3:00 p.m., S2 DON was interviewed and asked what she put in place to correct the system failure of not verifying the nursing license for S13LPN? She stated that she will now call state board and check the site of the compliance department to see if there has been any action placed against the license of the employee. When asked who will be responsible to do this, she stated the ADON but confirmed that this was not in the facility ' s policy but that she would be changing the policy. The facility's policy was that the Director of Nursing would verify licensure. When asked for the documentation of the QA of this incident, S2DON stated that she did not have any documentation of the QA or procedure that was put into place after facility found out that the nurse did not have a license verification in her personnel file. S2DON stated she did not put anything in writing and that there was no policy and procedure to address the verification of licenses when she is not at work. S13LPN's personnel chart was reviewed and revealed Medication Deviation Report Form for F21 dated 9/30/12. On the form it was documented that the resident did not receive [MEDICATION NAME] .5 mg po BID - 8:00 am dose and [MEDICATION NAME] 5/500 po QID - 12:00 noon dose was not given. These medication was not administered by S13LPN while she was on duty. The Medication Deviation Report Form for F20 was reviewed and revealed that she did not received her [MEDICATION NAME] .5 mg po TID the 8:00 am dose and [MEDICATION NAME] 75 mg po BID the 8:00 am dose. These medications were not administered to the residents by S13LPN while she was on duty. This was confirmed by the facility during a random narcotic count of S13LPN's medication cart after the nurse was relieved of her duties. 2. Review of the clinical record revealed that resident F1 was a 92 y/o white male with the following Diagnosis: [REDACTED]. Review of the MDS Minimum Data Set assessment dated [DATE] of F1 ' s Cognitive Pattern Section revealed that the resident had a BIMS (Brief Interview Memory Score) summary score of 8, moderately impaired. Review of the clinical record of F5 revealed the following Diagnosis: [REDACTED]. Review of the Quarterly MDS assessment dated [DATE] of F5 ' s Cognitive Pattern Section revealed that the resident had a BIMS summary score of 5, severe impairement. Record review of the Activity Progress Notes revealed the following documentation: 9/28/12 Today during remember when RAD (Resident Activity Director), reeducated residents that if they see someone touch someone else in a wrong way that they need to report the situation to someone immediately. F6 stated she saw F1 the day before yesterday come to the feeders table and touch on F5. F6 said she hollered at him to leave her alone and he went on his way. F7 also reported that he was touching on F5 a while back in the vestibule area where she sits. F7 went and scared him away from her. I asked if they reported this to anyone and residents both stated, no RAD informed them that they need to report a situation like this as soon as it happens and not to wait. Further review of the notes that was written by the Activity Director revealed the following documentation: On 9/28/12 (Activity) was having an activity with residents and a couple of them stated that F1 was inappropriately touching a female resident in hallway and in dining room. She then reported it to department heads. It was discussed that he needed to be redirected. SSD (Social Service Director) questioned F1 about inappropriately touching a female and he denied it and said I will speak to Mr. (NAME REDACTED) .because they are making things up about him. SSD continued to explain to him that he is not to touch anyone male or female. He kept saying, whoever said that is trying to get him in trouble. He then returned to therapy. Review of the Social Progress Notes revealed the following documentation: 10/3/12 F1 was told by SSD that he was not allowed on hall 500. He was upset, but agreed to the stipulation. 10/16/12 During a birthday party on Station A, F1 would approach a female resident a couple of time try to get her attention, by touching her shoulder. He was re-directed by the Activity Director and was told if he continued to go near her or touch her, he would be sent to his room until after party. Activity Director & staff monitored both residents and no other problems occurred. 10/26/12 F1 was found going down 600 and was re-directed. He did state why? And it was explained to him and he stated he never did anything to anyone. He said he wanted to go visit his female friend on the hall, SSD explained, It was not possible and he could not go on hall 600 either. 10/29/12 SSD call F1 contact ( .) to let her know he touched a female inappropriately and was unable to go on hall 500 or 600. He has been re-directed several times by staff. SSD explained he will say & is his girl friend or sometimes denies knowing her. SSD explained that if he does it again, we will send him to a psych facility. Resident F1:Review of F1's Care Plan revealed the following: Problem Onset 9/13/12: Potential for Psychosocial well being altered r/t behavior r/t cognitive deficits r/t does not want daughter called with new orders I don ' t want my daughter bothered r/t refuses to keep neb in bag r/t takes things that don ' t belong to him. 9/28/12 Resident reported witnessing F1 touching on a female resident. 10/16/12 touching female resident Goal & Target date: Will attain and maintain psychosocial health and well being as evidenced by all needs being met and continue physical functioning 12/10/12 Will indicate understanding by answering appropriately 12/10/12 Approaches: Orient daily and prn; Encourage to express needs and feelings; Interact with resident as often as possible; Involve resident in all planning of care; Medicate as ordered; Monitor effectiveness of medication if not effective MD will be notified; Observe for expressions of Depression or loneliness; Encourage to attend activity of choice; Reality orientation during walking hours, do not support confusion, open blinds during the day; Plays cards, enjoy music, reads, views TV, attends rosary and mass, courtyard visit when weather permits; Allow space for resident and friend for games; History of being caught eating coco butter lotion, redirected. 9/28/12 SSD redirected resident; 10/3/12 SSD informed resident he was not allowed down hall 500 d/t reports given on 9/28/12 per other resident staff informed monitor resident; 10/16/12 redirected per staff easily Continue to monitor. Record review of the facility 's Policy and Procedure for Accidents and Incidents - Investigating and Reporting revealed the following: Policy Statement - All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy interpretation and Implementation: 1. The attending nurse, department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be include on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name (s) of witnesses and their accounts of the accident or incident; f. The injured person ' s account of the accident or incident; g. The time the injured person ' s Attending Physician was notified, as well as the time the time the physician responded and his or her instructions; h. The date/time the injured person ' s family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. The attending nurse, department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. The Director of Nursing shall ensure that the Administrator reviews Report of Incident/Accident form for each occurrence. In an interview on 11/20/12 at 8:40 a.m. with F1 he was asked how he gets around in his wheelchair. He stated that he has the walker but it is easier to get around in his wheelchair. He indicated that he can go anywhere in the facility except on the other side. He disclosed that they told him he cannot go on the other side because of rules and regulations. In an interview on 11/20/12 at 9:09 a.m. with S11, CNA revealed that F1 gets around in his wheelchair and he does not need assistance to propel himself. She disclosed that the resident was not allowed on the 400 and 500 halls. She stated that she did not know why he was restricted from those halls. Interview on 11/20/12 at 12:00 p.m. with S5, SSD revealed that she receives the incident reports from whom ever notice or if family reports. She stated that the reports are given to her and she gives them to the department to take care of the issue or she may handle them herself. She indicated that abuse issues are handled by the Administrator, DON, or herself. In an interview on 11/20/12 at 12:35 p.m. with S6, Activity Director revealed that she remember the incident with resident F1 on 10/16/12 and she documented it in her notes. She stated that the resident was at the activity and he was on one end of the room and when he went to the bathroom he saw F5 and he reached out to touch the resident. She indicated that she reported the incident to the SSD. She disclosed that she did not complete an Incident Report. She stated that this was looked at the last time the state surveyors were here. She revealed that F5 was cognitively impaired and does not know what is going on. In a further interview on 11/20/12 at 12:50 p.m. with the SSD she stated that resident F1 was informed of the reason that he was not allowed on the 500 and 600 halls and he at times would be confused but had accepted his restrictions. She confirmed that the incident that occurred was not documented on an Incident Report. She revealed that she documented in her notes and there were notes in the Activity Progress Notes. She indicated that they conducted two meetings to discuss the issue. She added that they put into place to keep the resident off the 500 and 600 halls. In an interview on 11/20/12 at 2:20 p.m. with S2, RN/DON revealed that F1 cannot come on the 500 and 600 halls. She stated that F1 thinks that F5 is his girlfriend or wife. She indicated that F5 sat in a certain area on the 500 hall and F1 is not allowed to come back to the area. She disclosed that is what was put into place to protect that resident. She confirmed that an Incident Report was no completed. In an interview on 11/20/12 at 2:37 p.m. with S7, PT revealed that F1 was initially being escorted to the Physical Therapy department, then the resident began coming to the therapy department on his own. She stated that they then started seeing the resident in his room or they would bring him outside. In an interview on 11/20/12 at 3:05 p.m. with S9, LPN/MDS revealed that resident F1 was not allowed on the 500 and 600 Halls. She stated that the Care Plan did not reflect that the resident was not allowed on the 600 Hall. She indicated that resident F1 was attending Physical Therapy and he would go to the Nurses Station A and the nurses would call for PT and they would come and escort the resident back to PT and they will bring him back to his room. She disclosed that Physical Therapy was then seeing F1 in his room. She indicated that these were interventions, but the care plan did not reflect those interventions. She revealed that F1 was discussed in meetings.

Based on observation, record review and interview, the facility failed to provide an accurate assessment which ensured 1. Implementation of resident #6's physician's orders [REDACTED]. 2. that care plan interventions, for pressure relieving devices, were provided to #6's geri-chair and wheelchair, 3. that a system was in place to ensure CNAs were notified of physician orders [REDACTED]. 4. that a system of supervision and monitoring was in place to ensure resident #6's plan of care was implemented correctly to prevent development of pressure ulcers. Actual harm occurred when, due to a lack of assessments, two (2) pressure sores were found on the resident which had developed into Stage II and a Stage III prior to being identified. The resident was 1 (#6) of 2 (#8) residents reviewed with pressure sores. According to the Resident Census and Conditions of Residents Report there were 12 residents in the facility identified with pressure sores in a facility where 92 residents lived. Findings: Resident #6: The resident was admitted to the facility on [DATE]. His current [DIAGNOSES REDACTED]. His MDS assessment dated [DATE] revealed that he had partial loss of his right arm, right leg and both feet and complete loss of his left hand and arm. Resident #6 required total assistance with all of his ADLs. Resident #6 was admitted to Hospice on 5-10-12 with a [DIAGNOSES REDACTED]. Review of the Hospice POC dated 8-22-12 revealed that #6 was eating well and his pain was described as better with no break thru pain noted. His pressure sore risk assessment dated [DATE] revealed him to be scored at a 14 (12 or less representing high risk). The assessment went on to reveal that friction and shear was scored as #1 = Problem = requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. Resident #6 was currently receiving daily wound care to his multiple skin tears. Review of #6's wound care treatment note dated 10-4-12 at 1:00 p.m., (written by the wound care nurse at that time) revealed that while she was assisting the CNA supervisor with #6's a.m. care, she noticed a Stage III ulcer to #6's left lower leg which measured 2.0x3.0x0.8cm. The wound bed was noted with dark edges, 50% yellow slough and a small amount of serious drainage. Approximately 10% of the wound bed had a white shiny appearance. Also the wound care nurse discovered a Stage II pressure sore to #6's left inner thigh which measured 0.5x0.8x less than 0.1cm. This Stage II wound bed was moist, red and without drainage. The note revealed that at 1:20 p.m. a call was placed to the physician and the wound care nurse spoke with the physician and described in detail the appearance of both areas. New wound care orders were given by the physician then the wound care nurse notified Hospice and #6's family. The physician's wound care order read as follows: 1.) Stage III to LLE = Clean area with NS, pat dry, apply Santyl to wound bed, cover with calcium alginate and dressing QD. 2.) Stage II area to left inner thigh = Clean area with NS, pat dry, apply [MEDICATION NAME] and cover with dressing QD. A review was done of the Weekly Skin Audit forms performed by the facility nurses. On 10-1-12 (3 days prior to the discovery of the 2 pressures sores) a skin audit was conducted by one of the facility nurses and there was no documentation of a wound to #6's left lower leg or to his left inner thigh. Observation of #6's wound care was done with #S5LPN (the new wound care nurse) on 10-15-12 at 2:20 p.m. There were 3 areas being cared for on #6's left lower leg. Two areas appeared as dark scabbed over areas with no drainage. These areas were described as unstagable on the pressure sore log dated 10-11-12. These areas were being treated as per physician's orders [REDACTED]. The wound bed was noted to be red with no drainage and was approximately 0.5cm. in depth. The pressure sore was cleaned with NS then wet to dry gauze was packed in the wound bed. The pressure sore was then covered with Kerlix and secured with tape. The Stage II pressure sore located on #6's left inner thigh was cleaned with normal saline, patted dry, [MEDICATION NAME] applied then covered with a dressing. On 10-15-12 at 2:30 p.m., during the wound care observation, #S5 stated that she was not involved in the discovery of the 2 pressure sores, however, the previous wound care nurse told her (S5) about them and she was very upset because these should have been discovered earlier. An interview was held with #S2DON on 10-16-12 at 11 a.m. She stated that the resident should have never had a Stage III and Stage II ulcer found on him because he was receiving care to his skin tears 3 times a week, Hospice was seeing him several times a week, the facility staff CNAs provided ADL care daily and the facility nurses had been documenting weekly skin audits for the resident. Review of #6's current physician's orders [REDACTED]. Review of #6's current care plan revealed an intervention under Skin Integrity which read as follows; Pressure relieving device to chair and bed. An observation of #6 was done on 10-15-12 at 2:30 p.m. He was observed in bed with no pillows under or around his left arm and left leg. His geri-chair was located beside his bed and there was no pressure relieving device in the chair. During an interview with #S9CNA (who was in #6's room at the time) she stated she knew nothing about elevating #6's left arm and left leg on 2 pillows and also stated there was no pressure relieving device for #6's geri chair or bed. Another observation was done on 10-16-12 at 1:20 p.m. Resident was in bed awake and oriented. He stated he had just been put back to bed after his lunch. He was asked if anyone ever placed pillows under his left arm and left leg and he stated "no". There also was no pressure relieving device noted in his geri chair located in his room. The last observation of #6 was done on 10-17-12 at 1:00 p.m. He was awake in bed, talking and alert. Again there were no pillows elevating he left arm and left leg and no pressure relieving device observed in his empty geri chair in his room. An interview was held with 2 CNAs who 10-17-12 at 2:00 p.m. #S10CNA stated she provided care to #6 and had never been told to elevate his left arm and/or left leg tid (three times a day). She stated if this was one of her duties it would be listed in the ADL book at the nurses station. #S11CNA stated she worked #6's hall and sometimes provided care however didn't know she was supposed to elevate his left arm and left leg on pillows. On 10-17-12 at 2:10 p.m., a review of the ADL book, located at nurse's station, was done with #S10CNA. There was no order for the CNAs to elevate #6's left arm and left leg for 30 minutes three times a day.

Based on observation, record review and interview, the facility failed to: 1. Implement resident #6's physician's orders dated 10/2012 to elevate #6's left arm and left leg with 2 pillows for 30 minutes tid (three times a day), 2. Implement identified care plan interventions for pressure relieving device to the chair for resident #6, 3. Have a system in place to ensure CNAs were notified of physician orders for pressure relieving devices to resident #6's chair and bed and 4. Have a system of supervision and monitoring in place to ensure resident #6's plan of care was implemented correctly to prevent development of pressure ulcers. Actual harm occurred when two pressure sores were found on the resident which had developed into Stage II and a Stage III prior to being identified. The resident was 1 (#6) of 2 (#8) residents reviewed with pressure sores. According to the Resident Census and Conditions of Residents Report there were 12 residents in the facility identified with pressure sores in a facility where 92 residents lived. Findings: Resident #6: The resident was admitted to the facility on [DATE]. His current [DIAGNOSES REDACTED]. His MDS assessment dated [DATE] revealed that he had partial loss of his right arm, right leg and both feet and complete loss of his left hand and arm. Resident #6 required total assistance with all of his ADLs. Resident #6 was admitted to Hospice on 5-10-12 with a [DIAGNOSES REDACTED]. Review of the Hospice POC dated 8-22-12 revealed that #6 was eating well and his pain was described as better with no break thru pain noted. His pressure sore risk assessment dated [DATE] revealed him to be scored at a 14 (12 or less representing high risk). The assessment went on to reveal that friction and shear was scored as #1 = Problem = requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. Resident #6 was currently receiving daily wound care to his multiple skin tears. Review of #6's wound care treatment note dated 10-4-12 at 1:00 p.m., (written by the wound care nurse at that time) revealed that while she was assisting the CNA supervisor with #6's a.m. care, she noticed a Stage III ulcer to #6's left lower leg which measured 2.0x3.0x0.8cm. The wound bed was noted with dark edges, 50% yellow slough and a small amount of serious drainage. Approximately 10% of the wound bed had a white shiny appearance. Also the wound care nurse discovered a Stage II pressure sore to #6's left inner thigh which measured 0.5x0.8xless than 0.1cm. This Stage II wound bed was moist, red and without drainage. The note revealed that at 1:20 p.m., a call was placed to the physician and the wound care nurse spoke with the physician and described in detail the appearance of both areas. New wound care orders were given by the physician then the wound care nurse notified Hospice and #6's family. The physician's wound care order read as follows: 1.) Stage III to LLE = Clean area with NS, pat dry, apply Santyl to wound bed, cover with calcium alginate and dressing QD. 2.) Stage II area to left inner thigh = Clean area with NS, pat dry, apply [MEDICATION NAME] and cover with dressing QD. A review was done of the Weekly Skin Audit forms performed by the facility nurses. On 10-1-12 (3 days prior to the discovery of the 2 pressures sores) a skin audit was conducted by one of the facility nurses and there was no documentation of a wound to #6's left lower leg or to his left inner thigh. Observation of #6's wound care was done with #S5LPN (the new wound care nurse) on 10-15-12 at 2:20 p.m. There were 3 areas being cared for on #6's left lower leg. Two areas appeared as dark scabbed over areas with no drainage. These areas were described as unstagable on the pressure sore log dated 10-11-12. These areas were being treated as per physician's orders. The Stage III pressure sore to his left lower leg had a moderate amount of yellow slough located to the wound bed. The wound bed was noted to be red with no drainage and was approximately 0.5cm. in depth. The pressure sore was cleaned with NS then wet to dry gauze was packed in the wound bed. The pressure sore was then covered with Kerlix and secured with tape. The Stage II pressure sore located on #6's left inner thigh was cleaned with normal saline, patted dry, [MEDICATION NAME] applied then covered with a dressing. On 10-15-12 at 2:30 p.m., during the wound care observation, #S5 stated that she was not involved in the discovery of the 2 pressure sores, however, the previous wound care nurse told her (S5) about them and she was very upset because these should have been discovered earlier. An interview was held with #S2DON on 10-16-12 at 11 a.m. She stated that the resident should have never had a Stage III and Stage II ulcer found on him because he was receiving care to his skin tears 3 times a week, Hospice was seeing him several times a week, the facility staff CNAs provided ADL care daily and the facility nurses had been documenting weekly skin audits for the resident. Review of #6's current physician's orders (10/2012) revealed an order written [REDACTED]. Review of #6's current care plan revealed an intervention under Skin Integrity which read as follows; Pressure relieving device to chair and bed. An observation of #6 was done on 10-15-12 at 2:30 p.m. He was observed in bed with no pillows under or around his left arm and left leg. His geri-chair was located beside his bed and there was no pressure relieving device in the chair. During an interview with #S9CNA (who was in #6's room at the time) she stated she knew nothing about elevating #6's left arm and left leg on 2 pillows and also stated there was no pressure relieving device for #6's geri chair or bed. Another observation was done on 10-16-12 at 1:20 p.m. Resident was in bed awake and oriented. He stated he had just been put back to bed after his lunch. He was asked if anyone ever placed pillows under his left arm and left leg and he stated "no". There also was no pressure relieving device noted in his geri chair located in his room. The last observation of #6 was done on 10-17-12 at 1:00 p.m. He was awake in bed, talking and alert. Again there were no pillows elevating he left arm and left leg and no pressure relieving device observed in his empty geri chair in his room. An interview was held with 2 CNAs who 10-17-12 at 2:00 p.m. #S10CNA stated she provided care to #6 and had never been told to elevate his left arm and/or left leg tid (three times a day). She stated if this was one of her duties it would be listed in the ADL book at the nurses station. #S11CNA stated she worked #6's hall and sometimes provided care however didn't know she was supposed to elevate his left arm and left leg on pillows. On 10-17-12 at 2:10 p.m., a review of the ADL book, located at nurse's station, was done with #S10CNA. There was no order for the CNAs to elevate #6's left arm and left leg for 30 minutes three times a day.

Based on observation, record review, and staff interview, the facility failed to provide each Resident services in accordance with their written plan of care as evidenced by: 1. the failure of staff to: a) report Resident #6's signs and symptoms of infection as directed in her plan of care, and b) blood sugar results greater than 400 to Resident #6's physician as ordered; 2. the failure to notify Resident #9's Physician of culture and sensitivity results as ordered; 3. the failure to apply pads to Resident #1's shins/gerisleeves to bilateral lower extremities as ordered; 4. the failure to report a change in Resident #3's skin condition to the nurse as directed in her plan of care; and 5. the failure to ensure a resident dependent on staff for all care received two person physical assistance for all activities of daily living. (#14) for 5 (#1, #3, #6, #9, #14) out of 17 sampled residents (#1-#17). Findings: 1. Resident #6 was an [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #6's Physician orders [REDACTED]. A review of Resident #6's Nurses notes revealed on 6/21/12 at 4:45 PM, a blood sugar result of 436 was documented with 10 units of regular insulin administered. The Resident's physician was paged. At 8:00 PM, Resident #6's blood sugar result was 326 and 8 units of regular insulin was administered. Dr. ---- did not return page was documented. There was no documented evidence the physician was ever notified of the high blood sugar results. On 8/28/12 at 2:37 PM, during an interview with RN ADON S11, she confirmed Resident #6 had two high blood sugar results on 6/21/12, and no one followed up regarding the Physician not returning the page. A review of Resident #6's plan of care with a target date of 7/26/12 revealed a problem of at risk for infection related to surgical wounds, urinary tract infection (5/3/12 and 6/22/12), and [MEDICAL CONDITION]. A goal listed was signs and symptoms of infection will be promptly and accurately identified through nursing assessment every shift, and a coordinating approach was report signs and symptoms of infection: elevated temperature, loss of appetite, flushed or pale appearance, nausea, vomiting or diarrhea. A review of Resident #6's Routine standing orders revealed [MEDICATION NAME] was ordered for nausea with instructions of, If no improvement or persistent nausea/vomiting notify MD within 8 hours. Resident #6's weekly vital signs form had a documented temperature of 95.3 on 6/21/12. There was no documented evidence the staff assessed Resident #6 after recording the abnormally low temperature or that they notified her Physician of the finding. On 8/28/12 at 2:37 PM, RN ADON S11 confirmed that Resident #6's temperature of 95.3 on 6/21/12 was abnormal. She stated she would have called the Resident's doctor to report the temperature. On 6/26/12 at 12:45 PM, Resident #6 nurses notes revealed she was lying in bed, complained of nausea and vomiting. A small amount of mucous vomit noted in pan. [MEDICATION NAME] 12.5 mg suppository per rectum was administered. There was no documented evidence that Resident #6's physician was notified of her nausea and vomiting. On 6/27/12 at 1:00 PM, Resident #6's nurses notes revealed she had decreased appetite and continued to complain of nausea. [MEDICATION NAME] suppository 12.5 mg administered. There was no documented evidence that Resident #6's physician was notified of her nausea. Then the nurses notes on 6/28/12 at 07:30 AM, Resident #6's CNA reported that the resident was having watery stools. Resident #6 was given her morning medications, but with only a sip of water, began to gag. Did not take medication and refused morning meal. There was no documented evidence, Resident #6's physician was notified. 2. Resident #9: A review of Resident #9's Medication Administration Record [REDACTED]. This was 7 days after the Resident complained of burning with urination. During a telephone interview with Resident #9's Physician on 9/5/12 at 3:33 PM, regarding the Laboratory result on 6/15/12. She stated that the staff is supposed to call her with the culture and sensitivity results, but if they just fax it to her office on Friday, she may not get the result until the following Monday. She stated that was the case with Resident #9's laboratory result of 6/15/12, so the antibiotic did not get ordered until 6/18/12. A review of Resident #9's Physician's progress notes dated 7/24/12 revealed an order to collect a urinalysis and culture and sensitivity (C&S), the last C&S was sensitive to [MEDICATION NAME], begin [MEDICATION NAME] X 3 days, culture pending. A review of Resident #9's laboratory results dated [DATE] revealed the organism E. Coli was identified and was sensitive to the medication [MEDICATION NAME]. There was no documented evidence Resident #9's Physician was notified of the culture results as ordered. A review of Resident #9's Physician orders [REDACTED]. A review of Resident #9's Medication Administration Record [REDACTED]. She did not receive any [MEDICATION NAME] on 7/28/12, 7/29/12, and 7/30/12. [MEDICATION NAME] was started again on 7/31/12 at 6:00 PM. During a telephone interview with Resident #9's Physician on 9/5/12 at 3:33 PM, she revealed the facility did not contact her with the resident's culture and sensitivity results on 7/27/12 as she had ordered, and that was why there was a gap in the antibiotic administration. 3. Resident #1: During a review of Resident #1's physician's orders [REDACTED]. Preventative for frequent skin tears with an order date since 3-26-12. The Resident's current care plan was noted with the Problem of : Skin Integrity, Impaired with the approach of Geri-sleeves to bilateral lower extremities at all times per MD order. During an interview and observation of Resident #1 in her room on 8-27-12 at 1:45 p.m., CNA S14 stated that she had been working at the facility for about 5 months and always worked the hall of Resident #1. She explained that Resident #1 had some bruises and scrapes to her lower extremities from trying to get out of bed. An observation of the Resident ' s lower extremities at that time revealed the presence of bruising, dressings, and skin tears at various healing stages. There were no Geri-sleeves observed on her lower extremities or pads to her shins noted. On 8-28-12 at 1:05 p.m., an observation was made of Resident #1 with CNA S10. She confirmed the Resident ' s bilateral lower extremities had multiple skin tears of various healing stages, some covered with dressings, and bruises to her bilateral lower extremities. There were no Geri-sleeves observed on her lower extremities or pads to her shins noted. A review of Resident #1's Treatment Administration Record (TAR) for the month of August 2012, revealed the order for bilateral pads to shins at all times preventative for frequent skin tears, start 3-26-12. The form was noted to contain the initial of the treatment nurses for the 7 a.m., 3 p.m., and 11 p.m. boxes for each date of August 2012 through the present date of 8-27-12 with the initial of LPN Treatment Nurse S15 noted in the 7 a.m. box for August 27, 2012. The August 2012 weekly skin assessments documented the resident had skin tears to the left posterior knee, right lower leg, and right lateral knee. The July 2012 weekly skin assessment documented skin tears to the lower extremities, right distal leg, right proximal leg, and left lateral leg. During an interview with the RN ADON S11 on 8-28-12 at 3:50 p.m., she confirmed the entry in Resident #1's care plan and explained that the Geri-sleeves were used to protect the resident's lower extremities from skin tears and bruising and were to be used on the resident at all times. NOTE : Resident #1 had been observed several times on 8/27/12 and 8/28/12 with no protective pads/sleeves on her lower extremities in place. RN ADON S11 and this Surveyor entered Resident #1's room at this time and RN ADON S11 confirmed that Resident #1 was in bed, had no Bilateral Pads to shins/Geri-sleeves, or other devices in place, or within her room. RN ADON S11 stated the (Pads/Geri-sleeves) should have been on the Resident and/or in the Resident ' s room. RN ADON S11 observed and confirmed that Resident #1 ' s lower extremities were noted with skin tears, some with dressings, and bruising. She also confirmed the Bilateral Pads to Shins/Geri-sleeves were ordered to prevent Frequent Skin Tears and were not in use at that time. During an interview with CNA S23, on 8-28-12 at 4:00 p.m., she confirmed she cared for Resident #1 and when asked about the resident ' s (Geri-sleeves), she stated "don't know anything about them". CNA S23 then retrieved the CNA - ADL book, which the CNAs use to note and document the care/services needed and delivered to residents. After reviewing Resident #1 ' s August 2012 ADL log, CNA S23 confirmed there were instructions/entries for the Geri-sleeves to bilateral lower extremities at all times per MD order. NOTE: the ADL form for the Geri-sleeves was initialed as done in the timed boxes of 6 am, 2 pm, and 10 pm on 8-28-12 when it was 4 p.m. at the time of review. On 8-28-12 at 4:00 p.m. during an interview with LPN S24, she confirmed Resident #1's Geri-sleeves were ordered to prevent skin tears and bruises to her lower extremities. LPN S24 confirmed that Resident #1 currently had skin tears and bruising to bilateral lower extremities. 4. Resident #3: A review of Resident #3's clinical record revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/12 at 11:45 a.m., an interview with Resident #3 revealed she had pain to her buttocks. The resident's daughter was present at the time of this interview and revealed her mother had a diaper rash to her right buttocks for the past couple of days. On 8/28/12 at 12:20 p.m., an observation of Resident #3 ' s skin revealed she had an excoriated area approximately 4 cm long and 1 cm wide to her Right lower buttocks. The first layer of skin was broken and bright red over this area. At this time, S15 Treatment Nurse stated this wound was not noted on the last assessment done on 8/24/12. She further revealed she felt this wound was caused by urine and the diaper. On 8/28/12 at 12:55 p.m., S20CNA revealed she helped S21CNA give Resident #3 a Bed bath that morning. S20CNA further revealed she did notice that Resident #3 had an excoriated area to her Right buttocks and did not notify the LPN of this wound because S21 CNA was assigned Resident #3. On 8/28/12 at 1:00 p.m., S22LPN revealed she did not know that Resident #3 had an excoriated area to her Right buttocks. She further revealed the CNA did not notify her of an excoriated area to the resident's Right buttocks. On 8/28/12 at 1:05 p.m., an interview with S21CNA revealed she gave Resident #3 a bed bath that morning and she provided incontinent care for the Resident two times that day. S21CNA further revealed she noticed Resident #3 had redness to her right buttocks and did not notify the LPN that the area was red. S21CNA confirmed it was the facility's policy to notify the LPN of any changes in the Resident's skin. Record review of Resident #3 Weekly skin assessment for the dates of 8/3/12, 8/10/12, 8/17/12 and 8/24/12 revealed there was no documentation of the resident having excoriation to her Right buttocks. On 8/28/12 at 1:20 p.m., an interview with S15 Treatment Nurse revealed the CNA staff were to report any changes or any abnormal skin conditions to the Treatment Nurse or the Floor nurse . She confirmed that a red area or excoriated skin should be reported. A review of Resident #3's ADL Flow Sheet for 8/28/12 failed to reveal evidence or documentation that Resident #3's red, excoriated skin was identified. A review of Resident #3's Care Plan revealed Resident #3 ' s Skin Integrity was Impaired related to incontinence of bowel and bladder. The Resident will remain free from tissue injury related to Episodes of incontinence and will be managed by the nursing staff as evidenced by being clean , dry, free of odor and skin breakdown. The CNA (staff) were to report any red or open areas to the LPNs. The LPNs were to assess the residents skin weekly. 5. Resident #14: A review of Resident #14's clinical record revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was bed bound and in a vegetative state. Resident #14's MDS dated [DATE] revealed he was comatose and was totally dependent for all activities of daily living with Two + persons physical assist for bed mobility, dressing, toileting, bathing, and personal hygiene. Resident #14 was always incontinent of urine and bowel. On 9/4/12 at 3:10 p.m., S4LPN revealed the resident was dependent on staff for all care and was a two person physical assist for all activities of daily living. During an interview on 9/5/12 at 3:15 p.m., S8 CNA confirmed Resident #14 was totally dependent on staff for all needs and revealed he assisted the resident alone, without the assistance of another person. During an interview with S1DON on 9/5/12 at 10:15 a.m., S1DON confirmed Resident #14 needed two person physical assist for bathing and incontinent care. S1DON revealed he was aware that some of the CNAs provided incontinent care without a second person.

Based on record review and interview, the facility failed to meet professional standards of quality care and failed to follow the facility's policy and procedure by failing to: 1. Ensure the Director of Nursing (DON) verified that the LPN was licensed to work in the facility as per the facility's policy and procedure 2. Have a back-up system in place to specify who would address the issue of license verification if the DON was not on duty in the facility. 3. Have documentation of QA and what was placed into affect concerning verification of licensed staff after this incident occurred. 4. Ensure that F20 and F21 received their medications on 9/30/12 as ordered by the physician. 5. Follow the facility's policy and procedure to verify current licensure status of a prospective employee prior to employment of the LPN for an employee hired on 7/25/12 and allowed to work as an LPN in the facility until terminated on 9/30/12. Residents F20 and F21, and all the residents residing on Halls 100 and 300 (F3,F12-14, F19, F22-39) were placed in immediate jeopardy when S13LPN, who was hired to care for residents, but was not licensed to care for the residents. The immediate jeopardy started on 7/25/12 when S13LPN was hired by the facility to work without a license and continued until 9/30/12 when it was observed by the DON that S13LPN was on duty and impaired. On 9/30/12, the immediate jeopardy was removed when the DON relieved S13LPN of her duties and sent the nurse to take a drug test at a local hospital. S13LPN was terminated by the facility on 9/30/12. All residents on 100 hall and 300 hall from 7/25/12 to 9/30/12 were in immediate jeopardy as a result of unlicensed staff providing direct care services in the role of LPN. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La. Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended on 6/29/12. (This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12). Findings: 1. The Employee Information (Time Sheets) was reviewed and S13LPN first shift she worked for the facility was on 7/25/12 . She continued working with the facility until 9/30/12 when she was sent home by S2DON for being impaired. She clocked out of the facility at 1:36 pm. An interview with the S2DON on 11/26/12 at 12:16 pm was conducted and she stated that S13LPN was a full time nurse in the facility. She stated that S13LPN was employed with the facility on 7/11/11 and on 12/8/11 she was placed on medical leave due to a [MEDICAL CONDITION]. S13LPN returned to the facility on [DATE] as a part time LPN doing the weekend special (double shifts). She would work 32 hours. S2DON confirmed during a review of her employment records from 7/11/11 to 12/8/11 and from 7/25/12 to 9/30/12 that she could not find the verification of the LPN ' s nursing license. The Client Incident Report was reviewed and revealed under the section Case Notes - Description - "On September 30, 2012 - I _____ (S2DON) was called by _____ (S4LPN) who was concerned about the number of calls she had received from S13LPN. States she also received a call from another LPN who voiced concern regarding S13LPN ' s behavior. I advised her I would go to facility she was already planning to go. I arrived at approximately 12:40 pm , and found S13LPN and S4LPN at the medication cart. S4LPN was attempting to perform a narcotic count and S13LPN was standing at the side of the cart. S13LPN immediately began telling me that we should be more concerned with her being sick and having to work than in counting medications. I advised S13LPN her behavior was impaired and she needed to do a drug screen, she did not want to give up the cart and began arguing with S4LPN. I advised her I would do the narcotic count with her then she would go for her drug screen. While doing narcotic count it was discovered that two residents had medications signed for that had not been administered. I then told her to leave, she reported she hadn't ' t signed for the medications she had administered since 6 am, in fact she never signed for her medications until the end of her shift. (she was scheduled to work 6 am- 10 pm.) I advised her this was against facility policy, she argued with me, but finally left after signing MAR." Drug screen results were received 10/2/12 at 4:15 pm. On 10/3/12 La. Board of Licensed Practical Nurse Examiners was notified of results. LPN was terminated. Summary: Impaired nurse was identified and sent for testing, positive test results received, employee was terminated. On 11/26/12 at 12:51 pm, a termination letter was provided from the facility and confirmed by S2DON that the letter was completed on this date (11/26/12). Reason for Separation: working without a license. Drug Screen Urine 9 Panel collected 9/30/12 and reported on 10/1/12 revealed that S13LPN tested positive for [MEDICATION NAME], Cocaine and Opiates. Documentation in S13LPN's personnel chart by S2DON revealed that S13LPN' s license was suspended for failing to respond to request from Louisiana Board of Practical Nursing on 6/29/12. Documentation in S13LPN's personnel chart by S2DON revealed that on 10/3/12 she spoke to La Board of Licensed Practical Nurse Examiners- who informed her that S13LPN's license had been suspended 6/29/12. ( This date is prior to when S13LPN was employed by the facility for the second time on 7/25/12) On 11/26/12 at 12:55 pm, an interview was conducted with S2DON and stated the she was called on 9/30/12 by S4LPN and the LPN that was working with S13LPN. S2DON stated that when she arrived at facility S13LPN stated she was sick and she observed that she could not speak in complete sentences. S2DON stated, " Her thoughts were not coherent. She was arguing with me about not wanting to give up her cart- stating she was responsible for it. I told her she was impaired and she stated she had to sign out her medications. I told her that it was not the facility ' s policy to sign meds at the end of the shift and that she should have been signing out for the meds as she gave them. She then went to the MAR and signed out her meds." The facility ' s policy and procedure for nursing verification of licensure was reviewed and revealed: Policy Statement- Nursing service personnel who require a license of certification to provide resident care or treatment without direction or supervision within the scope of the individual ' s license or certification must present verification of such license or certification prior to or upon employment. Policy Interpretation and Implementation: 1. Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of Nursing Services prior to or upon employment. 2. Nursing personnel requiring a license/certification will not be permitted to perform direct resident care services unless authorized by the Medical Director until all licensing/background checks have been completed. ***** 2. F21. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident ' s physician's order [REDACTED]. The resident ' s MAR was reviewed and revealed that S13 LPN initialed on 9/30/12 at 8:00 am that she administered the 8:00 am dose of [MEDICATION NAME] .5 mg and for the 8:00 am dose of [MEDICATION NAME] 5/500 mg there was no documentation by S13LPN that she administered the 8:00 am dose or the 12:00 noon dose. The facility ' s documentation revealed during a random narcotic count after S13LPN was relieved on her medication cart, on the Medication Deviation Report, the facility documented that on 9/30/12 the [MEDICATION NAME] .5 mg, 8:00 am dose was not given. The facility ' s documentation revealed the resident did not receive her scheduled dose of [MEDICATION NAME] 5/500 for the 12:00 noon dose. 3. F20. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The physician's order [REDACTED]. The resident ' s Medication Administration Record (MAR) was reviewed and revealed that on 9/30/12 S13LPN ' s initial was documented in the box that she administered [MEDICATION NAME] 7.5mg for the 8:00 am dose. S13LPN documented next to [MEDICATION NAME] .5 mg one by mouth tid that she administered the 8:00 am and the 12:00 am dose. The facility ' s documentation on the Medication Deviation Report revealed that the facility did a random narcotic count after S13 LPN was relieved of her medication cart. The facility found F20 did not received her [MEDICATION NAME] .5 mg at 8:00 am and [MEDICATION NAME] 75 mg for the 8:00 am. The nurse signed out for the does but when the narcotic count was performed by the facility, there was one additional medication in resident ' s medication card which meant that S13LPN had not given the resident the [MEDICATION NAME] or the [MEDICATION NAME] but had signed out for them.

Based on observations, record reviews, and interviews the facility failed to protect a cognitively impaired resident from abuse for 1 of 4 residents reviewed for abuse (Resident #2). The facility failed to: 1. ensure that Resident #3, who had documented [DIAGNOSES REDACTED].#2) 2. care plan and implement interventions to supervise Resident #2 and resident #3 to prevent inappropriate sexual behaviors after S6CNA observed Resident #3 fondling Resident #2's breast on 11/9/11 while in the dining room. 3. ensure that Resident #2 was protected from physical abuse by Resident #4, her roommate who had a documented history of slapping Resident #2. 4. implement supervison of Resident #2 to prevent physical abuse by Resident #4 on 3/27/12 after S3LPN observed Resident #4 putting his handscompletely around resident #2's neck and trying to choke Resident #2. Resident #2 had a BIMS (Brief Interview of Mental Status) score of 1, which indicated her cognition was severely impaired. Resident #2 ' s [DIAGNOSES REDACTED]. On 11/9/11 at 11:50 a.m., Resident #2 was placed in an Immediate Jeopardy situation, when S6 CNA observed resident #3 touching Resident #2's breast while in the dining room. The Immediated Jeopardy situation ended for Resident #2 when resident #3 was transferred to the psychiatric faciltiy. On 11/16/11 at 5:00 pm, Resident #2 was placed in Immediate Jeopardy when Resident #3 returned to the facility and the facility failed to put interventions in place to protect Resident #2 from sexual abuse from Resident #3. According to the facility 's Incident and Accident Report Form dated 3/24/12, Resident #3 was observed by staff touching Resident #2 ' s chest and stomach on 3/24/12 at 12:30 p.m. Resident #3 was admitted to a psychiatric facility on 3/24/12 at 5:15 p.m. The Immediate Jeopardy situation continued for Resident #2 because the facility failed to implement measures on Resident #4 ' s care plan that would protect her from physical abuse by Resident #4. The facility had documentation of their suspicion of physical abuse by Resident #4. According to the facility 's Incident and Accident Report Form, dated 3/27/12 timed 6:45 a.m., Resident #4 was observed by staff pinching Resident #2. During an interview on 3/30/12 at 10:15 a.m., S3LPN revealed she witnessed Resident #4 choking and pinching Resident #2 on 3/27/12. Resident #4 was admitted to a psychiatric facility on 3/28/12 at 3:00 p.m. The Immediate Jeopardy situation ended for Resident #2 on 3/28/12 because Resident #3 and #4 were no longer in the facility. Resident #2 continued to be in Immediated Jeopardy on 3/29/12 at 3:20 p.m., Resident #3 returned to the facility and the facility failed to put interventions in place to protect Resident #2 from sexual abuse from Resident #3. The Immediate Jeopardy situation ended on 3/30/12 at 5:15 p.m. when Resident #3 was placed on one to one supervision and Resident #4 remained at the psychiatric facility. S1DON was notified of the Immediate Jeopardy situation on 3/30/12 at 4:15 p.m. The facility 's Plan of Removal, which included one to one observation/monitoring of Resident #3 while he was in the facility, was accepted on 4/3/12 at 2:30 p.m. This reduced the scope and severity to the potential for more than minimal harm. Findings: Resident #2: A review of Resident #2 ' s clinical record revealed she was a [AGE] year old female with the following Diagnoses: [REDACTED]. Resident #2 had a BIMS (Brief Interview of Mental Status) score of 1, which indicated her cognition was severely impaired. 1. A review of an Incident and Accident Reporting Form, dated 11/9/11 revealed that an incident occurred with Resident #2 at 11:50 a.m. in Dining Room A. This form was completed by S3LPN and the description read: "Observed with staff, Resident #3 was observed attempting to touch (Resident #2's) breast. Resident #2 stated, "I wouldn't let him go any further." Resident #3 stated, "Does that feel good baby?" Resident #2 stated "Leave my breast alone." The Incident Investigation form attached to Resident #2's Incident and Accident Reporting Form, dated 11/9/11, revealed the following description: Resident #2 was inappropriately fondled. Resident #3 was observed touch(ing) Resident #2 ' s breast and asking her " Baby does that feel good. " Resident #2 stated, " Leave me alone. " The Cause of Incident was blank. S6CNA was identified as Staff Involved and/or Witnesses. Interventions read: Removed Resident #3 and notified S11SSD and S1DON to follow up. Corrective Action read: Monitor and instruct staff on how to handle this type of situation. Resident #3 Psych consult and admission. The Statement written and signed by S6CNA on 11/9/11 revealed that S6CNA was at the feeder ' s table and observed Resident #3 touching Resident #2's breast through her clothes. S6CNA heard Resident #3 ask Resident #2 if it felt good. S6CNA told Resident #3 to stop and to get away from Resident #2. S6CNA revealed that Resident #3 hurried and went outside because she had seen what he had done to Resident #2. S6CNA reported the incident to S3LPN. Record review of Resident #3's Care Plan dated 11/10/11 revealed that there were no interventions for supervision/monitoring of the resident to prevent reoccurrence of the inappropriate fondling. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm revealed that he receives his information to update care plans from physician's telephone orders and directly from staff when they report things. He disclosed that he was aware of the incident that occurred with Resident #2 on 11/9/11. He stated that he was told that the staff would be watching Resident #2 whenever she would come out of her room. S2LPN/Adm revealed that this was discussed during QA meetings and they did not go into detail about how and what the supervision /monitoring would include. He confirmed that he did not implement it on the care plan. He revealed that he did consider it a problem; no one should have that done to them. S2LPN/Adm stated that he did not know if the staff was doing what was told to him. He disclosed that the documentation of the supervision/monitoring would have been put on the MAR's. An interview on 3/30/12 at 1:55 p.m. with S1DON confirmed that on 11/9/11, Resident #2 was sexually assaulted by Resident #3. He revealed that what was implemented to keep the resident safe was to watch her at all times when she came out of her room. He revealed that the resident when out of her room would be put in the TV room or in view in the Dining area. The DON stated that whether it was on the care plan or not the staff knew to keep her in view. Record review of the facility's Preventing Resident Abuse, Abuse Prevention Program and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 2. A review of the facility's investigation of a bruise to the left side of Resident #2's cheek on 2/17/12 revealed the facility classified the bruise as an injury of unknown origin. A review of the Louisiana DHH Client Incident Report dated 2/17/12 at 1:30 p.m., the facility stated that given the past occurrence of Resident #4 slapping Resident #2, they could not deny the possibility that Resident #4 was responsible for the incident on 2/17/12. Further review of the attached Telephone Conversation conducted on 2/22/12 by S21Administrator with Resident #2's and #4 ' s responsible party revealed the following: "You know the past. Dad slapped mom before and had to go to.... Psych facility for med adjustment. " An interview on 3/29/12 at 3:10 p.m. with S1DON revealed that on 2/17/12, Resident #2 was discovered with a bruise to the left cheek. He stated that all the staff was questioned about the bruise. He revealed the resident's husband was question and he denied knowing what happened. The DON disclosed that the family felt that the husband Resident #4 had slapped Resident #2 and caused the bruise, since he had done it before. Record review of Resident #4's Care Plan dated 1/12/12 revealed there no interventions developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. Record review of the facility's Preventing Resident Abuse. Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 3. A review of an Incident and Accident Reporting Form, dated 3/24/12 revealed that another incident occurred with Resident #2 at 12:30 p.m. in Dining Room A. This form was completed by S1DON and the description of the incident revealed Resident #2 was in her geri chair in St A Dining Room. Resident #2 was covered and resting. CNA witnessed another resident pulling Resident #2 ' s covers down and touching her chest and abdomen. The witness listed on this form was S5Housekeeper. A review of Resident #2 ' s Incident Investigation Form, dated 3/24/12, was completed by S1DON and revealed the following: Narrative Description: CNA discovered resident #2's chest and stomach being touched by resident #3. No injury. Cause of Incident: Resident #2 being touched inappropriately by another resident. Staff Involved and/or witnesses: S5Housekeeper. Interventions: (facility left blank) Corrective Action: Resident removed from situation and assessed by S12LPN. The Witness Statement form attached to Resident #2 ' s Incident and Accident Reporting Form, dated 3/24/12, was blank. An observation on 3/30/12 at 9:50 a.m. revealed Resident #2 sitting in a geri-chair in the TV room alone and not in view of the facility's staff. The TV was noted to be on and Resident #2 had a blanket covering her. An observation on 3/30/12 at 9:52 a.m. revealed two CNA's sitting at the feeder table located in the corner near the serving line of the Station A Dining Room. The TV room was located at the opposite side of the Station A Dining Room, but Resident #2 was not in view of the two CNA's. An interview on 3/30/12 at 9:55 a.m. with S4CNA revealed that Resident #2 was blind and staff was not providing one-on-one supervision. She disclosed that Resident #2 would not recognize if someone approached her. She revealed that the resident recognized voices if you identify yourself. S4CNA stated that when resident #2 is in the Dining Room or TV room they do not have to stay with her at all times. She revealed that they will put the resident in the TV room and turn the heater on because she gets cold and the resident goes to sleep. The CNA stated that she heard about Resident #2 being felt on by Resident #3. She revealed that another housekeeper witnessed that over the weekend and reported it. She stated that they sent Resident #3 to..... for evaluation, and he came back on yesterday 3/29/12 in the evening. She disclosed that they do not have to do anything for supervision/monitoring on him. An observation on 3/30/12 at 10:10 a.m. revealed Resident #3 in his room lying in bed asleep there was no staff present in the room supervising/monitoring him. An interview on 3/30/12 at 10:15 a.m. with S3LPN revealed that on Saturday it was reported that Resident #2 was fondled by Resident #3. She revealed that she read it in the nurses ' notes. She stated that Resident #3 was sent out to the Psych hospital. S3LPN confirmed that Resident #3 returned to the facility on yesterday 3/29/12. She disclosed that there was no one on one monitoring being done on Resident #3. An interview on 3/30/12 at 10:25 a.m. S3LPN confirmed that according to S1DON, Resident #3 committed that act on Resident #2 once before and another female. She stated that he was sent out to the psych hospital then. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm admitted that he became aware a week ago of the incident of fondling that had occurred with Resident #2 being fondled and that it was again Resident #3. S2LPN revealed that there were no interventions put in place for supervision/monitoring of Resident #3 to prevent re-occurrence. He disclosed that the supervision/monitoring should have been care planed. An interview on 3/30/12 at 1:55 p.m. with S1DON confirmed that on 3/24/11 Resident #2 was again sexually assaulted by Resident #3. He confirmed that because there was a re-occurrence of the act from the same resident the staff was not supervising/monitoring Resident #2. S1DON confirmed that S5Housekeeper was the staff who witnessed the fondling, worked in housekeeping and was not a CNA. During a phone interview on 4/12/12 at 1:16 p.m., S20 Office Manager confirmed that S5Housekeeper was a housekeeper and had never worked for the facility as a CNA. S20 Office Manager clarified that S1DON had inadvertently documented that S5Housekeeper was a CNA on Resident #2 ' s Incident and Accident Reporting Form, dated 3/24/12. Record review of the Doctors Orders dated 3/29/12 revealed Resident #3 was readmitted to the facility and there were no orders to supervise/monitor the resident to prevent inappropriate fondling. Record review of Resident #3's Care Plan dated 3/24/12 revealed that there were no interventions developed for supervision/monitoring to prevent inappropriate fondling. Record review of Resident #3's MAR's (Medication Administration Record), TAR's (Treatment Administration Record) and CNA (Certified Nurse Assistant) Flow Records for the months of February and March 2012 revealed that there was no documentation that supervision/monitoring was being done on the resident. A review of the facility's Preventing Resident Abuse, Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 4. The Incident Accident Reporting Form dated 3/27/12, time 6:45 a.m. revealed the name of Resident # 4, Resident #2 's husband written in on the Report as followed: Describe exactly what happened: S3LPN instructed me that resident #4 pinched wife resident #2 who is also a resident here. Resident #2 yelled, "Son of [***] you pinched me stop, police, police" nurse counseled him not to touch wife inappropriately. The doctor and responsible party were notified. Further review of the attached Incident Investigation form dated 3/27/12 revealed the following: Narrative Description: Resident pinched wife who is roommate, on right upper arm. Cause of Incident: Frustration of husband. Staff Involved: S3LPN. Interventions: Resident counseled and Psych consult. Corrective Action: admitted to psychiatric facility on 3/28/12 at 3:00 p.m., Spoke to daughter by phone 3/27/12 and 3/28/12 did not want to send dad until met with me. An interview on 3/29/12 at 2:05 p.m. with S3LPN revealed that Resident #2 does have a roommate and it was her husband Resident #4. She disclosed that Resident #2's husband was at a Psych facility because he was physically abusing her. She revealed that on 3/27/12 she found Resident #4 trying to choke Resident #2 and he was pinching the resident on her arm. S3LPN stated that she heard Resident #2 hollering and when she went to see what was going on with the resident she witnessed Resident #4 choking her neck and pinching Resident #2 on her arm. She revealed that Resident #4 stated that he was giving her love pinches. S3LPN demonstrated to this surveyor and the surveyor in training, how Resident #4 put his hands completely around Resident #4 ' s neck. An interview on 3/29/12 at 3:10 p.m. with S1DON revealed he met with the family on yesterday 3/28/12, and recommended to the family that Resident #2 be put in another room. He stated that the husband complained that he could not sleep because of Resident #2's outburst. S1DON revealed that no decision was made and Resident #4 was sent out to a Psych facility because he was pinching Resident #2. He disclosed that the incident was witnessed by staff. The DON confirmed that Resident #4 was sent to the Psych hospital after meeting with the family on 3/28/12. Record review of Resident #4's Care Plan dated 1/12/12 revealed that no interventions were developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. Record review of Resident #4's MAR's, TAR's, and CNA Flow Records for February and March 2012 revealed that there was no documentation that supervision/monitoring was being done. A review of the facility's Preventing Resident Abuse, Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator.

Based on observations, record reviews, and interviews the facility failed to protect a cognitively impaired resident from abuse for 1 of 4 residents reviewed for abuse (Resident #2). The facility failed to: 1. ensure that Resident #3, who had documented [DIAGNOSES REDACTED].#2) 2. care plan and implement interventions to supervise Resident #2 and resident #3 to prevent inappropriate sexual behaviors after S6CNA observed Resident #3 fondling Resident #2's breast on 11/9/11 while in the dining room. 3. ensure that Resident #2 was protected from physical abuse by Resident #4, her roommate who had a documented history of slapping Resident #2. on 11/9/11 while in the Dining room. 4. implement supervison of Resident #2 to prevent physical abuse by Resident #4 on 3/27/12 after S3LPN observed Resident #4 putting his handscompletely around resident #2's neck and trying to choke Resident #2. Resident #2 had a BIMS (Brief Interview of Mental Status) score of 1, which indicated her cognition was severely impaired. Resident #2 ' s [DIAGNOSES REDACTED]. On 11/9/11 at 11:50 a.m., Resident #2 was placed in an Immediate Jeopardy situation, when S6 CNA observed resident #3 touching resident #2's breast while in the dining room. esident #2 was placed in Immediate Jeopardy when Resident #3 returned to the facility and the facility failed to put interventions in place to protect Resident #2 from sexual abuse from Resident #3. According to the facility ' s Incident and Accident Report Form dated 3/24/12, Resident #3 was observed by staff touching Resident #2 ' s chest and stomach on 3/24/12 at 12:30 p.m. Resident #3 was admitted to a psychiatric facility on 3/24/12 at 5:15 p.m. The Immediate Jeopardy situation continued for Resident #2 because the facility failed to implement measures on Resident #4 ' s care plan that would protect her from physical abuse by Resident #4. The facility had documentation of their suspicion of physical abuse by Resident #4. According to the facility ' s Incident and Accident Report Form, dated 3/27/12 timed 6:45 a.m., Resident #4 was observed by staff pinching Resident #2. During an interview on 3/30/12 at 10:15 a.m., S3LPN revealed she witnessed Resident #4 choking and pinching Resident #2 on 3/27/12. Resident #4 was admitted to a psychiatric facility on 3/28/12 at 3:00 p.m. The Immediate Jeopardy situation ended for Resident #2 on 3/28/12 because Resident #3 and #4 were no longer in the facility. Resident #2 continued to be in Immediated Jeopardy on 3/29/12 at 3:20 p.m., Resident #3 returned to the facility and the facility failed to put interventions in place to protect Resident #2 from sexual abuse from Resident #3. The Immediate Jeopardy situation ended on 3/30/12 at 5:15 p.m. when Resident #3 was placed on one to one supervision and Resident #4 remained at the psychiatric facility. S1DON was notified of the Immediate Jeopardy situation on 3/30/12 at 4:15 p.m. The facility ' s Plan of Removal, which included one to one observation/monitoring of Resident #3 while he was in the facility, was accepted on 4/3/12 at 2:30 p.m. This reduced the scope and severity to the potential for more than minimal harm. Findings: Resident #2: A review of Resident #2 ' s clinical record revealed she was a [AGE] year old female with the following Diagnoses: [REDACTED]. Resident #2 had a BIMS (Brief Interview of Mental Status) score of 1, which indicated her cognition was severely impaired. 1. A review of an Incident and Accident Reporting Form, dated 11/9/11 revealed that an incident occurred with Resident #2 at 11:50 a.m. in Dining Room A. This form was completed by S3LPN and the description read: "Observed with staff, Resident #3 was observed attempting to touch (Resident #2's) breast. Resident #2 stated, "I wouldn't let him go any further." Resident #3 stated, "Does that feel good baby?" Resident #2 stated "Leave my breast alone." The Incident Investigation form attached to Resident #2's Incident and Accident Reporting Form, dated 11/9/11, revealed the following description: Resident #2 was inappropriately fondled. Resident #3 was observed touch(ing) Resident #2 ' s breast and asking her " Baby does that feel good. " Resident #2 stated, " Leave me alone. " The Cause of Incident was blank. S6CNA was identified as Staff Involved and/or Witnesses. Interventions read: Removed Resident #3 and notified S11SSD and S1DON to follow up. Corrective Action read: Monitor and instruct staff on how to handle this type of situation. Resident #3 Psych consult and admission. The Statement written and signed by S6CNA on 11/9/11 revealed that S6CNA was at the feeder ' s table and observed Resident #3 touching Resident #2's breast through her clothes. S6CNA heard Resident #3 ask Resident #2 if it felt good. S6CNA told Resident #3 to stop and to get away from Resident #2. S6CNA revealed that Resident #3 hurried and went outside because she had seen what he had done to Resident #2. S6CNA reported the incident to S3LPN. Record review of Resident #3's Care Plan dated 11/10/11 revealed that there were no interventions for supervision/monitoring of the resident to prevent reoccurrence of the inappropriate fondling. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm revealed that he receives his information to update care plans from physician's telephone orders and directly from staff when they report things. He disclosed that he was aware of the incident that occurred with Resident #2 on 11/9/11. He stated that he was told that the staff would be watching Resident #2 whenever she would come out of her room. S2LPN/Adm revealed that this was discussed during QA meetings and they did not go into detail about how and what the supervision /monitoring would include. He confirmed that he did not implement it on the care plan. He revealed that he did consider it a problem; no one should have that done to them. S2LPN/Adm stated that he did not know if the staff was doing what was told to him. He disclosed that the documentation of the supervision/monitoring would have been put on the MAR's. An interview on 3/30/12 at 1:55 p.m. with S1DON confirmed that on 11/9/11, Resident #2 was sexually assaulted by Resident #3. He revealed that what was implemented to keep the resident safe was to watch her at all times when she came out of her room. He revealed that the resident when out of her room would be put in the TV room or in view in the Dining area. The DON stated that whether it was on the care plan or not the staff knew to keep her in view. Record review of the facility's Preventing Resident Abuse, Abuse Prevention Program and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 2. A review of the facility's investigation of a bruise to the left side of Resident #2's cheek on 2/17/12 revealed the facility classified the bruise as an injury of unknown origin. A review of the Louisiana DHH Client Incident Report dated 2/17/12 at 1:30 p.m., the facility stated that given the past occurrence of Resident #4 slapping Resident #2, they could not deny the possibility that Resident #4 was responsible for the incident on 2/17/12. Further review of the attached Telephone Conversation conducted on 2/22/12 by S21Administrator with Resident #2's and #4 ' s responsible party revealed the following: "You know the past. Dad slapped mom before and had to go to.... Psych facility for med adjustment. " An interview on 3/29/12 at 3:10 p.m. with S1DON revealed that on 2/17/12, Resident #2 was discovered with a bruise to the left cheek. He stated that all the staff was questioned about the bruise. He revealed the resident's husband was question and he denied knowing what happened. The DON disclosed that the family felt that the husband Resident #4 had slapped Resident #2 and caused the bruise, since he had done it before. Record review of Resident #4's Care Plan dated 1/12/12 revealed there no interventions developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. Record review of the facility's Preventing Resident Abuse. Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 3. A review of an Incident and Accident Reporting Form, dated 3/24/12 revealed that another incident occurred with Resident #2 at 12:30 p.m. in Dining Room A. This form was completed by S1DON and the description of the incident revealed Resident #2 was in her geri chair in St A Dining Room. Resident #2 was covered and resting. CNA witnessed another resident pulling Resident #2 ' s covers down and touching her chest and abdomen. The witness listed on this form was S5Housekeeper. A review of Resident #2 ' s Incident Investigation Form, dated 3/24/12, was completed by S1DON and revealed the following: Narrative Description: CNA discovered resident #2's chest and stomach being touched by resident #3. No injury. Cause of Incident: Resident #2 being touched inappropriately by another resident. Staff Involved and/or witnesses: S5Housekeeper. Interventions: (facility left blank) Corrective Action: Resident removed from situation and assessed by S12LPN. The Witness Statement form attached to Resident #2 ' s Incident and Accident Reporting Form, dated 3/24/12, was blank. An observation on 3/30/12 at 9:50 a.m. revealed Resident #2 sitting in a geri-chair in the TV room alone and not in view of the facility's staff. The TV was noted to be on and Resident #2 had a blanket covering her. An observation on 3/30/12 at 9:52 a.m. revealed two CNA's sitting at the feeder table located in the corner near the serving line of the Station A Dining Room. The TV room was located at the opposite side of the Station A Dining Room, but Resident #2 was not in view of the two CNA's. An interview on 3/30/12 at 9:55 a.m. with S4CNA revealed that Resident #2 was blind and staff was not providing one-on-one supervision. She disclosed that Resident #2 would not recognize if someone approached her. She revealed that the resident recognized voices if you identify yourself. S4CNA stated that when resident #2 is in the Dining Room or TV room they do not have to stay with her at all times. She revealed that they will put the resident in the TV room and turn the heater on because she gets cold and the resident goes to sleep. The CNA stated that she heard about Resident #2 being felt on by Resident #3. She revealed that another housekeeper witnessed that over the weekend and reported it. She stated that they sent Resident #3 to..... for evaluation, and he came back on yesterday 3/29/12 in the evening. She disclosed that they do not have to do anything for supervision/monitoring on him. An observation on 3/30/12 at 10:10 a.m. revealed Resident #3 in his room lying in bed asleep there was no staff present in the room supervising/monitoring him. An interview on 3/30/12 at 10:15 a.m. with S3LPN revealed that on Saturday it was reported that Resident #2 was fondled by Resident #3. She revealed that she read it in the nurses ' notes. She stated that Resident #3 was sent out to the Psych hospital. S3LPN confirmed that Resident #3 returned to the facility on yesterday 3/29/12. She disclosed that there was no one on one monitoring being done on Resident #3. An interview on 3/30/12 at 10:25 a.m. S3LPN confirmed that according to S1DON, Resident #3 committed that act on Resident #2 once before and another female. She stated that he was sent out to the psych hospital then. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm admitted that he became aware a week ago of the incident of fondling that had occurred with Resident #2 being fondled and that it was again Resident #3. S2LPN revealed that there were no interventions put in place for supervision/monitoring of Resident #3 to prevent re-occurrence. He disclosed that the supervision/monitoring should have been care planed. An interview on 3/30/12 at 1:55 p.m. with S1DON confirmed that on 3/24/11 Resident #2 was again sexually assaulted by Resident #3. He confirmed that because there was a re-occurrence of the act from the same resident the staff was not supervising/monitoring Resident #2. S1DON confirmed that S5Housekeeper was the staff who witnessed the fondling, worked in housekeeping and was not a CNA. During a phone interview on 4/12/12 at 1:16 p.m., S20 Office Manager confirmed that S5Housekeeper was a housekeeper and had never worked for the facility as a CNA. S20 Office Manager clarified that S1DON had inadvertently documented that S5Housekeeper was a CNA on Resident #2 ' s Incident and Accident Reporting Form, dated 3/24/12. Record review of the Doctors Orders dated 3/29/12 revealed Resident #3 was readmitted to the facility and there were no orders to supervise/monitor the resident to prevent inappropriate fondling. Record review of Resident #3's Care Plan dated 3/24/12 revealed that there were no interventions developed for supervision/monitoring to prevent inappropriate fondling. Record review of Resident #3's MAR's (Medication Administration Record), TAR's (Treatment Administration Record) and CNA (Certified Nurse Assistant) Flow Records for the months of February and March 2012 revealed that there was no documentation that supervision/monitoring was being done on the resident. A review of the facility's Preventing Resident Abuse, Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator. 4. The Incident Accident Reporting Form dated 3/27/12, time 6:45 a.m. revealed the name of Resident # 4, Resident #2 's husband written in on the Report as followed: Describe exactly what happened: S3LPN instructed me that resident #4 pinched wife resident #2 who is also a resident here. Resident #2 yelled, "Son of [***] you pinched me stop, police, police" nurse counseled him not to touch wife inappropriately. The doctor and responsible party were notified. Further review of the attached Incident Investigation form dated 3/27/12 revealed the following: Narrative Description: Resident pinched wife who is roommate, on right upper arm. Cause of Incident: Frustration of husband. Staff Involved: S3LPN. Interventions: Resident counseled and Psych consult. Corrective Action: admitted to psychiatric facility on 3/28/12 at 3:00 p.m., Spoke to daughter by phone 3/27/12 and 3/28/12 did not want to send dad until met with me. An interview on 3/29/12 at 2:05 p.m. with S3LPN revealed that Resident #2 does have a roommate and it was her husband Resident #4. She disclosed that Resident #2's husband was at a Psych facility because he was physically abusing her. She revealed that on 3/27/12 she found Resident #4 trying to choke Resident #2 and he was pinching the resident on her arm. S3LPN stated that she heard Resident #2 hollering and when she went to see what was going on with the resident she witnessed Resident #4 choking her neck and pinching Resident #2 on her arm. She revealed that Resident #4 stated that he was giving her love pinches. S3LPN demonstrated to this surveyor and the surveyor in training, how Resident #4 put his hands completely around Resident #4 ' s neck. An interview on 3/29/12 at 3:10 p.m. with S1DON revealed he met with the family on yesterday 3/28/12, and recommended to the family that Resident #2 be put in another room. He stated that the husband complained that he could not sleep because of Resident #2's outburst. S1DON revealed that no decision was made and Resident #4 was sent out to a Psych facility because he was pinching Resident #2. He disclosed that the incident was witnessed by staff. The DON confirmed that Resident #4 was sent to the Psych hospital after meeting with the family on 3/28/12. Record review of Resident #4's Care Plan dated 1/12/12 revealed that no interventions were developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. Record review of Resident #4's MAR's, TAR's, and CNA Flow Records for February and March 2012 revealed that there was no documentation that supervision/monitoring was being done. A review of the facility's Preventing Resident Abuse, Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator.

Based on observations, record reviews, and staff interview the facility failed to ensure each resident receives adequate supervision to prevent and protect from abuse were adhered to by staff as evidenced by failures to: 1. Ensure staff implemented the appropriate level of supervision for Resident #3 who had a documented [DIAGNOSES REDACTED]. On 11/9/11 at 11:50 a.m. Resident #3 was observed touching resident #2 ' s breast while stating, " Baby does that feel good. " As a result resident #2 was placed in an Immediate Jeopardy situation. On 11/10/11 at 9:30 a.m. Resident #3 was admitted to a Psychiatric Facility and Resident #2 was no longer in an Immediate Jeopardy situation. On 11/16/11 at 5:00 p.m. Resident #3 returned to the facility and the facility failed to put interventions in place to protect Resident #2. As a result, resident #2 was placed in an Immediate Jeopardy situation. 2. Ensure staff implemented the appropriate level of supervision for Resident #4 who had a documented history of slapping Resident #2. On 2/17/12 Resident #2 had a bruise on her left cheek which was classified as an injury of unknown origin and the facility could not deny the possibility that Resident #4 (who is the spouse of Resident #2 and resides in the same room) responsible for this incident. The facility failed to implement the appropriate level of supervision for Resident #4 who according to documentation had a history of [REDACTED]. 3. Implement interventions to further protect Resident #2 from abuse by Resident #3. This resulted in a second occurrence of sexual abuse on 3/24/12 at 12:30 p.m. when Resident #3 was observed touching Resident #2 ' s chest and stomach. Resident #3 was admitted to a psychiatric facility on 3/24/2012 at 5:15 p.m. The Immediate Jeopardy situation continued for Resident #2 because the facility failed to implement measures on Resident #4 ' s care plan that would protect resident #2 from physical abuse. 4. Implement interventions to further protect Resident #2 from physical abuse by Resident #4. This resulted in a second occurrence of physical abuse on 3/27/12 at 6:45 a.m. when Resident #4 was observed choking and pinching Resident #2. Resident #4 was admitted to a psychiatric facility on 3/28/12 at 3:00 p.m. The Immediate Jeopardy situation ended for Resident #2 on 3/28/12 because Resident #3 and #4 were no longer in the facility. 5. On 3/29/12, Resident #3 returned to the facility and the facility failed to implement interventions to protect Resident #2 from sexual abuse from Resident #3. As a result Resident #2 was placed in Immediate Jeopardy. The Immediate Jeopardy situation ended on 3/30/12 at 5:15 p.m. when Resident #3 was placed on one to one supervision and Resident #4 remained in the psychiatric facility. S1DON was notified of the Immediate Jeopardy situation on 3/30/12 at 4:15 p.m. The deficient practice remains at the level of potential for more than minimal harm for Resident #2. Findings: 1. A review of an Incident and Accident Reporting Form, dated 11/9/11 revealed that an incident occurred with Resident #2 at 11:50 a.m. in Dining Room A. This form was completed by S3LPN and the description read: "Observed with staff, Resident #3 was observed attempting to touch (Resident #2's) breast. Resident #2 stated, "I wouldn't let him go any further." Resident #3 stated, "Does that feel good baby?" Resident #2 stated "Leave my breast alone." The Incident Investigation form attached to Resident #2's Incident and Accident Reporting Form, dated 11/9/11, revealed the following description: Resident #2 was inappropriately fondled. Interventions read: Removed Resident #3 and notified S11SSD and S1DON to follow up. Corrective Action read: Monitor and instruct staff on how to handle this type of situation. Resident #3 Psych consult and admission. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm revealed that he receives his information to update care plans from physician's telephone orders and directly from staff when they report things. He disclosed that he was aware of the incident that occurred with Resident #2 on 11/9/11. He stated that he was told that the staff would be watching Resident #2 whenever she would come out of her room. S2LPN/Adm revealed that this was discussed during QA meetings and they did not go into detail about how and what the supervision /monitoring would include. He confirmed that he did not implement it on the care plan. He revealed that he did consider it a problem; no one should have that done to them. S2LPN/Adm stated that he did not know if the staff was doing what was told to him. He disclosed that the documentation of the supervision/monitoring would have been put on the MAR's. 2. A review of the facility's investigation of a bruise to the left side of Resident #2's cheek on 2/17/12 revealed the facility classified the bruise as an injury of unknown origin. A review of the Louisiana DHH Client Incident Report dated 2/17/12 at 1:30 p.m., the facility stated that given the past occurrence of Resident #4 slapping Resident #2, they could not deny the possibility that Resident #4 was responsible for the incident on 2/17/12. Further review of the attached Telephone Conversation conducted on 2/22/12 by S21Administrator with Resident #2's and #4 ' s responsible party revealed the following: "You know the past. Dad slapped mom before and had to go to.... Psych facility for med adjustment. " An interview on 3/29/12 at 3:10 p.m. with S1DON revealed that the family felt that the husband Resident #4 had slapped Resident #2 and caused the bruise, since he had done it before. Record review of Resident #4's Care Plan dated 1/12/12 revealed there no interventions developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. 3. A review of an Incident and Accident Reporting Form, dated 3/24/12 revealed that another incident occurred with Resident #2 at 12:30 p.m. in Dining Room A. This form was completed by S1DON and the description of the incident revealed Resident #2 was in her geri chair in St A Dining Room. Resident #2 was covered and resting. CNA witnessed another resident pulling Resident #2 ' s covers down and touching her chest and abdomen. The witness listed on this form was S5Housekeeper. A review of Resident #2 ' s Incident Investigation Form, dated 3/24/12, was completed by S1DON and revealed the following: Interventions: (facility left blank) Corrective Action: Resident removed from situation and assessed by S12LPN. An observation on 3/30/12 at 9:50 a.m. revealed Resident #2 sitting in a geri-chair in the TV room alone and not in view of the facility's staff. The TV was noted to be on and Resident #2 had a blanket covering her. An observation on 3/30/12 at 9:52 a.m. revealed two CNA's sitting at the feeder table located in the corner near the serving line of the Station A Dining Room. The TV room was located at the opposite side of the Station A Dining Room, but Resident #2 was not in view of the two CNA's. An interview on 3/30/12 at 9:55 a.m. with S4CNA revealed that Resident #2 was blind and staff was not providing one-on-one supervision. She disclosed that Resident #2 would not recognize if someone approached her. She revealed that the resident recognized voices if you identify yourself. S4CNA stated that when resident #2 is in the Dining Room or TV room they do not have to stay with her at all times. She revealed that they will put the resident in the TV room and turn the heater on because she gets cold and the resident goes to sleep. The CNA stated that she heard about Resident #2 being felt on by Resident #3. She revealed that another housekeeper witnessed that over the weekend and reported it. She stated that they sent Resident #3 to..... for evaluation, and he came back on yesterday 3/29/12 in the evening. She disclosed that they do not have to do anything for supervision/monitoring on him. An observation on 3/30/12 at 10:10 a.m. revealed Resident #3 in his room lying in bed asleep there was no staff present in the room supervising/monitoring him. An interview on 3/30/12 at 10:15 a.m. with S3LPN revealed that on Saturday it was reported that Resident #2 was fondled by Resident #3. She revealed that she read it in the nurses ' notes. She stated that Resident #3 was sent out to the Psych hospital. S3LPN confirmed that Resident #3 returned to the facility on yesterday 3/29/12. She disclosed that there was no one on one monitoring being done on Resident #3. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm admitted that he became aware a week ago of the incident of fondling that had occurred with Resident #2 being fondled and that it was again Resident #3. S2LPN revealed that there were no interventions put in place for supervision/monitoring of Resident #3 to prevent re-occurrence. He disclosed that the supervision/monitoring should have been care planed. An interview on 3/30/12 at 1:55 p.m. with S1DON confirmed that on 3/24/11 Resident #2 was again sexually assaulted by Resident #3. He confirmed that because there was a re-occurrence of the act from the same resident the staff was not supervising/monitoring Resident #2. S1DON confirmed that S5Housekeeper was the staff who witnessed the fondling, worked in housekeeping and was not a CNA. During a phone interview on 4/12/12 at 1:16 p.m., S20 Office Manager confirmed that S5Housekeeper was a housekeeper and had never worked for the facility as a CNA. S20 Office Manager clarified that S1DON had inadvertently documented that S5Housekeeper was a CNA on Resident #2 ' s Incident and Accident Reporting Form, dated 3/24/12. Record review of the Doctors Orders dated 3/29/12 revealed Resident #3 was readmitted to the facility and there were no orders to supervise/monitor the resident to prevent inappropriate fondling. Record review of Resident #3's Care Plan dated 3/24/12 revealed that there were no interventions developed for supervision/monitoring to prevent inappropriate fondling. Record review of Resident #3's MAR's (Medication Administration Record), TAR's (Treatment Administration Record) and CNA (Certified Nurse Assistant) Flow Records for the months of February and March 2012 revealed that there was no documentation that supervision/monitoring was being done on the resident. 4. The Incident Accident Reporting Form dated 3/27/12, time 6:45 a.m. revealed the name of Resident # 4, Resident #2 's husband written in on the Report as followed: Describe exactly what happened: S3LPN instructed me that resident #4 pinched wife resident #2 who is also a resident here. Resident #2 yelled, "Son of [***] you pinched me stop, police, police" nurse counseled him not to touch wife inappropriately. The doctor and responsible party were notified. Further review of the attached Incident Investigation form dated 3/27/12 revealed the following: Interventions: Resident counseled and Psych consult. Corrective Action: admitted to psychiatric facility on 3/28/12 at 3:00 p.m., Spoke to daughter by phone 3/27/12 and 3/28/12 did not want to send dad until met with me. An interview on 3/29/12 at 2:05 p.m. with S3LPN revealed that Resident #2 does have a roommate and it was her husband Resident #4. She disclosed that Resident #2's husband was at a Psych facility because he was physically abusing her. She revealed that on 3/27/12 she found Resident #4 trying to choke Resident #2 and he was pinching the resident on her arm. S3LPN stated that she heard Resident #2 hollering and when she went to see what was going on with the resident she witnessed Resident #4 choking her neck and pinching Resident #2 on her arm. She revealed that Resident #4 stated that he was giving her love pinches. S3LPN demonstrated to this surveyor and the surveyor in training, how Resident #4 put his hands completely around Resident #4 ' s neck. An interview on 3/29/12 at 3:10 p.m. with S1DON revealed he met with the family on yesterday 3/28/12, and recommended to the family that Resident #2 be put in another room. He stated that the husband complained that he could not sleep because of Resident #2's outburst. S1DON revealed that no decision was made and Resident #4 was sent out to a Psych facility because he was pinching Resident #2. He disclosed that the incident was witnessed by staff. The DON confirmed that Resident #4 was sent to the Psych hospital after meeting with the family on 3/28/12. Record review of Resident #4's Care Plan dated 1/12/12 revealed that no interventions were developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. Record review of Resident #4's MAR's, TAR's, and CNA Flow Records for February and March 2012 revealed that there was no documentation that supervision/monitoring was being done. A review of the facility's Preventing Resident Abuse, Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator.

Based on Resident interview, staff interview, and record review, the facility ' s Administration failed to ensure all policies and procedures relative to abuse prevention and investigation were adhered to by staff as evidenced by failures to: 1. Ensure staff implemented the appropriate level of supervision for Resident #3 who had a documented [DIAGNOSES REDACTED]. On 11/9/11 at 11:50 a.m. Resident #3 was observed touching resident #2 ' s breast while stating, " Baby does that feel good. " As a result resident #2 was placed in an Immediate Jeopardy situation. On 11/10/11 at 9:30 a.m. Resident #3 was admitted to a Psychiatric Facility and Resident #2 was no longer in an Immediate Jeopardy situation. On 11/16/11 at 5:00 p.m. Resident #3 returned to the facility and the facility failed to put interventions in place to protect Resident #2. As a result, resident #2 was placed in an Immediate Jeopardy situation. 2. Ensure staff implemented the appropriate level of supervision for Resident #4 who had a documented history of slapping Resident #2. On 2/17/12 Resident #2 had a bruise on her left cheek which was classified as an injury of unknown origin and the facility could not deny the possibility that Resident #4 (who is the spouse of Resident #2 and resides in the same room) responsible for this incident. The facility failed to implement the appropriate level of supervision for Resident #4 who according to documentation had a history of [REDACTED]. 3. Implement interventions to further protect Resident #2 from abuse by Resident #3. This resulted in a second occurrence of sexual abuse on 3/24/12 at 12:30 p.m. when Resident #3 was observed touching Resident #2 ' s chest and stomach. Resident #3 was admitted to a psychiatric facility on 3/24/2012 at 5:15 p.m. The Immediate Jeopardy situation continued for Resident #2 because the facility failed to implement measures on Resident #4 ' s care plan that would protect resident #2 from physical abuse. 4. Implement interventions to further protect Resident #2 from physical abuse by Resident #4. This resulted in a second occurrence of physical abuse on 3/27/12 at 6:45 a.m. when Resident #4 was observed choking and pinching Resident #2. Resident #4 was admitted to a psychiatric facility on 3/28/12 at 3:00 p.m. The Immediate Jeopardy situation ended for Resident #2 on 3/28/12 because Resident #3 and #4 were no longer in the facility. 5. On 3/29/12 at 3:20 p.m., Resident #3 returned to the facility and the facility failed to implement interventions to protect Resident #2 from sexual abuse from Resident #3. As a result Resident #2 was placed in Immediate Jeopardy. The Immediate Jeopardy situation ended on 3/30/12 at 5:15 p.m. when Resident #3 was placed on one to one supervision and Resident #4 remained in the psychiatric facility. S1DON was notified of the Immediate Jeopardy situation on 3/30/12 at 4:15 p.m. The deficient practice remains at the level of potential for more than minimal harm for Resident #2. Findings: 1. A review of an Incident and Accident Reporting Form, dated 11/9/11 revealed that an incident occurred with Resident #2 at 11:50 a.m. in Dining Room A. This form was completed by S3LPN and the description read: "Observed with staff, Resident #3 was observed attempting to touch (Resident #2's) breast. Resident #2 stated, "I wouldn't let him go any further." Resident #3 stated, "Does that feel good baby?" Resident #2 stated "Leave my breast alone." The Incident Investigation form attached to Resident #2's Incident and Accident Reporting Form, dated 11/9/11, revealed the following description: Resident #2 was inappropriately fondled. Interventions read: Removed Resident #3 and notified S11SSD and S1DON to follow up. Corrective Action read: Monitor and instruct staff on how to handle this type of situation. Resident #3 Psych consult and admission. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm revealed that he receives his information to update care plans from physician's telephone orders and directly from staff when they report things. He disclosed that he was aware of the incident that occurred with Resident #2 on 11/9/11. He stated that he was told that the staff would be watching Resident #2 whenever she would come out of her room. S2LPN/Adm revealed that this was discussed during QA meetings and they did not go into detail about how and what the supervision /monitoring would include. He confirmed that he did not implement it on the care plan. He revealed that he did consider it a problem; no one should have that done to them. S2LPN/Adm stated that he did not know if the staff was doing what was told to him. He disclosed that the documentation of the supervision/monitoring would have been put on the MAR's. 2. A review of the facility's investigation of a bruise to the left side of Resident #2's cheek on 2/17/12 revealed the facility classified the bruise as an injury of unknown origin. A review of the Louisiana DHH Client Incident Report dated 2/17/12 at 1:30 p.m., the facility stated that given the past occurrence of Resident #4 slapping Resident #2, they could not deny the possibility that Resident #4 was responsible for the incident on 2/17/12. Further review of the attached Telephone Conversation conducted on 2/22/12 by S21Administrator with Resident #2's and #4 ' s responsible party revealed the following: "You know the past. Dad slapped mom before and had to go to.... Psych facility for med adjustment. " An interview on 3/29/12 at 3:10 p.m. with S1DON revealed that the family felt that the husband Resident #4 had slapped Resident #2 and caused the bruise, since he had done it before. Record review of Resident #4's Care Plan dated 1/12/12 revealed there no interventions developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. 3. A review of an Incident and Accident Reporting Form, dated 3/24/12 revealed that another incident occurred with Resident #2 at 12:30 p.m. in Dining Room A. This form was completed by S1DON and the description of the incident revealed Resident #2 was in her geri chair in St A Dining Room. Resident #2 was covered and resting. CNA witnessed another resident pulling Resident #2 ' s covers down and touching her chest and abdomen. The witness listed on this form was S5Housekeeper. A review of Resident #2 ' s Incident Investigation Form, dated 3/24/12, was completed by S1DON and revealed the following: Interventions: (facility left blank) Corrective Action: Resident removed from situation and assessed by S12LPN. An observation on 3/30/12 at 9:50 a.m. revealed Resident #2 sitting in a geri-chair in the TV room alone and not in view of the facility's staff. The TV was noted to be on and Resident #2 had a blanket covering her. An observation on 3/30/12 at 9:52 a.m. revealed two CNA's sitting at the feeder table located in the corner near the serving line of the Station A Dining Room. The TV room was located at the opposite side of the Station A Dining Room, but Resident #2 was not in view of the two CNA's. An interview on 3/30/12 at 9:55 a.m. with S4CNA revealed that Resident #2 was blind and staff was not providing one-on-one supervision. She disclosed that Resident #2 would not recognize if someone approached her. She revealed that the resident recognized voices if you identify yourself. S4CNA stated that when resident #2 is in the Dining Room or TV room they do not have to stay with her at all times. She revealed that they will put the resident in the TV room and turn the heater on because she gets cold and the resident goes to sleep. The CNA stated that she heard about Resident #2 being felt on by Resident #3. She revealed that another housekeeper witnessed that over the weekend and reported it. She stated that they sent Resident #3 to..... for evaluation, and he came back on yesterday 3/29/12 in the evening. She disclosed that they do not have to do anything for supervision/monitoring on him. An observation on 3/30/12 at 10:10 a.m. revealed Resident #3 in his room lying in bed asleep there was no staff present in the room supervising/monitoring him. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm admitted that he became aware a week ago of the incident of fondling that had occurred with Resident #2 being fondled and that it was again Resident #3. S2LPN revealed that there were no interventions put in place for supervision/monitoring of Resident #3 to prevent re-occurrence. He disclosed that the supervision/monitoring should have been care planed. An interview on 3/30/12 at 1:55 p.m. with S1DON confirmed that on 3/24/11 Resident #2 was again sexually assaulted by Resident #3. He confirmed that because there was a re-occurrence of the act from the same resident the staff was not supervising/monitoring Resident #2. S1DON confirmed that S5Housekeeper was the staff who witnessed the fondling, worked in housekeeping and was not a CNA. During a phone interview on 4/12/12 at 1:16 p.m., S20Office Manager confirmed that S5Housekeeper was a housekeeper and had never worked for the facility as a CNA. S20 Office Manager clarified that S1DON had inadvertently documented that S5Housekeeper was a CNA on Resident #2 ' s Incident and Accident Reporting Form, dated 3/24/12. Record review of Resident #3's Care Plan dated 3/24/12 revealed that there were no interventions developed for supervision/monitoring to prevent inappropriate fondling. 4. The Incident Accident Reporting Form dated 3/27/12, time 6:45 a.m. revealed the name of Resident # 4, Resident #2 's husband written in on the Report as followed: Describe exactly what happened: S3LPN instructed me that resident #4 pinched wife resident #2 who is also a resident here. Resident #2 yelled, "Son of [***] you pinched me stop, police, police" nurse counseled him not to touch wife inappropriately. The doctor and responsible party were notified. Further review of the attached Incident Investigation form dated 3/27/12 revealed the following: Interventions: Resident counseled and Psych consult. Corrective Action: admitted to psychiatric facility on 3/28/12 at 3:00 p.m., Spoke to daughter by phone 3/27/12 and 3/28/12 did not want to send dad until met with me. An interview on 3/29/12 at 2:05 p.m. with S3LPN revealed that Resident #2 does have a roommate and it was her husband Resident #4. She disclosed that Resident #2's husband was at a Psych facility because he was physically abusing her. She revealed that on 3/27/12 she found Resident #4 trying to choke Resident #2 and he was pinching the resident on her arm. S3LPN stated that she heard Resident #2 hollering and when she went to see what was going on with the resident she witnessed Resident #4 choking her neck and pinching Resident #2 on her arm. She revealed that Resident #4 stated that he was giving her love pinches. S3LPN demonstrated to this surveyor and the surveyor in training, how Resident #4 put his hands completely around Resident #4 ' s neck. Record review of Resident #4's Care Plan dated 1/12/12 revealed that no interventions were developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. 5. Record review of Resident #3's Nurses' Notes dated 3/29/12 at 3:20 p.m. revealed the following documentation: Return to facility in ... van . Readmit to facility under the care of .......Continue with previous N.H. (Nursing Home) orders. Record review of the Doctors Orders dated 3/29/12 revealed Resident #3 was readmitted to the facility and there were no orders to supervise/monitor the resident to prevent inapproriate fondling. Record review of Resident #3's Care Plan dated 3/29/12 revealed that there were no interventions developed for supervision/monitoring to prevent inappropriate fondling. An interview on 3/30/12 at 10:15 a.m. with S3LPN revealed she read it in the nurses ' notes. that Resident #3 was sent out to the Psych hospital. She confirmed that Resident #3 returned to the facility on yesterday 3/29/12. She disclosed that there was no one on one supervision/monitoring being done on Resident #3. A review of the facility's Preventing Resident Abuse, Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator.

Based on Resident interview, staff interview, and record review, the facility ' s Administration failed to ensure all policies and procedures relative to abuse prevention and investigation were adhered to by staff as evidenced by failures to: 1. Ensure staff implemented the appropriate level of supervision for Resident #3 who had a documented [DIAGNOSES REDACTED]. On 11/9/11 at 11:50 a.m. Resident #3 was observed touching resident #2 ' s breast while stating, " Baby does that feel good. " As a result resident #2 was placed in an Immediate Jeopardy situation. On 11/10/11 at 9:30 a.m. Resident #3 was admitted to a Psychiatric Facility and Resident #2 was no longer in an Immediate Jeopardy situation. On 11/16/11 at 5:00 p.m. Resident #3 returned to the facility and the facility failed to put interventions in place to protect Resident #2. As a result, resident #2 was placed in an Immediate Jeopardy situation. 2. Ensure staff implemented the appropriate level of supervision for Resident #4 who had a documented history of slapping Resident #2. On 2/17/12 Resident #2 had a bruise on her left cheek which was classified as an injury of unknown origin and the facility could not deny the possibility that Resident #4 (who is the spouse of Resident #2 and resides in the same room) responsible for this incident. The facility failed to implement the appropriate level of supervision for Resident #4 who according to documentation had a history of [REDACTED]. 3. Implement interventions to further protect Resident #2 from abuse by Resident #3. This resulted in a second occurrence of sexual abuse on 3/24/12 at 12:30 p.m. when Resident #3 was observed touching Resident #2 ' s chest and stomach. Resident #3 was admitted to a psychiatric facility on 3/24/2012 at 5:15 p.m. The Immediate Jeopardy situation continued for Resident #2 because the facility failed to implement measures on Resident #4 ' s care plan that would protect resident #2 from physical abuse. 4. Implement interventions to further protect Resident #2 from physical abuse by Resident #4. This resulted in a second occurrence of physical abuse on 3/27/12 at 6:45 a.m. when Resident #4 was observed choking and pinching Resident #2. Resident #4 was admitted to a psychiatric facility on 3/28/12 at 3:00 p.m. The Immediate Jeopardy situation ended for Resident #2 on 3/28/12 because Resident #3 and #4 were no longer in the facility. 5. On 3/29/12, Resident #3 returned to the facility and the facility failed to implement interventions to protect Resident #2 from sexual abuse from Resident #3. As a result Resident #2 was placed in Immediate Jeopardy. The Immediate Jeopardy situation ended on 3/30/12 at 5:15 p.m. when Resident #3 was placed on one to one supervision and Resident #4 remained in the psychiatric facility. S1DON was notified of the Immediate Jeopardy situation on 3/30/12 at 4:15 p.m. The deficient practice remains at the level of potential for more than minimal harm for Resident #2. Findings: 1. A review of an Incident and Accident Reporting Form, dated 11/9/11 revealed that an incident occurred with Resident #2 at 11:50 a.m. in Dining Room A. This form was completed by S3LPN and the description read: "Observed with staff, Resident #3 was observed attempting to touch (Resident #2's) breast. Resident #2 stated, "I wouldn't let him go any further." Resident #3 stated, "Does that feel good baby?" Resident #2 stated "Leave my breast alone." The Incident Investigation form attached to Resident #2's Incident and Accident Reporting Form, dated 11/9/11, revealed the following description: Resident #2 was inappropriately fondled. Interventions read: Removed Resident #3 and notified S11SSD and S1DON to follow up. Corrective Action read: Monitor and instruct staff on how to handle this type of situation. Resident #3 Psych consult and admission. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm revealed that he receives his information to update care plans from physician's telephone orders and directly from staff when they report things. He disclosed that he was aware of the incident that occurred with Resident #2 on 11/9/11. He stated that he was told that the staff would be watching Resident #2 whenever she would come out of her room. S2LPN/Adm revealed that this was discussed during QA meetings and they did not go into detail about how and what the supervision /monitoring would include. He confirmed that he did not implement it on the care plan. He revealed that he did consider it a problem; no one should have that done to them. S2LPN/Adm stated that he did not know if the staff was doing what was told to him. He disclosed that the documentation of the supervision/monitoring would have been put on the MAR's. 2. A review of the facility's investigation of a bruise to the left side of Resident #2's cheek on 2/17/12 revealed the facility classified the bruise as an injury of unknown origin. A review of the Louisiana DHH Client Incident Report dated 2/17/12 at 1:30 p.m., the facility stated that given the past occurrence of Resident #4 slapping Resident #2, they could not deny the possibility that Resident #4 was responsible for the incident on 2/17/12. Further review of the attached Telephone Conversation conducted on 2/22/12 by S21Administrator with Resident #2's and #4 ' s responsible party revealed the following: "You know the past. Dad slapped mom before and had to go to.... Psych facility for med adjustment. " An interview on 3/29/12 at 3:10 p.m. with S1DON revealed that the family felt that the husband Resident #4 had slapped Resident #2 and caused the bruise, since he had done it before. Record review of Resident #4's Care Plan dated 1/12/12 revealed there no interventions developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. 3. A review of an Incident and Accident Reporting Form, dated 3/24/12 revealed that another incident occurred with Resident #2 at 12:30 p.m. in Dining Room A. This form was completed by S1DON and the description of the incident revealed Resident #2 was in her geri chair in St A Dining Room. Resident #2 was covered and resting. CNA witnessed another resident pulling Resident #2 ' s covers down and touching her chest and abdomen. The witness listed on this form was S5Housekeeper. A review of Resident #2 ' s Incident Investigation Form, dated 3/24/12, was completed by S1DON and revealed the following: Interventions: (facility left blank) Corrective Action: Resident removed from situation and assessed by S12LPN. An observation on 3/30/12 at 9:50 a.m. revealed Resident #2 sitting in a geri-chair in the TV room alone and not in view of the facility's staff. The TV was noted to be on and Resident #2 had a blanket covering her. An observation on 3/30/12 at 9:52 a.m. revealed two CNA's sitting at the feeder table located in the corner near the serving line of the Station A Dining Room. The TV room was located at the opposite side of the Station A Dining Room, but Resident #2 was not in view of the two CNA's. An interview on 3/30/12 at 9:55 a.m. with S4CNA revealed that Resident #2 was blind and staff was not providing one-on-one supervision. She disclosed that Resident #2 would not recognize if someone approached her. She revealed that the resident recognized voices if you identify yourself. S4CNA stated that when resident #2 is in the Dining Room or TV room they do not have to stay with her at all times. She revealed that they will put the resident in the TV room and turn the heater on because she gets cold and the resident goes to sleep. The CNA stated that she heard about Resident #2 being felt on by Resident #3. She revealed that another housekeeper witnessed that over the weekend and reported it. She stated that they sent Resident #3 to..... for evaluation, and he came back on yesterday 3/29/12 in the evening. She disclosed that they do not have to do anything for supervision/monitoring on him. An observation on 3/30/12 at 10:10 a.m. revealed Resident #3 in his room lying in bed asleep there was no staff present in the room supervising/monitoring him. An interview on 3/30/12 at 10:15 a.m. with S3LPN revealed that on Saturday it was reported that Resident #2 was fondled by Resident #3. She revealed that she read it in the nurses ' notes. She stated that Resident #3 was sent out to the Psych hospital. S3LPN confirmed that Resident #3 returned to the facility on yesterday 3/29/12. She disclosed that there was no one on one monitoring being done on Resident #3. An interview on 3/30/12 at 12:50 p.m. with S2LPN/Adm admitted that he became aware a week ago of the incident of fondling that had occurred with Resident #2 being fondled and that it was again Resident #3. S2LPN revealed that there were no interventions put in place for supervision/monitoring of Resident #3 to prevent re-occurrence. He disclosed that the supervision/monitoring should have been care planed. An interview on 3/30/12 at 1:55 p.m. with S1DON confirmed that on 3/24/11 Resident #2 was again sexually assaulted by Resident #3. He confirmed that because there was a re-occurrence of the act from the same resident the staff was not supervising/monitoring Resident #2. S1DON confirmed that S5Housekeeper was the staff who witnessed the fondling, worked in housekeeping and was not a CNA. During a phone interview on 4/12/12 at 1:16 p.m., S20 Office Manager confirmed that S5Housekeeper was a housekeeper and had never worked for the facility as a CNA. S20 Office Manager clarified that S1DON had inadvertently documented that S5Housekeeper was a CNA on Resident #2 ' s Incident and Accident Reporting Form, dated 3/24/12. Record review of Resident #3's Care Plan dated 3/24/12 revealed that there were no interventions developed for supervision/monitoring to prevent inappropriate fondling. 4. The Incident Accident Reporting Form dated 3/27/12, time 6:45 a.m. revealed the name of Resident # 4, Resident #2 's husband written in on the Report as followed: Describe exactly what happened: S3LPN instructed me that resident #4 pinched wife resident #2 who is also a resident here. Resident #2 yelled, "Son of [***] you pinched me stop, police, police" nurse counseled him not to touch wife inappropriately. The doctor and responsible party were notified. Further review of the attached Incident Investigation form dated 3/27/12 revealed the following: Interventions: Resident counseled and Psych consult. Corrective Action: admitted to psychiatric facility on 3/28/12 at 3:00 p.m., Spoke to daughter by phone 3/27/12 and 3/28/12 did not want to send dad until met with me. An interview on 3/29/12 at 2:05 p.m. with S3LPN revealed that Resident #2 does have a roommate and it was her husband Resident #4. She disclosed that Resident #2's husband was at a Psych facility because he was physically abusing her. She revealed that on 3/27/12 she found Resident #4 trying to choke Resident #2 and he was pinching the resident on her arm. S3LPN stated that she heard Resident #2 hollering and when she went to see what was going on with the resident she witnessed Resident #4 choking her neck and pinching Resident #2 on her arm. She revealed that Resident #4 stated that he was giving her love pinches. S3LPN demonstrated to this surveyor and the surveyor in training, how Resident #4 put his hands completely around Resident #4 ' s neck. Record review of Resident #4's Care Plan dated 1/12/12 revealed that no interventions were developed for supervision/monitoring to keep Resident #2 safe from physical abuse by Resident #4. A review of the facility's Preventing Resident Abuse, Abuse Prevention Program, and Abuse Investigations for Policy Interpretation and Implementation revealed the following: 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: h. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; i. The implementation of changes to prevent future occurrences of abuse. 8. While the investigation is being conducted, accused individual (s) not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the Administrator.

Based on observations and interviews, the facility failed to ensure that the resident environment was free of accident hazards for 2 of 6 Hall (Area A and B) and 1 of 1 pay phone areas (Area C) by; 1. failing to ensure that resident bathroom/toilet rooms were properly equipped with a functioning communication system, area A and area B; 2. failing to ensure that a resident bathroom/toilet room was safe from the potential of a resident locking themselves within a room which had no key access, once the doors were locked from inside of that room, area A; and 3. failing to observe, acknowledge, and clean up water on the floor of the hall at area C. Findings: During the initial tour on 2-12-12 at 11:45 a.m., an observation of area "A", bath/toilet room, was made. Area A was noted to contain no communication system. The same bath/toilet room, Area A, was also noted with two entry/exit doors. Each of the two doors was noted to lock from the inside of the room. During interviews, on 2-16-12 at 10:30 a.m., with S10LPN, S11CNA, and S12CNA, all 3 staff confirmed that they worked on the hall of which Area A was located. Each of the three staff members confirmed that Area A, (bath/toiletrooms), contained no communication system and the doors of Area A had locks which locked on the inside of the doors. Each of the 3 staff members, (S10LPN, S11CNA and S12CNA), confirmed that they had no knowledge of who, or if anyone in the facility had a key/device to unlock the doors of Area A, if the doors were locked from the inside. Each of the three staff also confirmed that the unit of which Area A was located, contained 2 out of the 9 residents which were capable of, and did utilize Area A bath/toilet room independently and without staff assistance. The 3 staff members identified residents #72, and #119 as independently utilizing Area A. During the environmental tour, on 2-17-12 at 9:00 a.m., with S7Administrator (Adm) and S8Maintanence (Maint), both staff confirmed the lack of a communication system in Area A, and the fact that the doors locked from the inside in Area A bath/toilet room. In addition, S7Adm confirmed that Area B bath/toilet rooms on an adjacent unit/hall, had a non-operable call/communication system for the handicapped toilet. The pull string for Area B call/communication system near the handicapped toilet was noted to have ran through some eyelets under the sink and along the wall. S7Adm attempted to trigger the call/communication system from the toilet, and was not able to do so due to the eyelets/obstacles of which the pull string was ran through. S7Adm confirmed that the call/communication system was not operable to residents who used the handicapped toilet in Area B. An observation on 2-14-12 at 9:05 a.m., revealed a puddle of water was noted on the floor in the hall and at the entrance to the Area C. S9Office Assistant explained that Area C was used by staff and residents alike. The water on the floor remained and was unnoticed/not addressed by staff as they wheeled carts by, and walked by the puddle on the floor. S5LPN was observed to wheel her medication cart along side of the puddle at 9:38 a.m. S15 and S16Housekeeping were observed to wheel a cart, walk by, and not notice/address the puddle on the floor. An interview with S16HSKP at that time, 9:38 a.m., confirmed the room of which the puddle was near, was Area C, and Area C was for use by residents and staff. Once the puddle was pointed out by the surveyor, S16HSKP noticed and addressed the puddle on the hall floor.