Every finding on record at Golden Years Nursing and Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established national guidelines, were prepared in advance and were followed for 1-of -1 reviewed for menus. 1. The facility failed to ensure current, accurate menus were provided and visible to residents for one dining area 2. The facility failed to ensure residents were offered individual menus for meal which is not a homelike environment. These deficient practices could place at risk of not getting food that they want or like. Findings included: Observation on 8-05-2025 at 11:15 am, revealed There were no menus posted in the dining room. The menu was written on the chalkboard right before residents were served lunch. There was only one menu in the facility on one of the halls. The menu located on information board from a previous month and did not include the current lunch items. The menu on the board was beef stew and baked ham was served, The menu on the board was in small print.Interview on 8/7/2025 at 9:30 AM, Resident #56 stated during, she did not know what meal she was going to have until the meal was brought to her room. She said she did not have a menu in her room. She stated she did not know where the menu was located. Resident #56 stated she would like to know if there were other options on the menu besides what she got. Resident did not know that she could get a menu. She stated that in the past she has received a menu in the past, but that has been several months ago. Interview on 8/7/2025 at 9:40 AM, Resident #7 stated during Sometimes the food is okay, but I would like to know what I am eating ahead of time. Resident #7 stated she was bed-bound and could not get out of the room to see what was on the menu. She stated she would like to know what she was having before they brought the food in case, she wanted something else. She expressed frustration about not knowing what was on the menu. Interview on 8/7/2025 at 9:50 PM, Resident #7 stated she did not know where the menu was in the building. She said she did not have a menu in her room and was not told what was on the menu. She said she did not know what she was going to get for her meal. Resident #7 stated she ate in the dining room and was unsure where the menu was in the facility. The resident stated she did not know what the substitute item was on the menu. Interview on 8/7/2025 at 9:50 AM, the DM stated during residents only got a menu if they asked for it. He said residents at the facility did not usually ask for a substitute meal because they liked the food being served. He said the menu was on the board towards the front of the facility. He said that was the only menu posted. He said they wrote down the menu on the chalkboard in the kitchen in the morning, so residents knew what they were having for lunch after breakfast is served. DM manager said he put the menu out for residents to see and it is the one that he gets from [NAME]. DM manager said besides the one menu that is posted he writes the menu on the chalk board in the dining room. Interview on 8/7/2025 at 11:10 AM, the ADM stated Residents should be able to have access to the menus so that they know what their meal is going to be The menu should be posted in more than one place in the facility, and it should be big enough for the residents to see. The menu is written on the chalkboard in the kitchen before the meal is served in the dining room.Record review of Menus and Adequate Nutrition Policy, revised on 7/16/2025, reflected Policy.Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitution shall comprise of foods with comparable nutritive value.Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance.Alternatives shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking. Review of the federal food code. Federal food safety regulations for nursing homes are primarily outlined in 42 CFR S 483.60, which addresses food and nutrition services. These regulations emphasize providing residents with a nourishing, palatable, and well-balanced diet that meets their individual nutritional needs and preferences. Key aspects include ensuring food safety, proper staffing, and adherence to dietary requirements.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure that expired foods were discarded. 2. The facility failed to ensure the food processor was sanitized between each food item. 3. The facility failed to ensure food items were labeled and dated. 4. The facility failed to ensure that serving utensils and dishes were not stored dirty.These failures could place residents at risk for foodborne illness, causing the residents to get sick in 1 of 1 kitchen. Findings included: Observation on 8/05/2025 at 7:30 AM of the walk-in refrigerator reflected the following:- Tomatoes in a sealed bag were dated 7-22 with no discard date. - Strawberries in a container had no date and were moldy. - A cardboard box, dated 7-02-2025, contained green grapes were brown. - Sliced cheese in a Ziplock bag, dated 8-01-25, had no discard date. - Celery in a sealed bag, dated 8-02-25 had no discard date. - Asparagus in a Ziplock bag, dated 8-01-25, had no discard date.Observation on 8/05/2025 at 7:40 AM of the kitchen reflected the following:- Blue coffee cups on a dishwasher rack with other clean items had white debris on the cups. - Utensils in a dishwasher rack were mixed with clean and dirty utensils. - Serving utensils stored in a clear container had food debris in with the serving utensils. Observation on 8/05/2025 at 11:04 AM of the kitchen reflected the following:CK A Pureed the green beans, then rinsed the food processor in hot water without sanitizing the food processor. There were still pureed green beans inside the food processor when CK A pureed baked beans. CK A then rinsed the blender in hot water, but it was not sanitized before pureeing the bread. CK A then Pureed the cabbage without sanitizing the food processor. CK A rinsed the blender in hot water and did not sanitize the food processor before pureeing the ham.Observation on 8/06/2025 at 11:15 AM of the kitchen reflected the following:CK A pureed the chicken, then rinsed the food processor in hot water without sanitizing it for the next food item. CK A pureed the green beans, then rinsed the food processor in hot water without sanitizing it for the next food item. CK A pureed the potatoes. An interview on 8/07/2025 at 10:20 AM with CK B CK B stated when he put a food item in a container, he added the date on the container. CK B stated he checked daily for expired food items. If he saw an expired food item, he then threw it away. CK B stated any prepared food items past 3 days were thrown away. CK2 said there was no list they went by that told him how many days an item could be stored before it was thrown away. CK B stated prepared food was stored for three days before being discarded. CK B stated the kitchen was cleaned daily. CK B said there was a cleaning checklist they used. CK B said he was supposed to clean and sanitize the food processor in between food items. CK B said he forgot to do it this time. CK B said he was supposed to change his gloves when he did something else and came back to pureeing food. CK B said it had been a while since there was any training. CK B stated a resident could get sick if the equipment was not thoroughly cleaned and he did not change his gloves.An interview on 8/07/2025 at 10:29 AM with the DA revealed when the truck arrived, all staff are responsible to make sure that food items are dated. When a prepared item was placed in a Ziplock bag, it should have the date it was stored and an expiration date. If she noticed food going bad, she informed the DM and disposed of it. The DA mentioned everyone checked the walk-in cooler for expired items. The DA said staff did not put the expiration date on the packages. The DA stated prepared items should be discarded after three days because then the item is not good. The DA said the kitchen was cleaned daily at the end of each shift, including sweeping and mopping. DA said that residents could get sick if hand hygiene was not followed.An interview on 8/07/2025 at 10:20 AM with the DM revealed they went by newest item in the back and the oldest in the front. The DM said items were checked daily to see if there were any expired food. If there was expired food in the cooler it should be thrown away. The DM said food should be labeled with the name of the item, the date it was added, as well as the expiration date. The DM stated there was a list that had the shelf life of different foods. The kitchen was cleaned and sanitized daily. There were policies for sanitation, hand hygiene and food storage. The DM stated if equipment and utensils were not sanitized or cleaned, then it could be an infection control issue. An interview on 8/07/2025 at 10:20 AM with the ADM revealed when a food item was prepared and stored in a Ziplock bag, it should have the date it was put in the bag and the expiration date. The DM said when there was an out-of-date item, it should be thrown out. Looking for items should be checked weekly by staff. The kitchen should be cleaned and sanitized daily. There were polices in place for out-of-date food and the food should be discarded, and Kitchen equipment should be sanitized. The expectations are for staff to check for out-of-date food items and sanitized equipment. The ADM stated if out-of-date food was served to the residents, they could get sick. The ADM stated if equipment and utensils were not sanitized or cleaned, and said that CK A and CK B said they forgot to sanitize the equipment. then it could be an infection control issue.Record review of the facility's Sanitation policy, updated October 2008, reflected Policy Interpretation and Implementation: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.4. Sanitizing of environmental surfaces must be performed with one of the following solutions:a. 50-100 ppm chlorine solution.b. 150-200 ppm quaternary ammonium compound (QAC); orc. 12.5 ppm iodine solution.5. Sanitizing of utensils and removable parts of equipment should be accomplished in one of the following ways:a. Contact for at least 30 seconds with an iodine solution (at approved concentration);b. Contact with QAC (at approved concentration) per manufacturer's instructions.c. Contact for at least l 0 seconds with a chlorine (at approved concentration); ord. Immersion for thirty (30) seconds in hot (at least 171 F) water.Record Review of the facility's, undated, Food Storage Policy reflected: All foods shall be dated with the month and year received and shall be rotated on the first in/first out basis upon receipt. The oldest items are to be moved to the front to be used first. Food shall be purchased in quantities which can be stored properly. Frozen products purchased in larger quantities than needed are divided into appropriate quantities, wrapped, and labeled with the description of the product, the date it was wrapped and placed in the freezer.

Based on interview and record review, the facility failed to ensure that the medical record was complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to document nursing progress notes, assessments, or transfer documents when Resident #1 was transferred to the acute care hospital on 10/28/24. This failure could place residents at risk for not receiving appropriate care due to incomplete information in the chart. Findings included: Review of Resident #1's admission MDS assessment, dated 10/04/24, Section A (Identification Information) reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including hypertension (high blood pressure), peripheral vascular disease, (disorder of the blood vessels outside of the heart, often decreased blood flow to the limbs) renal insufficiency (poor kidney function), diabetes mellitus (a condition that affects the way the body processes blood sugar), cerebrovascular accident (stroke), and subacute osteomyelitis right ankle and foot (a chronic infection of bone). Section C (Cognitive Patterns) reflected a BIMS score of 9 indicating moderately impaired cognition. Section M (Skin Conditions) reflected an infection of the foot and surgical wounds. Review of Resident #1's electronic medical record reflected there were no assessments completed on 10/28/24. Review of Resident #1's electronic medical record reflected there were no progress notes written 10/28/24 that reflected the resident's status, a change in status, or an emergent condition that warranted transfer to the acute hospital. There was no progress note that reflected the provider was notified nor an order to transfer to the acute hospital received. Review of Resident #1's electronic medical record reflected there was no physician order to transfer the resident to the acute hospital. Review of Resident #1's electronic medical record reflected a progress note dated 10/28/24 at 9:00 PM, written by LVN A, Ambulance transportation here to take resident to [name] ER. RP notified. During an interview on 10/30/24 at 10:45 AM, the DON stated Resident #1 had wounds, and despite the interventions, the wounds had not improved. The plan had been to send the resident back to the hospital where the surgical team would request a consult from the vascular team. She stated the resident went to the ED then was admitted to the hospital. She stated the MDS nurse monitored completion of assessments but no one monitored the progress notes. During a telephone interview on 10/30/24 at 4:03 PM, LVN A stated she was told EMS was scheduled to take the resident to the hospital so he could see the surgeon. She stated when EMS arrived, the resident was awake. I told him where he was going and told him I would call his family . She stated when a resident was sent out of the facility, the nurse was expected to write a note and complete an assessment. She stated, I didn't do it. She stated it was a busy time and she was going to go back later to complete the documentation but did not. She stated not documenting could lead to a lack of communication, not knowing the baseline or if changes occurred. During a telephone interview on 10/30/24 at 4:12 PM, LVN B stated she had contacted the surgeon about the wounds not improving and the surgeon said to send him to the ER. She stated EMS showed up but before they got to the resident, they received an emergent call so they left stating they should be back around 7 or 8:00 PM. She stated she left the facility around 7:30 PM and EMS had not yet returned. She stated she could not remember if she documented the conversation with the surgeon. She stated, I know I should have written a note, usually I do. She stated when a resident was sent out to the hospital, the nurse was expected to complete a transfer note. She stated the nurses were expected to document changes in the resident's condition. During an interview on 10/30/24 at 4:30 PM, the DON stated it was her expectation that documentation was completed accurately and timely. She expected the documentation to depict a good view of the resident. She stated not documenting in the resident's medical record could lead to staff not knowing if the resident had a change, was declining, or improving. The lack of communication or documentation could lead to a delay in care. During an interview on 10/30/24 at 4:37 PM, the ADM stated he expected accurate documentation and timely. He stated, When time is of the essence and trying to get someone transferred out, there is the human error aspect. He stated the nurses were aware of the documentation expectations. He stated delay of care would be the biggest negative outcome of not documenting in the resident's medical record. Review of the facility policy revised July 2017 and titled, Charting and Documentation reflected in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations: d. Changes in the resident's condition: e. Events, incidents or accidents involving the resident.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for 1 of 1 full recertification survey (Survey A) reviewed for survey results. The facility failed to post the results of Survey A dated 04/27/23 in a public area for all residents and visitors to view on 07/01/24. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility. Findings included: During a confidential interview with 11 anonymous residents, all 11 agreed they had not ever seen the results of any of the previous State Agency inspections or noticed them posted or advertised in any public area around the facility. Seven of the 11 residents interviewed stated they would have wanted to view the survey results and wanted to know how they could do so. Observation on 07/01/24 at 03:11 PM revealed no survey results posted in any public area anywhere in the facility. During an interview on 07/01/24 at 04:02 PM, the ADM stated he had just begun working at the facility a few weeks prior, and he thought the survey results book had been posted in a bracketed wire file folder hung outside his office door, but he had confirmed it was not hung there. He stated he was responsible for ensuring the survey results were available for residents, staff, and visitors to read. He stated the potential negative impact of not having survey results available was people would not know what was going on in their home. Review of facility policy dated April 2017 and titled Examination of Survey Results reflected the following: Survey reports and plans of correction are readily accessible to the resident, family members, resident representatives and to the public. Policy Interpretation and Implementation 1. Residents may examine the results of the most recent survey of the facility conducted by federal or state surveyors, as well as any plans of correction in effect. 2. A copy of the most recent survey report and any plans of correction are kept in a binder in the residents' day room. 3. Survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request. 4. Information concerning the rights to examine, the location of and how to request preceding years' survey reports and plans of correction (and related materials as noted above) are posted on the resident bulletin board and at each nurses' station.

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care based on the comprehensive assessment of a resident and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 16 Residents reviewed for quality of care The facility failed to perform Resident #33's left fifth toe wound treatment as ordered on 07/01/24. This failure placed residents at risk of worsening infection, sepsis, and amputation. Findings included: Review of the undated face sheet for Resident #33 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included congestive heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), type two diabetes mellitus, morbid obesity, need for assistance with personal care, difficulty in walking, long-term use of anticoagulants, and venous insufficiency (malfunction of venous walls and/or valves in systemic circulation, especially in the legs, that result in peripheral pooling of blood known as stasis). Review of the quarterly MDS assessment for Resident #33 dated 05/22/24 reflected a BIMS score of 15, indicating an intact cognitive response. It reflected that she did not have an infection or other wound of the foot during the lookback period (seven days of data from which the assessment results are drawn). Review of laboratory culture results for Resident #33 dated 06/25/24 reflected MRSA was detected in a sample taken from the fluid filled blister on her left fifth toe on 06/24/25. Review of the care plan for Resident #33 dated 07/01/24 reflected the following: Altered skin integrity non pressure related to: Right 5th toe fluid filled blister. Affected area will heal without complications through next review date. o Antibiotic ointment per MD order o Evaluate need for pain reliever prior to cleansing or dressing changes o Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings o Notify practitioner if symptoms worsen or do not resolve o Treatments as ordered o Weekly Wound evaluation Review of physician orders for Resident #33 reflected an order for Mupirocin External Ointment 2 % (Mupirocin) Apply to Left small toe topically every day shift for Staph infection for 10 Days with a start date of 06/25/24 and an end date of 07/05/24. Review of the June 2024 and July 2024 TAR for Resident #33 reflected the following treatment was documented on 06/30/24 and 07/01/24 by LVN A: Mupirocin External Ointment 2 % (Mupirocin) Apply to Left small toe topically every day shift for Staph infection for 10 Days. Observation and interview on 07/02/24 at 09:16 AM revealed Resident #33 seated in her easy chair with her feet elevated. She had a sign on her door indicating contact precautions were in place, and her left foot was wrapped in gauze. The date 06/30/24 was written on a piece of white tape on the gauze. Resident #33 stated she had a blister on her foot and was receiving wound treatment for it. She stated she thought she had gotten wound treatment the day before but was not completely sure. She stated it had not been done that day. She stated the wound did not hurt. During observation and an interview on 07/02/24 at 11:05 AM, the DON was preparing to administer medications to Resident #33. She stated she had not yet been in Resident #33's room and had not seen the bandage on her foot. The DON went into Resident #33's room and returned within a few moments. She stated the bandage on Resident #33's left foot was dated 06/30/24. She stated she needed to check the orders to determine why the bandage was documented as changed on 07/01/24 but still dated 06/30/24. During an interview on 07/02/24 at 02:00 PM, the DON stated she had determined the wound treatment for Resident #33's fifth left toe had not been completed by LVN A. She stated LVN A had made a mistake and thought she completed the treatment so had signed the TAR to indicate as such, but she could not find the notes that the treatment had been done. The DON stated it was only her second day at the facility, and she had not developed a system for monitoring to ensure wound care was completed, but she had already started in-servicing the staff on the failure. She stated the potential impact of not receiving antibiotic ointment on a skin infection was worsening infection. Observation on 07/02/24 at 03:00 PM revealed LVN B provided the wound treatment to Resident #33's blister to the left fifth toe. Observation of the wound revealed a large fluid-filled blister the size of the entire fifth (pinky) toe. The blister membrane was intact, and the fluid inside it was slightly serous (clear with a slight yellow). The fifth toe was almost completely obscured by the blister. During an interview on 07/02/24 at 04:18 pm, LVN A stated yesterday, 07/01/24, was her first day back at the facility after a leave of absence. She stated she was not familiar with all the wounds in the building but normally, she kept track of her treatments by looking at the TARs for all of her residents and handwriting the orders down on a piece of paper. She stated she then documented her notes about the wound on the paper and entered all of it into the system when she was done. She stated she did not pull a report of treatments; she just went through and looked at all of her residents. LVN A stated she had Resident #33 on her list and had no excuses for not performing the treatment. She stated there were four or five new residents after coming back, and she was getting to know them, and she was not in the groove of things. LVN A stated she had a new admission after 03:00 PM on 07/01/24 and she got distracted and marked Resident #33's treatment as done when it was not. LVN A stated the orders for Resident #33's blister were to cleanse with normal saline and apply mupirocin. LVN A stated she was trained to complete all her treatments as ordered and to only document in the EMR if she completed the treatment. She stated the potential impact of the treatment not being done as ordered was the infection could become worse, Resident #33 could get sick and possibly even die. During an interview on 07/03/24 at 02:00 PM, the ADM provided policy on Medication and Treatment Orders, but these were not relevant to the failure. There was no other policy that was specifically relevant to the failure.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 05/21/2024. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 5/21/2024 and ended on 5/22/2024 The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings were: Record review of Resident # 1's face sheet, dated 6/3/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE] with diagnosis that includes Schizophrenia ( a disorder that affects a person's ability to think, feel and behave clearly.), Type 2 Diabetes Mellitus ( A long term condition in which the body has trouble controlling blood sugar and using it for energy) and , Mild intellectual disabilities ( is a neurodevelopmental disorder that affects intellectual functions and daily living skills,) Record review of Resident's # 1 Admission MDS, dated [DATE] reflected a BIMS revealed resident was not appropriate for an evaluation as resident in rarely/ never understood. Section E revealed wandering occurred to 1 to 3 days, with no significant risk of getting to a potentially dangerous place. Record review of Resident # 1's wandering/elopement risk assessment tool dated 5/2/204 had a score of 7 (moderate risk} , resident ambulates independently and a history of wandering behaviors, no history of elopement from home or previous facility. Review of Resident #1's care plan dated 5/3/2024 reflected problems of wandering and risk for elopement with interventions that include a wander guard and redirection for the exit doors. Review of Resident #1's orders dated 5/2/2024 reflected an order for signaling device is use, Signaling Device: Change electronic monitoring device according to manufacture's recommendations and PRN if noted non-functional, and Signaling Device: check electronic monitoring device via testing machine every day, every night shift for wandering/exit seeking. Review of Resident #1's Treatment Record for the month of May 2024, reflected Signaling device check done daily on night shift. Observation on 5/2/2024 at 12:45pm of the alarm response at the front door of the facility reflected the wander guard functional and sufficiently loud to alert the staff of a potential elopement. During a phone interview on 6/3/2024 at 1:00 PM LVN A stated if a resident was not able to not be located a code pink was called a code Pink after searching the facility, they are to notify the Administrator, DON, and responsible party. A search of the ground was then completed and if not found the local police are notified. She stated there was a pink binder at both nurse's station with all resident's that are at risk of elopement with there picture and face sheet. She stated they had an elopement drill, and they were in-services on the elopement policy and protocol and abuse and neglect. During an interview on 6/3/2024 at 1:15 PM with CNA B stated that if she could not find a resident, she would let the charge nurse know and help with the search, she is not sure when, but a some point the nurse will notify the administrator, DON and family members. If there is a missing resident, they will call a CODE PINK then we start making sure all of my resident are accounted for and then help the others to look for theirs. We had a drill a couple of weeks ago, along with an in-service on elopement and abuse and neglect. The Abuse coordinator lithe administrator,and if he is not here, she would let the charge nurse and the DON know. During an interview on 6/3/2024 at 2:00 PM with the DON he stated saw Resident #1 in the dining room at 5:45 PM looking for some more to eat. The DON stated he received a phone call at 6 PM that a off duty employee had seen the resident in the parking lot of a local grocery store, about a block away and brought him back to the facility. The wander guard did go off when the resident returned to the building. He stated they were unable to determine how the resident left the building, placed him on one to one and moved him to a sister facility with a secure unit. The front door is now locked at all times with a code for entrance and exit, delay exit is still active. at the time of the incident, it was unlocked till 8 PM for visiting hours and there was no one at the desk after PM. During an interview on 6/3/2024 at 2:30pm with Maintenance director reported they have done an code Pink elopement drill on both shifts since the incident, the Fire safety company has come out and tested the doors with sensors on them and verified they are working and increased the sensitivity and the volume of the alarm. Record review of policy Wandering/ Elopement revised March 2019 reflected 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building, and premises and c If the resident is not located notify the administrator, and the director of nurses, the resident's legal representative, the attending physician, law enforcement officials and (as necessary) volunteer agencies. The DON was notified on 6/3/2024 at 5:45 PM that a past non-compliance Immediate Jeopardy had been identified due to the above failures. The facility course of action prior to surveyor entrance included: Record review of Resident # 1 Progress notes, he was initial placed on 1:1 supervision and moved to a sister facility with a secure unit, on 5/21/2024 The facility contacted the alarm company, who increased the volume and sensitivity for the alarm system on 5/22/2024 confirmed with invoice of work dated 6/3/2024. Record review of Provider instigation revealed all residents with wander guards were checked for functioning, Interview with DON on 6/3/2024 at 4:00pm the facility has standing MD orders on all residents with a wander guard has the device checked daily on the nightshift, that include placement, function with a testing device and skin assessment under the device. Interview with Maintenance director stated that immediately after the elopement incident, the front doors to the facility were locked with entry and exit code required 24 hours a day, previously they were unlocked till 8 PM with no one at the desk after PM. Review of In-services reflected the facility had an elopement drill on 5/22/2024 for all staff members on both shifts. Record review of an In-service training dated 5/22/2024, related to elopement and abuse and neglect revealed 50 out of 50 staff member's signatures. Interview were conducted with 17 employees on 6/3/2024 between 10 am and 4 PM, which consisted of LVN's ( 2) Medication Aides(1), CNA's (4), Physical therapist, Physical therapy assistance (3) Occupational therapist, Certified Occupational therapy assistance (2), Speech Therapist and Housekeepers (2) on 6/3/2024 from 10:00 am to 2:00 PM revealed they had received in-services on Elopement Response, All were able to state the key elements of the elopement policy which included If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building, and premises and c If the resident is not located notify the administrator, and the director of nurses, the resident's legal representative, the attending physician, law enforcement officials and (as necessary) volunteer agencies.

Based on interviews and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of 1 of 3 (Resident # 2) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident's #2's Ativan 0.5 mg, 60 tablets (an anti-anxiety medication) received from the pharmacy on 5/22/2024 at 12:17 am and reported missing 5/22/2024 during the day shift. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. The non-compliance was identified as Past non-compliance, the facility had corrected the non-compliance before the survey began. Findings included: Review of Resident # 2's faced sheet printed `5/22/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Alzheimer's disease ( A progressive disease that destroys memory and other important mental functions) , Cognitive communication deficit ( a communication difficulty caused by a cognitive impairment, this impairment can affect any aspect of communication, including verbal and nonverbal language, ,speaking, listening, reading writing and social interaction) and palliative care(specialized medical care for people living with a serious illness) Review of Resident's #2's of admission MDS dated [DATE] revealed a BIMS score of 3 which can indicate a serve cognitive impairment, Resident was receiving hospice care. Review of Resident # 2's physician orders dated 6/3/2024 revealed order written on 5/5/2024 Ativan 0.5 mg Po PRN Q 4 hours for anxiety. Review of the provider investigation report dated 5/31/2024 reflected, on 5/22/2024 at 12: 17 am the pharmacy delivered 60 (sixty) tablets of Ativan 0.5 mg for Resident # 2, packing slip from the pharmacy was signed by LVN A as received. Medication was noticed as missing, on the next shift. A search of the facility's medication rooms and medication carts and the medication was not located. The report reflected no injury or harm to the resident as medication was available in the emergency medication kit and the facility replaced the missing medication after the investigation was completed, the facility notified Hospice, the responsible party, the medical director, and the police. Statements were obtained and staff were drug tested . The investigation findings confirmed the drug diversion. Review of the pharmacy packing slip dated 5/22/2024 reflected Ativan 0.5 mg 60 tablets was delivered to the facility and signed as received by LVN A Review of the Business card left by the responding police officer reflected, Case No: 24-002740. Review of Inservice dated 5/22/2024 reflected that all LVN and RN's were inserviced on Controlled Substance that included the process for accepting scheduled medications from the pharmacy. Review of LVN A employee file reflected an counseling on 5/24/2024 for not following the controlled substance policy. During a phone interview on 6/3/2024 am 12:55 PM with the local police department desk sergeant, the investigator on the case was working night shift this week, left message for return phone call. No return phone call received prior to exit. During phone interview on 6/3/2024 at 1:00 PM LVN A stated that she does not remember getting the Ativan for Resident # 2 when the medication was delivered on 5/22/2024. She remembers receiving the other medication that she signed for as she had to lock it up in the refrigerator. She was not sure why she signed for the medication if she didn't see it, she stated it was her usual practice to verify each medication prior to signing the delivery receipt. She stated she was counseled on not following the Controlled substance policy after being inserviced on it. During an interview with LVN B on 6/3/2024 at 1:30 PM she was inserviced on accepting controlled substances from the pharmacy and was able to verbalize the process for accepting scheduled medications from the pharmacy. During an interview with DON on 6/3/2024 at 2:00 PM stated they did not identify a perpetrator or find the missing medications. He stated he was not sure the medication was even delivered, as the receiving nurse does not recall putting the medication in the lock box. After the medication was discovered missing, the facilities medication rooms and cart were searched, pharmacy was notified and stated since the medication was signed for, they would not be doing an investigation. There was no narcotic sign out sheet, which was delivered with the medication found. She stated that all staff were drug tested with negative results. He stated the medication and the sign out sheet were never located, and the medication was replaced by the facility. He stated that the medication was available in the emergency drug kit, so no doses were missed, there was no adverse reaction to the resident. Review of the facility policy Controlled Substances revised November 2022 reflected 3. Controlled substances are counted upon deliver. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record The facility course of action prior to surveyor entrance included: 1. Review of in-service conducted on 5/23/204 revealed all licensed staff were in-serviced on controlled substances that included the process for accepting controlled substance from the pharmacy. 2. Interview with DON on 6/3/2024 at 2 PM. LVN A was consoled on 5/23/2024 for not following policy and procedure. 3. Interview with DON on 6/3/2024 at 2 PM medication was replaced by the facility on 5/30/204.

Based on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates for 1of 2 medication rooms and 2 of 4 medication carts reviewed for medication storage. -The facility failed to date a multi-use product (eye drops) when the product was first opened according to manufacture and professional standards. -The facility failed to ensure expired medications were removed from the medication carts and medication rooms. -The facility failed to ensure medications were stored in a clean, safe, and sanitary manner. These failures place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 04/25/2023 at 2:57 PM revealed the facility North Medication room with a bottle Of Vitamin E 1000 IU with an expiration date of 07/2022. Observation on 04/25/2023 at 3:00 PM revealed the North Medication cart with a bottle of Aspirin 325mg with an expiration date of 09/2022. Observation further revealed Resident #22's Latanoprost eye drops open without an open date and Resident #30's bottle of artificial tears eye drops open with no open date. Observation on 04/25/2023 at 3:10 PM revealed the South Medication cart with an open bottle of Lactulose with a sticky liquid on both sides of the bottle. When the bottle of lactulose was pulled out the cart a box of Mucinex, Imodium and AZO Cranberry tablets were stuck to the side of the bottle with the sticky liquid in and on the boxes of medication that were stuck to the Lactulose bottle. In an interview on 04/25/2023 at 3:15 PM the DON stated that eye drops should be labeled with an open date when they are opened. The DON further stated that all medications on the carts should have readable labels with medications stored in a manner that keeps them clean and dry. The DON and carts should be checked by the Nurses during the medication pass to ensure no expired medications are on the carts to ensure residents are not receiving expired medications to might have altered therapeutic effects. Review of the facility's Policy Storage of Medications dated April 2021 reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater for when the facility had a medication error rate of 20% based on 7 of 35 opportunities, which involved 3 of 5 residents (Resident #2, Resident #11, and Resident #22) and 1 of 3 LVN's (LVN A) observed during medication administration. A) Resident #2 had a physician order for Preser Vision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools. LVN A failed to administer the medications. B) Resident #11 had a physician order for Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily. LVN A failed to administer the medications. C) Resident #22 had a physician order for Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily. LVN A failed to administer the medications. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications. Findings Include: A) Review Resident #2 Face sheet dated 04/27/2023 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnosis Cataract (a clouding of the lens of the eye or of its surrounding transparent membrane that obstructs the passage of light), Chorioretinal scars (a pigmentary change in the back of the eye that may result from an infection, injury, or inflammation), and Vitreous degeneration (a change or deterioration of the vitreous humor, the gel-like substance that fills the inside of the eye and helps with vision and eye shape). Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 12 indicating mild cognitive impairment. Resident #2 was assessed to require extensive to dependent assist with all ADLs. Review of Resident #2's Comprehensive Care Plan reflected a focus area dated 04/14/2021 Resident has impaired visual function related diagnosis of glaucoma and history of cataracts Review of Resident #22 Consolidated Physician dated 04/27/2023 reflected an order for PreserVision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools. Observation on 04/26/2023 at 8:33 AM revealed LVN A preparing Resident #2's 9:00 AM medication for administration. The medications included the following: -Myrbetrig 50 mgER on e tab -Docusate Sodium 100 mg one capsule -Fexofenadine Hydrochloride 180 mg one tablet -Vitamin D3 25mcg (1000 IU) two tabs -Multi vitamin with minerals one tab -Tussin DM Liquid 10-200mg/ML 10 MLS LVN A did not administer Resident #2's PreserVision AREDS 2 capsule one by mouth two times daily and Probiotic capsule one capsule by mouth one time day for loose stools. B) Review of Resident #11's Face sheet dated 04/27/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening.), Diabetes Mellitus Type II (a chronic disease where the body has high blood sugar, insulin resistance, and relative lack of insulin), Pressure ulcer of Sacral Region. Review of Resident #11's Significant change in status MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 9 indicating he had mild cognitive impairment. Resident #11 was further assessed to require extensive assist with all ADLs. Review of Resident # 11's Consolidated Physician dated 04/27/2023 reflected an order for Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily. Observation on 04/26/2023 at 8:40 AM revealed LVN A preparing Resident #11's 9:00 AM medication for administration. The medications included the following: -Pro-state liquid 30 ML -Ciprofloxacin 500 mg one tablet -Hydrocodone/ Apap 5-325mg one tablet -Gabapentin 300 mg one tablet -Famotidine 20 mg tablet -Amlodipine 5mg one tablet -Labetalol 100 mg one tablet - Decubi-Vit oral capsule one tablet LVN A did not administer Resident #11's Potassium Chloride Oral Packet 20 MEQs give 2 packets by mouth two times daily and Probiotic capsule one by mouth three times daily. C) Review of Resident #22's Face sheet reflected a [AGE] year-old female admitted on [DATE] with the following diagnosis of Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Atherosclerotic heart disease (A condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall. Symptoms vary depending on the clogged artery.), and Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache). Review of Resident #22 Quarterly MDS dated [DATE] reflected Resident #22 was assessed to have a BIMS score of 4 indicating serve cognitive impairment. Resident #22 was further assessed to require extensive assist with all ADLs. Resident #22 was assessed to have coronary artery disease and Hypertension. Review of Resident #22's Comprehensive Care Plan reflected a focus area dated 09/05/2018, Resident has coronary artery disease interventions included Give all cardiac meds as ordered by the physician .Give meds for hypertension . Review of Resident #22 Consolidated Physician dated 04/27/2023 reflected an order for Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily. Observation on 04/26/2023 at 9:14 AM revealed LVN A preparing Resident #22's 9:00 AM medication for administration. The medications included the following: -Decubi-Vit one tablet -Buspirone 10mg one tablet -Eliquis 5mg one tablet -Hydroxyzine HCL 25 mg one tablet -Fluoxetine 10 mg one tablet -Memantine HCL 10 mg tablet LVN A did not administer Resident #22's Lisinopril 10 mg by mouth one time day, Aspirin 81mg chewable tablet one time daily, and Probiotic capsule one by mouth daily. In an interview on 10:38 AM LVN A stated after reviewing the medications given to Resident #2 that she did not administer her physician ordered PreserVision AREDS 2 or Probiotic capsule. LVN further stated after reviewing the medications given to Resident #11's that she did not administer his physician ordered Potassium Chloride or Probiotic capsule. LVN A further stated after reviewing the medications given to Resident #22 that she did not administer her physician ordered Lisinopril, Aspirin, or Probiotic. LVN A stated she thought she was checking off all the medications as she went but she must have missed some of the medications because she was nervous. In an interview on 04/26/2023 at 10:41 AM the DON stated she reviewed all the missed medications with LVN A. The DON stated LVN A stated she missed the medications and was not sure how. The DON stated she expected nurses who pass medication to follow the 10 rights of medication administration and to administer all the medications the resident's physician ordered . Review of LVN A's Licensed Nurse orientation/ Annual Skills/ Competency Checklist dated 05/18/2022 reflected she was checked off to have successfully completed Medication Administration. In an interview on 04/26/2023 at 1:46 PM the RNC stated he could not see how LVN A missed all those medications for Resident #2, #11 and #22 during her med pass when she could see them in PCC . The RNC stated he started an action plan and would re-train LVN A. Review of the facility's policy Administering Medications dated quarter 3 2021 reflected Medications shall be administered in safe and timely manner and as prescribed .medications must be administered in accordance with the orders, including any required time frame .The individual administering the medications must check the label carefully to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for one (Resident #2) of 15 residents reviewed for care plans. The facility failed to identify Resident #2's preference for wearing a hospital gown daily instead of her personal clothing. This failure put residents at risk for their preferences not to be honored and decreased quality of life. Findings included: Review Resident #2 Face sheet dated 04/27/2023 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnosis Cataract (a clouding of the lens of the eye or of its surrounding transparent membrane that obstructs the passage of light), Chorioretinal scars (a pigmentary change in the back of the eye that may result from an infection, injury, or inflammation), and Vitreous degeneration (a change or deterioration of the vitreous humor, the gel-like substance that fills the inside of the eye and helps with vision and eye shape). Review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 12 to indicate mild cognitive impairment. Resident #2 required extensive assistance by one staff member for dressing and personal hygiene. Review of Resident #2's care plan dated 03/10/2023 revealed Resident #2 required staff to assist me to choose simple comfortable clothing that enhances the resident's ability to dress self. Review of care plan did not include Resident #2's preference to wear a hospital gown instead of her personal clothing. In an observation and interview on 04/25/2023 at 9:57 AM, Resident #2 was in her wheelchair wearing a hospital gown. Resident #2 stated she just had a shower and said she asked to wear the hospital gown. Resident #2 pointed at her clothes in the cabinet in her room and said she had clothes but liked to wear the hospital gown because it was more comfortable. In a follow-up observation on 04/26/2023 at 9:10 AM, Resident #2 wore a hospital gown while watching TV in her room. In an interview on 04/26/2023 at 10:00 AM, the DON stated she was new to the facility and unsure of whether it was Resident #2's preference to wear a hospital gown or not. She stated she would check with staff and her documentation. She stated Resident #2 did have her own clothing to wear. In an interview on 04/27/2023 at 10:13 AM, CNA J stated Resident #2 preferred to wear a hospital gown because it was more comfortable for her. She stated Resident #2 said it made her feel cooler and Resident #2 felt like her clothes were too restrictive. She stated she was not sure if Resident #2's preference for a hospital gown was included on her care plan. In a follow-up interview on 04/27/2023 at 11:30 AM, the DON stated it was Resident #2's preference to wear a hospital gown instead of her clothing. She stated Resident #2's preference to wear a hospital gown was not on her care plan. She stated Resident #2's preference for wearing a hospital gown instead of her personal clothing should be on the care plan so anyone caring for Resident #2 knew that it was Resident #2's preference. She stated adding Resident #2's preference to wear the hospital gown to her care plan ensured the facility was not violating any dignity issues for Resident #2. In an interview on 04/27/2023 at 11:55 AM, the MDS NURSE stated Resident #2's preference for wearing a hospital gown over Resident #2's personal clothing should have been added to Resident #2's care plan. She stated she was not made aware of Resident #2's preference until recently and had not had a chance to add the information to Resident #2's care plan. She stated anytime there was change for a reference that affected their including resident preferences she tried to update their care plan immediately or within a day or two to ensure continuity of care among caregivers . She said not updating a residents care plan could result in confusion for a resident's preferences and needs not being met. Review of Care Plans, Comprehensive Person-Centered Policy dated Quarter 3 2018 revealed a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further revealed the care planning process will . Incorporate the resident's personal and cultural preferences in developing the goals of care.

Based on observation, interview and record review the facility failed to provide a therapeutic diet as prescribed by the attending physician for one (Resident #15) of eight residents reviewed for therapeutic diet. The facility failed to provide Resident #15 with the therapeutic diet as prescribed by her attending physician when she was provided a meal with extra carbohydrate portions when she was prescribed a consistent carbohydrate diet order. This failure put residents at risk for health complications related to in adherence to diet order, increased blood sugar and decreased quality of life. Findings included: Review of Resident #15's Face Sheet dated 04/27/2023 revealed Resident #15 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnoses of pulmonary disease (disease of the lungs that causes trouble breathing), type 2 diabetes, high blood pressure, bipolar disorder (mood disorder in which mood alternates from manic to depression) and arthritis. Review of Resident #15's quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of two to indicate severely impaired cognition. Resident #15 was noted to required a therapeutic diet. Review of Resident #15's Care Plan dated 06/23/2022 revealed Resident #15 had diabetes mellitus with the goal of no complication related to diabetes through review date. Resident #15 had interventions including dietary consult for nutritional regimen and ongoing observation, discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan and compliance with nutritional regimen. Review of Resident #15's Physician Orders dated 03/15/2023 revealed Resident #15 was ordered a Consistent Carbohydrate diet, regular texture and regular consistency. In an observation on 04/25/2023 at 12:25 PM, Resident #15 was in the dining room eating a dinner roll. Additionally on Resident #15's tray there were two pieces of fried fish, white rice and pasta salad. Review of Resident #15's tray card dated 04/25/2023 revealed Resident #15 received CCHO (Consistent Carbohydrate) diet, Finger Foods and thin liquids. In an interview on 04/27/2023 at 11:18 AM, the DM stated Resident #15 received the pasta salad as a finger food selection as it would be easier for Resident #15 to feed herself than the zucchini or rice offered with the regular meal. When asked if the rice, pasta salad and dinner roll included with the meal was consistent with a CCHO diet order, she said no the pasta salad should have been substituted for the rice and an alternative offered with the meal besides a starch. She stated Resident #15 received more carbohydrates with her meal that residents with a regular diet order. In an interview on 04/27/2023 at 11:30 AM, the DON stated the therapeutic diet for Resident #15 should have been followed in that Resident #15 was ordered a consistent carbohydrate diet and should be served less carbohydrates than residents on a regular diet. She stated the addition of pasta salad with rice, fried fish and a dinner roll was consistent with professional guidelines for a consistent carbohydrate diet order. She stated failure to serve the physician ordered therapeutic diet could result in Resident #15 experiencing high blood sugar and poor control of Resident #15's diabetes mellitus. In an interview on 04/27/2023 at 11:41 AM, the RD stated she could not determine whether Resident #15 was served the physician ordered consistent carbohydrate diet when she was served pasta salad, rice, fried fish and a dinner roll . She said she did not know if the food served was consistent with professional guidelines for a consistent carbohydrate diet. She stated she did not know if serving more starch food choices to a resident on a consistent carbohydrate diet than residents on a regular diet was within professional guidelines. She stated she did not know what the outcome might be if a diabetic resident was served more starch foods than a resident on a regular diet that is not diabetic. Review of Resident #15's quarterly Nutrition assessment dated [DATE] revealed Resident #15 was ordered a consistent carbohydrate diet (CCD) with no significant weight gain or loss recently. Review of Diet Abbreviations and textures (undated) revealed CCHO-Consistent Carbohydrate-Diabetic-No sugar.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of one resident reviewed for catheter care (Resident #11). The facility failed to ensure Resident #11's catheter was secured to his body with a catheter secure device. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings Included: Review of Resident #11's Face sheet dated 04/27/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening.), Diabetes Mellitus Type II (a chronic disease where the body has high blood sugar, insulin resistance, and relative lack of insulin), Pressure ulcer of Sacral Region. Review of Resident #11's Significant change in status MDS dated [DATE] reflected Resident #11 was assessed to have a BIMS score of 9 indicating he had mild cognitive impairment. Resident #11 was further assessed to require extensive assist with all ADLs. Resident #11 was assessed to have an indwelling catheter. Review of Resident #11's Care Plan reflected a focus area initiated on 01/27/2023 and revised on 04/21/2023 Alteration in elimination of bowel and bladder related to incontinent of bowel and indwelling foley catheter, has history of UTI and the potential for recurrence. Interventions included .Anchor catheter, avoid excessive tugging on the catheter during transfer and delivery of care . Review of Resident #11's History and Physical dated 03/17/2023 reflected Resident #11 had history of chronic foley catheter and history of penis damage from foley. Observation on 04/26/2023 at 2:00 PM revealed Resident #11 in room in bed. Resident #11 had a Foley Catheter in place without a device to secure the catheter to his leg. Observation and interview on 04/27/2023 at 9:29 AM revealed Resident #11 in room in bed. Observation with the DON revealed resident with no catheter secure device was in place. Further observation revealed Resident #11's meatus and glans (penis) were split from the tip of the glans to base. The DON stated the resident should have a catheter secure device in place in prevent further injury to his glans. The DON stated it was the nurse on duty responsibility to ensure catheter care is done and to ensure the catheter secure device is in place . In an interview on 04/27/2023 at 9:49 AM LVN A stated she was responsible for catheter care and to ensure catheter secure devices are in place. LVN A stated she did not notice that Resident #11 did not have a catheter secure device in place. LVN A stated there should have been one but usually they have an order for it, and she did not see one . In an interview 04/27/2023 at 9:51 AM the DON stated the nursing staff should ensure the catheter secure devices are in place for residents with indwelling urinary catheters and the devices should be checked regularly. The DON further stated that the lack of the catheter secure device could cause further penis damage and or infections. Review of the facility's policy Catheter Care, Urinary dated 3rd Quarter 2018 reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: Catheter tubing should be strapped to the resident's inner thigh.) .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 32 of 32 residents review for infection control. (Resident #1 to #32) A) The facility failed to properly screen all staff and visitors entering the building and staff failed to wear full Personal Protection Equipment (PPE) while on a COVID isolation unit. B) The facility failed to properly store ice scoop. Scoop was exposed sitting on ice cart railing on COVID isolation unit. C) The facility failed to ensure soiled and clean linen were washed, dried, folded and stored separately. This deficient practice could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: A. Observation on the Covide-19 unit on 10/27/2020 at 5:30 AM revealed, Nurse B opened door for this surveyor. No temperature screening or health questionnaire performed. Interview on 10/27/2020 at 6:55 AM Nurse A stated she has been with the parent company for 2 years. When asked if he usually dons PPE prior to having his temperature checked and health screening performed, he responded that he was on vacation last week and that as soon as he walked in the door someone told him state (surveyors) was here and he hurried up to throw all his PPE on. Interview on 10/27/2020 at 7:00 AM Nurse B was asked if it's common practice to go to temperature screening and health questionnaire for employees coming on shift after they have already entered the building and donned their PPE? Nurse B replies, Well he was supposed to come to me and let me know that he was here. She stateed that she understands employees need to be screened as soon as they come through the door . Interview on 10/27/2020 at 7:35 AM Housekeeping C stated he has been employed [AGE] years at this facility. He stated his role at the facility was to make sure all the floors are always clean and to clean the bathrooms daily on the COVID-19 unit. Surveyor inquired as to why he did not get his temperature taken right away. Housekeeping C stated because he rode his bike to work he would have to wait until his body warns up to get a more accurate reading. Observation on 10/27/2020 at 1:05 PM Housekeeping D was sitting in chair wearing a face mask and face shield but not wearing a gown or gloves by the plastic divider on the COVID-19-unit side of the facility. Housekeeping D replies that he knows he is not wearing gloves or a gown, but he is just sitting there not doing anything. Surveyor started to ask if he understands why and he stated, Yeah I understand and that I have to wear them. Upon entery into the facility 10/27/2020 at 5:30 AM on the non-COVID unit Nurse E opened the door to allow surveyor to enter building. No temperature was taken, or health questions asked of surveyor. Observation on 10/27/2020 at 5:33 AM Resident Care Specialist F was observed wearing shield on top of her head instead of it worn properly in front of her face. She wore her medical mask below her nose. Interview on 10/27/2020 at 6:13 AM Resident Care Specialist F stated she had worked at the facility for a few months and that she worked on the other side of the building but came to the negative side when they put up the plastic barriers. When asked why she was wearing shield on top of her head, Resident Care Specialist F stated she can't see thru the shield or goggles because they fog up. She repositioned her mask with her hand. Review of document provided by the DON for policy dated October 2, 2020 reflected the following in part: As of May 14, full PPE is recommended in the following areas: Admission units Observation units Dedicated areas where residents with suspected or confirmed COVID-19 are located, and, Other units as directed by local/state health departments. Recommended PPE: Admission Units, Observation Units & Suspected or Confirmed COVID-19 The PPE recommended when caring for a resident on an admission unit, an observation unit, or a resident with suspected or confirmed COVID-19, regardless of the presence of symptoms includes: N95 Respirator/ The center should implement extended use of N95 respirators. N-95 masks may remain in place between symptomatic and asymptomatic residents unless soiled or damaged. Eye protection/ The center should implement extended use of eye protection. Eye protection may remain in place between symptomatic and asymptomatic residents unless soiled or damaged. Reusable eye protection (e.g., goggles, face shields) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Gloves/ Gloves are in adequate supply and conventional use of gloves by staff should be the practice at this time. Gowns/Use disposable or cloth gowns when providing direct care to residents requiring transmission-based precautions or when splash and/or spray is anticipated per Standard Precautions. Page 16 and 17 reflected: Screening Process for Visitors A licensed nurse will screen all visitors (those allowed to enter based on above exception) at each visit. The screening will assist in determining whether any of the following mandatory restriction criteria is met. A screening tool has been created to use for all screenings that includes specific questions regarding presence of symptoms and potential exposure to COVID-19. Note: Center leadership should consult with the DDCS for assistance in establishing a plan for screening in the temporary absence of a licensed nurse in the screening process. As part of the screening process, visitors will identify whether they have worked in a nursing facility, medical office, or other healthcare setting that has confirmed COVID-19 cases in the past 14 days. This information will be evaluated as part of the screening process to determine ability to visit. If a visitor answers a positive response to one or more questions, that alone does not warrant sending someone home, unless fever is present. The Infection Preventionist or licensed nurse should review the screening tool and discuss the findings with the individual. The Infection Preventionist or licensed nurse should make the decision on whether the person can work/enter the facility and should document their clinical reasoning. Completed screening tools will be maintained in a binder or in a folder for documentation purposes. Surveyor Entry In the event of surveyor entry, conduct the visitor screening per the memo guidance. If the surveyor indicates that they had potential or known contact with COVID-19 and used PPE appropriately during that contact, the surveyor is considered to pose a low risk to transmission and must be granted access. Document the findings of the screening and the statement of the proper use of PPE on the screening form. Surveyors may not enter a facility if they have a fever. Page 18 reflected: Agency representatives must follow infection control practices, including being screened wearing a face mask while at the center, performing hand hygiene when entering and leaving the center, social distancing, etc. Employee and Essential Healthcare Screening Center staff, agency personnel and other essential healthcare personnel must be screened on entrance and/or at the beginning of their assigned Shift and 'prior to working with residents by the Infection Preventionist or a dedicated charge nurse. An employee screening log will be used to document essential healthcare personnel, staff, agency, and facility-assigned staff responses. (Use the employee screening log in this tool kit.) Page 19 reflected: The screening will include a temperature check (fever is considered >100F) and documentation of absence of cough, shortness of breath, chills, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. This list does not include all possible symptoms. CDC will continue to update this list as more is learned about COVID-19. The facility must actively screen facility, agency staff and essential health care providers who have worked in or entered other facilities with suspected or confirmed CO VI D-19, and restrict them appropriately to reduce the spread of COVID-19 and/or respiratory illness. The screening tool includes questions regarding whether the employee works/has worked at another nursing facility, center, or medical practice where suspected or confirmed cases of COVID-19 are present. TEXAS Specific: Institute a practice to screen employees twice a shift (once upon entrance to the facility and a second screening during their shift). Please use the employee screening log for employee screening. Review of Screening Questions for Visitor/Vendor/Surveyor Effective date August 5, 2020 reflected questions to include: Visitor/Vendor/Surveyor: To help ensure the safety of our residents and healthcare workers, visitation is restricted. A nurse will assist you with questions regarding the information on this form. This form is required for all visitors during [MEDICATION NAME] care situations, for vendors, and for surveyors. 1. Have you completed hand hygiene by washing your hands or using alcohol-based hand rub (ABHR) upon entry to the center? 2. Do you have, or have you had in the past 24 hours, any of the following symptoms? Presence of a fever will prohibit visitation even if other symptoms are not present. Cough, Shortness of Breath, Fever, Diarrhea, Sore Throat, Chills, Repeated shakes with chills, Muscle Pain or body aches, Headache, Nausea and/or Vomiting, New onset of loss of taste or smell, Congestion or runny nose or None of the above. If any of the items are checked, a licensed nurse must evaluate for other plausible causes (i.e., Asthma, allergies [REDACTED]. Based on the evaluation results, the visitor may be prohibited from entry. 3. Temperature (A fever is defined as a temperature >100F) U Record reading. 4. In the past 14 days, have you had any contact with any person with known Coronavirus COVID-19 or who may be under evaluation for exposure to Coronavirus COVID-19 or who is ill with respiratory illness? 5. In the past 14 days, have you worked in a nursing facility, medical office, or other healthcare setting that has confirmed COVID-19 cases? 6. Have you, or anyone you have had contact with, traveled internationally within the past 14 days? For visitors, if no, the facility must educate the visitor on items 1 -7. If vendor or surveyor, educate on item #7 only: 7. Self-monitor for signs and symptoms of respiratory infection for 14 days after exiting the facility. If symptoms occur, self-isolate at home, contact your health care provider, and immediately notify this facility of the date you were in here, the individuals you were in contact with and the location within the facility you visited. Review of Employee and Essential Healthcare Personnel Screening Log dated 5/4/20 reflected screening questions including: 1) Temperature check 2) Have you had in the past 24 hours, any of the following symptoms? Cough, Shortness of Breath, Fever, Congestion, runny nose, Diarrhea, Sore Throat, Chills, Rigors, Muscle Pain or body aches, Headache, Nausea and/or Vomiting, New loss of taste or smell? 3) Have you taken any fever reducing medication containing Tylenol, [MEDICATION NAME], or cold and sinus medication with-in the past 24 hours? 4) Have you or anyone you have had contact with, traveled internationally in the past 14 days? 5) In the past 14 days have you had any contact with any person with known coronavirus COVID-19 or who may be under evaluation for exposure to COVID-19 or is with respirator illness? 6) In the past 14 days have you worked in or entered a facility with suspected or confirmed COVID-19 infections. IF yes, did you wear proper PPE? 7)Is there evidence of COVID-19 exposure? 8) Instruction Handout Reviewed/Provided 9) Nurses name completing the screening- Utilize clinical judgment and the guidelines. B. Observation on 10/27/2020 at 12:15 PM revealed a white scoop for ice sitting on the backside rail on the ice chest cart on the COVID unit and was not bagged or sealed. In an interview on 10/27/2020 at 12:55 PM Nurse G stated, He states his expectation is that the ice scoop should be in a plastic bag secured to the side of the ice chest. Observation on 10/27/2020 at 12:58 PM Nurse G was walking up to Resident Care Specialist H and explained to her that the ice scoop needs to be in a plastic bag instead of being left out in the open getting contaminated. Review of Infection Prevention Manual- Ice Chest and Ice Machines revision dated 2/2018 page 28 reflected to include: Purpose: To ensure resident safety in use of ice and ice machines. POLICY: The following policy should be followed to reduce the likelihood of contamination of ice chests (ice storage compartments) and ice machines: I. Ice machines that dispense ice directly into portable containers at the touch of a control provide a more sanitary method to store and obtain ice than use of ice chests. II. Access to ice chests and machines should be limited. III. All ice handlers should be taught the following precautions: A. Perform hand hygiene before obtaining ice. B. Hold scoop used with ice chest by handle; do not touch bowl surface with hands. C. Do not handle ice with hands. D. Do not return unused ice to an ice storage chest. E. Do not leave ice scoop inside ice storage chest. F. Keep access doors to chests closed except when removing ice. IV. Ice scoops used should be smooth and impervious and should be kept on an uncovered stainless steel, impervious plastic or fiberglass tray on top of the chest or in a mounted holder when not in use. The tray or holder and the scoop should be run through a dishwasher daily or otherwise disinfected every 12-24 hours. VII. Conduct microbiologic sampling of ice, ice chests, and ice-making machines and dispensers where indicated during an epidemiologic/outbreak investigation. C. Observation of laundry room on 10/24/2020 at 11:45 AM revealed there was no seperation between the washer area and dryer area. Observation of clean clothes (socks, underwear, small items) were stored in small gray bins that sat directly in front of the washers and also sat next to a sink where staff wash hands in the laundry room. Laundry Aide M was wearing a gown, mask and her shield was worn on top of her head while working with the linens. In an interview on 10/24/2020 at 11:56 AM Laundry Aide M stated Laundry is handed off between the plastic barrier just like food is distributed. The disposable bags of COVID laundry are handed off through the plastic barrier from a dirty tub to a clean tub. She takes the (now dirty tub) to the sorting room. After sorting, the tubs of linens are brought in the door to the washers and dryers, on the entrance side of the laundry room and loaded into the washers. She states once the tub of linens goes into the laundry room she removes it from the tub (s) places it (linens) into the washer and then sanitizes the tub before it goes back out of the room. From the washer it (linens) goes into the dryer, from the dryer and once completed folding or hanging, laundry goes back to the zipper where it is handed to the staff on the (COVID) positive side for laundry to be returned. She stated she moves her shield up (top of head) because it fogs up and makes it hard to see. When asked she stated, Regular laundry does not go in a disposable bag. In an interview on 10/27/2020 at 7:01 AM Laundry Aide L Laundry Aide L stated, we washed linens are placed on the gray open bins and then tranfered to residents residing on both covid-19 postive and non covid-19 side of the building. In an interview and observation 10/27/200 at 7:10 AM Laundry/Housekeeping Manager stated full PPE which means gown, shield and masks hould be should be worn by staff when they are working in the Laundry room. While interviewing Manager observations revealed Laundry Aide L in the laundry room handling clean linen without faceshield on. During interview outside the laundry exit door we observed Laundry/Housekeeper Aide L had just gotten done with washing her whites and they were in a yellow bin that she just moved out of the way towards the washer and was cleaning the lint from the dryer, is that correct process? Supervisor said Yes, but she should be wearing a mask, shield and gown. When asked, should everybody be in full PPE when they're working laundry in this room (laundry room) at least a gown, mask and shield and it is worn all day long by your staff? Her response was Yes. When asked if the laundry was always in this room she responded, I have been here [AGE] years and it's (laundry) has always been in his room. In an interview on 10/27/2020 at 10:00 AM Director of Facility Engineering, Craig Sharp stated, There are no seperation between the washers and dryers due to the age of the building, I believe it was built in 1958 but we can accommodate that. In an interview on 10/27/2020 at 10:02 AM DON stated her expectation is that policy should be followed for screening all staff and visitors. That all ice scoops should be kept in a tray mounted on cart when not in use. DON was not aware that the washer and dryer needed to be seperated where washing dirty linens, drying, folding and storing clean linens were processed in the same room. Interview on 10/27/2020 at 10:15 AM Administrator stated that everyone that comes into the building be screened properly. She states that her expectations of the ice scoops should be properly stored. The administrator stated, she was not aware that the washer and dryer needed to be seperated where washing dirty linens, drying, folding and storing clean linens were processed in the same room. Administrator stated she did not know that the washer and dryer needed to be seperated where washing, drying, folding and storing clean linens were processed. Review of document provided by Administrator labeled Laundry In-Service dated 5-49-- 1/1/2000 reflected the following: PURPOSE: To ensure that soiled linen is handled properly on the units and in the Laundry. Handling Soiled Linen on Units: There should be Soiled Linen containers on each unit. This is where Nursing will place soiled linens as they finish caring for residents. These containers must be lined with an impervious liner to prevent leaks or breaks. Soiled linen must be picked up at scheduled times so linen does not accumulate beyond what the containers can handle. Laundry personnel must use proper personal protective equipment when pulling the soiled linens from the floor (gloves, apron, goggles, etc.). A cart designated only for soiled linen must be used to pull the linen from the floors. This linen cart should be large enough to hold the linen from several containers and must have a cover when moved through patient areas. On the unit, open one container at a time. Tie off the bag in that container. Remove the bag and place in the Soiled Linen cart. Replace liner with clean liner. Repeat this process until all containers are empty or the Soiled Linen cart is fill. Do not load the Soiled Linen cart to the point where the lid does not close Transport Soiled Linen cart to Soiled Linen Room in Laundry. Review of Infection Prevention Program Overview, revision dated 2/2018 reflected the following to include: I. GOALS The goals of the infection prevention program are to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection by: A. Decreasing the risk of infection to residents and personnel. B. Monitoring for occurrence of infection, implementing appropriate control measures, and incorporating Antibiotic Stewardship practices. C. Identifying and correcting problems relating to infection prevention practices; and, D. Maintaining compliance with state and federal regulations relating to infection prevention. II. SCOPE OF THE INFECTION PREVENTION PROGRAM The infection prevention program is comprehensive, based on the individual facility assessment and accepted national standards, in that it addresses identification, detection, prevention, investigation, control, and reporting of communicable diseases and infections among residents and personnel. The scope of services depends on the resident population, function, and specialized needs of the healthcare facility. THE MAJOR ACTIVITIES OF THE PROGRAM ARE: A. SURVEILLANCE OF INFECTIONS WITH IMPLEMENTATION OF CONTROL MEASURES AND PREVENTION OF INFECTIONS There is on-going monitoring for communicable diseases and infections among residents and personnel and subsequent documentation of infections that occur. Prevention of spread of infections is accomplished by use of hand hygiene, standard precautions, transmission-based precautions, as indicated, and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness. Staff and resident education focuses on risk of infection and practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment. Immunizations are offered as appropriate to residents and personnel to decrease the incidence of preventable infectious diseases. B. OUTBREAK INVESTIGATION Systems are in place to facilitate recognition of increases in infections as well as clusters and outbreaks. E. STAFF EDUCATION Training of staff in infection prevention begins with orientation of new hires and occurs at least annually. F. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI) Infection prevention is a component of the facility's quality assurance program and infection prevention reports are made to the QAPI committee. In addition, infection prevention rounds are made to assess the level of quality provided and actions for improvement are taken as needed. G. CONSULTATION The infection Preventionist serves as a resource for all staff and all departments relating to prevention of infections. III. DIVISION OF RESPONSIBILITIES FOR INFECTION PREVENTION ACTIVITIES The administrator/chief executive officer is ultimately responsible for the infection prevention program. A. INFECTION PREVENTIONIST Responsibility is delegated to the Infection Preventionist (IP) to carry out the daily functions of the infection prevention program. Those functions are described in the IP job description. The IP has knowledge, competence, interest in infection prevention, and appropriate qualifications. B. Employee infections and exposures to bloodborne pathogens or communicable diseases are reported by the employee to the employee's supervisor.

Based on observation, interview and record review the facility failed to ensure it was free of medication error rates of five percent (%) or greater. There were 2 errors in 26 opportunities resulting in a 7.69 % error rate administering medication for two of four residents (Residents #9 and #15) LVN A failed to administer medications to Resident #15 as ordered by her physician. LVN B failed to administer medications to Resident #9 as ordered by her physician. These failures could affect all residents who LVN A and LVN B administered medications to, by placing them at risk for receiving less than therapeutic benefits from medications. The findings include: [NAME] Resident #15 Review of the clinical record for Resident #15 reflected an [AGE] year-old female with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #15's most recent MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no impairment. Review of Resident #15's Care Plan revealed resident had ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, [MEDICAL CONDITION], poor endurance, pain. Review of the physician orders [REDACTED]. Observation on 10/16/2019 at 8:16 AM during medication administration reflected, LVN A gave Resident #15 Aspirin 81mg EC ([MEDICATION NAME] coated) 1 tablet PO. In an interview on 10/16/19 at 11:00 AM LVN A stated she gave Resident #15 Aspirin 81mg [MEDICATION NAME] coated because the order did not say to crush the medication. She also stated if the order says crushed then she would have given Aspirin 81mg chewable. She later stated the order should have indicated Aspirin 81mg EC before the nurses give the EC tablet to Residents. B. Resident #9 Review of the clinical record for Resident #9 reflected an [AGE] year-old female with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #9's most recent MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Review of Resident #9's Care Plan revealed resident had ADL self-care performance deficit related fluctuating cognitive impairment. Review of the physician orders [REDACTED]. Observation on 10/16/2019 at 8:39 AM during medication administration reflected LVN B gave Resident #9 Aspirin 81mg EC ([MEDICATION NAME] Coated) 1 PO. In an interview on 10/16/19 at 11:11 AM LVN B stated she gave Resident #9 Aspirin 81mg EC PO. She also stated the order did not say EC, and she guess the order should have indicated EC. She also stated the order doesn't indicate chewable or [MEDICATION NAME] coated either. In an interview on 10/16/19 at 11:52 AM the ADON stated for Aspirin, usually the order will indicate chewable or [MEDICATION NAME] coated. She also stated she is not sure why [MEDICATION NAME] coated medications are given. She later stated if there is no specific on the order, she assume it is [MEDICATION NAME] coated. In an interview on 10/16/19 2:02 PM the DON stated when there is an order for [REDACTED]. Review of facility Medication Error Policy revised (MONTH) (YEAR) reflected, medication error means any preventable event that may cause or lead to inappropriate medication use, inaccurate medication administration, or harm while the medication is in control of the health care professional and/or resident. An event of medication error may be related to oversights in: --Professional practice, procedures and systems, including prescribing; --communication/transmission of orders; --product labeling; --packaging or nomenclature Review of facility General Dose Preparation and Medication Administration policy revised on 01/01/2013 reflected; --facility staff should verify that the medication name and dose are correct and should inspect the medication for contamination, particulate matter

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assure the accurate receiving of medications for one (1) of five (5) residents observed on medication pass medication (Resident #6) by one (1) of two (2) LVNs observed for medication pass (LVN Z). Resident #6 had physician orders [REDACTED]. LVN Z was observed during a medication pass on 08/03/16 omitting administering the Glipizide 5 mg. because it was unavailable. These deficient practices could affect residents receiving physician ordered Glipizide by placing them at risk for delayed physician ordered medical treatments and worsening of medical conditions. The Findings Include: Review of a Face Sheet for Resident # 6 reflected she was [AGE] years old with an original admission date of [DATE] with diagnoses' that included Type II Diabetes Mellitus, Dementia, Primary Hypertension, Anxiety and Psychosis. Review of a Quarterly MDS for Resident #6 dated 07/18/16 reflected she had minimal cognitive impairment and required assistance of one to two staff for activities of daily living, with the exception of eating that required supervision only. Review of a care plan for Resident #6 dated 07/18/16 reflected she was on a low concentrated sweets/low refined carbohydrate mechanical soft diet for Diabetes. Interventions included administer Diabetes medications (oral and injectable) as ordered and monitor blood glucose four times daily and as needed. Review of physician orders [REDACTED]. -Glipizide 5 mg. one table twice daily for Diabetes at 7:30 and 4:30 PM -Metformin HCL Tablet 1000 mg. with meals at 7:00 AM and 5:30 PM -Insulin Regular Human Solution 100 units/ml inject as per sliding scale for Diabetes Mellitus -Blood glucose levels 161-180 give units of insulin An observation on 08/03/16 at 8:30 AM revealed LVN Z preparing medications for a medication pass for Resident #6. During the observation LVN Z stated she knew Resident #6's Glipizide 5 mg. was scheduled for 07:30 AM, but she was still within the one hour before or after time since it was 8:30 AM. As LVN Z started preparing the medications she realized could not find Glipizide 5 mg. tablets on the cart or in the medication room. LVN Z confirmed the medication had been ordered from the pharmacy on 08/01/16 and that the last dose was given on 08/02/16 at 4:30 PM. An observation on 08/03/16 at 11:50 AM during an observed medication pass revealed LVN Z performing a schedule finger stick blood glucose monitoring test for Resident # 6. Resident #6 stated she did not feel well and had vomited in the past 15 minutes. There was vomitus visible on her pants and shoes. The glucose monitor reading for Resident #6 was 162 mg/dl (normal levels after a meal are 140 or less). LVN Z then administered 3 units of Humulin insulin according to the physician orders [REDACTED]. In an interview on 08/03/16 immediately after LVN Z administered the 3 units of Humulin insulin to Resident #6, LVN Z stated Resident # 6 very seldom required sliding scale insulin at lunchtime. LVN Z added missing the morning dose of Glipizide 5 mg. could have contributed to Resident #6's elevated blood glucose. LVN Z stated she had not contacted the pharmacy regarding Resident #6 Glipizide to determine the medication had not been delivered. In an interview on 08/03/16 at 5:00 PM the DON stated the facility recently changed to ordering all medications electronically rather than via fax. The DON stated Resident #6's Glipizide 5 mg. was ordered on [DATE] and should have been delivered on 08/02/16, but it wasn't. The DON stated it was the expectation that LVN Z call the pharmacy and ask for an emergency delivery when she noticed the medication was unavailable and a dose was due. The DON also stated she was in the process of completing a Medication Error Report for Resident #6. The facility provided a printout of the computer module for medication orders, but did not have a policy. The DON provided a facility census of one resident currently receiving intramuscular injections and three residents currently receiving Glipizide.

Based on observation, interview, and record review the facility failed to ensure that it was free of medication error rates of five percent or greater for one (1) of one (1) medication administration via intramuscular injection observed and one (1) of one (1) oral diabetic medication omission by one (1) of two (2) LVNs observed for medication pass (LVN Z). A Resident #6 had physician orders [REDACTED]. LVN Z was observed during a medication pass on 08/03/16 omitting administering the [MEDICATION NAME] 5 mg. because it was unavailable. B. Resident #11 had physician orders [REDACTED].(an antibiotic) intramuscular and LVN Z did not administer an injection according to standard nursing practice, when she gave the injection in the lower and inner portion of the right buttocks and close to the sciatica nerve. These deficient practices could affect one resident currently receiving intramuscular medications by placing them at risk for injury to the sciatica nerve causing possible pain, leg weakness, and permanent nerve damage and/or cause an abscess to develop due to injections given in a site with poor absorption; and three residents receiving physician ordered [MEDICATION NAME] by placing them at risk for elevated blood sugars requiring additional physician ordered interventions, and possible worsening of Diabetes and related medical conditions. The Findings Include: A. Review of a Face Sheet for Resident # 6 reflected she was [AGE] years old with an original admission date of [DATE] with diagnoses' that included Type II Diabetes Mellitus, Dementia, Primary Hypertension, Anxiety and [MEDICAL CONDITION]. Review of a Quarterly MDS for Resident #6 dated 07/18/16 reflected she had minimal cognitive impairment and required assistance of one to two staff for activities of daily living, with the exception of eating that required supervision only. Review of a Care Plan for Resident #6 dated 07/18/16 reflected she was on a low concentrated sweets/low refined carbohydrate mechanical soft diet for Diabetes. Interventions included administer Diabetes medications (oral and injectable) as ordered and monitor blood glucose four times daily and as needed . Review of physician orders [REDACTED]. -[MEDICATION NAME] 5 mg. one table twice daily for Diabetes at 7:30 and 4:30 PM -[MEDICATION NAME] HCL Tablet 1000 mg. with meals at 7:00 AM and 5:30 PM -Insulin Regular Human Solution 100 units/ml inject as per sliding scale for Diabetes Mellitus -Blood glucose levels 161-180 give units of insulin An observation on 08/03/16 at 8:30 AM revealed LVN Z preparing medications for a medication pass for Resident #6. During the observation LVN Z stated she knew Resident #6's [MEDICATION NAME] 5 mg. was scheduled for 07:30 AM, but she was still within the one hour before or after time since it was 8:30 AM. As LVN Z started preparing the medications she realized she could not find [MEDICATION NAME] 5 mg. tablets on the cart or in the medication room. LVN Z confirmed the medication had been ordered from the pharmacy on 08/01/16 and that the last dose was given on 08/02/16 at 4:30 PM. An observation on 08/03/16 at 11:50 AM during an observed medication pass revealed LVN Z performing a schedule finger stick blood glucose monitoring test for Resident # 6. Resident #6 stated she did not feel well and had vomited in the past 15 minutes. There was vomitus visible on her pants and shoes. The glucose monitor reading for Resident #6 was 162 mg/dl (normal levels after a meal are 140 or less). LVN Z then administered 3 units of [MEDICATION NAME]according to the physician orders [REDACTED]. Observation of LVN Z's medication pass revealed two (2) medication errors out of 25 observed passes for a total medication error rate of 5%. In an interview on 08/03/16 immediately after LVN Z administered the 3 units of Humalin insulin to Resident #6, LVN Z stated Resident # 6 very seldom required sliding scale insulin at lunchtime. LVN Z added missing the morning dose of [MEDICATION NAME] 5 mg. could have contributed to Resident #6's elevated blood glucose. LVN Z stated she had not contacted the pharmacy regarding Resident #6 [MEDICATION NAME] to determine the medication had not been delivered. In an interview on 08/03/16 at 5:00 PM the DON stated the facility recently changed to ordering all medications electronically rather than via fax. The DON stated Resident #6 ' s [MEDICATION NAME] 5 mg. was ordered on [DATE] and should have been delivered on 08/02/16, but it wasn't. The DON stated it was the expectation that LVN Z call the pharmacy and ask for an emergency delivery when she noticed the medication was unavailable and a dose was due. The DON also stated she was in the process of completing a Medication Error Report for Resident #6. B. Review of a Face Sheet for Resident #11 revealed he was [AGE] years old with an original admission date of [DATE] and diagnoses' that included Stroke with dominate side weakness, Urinary Tract Infection, [MEDICAL CONDITION], and Major [MEDICAL CONDITION]. Review of a Quarterly MDS for Resident #11 dated 06/27/16 reflected he had minimal cognitive impairment and required assistance of two staff for transfers, bed mobility and toileting. Review of a Care Plan for Resident #11 dated 08/01/16 reflected: resident has a urinary tract infection related to bowel incontinence and immobility. Interventions: Give physician ordered [MEDICATION NAME] 1gram intramuscular once daily for 5 days. Review of physician orders [REDACTED]. Reconstitute (mix to form a liquid) with 2.1 cc ' s of [MEDICATION NAME] HCL 1% ( a local anesthetic used to reduce pain or sensation at the site of injection). An observation on 08/03/16 during a medication pass revealed LVN Z administering a [MEDICATION NAME] 1 gram injection to Resident #6. LVN Z had Resident # 6 stand, cleansed the right buttock and then injected the medication on the mid portion of the right buttock and approximately 4 to inches below top of the gluteal folds and close to the sciatica nerve. LVN Z also did not displace the skin and subcutaneous tissue of the injection site in order to give the injection deep into the muscle. While administering the injection LVN Z stated she chose the injection site because it was soft. In an interview with the DON on 08/04/16 at 10:00 AM, the DON stated she did a skills check off with LVN Z for intramuscular injections due to the error in placement of the injection on 08/03/16. The DON stated it was her expectation that all licensed staff use proper technique in administering intramuscular injections to avoid injuries or complications. Review of the facility's Intramuscular Injection Procedure dated 07/10/15 reflected the following: Introduction: Intramuscular (IM) injections deposit medication deep into the muscle tissue and provide rapid systemic action and absorption of relatively large doses of medication. The site of the IM injection must be chosen carefully taking into consideration the patient's general health status and the purpose of the injection. Implementation: Locating the IM site: Have the patient sit, stand, or lie laterally. Locate the greater trochanter of the femur (a lateral part of the femur that gives attachment to the gluteal muscles. Then spread your index and middle fingers from the anterior iliac spine to as far as you reach. Displace the subcutaneous tissue by pulling the skin of the injection site laterally. The DON provided a facility census of one resident currently receiving intramuscular injections and three residents currently receiving [MEDICATION NAME]. - -

Based on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized when: The facility failed to maintain clinical records for One (1) of Seven Residents (Resident #4) when resident #4's physician prescribed [MEDICATION NAME] was not transcribed to the MAR. This deficient practice placed 45 residents at risk for not receiving care or services as ordered/prescribed by the physician. Findings Include: Review of Resident #4's Face Sheet reflected a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] reflected a BIMS score of six (6) indicating severe cognitive impairment. The assessment reflected Resident # 4 required two person extensive assistance for eating bed mobility. Review of Physician order [REDACTED]. Review of the June MAR for Resident #4 reflected the Physician order [REDACTED]. In an interview on 06/24/2015 at 4:45 PM LVN C stated she wrote the order and asked another staff member to transcribe to the MAR. LVN C further stated the transcription never took place. In an interview on 06/24/2015 at 5:15 P.M. The DON stated LVN C should have finished transcribing the order and not have asked another staff member to complete her work. Review of Physician order [REDACTED]. Physician orders [REDACTED]. Transcribing a Written Order 2. After noting an order, the receiving licensed nurse transcribes it in permanent ink on the MAR indicated [REDACTED] Review of the CMS-672 reflected a census of 45 residents.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (1) of two (2) medication rooms when the Emergency Intravenous (IV) Kit was left unlocked in the South Medication Room. This deficient practice placed 45 residents at risk for not having the emergency IV medications available when needed, potential diversion of the IV medications, and a decreased quality of life. Findings include: Observation on 06/24/2015 at 11:15 AM revealed the South Medication Room with an IV Emergency Kit that was not locked or secured with the zip tie. The Box contained the following medications: [REDACTED]. The Kit also contained the IV sets and dressing change kits. In an interview on 06/24/2015 at 11:20 AM the DON stated the IV Emergency Kit should be locked with the zip tie. She stated she expected staff to keep it secured when they are not using it. Review of the facility's policy entitled The Nurses' Infusion Manual for Long Term Care Facilities revised 08/15/2008 reflected the IV medications were the responsibility of the staff and should be stored appropriately. The facility provided a CMS Form 672 reflected 45 residents in the facility.

Based on observation, interview and record review the facility failed to store and prepare food under sanitary conditions for one (1) of one (1) main kitchen when: A) Dietary staff failed to properly date and label refrigerated foods in one (1) of one (1) walk-in refrigerators and one (Freezer #1) of two (2) freezers used for one (1) of one (1) main kitchens; B) Dietary staff failed to properly maintain the freezer by checking temperatures accurately to ensure proper freezing of items place in the freezer and that these items are held at temperatures of zero (0) degrees and below for one (1) of two (2) freezers used for (1) of one (1) main kitchen. C) Dietary staff failed to use sanitary procedures while performing meal service from one (1) of one (1) steam table. These deficient practices placed 44 residents who are served meals and snacks from the main kitchen at risk for nausea, diarrhea and stomach cramps due to food borne illness. Findings Include: A) Observation made on 06/23/2015 at 10:30 AM revealed there were three containers of food with tomato sauce, chicken noodle soup, and meatballs with gravy. The lids were not properly sealed. These food items were located to the immediate left as you walk into the the refrigerator on the second shelf. Observation on 6/23/15 at 10:45 AM in the walk in refrigerator revealed one 24 ounce yellow mustard container with the lid found opened and the item was dated 5/15/15 as opening date. Observation on 6/24/15 at 10:35 AM in the walk-in refrigerator revealed a container of green peas; the lid was not properly sealed. This observation also revealed one (1) half (1/2) gallon of opened cultured low fat milk in a carton, it was half empty with the Best By Date of 6/14/15, and seven (7) one half gallons of cultured low fat milk with expiration date of 6/22/15. During an interview on 6/24/15 at 10:40 AM Dietary Aide I stated the cultured low fat buttermilk in the walk in refrigerator was delivered this morning. Dietary Aide I stated she did not know all the milk was expired upon arrival. During an interview on 6/23/15 at 10:46 AM the Dietary Supervisor stated the lids on the containers are to be closed properly, and when the food has been found with lids not closed properly, the items are thrown away. I need to get my people to close lids properly and follow protocol. The Dietary Supervisor disposed of the foods where the lids had not been properly sealed today. During an interview on 06/24/2015 at 10:48 AM, the Dietary Supervisor stated with regard to the buttermilk being delivered already expired that he was calling the Area Manager for his vendor and having all the buttermilk replaced immediately. They were checking all the other milk and dairy products from this vendor to ensure they were fresh. Record review reflects the Dietary Operations, Cold Storage Areas policy, Revision Date February 2010 which stated: Policy: It is the policy to store food under safe and sanitary conditions. Fundamental Information: Refrigerators and freezers are designed to keep food cold enough to prevent or slow the growth of bacteria as well as preserve the freshness and quality of foods. Units work effectively and efficiently when maintained, cleaned, and serviced. Procedure: 1. Record and monitor temperatures of refrigerators and freezers at least three times daily on form Record of Refrigeration Temperatures (OP3 0210.03 A2) found on the Intranet web site. Temperatures must be monitored and recorded on all units in which food for resident consumption is stored (i.e., activity department and nourishment rooms). 2. Inspect refrigerators and freezers regularly for leaks, frozen areas, and dust on compressor units. Report problems/concerns according to the facility's preventative maintenance program. 3. Keep refrigerator and freezer doors closed at all times, unless in immediate use, to minimize temperature fluctuations . 6. Date and label all products removed from original containers. 7. Store cold foods until their use by date, expiration date. Refer to Storage Periods: Refrigerated Foods (OP3 0210.04) for guidelines for food without expiration dates . 13. Freezers should maintain foods in a frozen, solid state . B) Observation on 06/23/15 at 10:48 AM revealed Freezer #1 was working; however, Freezer #1 had temperatures of 50 degrees and 59 degrees on their two internal thermometers. These temperatures were taken and witnessed by dietary staff. Dietary staff had a thermometer hanging from the top right shelf and it was hardly readable. When the second door was open, there was a large brisket (estimated 30 pounds) shrink wrapped in its original packaging lying on top of several boxes of frozen ground beef. It was hard and still frozen in the middle but the ends and the sides had begun to thaw. In an interview with Dietary Supervisor on 06/23/2015 at 10:39 AM, he stated he had not noticed the temperature of Freezer #2 had risen again and this potential safety concern had not been reported it to him. The Dietary Supervisor stated he would have it repaired by maintenance and see if it could be added to a checklist for monitoring. Interview with the Dietary Supervisor on 06/23/2015 stated the Maintenance Supervisor had Freezer #1 had cooled down but he needs to recheck it. The Dietary Supervisor stated he would be moving all of the food from Freezer #1 to the larger Freezer #2. The brisket had been placed in the freezer on the previous work day; however, he disposed of the large brisket for potential safety reason. Dietary staff were seen moving the frozen foods from Freezer #1 to Freezer #2. Interview with the Maintenance Supervisor on 06/24/2014 at 10:30 AM stated he had the Freezer #1 working this morning and he was working with service technicians to coordinate repairs. Record review reflects the Dietary Operations, Cold Storage Areas policy, Revision Date February 2010 which stated: Policy: It is the policy to store food under safe and sanitary conditions. Fundamental Information: Refrigerators and freezers are designed to keep food cold enough to prevent or slow the growth of bacteria as well as preserve the freshness and quality of foods. Units work effectively and efficiently when maintained, cleaned, and serviced. Procedure: 4. Record and monitor temperatures of refrigerators and freezers at least three times daily on form Record of Refrigeration Temperatures (OP3 0210.03 A2) found on the Intranet web site. Temperatures must be monitored and recorded on all units in which food for resident consumption is stored (i.e., activity department and nourishment rooms). 5. Inspect refrigerators and freezers regularly for leaks, frozen areas, and dust on compressor units. Report problems/concerns according to the facility's preventative maintenance program. 6. Keep refrigerator and freezer doors closed at all times, unless in immediate use, to minimize temperature fluctuations . 13. Freezers should maintain foods in a frozen, solid state . Interview with the Administrator on 06/24/2015 at 2:00 PM, she stated she expected Freezer #1 to be fixed and fully operational by the end of today. She stated kitchen items such as the low freezer temperatures and loose metal panel on the electrical box with the start/stop button for the garbage disposal will be added to the TELLS list. C) Observation on 6/24/15 at 11:50 am in the kitchen revealed Dietary Cook J serving portions for the lunch meal on warm plates. The Dietary Cook J used a rubber plate holder with a suction cup to pick up each warm plate from a stack of plates in the heated dish dispenser. Dietary Cook J placed the rubber plate holder on the stainless steel edge of the plate warmer. During an interview on 6/24/15 at 11:50 am, the Dietary Cook J stated the rubber plate holder was not suppose too touch the outside surface of the plate warmer. Dietary Cook J also stated after each use the rubber plate holder should be placed on the next plate to be used for serving. Observation on 6/24/15 at 12:00 PM revealed Dietary Aide I using her bare hands to pick-up parsley and put it on plates to be served to the residents. The Dietary Aide I was touching the plate, tray and steam table prior to serving the parsley. The Dietary Aide I was unable to wash or sanitize her hands between each serving. During an interview on 6/24/15 at 12:00 PM, the surveyor asked Dietary Aide I should she use her bare hands to pick up parsley and then put it on resident's plates to be served. Dietary Aide I stated she was told it was cross contamination when using gloves, because she would touch the plate and then touch the warming cart. Dietary Aide I then got a pair of tongs and used it to place the parsley on the plates. During an interview on 6/24/15 at 12:05 PM the Dietary Supervisor stated Dietary Aide I should use tongs to put the parsley on resident's plates. Review of Policy and Procedure titled Food Handling Practices dated March 2009, reflected the following: Procedure 3. Use appropriate utensils, such as forks, knives, scoops or spoons to avoid direct handling of food. 5. Use tongs in meal service to portion meats, bread, garnishes, baked potatoes, cookies, etc. Place tongs on a plate or back into the steam table pan with handle up after each use. The CMS Form 672 reflected a census of 45 and the facility stated 44 residents received meals from Dietary Services.

Based on observation, interview, and record review, the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior for one of two halls reviewed for housekeeping services when: A) A brown substance was found on Resident #3, #8, #17, and #18's bathroom sink, floor, wall, and toilet on. B) A soiled brief was found in the trash can in Resident #3, #8, #17, and #18's bathroom. This deficient practice placed 24 residents who resided on the North Hall at risk for unsanitary conditions. Findings Include: A) Observation on 06/23/2015 at 10:25 AM revealed multiple brown smears on Resident #3, #8, #17, and #18's bathroom sink, wall, floor, and toilet on the North Hall. In an interview on 06/25/2015 at 9:54 AM the Housekeeping Supervisor stated it is the CNAs responsibility to clean up the brown smears and housekeeping is to come in and disinfect the area. The Housekeeping Supervisor stated the brown smears were poop. The Housekeeper Supervisor stated housekeeping staff make rounds once per shift, unless they are notified of an issue. In an interview on 06/25/15 at 9:46 AM Housekeeper H stated housekeeping is responsible for disinfecting the bathrooms and CNAs are responsible for cleaning up the mess and then inform housekeeping for disinfection. In an interview on 06/25/2015 at 10:02 AM CNA A stated it is her responsibility to clean up any messes and then to notify housekeeping they are needed to disinfect the bathrooms. In an interview on 06/23/2015 at 10:25 AM the ADON stated the bathroom should not have been in its' current condition and that housekeeping and CNA staff are responsible for the cleanliness of the bathrooms. The ADON stated the brown smears were from a resident's bowel movement and housekeeping should have cleaned this area. Review of the Housekeeping Services Policy dated 1/1/2000 reflected the following: Purpose: To show Housekeeping employees the proper method to sanitize a washroom or bathroom in a long term care facility. 5. Clean and Sanitize Commode- The commode includes the tank, the seat, the bowl and the base. Using a separate rag and a germicide solution, wipe every area of the commode. Use Johnny mop to disinfect the inside of the bowl. Use bowl cleaner sparingly and only inside of bowl. 6. Spot Clean Walls and/or Partitions Wipe walls- especially by trash containers, light switches and door handles. B) Observation on 06/23/2015 at 10:25 AM revealed soiled brief in the bathroom trash can in the bathroom used by Resident #3, #8, #17, and #18's on the North Hall. In an interview on 06/25/2015 at 9:54 AM the Housekeeping Supervisor stated the soiled briefs are to be tied up in a plastic bag and brought to the hopper room by the CNAs. The housekeeping supervisor further stated that soiled briefs are not to be left in the trash can under any circumstances. In an interview on 06/25/15 at 9:46 AM Housekeeper H stated housekeeping is responsible for taking the soiled briefs to the hopper room and housekeeping department should take all the trash from the hopper room to the outside garbage cans. In an interview on 06/25/2015 at 10:02 AM CNA A stated it is her responsibility to take soiled briefs to the hopper room after incontinent care and soiled briefs are to not be left in a trash can. In an interview on 06/23/2015 at 10:25 AM the ADON stated the bathroom trash should not contain soiled briefs and the CNAs are to tie the soiled briefs in a trash bag and take to the hopper room. Review of the incontinent care policy reflected that soiled briefs should be discarded; however, the policy did not reflect a specific process on how to discard the brief. The facility provided a list of 24 residents who resided on the North Hall.

A complaint investigation # 7 was started on [DATE] and re-opened in conjunction with an Annual Health survey on [DATE]-[DATE]. The facility census was 46. Based on observation, interview and record review the facility failed to implement written policy and procedures to prevent neglect. The facility failed to protect 1 of 1 resident (Resident # 1) with a history of a [MEDICAL CONDITION] by failing to ensure the resident received adequate supervision to prevent accidents. The facility allowed Resident #1 to keep wine in her personal refrigerator and drink unsupervised. Resident #1 also kept Tylenol PM (an over-the-counter [MEDICATION NAME]/sleep aide medication) in her room. Resident # 1 became unresponsive and was sent to the emergency room (ER) where she was diagnosed with [REDACTED]. This deficient practice affected Resident # 1 and could place any resident who might have personal items including alcohol and over the counter medications in their room at risk for dehydration, confusion, nausea, aspiration pneumonia, sedation and possible death. Findings Include: Review of the facility Abuse and Neglect Prohibition policy dated September, 2011 reflected: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin and misappropriation of property. The definition of Neglect was reflected as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Injuries of unknown origin may occur as a result of neglect." Prevention: 4. Residents identified by staff as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. Identification: 2. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression. Investigation 2. The facility will report such allegations to the state, in accordance with state regulation. 3. The facility will report all investigation findings to the state in accordance with state regulations. Review of Resident # 1 ' s Facesheet reflected the resident is an [AGE] year old female who entered the facility on [DATE]. Resident # 1 ' s [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial assessment dated [DATE] and 30 day MDS assessment dated [DATE] reflected Resident # 1 had a score of 15 for Cognitive Status which is indicative of the resident being fully cognitively aware. Review of Resident # 1 ' s Care Plan dated [DATE] reflected Resident # 1 has cognitive impairment as evidenced by impaired ability to understand others. The Care Plan reflected Resident # 1 had Depression/Anxiety/Sad Mood related to Depression and Anxiety. Interventions for the Depression and Anxiety included review of drug regime and possible interactions. Review of Resident # 1 ' s Psychological Screening Evaluation dated [DATE] reflected the resident had a suicide attempt a few months ago very soon after her husband died in September of 2011. She apparently took about 30 Tylenol PM tablets. She was a resident at a nursing home at that time. Review of Change of Condition form dated [DATE] at 6:10 PM and completed by LVN E reflected Resident # 1 appeared lethargic and her speech was slurred. Review of Nursing Progress Notes dated [DATE] reflected LVN E went in to give Resident # 1 her evening medication and observed the resident in a chair, lethargic, her skin was warm and dry. The vital signs were recorded as blood pressure ,[DATE] millimeters of mercury (mmHg). The notes further reflected " Resident has alcoholic beverage (wine) she drinks from her personal refrigerator." A cool towel was applied to Resident # 1 ' s face per nurse and the resident pushed the nurse ' s hand back and eyes opened and closed. Resident # 1 ' s speech was slurred. An order was received to send Resident # 1 to the emergency room . In an interview on [DATE] at 6:15 PM LVN E stated Resident # 1 had a physician order to have wine. LVN E stated Resident # 1 ' s daughter brings the wine to her and she keeps it in her refrigerator. LVN E stated she sent Resident # 1 to the ER a few days ago because she was asleep in her chair and when she checked her vital signs the bottom number was low in her blood pressure check. The LVN stated she knew she had wine in her room as she had an order to have wine every day. Review of a physician order dated [DATE] reflected Resident # 1 " may have one mini bottle of wine every day." Observation made on [DATE] at 5:45 PM revealed Resident # 1 laying supine in bed at the hospital. Resident # 1 was demented and could not hold a conversation. The resident was worried about furniture being removed from her house and asked me to get her silverware from the other room. In an interview on [DATE] at 4:50 PM the hospital Registered Nurse (RN) A stated Resident # 1 was admitted to the hospital on [DATE] with possible aspiration pneumonia, possible attempted suicide by taking a massive amount of Tylenol and drinking an enormous amount of Alcohol. RN A stated Resident # 1 had been very confused since entering the hospital on [DATE], and had been talking about her husband and son (both who are deceased ) as if they were coming to get her. Review of the Emergency Physician Record dated [DATE] reflected Resident # 1 had entered theER on that date at 7:20 PM when the nursing home staff noticed her acting strange and the resident may have been drinking a lot of wine. By the time the emergency department personnel had gotten to the nursing facility Resident # 1 was only responsive to self and had vomited two times. The Clinical Impression reflected was admitted to the hospital with [REDACTED]. Review of the lab value for Tylenol in Resident # 1 ' s blood dated [DATE] reflected the resident had greater than 300.0 micrograms per milliliter (ug/mL) in her system (Low = 10.0 and High = 30.0). The form reflected an estimation of 6 to 8 hours post ingestion. Review of the lab value for Alcohol in Resident # 1 ' s blood dated [DATE] reflected the resident had 42.0 Milligrams per Deciliter (mg/dL) in her system. (Low = 0.0 and High - 5.0) In an interview on [DATE] at 6:45 PM the with the Administrator and Director of Nurses (DON) Administrator stated Resident # 1 did keep wine in her room as she had a physician order to have it. The Administrator stated Resident # 1 ' s daughter would bring the wine to the facility and store it in a personal refrigerator in the resident ' s room. The Administrator stated upon Resident # 1 ' s admittance to the hospital facility staff completed a search of the resident ' s room and found 4 miniature bottles of wine plus a 5 liter box of wine in the resident ' s refrigerator. In addition the facility found one empty bottle of Equate brand [MEDICATION NAME] PM (Tylenol) that originally contained 100 pills and a partially full bottle of [MEDICATION NAME] PM that contained 88 pills in Resident # 1 ' s drawer. The DON stated Resident # 1 was allowed to keep wine in her room as she had a physician order to receive it and stated it is not the policy of the facility to go through a resident ' s personal items in the drawers in search of over the counter medications, nor is it the policy of the facility to search a resident ' s personal refrigerator. In an interview on [DATE] at 10:00 AM the DON stated Resident # 1 was not able to administer her own medications. The DON stated Resident # 1 should not have had any medication, including over the counter medication in her room. Review of the facility Admission Policy dated February, 2011 reflected under Pharmacy Services " Resident may not bring medications or drugs onto Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. All medications must be administered according to physician orders. Qualified Staff shall administer medications unless the Resident ' s Attending Physician writes an order authorizing the Resident to self-administer medications, in which case the Resident may administer his or her own medications under the guidance of a registered or licensed practical nurse. Review of the facility Medication Administration policy dated [DATE] reflected " Resident Medications are administered in an accurate, safe, timely and sanitary manner " . Fundamental Information reflected " Authorized Personnel - Medications are prepared, administered and recorded only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications " . Review of the facility policy entitled Food Functions for Resident Meals dated February, 2010 reflected Alcoholic Beverages: " A physician ' s order is necessary for beer, wine and other alcoholic beverages served to residents. Beer, wine and other alcoholic beverages are stored, and distributed by the Nursing department " . Review of the facility policy entitled Residents ' Personal Property dated February, 2010 reflected under Personal Refrigerators: 4. Staff will check refrigerator temperatures once daily. 5. Any unlabeled, undated or expired foods/liquids will be removed and discarded without notice. In an interview on [DATE] at 10:00 AM the DON stated she was embarrassed to say she did not know what the policy stated regarding residents keeping alcohol in their rooms and had thought since Resident # 1 had a physician order for [REDACTED]. The facility provided a list of 1 resident (Resident # 1) who was allowed to keep alcohol in her room

A complaint investigation # 7 was started in conjunction with a annual survey and investigation on [DATE] through [DATE]. The facility census was 46. Based on observation, interview and record review the facility failed to implement policy and procedures to prevent neglect. The facility failed to protect 1 of 1 resident (Resident # 1) with a history of a [MEDICAL CONDITION] by failing to ensure the resident received adequate supervision to prevent accidents. The facility allowed Resident #1 to keep wine in her personal refrigerator and drink unsupervised. Resident #1 also kept Tylenol PM (an over-the-counter [MEDICATION NAME]/sleep aide medication) in her room. Resident # 1 became unresponsive and was sent to the emergency room (ER) where she was diagnosed with [REDACTED]. This deficient practice affected Resident # 1 and could place any resident who might have personal items including alcohol and over the counter medications in their room at risk for dehydration, confusion, nausea, aspiration pneumonia, sedation and possible death. Findings Include: Review of Resident # 1 ' s Facesheet reflected the Resident is an [AGE] year old female who entered the facility on [DATE]. Resident # 1 ' s [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial assessment dated [DATE] and 30 day MDS assessment dated [DATE] reflected Resident # 1 had a score of 15 for Cognitive Status which is indicative of the resident being fully cognitively aware. Review of Resident # 1 ' s Care Plan dated [DATE] reflected Resident # 1 has cognitive impairment as evidenced by impaired ability to understand others. The Care Plan reflected Resident # 1 had Depression/Anxiety/Sad Mood related to Depression and Anxiety. Interventions for the Depression and Anxiety included review of drug regime and possible interactions. Review of Resident # 1 ' s Psychological Screening Evaluation dated [DATE] reflected the resident had a suicide attempt a few months ago very soon after her husband died in September of 2011. She apparently took about 30 Tylenol PM tablets. She was a resident at another nursing home at that time. Review of Change of Condition form dated [DATE] and completed by Licensed Vocational Nurse (LVN) E reflected Resident # 1 appeared lethargic at 6:10 PM and her speech was slurred. Review of Nursing Progress Notes dated [DATE] reflected LVN E went in to give Resident # 1 her evening medication at 6:10 PM and observed the resident in a chair, lethargic, her skin was warm and dry. The vital signs were recorded as blood pressure ,[DATE] millimeters of mercury (mmHg). The notes further reflected " Resident has alcoholic beverage (wine) she drinks from her personal refrigerator". A cool towel was applied to Resident # 1 ' s face per nurse and the resident pushed the nurse ' s hand back and eyes opened and closed. Resident # 1 ' s speech was slurred. An order was received to send Resident # 1 to the emergency room . In an interview on [DATE] at 6:15 PM LVN E stated Resident # 1 had a physician order to have wine. LVN E stated Resident # 1 ' s daughter brings the wine to her and she keeps it in her refrigerator. LVN E stated she sent Resident # 1 to the ER a few days ago because she was asleep in her chair and when she checked her vital signs the bottom number was low in her blood pressure. The LVN stated she knew she had wine in her room as she had an order to have wine every day. Review of a physician order dated [DATE] reflected Resident # 1 " may have one mini bottle of wine every day." Observation made on [DATE] at 5:45 PM revealed Resident # 1 laying supine in bed at the hospital. Resident # 1 was demented and could not hold a conversation. The resident was worried about furniture being removed from her house and asked me to get her silverware from the other room. In an interview on [DATE] at 4:50 PM the hospital Registered Nurse (RN) A stated Resident # 1 was admitted to the hospital on [DATE] with possible aspiration pneumonia, possible attempted suicide by taking a massive amount of Tylenol and drinking an enormous amount of Alcohol. RN A stated Resident # 1 had been very confused since entering the hospital on [DATE], and had been talking about her husband and son (both who are deceased ) as if they were coming to get her. Review of the Emergency Physician Record dated [DATE] reflected Resident # 1 had entered theER on that date at 7:20 PM when the nursing home staff noticed her acting strange and the resident may have been drinking a lot of wine. By the time the emergency department personnel had gotten to the nursing facility Resident # 1 was only responsive to self and had vomited two times. The Clinical Impression reflected was admitted to the hospital with [REDACTED]. Review of the lab value for Tylenol in Resident # 1 ' s blood dated [DATE] reflected the resident had greater than 300.0 micrograms per milliliter (ug/mL) in her system (Low = 10.0 and High = 30.0). The form reflected an estimation of 6 to 8 hours post ingestion. Review of the lab value for Alcohol in Resident # 1 ' s blood dated [DATE] reflected the resident had 42.0 Milligrams per Deciliter (mg/dL) in her system. (Low = 0.0 and High - 5.0) In an interview on [DATE] at 6:45 PM the with the Administrator and Director of Nurses (DON) Administrator stated Resident # 1 did keep wine in her room as she had a physician order to have it. The Administrator stated Resident # 1 ' s daughter would bring the wine to the facility and store it in a personal refrigerator in the resident ' s room. The Administrator stated upon Resident # 1 ' s admittance to the hospital facility staff completed a search of the resident ' s room and found 4 miniature bottles of wine plus a 5 liter box of wine in the resident ' s refrigerator. In addition the facility found one empty bottle of Equate brand [MEDICATION NAME] PM (Tylenol) that originally contained 100 pills and a partially full bottle of [MEDICATION NAME] PM that contained 88 pills in Resident # 1 ' s drawer. The DON stated Resident # 1 was allowed to keep wine in her room as she had a physician order to receive it and stated it is not the policy of the facility to go through a resident ' s personal items in the drawers in search of over the counter medications, nor is it the policy of the facility to search a resident ' s personal refrigerator. In an interview on [DATE] at 10:00 AM the DON stated Resident # 1 was not able to administer her own medications. The DON stated Resident # 1 should not have had any medication, including over the counter medication in her room. Review of the facility Admission Policy dated February, 2011 reflected under Pharmacy Services " Resident may not bring medications or drugs onto Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law." All medications must be administered according to physician orders. Qualified Staff shall administer medications unless the Resident ' s Attending Physician writes an order authorizing the Resident to self-administer medications, in which case the Resident may administer his or her own medications under the guidance of a registered or licensed practical nurse. Review of the facility Medication Administration policy dated [DATE] reflected " Resident Medications are administered in an accurate, safe, timely and sanitary manner " . Fundamental Information reflected " Authorized Personnel - Medications are prepared, administered and recorded only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications " . Review of the facility policy entitled Food Functions for Resident Meals dated February, 2010 reflected Alcoholic Beverages: " A physician ' s order is necessary for beer, wine and other alcoholic beverages served to residents. Beer, wine and other alcoholic beverages are stored, and distributed by the Nursing department " . Review of the facility policy entitled Residents ' Personal Property dated February, 2010 reflected under Personal Refrigerators: 4. Staff will check refrigerator temperatures once daily. 5. Any unlabeled, undated or expired foods/liquids will be removed and discarded without notice. In an interview on [DATE] at 10:00 AM the DON stated she was embarrassed to say she did not know what the policy stated regarding residents keeping alcohol in their rooms and had thought since Resident # 1 had a physician order for [REDACTED]. Review of the facility Abuse and Neglect Prohibition policy dated September, 2011 reflected: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin and misappropriation of property. The definition of Neglect was reflected as " failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Injuries of unknown origin may occur as a result of neglect." Prevention: 4. Residents identified by staff as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. Identification: 2. The facility supervisory staff will integrate into the supervisory process monitoring staff members and residents for behavior indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum of aggression. Investigation 2. The facility will report such allegations to the state, in accordance with state regulation. 3. The facility will report all investigation findings to the state in accordance with state regulations. The facility provided a list of 1 resident (Resident # 1) who was allowed to keep alcohol in her room

Based on observation,interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision and assistance to prevent accidents when: A. The facility failed to ensure the environment remained as free from accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) who had a prior suicide attempt, was allowed to keep alcohol and kept Tylenol PM (an analgesic and over-the-counter sleet aide medication) in her room. Resident # 1 had a physician order to have 1 mini bottle of wine per day. The facility allowed Resident # 1 to keep wine in her room and drink unsupervised. Resident # 1 became unresponsive and was sent to the Emergency Department (ER) where she was diagnosed with [REDACTED]. This deficient practice affected Resident # 1 and could place any resident who might have personal items including alcohol and over the counter medications in their room at risk for dehydration, confusion, nausea, aspiration pneumonia, sedation and possible death. B. Failure to keep the dishwashing area (with cleaning, sanitizing and disinfection supplies) adequately secure when not in use. This deficient practice has the potential to cause injury and possible accidental ingestion of hazardous materials to any of the 38 mobile residents who could enter the dishwashing area in the facility. The findings include: A. Review of Resident # 1 ' s Facesheet reflected the resident is an [AGE] year old female who entered the facility on [DATE]. Resident # 1 ' s [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Initial assessment dated [DATE] and 30 day MDS assessment dated [DATE] reflected Resident # 1 had a score of 15 for Cognitive Status which is indicative of the resident being fully cognitively aware. Review of Resident # 1 ' s Care Plan dated [DATE] reflected Resident # 1 has cognitive impairment as evidenced by impaired ability to understand others. The Care Plan reflected Resident # 1 had Depression/Anxiety/Sad Mood related to Depression and Anxiety. Interventions for the Depression and Anxiety included review of drug regime and possible interactions. Review of Resident # 1 ' s Psychological Screening Evaluation dated [DATE] reflected the resident had a suicide attempt a few months ago very soon after her husband died in September of 2011. She apparently took about 30 Tylenol PM tablets. She was a resident at another nursing home at that time. Review of Change of Condition form dated [DATE] and completed by LVN E reflected Resident # 1 appeared lethargic and her speech was slurred. Review of Nursing Progress Notes dated [DATE] reflected LVN E went in to give Resident # 1 her evening medication and observed the resident in chair, lethargic and her skin was warm and dry. The vital signs were recorded as blood pressure ,[DATE] millimeters of mercury (mmHg). The notes further reflected " Resident has alcoholic beverage (wine) she drinks from her personal refrigerator." A cool towel was applied to Resident # 1 ' s face per nurse and the resident pushed the nurse ' s hand back and eyes opened and closed. Resident # 1 ' s speech was slurred. An order was received to send Resident # 1 to the emergency room . In an interview on [DATE] at 6:15 PM Licensed Vocational Nurse (LVN) E stated Resident # 1 had a physician order to have wine. LVN E stated Resident # 1 ' s daughter brings the wine to her and she keeps it in her refrigerator. LVN E stated she sent Resident # 1 to the ER a few days ago because she was asleep in her chair and when she checked her vital signs the bottom number was low in her blood pressure check. The LVN stated she knew she had wine in her room as she had an order to have wine every day. Review of a physician order dated [DATE] reflected Resident # 1 " may have one mini bottle of wine every day." Observation made on [DATE] at 5:45 PM revealed Resident # 1 laying supine (on her back) in bed at the hospital. Resident # 1 was demented and could not hold a conversation. The resident was worried about furniture being removed from her house and asked me to get her silverware from the other room. In an interview on [DATE] at 4:50 PM the hospital Registered Nurse (RN) A stated Resident # 1 was admitted to the hospital on [DATE] with possible aspiration pneumonia, possible attempted suicide by taking a massive amount of Tylenol and drinking an enormous amount of Alcohol. RN A stated she had never seen an alcohol level that high especially in a lady Resident # 1 ' s age. RN A stated Resident # 1 had been very confused since entering the hospital on [DATE], and had been talking about her husband and son (both who are deceased ) as if they were coming to get her. Review of the Emergency Physician Record dated [DATE] reflected Resident # 1 had entered theER on that date at 7:20 PM when the nursing home staff noticed her acting strange and the resident may have been drinking a lot of wine. By the time the emergency personnel had gotten to the nursing facility Resident # 1 was only responsive to self and had vomited two times. The Clinical Impression reflected was admitted to the hospital with [REDACTED]. Review of the lab value for Tylenol in Resident # 1 ' s blood dated [DATE] reflected the resident had greater than 300.0 micrograms per milliliter (ug/mL) in her system (Low = 10.0 and High = 30.0). The form reflected an estimation of 6 to 8 hours post ingestion. Review of the lab value for Alcohol in Resident # 1 ' s blood dated [DATE] reflected the resident had 42.0 Milligrams per Deciliter (mg/dL) in her system. (Low = 0.0 and High - 5.0) In an interview on [DATE] at 6:45 PM the with the Administrator and Director of Nurses (DON) Administrator stated Resident # 1 did keep wine in her room as she had a physician order to have it. The Administrator stated Resident # 1 ' s daughter would bring the wine to the facility and store it in a personal refrigerator in the resident ' s room. The Administrator stated upon Resident # 1 ' s admittance to the hospital facility staff completed a search of the resident ' s room and found 4 miniature bottles of wine plus a 5 liter box of wine in the resident ' s refrigerator. In addition the facility found one empty bottle of Equate brand Acetaminophen PM (Tylenol) that originally contained 100 pills and a partially full bottle of Acetaminophen PM that contained 88 pills in Resident # 1 ' s drawer. The DON stated Resident # 1 was allowed to keep wine in her room as she had a physician order to receive it and stated it is not the policy of the facility to go through a resident ' s personal items in the drawers in search of over the counter medications, nor is it the policy of the facility to search a resident ' s personal refrigerator. Review of the facility Admission Policy dated February, 2011 reflected under Pharmacy Services " Resident may not bring medications or drugs onto Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. All medications must be administered according to physician orders. Qualified Staff shall administer medications unless the Resident ' s Attending Physician writes an order authorizing the Resident to self-administer medications, in which case the Resident may administer his or her own medications under the guidance of a registered or licensed practical nurse. Review of the facility Medication Administration policy dated [DATE] reflected " Resident Medications are administered in an accurate, safe, timely and sanitary manner " . Fundamental Information reflected " Authorized Personnel - Medications are prepared, administered and recorded only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications " . In an interview on [DATE] at 10:00 AM the DON stated Resident # 1 was not able to administer her own medications. The DON stated Resident # 1 should not have had any medication, including over the counter medication in her room. Review of the facility policy entitled Food Functions for Resident Meals dated February, 2010 reflected Alcoholic Beverages: " A physician ' s order is necessary for beer, wine and other alcoholic beverages served to residents. Beer, wine and other alcoholic beverages are stored, and distributed by the Nursing department " . Review of the facility policy entitled Residents ' Personal Property dated February, 2010 reflected under Personal Refrigerators: 4. Staff will check refrigerator temperatures once daily. 5. Any unlabeled, undated or expired foods/liquids will be removed and discarded without notice. In an interview on [DATE] at 10:00 AM the DON stated she was embarrassed to say she did not know what the policy stated regarding residents keeping alcohol in their rooms and had thought since Resident # 1 had a physician order for [REDACTED]. The DON again stated Resident # 1 should never have had Acetaminophen PM in her room. The facility provided a list of 1 resident (Resident # 1) who was allowed to keep alcohol in her room. B. Observation on [DATE] at 2:30 PM and on [DATE] at 4:39 PM revealed the dietary door on the odd side of the kitchen was open to the dishwashing station. Inside of the door revealed a counter with two large square tubs filled with soap and water, and under the washing counter was a gallon of bleach, and an aerosol can of degreaser. There was no staff observed inside of the door or dishwashing room area. In an Interview on [DATE] at 4:43 PM the Dietary Manager stated that the dietary door on the odd side of the kitchen only stays open if someone is standing in the doorway doing dishes. She further stated that residents have walked into the kitchen in the past. Observation on [DATE] at 9:59 AM revealed in the courtyard (the smoking area for residents and staff) seven cigarette butts lying on top of the ashtray. A large, unlocked red bucket with a label that read oily waste that was filled three quarters full of cigarette butts and ashes. Two cigarette butts were lying on the ground. In an interview on [DATE] at 4:58 PM the DON stated there were two wandering residents in the facility. Review of facility Form CMS 672 reflected a census of 46.

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #1) reviewed for falls received adequate assistance devices to prevent accidents. Resident #1 rolled out of her bed on 07/10/11 at 12:05 AM while reaching for something on her nightstand. Resident #1 sustained a femur fracture during the fall. Resident #1 had quarter size rails on her bed that did not extend pass the top of the Bariatric mattress(a pressurized fluctuating air mattress) which was placed in a standard bed frame. The resident was transferred to a regional hospital on [DATE] and returned on 07/16/11. Resident #1 was placed back in the same bed she fell out of with the possibility of falling again. This deficient practice resulted in an Immediate Jeopardy (IJ) on 08/09/11. The Director of Nurses was notified that the IJ was called relating to physician notification in a timely manner. Although the IJ was lowered on 08/10/11 the facility remained out of compliance at a Severity of Actual Harm at a Scope of Pattern that is not Immediate Jeopardy as the facility was still monitoring implementation of the Plan of Removal. This deficient practice contributed to Resident #1's fall and caused a delay in medical intervention and treatment for [REDACTED]. This deficient practice could also affect the additional 4 residents reviewed for falls. Findings include: The original complaint investigation was conducted on 07/26/2011. The complaint investigation was re-opened on 08/09/11 to gather additional information. An Immediate Jeopardy (IJ) with Substandard Quality of Care (SQC) was identified on 08/09/11. The surveyor exited on 08/10/11. In an interview on 07/26/11 at 10:00 AM the director of nurses (DON) stated Resident #1 fractured her femur when she rolled out of bed. The DON stated Resident #1 weight is 326 pounds and she is on a Bariatric bed. She stated Resident #1 was receiving physical therapy services. She stated the bed rails she identifies as quarter rails and not half rails. Review of the incident/accident report dated 07/10/11 at 12:05 AM Resident #1 was found on the floor with no injury. Findings documented no apparent injuries. No answer to a phone call to the physician on 07/10/11 at 6:45 AM. The Change of condition note was faxed to the physician at 7:00 AM. The Change of Condition form dated that Resident #1 fell out of bed on 07/09/10. The 07/10/11 date was a Sunday. In an interview on 07/26/11 at 11:48 AM the attending physician stated he did not know about Resident #1's fall until he came into the office on Monday morning. He stated no one called him or at least he did not receive any calls or messages on 07/10/11, which was Sunday, from the facility. He stated anything they faxed on 07/10/11 went to his office as he does not have a fax at home. He stated he could not remember if he ordered Resident #1 to the local hospital or to the regional hospital first. He stated he was not called until the x-ray report was sent. He stated when he saw the x-ray, "I freaked out". He stated he was very upset and he called immediately to have Resident #1 transported. In an interview on 07/26/11 at 11:55 AM Licensed Vocational Nurse (LVN) #2 stated the dates she wrote as 07/10/11 should have been dated 07/11/11. She stated the night nurse said she had called and left a message with the doctor. LVN #2 stated she was helping the night nurse at shift changed and faxed the Change of Condition form to the physician. She stated she had talked with the nurse at the physician's office on 07/11/11 in the morning to report Resident #1 was in pain and the nurse told her to transport to the hospital. LVN #2 stated Resident #1 only had Tylenol for pain. She stated she called Emergency Medical Services (EMS) and they felt Resident #1 needed to go to the regional hospital as the local hospital did not have orthopedic care. They called the physician and he ordered transport to the regional hospital instead of the local hospital. LVN #2 stated that LVN #1 was in charge of the situation and she just helped by faxing the change of condition form to the physician. She stated she understood that LVN #1 had spoke with the physician after Resident #1 fell out of her bed. In an interview on 07/26/11 at 12:05 PM LVN #1 stated Resident #1 rolled out of her bed at 12:05 AM which was on 07/10/11. She stated she called the physician at 6:45 AM and left a message and faxed the Change of Condition report at 7:00 AM. She stated she checked on Resident #1 during the night and the last time was at 6:30 AM. At 6:30 AM Resident #1 said her leg was hurting. She asked the resident where her leg hurt and she laid her hand on her thigh. Resident #1 did not complain of pain prior to this time. She stated she did not manipulate Resident #1's leg because it was stiff and big. She stated she felt down the thigh and Resident #1 did not complain of pain. She stated she did not see any bruising or swelling and the skin looked okay to her. LVN #1 stated she did not get an answer from the physician at 6:45 AM call so she ordered the x-ray. She stated the DON had told them, in the past, that if an x-ray was needed they could go ahead and order it as this particular physician was okay with this. LVN #1 stated she called mobile x-ray between 6:45 AM and 7:00 AM. She stated the mobile x-ray person asked if this was a STAT x-ray as the x-ray tech did not come on duty until 7:30 AM. LVN #1 stated she told them it was not a STAT x-ray and it was okay to wait until the tech came in. LVN #1 stated it took 4 people to get Resident #1 off the floor and back to bed using a mechanical lift. LVN #1 stated Resident #1 did not complain of a specific area of pain during the rolling and manipulation of her body getting it into the lift sling. LVN #1 stated Resident #1 said she was okay. She stated she was unable to get Resident #1 to tell her how she fell out of bed. She felt any mention of pain from Resident #1 was because of moving her around to get her in the sling and getting her in bed. LVN #1 stated she has requested full bed rails on Resident #1's bed in the past as the quarter rail are not high enough. She stated she did not know when she will get them. LVN #1 stated Resident #1 had full side rails until the Bariatric bed was put in place. In an interview on 07/26/11 at 9:38 AM, the hospital Social Worker stated, "Doctors were concerned as Resident #1 was hemorrhaging in the fracture area of the leg. The doctors said she could have bled to death during the length of time it took to transfer her to the hospital. She did receive a blood transfusion". Observation on 07/26/11 at 10:05 AM Resident #1 was laying on a Bariatric mattress and a standard bed frame with a stimulator in place for bone growth stimulation and for pain to the right leg. Resident #1 had a leg brace in place to the right leg. There were quarter side rails on the upper portion of the bed. The side rails were in the up position with the Bariatric air mattress extending over the top of the bed rails and the resident could not use the rails to pull or reposition herself. In an interview on 07/26/11 at 10:05 AM Resident #1 stated she fell out of bed. She stated she was reaching for something on her night stand and rolled out on the floor. She stated she did not have the rails to hold on to. Resident #1 stated the staff got her back to bed and a man came in to take pictures of her leg later in the morning. Review of the Resident Transfer Form Resident #1 was transferred to the hospital on [DATE]. Review of the history and physical dated 07/11/11 from the regional hospital reflected: "Resident #1 is relatively bedridden. She apparently reached over to get a remote and because her bed rails were not up she fell out of bed and sustained a right distal femur shaft fracture. Her [DIAGNOSES REDACTED]. She has a history of seizures. The Plan as documented was to manage non-operatively because of her not being mobile and the case will be challenging with her obesity and her heart disease. The plan is to transfuse at least one unit of packed red cells." Review of the mobile x-ray results dated 07/10/11 at 10:22:29 CDT for the right knee documented a fracture of the distal shaft of the femur. Portable right femur x-ray dated 07/10/11 at 10:20:28 CDT documented an acute spiral fracture of the distal shaft of the femur. Review of the Medication Administration Record (MAR) for July 2011 identified Acetaminophen 500 mg, 2 tablets by mouth every day at 6:00 AM. Resident #1 fell out of bed on 07/10/11 at 12:05 AM and did not receive pain medication until her routine dose of Acetaminophen at 6:00 AM. Further review of the MAR identified Acetaminophen being administrated on 07/10/11 at 9:00 PM. Review of the care plan dated 07/11/08 and last updated on 05/02/11 identified the need for full side rails times two. Resident #1 had quarter side rails on her bed. In an interview on 07/26/11 at 11:20 AM Resident #1 stated she could not remember if the side rails were up on her bed or not. She stated she only has half side rail. She said she had asked at one time for full side rails and she had them but did not know what happened or why she only had half rails now. Review of the restraint assessments for Resident #1 had the following documentation. Restraint assessment/consent dated 01/19/11 identified side rails needed for mobility. The consent was not specific to half or full side rails. On 12/06 the restraint assessment/consent identified the need for full side rails for mobility and safety. Review of the fall risk assessment dated [DATE] documented Resident #1 as a high risk for falls with a score of 12. A score of 10 or above represents high risk. Review of the nurse's notes as written in order of documentation dated 07/10/11: at 3:05 PM, "x-ray results in with spiral fracture noted to distal femur. Dr notified. In bed without complaint of pain will monitor." At 9:40 PM fall follow up. In bed this shift. X-ray results fracture of the distal femur. APAP (acetaminophen - Tylenol) 500 tabs 2 by mouth times one for pain. Voice no other complaints. Responsible party her to see her and inquired about residents fall. Informed him of the x-ray results and that the doctor would evaluate and order treatment for [REDACTED]. At 11:10 AM doctor returned call and new order to send to the local hospital for evaluation and treatment. EMS (emergency medical services) call relating to the fracture and called the doctor and an order to send resident to the regional hospital emergency room for evaluation and treatment. Family notified of resident status and transfer. In an interview on 07/26/11 at 11:40 AM the DON stated that the times and dates documented by the day nurse and the night nurse was not correct. There was confusion regarding the documented times and date. She stated she called the day nurse and the day nurse stated that she had documented 07/10/11 at 7:30 AM and 07/10/11 at 11:10 AM should have been documented as 07/11/11 at 7:30 AM and 07/11/11 at 11:10 AM. In an interview on 07/26/11 at 12:55 PM LVN #1 verified that Resident #1 did fall out of her bed on 07/10/11 at 12:05 AM. She stated she must have documented the wrong date when she put 07/09/11 as the date of the fall on the Change of Condition report faxed to the Physician on 07/10/11 at 7:00 AM. Review of the telephone order dated 07/11/11 at 11:20 AM identified resident #1 to be sent to the emergency room at a regional hospital to be evaluated at treated. [DIAGNOSES REDACTED]. In an interview on 07/26/11 at 12:40 AM the mobile x-ray office person stated that the x-ray tech was dispatched to the facility at 7:30 AM. There were multiple x-rays done at that time and the tech finished at 10:00 AM. The x-ray reports were provided to the facility at 10:22 AM. The office person stated that the original call came in at 6:49 AM and it was not a STAT x-ray so the tech was dispatched at 7:30 AM. In an interview on 07/26/11 at 1:20 PM LVN #1 verified that Resident #1 was in pain when she fell and while they were moving her back into her bed but did not complain after that. The x-ray was ordered when Resident #1 told her she was now hurting at 6:30 AM. LVN #1 stated she gave Resident #1 her routine Tylenol order. On 08/09/11 at 3:55 PM the Director of Nurses (DON) was notified of the immediate jeopardy (IJ) in the area of Quality of Care due to the failure to prevent neglect. The facility failed to notify the primary physician in a timely manner when Resident #1 fell out of her bed on 07/10/11 at 12:05 AM and mobile X-ray was obtained on 07/10/11 at 10:22 AM indicating a fracture of the distal shaft of the femur. The primary care physician did not receive notification until 07/11/11 at 11:20 AM and an order was given to transfer Resident #1 to the emergency room for evaluation and treatment some 24 hours later. The investigator requested a Plan of Removal for the IJ from the Director of Nurses. The Administrator was not in the facility due to illness. In an interview on 08/09/11 at 3:55 PM the DON stated she had already in-serviced the nurses on calling the physician and not leaving a fax without verbally talking to the physician and getting a response from the physician. Review of the in-service report dated 07/27/11 all licensed nursing staff was in-serviced on, "notification of physician". Physician notification must be made immediately following any change of condition or incident. If you are unable to reach the primary care physician notify the Medical Director immediately. If in the event you are unable to reach either contact the DON and/or Administrator. Observation on 08/09/11 at 4:00 PM Resident #1 was in a different bed that allowed the Bariatric mattress to lay flat as intended. There were two quarter side rails on both sides of the bed frame. In an interview on 08/09/11 at 4:00 PM Resident #1 stated the bed was better now as she could reach the bed rails. She stated she did not have a fear of falling and her leg was better. Review of incident and accidents reports that had occurred from 07/26/11 to 08/09/11 and the change of condition reports of notification to the physician for Resident #2, 5, 6, 7, 8, and 9 had documentation of the following. -Resident #2 was found to have a bruise to the back of her head of unknown origin on 07/26/11. The incident report had documentation that the physician was notified by fax. No date or time was documented but signed on 07/31/11. On the change of condition form (a communication form to the physician) documents the Physician was notified by fax with no Physician name date or time and the confirmation "received" was not attached as instructed on the form. The physician was notified on 07/31/11 which is a Sunday. The staff was in-serviced prior to 08/09/11 and did not follow facility protocol. - Resident #6 on 08/01/11 was found trying to let down the side rail and sustained a 2 inch skin tear to the right forearm. There is documentation on the incident and accident report that the physician was notified at 11:15 PM on 08/01/11. On the change of condition form (a communication form to the physician) documents the Physician was notified by fax on 08/01/11 at 11:15 PM and the confirmation of "received" was not attached as instructed on the form. The change of condition report was faxed to the physician on 08/01/11 at 11:15 PM (Monday night). The staff was in-serviced prior to 08/09/11 and did not follow facility protocol. -Resident #7 bumped his toe in the shower and tore his left great toe nail on 08/01/11. The physician was notified by fax at 4:00 PM as documented on the accident/incident report. On the change of condition form (a communication form to the physician) did not documents how the Physician was notified of the incident and the confirmation of "received" was not attached as instructed on the form. The nurse documented to refer to podiatrist. The staff was in-serviced prior to 08/09/11 and did not follow facility protocol. -Resident #9 on 07/27/11 at 9:00 AM slid out of his wheelchair and sustained a skin tear to his left forearm. The incident/accident report documents the physician was notified at 10:00 AM. On the change of condition form (a communication form to the physician) documents the Physician was notified by fax on 07/27/11 at 10:00 AM and the confirmation of received was not attached as instructed on the form. The staff was in-serviced prior to 08/09/11 and did not follow facility protocol. In an interview on 08/09/11 at 5:00 PM the DON stated that the in-service to the nursing staff was not being followed. She stated she would re-in-service the staff starting immediately. In an interview on 08/10/11 at 9:40 AM the DON stated all nursing staff had been re-in-serviced and told to verbally notify the Physician and get a response. During this time the Regional Vice President was also in the interview and he stated that they had conducted an Interdisciplinary team meeting with the Medical Director and had discussed the issues. The DON stated the nurse's are not to send only faxes to the primary physician, but they have to call; and document who they spoke with and the time with any changes in nurses notes with an orders. In an interview on 08/10/11 at 10:18 AM LVN #2 stated she had been in-serviced. She stated that faxes can not be sent; only for lab work and they still have to have verbal acknowledgment from the physician that they received the lab results. On weekends if they can not reach the physician then they call the Medical Director and if they can not reach either one then the DON and/or Administrator is notified. The family is also notified. She stated the notification, date and time along with who was spoke to are to be documented. In an interview on 08/10/11 at 10:25 AM LVN #4 stated she received another in-service and no faxes can be sent except for lab results. Even with the lab results being faxed; confirmation has to be received by the physician. She stated they are to call the physician and if they can not reach him they are to call the Medical Director. If they can not be reached then the DON and the Administrator is to be notified. LVN #4 stated the information would be documented on the 24 hour report for the next shift to follow up on if needed. She stated she works part time in the facility. In an interview on 08/10/11 at 10:30 AM RN #1 stated she had been in-serviced and they were to send no faxes to the physicians. They have to receive verbal confirmation that they, the physician received the report. She stated they are to call the physician and if they can not reach him they are to call the Medical Director. If they can not be reached then the DON and the Administrator is to be notified. In an interview on 08/10/11 at 10:35 AM Assistant Director of Nurses (ADON) ADON/LVN stated she was in-serviced on proper procedures for notification of the physician relating to incident/accidents and changes of condition. She stated they can no longer fax information and expect this to be enough. They can fax but they need a verbal confirmation from the physician. Then they can document who was told, date and time. She stated they are to call the physician and if they can not reach him they are to call the Medical Director. If they can not be reached then the DON and the Administrator is to be notified. A Plan of Removal was submitted on 08/10/11 by the DON and the Regional Vice President of Operations at 11:55 AM. A plan of removal of the Immediate Jeopardy (IJ) was accepted by the investigator on 08/10/11 at 11:55 AM. The plan of removal included: Golden Years Nursing Center respectfully submits this plan to lift the allegations of immediate jeopardy to resident health and well being identified on 08/09/11. 1. Resident identified to have been affected by the alleged deficient practice. The resident sustained [REDACTED]. Resident complained of pain to the right hip and foot. An X-ray of right hip and right foot was obtained. The X-ray results showed a fracture to the distal shaft of the femur. Resident was transferred to ER for treatment on 07/11/11. The resident returned to the facility with a physician orders [REDACTED]. Upon re-admissions to the facility, the resident was assessed for fall risk and interventions were implemented. The resident's care plan and Care Cardexes were updated to reflect the current interventions. 2. Resident with potential to be affected by the alleged deficient practice. Residents at risk for falls have the potential to be affected by the alleged deficient practice. A 100 % audit of fall risk assessments was completed to identify residents at risk for falls. The care plans and Care Cardexes of residents as at risk for falls have been updated to reflect interventions, as necessary. A 100 % audit of residents identified to have been treated for [REDACTED]. Those residents identified as experiencing pain were assessed and the physician was notified regarding the results of the assessments. New orders were implemented; care plans and Care Cardexes were updated to reflect current treatments. An audit of incident reports from July 26th, 2011 to present was completed to ensure timely notification of change in condition to the physician and to ensure intervention were implemented. Residents identified as having a change in condition have been assessed: orders received, where indicated, and care plans and care Cardexes updated to reflect current interventions. 3. Systemic Measures Residents are assessed for fall risk upon admissions and then reassessed on re-admission, quarterly, annually and with a change of condition. During morning meeting Monday through Friday, residents with falls will be reviewed by the Interdisciplinary Team (IDT) to ensure timely notification of physicians. Falls that occur on Saturday and Sunday will be reviewed by the weekend supervisor to ensure timely notification of physicians. Director of Nursing and Administrator will be notified of any significant injury as they occur. Residents with new orders/interventions will have their care plans and care Cardexes updated to reflect current treatments. Residents identified as having falls or a risk for falls will be added to the Falling Star Program until the IDT reviews the residents at the weekly Care Management Risk Review meeting to determine further interventions and monitoring as necessary. Education The licensed nursing staff will be educated on 08/10/11 by the DON or designee. Notification of Physician must be completed immediately following any change of condition or incident. When an incident or change of condition occurs notification must be made by phone not fax. If you are unable to reach the residents primary care physician notify the medical director. If you are unable to reach either call the Administrator or Director of Nursing. The notification attempts must be documented every time until notification is made. If emergency, call 911 and contact the Administrator or Director of Nursing. This protocol applies to significant injures. If unable to reach physician notify Administrator and Director of Nursing and send Resident to the ER. The licensed nursing staff will be educated on 08/10/11 by the DON on proper assessment of the resident when significant injury occurs. Licensed nurse will evaluate resident by completing a head to toe assessment to assist with identification of physical injury. The licensed nursing staff was educated on 08/09/11 by Director of Nursing on the Fall Management System and the Pain Management System, to include the timely notification of change in condition to the physician. All licensed nurses will be educated quarterly on these systems for one year and annually, thereafter. The licensed nursing staff was educated on 08/09/11 regarding the policy and procedure for abuse and neglect prohibition by the Director of Nursing and /or designee. This education included the timely notification of the physician when a change in condition occurs. All newly hired nursing staff and PRN staff will be educated on the Fall Management System, Pain Management System and the Abuse and Neglect Prohibition Policies and Practices prior to assuming their responsibilities. On a quarterly basis for one year and annually thereafter all staff will be required to complete education regarding the Fall Management System, Timely MD notification of significant injury, Pain Management System and the Abuse and Neglect Prohibition Policies and Practices. The Director of Nursing or designee will compare the employee roster with the attendance sheet to make sure that all staff have been educated regarding these policies as scheduled above. 4. Quality Assessment and Assurance On 08/10/11 the Quality Assessment and Assurance Committee members (including the Regional vice President of Operations, DON, ADON, social Worker and other members of the IDT, conducted an AD HOC Quality Assessment and Assurance meeting to review and approve this plan. The facility ' s Medical Director also approved the plan. The DON/designee will monitor incident/accident reports and change of condition forms to ensure notification has been made weekly for one month and report to the Committee any trends/patterns identified. The facility will continue to follow policy and procedures related notification of change in condition and Incident/Accident Reporting. The quality Assessment and Assurance Committee will meet weekly for 4 weeks and then monthly thereafter to ensure the facility remains compliant with this plan. The Regional Clinical Director and/or designee will review the Quality Assessment and Assurance Committee minutes' weekly for 4 weeks and then monthly for 6 months to ensure oversight of this plan. The Director of Nurses was notified on 08/10/11 at 11:55 AM that the IJ was lowered to a NIJ at a severity level of "Actual Harm that is not Immediate Jeopardy" as a pattern as the facility was still monitoring implementation of the Plan of Removal.

Based on observation, interview and record review, the facility failed to immediately consult the physician for one (1) of 5 residents reviewed for falls when the resident fell out of her regular bed which had a Bariatric air mattress (a fluctuating air pressurized mattress) and sustained a fractured femur (Resident #1). The resident was transferred to a regional hospital on [DATE] and returned on 07/16/11. Resident #1 was placed back in the same bed she fell out of with the possibility of falling again. This deficient practice resulted in an Immediate Jeopardy (IJ) on 08/09/11. The Director of Nurses was notified that the IJ was called relating to physician notification in a timely manner. Although the IJ was lowered on 08/10/11 the facility remained out of compliance at a Severity of Actual Harm at a Scope of Pattern that is not Immediate Jeopardy as the facility was still monitoring implementation of the Plan of Removal. This deficient practice caused a delay in medical intervention and treatment for [REDACTED]. This deficient practice could also affect the additional 4 residents reviewed for falls. Findings include: The original complaint investigation was conducted on 07/26/2011. The complaint investigation was re-opened on 08/09/11 to gather additional information. An Immediate Jeopardy (IJ) with Substandard Quality of Care (SQC) was identified on 08/09/11. The surveyor exited on 08/10/11. In an interview on 07/26/11 at 10:00 AM the Director of Nurses (DON) stated Resident #1 fractured her femur when she rolled out of bed. The DON stated Resident #1 weight is 326 pounds and she is on a Bariatric bed. She stated Resident #1 was receiving physical therapy services. Review of the incident/accident report dated 07/10/11 of the fall occurring at 12:05 AM documented Resident #1 was found on the floor with no apparent injuries. No answer to a phone call to the physician on 07/10/11 at 6:45 AM. The Change of condition note was faxed to the physician's office at 7:00 AM. The Change of Condition form documented Resident #1 fell out of bed on 07/09/10 incorrectly as she had fell at 12:05 AM Sunday 07/10/11. In an interview on 07/26/11 at 11:48 AM the Attending Physician stated he did not know about Resident #1's fall until he came into the office on Monday morning. He stated no one called him or at least he did not receive any calls or messages on 07/10/11, which was Sunday, from the facility. He said anything they faxed on 07/10/11 went to his office as he does not have a fax at home. He stated he could not remember if he ordered Resident #1 to the local hospital or to the regional hospital. He stated he was not called until the x-ray report was sent. He stated when he saw the x-ray, "I freaked out". He stated he was very upset and he called the facility immediately to have Resident #1 transported to the hospital. In an interview on 07/26/11 at 9:38 AM, the hospital Social Worker stated, "Doctors were concerned as Resident #1 was hemorrhaging in the fracture area of the leg. The doctors said she could have bled to death during the length of time it took to transfer her to the hospital. She did receive a blood transfusion". In an interview on 07/26/11 at 11:55 AM Licensed Vocational Nurse (LVN) #1 stated the dates she wrote as 07/10/11 should have been dated 07/11/11. She stated the night nurse said she had called and left a message with the doctor. LVN #2 stated she was helping the night nurse at shift changed and faxed the Change of Condition form to the physician. She stated she had talked with the nurse at the physician's office on 07/11/11 in the morning to report Resident #1 was in pain and the nurse told her to transport to the hospital. LVN #2 stated Resident #1 only had Tylenol for pain. She stated she called Emergency Medical Services (EMS) and they felt Resident #1 needed to go to the regional hospital as the local hospital did not have orthopedic care. They called the physician and he ordered transport to the regional hospital instead of the local hospital. LVN #2 stated that LVN #1 was in charge of the situation and she just helped by faxing the change of condition form to the physician. In an interview on 07/26/11 at 12:05 PM LVN #1 stated Resident #1 rolled out of her bed at 12:05 AM which was on 07/10/11. She stated she called the physician at 6:45 AM and left a message and faxed the Change of Condition report at 7:00 AM. She stated she checked on Resident #1 during the night and the last time was at 6:30 AM. At 6:30 AM Resident #1 said her leg was hurting. She asked the resident where her leg hurt and she laid her hand on her thigh. Resident #1 did not complain of pain prior to this time. She stated she did not manipulate Resident #1's leg because it was stiff and big. She stated she felt down the thigh and Resident #1 did not complain of pain. She stated she did not see any bruising or swelling and the skin looked okay to her. LVN #1 stated she did not get an answer from the physician at 6:45 AM call so she ordered the x-ray. She stated the DON had told them, in the past, that if an x-ray was needed they could go ahead and order it as this particular physician was okay with this. LVN #1 stated she called mobile x-ray between 6:45 AM and 7:00 AM. She stated the mobile x-ray person asked if this was a STAT x-ray as the x-ray tech did not come on duty until 7:30 AM. LVN #1 stated she told them it was not a STAT x-ray and it was okay to wait until the tech came in. LVN #1 stated it took 4 people to get Resident #1 off the floor and back to bed using a mechanical lift. LVN #1 stated Resident #1 did not complain of a specific area of pain during the rolling and manipulation of her body getting it into the lift sling. LVN #1 stated Resident #1 said she was okay. She stated she was unable to get Resident #1 to tell her how she fell out of bed. She felt any mention of pain from Resident #1 was because of moving her around to get her in the sling and getting her in bed. LVN #1 stated she has requested full bed rails on Resident #1's bed in the past as the half rails are not high enough. LVN #1 stated Resident #1 had full side rails until the Bariatric bed was put in place. Review of the history and physical dated 07/11/11 from the hospital reflected: "Resident #1 is relatively bedridden. She apparently reached over to get a remote and because her bed rails were not up she fell out of bed and sustained a right distal femur shaft fracture. Her [DIAGNOSES REDACTED]. She has a history of [MEDICAL CONDITION]. The Plan as documented was to manage non-operatively because of her not being mobile and the case will be challenging with her obesity and her [MEDICAL CONDITION]. The plan is to transfuse at least one unit of packed red cells." In an interview on 07/26/11 at 10:05 AM Resident #1 stated she fell out of bed as she was reaching for something on her night stand. Resident #1 stated the staff got her back to bed and a man came in to take pictures of her leg later in the morning. Review of Resident #1 "Resident Transfer Form" documented transferred to the hospital on [DATE]. Review of the nurse's notes as written in order of documentation: 07/10/11 At 3:05 PM, "x-ray results in with spiral fracture noted to distal femur. Doctor notified. In bed without complaint of pain, will monitor." At 9:40 PM "fall follow up. In bed this shift. X-ray results [MEDICAL CONDITION] femur. [MEDICATION NAME] - Tylenol (APAP) 500 tablets 2 by mouth times one for pain. Voice no other complaints. Responsible party here to see her and inquired about residents fall. Informed him of the x-ray results and that the doctor would evaluate and order treatment for [REDACTED]. 07/10 7:30 AM "Doctor called and left message about residents fracture and need for treatment, requiring transfer to the local hospital awaiting return phone call, received at 6:30 AM APAP 500 mg as scheduled for pain with movement; resting in bed without pain and call light in reach awaiting return call." At 11:10 AM "doctor returned call and new order to send to the local hospital for evaluation and treatment. EMS (emergency medical services) called relating to the fracture and called the doctor and an order to send resident to emergency room for evaluation and treatment. Family notified of resident status and transfer." In an interview on 07/26/11 at 11:40 AM the DON stated that the times and dates documented by the day nurse and the night nurse was not correct. There was confusion regarding the documented times and date. She stated she called the day nurse and the day nurse agreed that she had documented 07/10/11 at 7:30 AM and 07/10/11 at 11:10 AM should have been documented as 07/11/11 at 7:30 AM and 07/11/11 at 11:10 AM. In an interview on 07/26/11 at 12:55 PM LVN #1 verified that Resident #1 did fall out of her bed on 07/10/11 at 12:05 AM. She stated she must have documented the wrong date when she put 07/09/11 as the date of the fall on the Change of Condition report faxed to the Physician on 07/10/11 at 7:00 AM. Review of the telephone order dated 07/11/11 at 11:20 AM identified Resident #1 to be sent to the emergency room to be evaluated and treated for [REDACTED]. In an interview on 07/26/11 at 12:40 AM the mobile x-ray office person stated that the x-ray tech was dispatched to the facility at 7:30 AM. There were multiple x-rays done at that time and the tech finished at 10:00 AM. The x-ray reports were provided to the facility at 10:22 AM. The office person said that the original call came in at 6:49 AM and it was not a STAT x-ray so the tech was dispatched at 7:30 AM. Review of the policy and procedure for Change of Condition dated June 2008 was not specific to the process of notifying the physician in case of emergency or of incidents/accidents to a resident. In an interview on 08/10/11 at 11:45 AM the DON stated she did not have a specific policy and procedure to notify the physician of emergencies or accidents/incidents. A Plan of Removal for the IJ was submitted on 08/10/11 at 11:55 AM by the DON and the Regional Vice President of Operations. . A plan of removal of the Immediate Jeopardy (IJ) was accepted by the investigator on 08/10/11 at 11:55 AM. The plan of removal included: Golden Years Nursing Center respectfully submits this plan to lift the allegations of immediate jeopardy to resident health and well being identified on 08/09/11. 1. Resident identified to have been affected by the alleged deficient practice. The resident sustained [REDACTED]. Resident complained of pain to the right hip and foot. An X-ray of right hip and right foot was obtained. The X-ray results showed a fracture to the distal shaft of the femur. Resident was transferred to ER for treatment on 07/11/11. The resident returned to the facility with a physician orders [REDACTED]. Upon re-admissions to the facility, the resident was assessed for fall risk and interventions were implemented. The resident's care plan and Care Cardexes were updated to reflect the current interventions. 2. Resident with potential to be affected by the alleged deficient practice. Residents at risk for falls have the potential to be affected by the alleged deficient practice. A 100 % audit of fall risk assessments was completed to identify residents at risk for falls. The care plans and Care Cardexes of residents as at risk for falls have been updated to reflect interventions, as necessary. A 100 % audit of residents identified to have been treated for [REDACTED]. Those residents identified as experiencing pain were assessed and the physician was notified regarding the results of the assessments. New orders were implemented; care plans and Care Cardexes were updated to reflect current treatments. An audit of incident reports from July 26th, 2011 to present was completed to ensure timely notification of change in condition to the physician and to ensure intervention were implemented. Residents identified as having a change in condition have been assessed: orders received, where indicated, and care plans and care Cardexes updated to reflect current interventions. 3. Systemic Measures Residents are assessed for fall risk upon admissions and then reassessed on re-admission, quarterly, annually and with a change of condition. During morning meeting Monday through Friday, residents with falls will be reviewed by the Interdisciplinary Team (IDT) to ensure timely notification of physicians. Falls that occur on Saturday and Sunday will be reviewed by the weekend supervisor to ensure timely notification of physicians. Director of Nursing and Administrator will be notified of any significant injury as they occur. Residents with new orders/interventions will have their care plans and care Cardexes updated to reflect current treatments. Residents identified as having falls or a risk for falls will be added to the Falling Star Program until the IDT reviews the residents at the weekly Care Management Risk Review meeting to determine further interventions and monitoring as necessary. Education The licensed nursing staff will be educated on 08/10/11 by the DON or designee. Notification of Physician must be completed immediately following any change of condition or incident. When an incident or change of condition occurs notification must be made by phone not fax. If you are unable to reach the residents primary care physician notify the medical director. If you are unable to reach either call the Administrator or Director of Nursing. The notification attempts must be documented every time until notification is made. If emergency, call 911 and contact the Administrator or Director of Nursing. This protocol applies to significant injures. If unable to reach physician notify Administrator and Director of Nursing and send Resident to the ER. The licensed nursing staff will be educated on 08/10/11 by the DON on proper assessment of the resident when significant injury occurs. Licensed nurse will evaluate resident by completing a head to toe assessment to assist with identification of physical injury. The licensed nursing staff was educated on 08/09/11 by Director of Nursing on the Fall Management System and the Pain Management System, to include the timely notification of change in condition to the physician. All licensed nurses will be educated quarterly on these systems for one year and annually, thereafter. The licensed nursing staff was educated on 08/09/11 regarding the policy and procedure for abuse and neglect prohibition by the Director of Nursing and /or designee. This education included the timely notification of the physician when a change in condition occurs. All newly hired nursing staff and PRN staff will be educated on the Fall Management System, Pain Management System and the Abuse and Neglect Prohibition Policies and Practices prior to assuming their responsibilities. On a quarterly basis for one year and annually thereafter all staff will be required to complete education regarding the Fall Management System, Timely MD notification of significant injury, Pain Management System and the Abuse and Neglect Prohibition Policies and Practices. The Director of Nursing or designee will compare the employee roster with the attendance sheet to make sure that all staff have been educated regarding these policies as scheduled above. 4. Quality Assessment and Assurance On 08/10/11 the Quality Assessment and Assurance Committee members (including the Regional vice President of Operations, DON, ADON, social Worker and other members of the IDT, conducted an AD HOC Quality Assessment and Assurance meeting to review and approve this plan. The facility's Medical Director also approved the plan. The DON/designee will monitor incident/accident reports and change of condition forms to ensure notification has been made weekly for one month and report to the Committee any trends/patterns identified. The facility will continue to follow policy and procedures related notification of change in condition and Incident/Accident Reporting. The quality Assessment and Assurance Committee will meet weekly for 4 weeks and then monthly thereafter to ensure the facility remains compliant with this plan. The Regional Clinical Director and/or designee will review the Quality Assessment and Assurance Committee minutes' weekly for 4 weeks and then monthly for 6 months to ensure oversight of this plan. The Director of Nurses was notified on 08/10/11 at 11:55 AM that the IJ was lowered to a NIJ at a severity level of "Actual Harm that is not Immediate Jeopardy" as a pattern as the facility was still monitoring implementation of the Plan of Removal.