Every finding on record at Harbor Haven Health & Rehabilitation

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R7) of 2 sampled residents. R7 was on enhanced barrier precautions (EBP) for a left heel pressure injury. Staff did not appropriately change gloves and cleanse hands during wound care. Findings include: The facility's Isolation Precautions policy, revised 3/2025, indicates: .Guidelines for Standard Precautions: .B. Gloves: Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, non-intact skin, mucous membranes, and contaminated items. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms . R7 was admitted to the facility on [DATE]. R7 had a diagnosis of progressive neurological conditions and a pressure injury on the left heel. A Minimum Data Set (MDS) assessment, dated 4/23/26, stated R7 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. Surveyor reviewed R7's wound care orders. The orders indicated to cleanse open area on left ankle with wound cleanser and apply Mepilex every other day (dated 6/5/26) and cleanse open area on right ankle with wound cleanser and apply Meplilex every other day (dated 6/5/26). On 6/30/26 at 1:15 PM, Surveyor observed Registered Nurse (RN)-C complete wound care for R7's left and right ankle wounds. RN-C completed hand hygiene and donned a gown and gloves. RN-C removed a dressing from R7's left ankle, cleansed the wound with wound cleanser, and applied Mepilex without changing gloves or completing hand hygiene. RN-C then completed hand hygiene, donned gloves, and removed a dressing from R7's right ankle. RN-C cleansed and measured the right ankle wound and applied Mepilex without changing gloves or completing hand hygiene. On 6/30/26 at 1:28 PM, Surveyor interviewed RN-C who indicated they should have changed gloves in between dirty and clean tasks during wound care. RN-C indicated they weren't familiar with the dressing change because it was usually completed on the PM shift. On 6/30/26 at 1:35 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should change gloves in between dirty and clean tasks during wound care.

Based on observation, resident and staff interview, and record review, the facility did not ensure call lights were within reach for 1 Resident (R) (R24) of 20 sampled residents. On 2/19/24, Surveyor observed R24's call light on the wall behind an armoire. The call light contained a call button, but not a cord. The call light was not within reach or easily accessible to R24. Findings include: The facility's Resident Call Light policy, dated 6/16/97, indicates: Every resident shall have a functioning call light accessible to them at all times while on bedrest, therefore, allowing the resident to call for assistance from nursing staff as needed (as they are cognitively and physically able) .8. Position call light so as to make it accessible to resident. When appropriate, review call light placement and use with resident before leaving the room. The facility's undated ADL (activities of daily living) Standards of Care policy states in bold, capitalized underlined letters: Ensure call light or appropriate communication device is within resident reach. 1. On 2/19/24 at 11:23 AM, Surveyor entered R24's room and noted R24's call light was on the wall behind an armoire that was approximately 6-7 feet tall, 4 feet wide, and 2 feet deep. The call light was a button unit without a cord and was approximately 4 inches long from the wall. The call light was not within reach or easily accessible to R24. In addition, Surveyor noted a nightstand on the right front side of the armoire also prevented access to the call light. On 2/20/24, Surveyor reviewed R24's medical record. R24's plan of care indicated R24 was at risk for falls. Call light use was not indicated in R24's care plan. Surveyor requested a call light assessment to evaluate R24's ability to use the call light system. An assessment was not provided. On 2/21/24 at 9:53 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who indicated R24 had not fallen. CNA-H verified in order for R24 to use the call light, there needed to be a longer cord that reached around the armoire. On 2/21/24 at 10:08 AM, Surveyor interviewed CNA-I who did not know R24 had a 4-inch call light and was unsure why. CNA-I indicated R24 needed to be in close range in order to use the call light behind the armoire. On 2/21/24 at 10:24 AM, Surveyor interviewed Registered Nurse (RN)-J who stated RN-J did not know R24 had a 4-inch call light and wasn't sure if R24 could use a call light. On 2/21/24 at 12:25 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B believed staff didn't take the call light location into consideration when they moved R24's armoire. DON-B stated the armoire would be moved again to provide access to the call light. On 2/21/24 at 2:23 PM, Nursing Home Administrator (NHA)-A informed Surveyor the facility did not complete a specific call light assessment, however, the facility completed multiple other assessments prior to R24's admission.

Based on staff and resident interview, and record review, the facility did not ensure effective pain management was provided for 1 Resident (R) (R218) of 20 sampled residents. R218 was not provided effective pain management from 12/21/23 through 12/26/23. Findings include: The facility's Pain Management policy, dated 11/30/216, contained the following information: Pain is whatever the experiencing person says it is, existing whenever he/she says it does .4. Complete an assessment of the pain and document the assessment in ECS (electronic medical charting system) when any of the following conditions are present: a. Pain rating of 4 or greater (moderate and above); b. Continues unchanged for 48 hours; c. Daily pain is reported for 7 days. From 2/19/24 through 2/21/24, Surveyor reviewed R218's medical record. R218 was admitted to the facility on [DATE] with diagnoses including dementia, coronary artery disease, heart failure, and peripheral vascular disease (PVD). R218 had an activated power of attorney (POA). According to staff, R218 could make R218's needs known. R218 discharged from the facility on 12/27/23. A nursing note, dated 12/21/23, indicated R218 was yelling out in pain, reported pain in the left hip, and had a hard time lifting or moving the left leg. R218 yelled out when staff attempted to move R218, stated the ball and socket was out of place, and requested to stay in bed. R218 also had increased anxiety about the holidays and seeing family. R218's physician was updated and ordered an X-ray of the left hip. The X-ray was negative for fracture. There were no new orders on 12/21/23 for R218's pain. Surveyor reviewed R218's medication administration records (MARs) which included the following orders: -Acetaminophen 500 milligrams (mg) 2 tablets three times daily for pain (start date 5/2/22). -Alprazolam 0.25 mg three times daily for anxiety (start date 5/2/22). -Acetaminophen 500 mg 1 tablet every 6 hours for pain (start date 5/2/22). -Alprazolam 0.25 mg twice daily as needed (PRN) for anxiety (start date 12/22/23). -Tramadol 50 mg twice daily for pain (start date 12/26/23). -Tramadol 50 mg one time dose at 11:30 AM on 12/27/23. R218 received scheduled medication as ordered. R218's first documented dose of PRN acetaminophen was on 12/25/23 at 3:15 PM, with no follow up result documented. On 12/26/23 at 5:44, AM staff documented no further complaints of pain in response to R218's PRN acetaminophen administered on 12/25/23. On 12/26/23, a new order for tramadol was received for continued reports of left hip pain. R218's MAR documented two doses of tramadol were administered on 12/26/23 in addition to R218's current pain regimen. On 12/27/23, R218's MAR indicated R218 received a scheduled dose and a onetime dose of tramadol before R218 was transferred to the hospital. R218's medical record did not include documentation of non-pharmacological pain interventions between 12/21/23 and 12/27/23. R218's medical record contained a quarterly pain assessment, dated 11/13/23, that indicated R218 did not have pain. A head-to-toe assessment, dated 12/19/23, indicated R218 had chronic shoulder and neck pain and used oral analgesics three times daily and PRN along with rest. A head-to-toe assessment, dated 12/26/23, indicated R218 had chronic leg pain and used oral analgesics and ice. A pain assessment and evaluation of R218's left hip, dated 12/26/23, indicated R218's pain level was not acceptable and new orders were obtained. R218's medical record contained nursing notes, dated 12/21/23, regarding R218's new onset of acute left hip pain. R218's medical record did not contain any follow up assessments of R218's left hip pain and did not indicate other pharmacological or non-pharmacological interventions were offered or provided from 12/21/23 through 12/25/23. On 2/20/23 at 11:46 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated R218 had the most pain while being transferred via sit-to-stand lift. CNA-C recalled a discussions of changing R218's transfer status to a Hoyer lift, but was unsure if R218's transfer status was changed. On 2/20/23 at 12:29 PM, Surveyor interviewed CNA-D who stated R218 had the most pain while transferring via sit-to-stand lift. CNA-D indicated CNA-D helped care for R218 on and off from 12/21/23 through 12/26/23 and stated R218 ate in bed more, was in R218's recliner more, and was not R218's usual self. CNA-D stated R218 liked to sit in R218's wheelchair which was not comfortable at that time. On 2/20/23 at 2:17 PM, Surveyor interviewed CNA-E who stated R218 completed of pain more while transferring to the bathroom via sit-to-stand lift. CNA-E stated CNA-E provided ice packs for R218's pain. CNA-E indicated R218 told CNA-E that R218 knew R218's hip was broken, but an X-ray indicated it was not. CNA-E stated R218 liked to be in R218's wheelchair and liked bingo, however, R218 was in bed and R218's recliner more during that time. CNA-E could not recall if R218's transfer status was evaluated or changed. On 2/21/24 at 9:43 AM, Surveyor interviewed Physical Therapist (PT)-F who worked with R218 from 11/2/23 through 12/12/23 for upper body strengthening. PT-F stated PT-F was not asked to evaluate R218's transfer status after R218 reported left hip pain. PT-F verified between 12/21/23 and 12/27/23, R218 was not evaluated by physical therapy. PT-F also verified R218 remained a sit-to-stand transfer from 12/21/23 through 12/27/23. On 2/21/24 at 12:17 PM, Surveyor interviewed Director of Nursing (DON)-B who stated with a new onset of pain, nurses are expected to assess a resident. DON-B indicated nurses have options in a resident's medical record to initiate a to do list specific for a resident assessment, including a stop and watch tool and a nursing 24 hour board to follow acute situations. When Surveyor indicated R218's medical record did not contain follow up assessments of R218's left hip pain between 12/21/23 and 12/26/23, DON-B verified the above process did not occur and recommended Surveyor interview Medical Director (MD)-G (R218's physician). On 2/21/24 at 1:12 PM, Surveyor interviewed MD-G who stated nursing staff notified MD-G of R218's pain, but could not verify when MD-G was notified. MD-G indicated when staff noted R218 had increased pain, MD-G ordered an X-ray, talked about a therapy evaluation, and ordered a CT (Computed Tomography) scan. On 12/27/23, R218 was sent to the hospital for a CT scan which indicated a left hip fracture. R218 did not return to the facility. MD-G indicated R218 was not visibly in a lot of pain while sitting, but complained of pain more during transfers. MD-G stated MD-G expected nursing staff to involve physical therapy to evaluate R218's transfer status. R218 had a diagnosis of dementia which also contributed to increased confusion during that time frame. R218's medical record indicated MD-G was updated on 12/21/23, 12/26/23 and 12/27/23. No other documentation was provided.

Based on record review and staff interview, the facility did not ensure all alleged violations involving resident-to- resident altercations were reported timely to the State Agency (SA) and/or reported timely to the facility's administration for 4 Residents (R) (R5, R4, R1 and R2) of 6 sampled residents. The facility's administration was informed of a resident-to-resident altercation between R4 and R3 on 2/11/23. During the investigation, the facility was alerted to a previous resident-to-resident altercation between R4 and R5 on 2/11/23. Staff did not report the interaction between R4 and R5 to the facility's administration timely. In addition, the facility did not report the altercation between R4 and R5 to the SA until 2/20/23. The facility's administration was informed on 12/5/22 of a resident-to-resident altercation that occurred between R1 and R2 at 12:00 PM. The facility did not report the resident-to-resident altercation to the SA within the required timeframe. Findings include: The facility's Resident Abuse/Complaints-Investigation and Prevention policy, dated 7/17/19, contained the following information: .Staff members are trained on this subject at every new employee orientation, for all staff at least annually, and additionally based on the needs of the facility as assessed at any given time. Furthermore, each staff member is responsible for immediately reporting any allegations or complaints in person and ensuring the safety of the residents, regardless of a diagnosis, psychosis, delusions, or cognitive impairment, as part of his/her assigned duties. Allegations involving resident mistreatment, neglect, abuse, misappropriation of resident property, exploitation, and injuries of unknown source shall be reported immediately and not to exceed 24 hours after the incident. This immediate reporting shall be made to the Nursing Home Administrator or designees, who will complete the electronic Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report form via the Misconduct Incident Reporting (MIR) system .The purpose of this procedure is to investigate and document any resident complaint or concern about any issue, regardless of a resident's diagnosis of psychosis, delusions, or cognitive impairment, in order to ensure that the resident's complaint or concern is dealt with on a timely basis and in a complete manner . 1. On 3/1/23, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance and metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function). R3's Minimum Data Set (MDS) assessment, dated 12/12/22, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R3 had moderate cognitive impairment. R3's guardianship documents, dated 1/21/22, indicated R3's court-appointed guardian was responsible for R3's healthcare decisions. On 3/1/23, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance, major depressive disorder and anxiety disorder. R4's MDS assessment, dated 1/9/23, contained a BIMS score of 4 out of 15 which indicated R4 had severe cognitive impairment. R4's guardianship documents, dated 11/18/19, indicated R4's court-appointed guardian was responsible for R4's healthcare decisions. On 3/1/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance and anxiety disorder. R5's MDS assessment, dated 12/19/22, contained a BIMS score of 2 out of 15 which indicated R5 had severe cognitive impairment. R5s guardianship documents, dated 3/11/21, indicated R5's court-appointed guardian was responsible for R5's healthcare decisions. On 3/1/23, Surveyor reviewed facility-provided investigation documents which contained the following information: .On 2/11/23 at approximately 4:00 PM on (R4's unit), staff observed (R4) swat (R3) in the left arm/shoulder area with a magazine .Based on further investigation, it should be noted (R4) also made brief and light contact with another resident with the same magazine. (R4) previously took the magazine (R4) used to hit (R3) in the arm from another resident (R5). Staff reported (R5) objected to (R4) taking the magazine from (R5) at which point (R4) lightly swatted (R5) on the top of the hand as (R5) was telling (R4) to give (the magazine) back . The investigation documents included a written statement from Registered Nurse (RN)-D, dated 2/13/23, that contained the following information: (R4) (was increasingly) anxious all shift. (R4) approached (R5) .and grabbed a magazine out of (R5's) hand. (R5) stated, That's mine! Give it back! (R4) swatted (R5) on the hand (with) the magazine. (RN-D) intervened. (R4) walked toward (R3) who was sitting at the nurses' station. (R3) told (R4) that (R4) started it. (R4) swatted (R3) on the (left arm) (with) the magazine. (RN-D) intervened . Included in the investigative documents was a print-out of R4's nursing progress notes which contained an entry, dated 2/11/23, with the following information: .BEHAVIOR: Snatched the magazine (R5) was holding. (R5) retaliated and screamed this is mine, give it to me! (R4) slapped (R5's) hand with the magazine, staff intervened and set them apart. (R5) went in (R5's) room and (R4) turned to (R3). When (R3) commented that (R4) was the one who started the fight, (R4) hit (R3's) arm with the magazine as well . Hand written on the print-out was *DON (Director of Nursing) notified of incident between (R4) (and) (R3). Further information (regarding) (R5) (and) (R4) was discovered on 2/13/23 after initial report was submitted. On 3/1/23 at 12:25 PM, Surveyor interviewed RN-D who verified RN-D was the nurse on duty at the time of the above incidents. RN-D reiterated the events as indicated in RN-D's statement and stated RN-D's main concern was keeping residents safe. RN-D stated RN-D stayed on the unit to ensure resident safety and did not return to the nurses' station until the next nurse arrived for duty. RN-D stated RN-D gave report to Licensed Practical Nurse (LPN)-C and included the incident between R4 and R5 as well as the incident between R4 and R3. RN-D stated, I think (LPN-C) was the one that called (DON-B). RN-D indicated the incidents occurred at approximately 4:30 PM on 2/11/23 and RN-D's shift ended at 6:00 PM. RN-D stated shift change report was verbal and verified there was no documentation of what was said in shift change reports. On 3/1/23 at 12:53 PM, Surveyor interviewed LPN-C via phone. LPN-C verified LPN-C received shift report from RN-D on 2/11/23. LPN-C stated LPN-C called DON-B at approximately 6:30 PM and stated, I told (DON-B) (R4) hit (R3) with a magazine. When questioned, LPN-C verified RN-D told LPN-C in report that R4 also hit R5. When questioned, LPN-C stated LPN-C also told DON-B that R4 hit R5. On 3/1/23 at 1:00 PM, Surveyor interviewed DON-B who verified LPN-C notified DON-B of the incident between R4 and R3. DON-B stated, (LPN-C) had called me and walked me through that (R4) had a magazine or paper. (R3) had made a comment and (R4) tapped (R3) lightly with magazine. I then had (LPN-C) give the phone to (Certified Nursing Assistant (CNA)-E) who was the CNA that was there (when it happened). DON-B stated DON-B spoke with CNA-E and said, I had (CNA-E) walk me thru about what happened between (R4) and (R3). DON-B indicated the initial report was about R4 and R3 then stated, But on Monday (2/13/23) when we reviewed (name brand of electronic medical record) charting we noticed (R4) had hit (R5) prior to hitting (R3). When questioned what DON-B would have done had DON-B been told about both incidents on 2/11/23, DON-B stated I would have reported (to SA) separately. On 3/1/23 at 1:33 PM, Surveyor interviewed DON-B who indicated the facility provided staff with one-on-one re-education regarding reporting timely when we called them for interviews. DON-B verified LPN-C only told DON-B about the incident between R4 and R3 because that what was told to (LPN-C) in report. DON-B verified the facility did not re-educate all staff about reporting timely. On 3/1/23 at 2:14 PM, Surveyor interviewed Social Worker (SW)-F who provided Surveyor with the document below. SW-F verified the document indicated RN-D was the only staff member re-educated on reporting requirements. On 3/1/23, Surveyor reviewed a facility-provided undated and unsigned document that contained the following information: Social worker met with (RN-D) on Monday, February 13, 2022 (sic) to obtain information regarding a resident-to-resident incident reported to DON that occurred between (R4) and (R3) on Saturday, February 11, 2022 (sic). Upon reviewing information for (R4) and (R3) related to the incident, behavior documentation for (R4) indicated (R4) had contact with an additional resident, (R5), prior to making contact with resident (R3) .(SW-F) spoke with (RN-D) regarding the importance of reporting incidents to the DON/Administrator when more than one resident may have been impacted . 45942 2. On 3/1/23, Surveyor reviewed R1's medical record. R1's latest admission to the facility was on 8/25/22 with diagnoses to include dementia with behavioral disturbance, restlessness and agitation. R1's MDS assessment, dated 2/20/23, contained a BIMS score of 1 out of 15 which indicated R1 had severe cognitive impairment. On 3/1/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses to include Alzheimer's disease, unspecified dementia with other behavioral disturbance and obsessive-compulsive disorder (OCD) (a pattern of unwanted thoughts and fears (obsessions) that leads one to do repetitive behaviors (compulsions)). R2's MDS assessment, dated 12/19/22, contained a BIMS score of 7 out of 15 which indicated R2 had severe cognitive impairment. On 3/1/23, Surveyor reviewed facility-provided investigation documents regarding a resident-to-resident altercation that occurred on 12/24/25 at 12:00 PM. After R2 finished eating lunch, R2 approached the sliding garbage receptacle while R1 stood by the garbage receptacle and moved the receptacle back and forth. R2 threw R2's food away and closed the garbage receptacle lid on R1's left hand which resulted in an abrasion to R1's left thumb. Prior to the incident, R1 was wandering in the dining area with staff supervision. Staff indicated R2 fixates on dining times and what R2 perceives as residents being in the right place during those times. R2 may have been upset because R1 was not in the right place and wandering around. R1 and R2 were separated and remained separated. R1 and R2 were interviewed as well as staff who were present and other residents. Staff education was completed. R1 and R2's representatives and provider were contacted following the incident. R1 and R2's care plans were updated and SW-F followed up with both residents. The Interdisciplinary Team (IDT) discussed the incident, but could not substantiate if R2's action was deliberate. On 3/1/23 at 11:53 AM, Surveyor interviewed DON-B who confirmed LPN-G was the nurse on duty at the time of the incident. DON-B verified LPN-G reported the incident to DON-B on 12/24/22 at 12:00 PM; however, DON-B did not report the incident to the SA until 12/25/22 at 8:30 PM. DON-B stated DON-B was on-call 24 hours on the day of 12/25/22, but could not find a computer to submit the above incident within 24 hours after being informed. DON-B stated DON-B's earliest access to a computer was at 8:30 PM on 12/25/22. When Surveyor asked DON-B if anybody else could have reported the incident, DON-B indicated Nursing Home Administrator (NHA)-A and SW-F had access to submit reports online via the Misconduct Incident Reporting (MIR) system. DON-B indicated NHA-A was out of the country and SW-F was not working. DON-B agreed DON-B could have called SW-F to submit the incident.

Based on observation, record review and staff interview, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 30 opportunities which resulted in a 6.67% medication error rate affecting 2 Residents (R) (R39 and R44) of 10 residents observed during medication pass. R39 had an order for [REDACTED]. R44 had an order for [REDACTED]. During the observation of R44's AM medication administration, [MEDICATION NAME] Sodium was given at 9:10 AM when R44 had just finished breakfast. Findings include: 1. On 1/30/19 at 11:58 AM, Surveyor observed RN (Registered Nurse)-C administer medication to R39. Prior to the administration of the medication, Surveyor and RN-C verified the amount of insulin in the prepared syringe. Surveyor observed RN-C administer 9 units of [MEDICATION NAME] Insulin. R39 had not yet been served lunch when the dose of insulin was administered. On 1/30/19 at 3:00 PM, Surveyor reviewed the physician orders [REDACTED]. On 1/31/19 at 7:58 AM, Surveyor interviewed RN-C. RN-C stated the order was recently changed and RN-C didn't realize it at the time of administration. RN-C verified the insulin dose should have been administered after the meal. On 1/31/19 at 09:30 AM, DON (Director of Nursing)-B came to Surveyor. RN-C had told DON-B about the above insulin situation. DON-B discussed situation with Surveyor. During the discussion DON-B verified that since the order stated to give the insulin after meals, the insulin should have been given after the meal. 2. On 1/31/19 at 9:10 AM , Surveyor observed RN-D administer medication to R44. Prior to the administration of the medication, Surveyor and RN-D verified the number of pills that were prepared. Surveyor observed RN-D administer: 20mg (milligrams) of Paraxetine HCL (used to treat depression), 88mcg (micrograms) of [MEDICATION NAME] sodium (used to treat [MEDICAL CONDITION]), 25mg-100mg of [MEDICATION NAME]-[MEDICATION NAME] (used to treat [MEDICAL CONDITION] Diease), 100mg of [MEDICATION NAME] (used to treat nerve pain), 81mg of aspirin (used to lower risk of [MEDICAL CONDITION]), 20mg of [MEDICATION NAME] (used in the prevention of ulcers), and 100mg of [MEDICATION NAME] hcl (used to treat influenza). R44 had just finished eating breakfast with empty meal tray sitting on over-bed table in front of R44. On 1/31/19 at 10:47 AM, Surveyor reviewed R44's medical record. R44's care plan did not mention when R44 preferred to receive [MEDICATION NAME]. Full prescribing information for [MEDICATION NAME] Sodium found on-line at https://www.pdr.net/full-prescribing-information/[MEDICATION NAME]-[MEDICATION NAME]-sodium-26 stated, Administer once daily, preferably on an empty stomach, one-half to one hour before breakfast. On 1/31/19 at 10:52 AM, Surveyor interviewed R44 who indicated R44 has, been on [MEDICAL CONDITION] med for months and that R44 usually takes it on empty stomach. On 1/31/19 at 10:54 AM, Surveyor interviewed RN-D who stated when asked, [MEDICATION NAME] is a [MEDICAL CONDITION] medication, I heard it should be taken 1/2 hr before eating. RN-D indicated there are resource materials (nursing drug books) available when asked. RN- D stated that R44 has an order stating, may give AM medications between 5am and 10am daily' but that R44 should have received [MEDICATION NAME] before breakfast. On 1/31/19 at 11:37 AM, Surveyor interviewed DON-B who verified, [MEDICATION NAME] should have been given on empty stomach.

Based on record review and staff interview, the facility did not ensure 6 Residents (R) (R72, R173, R51, R49, R13 and R29) of 6 residents reviewed for hospitalization s and discharges received required written transfer notification including the reason for their transfer, the location of their transfer, their appeal rights and the contact information for the State Long-Term Care Ombudsman. R72 was transferred to the hospital on [DATE]. R72 and/or R72's representative were not provided with a written notice at the time of the transfer. R173 was transferred to the hospital on [DATE]. R173 and/or R173's representative were not provided with a written notice at the time of the transfer. R51 was transferred to the hospital on [DATE] and 12/20/18 . R51 and/or R51's representative were not provided a written transfer notice for the above transfers. R49 was transferred to the hospital on [DATE]. R49 and/or R49's representative were not provided a written transfer notice. R13 was discharged to the hospital on [DATE]. R13 and/or R13's legal representative were not provided with a written transfer notice. R29 was discharged to the hospital on [DATE], 10/22/18 and 11/10/18. R29 and/or R29's legal representative were not provided with a written transfer notice. Findings include: 1. On 1/31/19, the Surveyor reviewed R72's medical record. R72 was transferred to the hospital on [DATE] following a fall and head contusion. R72's medical record did not include documentation that a written transfer notice was given to R72 or R72's representative at the time of the transfer. 2. On 1/31/19, the Surveyor reviewed R173's medical record. R173 was transferred to the hospital on [DATE] for aspiration pneumonia. R173's medical record did not include documentation that a written transfer notice was given to R173 or R173's representative at the time of the transfer. 3. The Surveyor reviewed R51's medical record which indicated R51 was transferred to the hospital on [DATE] and 12/20/18. The resident's medical record did not include documentation that a written transfer notice had been given to the resident and/or representative for the above transfers. On 2/1/19 at approximately 11:00 AM, DON-B verified R51 or the resident's representative did not receive a transfer notice regarding the transfers on 10/26/18 and 12/20/18. 4. Surveyor reviewed R49's medical record which indicated R49 was transferred to the hospital on [DATE]. The resident's medical record did not include documentation that a written transfer notice had been given to the resident and/or representative for the above transfer. 5. On 1/31/19, the Surveyor reviewed R13's electronic medical record. R13 was transferred to the hospital on [DATE]. The Surveyor did not find documentation or a copy of a written transfer notice given to R13 or R13's legal representative. On 1/31/19 at 2:55 p.m., DON-B verified the facility had not given R13 or R13's legal representative a written transfer notice when R13 was hosptalized on [DATE]. 6. On 1/31/19, the Surveyor reviewed R29's electronic medical record. R29 was transferred to the hospital on [DATE], 10/22/18 and 11/10/18. The Surveyor did not find documentation or a copy of a written transfer notices given to R29 or R29's legal representative. On 1/31/19 at 2:55 p.m., DON-B verified the facility had not given R29 or R29's legal representative a written Transfer notice when R29 was hosptalized on [DATE], 10/22/18 and 11/10/18. On 1/31/19, the Surveyor interviewed DON-B regarding the transfer notices for all six of the above residents requested by the surveyors. DON-B thought the surveyors were asking for room transfer notices and did not realize the facility was required to provide the residents and the residents' representatives with a written transfer notice including the date of the transfer, the location, the reason for the transfer along with information for the Ombudsman and the State survey agency regarding the residents' appeal rights. On 1/31/19, at approximately 4:00 p.m., the Surveyor met with NHA (Nursing Home Administrator)-A. NHA-A verified that the facility does not provide a written transfer notice with the required information to the residents and/or their representative as required.

Based on observations and staff interviews, the facility did not ensure the resident's environment remained free of accident hazards for 8 (Resident 18, 19, 20, 21, 22, 23, 24 and 25) sampled and supplemental sampled residents residing on the Sunrise unit and 3 (Resident 26, 27 and 28) supplemental sampled residents residing on Sunset unit. The steam wells for the steam tables were turned on before each meal on the Sunrise and Sunset units and then would leave the kitchen area without direct supervision. Two of three units that have steam tables built into the islands and countertops in the vicinity of the residents rooms, contained stainless steel domed lids that were very hot to touch and did not have proper devices in place to prevent injuries from occurring. The temperatures of the large heated domed covers of the steam tables were at dangerous levels that reached 135.2 degrees F (Fahrenheit) to 204.5 degrees F. The facility's practices had the potential to affect 8 out of 19 residents residing on Sunrise unit and 3 out of 16 residents residing on Sunset unit. Findings include: According to The State Operations Manual, water may reach hazardous temperatures: Water Temperature Time Required for a 3rd Degree Burn to Occur 155 F 1 second 148 F 2 seconds 140 F 5 seconds 133 F 15 seconds On 8/15/16 11:18 a.m., during the environmental tour on Sunris, Surveyor observed the open concept kitchen with resident rooms located on both sides of the kitchen on the Sunrise unit. The kitchenette was not directly supervised by staff at this time. The three large metal domed covers over the steam wells were very hot to the touch. The steam table was located in the island, allowing sufficient room for a resident in a wheelchair to touch the metal domed covers. In addition, a resident standing on the outside of the island could easily reach over and touch the metal domed covers of the steam table. On 8/15/16 at 11:20 a.m., using the facility's thermometer, Surveyor obtained temperatures of all three steam wells of the steam table by placing the thermometer underneath the metal domed cover. From left to right the steam wells/metal domed cover temperatures were 156.7 degrees F, 160.3 degrees F and 147 degrees F. These temperatures were verified by AA (Activity Assistant)-D. In addition, AA-D verified the first two large metal domed covers were very hot to the touch. At this time there were three staff members observed on the unit: 1 nurse with her medication cart behind the nurse's station was passing medications, 1 CNA (Certified Nursing Assistant) who was in and out of resident rooms providing cares and AA-D. AA-D was providing an activity for some of the residents on the unit. On 8/15/16 at 11:30 a.m., Surveyor , RN (Registered Nurse)-C and NHA (Nursing Home Administrator)-B observed the kitchenette on Sunrise unit. RN-C touched the tops of the large metal domes covering the steam wells/steam table and indicated they were very hot to the touch. NHA-B indicated the open concept kitchenette should be attended by staff and only staff can turn the steam wells on by using a key. On 8/15/16 at 11:35 a.m., Surveyor rechecked the temperatures of all three steam wells of the steam table using a facility thermometer. At this time, the temperatures going left to right were 202.5 degrees F, 204.5 degrees F and 178.2 degrees F. These temperatures were verified by RN-C and NHA-B. On 8/15/16 at 11:40 a.m., Surveyor , NHA-B and RN-C went to check the temperatures of the large metal domed covers over the three steam wells/steam table on the Sunset unit. The open concept kitchenette had resident rooms located on either side. The steam table was located in the island, allowing sufficient room for a resident in a wheelchair to touch the metal domed covers. In addition, a resident standing on the outside of the island could easily reach over and touch the metal domed covers of the steam table. On 8/15/16 at 11:43 a.m., using the facility's thermometer, Surveyor placed the thermometer underneath the metal domed cover and obtained the following temperatures from left to right for the three steam wells; 130.1 degrees F, 130.8 degrees F and 145.8 degrees F. DM (Dietary Manager)-E then joined Surveyor , NHA-B and RN-C. On 8/15/16 at 11:50 a.m., Surveyor rechecked the temperatures of all three steam wells of the steam table using a facility thermometer. At this time, the temperatures going left to right were 140.5 degrees F, 132.2 degrees F and 155 degrees F and verified by DM-E. DM-E indicated dietary staff should be directly supervising the heating steam wells while they complete their duties until they leave for a very short period to go to the kitchen to bring back the food for the meal services. On 8/15/16 at approximately 3:00 p.m., Surveyor measured the distances between the back counters and shell cooler with the front counter with the steam wells. The distance between the counter and the steam wells was 56 inches, and 42 inches between the shell cooler and the steam wells. Due to the set up and location of the open concept kitchenettes residents would take the path through the kitchenette to reach their rooms or visa versa. On 8/15/16 at 3:50 p.m., NHA-B and DM-E were training dietary staff on how to use the newly purchased fire blankets to cover the large metal domed covers over the heating steam wells to protect residents from accidentally burning themselves on the covers. On 8/16/16 at 12:12 p.m., DM-E faxed over the following information for Surveyor to review. The information provided by DM-E is as follows: ~ Breakfast- the steam wells are turned on at 7:15 a.m. and meal service begins at 7:50 a.m. ~ Lunch- the steam wells are turned on at 11:00 a.m. and meal service begins at 12:00 p.m. ~ Supper- the steam wells are turned on at 5:00 p.m. and meal service begins at 5:50 p.m. According to the information provided, dietary staff have multiple duties in preparation for each meal and routine tasks. The heating steam wells are left unsupervised for a short period of time while staff go to the kitchen to pick up the food to be served for the meal.

Based on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures assuring the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of residents in 2 of 3 medication rooms. The Island Unit medication refrigerator contained an expired, opened multi-use vial of Aplisol tuberculin test that was administered to 25 residents and had the potential to affect 15 additional residents. The Sunrise/Sunset medication refrigerator contained two boxes of Prevnar 13 vaccine which were observed to have evidence of being frozen. The boxes observed had the potential to affect 8 residents. The Sunrise/Sunset medication room contained an unopened, expired stock supply bottle of Calcium 600 plus D. Findings include: According to the facility's document labeled HH Island, Unit Nurse 7 years, an entry dated 7/2/10 at 9:42 a.m., instructed nursing staff to: Clean medication room, including fridge 1st Friday and 3rd Friday on night shift. Check expiration dates of all medications .(order and discard as needed) on 2nd and 4th Friday, night shift. The facility's Recommended Minimum Medication Storage Parameters (based on manufacturer guidance), last revised March 31, 2016, instructed: Aplisol Injection: Store in refrigerator at 36 - 46 degrees F (Fahrenheit) .Date when opened and discard unused portion after 30 days. Prevnar 13 Injection: Store in refrigerator at 36 - 46 degrees F. Do not freeze . A product insert for Prevnar 13 Vaccine instructed: Do not freeze. Discard the vaccine if it has been frozen. 1. On 8/16/16, at 1:05 p.m., Surveyor performed a routine observation of the Island unit medication refrigerator. Within the refrigerator was an opened, multi-use bottle of Aplisol, Tuberculin Purified Protein Derivative Diluted, for performing Tuberculin skin testing. The 5 ml (milliliter) vial, lot number 3, contained 5 TU (tuberculin units)/0.1 ml, the equivalent of 50 tests, remained approximately 1/3 full and was labeled with an open date of 12/30/15. RN (Registered Nurse)-H confirmed the above observation and verified that once opened, the vial should have been discarded after 28 days. On 8/16/18, at 1:15 p.m., RNUM (Registered Nurse Unit Manager)-K verified to Surveyor the the Aplisol vial was expired and confirmed staff should be following a system of night shift staff checking the refrigerator for expired medications. On 8/16/16, at 2:35 p.m., IPRN (Infection Prevention Registered Nurse)-J verified to Surveyor that 35 doses of Aplisol had been given to 25 residents, since it expired on 1/29/16; doses were administered between 5/24/16 and 8/12/16. IPRN-J confirmed 15 tests remained in the vial and would have potentially been given to residents. On 8/16/16, at 3:30 p.m., Surveyor interviewed DON (Director of Nursing)-I, who confirmed the doses given from the Aplisol vial were only for residents and not given to employees. 2. On 8/16/16, at 11:52 a.m., Surveyor performed a routine observation of the Sunrise/Sunset unit medication room and refrigerator. RN (Registered Nurse)-F, confirmed the thermometer inside the refrigerator read 41 degrees F and displayed a temperature log which indicated temperatures within the 36 - 46 degree F range requirement. Within the medication refrigerator were two boxes of Prevnar 13 pneumococcal vaccine, banded together, resting on a shelf and touching the back wall of the mini-refrigerator. The short ends of the boxes were covered with a layer of ice, approximately 3-4 mm (millimeter) thick, where the boxes had contacted the wall of the refrigerator. The contents of pre-filled syringes inside the boxes was in liquid form, without obvious ice present. Labeling on both boxes indicated: Store in refrigerator; Do Not Freeze. One box, sealed, with lot number M , contained 10 unit doses. Eight doses remained in the second, unsealed, box with lot number M . RN-F verified the above observation and reported to the unit manager. On 8/16/16, at 11:56 a.m., Surveyor interviewed RNUM (Registered Nurse Unit Manager)-G, who confirmed the above observation and verified the vaccines could have been frozen. RNUM-G indicated a different storage container would be used in the future, to keep the vaccine packages from touching the refrigerator wall. RNUM-G indicated the refrigerator was new at the end of April 2016, when the remodeled unit was opened. On 8/16/16 at 12:05 p.m., Surveyor interviewed IPRN (Infection Prevention Registered Nurse)-J, who confirmed the potentially frozen vaccines were no longer usable. At 2:35 p.m., on 8/16/16, IPRN-J verified, to Surveyor , that the most recent delivery of Prevnar 13 vaccine was 7/11/16. However, of residents who were admitted after 7/11/16, none had received the lot number M . IPRN-J confirmed being unable to determine who had received the two missing doses of Prevnar 13 because the facility had received multiple doses with the same lot number. 3. On 8/16/16, at 12:05 p.m., during a routine tour of the Sunrise/Sunset medication room, Surveyor observed one unopened, house stock bottle of Calcium 600 mg (milligram) plus D, 60 tablets, with a manufacturer expiration date of 3/2016. RNUM-G verified the observation and confirmed the supplement was expired and would be disposed of. RNUM-G confirmed the licensed nursing staff was responsible for checking expiration dates on medications/supplements and indicated staff would be re-educated to store medications/supplements so those nearest to expiration would be positioned on the front of the shelf.

Based on observation, staff interviews, and record review, the facility did not ensure appropriate infection prevention measures were implemented for 1 (Resident 13) of 16 sampled residents during the provision of cares where hand hygiene for staff and residents was indicated. CNA (Certified Nursing Assistant)-A was observed providing cares for Resident 13. The CNA did not perform hand hygiene when gloves became soiled and prior to removing the soiled gloves and touching clean items in the resident's room. Additionally, CNA-A did not cue or offer for Resident 13 to wash hands after the resident had used the toilet. Findings include: According to the facility's Handwashing policy updated 8/2016, staff were directed to provide hand hygiene during multiple situations including after touching mucous membranes, body fluids, excretions, objects likely to be contaminated with infectious organisms, and after removing gloves. According to the most recent MDS (Minimum Data Set) assessment dated [DATE], Resident 13 had some cognitive impairment, required extensive staff assist with personal hygiene cares, and was incontinent of bowel and bladder. On 8/12/16 at 9:19 a.m., Surveyor observed CNA-A provide care for Resident 13. Upon entering the resident's room, Resident 13 was seated on the toilet and indicated resident had completed toileting and was ready for CNA-A to assist resident. CNA-A performed hand hygiene and applied disposable gloves. Urine and feces were observed in the toilet. The resident informed the CNA-A that the resident had already wiped self, but said the CNA should also do it to make sure resident did a good job. The resident stood up independently and held onto the grab bar while CNA-A used disposable wipes to provide pericare to the resident. The CNA completed wiping the resident, removed the soiled gloves, and without performing hand hygiene, CNA-A touched the resident, the resident's pants, and the resident's wheelchair before performing hand hygiene. Once seated in the wheelchair, CNA-A and Surveyor were exiting the bathroom and Resident 13 indicated resident was going to stay in the bathroom to brush teeth. The CNA exited the resident's room. On 8/16/16 at 10:40 a.m. CNA-A verified to Surveyor hand hygiene should have been performed when the soiled gloves were removed and prior to touching clean items. CNA-A indicated the resident is confused at times and although the resident stated resident had wiped self, the CNA did not think resident had done so because there was no toilet paper in the toilet. CNA-A also verified not cueing the resident to perform hand hygiene, and did not stay in the bathroom to ensure that Resident 13 had done so before brushing teeth.

Based on observation, staff interview and record review, the facility did not ensure that 1 (resident #10) of 15 sampled residents reviewed for pressure ulcer risk received necessary services to prevent pressure ulcers from developing. Resident #10 was assessed to be at risk for the development of pressure ulcers and was receiving preventative treatment for [REDACTED]. Resident #10 was to have heels free floated per current standard of practice. Resident #10 was observed in bed with soft Skil care boots on and with heels placed directly on the mattress, rather than free floating. Findings include: The Quick Reference Guide entitled, Pressure Ulcer Prevention, published by the NPUAP (National Pressure Ulcer Advisory Panel) in 2009 indicated high pressures over bony prominence's, for a short period of time, and low pressures over bony prominence's, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to. Ensure that the heels are free of the surface of the bed. Heel protection devices should elevate the heel, completely off loading them. The second edition published in 2014, entitled Prevention and treatment of [REDACTED]. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called 'floating heels.' Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows. 1. On 6/9/15, surveyor # reviewed resident #10's medical record. The face sheet dated 1/26/15, indicated the resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. Resident #10's significant change MDS (Minimum Data Set) assessment dated [DATE], documented the resident's cognition to be moderately impaired. The resident required extensive assistance with bed mobility, did not ambulate and only got out of bed once or twice during the assessment period. The MDS also indicated the resident was at risk for pressure ulcer development, had a pressure reducing device for chair and bed, was on a turning/repositioning program, and had a nutrition intervention to manage skin problems. Resident #10's current hospice plan of care followed by staff at the facility and dated 5/11/15, indicated staff were to document changes in skin integrity. The current Hospice Aide Progress Note followed by staff at the facility dated 6/8/15, indicated resident #10 was bedbound and did not have heel protectors applied. Resident #10's triggered CAA (Care Area Assessment) related to pressure ulcers dated 4/13/15, documented the resident did not have pressure ulcers, [MEDICATION NAME] in place on spine for preventative skin breakdown due to high risk, impaired nutrition, and being bedbound. Follow hospice care plan. A follow up assessment attached to the CAA dated 6/8/15, documented the resident had a specialty bed, had a change of position every two hours, Skil care boots at all times, and [MEDICATION NAME] dressing on spine for protection. Resident #10's Braden Scale assessment score of 17 completed on 6/13/15, documented the resident was at low risk for the development of pressure ulcers. Identified risks included the resident being bedfast, having very limited mobility and friction/shear being a problem. On 6/9/15 at 9:25 a.m., 10:20 a.m., 1:11 p.m., 1:46 p.m., and 2:55 p.m., surveyor # observed resident #10 laying in bed with soft Skil care boots on both feet and both heels were placed directly on the mattress rather than free floating. On 6/10/15 at 9:00 a.m., 11:15 a.m., 11:40 a.m., 12:06 p.m., and 12:12 p.m., surveyor # observed resident #10 laying in bed with soft Skil care boots on both feet and both heels were placed directly on the mattress rather than free floating. On 6/15/15 at 10:14 a.m., surveyor # observed CNA (Certified Nursing Assistant)-E and CNA-F provide cares for resident #10. The resident was laying in bed with soft Skil care boots on both feet and both heels were placed directly on the mattress. There was a flat pillow under the resident's legs. After repositioning the resident, CNA-F placed covers over the resident and indicated cares were completed. Surveyor # asked if the resident's heels should be free floating. CNA-E and CNA-F verified the heels should be floating in addition to wearing the soft boots. CNA-E stated the heels should be free floating and a second pillow was placed under the resident's legs to free float the heels. On 6/15/15 at 2:05 p.m., surveyor # interviewed ADON (Assistant Director of Nursing)-B regarding the prevention of pressure ulcers. ADON-B provided surveyor # with information regarding resident #10 and education provided to staff related to free floating heels when in bed. The information dated 6/15/15 indicated protective boots are provided by hospice for resident #10. Discussed with hospice nurse and aide to possibly put this specific intervention into all of their hospice care plans going forward to include free floating heels in addition to the Skil care boots. Education was given to all staff to ensure all residents have free floating heels when in bed. The education dated 6/15/15 indicated residents must have a pillow under their feet to off load pressure when in bed. If resident is wearing Skil care/protective boots, it is still necessary to FLOAT heels.

Based on record review, observation and staff interview, the facility did not ensure residents were free of a medication error rate of five percent or greater for 1 (resident #9) of 8 sampled and supplemental sampled residents observed during medication administration. Two of twenty-five opportunities observed during medication administration resulted in errors to equal an error rate of 8 percent. Resident #9's [MEDICATION NAME] inhaler was not administered as directed by the manufacturer. Findings include: 1. On 6/9/15 at 3:29 p.m., surveyor # observed RN (Registered Nurse)-C hand resident #9 an [MEDICATION NAME] 250/50 inhaler ready for inhalation. RN-C did not provide the resident with instructions to breathe out as long as possible prior to the inhalation, to hold breath for 10 seconds or longer after the inhalation and did not advise the resident to breathe out slowly as long as the resident could after inhaling the medication. Resident #9 inhaled the medication without breathing out as long as possible prior to the inhalation, did not hold breath for 10 seconds or longer after inhalation and did not breathe out slowly for as long as the resident could after inhaling the medication. RN-C verified the above observations and verified instructions were not provided to the resident prior to the administration of the inhaler. RN-C then stated the resident does it on (his/her) own. I don't have to tell (the resident) to clear lungs prior to inhalation. On 6/10/15 at 8:56 a.m., surveyor # observed RN-D hand resident #9 an [MEDICATION NAME] 250/50 inhaler ready for inhalation. RN-D did not provide the resident with instructions to breathe out as long as possible prior to the inhalation, to hold breath for 10 seconds or longer after the inhalation and did not advise the resident to breathe out slowly as long as the resident could after inhaling the medication. Resident #9 inhaled the medication without breathing out as long as possible prior to the inhalation, did not hold breath for 10 seconds or longer after inhalation and did not breathe out slowly for as long as the resident could after inhaling the medication. RN-D verified instructions were not provided to the resident prior to the administration of the inhaler and stated I usually give (the resident) breathing instructions daily before inhalation.forgot to provide instructions today prior to the inhalation of [MEDICATION NAME]. According to the manufacturer guidelines of [MEDICATION NAME], the person should breathe out through the mouth and push out as much air from the lungs as possible, push the top of the canister all the way down while breathing in deeply and slowly through the mouth, hold breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can.

Based on observation, staff interview and record review, the facility did not ensure that 1 (resident #21) of 1 sampled/supplemental sampled residents observed who received medications via enteral tube, received the appropriate treatment and services to prevent complications. Resident #21's enteral tube was not checked for correct placement prior to administering medications. Findings include: The facility policy entitled Feeding Tubes: Nutrition/Hydration, Medication, Safety Management dated May 1, 2015, indicated the facility would provide services to prevent feeding tube associated complications. The policy indicated staff check tube placement prior to administering medications using stethoscope and 5-10 ml (milliliter) air bolus unless physician orders [REDACTED]. The American Society for [MEDICATION NAME] and Enteral Nutrition (2009) provided Enteral Nutrition Practice Recommendations. The maintenance considerations indicated it is necessary to assure that the tube has remained in the desired location. Unfortunately, a gastric tube may migrate downward into the small bowel; a worse scenario is when a tube's tip dislocates upward into the esophagus. Obviously, an x-ray cannot be obtained several times a day to confirm tube location; thus, clinicians are forced to rely on a variety of bedside methods for this purpose. Among the methods that could be useful are determining if the external length of the tubing has changed since the time of the confirmatory radiograph, observing for negative pressure when attempting to withdraw fluid from the feeding tube, observing for unexpected changes in residual volumes, and measuring pH of the feeding tube aspirates. On 6/10/15, surveyor # reviewed resident #21's electronic medical record. The electronic medical record dated 6/10/15, indicated the resident was admitted to the facility with multiple diagnoses. Resident #21 received nutrition and medications via enteral tube. On 6/10/15 at 8:34 a.m., surveyor # observed RN (Registered Nurse)-A administer prescribed medications via the enteral tube to resident #21. While wearing gloves, RN-A flushed the enteral tubing with approximately 15 ml of water, administered medications with a flush of 15 ml water between medications, and then flushed the tubing with approximately 15 ml of water per physician orders. RN-A did not check the placement of the enteral tube prior to this observation. On 6/10/15 at 8:43 a.m., surveyor # interviewed RN-A regarding the observation. RN-A verified the above observations and stated normally do check placement prior to administering medications via enteral tube. On 6/11/15 at 12:01 p.m., surveyor # interviewed ADON (Assistant Director of Nursing)-B regarding checking placement of enteral tube prior to medication administration. ADON-B verified staff should check placement of the tube prior to administering medications per facility policy.

Based on observation, staff interview and record review, the facility did not store, prepare, distribute and serve food under sanitary conditions. Dietary staff did not follow proper hand hygiene during food preparation, trayline or food service, and before handling clean dishes after dishwashing. The facility did not store clean mixer parts and clean laundered aprons in an manner to protect them from contamination. A repair man was in the kitchen near clean without an appropriate facial hair restraint. The facility utilized a disinfectant rather than a sanitizer on food preparation areas, counters and clean equipment. In addition, this product was not approved to be used in food service areas. The facility's practices had the potential to affect 99 of 104 residents that resided at the facility. Findings Include: The 2013 Federal Food Code indicates epidemiological outbreak data repeatedly identify risk factors related to employee behaviors and preparation practices in food service establishments: 1. Contaminated equipment On 6/1/14 at approximately 9:00 a.m., FSD (Food Service Director)-B verified to surveyor # that they used the 2013 Federal Food Code as their standard of practice. STAFF DID NOT FOLLOW PROPER HAND HYGIENE DURING FOOD SERVICE, FOOD PREPARATION AND BEFORE HANDLING CLEAN DISHES DURING DISHWASHING The 2013 Federal Food Code indicated staff are to wash their hands between tasks and after touching contaminated equipment. On 6/2/14 surveyor # observed staff preparing plates of food to be served to the residents on trayline in the kitchen from 11:30 a.m. to 11:39 a.m. During that time surveyor # observed DA (Dietary Aide)-E working on the tray line placing bowls of salad and other cold items on the resident trays. At 11:32 a.m.. DA-E removed her gloves and left the trayline and entered the walk-in cooler touching the handle with her right hand to remove a tray full of small bowls of salad which she brought back to her station on the trayline. Without washing her hands DA-E donned a new pair of gloves and proceeded to handle the clean bowls of salad and place them on the resident trays. After doing this for a couple of minutes, DA-E removed her gloves and opened the small refrigerator under the trayline, removed an unknown item. DA-E without washing her hands donned another pair of gloves and proceeded to place bowls of salad and other items on the residents trays to be served for the noon meal. On 6/3/14 surveyor # observed food preparation from 8:29 a.m. to 9:14 a.m. The observations are as follows: ~ At 8:38 a.m., surveyor # observed DA-E wash the food preparation area with soap and water and then wipe the same area with sanitizer. Without washing her hands DA-E proceeded to handle six large baking sheets with her soiled hands. Afterwards, DA-E removed her gloves and washed her hands. ~ At 8:41 a.m., surveyor # observed DC (Dietary Cook)-C open the free standing cooler behind the food preparation area along the outside wall and remove a pan of cherry dessert, and without washing her hands donned a pair of gloves and proceeded to place the whipping cream on top of the cherry dessert. Afterwards, DC-C removed her gloves and washed her hands. ~ At 9:12 a.m., surveyor # observed DA-E open the walk-in cooler with her bare hand, enter and return with a large tub which she placed on the food preparation area. DA-E then opened the small refrigerator under the trayline and removed a plastic tube of whipping cream and placed it by the large tub. Without washing her hands, DA-E proceeded to handle several clean pans, placed them by the large tub and then opened the tub before leaving to wash her hands. At 9:14 a.m., surveyor # interviewed DA-E and she verified that she should wash her hands after touching any handles such as the walk-in cooler or refrigerator because they are considered dirty or contaminated. DA-E removed the contaminated pan, washed her hands and then picked up some clean pans to continue with her food preparation. On 6/3/14 surveyor # observed dishwashing in conjunction with food preparation from 8:54 a.m. to 9:01 a.m., DA-G was handling clean dishes after going through the dish machine. At approximately 8:58 a.m., DA-G was observed picking up a coffee carafe cover that had fallen onto the floor, and without washing her hands DA-G proceeded to handle clean dishes. DA-G was observed touching clean plates, cups and trays. At 9:01 a.m., surveyor # interviewed DA-G, and she at first indicated she gave the soiled cover back to staff to be washed again, but when asked if she should have handled clean dishes after touching the fallen cover, DA-G verified that she should not have. DA-G verified that she should have washed her hands before proceeding to handle clean dishes. On 6/3/14 at 9:28 a.m., ADFS-F (Assistant Director of Food Service) verified to surveyor # that staff should wash their hands after touching any handles or picking something up off of the floor. On 6/4/14 at 9:45 a.m., surveyor # met with NHA-A (Nursing Home Administrator) and DFS-B (Director of Food Service) and reviewed the above example of where staff should have washed their hands. DFS-B verified the refrigerator handles are considered dirty or contaminated and staff should wash their hands after touching them, and staff should wash hands after picking something up off of the floor. CLEAN MIXER PARTS AND LAUNDERED APRONS WERE NOT STORED SO THEY WERE PROTECTED FROM CONTAMINATION The 2013 Federal Food Code addresses the storage of equipment, utensils, linens. * In a clean location * Where they are not exposed to splash, dust, or other contamination * In a self-draining position that allows air drying * Covered or inverted On 6/1/14 at approximately 9:10 a.m., surveyor # along with FSD-B observed a metal pan located on the bottom shelf of a food preparation table across from the convection oven. The metal pan contained multiple mixer parts for the industrial mixer. The mixer parts were not covered to protect them for dust, dirt, splash, spatter and other contamination. In addition, there were crumbs and food debris on the bottom of the metal pan. Surveyor # observed this again on 6/3/14 at 8:29 a.m. On 6/1/14 at 9:17 a.m., surveyor # along with FSD-B observed multiple clean laundered aprons in a broken cardboard box located on a shelf in the dry storage area. The aprons were exposed to contamination from the cardboard box, dust, dirt, splash, spatter and other contamination. On 6/4/14 at 9:45 a.m., surveyor # met with NHA-A and DFS-B regarding the above issue and DFS-B verified that the clean laundered aprons should have not have been stored in the cardboard box and unprotected from contamination. Therefore, she had the aprons placed in the plastic tote with a cover to protect them from contamination. A REPAIR MAN WAS IN THE KITCHEN WITHOUT A FACIAL RESTRAINT According to the 2013 Federal Food Code food employees shall wear hair restraints such as beard restraints...... that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment; utensils, and linens; and unwrapped single-service and single-use articles. On 6/3/14 at 9:52 a.m., surveyor # was in the kitchen in the office doorway talking with ADFS-F when RM (repair man)-I walked through the kitchen to the office. RM-I had a fair amount of facial hair around his mouth (partial beard) longer than 1/4 of an inch. When asked where his facial restraint was by surveyor # , RM-I indicated that he did not know he needed one. ADFS-F gave RM-I a hair net and explained how he was to wear it. ADFS-F verified to surveyor # that RM-I should have been wearing a facial restraint while in the kitchen. On 6/4/14 at 9:45 a.m., surveyor # met with NHA-A and DFS-B and reviewed the concern regarding the repair man in the kitchen without a facial restraint. DFS-B verified the repair man should have been wearing a facial restraint while in the kitchen. THE FACILITY USED A DISINFECTANT INSTEAD OF A SANITIZER ON FOOD PREPARATION AREAS, COUNTERS AND CLEAN EQUIPMENT On 6/1/14 during the initial tour of the kitchen at approximately 9:30 a.m., surveyor # asked DFS-B how the facility sanitized their food preparation area, counters and clean equipment, and in addition asked of they used the quat sanitizer or a pre-mixed spray. DFS-B indicated the facility used quat sanitizer to clean the areas and then staff would spray with a pre-mixed spray afterwards. DFS-B added they used the pre-mixed spray on their food carts as well. Surveyor # asked DFS-B for a copy of the label for the pre-mixed spray. On 6/2/14 surveyor # reviewed the label for the pre-mixed spray provided by DFS-B. The facility used a product called pH7Q Ultra Disinfectant. The label did not contain directions on how to use the product; therefore, surveyor # used the EPA (Environmental Protection Agency) registered label number -129-4170. The EPA registered label for pH7Q Ultra Disinfectant revised 4/28/14, indicated disinfectant was corrosive and causes irreversible eye damage and skin burns. Harmful if inhaled, swallowed or absorbed through the skin. Do not get in eyes or on clothing. Do not use in food preparation , food handling and food storage areas. This product is not to be used on glassware, dishware, cookware or utensils. On 6/2/14 at approximately 11:10 a.m. surveyor # met with DFS-B in the presence of ADFS-F to talk about the information learned about pH7Q Ultra Disinfectant and how it should not be used in a food service setting. DFS-B indicated she had been instructed to use pH7Q from the Environmental Director. During the conversation, DFS-B indicated she thought staff only used the pH7Q on the food carts. This in is contradictions to what was said on 6/1/14. DFS-B called DC-C to the office and asked if staff used the pH7Q on anything other than the food carts. DC-C stated that staff use the pH7Q on everything. Surveyor # asked DC-C if staff used the pH7Q on the food preparation areas, counters and clean equipment such as the slicer, and DC-C answered, yes they did. Afterwards, surveyor # told DC-C that pH7Q could cause irreversible eye damage and should not be used in a food service setting. On 6/2/14 at 11:30 a.m., surveyor interviewed DC-C regarding staff usage of the pH7Q disinfectant. DC-C verified that all kitchen staff use pH7Q to sanitize the food preparation areas, counters, clean equipment and carts. O 6/2/14 at 11:40 a.m., surveyor # interviewed DA-D regarding the use of pH7Q Ultra. When asked if she used it to sanitize the food preparation areas, counters and clean equipment. DA-D verified that she did. O 6/2/14 at 11:41 a.m., surveyor # interviewed DC-AA regarding the use of pH7Q Ultra. When asked if she used it to sanitize the food preparation areas, counters and clean equipment. DA-D verified that she did. Surveyor # asked if she used on the slicer, and DC-AA answered, yes. On 6/2/14 at 11:55 a.m., surveyor interviewed a Customer Service Representative at Betco (BCS-H) regarding the use of pH7Q Ultra Disinfectant in a kitchen of a Skilled Nursing Facility. BCS-H told surveyor # that the facility should not be using pH7Q in a food service setting or food preparation area. BCS-H added, pH7Q it is not a sanitizer, but a disinfectant. On 6/2/14 at approximately 1:15 p.m., DFS-B came to surveyor # and verified that pH7Q should not be used in the kitchen on areas such as food preparation areas, counters or clean equipment.

Based on observations, record review and staff interviews, the facility did maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection during 5 of 13 opportunities observed for hand hygiene, during resident cares with resident #3, resident #11 and resident #15. CNA (Certified Nursing Assistant)-U did not appropriately remove soiled gloves and/or cleanse hands during the provision of cares for resident #11. LPN (Licensed Practical Nurse)-W did not appropriately remove soiled gloves and/or cleanse hands during the provision of wound care for resident #11. CNA-L and CNA-O did not appropriately cleanse hands after removing gloves during the provision of cares for resident #15. CNA-T did not wash/sanitize hands after glove removal and prior to touching personal and shared items during the provision of perineal care for resident #3. Findings include: Review of the Morbidity and Mortality Weekly Report dated 10/25/02 and published by the Centers for Disease Control and Prevention entitled "Guideline for Hand Hygiene in Health Care Settings" indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The facility's Hand Hygiene Policy dated May 1, 2006; indicated hand washing is a universally accepted practice to reduce contact transmission of microorganisms. It is recognized as one of the few infection control practices with clearly demonstrated efficacy, and remains the cornerstone of efforts to reduce the risk of infection. All staff are required to wash their hands after providing personal care and when performing tasks which would provide an opportunity for cross-contamination to occur. The absolute indications for and the ideal frequency of hand washing are not known. However, in the absence of a true emergency, staff should always wash their hands before and after touching wounds, whether surgical, traumatic or associated with an invasive device, after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood and body fluids, secretions, or excretions, and after removing gloves. 1. On 6/2/14 at 8:55 a.m., surveyor # observed CNA-U and CNA-V provide incontinence cares for resident #11. CNA-U verified the resident was incontinent of urine. While wearing gloves, CNA-U cleansed resident #11's groin, urethral, buttock, and anal areas with a washcloth. Without removing soiled gloves and without washing/sanitizing hands, CNA-U placed a clean incontinent brief under the resident and assisted CNA-V with attaching the brief. CNA-U then removed the soiled gloves and without washing/sanitizing hands, CNA-U placed a pillow under resident #11's left knee, assisted with rolling the resident to a side lying position, adjusted the pillow under the resident's head, placed a blanket and sheet over the resident, assisted with placing the bed cradle (prevents linen from touching the resident's feet) on the bed, and lowered the bed to the lowest position. CNA-U then washed hands. On 6/2/14 at 10:13 a.m., surveyor # interviewed CNA-U regarding the observation of incontinence care with resident #11. CNA-U stated "I knew I did that ...should have said something, took gloves off and washed hands" prior to touching resident #11's personal items. On 6/2/14 at 9:37 a.m., surveyor # observed LPN-W and RN (Registered Nurse)-X apply gloves prior to changing a soiled wound dressing on resident #11's coccyx. LPN-W removed the soiled dressing from the coccyx and without removing soiled gloves and washing/sanitizing hands, LPN-W cleansed the wound with gauze and wound cleanser, opened the Allevyn gentle border gauze dressing, wrote the date on the dressing with a Sharpie marker, placed the dressing on the coccyx, attached resident #11's incontinent brief, assisted RN-X with rolling the resident to a side lying position, placed two pillows on resident #11's left side, and placed the wound cleanser in a drawer of the treatment cart. LPN-W then removed the soiled gloves and washed hands. On 6/2/14 at 10:15 a.m., surveyor # interviewed LPN-W regarding the dressing change observation with resident #11. LPN-W stated "yes...should have removed gloves and washed hands after removing soiled dressing before putting new (clean) dressing on" and before touching resident #11's personal/shared items. 2. On 6/4/14 at 8:00 a.m., surveyor # observed incontinence cares provided for resident #15 by CNA-L and CNA-O. After removing the resident's undergarments, CNA-L cleansed the resident's genitals, pulling the foreskin down to clean, then wiping the groin of resident #15 with wet disposable wipes. The resident was rolled over and CNA-L cleansed the rectal area with wet wipes. CNA-L removed gloves and without hand hygiene, applied a clean brief. With gloved hands, CNA-O then assisted with peri-care, touching the genital area by pulling the foreskin back up. CNA-O then removed the soiled gloves and without hand hygiene, touched the resident's skin to roll him over, secured the brief, touched the sling, pants and pillows. With soiled hands CNA-L obtained pillows from the room-mate's bed and both CNA's floated resident #15's heels, touching skin, socks and linens. CNA-O then touched bed controls and privacy curtains before washing her hands. CNA-L touched the resident's wheel chair and privacy curtains before washing her hands. 3. On 6/2/14 at 9:15 a.m., surveyor # observed CNA-S and CNA-T provide perineal care for resident #3 while wearing gloves. CNA-T removed the soiled gloves and without washing/sanitizing her hands, applied new gloves. CNA-T then placed resident #3's clean brief on, touched clean bed linens, pillows, bed side rail, remote for the bed, and the call light. CNA-T then took off her gloves and washed her hands. On 6/2/14 at 9:35 a.m. surveyor # interviewed CNA-T regarding the observation of perineal care with resident #3. CNA-T stated "I have hand sanitizer in my pocket....if I remember to use it."

Based on observations and staff interviews the facility did not provide pharmaceutical services including procedures that assure accurate acquiring, receiving, dispensing and administering all medications to meet the needs of each resident. During medication pass, 1 (for resident # 6) of 27 medications observed, was not labeled with the most current dispensing instructions. Additionally, 1 of 5 medication carts in the facility, was observed unlocked and unsupervised while unidentified and unsecured pills were left on top of the medication cart in public areas. Findings include: Facility Policy and Procedure dated 2/1/06, entitled, "Medication Administration-General Guidelines," indicated, "Prior to administration, the medication and dosage schedule on the resident's MAR (medication administration record) is compared with the medication label. If the label and the MAR are different and the container is not flagged indicating a change in directions...the physician's orders [REDACTED]." A facility Policy and Procedure dated 1/1/02, entitled, "Relabeling Medication," indicated, "Medications may be relabeled in the facility...to reduce the expense of additional dispensation of medications following order changes or changes in labeling...Unit Nurse: 1. Enter new order on the physician order [REDACTED]. 2. Write dc/d in MAR and rewrite the new order...4. Notify Pharmacy if a new label is required. 5. Notify assistant director of nursing or director of nursing of need to relabel medication...Pharmacy: Send out new label...Medical Director, DON (Director of Nursing), ADON (Assistant Director of Nursing): 1. Affix new label directly over the incorrect label after verifying with the original new order written on the physician order [REDACTED]. Note "relabeled" under the order on the physician's orders [REDACTED]. 1. On 6/3/14 at 8:20 a.m., surveyor # observed medications administered to resident #6 by RN (Registered Nurse)-Q. A vial of Azopt eye drops was labeled with the instructions "One drop both eyes three times daily." RN-Q administered the eye drops to resident #6. Upon reconciliation of the eye drops with the physician's orders [REDACTED]." On 6/3/14 at 8:30 a.m., surveyor # interviewed RN-Q regarding resident #6's physician's orders [REDACTED]. RN-Q verified the Azopt eye drop order had changed on 5/7/14 and the pharmacy label was incorrect, as it instructed staff to instill one drop in both eyes three times daily. RN-Q verified that staff could not correctly verify the medication when the MAR (Medication Administration Record) and the pharmacy label do not match. 2. On 6/2/14 at 7:50 a.m., surveyor # entered the dining area of the "Sunrise" unit and observed three staff passing meal trays. The Sunrise unit's medication cart was positioned in the dining room between two tables with residents eating or waiting for their meal. A medication cup filled with unknown pills and tablets was noted on top of the medication cart. The medication cart was observed to be unlocked, as the push button lock was noted popped out (unlocked). During the next two minutes, the three staff were assisting residents and at times were unable to view the medication cart as they were turned away from the cart. At 7:52 a.m., LPN (Licensed Practical Nurse)-M approached the medication cart and pushed the lock button in stating "Oh, I was just passing trays." 3. On 6/2/14 at 9:05 a.m., surveyor # observed LPN-M maneuver the medication cart towards resident #17's room. LPN-M left the medication cart outside resident #17's room, remaining in the public day room where many residents congregated. Resident rooms on this unit lined the outside walls of a centralized "day room" (dining/activity/lounge area). Leaving the medication cart unlocked and turning her back away from the medication cart, LPN-M entered resident #17's room to administer the Fluticasone Nasal Spray to the resident. Upon exiting resident #17's room, surveyor # noted a medication cup that was left on the top of the medication cart with unknown tablets and pills inside of it. On 6/4/14 at 1:30 p.m., surveyor # reviewed medication administration policies with DON-N. During an interview with DON-N regarding unlocked medication carts, DON-N verified medication carts should be locked when not in use. Additionally, DON-N confirmed pills should not be left on top of the medication carts when the nurses walk away from the carts. DON-N stated when resident prescriptions change, staff should call the pharmacy to obtain a new label with the latest prescribing data.

Based on record review and staff interview, the facility did not ensure that 1 (Resident #2) of 21 resident's reviewed were free from significant medication errors. Resident #2 had received anticoagulant therapy (prevents blood from clotting). On 7/24/13, facility staff received an order to hold Resident #2's [MEDICATION NAME] (a drug used to prevent blood clots) due to elevated laboratory results. Resident #2 received [MEDICATION NAME] on 7/25/13 after a physician had ordered the medication to be held due to supratherapeutic blood level results. Resident #2 was transported to the ED (Emergency Department) on 7/28/14, and received 2 units of FFP (fresh frozen plasma) and vitamin K. The facility had not re-assessed their system and did not provide training to all licensed staff following the significant medication error to prevent a recurrence of this incident. Findings include: Geriatric Dosage Handbook, 12th Edition, dated 10/2006, lists Medication Safety Issues for [MEDICATION NAME] to include: High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error. Adverse effects of [MEDICATION NAME] ([MEDICATION NAME]) include, but are not limited to: Bleeding is the major adverse effect of [MEDICATION NAME]. Hemorrhage may occur at any site. Additional adverse effects include, but are not limited to: nausea, abdominal pain, fever, malaise, headache and dizziness. Resident #2's face sheet contained within the medical record and dated 8/26/13, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's medical record indicated the facility staff received a AMS (Anticoagulation Management Service) report regarding resident #2 on 7/24/13 that indicated the resident's INR (International Normalized Ratio) result was greater then 12. (INR is a lab test used to evaluate the affect of administration of anticoagulant drugs. The target range for INR in anticoagulant use is 2 to 3). The elevated INR results were called to the physician and the physician ordered vitamin K 2.5 mg (milligrams) po (by mouth) one time today, watch for bleeding and hold the [MEDICATION NAME] on 7/24/13, 7/25/14, and recheck the INR on 7/26/13. On 7/26/13, facility staff received a AMS report for resident #2 with an INR result of 10.99. The elevated INR results were called to resident #2's physician and the physician ordered vitamin K 2.5 mg po one time today, and hold the [MEDICATION NAME] on 7/26/13, 7/27/13, and recheck the INR on 7/28/13. On 7/28/13, facility staff received a AMS report for resident #2 with an INR result of greater then 12. The evaluated INR results were called to resident #2's physician and the physician ordered vitamin K 5 mg po today stat, and hold the [MEDICATION NAME] on 7/28/13, 7/29/13, and recheck the INR on 7/30/13. Resident #2's nurse's notes indicated on 7/28/13 at 3:00 a.m., resident was incontinent of urine x 2 during the night with pink tinge dark urine. A physician's telephone order dated 7/28/13 at 8:15 p.m. for resident #2 indicated, "Send to ED for evaluation due to brief saturated with blood and urine. INR this am was greater then 12." A hospital discharge summary dated 7/31/13, indicated that "Resident #2 initially presented on 7/28/13 with an elevated INR. In the ED, the resident was found to have an INR greater than 12. She (Resident #2) also had evidence of hematuria and questionable blood in the stool. As a result resident #2 was treated with 10 mg of vitamin K and 2 units of FFP. Her (resident #2) [MEDICATION NAME] was discontinued..." A medication error report dated 7/26/14 regarding resident #2 indicated the following: "date of incident: 7/25/13. Resident #2's [MEDICATION NAME] therapy was on hold due to INR greater than 12, a red "H" was placed on the MAR (Medication Administration Record) for the dosage for 7/24/13 and 7/25/13. Per conversation with the nurse on 7/25/13. The nurse gave the medication even though the MAR indicated [REDACTED] On 6/3/14 at 1:10 p.m., surveyor # met with DON (Director of Nursing)-N and reviewed the facility medication error reports. The facility's investigation indicated resident #2 received [MEDICATION NAME] after the physician ordered the [MEDICATION NAME] to be held. DON-N stated "the nurse who made the error was re-educated, but no other licensed staff." On 6/4/14 at 1:40 p.m., surveyor # interviewed DON-N regarding the medication error that occurred for resident #2. DON-N responded, "the MAR indicated [REDACTED]. I met with the nurses who work the unit, where the med error occurred. We talked about writing the word "HOLD" out onto the MAR indicated [REDACTED]. Surveyor # interviewed DON-N regarding if the facility licensed staff received training regarding [MEDICATION NAME] monitoring to prevent a recurrence of this incident. DON-N responded, "I did not go house wide with this information. We did do education on withholding medications prior to this incident, but not after this incident occurred. Starting today we will be doing a computer training titled, "Medication Administration: Avoiding common Errors" that all nurses have to complete by 6/11/14."

Based on observation, interview and record review, the facility did not ensure 1 (resident #4) of 6 sampled residents reviewed for psychoactive medication use were free from unnecessary drugs. Resident #4 received [MEDICATION NAME], an atypical antipsychotic medication scheduled daily and PRN (as needed) with inadequate monitoring, without a documented plan to decrease the current doses of the antipsychotic and administered the antipsychotic medication with inadequate indications for it's use. The medical record did not demonstrate that the behaviors were persistent, the behaviors were harmful to self or others and the facility did not consistently rule out medical, social or environmental causes for the behavior and did not consistently attempt individualized, non-pharmacological interventions prior to initiating the antipsychotics. Findings include: [MEDICATION NAME] (generic name quetiapine [MEDICATION NAME]) is an atypical antipsychotic medication, which is primarily used for the treatment of [REDACTED]. According to the Federal Drug Administration (FDA) current website, "Medicines like [MEDICATION NAME] (quetiapine [MEDICATION NAME]) can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] (quetiapine [MEDICATION NAME]) is not for treating [MEDICAL CONDITION] in the elderly with dementia." The "Black Box Warning" also indicates the increased potential for death related to taking this medication. Per review of the medical record, resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4's physician's admit orders dated 9/5/13 included the following: * [MEDICATION NAME] 25 mg (milligrams) PO (orally) BID, (two times a day) (at 7 a.m. and 8 p.m.) for agitation. * [MEDICATION NAME] 50 mg PO TID, (three times a day) PRN agitation. * [MEDICATION NAME] HCL, ([MEDICATION NAME]) 5 mg po twice daily at 7 a.m. and 8 p.m. for anxiety. The CNA (Certified Nursing Assistant) Care Plan dated 9/16/13 stated: "Problem: Potential for Alteration in Psychosocial well-being" Approachs included: * Encourage expression of feelings. * Establish daily routine. * Provide safe, nonthreatening environment. * Accept feelings as normal. * Assist in identifying areas of control. * Offer food, drink or toilet. Resident #4's Initial Admission Care Plan, dated 9/17/13, included the problem "Potential for Alteration in Mood: Anxiety, Loss of control, Inability to cope, Memory loss. Nurse approaches included: * Calm gentle approach and administer PRN [MEDICATION NAME]. * 1:1 with resident as needed to provide reassurance that he will be okay and that his family continue(s) to love and are supportive of him and they know where he is. * Offer coffee and snack. Resident #4's Initial Admission MDS (Minimum Data Set) assessment with a reference date of 9/18/13 indicated the resident has severe cognitive impairment and indicated the resident had no physical, verbal or other behavioral symptoms not directed toward others, however, did reject evaluation or care 1 to 3 days. Resident #4's CAA (Care Area Assessment) documented "Early stage dementia, continues to try and make sense of what is going on. Gets emotional with the separation from (spouse) and the fact that (resident #4) has some insight into failing memory/dementia dx, (diagnosis) will develop Care Plan." Behavioral Symptoms, associated with the admission MDS dated [DATE] included the following: * Rejection of care * Wandering - wanders daily * No mental illness * New environment Resident #4's medical record included the following without documentation that the anxious behavior was problematic for the resident or others and/or did not indicate that staff attempted non-pharmacological approaches identified on the care plan prior to administering the antipsychotic to resident #4: ~ 9/9/13: 1:04 p.m. NN (Nurse's notes) "is cooperative and pleasant with staff this shift." * 4:00 p.m. MAR- received [MEDICATION NAME] 50 mg for anxiety. * 10:31 p.m. NN "Resident was served today with papers for court. Writer and (Dr.) spoke with resident. Resident (#4) said he felt anxious. PRN given." ~ 9/22/13: 3:10 p.m. MAR- [MEDICATION NAME] for anxiety. * 3:10 p.m. NN- "Anxious after family left. Pacing on the unit, asking for someone to open the door. 'I need to get out' PRN [MEDICATION NAME] given." ~ 9/24/13: 1:30 p.m. MAR- was given PRN [MEDICATION NAME] for anxiety/agitation. No documentation in NN's related to the potential reason for anxiety. ~ 9/25/13: 4:30 p.m. MAR- was given PRN [MEDICATION NAME] for anxiety. * 9:32 p.m. NN- "Agitated this shift. PRN given." ~ 9/26/13: 3:30 p.m. MAR- was given PRN [MEDICATION NAME] for agitation. No documentation in NN's related to the potential reason for anxiety. ~ 10/1/13: 4:40 p.m. MAR- prn [MEDICATION NAME] given. No documentation in NN's related to the potential reason for anxiety. ~ 10/12/13: 5:30 pm. MAR- prn [MEDICATION NAME] given. No documentation in NN's related to the potential reason for anxiety. ~ 10/13/13: 8:34 p.m. NN- "Behavior: Resident carrying his garbage can out onto the unit, Redirected but did the same thing again. Resident agitated upon redirection, PRN given." No documentation on the MAR PRN given. ~ 10/14/13: 2:30 p.m. MAR- PRN [MEDICATION NAME] given. No documentation in NN's related to the potential reason for anxiety. ~ 10/17/13: 5:45 p.m. MAR- PRN [MEDICATION NAME] given, No documentation in NN's related to the potential reason for anxiety. ~ 10/18/13: 7:00 p.m. MAR- PRN [MEDICATION NAME] given, No documentation in NN's related to the potential reason for anxiety. ~ 10/19/13: 4:30 p.m. MAR- PRN [MEDICATION NAME] given. NN- "Agitated this shift after wife left. Unable to redirect to activity. PRN given." ~ 10/21/13: 9:43 a.m. NN- "EMOTIONAL STATE: appears emotionally well adjusted pleasant with staff, BEHAVIOR: is cooperative WANDERS; does not wander, VERBALLY ABUSIVE; is not verbally abusive PHYSICALLY ABUSIVE: is not physically abusive SOCIALLY INAPPROPRIATE: is not socially inappropriate RESISTS CARE: is not resistive to cares BEHAVIOR CHANGE: Behavior status has not changed since the last assessment" 11:30 A.M. MAR- PRN [MEDICATION NAME] given, No documentation in NN's related to the potential reason for anxiety. ~ 10/23/13: 1:30 p.m. MAR- PRN [MEDICATION NAME] given. NN- "Resident was restless, Telling his wife that he could not stay here. PRN [MEDICATION NAME] given at 1330." ~ 10/25/13: 4:45 p.m. MAR- PRN [MEDICATION NAME] given. NN- "After wife left, resident became agitated and pacing unit. PRN given." Resident #4's psychiatrist note dated 10/29/13 documented "...increase [MEDICATION NAME] 25 mg po TID (three times a day)...due to random incidents of change of personality. Axis I.1) Dementia, 2) [MEDICAL CONDITION]." ~ 11/13/13: 7:10 a.m. MAR-was given PRN [MEDICATION NAME] for agitation. No documentation in NN's related to the potential reason for anxiety. ~ 11/18/13: 10:06 a.m. NN stated, "resident appears very angry, glaring at his roommate as he is using the bathroom. When writer asked him why he is angry, (resident #4) stated, 'None of your (GD) business' PRN [MEDICATION NAME] given." ~ 11/19/14: 5:29 p.m. NN- Agitated at 7:10 p.m. [MEDICATION NAME] 50 mg PO given. ~ 11/22/13: 9:18 a.m. NN- "resident refused AM, (morning) cares, refused to shave, would not answer staff when they spoke with him. Appears very angry. When asked what was wrong, he stated nothing. PRN [MEDICATION NAME] given at 7:25 a.m." ~11/22/13: NN- transferred to a different room on the same unit...upset that his room was changed and said "I am not going to move in here, (if) I go anywhere, I will get the hell out of here." Resident #4 was pacing on the unit. "PRN [MEDICATION NAME] 50 mg given at 1310. "New orders obtained from (the physician) at 1330 and another 50 mg of [MEDICATION NAME] given for agitation." ~11/24/13: 12:00 p.m. NN- refused to eat, talk and leave his bed. He raised his voice when staff attempted to help him. PRN [MEDICATION NAME] was given. ~ 12/16/14: 2:45 p.m. MAR- PRN [MEDICATION NAME] was administered for agitation. No documentation in NN's related to the potential reason for agitation. ~ 1/16/14: 11:30 p.m. MAR- PRN [MEDICATION NAME] was administered for agitation. No documentation in NN's related to the potential reason for agitation. ~ 1/21/14: 7:15 p.m. MAR- PRN [MEDICATION NAME] was administered for agitation. No documentation in NN's related to the potential reason for agitation. ~ 2/4/14: 4:30 p.m. MAR- PRN [MEDICATION NAME] was administered for agitation. No documentation in NN's related to the potential reason for agitation. ~ 3/27/14: 3:08 p.m. MAR- PRN [MEDICATION NAME] was administered. NN- PRN MED GIVEN: ([MEDICATION NAME]) Quetiapine [MEDICATION NAME] mg tablet agitation when asked How is your mood? Resident replied 'bad.' Facial tension, grimacing, denies pain." ~ 5/20/14: 3:32 p.m. MAR- PRN [MEDICATION NAME] was administered. NN- PRN MED GIVEN: ([MEDICATION NAME]) Quetiapine [MEDICATION NAME] mg tablet given for agitation. Knocking on nurses station pacing on unit. ~ 5/21/14: 3:47 p.m. MAR- PRN [MEDICATION NAME] was administered. NN- PRN MED GIVEN: ([MEDICATION NAME]) Quetiapine [MEDICATION NAME] mg tablet given for agitation. Verbally abusive to staff." Although the activity records indicate that resident #4 received 1:1 for 20 minutes per day, on most days, these 1:1's did not correspond to the dates and times of demonstrated behaviors and prior to the administration of PRN [MEDICATION NAME]. On 6/2/14 at 7:41 a.m., surveyor # interviewed RN-FF regarding resident #4's behaviors. RN-FF stated "We read his body language. We know when he wants to be left alone." On 6/2/14 at approximately 8:15 a.m., surveyor # reviewed resident #4's MAR's and interviewed RN-FF regarding the location of non-pharmacological interventions that staff attempt prior to giving a PRN [MEDICATION NAME]. RN-FF stated "We document that in the notes in the computer." Resident #4's medical record did not demonstrate that the behaviors resident #4 exhibited were persistent or harmful to self or others and the facility did not consistently rule out medical, social or environmental causes for the behavior. Staff did not consistently attempt individualized or facility staff identified non-pharmacological interventions prior to initiating the antipsychotics. The resident's medical record did not have documented evidence that the facility tracked, trended or looked for patterns of behaviors.

Based on observations, staff interviews and record review, the facility did not ensure 2 (residents #2 and #16) of 8 sampled residents reviewed for falls received adequate supervision and assistive devices to attempt to prevent accidents. Resident #2 had history of falls and was assessed to be at risk for falls. An intervention on resident #2's plan of care indicated a clip alarm was to be used while the resident was in bed, to alert staff to resident #2 attempts to rise. The plan of care intervention was not consistently implemented. Resident #16 had a history of [REDACTED]. Interventions on resident #16's plan of care indicated the resident utilized a Tab alarm while in a chair and a motion sensor alarm while in bed. The motion sensor alarm did not alert staff on 5/19/14, when the resident fell out of bed. Findings include: 1. The manufacturer guidelines for the Attendant Magnet Alarms, which resident #2 used states, "...attach the device to a wheel chair, chair or bed using the strap, optional bed rail clip..." Resident #2's face sheet, contained within the medical record and dated 8/26/13, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's MDS (Minimum Data Set) assessment dated [DATE] indicated resident #2 had severe cognitive impairment and did not have any falls since admission or prior assessment, whichever was more recent. The MDS indicated that resident #2 required extensive assistance from staff for ADL's (Activities of Daily Living). Resident #2's current plan of care for falls, dated 5/16/13, indicated the resident was at risk for falls related to history of falls, incontinence, pain, and decline in cognitive status. Approaches on the plan of care were to have the following: "safety devices while in bed: tab alarm, bed in low position, lipped mattress, and mat on floor sink side of bed". The CNA (Certified Nursing Assistant) care plan dated 5/16/13 and utilized by direct care staff indicated "Safety Equipment in bed: tab alarm..." On 6/1/14 at 8:45 a.m., surveyor # observed resident #2 in bed. An alarm was placed on resident #2 to alert staff if the resident attempted to rise from the bed. The clip of the alarm was attached to the resident's clothing; however, the alarm was placed on the mattress near the resident's right shoulder and was not attached to the bed. On 6/1/14 at 2:10 p.m., surveyor # observed CNA-Y and CNA-Z transfer resident #2 to bed. The clip of the alarm was attached to the resident's clothing; however, the alarm was placed on the mattress next to resident's right shoulder and was not attached to the bed. On 6/2/14 at 7:55 a.m., surveyor # observed resident #2 in bed. The clip of the alarm was attached to the resident's clothing; however, the alarm was placed on the mattress near the resident's right shoulder and was not attached to the bed. On 6/2/14 at 9:35 a.m., surveyor # observed resident #2 in bed. The clip of the alarm was attached to the resident's clothing; however, the alarm was placed on the mattress, above the resident's head and was not attached to the bed. On 6/3/14 at 8:20 a.m. surveyor # observed resident #2 in bed. The clip of the alarm was attached to the resident's clothing; however, the alarm was placed on the mattress above the resident's head and was not attached to the bed. On 6/3/14 at 9:15 a.m., surveyor # and CNA-T observed resident #2 in bed with the clip alarm attached to resident's clothing. The alarm was placed on the mattress above the resident's head and not attached to the bed. Surveyor # interviewed CNA-T regarding resident #2's alarm placement. CNA-T stated the resident needs the alarm to alert staff because resident #2 can move around in bed. CNA-T then stated "Ever since her bed rails were removed a month ago, we've been setting the alarm on the mattress." On 6/3/14 at 10:20 a.m., surveyor # interviewed DON (Director of Nursing)-N related to resident #2's alarm placement. DON-N stated "Resident #2's alarm should be attached or mounted to something." 2. According to the Direct Supply Attendant PIR Alarms manufacturer guidelines, the motion sensor alarms are powered by one 9 V (volt) battery and the device should be tested along with checking the battery level before each use. According to an article entitled "Personal Alarms: Safety Device or Hazard?" provided by the Board on Aging and Long Term Care Ombudsman Program with a date of September 2006, if a facility is going to use alarms, it is necessary to establish a regular schedule to test the alarm to make sure it is still functional. Additionally, the article indicated long term care providers should establish a policy and procedure regarding alarms to guide the use and testing of the alarms. Resident #16's face sheet, contained within the medical record and dated 11/13/13, indicated the resident was admitted to the facility on [DATE] with multiple diagnoses. Resident #16's MDS assessment dated [DATE] indicated the resident's cognition was intact and the resident had a history of [REDACTED]. Resident #16 was totally dependent on staff for transfers. Resident #16's current plan of care dated 7/3/13 indicated the resident had a history of [REDACTED]. The care plan dated 5/19/14, indicated resident #16 remained at risk for falls due to the resident being delusional and not redirectable. The care plan also indicated resident #16 used a motion sensor alarm while in bed. Resident #16's progress note dated 5/19/14 at 4:04 a.m., indicated the resident was found on the floor mat in the room calling out after intentionally putting self on floor. The motion sensor alarm was not sounding because the battery was dead. A new battery was placed in the motion sensor alarm to keep the resident safe. The resident did not use the call light for assistance to get out of bed because the resident did not know how to use the call light. At 9:55 a.m., the progress note indicated the resident did not injure self after the fall from bed on 5/19/14. On 6/4/14 at 1:23 p.m., surveyor # interviewed RN (Registered Nurse)-K regarding the facility policy related to alarms and how often the batteries are checked on the motion sensor alarms to ensure the batteries are not dead. RN-K indicated the facility does not have a policy related to alarms and indicated there is not a system in place to ensure the batteries are charged. RN-K stated "When staff turn the alarm on and it (alarm) makes a funny beep, we change it (battery)." RN-K indicated that staff did not check or change batteries in the alarms that other residents use after resident #16's motion sensor did not sound; when the resident got out of bed because the battery was dead. On 6/4/14 at approximately 3:15 p.m., surveyor # and surveyor # interviewed DON-N regarding how often the motion sensor alarm's batteries are checked. DON-N indicated staff are to check the batteries when an alarm is turned on or off. DON-N stated the alarm sounds so staff know whether the alarm is working or not. DON-N verified the facility did not have a policy or a system in place to ensure the batteries are checked or changed on a regular basis, other than each time staff turn the device was turned on or off.

Based on observations, record review and staff interviews, the facility did not ensure that 2 (resident #8 and resident #5) of 15 residents reviewed for pressure ulcers and pressure ulcer risk received the necessary treatment and services to promote healing, prevent infection and prevent new pressure sores from developing. Resident #8 was at high risk for the development of pressure ulcers and currently had a stage II pressure ulcer on the left hip. The resident's written plan of care relating to skin integrity gave conflicting direction; to position resident #8 ON the left hip and to position the resident OFF the left hip. An interview with the wound nurse revealed the expectation would be to position the resident OFF the left hip. Several observations were made throughout the survey whereby resident #8 was positioned on the left hip, directly on the pressure ulcer. CNA (Certified Nursing Assistant) staff were unaware of how to position resident #8. Resident #5 was at high risk for the development of pressure ulcers and currently had an unstageable pressure ulcer on the left heel. The resident's written plan of care relating to skin integrity instructed staff to "reposition every two hours. Minimize pressure on bony prominences, such as floating heels. Heel protectors. Use pillow for positioning." Observations were made throughout the survey whereby resident #5 was positioned on the resident's back for greater than 2 hours, without a heel protector on the left heel and the heels not consistently floated. CNA staff were unsure of why there was only a heel protector on the right heel and not the left and did not know where the left heel protector was. Findings include: The 2009 National Pressure Ulcer Advisory Panel, "treatment of [REDACTED]. "1. Do not position an individual directly on a pressure ulcer." The Clinical Guideline, published by the National Pressure Advisory Board in 2009, entitled "Pressure Ulcer Prevention" encourages healthcare personnel to consider individuals who are bedfast and/or chairfast to be at risk of pressure ulcer development and to develop and implement a prevention plan when individuals have been identified at risk of developing pressure ulcers. The use of repositioning should be considered in all at-risk individuals. Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas. The Quick Reference Guide entitled "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Using a pillow under the calves so the heels are elevated (i.e., "floating") will accomplish reduction of pressure on heels. 1. On 6/1/14, surveyor # reviewed the medical record of resident #8. The undated facesheet contained within the medical record indicated resident #8 was admitted with [MEDICAL CONDITION] post [MEDICAL CONDITION] related to a subdural hematoma after a fall. Resident #8's most recent quarterly MDS (Minimum Data Set) assessment indicated resident #8 was non-verbal and severely cognitively impaired. Resident #8 was dependent upon staff to anticipate needs and required total staff assistance for mobility, transfers and hygiene. Additionally, the MDS indicated resident #8 had two stage II pressure ulcers. Resident #8's current written plan of care relating to skin integrity documented the following intervention that was added 9/17/13, "Patient to be positioned onto left side when in bed. Patient tends to lay on right side causing increased tone. Please position on left side frequently." An additional intervention for skin integrity was added 4/26/13 and indicated, "Do not lay on left hip, weight shift in bed with hips to 30 degrees keeping pressure off hips and coccyx." Resident #8's printed CNA Care Plan that is located in the resident's room on the closet door included to position the resident on their left side when in bed and "Do not lay on left hip." On 6/2/14 at 8:17 a.m., surveyor # observed resident #8 in bed during medication administration. Resident #8 was laying on the left side, facing the window. On 6/2/14 at 11:20 a.m., surveyor # interviewed CNA-O regarding resident #8. CNA-O stated "We turn (resident #8) on all sides equally." CNA-O indicated staff reposition the resident every two hours from back, to left side to the right side. During the interview, CNA-O stated they were unaware that resident #8 was to be kept off of any particular area. On 6/2/14 at 11:21 a.m., surveyor # interviewed CNA-R regarding resident #8. CNA-R verified resident #8 was repositioned every 2 hours from left to right to back side equally. On 6/2/14 at 3:00 p.m., surveyor # interviewed the facility's wound nurse RN (Registered Nurse)-Q regarding resident #8. RN-Q indicated the resident's written plan of care intervention to "keep resident on the left side" should have been deleted and agreed the two interventions were confusing. RN-Q verified the expectation would be for staff to keep resident #8 positioned off the left side. On 6/3/14 at 10:33 a.m., surveyor # observed CNA-O and CNA-P transfer resident #8 to bed. Pillows were placed behind resident #8's back to keep the resident on the left side, directly on the left ischial dressing. CNA-O stated "(resident) was facing the door (before) on the right side. Now we will face (resident) towards the window on the left side." On 6/4/14 at 9:30 a.m., surveyor # observed resident #8 in bed laying on the left side, facing the window. 2. Surveyor # reviewed resident #5's medical record. The medical record indicated resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. Upon admission, resident #5 was assessed to have no pressure ulcers. On 9/25/13, per a Pressure Ulcer Flow Sheet, an unstageable wound was first noted on resident #5's left heel. Treatment indicated, "Skil-care boots at all times." Resident #5's most recent MDS assessment dated [DATE], and the quarterly MDS assessment dated [DATE] both indicated the resident is severely cognitively impaired, is dependent on staff for all ADL'S (Activities of Daily Living) and is at risk for pressure ulcer development. Resident #5's undated CAA (Care Area Assessment) for Pressure Ulcers stated "Pressure ulcer (s) present: location: left heel. Possible complications: HOB (head of bed) elevated d/t (due to) continuous TUBE FEED,[MEDICAL CONDITION](gastroesophogeal reflux disorder), Excoriated area (on) Buttocks requires staff assistance to move sufficiently to relieve pressure over any one site. Requires pressure reducing mattress or seat cushion. Requires regular schedule of turning Q (every) 2 hr (hours), no pressure to left heel, skil-care boots. Will develop Care Plan..." Resident #5's comprehensive and CNA plan of care for Impairment of skin integrity, both dated 3/31/14, indicated "Reposition every two hours, Minimize pressure on bony prominences such as floating heels...Heel protectors...Use lift sheet to move resident in bed." On 6/2/14 at 7:30 a.m., surveyor # observed resident #5 in bed laying on the back with the HOB elevated approximately 45 degrees, with a foot tent over the feet. The right foot had a blue heel boot on and the left foot was laying directly on the bed and not free-floating, without a blue heel boot. On 6/2/14 at 8:40 a.m., surveyor # observed resident #5 in bed with the left heel laying directly on the bed without a Skil-care boot on and both heels were not free-floating. On 6/2/14 at 9:45 a.m., surveyor # interviewed CNA-BB regarding resident #5 and the use of the Skil-care boots. CNA-BB stated "(they) took off the left (Skil-care) boot because of the open area (on the left heel)." On 6/2/14 at 9:45 a.m., surveyor # observed CNA-BB and CNA-T reposition resident #5 on their right side, by pulling on the resident and without the use of a turn sheet, as per the resident's plan of care. On 6/2/14 at 12:25 p.m., surveyor # observed resident #5 laying in bed on their back with the left foot directly on the bed, not free-floating or with the Skil-care boot on. On 6/2/14 at 2:50 p.m., surveyor # interviewed the facility's wound nurse, RN-Q regarding resident #5's left heel ulcer. RN-Q stated the wound is "meaty red and closed around the middle. Staff had been using [MEDICATION NAME] before it opened. The wound started to open on 4/7/14 and has been stable. There is to be a pillow under the legs to free-float the heels at all times, plus the Skil-care boots are to be on both heels at all times." In addition, RN-Q stated she is the person to update the plan of cares for all resident with wounds. On 6/2/14 at 3:25 p.m., surveyor # observed CNA-CC and CNA-DD transfer resident #5 from the Broda chair to the bed. Once in bed, resident #5's legs were elevated on pillows and the left heel was in direct contact with the bed, without a Skil-care boot on. On 6/2/14 at 3:50 p.m., surveyor # interviewed CNA-CC and CNA-DD regarding the use of heel boots with resident #5. CNA-CC stated, "Blue boots should be on both heels, but, honestly, I haven't seen them on." CNA-DD stated, "I've seen them on both (heels) before." CNA-CC stated "Someone just went and found another one. I'm not going to lie to you."

Based on record review and staff interview, the facility did not ensure all alleged violations involving mistreatment, neglect, injuries of unknown source and misappropriation of resident property were reported immediately and thoroughly investigated for 1 (resident #10) of 21 residents reviewed for abuse. Resident #10 was found to have a bruise in the genital region. The facility did not thoroughly investigate resident #10's injury of unknown origin in attempt to ensure abuse had not occurred. Additionally, the facility did not immediately report the suspicious bruising to the State Survey and Certification Agency. Findings include: Facility Policy and Procedure entitled, "Resident Abuse/Complaints-Investigation and Prevention," dated 5/10/13, indicated: The definition for...injury of unknown source are as follows: An injury should be classified as an "injury of unknown source" when both of the following conditions are met: *The source of the injury was not observed by any person or the source could not be explained by the resident and *The injury is suspicious because of the extent or the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma)... A thorough investigation may follow and would include: * Interviewing alleged victim. * Interviewing other residents to determine if they have been abused or mistreated; or if they have witnessed or are thought to have knowledge of this incident. * Interviewing staff who worked the same shift. * Interviewing staff who have worked other shifts. * Collecting other information that corroborates or disproves the reported incident. Staff member discovering the injury: * Report incident to the unit nurse who then notifies the Nurse Manager. * An in-depth investigation on an unwitnessed injury will be required for unexplained bruising. * Immediately contact the DON (Director of Nursing) and the NHA (Nursing Home Administrator). * Contact Guardian. *Nurse Manager 1. Complete the "Online Alleged Nursing Home Resident Mistreatment Form...Social Services Director or Designee 2. Interview resident...3. Interview staff..." On 6/1/14, surveyor # reviewed the medical record of resident #10. The facesheet dated 4/11/14, contained within the medical record indicated resident #10 was admitted with [DIAGNOSES REDACTED]. Resident #10's most recent significant change MDS (Minimum Data Set) assessment dated [DATE], indicated resident #10 had severe cognitive impairment and was dependent upon staff for bed mobility and transfers. Resident #10's medical record included a APNP (Advanced Practice Nurse Practitioner) progress note dated 10/9/13 that documented: "S (subjective): Asked to see patient by nursing staff for injury to penis. Report states no redness to penis...pt (patient) does not report any incidents that would contribute to this injury. O (Objective): Ecchymosis (nonraised skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels) to posterior side of penis with bloody drainage noted at urethral (the canal through which urine is discharged from the bladder) opening. No [MEDICAL CONDITION] noted. Foreskin easily retractable. A (Assessment): Contusion (another name for a bruise) of penis P (Plan): ...expect bruising 2 - 4 weeks..." Nurse's notes dated 10/9/13 indicated resident #10 "...continues to have redness and swelling on the penis....APNP-J examined...writes that staff is to expect that resident will have bloody urine." On 6/2/14 at 2:15 p.m., surveyor # interviewed RN (Registered Nurse)-K regarding the genital bruising of resident #10. RN-K verified the incident was not reported to the State Survey and Certification Agency. RN-K indicated resident #10's discoloration on the penis was not bruising but excoriation because the resident was uncircumcised. RN-K stated there was no investigation because it was not an injury of unknown source. RN-K referred to telephone orders for resident #10, dated 9/1/13, indicating "irritated foreskin," and was unaware of the APNP progress note which referred to "ecchymosis, bruising and injury." On 6/4/14 at 10:50 a.m., surveyor # interviewed APNP-J regarding resident #10. APNP-J indicated she "distinctly remembered (the facility) telling me it was an injury and suspected it may have happened during a transfer, the penis could have gotten pinched. It definitely was a bruise, and at that time there was no discussion the swelling and bruising was related to excoriation." APNP-J reviewed the nurse charting from 10/9/13 and verified the documentation did not correspond to her assessment of the same day. APNP-J stated "My impression was it was not related to foreskin retraction or excoriation. This should have been treated as an injury of unknown origin and investigated..."

Based on record reviews and staff interviews, the facility did not implement policies and procedures that prohibited abuse when 3 (residents #22, #23, and #24) residents with mental illness and/or dementia made serious allegations of abuse. The allegations were not thoroughly investigated and not reported to the appropriate officials, including the state survey and certification agency. Additionally, the facility did not implement measures to prevent further potential abuse while investigations were in progress as directed in the facility's abuse policies and procedures. This had the potential to affect 70% of the residents in the facility whom had mental illness including dementia. 1. On 1/8/13 at 4:10 p.m., resident #23 alleged the night shift staff had sexually assaulted her. The facility did not follow abuse prohibition policies and procedures. A thorough investigation was not completed by the facility. The resident was not interviewed to determine the details of the allegation until 1/9/13. The facility did not interview night shift staff that worked from 1/7/13 into 1/8/13. No assessment of the resident had been completed. No additional residents were interviewed to determine the extent of the alleged potential abuse. The facility did not implement measures to keep the residents safe during the investigation. The allegation of sexual assault was not reported to the state survey and certification agency as directed in the facility's abuse policies and procedures. The allegation of sexual assault was not thoroughly investigated to determine if a reasonable suspicion of crime was present to determine if the allegation should have been reported to law enforcement. 2. On 2/11/13 at 7:20 a.m., resident #24 alleged she had been sexually assaulted during the night by staff. The facility did not follow abuse prohibition policies and procedures. The facility did not complete a thorough investigation. The facility did not interview night shift staff, and no assessment of the resident had been completed. No additional residents were interviewed to determine the extent of the potential abuse. The facility did not implement measures to keep the residents safe during the investigation. The allegation of sexual assault was not reported to the state survey and certification agency as directed by policies and procedures. The allegation of sexual assault was not thoroughly investigated to determine if a reasonable suspicion of crime was present to determine if the allegation should have been reported to law enforcement. 3. On 3/24/13, resident #22 alleged CNA (Certified Nursing Assistant)-X had verbally abused her. The facility did not implement measures to keep additional residents safe during the investigation as directed by the facility's abuse policies and procedures; CNA-X was allowed to care for other residents during the investigation. The allegation was not reported to the state survey and certification agency as required as directed by the facility's abuse policies and procedures. The failure of the facility to follow written policies and procedures that prohibited abuse for 3 cognitively impaired residents, when serious allegations of abuse were made, created a situation of Immediate Jeopardy. The Immediate Jeopardy began on 1/8/13 when the facility became aware of the first allegation of rape. The facility was formally notified on 5/10/13 that an Immediate Jeopardy situation existed. The jeopardy was removed on 5/11/13 but continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) until all staff are trained and corrective measures are fully implemented. Findings include: On 5/6/13, this facility had a census of 106 residents, of which 74 (70%) residents had a mental illness [DIAGNOSES REDACTED]. According to the facility's "Abuse/Complaints-Investigation and Prevention" policy and procedure dated 10/19/11, the facility will "ensure the rights, dignity, and safety of the residents." The policy indicated, "Allegations involving resident mistreatment, neglect, abuse, misappropriation of resident property, and injuries of unknown source shall be reported immediately and not to exceed 24 hours after the incident. This immediate reporting shall be made to the nursing home Administrator and to the Division of Quality Assurance." The policy defined several abuse terms. Verbal abuse was defined as "the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents." Sexual abuse was defined as " sexual harassment, sexual coercion, or sexual assault." The facility's abuse policy contained a procedure for a thorough investigation; "Collecting and preserving physical and documentary evidence; interviewing alleged victim(s) and witness(es); interviewing accused individual(s)...; interviewing other residents...; interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused; interviewing staff who worked previous shifts...; collecting other information that corroborates or disproves the reported incident; involving other regulatory authorities who may assist, e.g., local law enforcement." The facility's policy also indicated staff were directed to "Provide immediately for the safety of the resident if the complaint involves allegations of abuse... by instituting necessary precautions to prevent further occurrence," "This may involve sending the staff member home or suspending him/her until a determination can be made on the incident by the Complaint Investigative Team." According to the facility's undated "Reporting Reasonable Suspicion of a Crime in a Long-term Care Facility" addendum to the "Abuse/Complaints-Investigation and Prevention" policy and procedure, the facility was to comply with state and federal regulations by reporting any reasonable suspicion of a crime to protect residents by promoting a timely response to potential crimes. The addendum directed staff to report any reasonable suspicion of a crime to the state survey and certification agency and to local law enforcement with in two hours is serious bodily injury occurred or within 24 hours if serious bodily injury had not occurred. 1. Resident #23's face Sheet dated 9/12/12 indicated that the resident was admitted to the facility on [DATE]. The "Cumulative [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 12/11/12 indicated resident #23 had cognitive impairment and [MEDICAL CONDITION]. On 9/15/10 the facility developed a behavior care plan for resident #23 indicating the resident was manipulative and accusatory towards staff. According to a facility investigation, on 1/8/12 at 4:10 p.m., resident #23 asked CNA-T if she knew there was a room in the basement of the facility. CNA-T verified to the resident that she was aware of the room and it was used for storage. Resident #23 then told the CNA "'the noc (night) shift took me down to the basement and rape me and blood was running down my feet'." The facility investigation indicated several staff were interviewed, however, night shift staff who worked the night of 1/7/13 into 1/8/13 were not interviewed. The staff that were interviewed indicated the resident had not been acting out of the ordinary on 1/8/13. RN (Registered Nurse)-U wrote a statement on 1/9/13 indicating at 6:00 a.m. on 1/8/13 resident #23 had asked CNA-V to put some cream "'up in her vagina'." CNA-V did not write a statement until 1/14/13, the statement indicated on 1/8/13 resident #23 had asked CNA-V "'for cream for her vagina area'." Resident #23 reported the allegation of rape on 1/8/13. Documentation indicated that the resident has a [DIAGNOSES REDACTED]. On 1/9/13 SSD (Social Services Designee)-S interviewed resident #23 and indicated the resident did not always respond appropriately to questions asked. Resident #23 told SSD-S "'She stuck 2 fingers in my vagina and one in my rectum...She has bangs and wears her hair up in a clip'." Resident #23 verified to SSD-S she was not confusing this incident with a dressing change, and she did not want CNA-T to tell anyone else about the allegation of rape. Resident #23 also stated to SSD-S "'I was strong enough to stop her and she walked away. I shouldn't have told CNA-T now I'll be punished." The facility summary of the investigation noted the allegation was discussed by the facility's complaint team on 1/9/13 and determined that "due to resident's history of false accusations of staff with behavior of asking staff to administer a skin barrier cream to her vaginal area, along with mention of this happening every day, that there is nothing to substantiate this accusation." On 5/8/13 at 11:00 a.m. SSD-S, NHA (Nursing Home Administrator)-Z, and SW (Social Worker)-Y were interviewed by surveyor # and verified that resident #23 had no history of making allegations of rape prior to 1/8/13. SSD-S, NHA-Z, and SW-Y also verified to surveyor # that night shift staff were not interviewed, no additional residents were interviewed, no physical assessment of the resident was done secondary to the rape allegation, and the allegation and investigation were not reported to law enforcement or to the state survey and certification agency as directed by the facility's abuse policies and procedures. On 5/15/13 at 9:15 a.m. DON (Director Of Nursing)-I verified to surveyor # per a phone interview, the basement in the facility has storage rooms and offices. DON-I verified that resident #23 and any other resident would have no reason to be in the basement to know that there was a storage room there. DON-I also stated "I can't imagine why she'd (resident #23) ever be down there." 2. Resident #24's face sheet dated 5/9/13 indicated that the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated resident #24 was cognitively impaired, had [MEDICAL CONDITION] and verbal behaviors. According to the mood and behavior care plan dated 7/6/12, resident #24 had the potential to be manipulative, intrusive, verbally aggressive, and delusional. An Obstetrics/Gynecology exam note dated 8/28/12, provided by the facility on 5/10/13 in response to surveyor # 's concerns, indicated resident #24 "has been reported to have [MEDICAL CONDITION] of being pregnant and states that she is pregnant today as well." A Psychiatric note dated 9/25/12, also provided by the facility on 5/10/13, noted resident #24 was delusional about being pregnant and being raped after the Obstetrics/Gynecology exam. According to a facility investigation report, on 2/11/13 at 7:20 a.m., resident #24 told DES (Director of Environmental Services)-AA that she had been raped "last night" and "the directors did it." The facility immediately began an investigation. Night shift staff were not interviewed. Five day shift staff were interviewed and all indicated the resident had not verbalized any allegations of rape to them. On 2/11/13 SSD-S interviewed resident #24 twice regarding the allegation of rape. During the first interview, resident #24 stated to SSD-S "'Oh, I guess it didn't happen,'" then during the second interview the resident stated "'I did not say that this morning'." The investigation summary indicated the allegation was not substantiated because the resident changed her story and had multiple mental health issues. On 5/8/13 at 11:00 a.m., SSD-S, NHA-Z, and SW-Y were interviewed by surveyor # and verified that resident #24 frequently made comments to staff that she was pregnant and in labor, but on 2/11/13 was the first time they were aware of the resident making an allegation of rape. During this interview, SSD-S, NHA-Z, and SW-Y also verified to surveyor # that an assessment of the resident was not completed in response to the allegation of sexual assault, that night shift staff were not interviewed, the resident was not asked to identify an accused staff member, additional residents were not interviewed, interventions were not implemented to keep the residents safe during the investigation, the allegation and investigation were not reported to the state survey and certification agency as required and a determination was not made regarding if this allegation of rape was a reasonable suspicion of a crime or not. Resident #24 had made one allegation of rape to the facility staff and on 2/14/13, the facility developed a "Potential for Alteration in psychosocial well-being" care plan for the resident. The care plan indicated resident #24 "has [MEDICAL CONDITION] of being raped." In response to surveyor # 's concerns, on 5/9/13 the facility asked the Psychiatrist caring for resident #23 and resident #24 to offer a clinical opinion regarding both resident's allegations of rape. The Psychiatrist note indicated both residents routinely make statements based on [MEDICAL CONDITION] or paranoia, and neither resident was "typically capable at all of making conversation that is based on reality." The Psychiatrist also noted, ."..I would attribute claims like these... to their psychoses, and without any basis founded on reality." However, this Psychiatrist was not asked for an opinion regarding the allegations of rape until several months after the allegations were made, the Psychiatrist did not mention the increased risk of abuse for residents with mental illness, and the Psychiatrist's note did not address the fact that this was the first allegation of rape made by two residents only one month apart in the facility. 3. Resident #22's undated face sheet indicated that the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. According to the behavior care plan dated 2/8/12, resident #22 would frequently accuse staff of stealing money from her. The MDS dated [DATE] indicated resident #22 was cognitively impaired and had a behavior of refusing care. According to an investigation report, on 3/24/13 around 2:30 p.m., resident #22 told RN (Registered Nurse)-G that a CNA had "just" called her a "f...ing whore." The resident identified CNA-X, by pointing to her, as the one who had verbally abused her. The facility began an investigation, interviewed other residents, and interviewed both CNAs working at the time of the allegation. CNA-X stated she was in the resident's room at 2:05 p.m., but at 2:15 p.m. had taken a 5 minute break. The facility investigation indicated CNA-X was allowed to continue caring for residents during the investigation, just not resident #22. According to the facility work schedule, CNA-X had worked from 11:00 a.m. until 10:30 p.m. on 3/23/13 and 3/24/13, and from 2:00 p.m. until 10:00 p.m. on 3/26/13. On 5/8/13 at 11:00 a.m. SW-Y verified to surveyor # the investigation was not completed until 3/28/12 when it was signed and dated by NHA-Z, DON-I, and SW-Y. SW-Y also verified to surveyor # the allegation of verbal abuse was not reported to the state survey and certification agency as required and as directed by the facility's abuse policies and procedures. The failure to implement policies and procedures with respect to the prevention of abuse created a finding of immediate jeopardy. The jeopardy was removed on 5/11/13 after the facility revised policy and procedures regarding allegations, reporting requirements, protecting residents during the investigation and the thoroughness of the investigations for allegations. The facility processes where updated on 5/10/13 and the facility leadership began training of staff and residents for the expectations on 5/11/13.

Based on record review and staff interviews, the facility did not ensure allegations, involving 3 (residents #22, #23, and #24) of 5 residents who alleged abuse, were thoroughly investigated and reported to the appropriate officials, including the state survey and certification agency. Additionally, the facility did not implement measures to prevent further potential abuse while investigations were in progress. 1. On 1/8/13 at 4:10 p.m., resident #23 alleged the night shift staff had sexually assaulted her. The facility did not complete a thorough investigation. The resident was not interviewed to determine the details of the allegation until 1/9/13. The facility did not interview night shift staff that worked from 1/7/13 into 1/8/13. No assessment of the resident had been completed. No additional residents were interviewed to determine the extent of the potential abuse. The facility did not implement measures to keep the residents safe during the investigation. The allegation of sexual assault was not thoroughly investigated to determine if a reasonable suspicion of a crime was present to determine if the allegation should have been reported to law enforcement or to the state survey and certification agency. 2. On 2/11/13 at 7:20 a.m., resident #24 alleged she had been sexually assaulted during the night by staff. The facility did not complete a thorough investigation. Night shift staff were not interviewed and no assessment of the resident had been completed. Additional residents were not interviewed to determine the extent of the potential abuse. The facility did not implement measures to keep the residents safe during the investigation. The allegation of sexual assault was not thoroughly investigated to determine if a reasonable suspicion of a crime was present to determine if the allegation should have been reported to law enforcement or to the state survey and certification agency. 3. On 3/24/13, resident #22 alleged CNA (Certified Nursing Assistant)-X had verbally abused her. The facility did not implement measures to keep residents safe during the investigation, as CNA-X was allowed to care for other residents during the investigation. The allegation was not reported to the state survey and certification agency as required. The failure of the facility to conduct thorough investigations to rule out if abuse had occurred, protect residents during the investigations, and report the allegations to the appropriate authorities, created a situation of Immediate Jeopardy. The Immediate Jeopardy began on 1/8/13 when the facility became aware of the first allegation of rape. The facility was formally notified on 5/10/13 that an Immediate Jeopardy situation existed. The jeopardy was removed 5/11/13 but the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) until all staff are trained and processes fully implemented. Findings include: On 5/6/13, this facility had a census of 106 residents, of which 74 residents had a mental illness [DIAGNOSES REDACTED]. According to the facility's "Abuse/Complaints-Investigation and Prevention" policy and procedure dated 10/19/11, the facility will "ensure the rights, dignity, and safety of the residents." The policy indicated, "Allegations involving resident mistreatment, neglect, abuse, misappropriation of resident property, and injuries of unknown source shall be reported immediately and not to exceed 24 hours after the incident. This immediate reporting shall be made to the nursing home Administrator and to the Division of Quality Assurance." The policy defined several abuse terms. Verbal abuse was defined as "the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents." Sexual abuse was defined as " sexual harassment, sexual coercion, or sexual assault." The facility's abuse policy contained a procedure for a thorough investigation; "Collecting and preserving physical and documentary evidence; interviewing alleged victim(s) and witness(es); interviewing accused individual(s)...; interviewing other residents...; interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused; interviewing staff who worked previous shifts...; collecting other information that corroborates or disproves the reported incident; involving other regulatory authorities who may assist, e.g., local law enforcement." The facility abuse policy also indicated staff were directed to "Provide immediately for the safety of the resident if the complaint involves allegations of abuse... by instituting necessary precautions to prevent further occurrence...This may involve sending the staff member home or suspending him/her until a determination can be made on the incident by the Complaint Investigative Team." According to the facility's undated "Reporting Reasonable Suspicion of a Crime in a Long-term Care Facility" addendum to the "Abuse/Complaints-Investigation and Prevention" policy and procedure, the facility was to comply with state and federal regulations by reporting any reasonable suspicion of a crime to protect residents by promoting a timely response to potential crimes. The addendum directed staff to report any reasonable suspicion of a crime to the state survey and certification agency and to local law enforcement with in two hours is serious bodily injury occurred or within 24 hours if serious bodily injury had not occurred. 1. Resident #23's Face Sheet dated 9/12/12, indicated that the resident was admitted to the facility on [DATE]. The "Cumulative [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 12/11/12 indicated resident #23 had cognitive impairment and [MEDICAL CONDITION]. On 9/15/10 the facility developed a behavior care plan for resident #23 indicating the resident was manipulative and accusatory towards staff. According to a facility investigation, on 1/8/12 at 4:10 p.m. resident #23 asked CNA-T if she knew if there was a room in the basement of the facility. CNA-T verified to the resident that she was aware of the room and it was used for storage. Resident #23 then told the CNA "the noc (night) shift took me down to the basement and rape me and blood was running down my feet." The facility investigation indicated several staff were interviewed, however, no night shift staff who worked the night of 1/7/13 into 1/8/13 were interviewed. The staff that were interviewed indicated the resident had not been acting out of the ordinary on 1/8/13. RN (Registered Nurse)-U wrote a statement on 1/9/13 indicating at 6:00 a.m. on 1/8/13, resident #23 had asked CNA-V to put some cream "up in her vagina." CNA-V did not write a statement until 1/14/13, the statement indicated on 1/8/13 resident #23 had asked CNA-V "for cream for her vagina area." Resident #23 reported the allegation of rape on 1/8/13. Documentation indicated that the resident has a [DIAGNOSES REDACTED]. On 1/9/13 SSD (Social Services Designee)-S interviewed resident #23 and indicated the resident did not always respond appropriately to questions asked. Resident #23 told SSD-S "'She stuck 2 fingers in my vagina and one in my rectum...She has bangs and wears her hair up in a clip'." Resident #23 verified to SSD-S she was not confusing this incident with a dressing change, and she did not want CNA-T to tell anyone else about the allegation of rape. Resident #23 also stated to SSD-S "'I was strong enough to stop her and she walked away. I shouldn't have told CNA-T now I'll be punished." The facility summary of the investigation noted the allegation of abuse was discussed by the facility's complaint team on 1/9/13 and determined that "due to resident's history of false accusations of staff with behavior of asking staff to administer a skin barrier cream to her vaginal area, along with mention of this happening every day, that there is nothing to substantiate this accusation." On 5/8/13 at 11:00 a.m., SSD-S, NHA (Nursing Home Administrator)-Z, and SW (Social Worker)-Y were interviewed by surveyor # and verified that resident #23 had no history of making allegations of rape prior to 1/8/13. SSD-S, NHA-Z, and SW-Y also verified to surveyor # that night shift staff were not interviewed, additional residents were not interviewed, no physical assessment of the resident was done secondary to the rape allegation, the allegation and investigation were not reported to the state survey and certification agency and a determination was not made regarding if this allegation of rape was a reasonable suspicion of a crime or not. On 5/15/13 at 9:15 a.m., DON (Director Of Nursing)-I verified to surveyor # per a phone interview, the basement in the facility has storage rooms and offices. DON-I verified that resident #23 and any other resident would have no reason to be in the basement to know that there was a storage room there. DON-I also stated "I can't imagine why she'd (resident #23) ever be down there." 2. Resident #24's face sheet dated 5/9/13, indicated that the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated resident #24 was cognitively impaired, had [MEDICAL CONDITION] and verbal behaviors. According to the mood and behavior care plan dated 7/6/12, resident #24 had the potential to be manipulative, intrusive, verbally aggressive, and delusional. An Obstetrics/Gynecology exam note dated 8/28/12, provided by the facility on 5/10/13 in response to surveyor concerns, indicated resident #24 "has been reported to have [MEDICAL CONDITION] of being pregnant and states that she is pregnant today as well." A Psychiatric note dated 9/25/12, also provided by the facility on 5/10/13, noted resident #24 was delusional about being pregnant and being raped after the Obstetrics/Gynecology exam. According to a facility's investigation report, on 2/11/13 at 7:20 a.m. resident #24 told DES (Director of Environmental Services)-AA that she had been raped "last night" and "the directors did it." The facility immediately began an investigation. Night shift staff were not interviewed. Five day shift staff were interviewed and all indicated the resident had not verbalized any allegations of rape to them. On 2/11/13, SSD-S interviewed resident #24 twice regarding the allegation of rape. During the first interview, resident #24 stated to SSD-S "Oh, I guess it didn't happen" and during the second interview the resident stated "'I did not say that this morning'." The investigation summary indicated the allegation was not substantiated because the resident changed her story and had multiple mental health issues. On 5/8/13 at 11:00 a.m., SSD-S, NHA-Z, and SW-Y were interviewed by surveyor # and verified that resident #24 frequently made comments to staff that she was pregnant and in labor, but on 2/11/13 was the first time they were aware of the resident making an allegation of rape. During this interview, SSD-S, NHA-Z, and SW-Y also verified to surveyor # that an assessment of the resident was not completed in response to the allegation of sexual assault, that night shift staff were not interviewed, the resident was not asked to identify an accused staff member, additional residents were not interviewed, interventions were not implemented to keep the residents safe during the investigation, the allegation and investigation were not reported to the state survey and certification agency as required and a determination was not made regarding if this allegation of rape was a reasonable suspicion of a crime or not. Resident #24 had made one allegation of rape to the facility staff and on 2/14/13, the facility developed a "Potential for Alteration in psychosocial well-being" care plan for the resident. The care plan indicated resident #24 "has [MEDICAL CONDITION] of being raped." In response to surveyor # 's concerns, on 5/9/13 the facility asked the Psychiatrist caring for resident #23 and resident #24 to offer a clinical opinion regarding both resident's allegations of sexual assault. The Psychiatrist note indicated both residents routinely make statements based on [MEDICAL CONDITION] or paranoia, and neither resident was "typically capable at all of making conversation that is based on reality." The Psychiatrist also noted, ."..I would attribute claims like these... to their psychoses, and without any basis founded on reality." However, this Psychiatrist was not asked for an opinion regarding these allegations of rape until several months after the allegations were made, the Psychiatrist did not mention the increased risk of abuse for residents with mental illness, and the Psychiatrist's note did not address the fact that this was the first allegation of sexual assault made by two residents only one month apart in the facility. 3. Resident #22's undated face sheet indicated that resident #22 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. According to the behavior care plan dated 2/8/12, resident #22 would frequently accuse staff of stealing money from her. The MDS dated [DATE] indicated resident #22 was cognitively impaired and had a behavior of refusing care. According to an investigation report, on 3/24/13 around 2:30 p.m. resident #22 told RN (Registered Nurse)-G that a CNA had "just" called her a "f...ing whore." The resident identified CNA-X, by pointing to her, as the one who had verbally abused her. The facility began an investigation, interviewed additional residents, and interviewed both CNAs working at the time of the allegation. CNA-X stated she was in the resident's room at 2:05 p.m., but at 2:15 p.m. had taken a 5 minute break. The facility investigation indicated CNA-X was allowed to continue caring for residents during the investigation, just not resident #22. According to the facility work schedule, CNA-X had worked from 11:00 a.m. until 10:30 p.m. on 3/23/13 and 3/24/13, and from 2:00 p.m. until 10:00 p.m. on 3/26/13. On 5/8/13 at 11:00 a.m. SW-Y verified to surveyor # this investigation was not completed until 3/28/12, when it was signed and dated by NHA-Z, DON-I, and SW-Y. SW-Y also verified to surveyor # the allegation of verbal abuse was not reported to the state survey and certification agency as required. The failure to investigate allegations of abuse and to prevent further potential abuse from occurring while an investigation was in progress created a situation of immediate jeopardy. The jeopardy was removed on 5/11/13 after the facility revised their policy and procedures regarding allegations of abuse, reporting requirements, protecting residents during the investigation and the thoroughness of the investigations for allegations of abuse. The facility processes where updated on 5/10/13 and the facility leadership began training of staff and residents for the expectations on 5/11/13.

Based on record review and staff interview, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (resident #1) of 14 sampled residents. Resident #1 had a history of [REDACTED]. The facility did not initiate a behavior assessment to determine specific behaviors that resident #1 displayed in attempt to ensure other residents' safety. CNAs (Certified Nursing Assistants) indicated they were directed to keep resident #1 away from female residents, but a specific plan of care was not implemented. Resident #1 was observed sliding his hand up the inner thigh of resident #2. The facility did not assess resident #2 for injury, nor did the facility interview resident #1 to determine intent and awareness of his actions. The facility did not initiate a behavior assessment in attempt to determine causal factors, nor did the facility develop interventions to ensure other female residents' safety. Six days later, resident #1 was observed to have touched resident #3's breast. The facility did not provide re-education to staff after the incident to ensure staff knowledge of what procedures to follow when a resident displayed inappropriate behaviors. Findings include: The facility's policy and procedure titled, "Resident Incident Reports/Behavior Interdisciplinary Team," dated 2/1/11, indicated, "A Resident Incident Report is to be completed for all significant behaviors. Significant behavior may be an interaction between at least two individuals, which has the potential for a lasting negative effect." The policy and procedure directed staff to notify the NHA (Nursing Home Administrator) and the NHA would direct the unit staff as indicated. The BIDT (Behavior Interdisciplinary Team) would meet the same day of notification to review the significant behavior. The BIDT would review the incident report, care plan, care card, resident's medical record, including immediate interventions initiated. Revise plan of care as indicated. Although, the facility had a policy and procedure when significant behaviors occurred, it was not followed in this situation. On 1/4/12 and 1/10/12, surveyor # reviewed resident #1's medical record. According to the facesheet, dated 1/4/12, resident #1 was admitted to the facility on [DATE]. The "Cumulative [DIAGNOSES REDACTED]. The medical record contained a physician progress report, dated 12/2/11, which indicated resident #1 had "Mixed dementia thought secondary to vascular dementia and a component of [DIAGNOSES REDACTED]. This has been associated with disinhibition and sexually inappropriate behavior and verbalizations." On 1/4/12 at 8:40 a.m., surveyor # interviewed SW-A (Social Worker) regarding the physician progress notes [REDACTED].#1's sexually inappropriate behaviors and verbalizations that were displayed at the nursing home where he resided prior to admittance to the facility. SW-A indicated she was told by the previous facility staff that resident #1 only displayed sexual verbalizations towards staff at the previous facility, but also indicated at times resident #1 was placed on 1:1 observations. SW-A indicated that she did not understand why the 1:1 was implemented if the only inappropriate sexual displays were verbalizations. The medical record had not contained documentation if the physician who wrote the note was ever consulted regarding his documentation of sexually inappropriate behaviors. On 12/7/11, the facility developed a plan of care for "Potential for Behavior Problem: Sexual Behavior" related to cognitive status, manifested by making sexual comments to staff. The plan of care directed facility staff to: ~Provide 2 staff to provide cares. ~Provide an immediate firm approach to any sexual comments or behavior. ~Inform the resident that comments and behavior are inappropriate. ~If behavior continues assure resident's safety and reapproach later. ~Divert attention as needed. ~Social Services was to provide 1:1 visits. The plan of care did not include interventions for the potential for sexual behaviors and/or verbalizations towards other residents. On 12/8/11, the facility implemented a "Behavior Documentation Tool" which directed staff of the following: *Record the number of times resident #1 displayed socially inappropriate or disruptive behavior. *Record the number of times resident #1 was physically abusive towards residents or staff . *Record the number of times resident #1 was verbally abusive towards residents or staff The facility recorded the following on the "Behavior Documentation Tool": *Socially inappropriate behavior: ~1-3 times 3 three times on 12/8, 12/18 ~1-3 times once on 12/9, 12/15, 12/16, 12/27, 12/28, 12/29 ~1-3 times twice on 12/10, 12/17,12/21, 12/22 ~4-6 times once on 12/19, 12/25, 12/30 ~1-3 times twice and 4-6 times once on 12/23, 12/24 *Physically abusive behavior: ~1-3 times once on 12/17 and 12/30 *Verbally abusive behavior: ~1-3 times twice on 12/8 The tool did not differentiate who the behaviors were directed towards so the reader would have been unable to determine if behavior was directed towards residents or staff. In addition, the reader would have been unable to determine specifically what socially inappropriate behavior resident #1 displayed so a specific plan of care could have been developed. On 1/10/12 at 10:50 a.m., surveyor # interviewed SSD-C (Social Service Designee) what socially inappropriate behavior meant. SSD-C indicated it was defined in resident #1's plan of care. SSD-C and surveyor # reviewed resident #1's plan of care which indicated only verbally inappropriate without any other behavioral concerns. On 1/10/12 at 11:20 a.m., surveyor # interviewed RN-D (Registered Nurse) regarding if there was documentation in the medical record which would specifically define what socially inappropriate behavior was displayed by resident #1. RN-D stated socially inappropriate behavior could have meant a variety of behaviors and there was no documentation to define specifically what behavior was displayed. RN-D indicated if staff wanted to know what the behavior was they would need to speak with the CNA that documented the number of behaviors on the "Behavior Documentation Tool." The nurses' notes dated 12/9/11 at 11:00 a.m., indicated resident #1 was oriented to self and had impaired memory. Attempted to touch staff sexually and was kept away from female peers. Had poor insight and safety awareness. The nurses' notes dated 12/9/11 at 3:48 p.m., indicated resident #1 was alert and oriented times three, knew he was in a nursing home but forgetful and would ask. Resident has a history of making sexual comments and touching of female staff. Will monitor for behaviors and keep resident away from female peers at meals, etc. The nurses' notes dated 12/12/11 at 8:40 p.m., indicated resident was seated at table with all men for meals, and is moved away from female peers when he gets too close. The facility completed an MDS (minimum data set) assessment dated [DATE], with an assessment reference date of 12/13/11. The MDS indicated resident #1 had moderately impaired cognitive skills for decision making, had behavioral symptoms not directed towards others 4-6 days a week, but less than daily. The MDS indicated resident #1's behavior had not impacted others. The MDS also indicated resident #1 utilized a wheelchair for mobility and required extensive assistance with one person assistance for locomotion on the unit. On 1/10/12 at 11:15 a.m., surveyor # interviewed DON-B (Director of Nursing). DON-B indicated that resident #1 was able to self propel his wheelchair for short distances on the unit, but required staff assistance for longer distances on the unit, and that was why the MDS was coded requiring staff assistance. The facility completed a CAA (Care Area Assessment) for Behavioral Symptoms, dated 12/19/11. The Behavioral CAA indicated resident #1's behavior "is not serious." The description of the problem was "Resident is adjusting to the new unit and those who live and work here. He speaks loudly in general but has yelled per unit nurse. He had displayed a few episodes of inappropriate sexual behaviors but was easily redirected." On 1/10/12 at 10:50 a.m., surveyor # interviewed SSD-C who verified she had written the behavioral CAA on 12/19/11. SSD-C stated inappropriate sexual behaviors meant resident #1 had grabbed staff's buttocks and breasts and she had received the information verbally from staff when she was completing the CAA. SSD-C verified there was no documentation regarding the behavior in the medical record. SSD-C indicated she was not concerned of resident #1 potentially displaying sexually inappropriate behavior towards female residents, because resident #1 wasn't able to self propel his wheelchair. The nurses' notes dated 12/16/11 at 2:07 p.m. indicated resident #1 was speaking sexually towards staff asking them to "play with him," asking female visitors/staff to come over by him and hold his hand. Was verbally redirected. The nurses' notes dated 12/24/11 indicated resident #1 had inappropriate contact with a female resident. The CNA observed touching peri-area of female resident on the unit while sitting at the table. Was socializing with residents on the unit prior to the behavior. "..Able to make decisions which are consistent and reasonable." The facility had not initiated a behavior assessment to determine causal factors in attempt to prevent further sexually related behaviors toward female residents. The facility did not attempt to interview resident #1 to determine intent or knowledge of awareness of his actions, nor did the facility develop and implement interventions to prevent additional sexually related behaviors towards other female residents. There was no evidence that the incident was reported to the NHA. A nurses' notes dated 12/30/11 indicated resident #1 was observed touching another female resident inappropriately by a CNA on duty. Both residents were sitting up in their wheelchairs. A female resident was sitting in her wheelchair, by the Christmas tree, when resident #1 was observed rubbing her breasts over her shirt. The CNA asked resident #1 what he was doing, resident #1 responded "nothing, nothing." Resident #1 started to wheel self away and was removed by staff from the vicinity. Resident #1's plan of care for "Potential for Behavior Problem: Sexual Behavior, was revised on 1/2/12. The new problem listed Potential for Behavior Problem: sexual behavior toward staff and peers. The plan of care indicated the problem was manifested by making sexual comments to staff and peers. Has touched female peer inappropriately. New intervention directed staff to provide immediate firm approach to any sexual comments or behavior. Inform resident that comments and behavior are inappropriate. If behavior continues assure residents safety and reapproach later. Divert attention as needed. He is to be kept arms length away from female peers at all times. Staff must be aware of his presences as he can propel self and move around quickly. During any event/activity he should not be placed near women. The BIDT reviewed the 12/30/11 incident on 1/2/12. The BIDT indicated resident to resident contact. The resident touched a female resident's breast while she was out on the unit in her wheelchair and was fully clothed. Peer did not appear aware of the touch. She is alert but confused. No injury. The team indicated the incident was report to administration then to the police. Resident #1's care plan will be revised, a change to a different unit will be suggested to the power of attorney for healthcare. There is no evidence that the 12/24/11 incident was reviewed. On 1/4/12 at 8:10 a.m., surveyor # interviewed DON-B regarding resident #1. DON-B stated resident #1 was a recent admit to the facility and had sexually inappropriate verbalization towards staff at the previous facility where he resided. DON-B stated since the incident on 12/30/11, resident #1 had been relocated to the facility's locked unit where direct supervision was available, as the unit where resident #1 previously resided hadn't direct supervision at all times when in the common areas. DON-B indicated there were also only a few female residents that resided on the locked unit. On 1/4/12 at 9:50 a.m., surveyor # interviewed DON-B and RN-E (Registered Nurse) regarding 12/24/11 documentation of sexually inappropriate behavior towards a female resident. DON-B and RN-E verified they were not aware of the incident that had been documented in resident #1's medical record. DON-B stated the RN should have updated the supervisor on duty when the incident occurred. DON-B reviewed the staff schedule and stated RN-F (who also documented the incident) was the supervisor on duty. On 1/4/12 at 10:50 a.m., surveyor # interviewed RN-E regarding resident #1's behavior and plan of care. RN-E verified the plan of care was not developed for inappropriate sexual touching of female residents until 1/2/12, and the previous care plan was implemented for inappropriate sexual verbalization. RN-E stated resident #1 was relocated to the locked unit on 1/2/12, but verified the facility had not implemented retraining on resident to resident altercation procedures since the 12/24/11 or 12/30/11 incident had occurred. On 1/4/12 at 11:10 a.m., surveyor # interviewed DON-B regarding if the facility had provided any training to staff to ensure if resident to resident behaviors occurred that staff were aware of how to respond. DON-B stated she had a staff meeting on 10/26/11 which the topic was "Resident Abuse Prevention/Complaints/Investigations, in conjunction with a video for staff to watch. Staff who were unable to attend the meeting were to complete the video at a later date. DON-B stated RN-F had not watched the video as of yet. DON-B verified no other training had been implemented. On 1/4/12 at 11:38 a.m., surveyor # conducted a telephone interview with LPN-G regarding the incident which occurred on 12/30/11. LPN-G verified she had been updated by a CNA that on 12/30/11, resident #1 was observed rubbing resident #2's breast over her clothing in the common area on the unit. LPN-G stated residents were immediately separated and resident #2 was unaware of the incident that occurred. LPN-G stated she was not aware of any sexually inappropriate behavior prior to 12/30/11, but had heard from staff that they had redirected resident #1 from other female residents in the past to prevent him from inappropriately touching them due to his frequent sexual verbalizations and staff were unsure what he might have done. On 1/4/12 at 1:10 p.m., surveyor # interviewed SW-A regarding the facility policy that indicated the BIDT would review resident #1's medical record when resident to resident altercations had occurred. SW-A stated the BIDT must have missed the documentation, as the BIDT was unaware of the 12/24/11 incident. On 1/4/12 at 2:50 p.m., surveyor # conducted a telephone interview with RN-F regarding the documentation on 12/24/11. RN-F verified she had completed the documentation. RN-F stated she was told by CNA-H that she observed resident #1 seated by a female resident and had his hand touching her "crotch". RN-F stated she could not recall who the female resident was. RN-F indicated CNA-H separated the residents. RN-F stated she had spoken with another nurse about what to do with the information that was reported to her. RN-F could not recall which nurse she had spoken with. RN-F stated she hadn't notified the NHA (Nursing Home Administrator) nor the DON. RN-F stated the other nurse told her she didn't need to complete an incident report and only to document the incident in resident #1's medical record. RN-F verified she had not documented the incident in the female resident's medical record as she hadn't sustained any injury. RN-F stated she was unsure if resident #1's behavior was intentional, but had verified she had not interviewed resident #1 immediately after or at anytime in attempt to determine resident #1's intention or knowledge of his actions. RN-F indicated she was aware that resident #1 had a history of [REDACTED]. RN-F indicated she usually did not work on the unit where resident #1 resided on 12/24/11. RN-F stated she had been told by staff that worked on the unit that resident #1 was to be kept away from female residents but was unsure as to why. RN-F verified there was no change in resident #1's plan of care to prevent resident #1 from sexually inappropriately touching other residents, because resident #1 was already being monitored and was kept away from female residents. RN-F stated resident #1 would have had to self propel his wheelchair to the female resident, as that female resident wasn't capable of self propelling her wheelchair. RN-F stated she hadn't completed a physical assessment on the female resident to assess for any injury, but the female resident hadn't appeared in any distress. RN-F verified she hadn't reviewed the facility's policy and procedure for direction on how to respond to the incident because she had spoken with another nurse at the facility. On 1/4/12 at 5:00 p.m., surveyor # conducted a telephone interview with CNA-H regarding her observations of the incident on 12/24/11. CNA-H verified she was coming out of another resident's room when she observed resident #1 seated in his wheelchair next to resident #3. CNA-H stated she observed resident #1 having his hand placed inside resident #3's leg and was moving upwards. CNA-H indicated she immediately intervened and removed resident #1's hand from the upper inner thigh, just prior to him touching her vaginal area. CNA-H stated she removed resident #1 to the nurses' station and updated RN-F of the observation. CNA-H indicated she had not observed any response from resident #3 related to resident #1's actions. CNA-H stated she was aware that resident #1 had a history of [REDACTED]. CNA-H verified there were concerns that resident #1 might touch a female resident inappropriately and staff were directed to try and keep him away from female residents. CNA-H verified there had been no change in resident #1's plan of care to prevent resident #1 from inappropriately touching female residents immediately after the incident. CNA-H stated staff continued to monitor resident #1's whereabouts on the unit. CNA-H stated resident #1 was very mobile and self propelled his wheelchair about the unit. On 1/10/12 at 8:30 a.m., surveyor # interviewed DON-B regarding facility's expectation of response after the incident which occurred between resident #1 and resident #3 on 12/24/11. DON-B responded with implement a plan to protect other residents. There was no evidence that staff had been reeducated on the facility's policy and procedure for reporting behaviors and incidents. On 1/10/12 at 9:20 a.m., surveyor # interviewed RN-I regarding resident #1's behaviors. RN-I stated resident #1 was independent with mobility when utilizing a wheelchair on the unit (the unit in which he resided when the behaviors occurred). RN-I indicated resident #1 was confused and she was aware that resident #1 had a history of [REDACTED].#1 entering the facility. RN-I indicated she wasn't aware of any previous inappropriate sexual touching towards female residents. RN-I stated staff had concerns of the possibility of inappropriate sexual touching towards female residents and because of concerns CNAs were directed to remove from an area if resident #1 was too close to female residents and to have resident #1 consume his meals at a table with all males. RN-I verified the plan of care at that time did not indicate a concern for the potential of touching female residents or table seating and not to allow resident #1 close to female residents. RN-I indicated it was possible for resident #1 to have inappropriately touched female residents without staff supervision, but there were only a few female residents that resided on the unit that were not capable to notify staff if an altercation occurred. On 1/10/12 at 10:05 a.m., surveyor # interviewed CNA-J regarding resident #1's behavioral history. CNA-J stated resident #1 was very friendly and was verbally sexually inappropriate towards staff. CNA-J indicated she became aware of concerns that resident #1 had the potential to inappropriately touch female residents upon his admission to the facility. CNA-J indicated that she was directed to keep resident #1 away from female residents. CNA-J stated resident #1 self propelled his wheelchair on the unit (where the behaviors occurred). CNA-J indicated she had frequently redirected resident #1 from female residents. On 1/10/12 at 10:30 a.m., surveyor # interviewed CNA-K regarding resident #1's behavioral history. CNA-K stated resident #1 had intermittent confusion since admission to the facility. CNA-K stated resident #1 was able to self propel his wheelchair shortly after admittance to the facility. CNA-K indicated when resident #1 was admitted to the facility she had been directed to watch for any type of sexually inappropriateness. CNA-K stated staff were directed not to have resident #1 seated next to female residents during meals and to keep resident #1 away from female residents. CNA-K stated it wasn't always possible to observe the unit at all times, as staff are busy with residents in their rooms. CNA-K indicated she had redirected resident #1 from female residents every time she had worked. CNA-K stated she had heard staff say they observed resident #1 and resident #3 attempting to touch hands but wasn't sure who self propelled their wheelchair towards the other.