Every finding on record at Heritage House Nursing and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #1) residents reviewed for assistive devices.CNA A operated the Hoyer (mechanical) lift independently while lowering Resident #1 into bed on 3/24/2026.This failure placed residents at risk for accidents and injuries.Findings included:A record review of Resident #1's face sheet dated 3/24/2026 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of epilepsy (seizure disorder), morbid (severe) obesity, type 2 diabetes (uncontrolled blood sugar), chronic kidney disease, unspecified bone disorder, heart failure, unspecified psychosis, major depressive disorder (depression), and quadriplegia (paralysis from neck down).A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated little to no cognitive impairment. Section GG (Functional Abilities) reflected that she used a manual wheelchair and was dependent on staff for transitioning from lying to sitting and sitting to lying on the bed.A record review of Resident #1's care plan last reviewed on 2/11/2026 reflected that she required the use of a Hoyer lift for transfers. Interventions included that staff were to ensure that all Hoyer transfers were performed by two staff members.During an observation and interview on 3/24/2026 at 11:54 AM, CNA A was observed standing to the left of Resident #1's bed and she was lowering Resident #1 into bed using the Hoyer lift. After lowering Resident #1 into bed via the Hoyer lift, CNA B walked into Resident #1's room and set a box of gloves on Resident #1's bed. CNA A stated that she knew that two staff members were supposed to operate the Hoyer lift and said she was waiting for CNA B to grab gloves. CNA A stated that they wanted to take care of Resident #1 before trays came out for lunch. Observation revealed that the Hoyer lift in Resident #1's room had a sign that reflected notice: at least 2 staff members must assist during this lift.During an interview on 3/24/2026 at 12:02 PM, CNA B stated that she had just completed incontinent care for Resident #1 with CNA A and that she had been trained to have two staff members for Hoyer transfers. CNA B stated that she stopped to go get larger gloves and she did not know why CNA A operated the Hoyer by herself. CNA B Stated that CNA A usually did not use the Hoyer independently.During an observation and interview on 3/24/2026 at 12:11 PM, Resident #1 was observed in the dining room sitting at a table. Resident #1 stated that it was not too often that only one staff member operated the Hoyer lift and that she did not feel unsafe during Hoyer transfers.During an interview on 3/24/2026 at 12:40 PM, the DON stated that two people were supposed to operate the Hoyer whether it was a CNA, nurse or someone who had been trained. The DON stated that all CNAs had been trained on operating the Hoyer, including CNA A, and that CNA A had worked at the facility for along time. The DON stated, She knows better. The DON stated that injury or death could happen if only one staff member operated the Hoyer lift.During an interview on 3/24/2026 at 2:34 PM, the Administrator stated that he believed the Hoyer brand was European and he was having trouble finding the manual.During an interview on 3/24/2026 at 1:15 PM, the Administrator stated that staff should grab someone else to assist with operating the Hoyer for safe operations. The Administrator stated that CNA A had worked at the facility for over 30 years and she had been trained on operating the Hoyer. The Administrator stated that CNA A should have stopped when CNA B stepped out to get gloves. The Administrator stated that with one person operating the Hoyer, it could become imbalanced with the weight fluctuation and it could tip over and cause residents to be injured.A record review of the facility's undated policy titled Hydraulic Lift reflected the following: Hydraulic LiftThe hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It isreserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. Thenumber of staff to provide assistance with the transfer should be determined by the manufacturerrecommendations.

Based on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed. 1. The facility failed to properly label and/or date food items.2. The facility failed to dispose of expired food items. 3. The facility failed to correctly seal food items. 4. The facility failed to discard spoiled food items.These practices could cause foodborne illness or choking, particularly in a vulnerable population.Findings included:In an observation on 1/20/2026 at 9:00 AM of cooler 1 of 2 revealed the following:- Bacon in a zip top bag that was not labeled with an expiration date. - Celery that was brown, in a zip top bag dated 1-06 with no expiration date. In an observation on 1/20/2026 at 9:03 AM of freezer 1 of 2 revealed the following:- Pancakes that were not labeled with an open or expiration date on the bag. - Sausage and biscuits that were not labeled with an open or expiration date on the bag. In an observation on 1/20/2026 at 9:07 AM of cooler 2 of 2 revealed the following:- Ketchup in a container labeled with a date of 1-5-26, and with a use-by date of 1-12-26- Unknown Juice in a container with not labeled with what was in the container or an open or expiration date. - Butter in a zip top bag with no date of when it was put in the bag and no expiration date. - Juice in single-serve cups with no label of what was in the cup or not labeled with an open or expiration date. - Single-serving plastic containers of butter dated 1-7 and had an expiration date of 1-14In an observation on 1/20/2025 at 9:10 AM of freezer 1 of 2 revealed the following:- Beef patties labeled with a date 12-1-25 and no use-by date. - Pork Chops in a zip top bag dated 9-16 and no use-by date. - Meatballs in their original packaging with no use-by date. - Tamales in a clear bag that was not open or expiration date on the package. - Chicken in a clear bag that was not labeled with a date. - Pizza dough in a clear bag that was not labeled with a date. In an observation on 1/20/2026 at 9:15 AM of a pantry, 1 of 2, revealed the following:- Rotten potatoes in a cardboard box that were sprouting and soft to the touch did not have a use-by date.In an observation on 1/20/2026 at 9:15 AM of the facility's only kitchen revealed the following:- A clear container of flour labeled with a use-by date of 11-11-25In an interview on 1/22/2026 at 1:30 PM with the RDM, she stated that everyone was responsible for checking the dates on food and labeling items in the kitchen. The RDM stated that if an item was out of date, it should be discarded. The RDM stated that all food items in the kitchen should be labeled with the name of the item, the date the item was put in container and the expiration date. The RDM stated that the coolers should be checked daily for out-of-date items, and the freezers should be checked weekly. The RDM said staff received training on dating all food items and what to do with out-of-date items, and that training should be done bi-monthly. The RDM stated that residents could get sick if they were served out-of-date food. In an interview on 1/22/2026 at 1:38 PM with the DM, she stated that everyone who worked in the kitchen was responsible for checking for out-of-date items and labeling food. The DM said that she went behind the staff to check for out-of-date food items. The DM stated that when new items came in, they went behind the old items. The ADM stated that a resident could get sick if served food that was out of date. In an interview on 1/22/2026 at 2:00 PM with the ADM, he stated that all kitchen staff should label, date, and check for out-of-date food items. The ADM stated that all food items in the kitchen should be properly labeled and dated. The ADM stated that all out-of-date food items should be discarded, and that residents could get sick if they consumed food items that were out of date. Review of the facility's 'Dietary Services Policy & Procedure Manual' dated 2012 reflected: 7.0 Products without a dated shipping label should be dated when they are received by the facility, so there is a method to keep track of the age of the product.6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes.

Based on observation, interviews, and record review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 3 of 3 confidential residents interviewed for grievances.1. The facility failed to notify residents in writing of the findings and actions of the grievances they filed. 2. The facility failed to have prominent postings of who the grievance official was.3. The facility failed to inform residents and their family groups of how to file an anonymous grievance. This failure could affect resident's right to file an anonymous grievance and receive a written decision regarding the resolution of their grievance.Findings included:In an observation and interview on 01/22/2026 at 9:40 AM, revealed a white binder titled Grievance Forms affixed to a wall near the nurse's station. The contact list for the staff was outdated and did not include the current grievance official's contact information (due to the staff listed no longer being employed with the facility), the current ADM, the current DON, nor other current facility staff were listed on the Facility Contacts page located inside the [NAME]. The grievance forms were outdated and the SW stated they did not utilize that binder. In confidential interviews between 01/20/2026 and 01/22/2026 with residents who had filed grievances , revealed that none of the residents recalled getting written resolutions to their grievances. Not all residents recalled receiving verbal resolutions to their grievances, and some residents stated that their grievances had improved. All residents stated that they must obtain a grievance form from a staff member at the facility. In an interview on 01/22/2026 at 9:45 AM with the SW, she stated that no residents had expressed wanting to submit an anonymous grievance. She stated the process was that residents could go to her office and grab a grievance form, and they could also turn it into her office. She stated if she was not at the building, anyone could go into her office and grab a form. She stated that to inform residents of the resolution to their grievance, she would go talk to residents about the outcome, but that she did not provide a written response, but she could if a resident asked for one. She stated that the facility did not utilize the binder that was in a compartment affixed to the wall and acknowledged the contact list was outdated. She stated that she was the grievance official.In an interview on 01/22/2026 at 9:50 AM with the ADM and CRN, they stated that residents had the right to file an anonymous grievance if they wished, and to receive a written resolution to their grievance. He stated that the SW would work on updating the grievance binder and forms, to have accurate information provided to residents who wanted to file grievances. He stated the SW was the grievance official.Review of the facility's policy titled, Grievance dated 11/2/2016 reflected, The facility will notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations.The grievance official will: Issue written grievance decisions to the residentAll written grievances decisions will include: The date the grievance was received A summary statement of the resident's grievance The steps taken to investigate the grievance A summary of the pertinent findings or conclusions regarding the resident's concern(s) A statement as to whether the grievance was confirmed or not confirmed Any corrective action taken or to be taken by the facility as a result of the grievance The date the written decision was issued

Based on interviews, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #4, Resident # 28) of 8 residents reviewed for care plans. The facility failed to ensure Resident #4)comprehensive care plan was updated when he quit smoking. The facility failed to ensure Resident # 28's comprehensive care plan reflected current physician orders for weights . These failures could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. The Findings included: Review of Resident # 4 Face sheet printed 10/18/20244 reflected a [AGE] year-old male originally admitted [DATE] with a readmission on 3/29/2024. Diagnoses included Congestive Heart Failure (CHF) ( a chronic condition in which the heart does not pump blood as well as it should), Type2 Diabetes Mellitus ( a chronic condition that happens when you have a persistently high blood sugars effecting your body use of insulin) Chronic Obstructive Pulmonary disease (COPD)( a group of lung diseases that block airflow to the lungs and make it difficult to breath). Review of Resident # 4's annual MDS dated [DATE] reflected a BIMS score of 15 (which indicate cognitively intact). Section J revealed Current Tobacco use as 1 which indicates yes. Review of Resident # 4's Care plan revised 8/13/2024 reflected. Focus: Resident # 4 is a smoker Date Initiated: 05/16/2023 Revision on: 06/29/2023 Goal: Resident # 4 will smoke in designated area without any occurrence of injury over the next 92 days. Date Initiated: 12/06/2021 Revision on: 06/01/2023 Target Date: 11/11/2024. Interventions/ Task: 1. Perform smoking assessments according to facility policy. Date Initiated: 12/06/2021 2. Explain/show where designated area are and repeat prn Date Initiated: 12/06/2021 4. Keep all lighting materials at the nurses station, may have tobacco products on him. Date Initiated: 12/06/2021 Ensure that the resident and/or responsible is made aware of the facility smoking policy Date Initiated: 05/16/2023 Staff to provide direct supervision during scheduled smoke breaks. Date Initiated: 07/29/2023 Revision on: 08/01/2023 Staff will ensure that no oxygen is located in the designated smoking area Date Initiated 05/16/2023 Review of Resident # 28's Face sheet dated 10/18/2024 reflected a [AGE] year-old female originally admitted on [DATE] with a readmitted [DATE] with diagnosis that included Unspecified protein-calorie malnutrition ( an imbalances between the nutrients our body needs and the nutrients it gets) and CHF ( a chronic condition in which the heart does not pump blood as well as it should). Review of Resident # 28's Quarterly MDS July 23,2024 reflected a BIMS score of 2 (Severe cognitive impairment). Review of Resident # 28's Physician orders printed 10/18/2024 reflected: Regular diet Regular texture, Regular consistency, RED GLASS. Super Cereal w/Breakfast, shake on lunch and dinner trays Written 9/11/2024. Readycare 2.0 three times a day for weight maintenance for 60 Days Ready Care 2.0 -90 mls PO TID x 60 days written 9/9/2024. Super Cereal one time a day for weight maintenance written 9/9/2024. Admit to]Hospice for comfort measures Hospice Dx: GI Bleed Hospice Medical Physician every shift. Written 6/22/2024. No orders for weights noted. Review of Resident # 28' care plan reflected: Focus: Potential risk for Malnutrition Date initiated 7/11/2024 Goal: Maintain stable weight and nutritional parameters Date Initiated: 07/11/2024 Target Date: 12/29/2024 Interventions/Task: Monitor and document meal intake Date Initiated: 07/11/2024 Monitor resident weights Date Initiated: 07/11/2024 Focus: The resident has a significant unplanned/unexpected weight loss. Date Initiated: 07/11/2024 Revision on: 07/11/2024 Goal: The resident's weight will stabilize within 4 weeks Date Initiated: 07/11/2024 Target Date: 12/29/2024 Revision on: 09/20/2024 Target Date: 12/29/2024 Intervention/task: 2 cal/cc supplement with med pass Date Initiated: 09/09/2024 Administer dietary stimulant as ordered.(Mirtazapine 7.5 at HS) Date Initiated: 09/12/2024 Revision on: 09/20/2024 Notify the dietician of the weight loss upon their next visit Date Initiated: 07/11/2024 Notify the physician, resident and family of the weight loss Date Initiated: 07/11/2024 Weigh the resident weekly for at least 4 weeks or until weight has stabilized Date Initiated: 09/09/2024 Weight watchers assessment Date Initiated: 09/20/2024 Interview with Resident #4 on 10/17/2024 at 11:00 am stated that he had quit smoking in July 2024 and has not had any issues since then. Interview with the DON on 10/18/2024 at 12:30 PM revealed her expectations were that the care plan reflects an accurate picture of the resident and was updated in real time. She stated that she or the ADON were responsible for updating the care plan. The care plan should be updated when the residents condition changes She stated the care plan should be reviewed as part of the quarterly care plan meeting. The DON stated that Resident # 3 stopped smoking in July of 2024. She stated care plans not updated can lead to inappropriate care. Interview with MDS nurse on 10/18/2024 at 1:18 PM revealed that she was not responsible for the care plans, the IDT which consist of Nursing, therapy, the social worker and the activities director team was and she was not sure how they were updated. Interview with the ADM on 10/18/2024 at 2:00 PM revealed his expectation was that care plans be current and updated timely. He stated they had several methods to communicate the needs of the residents to the Interdisciplinary team such as morning meeting and order review. He stated that the IDT team was responsible for updating the care plan and that a care plan not updated can lead to the residents not receiving the care they need. Review of the Policy Care Plan Process, Person-centered care Revision May 5, 2023, revealed 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictate the need such as but not limited to falls and pressure ulcer/development.

Based on interview and record review, the facility failed to refer all level I residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 3 of 3 residents (Resident #3, #24 and #29) assessments reviewed for PASARR evaluations. The facility failed to demonstrate a PASRR I was completed on Resident #03 and failed to refer her to the appropriate, State-designated authority when she was diagnosed with bipolar disorder. The facility failed to refer Resident #24 to the appropriate, State-designated authority when he was diagnosed with Major Depressive Disorder and Unspecified Psychosis. The facility failed to refer Resident #29 to the appropriate, State-designated authority when she was diagnosed with schizoaffective disorder and Bipolar disorder. This failure could place residents at risk for missing services that could improve their quality of life and maintain their highest level of practicability. Findings include: Record review of Resident 3's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Epilepsy (seizures), Anemia in Chronic Kidney Disease, and Depression. Diagnoses of Suicidal Ideations was added 9/28/2021 and bipolar disorder was added on 9/29/2021. A diagnosis of stroke was also added on 10/12/2024. Record review of Resident 3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident 3's Care Plan, reflected a Focus area was initiated on 9/10/2021 for a Behavior problem related to suicidal behavior. Resident 03's interventions included a geri-psychiatric evaluation. Record review of Resident 3's Orders, reflected she had an 8/14/2024 active order for Prozac capsule 20 mg by mouth daily for Major Depressive Disorder, Recurrent which she was receiving. Record review of Resident 3's undated electronic medical chart reflected there was no PASRR level I or level II form for this resident. Record review of Resident 24's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Hypertension, Parkinsonism (Neurological Disorder), Major Depressive Disorder, and Unspecified Psychosis not due to a substance or known physiological condition. A diagnosis of Anxiety was added on 8/5/2024. Record review of Resident 24's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident 24's Care Plan, reflected a Focus area was initiated for Requires anti-depressant medications for diagnosis of Major Depressive Disorder on 3/7/2023 with a goal for resident to remain free from adverse reactions related to medications. Resident 24's interventions included to Administer medications as ordered. Record review of Resident 24's orders, reflected an 8/6/2024 active order for Sertraline HCL Tablets 100 mg by mouth daily related to Major Depressive Disorder which he was receiving. Record review of Resident 24's undated electronic chart reflected a 3/5/2023 PASRR I screen form that was marked negative. Record review of Resident 29's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Hypertension (high blood pressure), Heart Failure, Asthma, Anxiety Disorder and Major Depressive Disorder. On 3/3/2024 diagnoses of schizoaffective disorder (psychiatric disorder) and Bipolar disorder (severe mood disorder) were added for the resident. Record review of Resident 29's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 04, which indicated the resident's cognitive ability was severely impaired. Record review of Resident 29's Care Plan, reflected a Focus area was initiated on 3/20/2024 for mood problem related to Mood disorder, Bipolar disorder and Schizoaffective Disorder and requires anticonvulsant medication Depakote with a goal to improve the resident's mood. Resident 29's interventions included to take medications, Behavioral Health consults (psycho-geriatric team, psychiatrist, etc.). Record review of Resident 29's orders, reflected a 8/26/24 active order for Depakote Oral Tablet Delayed Release 125 mg-Give 1 tablet by mouth two times a day related to UNSPECIFIED MOOD (AFFECTIVE) DISORDER. Resident was receiving this medication. Record review of Resident 29's undated electronic medical chart reflected there were negative PASRR I forms on 10/13/2023, 1/3/2024, and 5/2/2024. PASRR I screening form on 6/14/2024 was positive for mental illness but no PASRR II form was located in the chart. In an interview on 10/17/2024 at 1:55 PM the RRN stated that there were no PASRR II forms for Residents #3, Resident #24 and Resident #29. She said Depakote for Resident 29 would not be coded as a PASRR related medication as it was an anticonvulsant. The RRN did acknowledge that the Depakote was ordered specifically for Mood (Affective) Disorder and not for seizures. In an interview on 10/18/2024 at 2:10 PM the DON stated, all residents needed PASRR screening on admission. She was unaware if a new diagnosis would require the resident to be screened. She stated she does not work with the PASRR forms or processes. In an interview on 10/18/2024 at 2:13 PM the CRN stated, every resident was PASRR screened on admission. She stated that if an existing resident gets a new psychiatric diagnosis that was coded on the MDS, then they need to be PASRR screened. She also stated that if the PASRR I form was positive, then the next step would be to alert the local authority for them to complete the PASRR II form. The CRN stated, it was important to do PASRR screening, so residents get services they need. She stated the negative outcome if screening was not done would be residents missing services that would improve quality of life. A record review of the facility policy titled, PASRR Level 1 Screen Policy and Procedure with a revision date of 3/6/2019 (no original date on policy) reflected the following: . It is the policy to obtain a PASRR Level 1 screening form from the referring entity prior to admission to the Nursing Facility. PASRR Program goal is to ensure individual receive the required services for their mental illness. For positive Preadmissions a PASRR 1 is entered into the portal and this becomes the notification to complete the PASRR Evaluation (PASRR II).

Based on observation, interviews and record review the facility failed to ensure a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 8 (Residents # 4,8,9,13,25,27,28 and 30) of 31 residents reviewed for consistent review of weight variances. The facility failed to ensure accurate resident weights for 8 (Residents # 4,8,9,13,25,27,28 and 30) of 31 Residents reviewed which resulted in significant weight variance. The facility failed to consistently monitor that effective interventions were put in place for residents with significant and/ or severe weight loss which resulted in weight variances. This failure resulted in resident with unidentified significant weight variance in resident with medical conditions being at risk for change in physical status. Findings Included: Review of Resident # 4's Face sheet printed 10/18/2024 reflected a [AGE] year-old male originally admitted [DATE] with a readmission on 3/29/2024. Diagnoses included CHF ( a chronic condition in which the heart does not pump blood as well as it should), Type2 Diabetes Mellitus (a chronic condition that happens when you have a persistently high blood sugars effecting your body use of insulin) and COPD (a group of lung diseases that block airflow to the lungs and make it difficult to breath). Review of Resident # 4's annual MDS dated [DATE] reflected a BIMS score of 15 (which indicate cognitively intact). Section K reflected no weight loss or gain of 5% in the last month or more than 10% in the 6 months Nutritional approaches reflected a Therapeutic diet. Review of Resident # 4's medical orders printed 10/18/2024 reflected no order for weights or parameters on when to notify MD of weight loss/gain. Order for monitor for edema was written 10/11/2024. Review of Resident's # 4 Care plan revised 11/26/2021, 5/20/2024, 8/13/2024 reflected: Focus Resident #4 has nutritional problem or potential nutritional problem r/t obesity (BMI 37.3) Goal none stated. Interventions/Task: Coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat. Appears concerned during meals. Monitor/record/report to MD s/sx of malnutrition: Emaciation (the state of being abnormally thin or weak) (Cachexia) ( a metabolic syndrome that causes a loss of muscle and body weight, often due to an underlying illness) , Muscles wasting, significant weight loss: 3 lb. is 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide, serve diet as ordered, monitor intake and record every meal. RD to evaluate and make diet change recommendations as needed. Focus: Resident is on diuretic therapy r/t CHF (bumex) Goal: Resident will be free of any discomfort or adverse side effects of diuretic therapy through the next review date. Intervention/tasks Administer medication as ordered, monitor vital signs as ordered and report to the physician if abnormal for this resident. Report any increased swelling of legs, arms, or face to the charge nurse, Report any increased swelling to the physician, report ordered labs to physician, resident could experience, dizziness, postural hypotension, fatigue, and an in increased risk for fall. Observe of possible side effects. Review of Resident's # 4's Weight summary report printed 10/18/2024 reflected weight on 7/30/2024 of 278.0. 8/2/2024 of 275.4 reflecting a 3 lb. weight loss in one week. Weight on 10/10/2024 was 276.6, Resident # 4's weight on 10/17/2024 witnessed by the surveyor was 274.8 weight. Resident #4's on 4/5/2024 documented as 295.0 which represents a 7.12% loss in 6 months. Review of resident's medical records shows emergency room visit on 3/2024 with shortness of breath and admitted , discharge diagnosis CHF. Resident went to the emergency roiagnom on [DATE] with abnormal labs and shortness of breath, admitted to the hospital, discharge diagnosis on 3/31/2024 was Respiratory Failure. Review of Resident # 4's Dietary note written by the RD dated 4/5/2024 reflected a 7.7% weight gain in 30 days. No new orders or progress notes indicating that the doctor was notified. Review of Resident's # 8 face sheet printed on 10/18/2024 reflected a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with diagnoses that include Cerebral Palsy ( a neurological disorder),and Unspecified Protein-calorie Malnutrition ( an imbalances between the nutrients our body needs and the nutrients it gets). Review of Resident's # 8 Quarterly MDS dated [DATE] reflected a BIMS score of 8 (Moderate Cognitive Impairment). Per documentation the resident is Dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity,) for eating. Section K reflected a loss of liquids/solids from mouth when eating or drinking, weight loss of 5% or more in the last month or loss of 10% or more is last 6 months coded as yes, not on a physician-prescribed weight loss regimen. Nutritional approaches reflected a mechanically altered diet. Review of Resident's # 8 medical orders printed 10/18/2024 Admit to [name of hospice] Hospice written 7/18/2024. Regular diet/consistency chocolate shake on lunch tray. Super cereal with breakfast per please feed order from hospice written 9/26/2024. Ready care 2.0 two times a day for weight maintenance/weight loss written 1/8/2024. No order for weight monitor/ or reporting variance to hospice. Intervention also include Red Glass program which places a red glass on the residents tray to notify staff the resident may need assistance or encouragement during meal time. Review of Resident's # 8 Care plan dated 8/6/2024 reflected. Focus Resident # 8 has a ADL self-care performance deficit Goal the goal section is blank. Interventions/Tasks staff with personal hygiene and oral care. Date Initiated: 11/10/2020 Revision on: 11/10/2020, EATING: Resident #8 requires (x)1 staff participation to eat. Date Initiated: 07/17/2024 Revision on: 07/18/2024, Resident # 8 has contractures of the of bilateral upper and lower extremities. (Knees and hands) Date Initiated: 10/29/2020 Revision on: 06/07/2024. TRANSFER: Resident # 8 requires total assistance with transfers. Date Initiated: 11/10/2020. TOILET USE: Resident # 8 is not toileted. Requires total assistance with incontinent care. Date Initiated: 05/03/2024, Revision on: 05/03/2024 Focus: Resident # 8 has a significant unplanned/unexpected weight loss due to recent hospitalization and diet changed to clear liquids per hospital on 7/17/24. Recent upgrade per speech therapy to pureed foods on 7/23/24. Further upgrade of diet to mechanical soft as pleasure feed per Hospice. Last diet upgrade 9/26/24 to REGULAR TEXTURE, regular consistency due to resident's refusal to eat if diet was not changed. Date Initiated: 07/25/2024 Revision on: 09/26/2024 Goal: Resident # 8 's weight will stabilize or improve through the next review date. Date Initiated: 07/25/2024 Target Date: 11/03/2024. Interventions/ Task Administer medications as ordered. (Remeron) Date Initiated: 09/09/2024 Chocolate shake on lunch tray Date Initiated: 08/06/2024 Initiate Red Glass Program Date Initiated: 07/24/2024 Monitor and document meal intake. Monitor Resident # 8 weights. Monitor Resident # 8's labs. Notify the physician for any negative findings, abnormal labs, or Resident # 8 noncompliance. Offer diet as ordered by the physician. Update food preferences as needed. Date Initiated: 07/25/2024 Refer to speech therapy for evaluation. Date Initiated: 07/25/2024. Super Cereal w/ breakfast Date Initiated: 09/12/2024 Review of Resident # 8's Weight Summary printed 10/18/2024 reflect weight on 8/2/2024 of 124.0. Resident # 8's weight on 8/15/2024 reflected a weight of 115.8 lb. Resident # 8's weight on 10/10/2024 was 104. Resident # 8's weight as observed by the surveyor on 10/17/2024 was 103.4 lb. Weight on 4/18/2024 was 116 lb, this reflects a 17.59% weight loss in 3 months which is a significant weight loss. Review of Resident # 9's Face Sheet printed revealed a [AGE] year-old male admitted on [DATE] with a readmission on 10/4/2024 with diagnoses that include CHF ( A chronic condition in which the heart does not pump blood as well as it should), malignant neoplasm of the transverse colon( cancerous tumor of the colon) and unspecified protein-calorie malnutrition ( an imbalances between the nutrients our body needs and the nutrients it gets). Review of Resident # 9's Quarterly MDS dated [DATE] reflected a BIMS score of 10 (Moderate Impairment). Section K reflected no swallowing disorder, weight gain of 5% or month in the last month or 10% or more in last 6 months coded as on a physician-prescribed weight gain program nutritional approaches included Therapeutic diet. Review of Resident # 9's medical orders revealed Regular texture, Regular consistency, Red Glass, Allergic to Chocolate, NSOT, Cardiac/diabetic ( has NRA for diabetic diet) written 10/9/2024, Ensure three times a day give 10 am, 2 PM, and 7 PM- family provides. Written 10/9/2024. Weekly weights every Thru for weight maintenance written 9/26/2024. Review of Resident # 9's Care Plan dated 10/17/2024 reflected : Focus: Resident # 9 has a diet order other than Regular and is at risk for unplanned weight loss or gain. RCS/LCS/NSOT Regular diet Allergic to Chocolate Date Initiated: 06/26/2024 Revision on: 10/17/2024. Goal: Resident # 9 will maintain ideal weight and receive proper nutrition daily x 90 days. Date Initiated: 06/26/2024 Target Date: 01/11/2025. Intervention/Task: 16 oz fluids with all meals 09/06/2024, Administer supplement (Prostat AWC) as ordered Date Initiated: 09/09/2024 Determine food preferences and provide within dietary limitations. Date Initiated: 06/26/2024. Encourage meal completion and document amount consumed. Date Initiated: 06/26/2024. Monitor weight per facility protocol Date Initiated: 06/26/2024, Offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. Date Initiated: 06/26/2024. Praise resident for eating well. Date Initiated: 06/26/2024, RD assess per facility protocol Date Initiated: 06/26/2024, Red Glass Program Date Initiated: 09/09/2024,Serve diet and snacks as ordered Date Initiated: 06/26/2024 ST eval and TX per Physicians orders Date initiated: 6/26/2024. Focus: Resident # 9 has a significant unplanned/unexpected weight loss Date Initiated: 06/28/2024. Goal: The resident will consume __x__50% of two of three meals/day through the review date. Date Initiated: 06/28/2024 Revision on: 6/28/2024 Target Date: 01/11/2025. Interventions: Administer dietary stimulant as ordered. Mirtazapine Date Initiated: 06/28/2024 Revision on: 06/28/2024. Alert DON if consumption is poor for more than 48 hours. Date Initiated: 06/28/2024, Encourage food related activities Date Initiated: 06/28/2024, Give the resident supplements as ordered. Alert nurse if not consuming on a routine basis. Supplements initiated are: Prostat AWC Date Initiated: 09/09/2024 Revision on: 09/09/2024, Labs as ordered. Report results to physician and ensure dietician is aware. Date Initiated: 06/28/2024, Monitor and encourage PO intake, meals, fluids and supplements Date Initiated: 09/09/2024, Monitor and record food intake at each meal. Date Initiated: 06/28/2024 Monitor and report any changes in the residents eating habits to the Date Initiated: 06/28/2024, Notify the dietician of the weight loss upon their next visit Date Initiated: 06/28/2024, notify the physician, Resident# 9 and family of the weight loss Date Initiated: 06/28/2024, Offer substitutes as requested or indicated. Date Initiated: 06/28/2024, Place a Red Glass on the Resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement, and substitutes. Date Initiated: 09/09/2024 Revision on: 09/09/2024, Provide hands on assistance with Resident # 9 during meals. Date Initiated: 06/28/2024 Revision on: 06/28/2024, Social Service Consult as needed Date Initiated: 06/28/2024, Weigh the resident weekly for at least 4 weeks or until weight has stabilized Date Initiated: 06/28/2024 Review of Resident # 9's Weight summary printed 10/18/2024 reflected a weight of 140.4 on 6/26/2024, weight on 10/10/2024 153, reweigh with surveyor observing on 10/17/2024 was 164.6. which is a 17.57% weight gain in 3 months. Review of Resident # 13's Face sheet printed on 10/18/2024 reflected a [AGE] year-old male original admitted [DATE] with a readmitted [DATE] with diagnoses that included Unspecified protein-calorie malnutrition(an imbalances between the nutrients our body needs and the nutrients it gets). Review of Resident # 13's Quarterly MDS dated [DATE] reflected a BIMS score of 11 (moderate Impairment). Section K reflected no swallowing issues, No weight gain or loss. No nutritional approached coded. Review of Resident # 13's physician orders printed on 10/18/2024 reflected Regular texture, Regular consistency, Red Glass, Resident to use covered cup for all hot liquids. No Pork products: Fluid restriction 1500 ml daily: intolerance to milk/milk products. HS Snacks. Written 6/23/2023. Weekly weights x 4 or until stabilized written 10/9/2024. Review of Resident # 13's Care Plan dated 7/23/2024 reflected: Focus: The resident has a significant unplanned/unexpected weight loss. Date Initiated: 10/04/2024 Revision on: 10/04/2024 Goal : The resident's weight will stabilize within 4 weeks. Date Initiated: 10/04/2024 Revision on: 10/04/2024 Target Date: 10/21/2024 Interventions/Task: Monitor and record food intake at each meal. Date Initiated: 10/04/2024 Revision on: 10/04/2024 Monitor and report any changes in the residents' eating habits to the DON. Date Initiated: 10/04/2024 Revision on: 10/04/2024 Notify the physician, resident and family of the weight loss. Date Initiated: 10/04/2024 Revision on: 10/04/2024 Place a Red Glass on the resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement, and substitutes Date Initiated: 10/04/2024 Revision on: 10/04/2024. Provide hands on assistance with resident during meals. Date Initiated: 10/04/2024 Provide verbal assistance and cues during meals. Date Initiated: 10/04/2024 Revision on: 10/04/2024 Weigh the resident weekly for at least 4 weeks or until weight has stabilized. Date Initiated: 10/04/2024 Revision on: 10/04/2024 Weight Watcher Program ( the facility weight monitoring plan) Date Initiated: 10/04/2024. Review of Resident # 13's Weight watcher program note dated 10/14/2024 reflected that the resident did have 0.7 weight gain. Red Glass program initiated, Provide physical hands-on assistance at meals, Encourage food related activities, and physician ordered Medication for appetite stimulant (Remeron 7.5 mg daily ordered 10/10/2024). Review of Resident # 13's Weight Summary report reflected weights on 4/30/2024 180 weight 10/4/2024 of 161.4 reweighs observed by surveyor on 10/17/2024 was 164.8 which reflected a 10.33% weight loss in 6 months. Review of Resident # 25's Face sheet dated 10/18/2024 reflected a [AGE] year-old male originally admitted on [DATE] with readmitted [DATE] with diagnoses that included Unspecified Protein-calorie malnutrition (an imbalances between the nutrients our body needs and the nutrients it gets) and Dementia long-term brain disorder causing personality changes and impaired memory, reasoning and social functioning. Review of Resident #25's Quarterly MDS dated [DATE].2024 reflected a BIMS score of 06 Severe cognitive Impairment). Section K reflected no swallowing disorder, No weight gain or loss, Nutritional Approaches reflected a mechanically altered diet. Review of Resident #25's Physician Orders printed on 10/18/2024 reflected: Renal diet Regular texture, Regular consistency, NRA for regular diet. large portions. PM snack. Apple, grape or cranberry juice w/ each meal written 10/09/2024. Weekly weights x 4 one time a day every Thru written 9/19/2024. Mirtazapine Oral Tablet 7.5 MG (Mirtazapine) Give 1 tablet by mouth one time a day for APPETITE STIMULANT written 3/25/2024. Review of Resident # 25's Care Plan dated 9/6/2024 reflected: Focus: Resident # 25 t has a diet order Regular and is at risk for unplanned weight loss or gain. Regular texture, Regular consistency, for weight maintenance NRA for regular diet. large portions. PM snack. Apple, grape or cranberry juice w/ each meal. Serve minimum 16 oz fluid each meal. Monitor and encourage PO intake meals, fluids and supplements. Date Initiated: 05/27/2024 Revision on: 06/14/2024. Goal: Resident # 25 will have no significant weight loss through the next review date. Date Initiated: 05/27/2024 Target Date: 09/03/2024. Focus: Monitor and record percentage of meal consumed. Report to DON if resident continues to eat less than 50% of meals. Date Initiated: 05/27/2024 Offer substitutes if resident does not like meal being served. Date Initiated: 05/27/2024. Provide hands on assistance with meals and feeding if needed. Date Initiated: 05/27/2024. Resident# 25 to be weighed according to facility protocol, typically at least once monthly. Date Initiated: 05/27/2024 Resident # 25 was prescribed Renal diet related to CKD stage 3 but refused meals which would contribute to further weight loss. Resident # 25's wishes were to remain on a regular diet. Resident has a Negotiated Risk Agreement on file completed 6/13/24. Date Initiated: 06/14/2024. Revision on: 06/14/2024 Serve diet as ordered. Date Initiated: 05/27/2024. Focus: Resident # 25 has a nutritional problem or potential nutritional problem r/t unspecified protein calorie malnutrition. Date Initiated: 02/23/2024 Revision on: 02/23/2024 Goal: The Resident # 25 will maintain adequate nutritional status as evidenced by maintaining weight within normal parameters), no s/sx of malnutrition, and consuming at least 50% of at least 2 meals daily through review date. Date Initiated: 02/23/2024 Revision on: 02/23/2024. Target Date: 09/03/2024 Interventions/Task : Administer medications as ordered. Monitor/Document for side effects and effectiveness. (MIRTAZAPINE) Date Initiated: 02/23/2024 Revision on: 02/23/2024. Discuss the Resident 25's feelings about weight and commitment to weight loss/gain as needed. Allow the resident to express feelings. Discuss positive coping behaviors, alternatives to overeating/under eating, feelings related to food, environmental issues, relationship and self-image concerns. Date Initiated: 02/23/2024 Revision on: 02/23/2024. Explain and reinforce to the Resident # 25 , the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Date Initiated: 02/23/2024 Revision on: 02/23/2024 Invite the resident to activities that promote additional intake Date Initiated: 02/23/2024 Revision on: 02/23/202 Large portions at each meal. Date Initiated: 06/05/2024 Mirtazapine 7.5 mg for appetite stimulant. Date Initiated: 06/05/2024 Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date Initiated: 02/23/2024 Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 02/23/2024 Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 02/23/2024 OT to screen and provide adaptive equipment for feeding as needed. Date Initiated: 02/23/2024 Provide and serve diet as ordered. Date Initiated: 02/23/2024 Provide, serve diet as ordered. Monitor intake and record q meal. Date Initiated: 02/23/2024 RD to evaluate and make diet change recommendation PRN. Date initiated 02/23/2024. Review of Resident # 25's weight summary printed 10/18/2024 reflected a weight on 6/10/2024 was 123.4. 10/3/2024 of 121.1 10/17/2024 weight as observed by surveyor was 128.6. which reflect a 6.1% Weight gain in 30 days Review of Resident # 27's Face Sheet dated 10/18/2024 reflected a [AGE] year-old female originally admitted [DATE] with diagnosis that include Paraplegia (a type of paralysis that affect the movement of the lower limbs). Review of Resident # 27's Admission MDS dated [DATE] reflected Cognitive patterns: resident has a short term memory problem with long term memory okay. No BIMS assessment conducted as resident is rarely/never understood). Eating requires Partial/moderate assistance (helper does less than half the effort). Section K reflected with no swallowing disorders Nutritional approaches coded at Mechanically altered diet. This was an admission assessment no weight loss or gain information was available. Review of Resident #27's care plan dated 9/28/2024 reflected: Focus: Resident # 27 has a significant unplanned/unexpected weight loss Date Initiated: 10/04/2024 Goal: The resident's weight will stabilize within 4 weeks Date Initiated: 10/04/2024 Target Date: 12/27/2024 Interventions/ Task : Administer dietary stimulant as ordered. Remeron 7.5 mg daily, Date initiated: 10/24/2024 , revision on: 10/04/2024 Monitor and record food intake at each meal. Date Initiated: 10/04/2024. Monitor and report any changes in Residents' # 27 eating habits to the DON Date Initiated: 10/04/2024 Notify the physician, resident and family of the weight loss Date Initiated: 10/04/2024 Place a Red Glass on the residents meal tray to identify the resident to staff as possibly needing assistance, encouragement, and substitutes Date Initiated: 10/04/2024 Provide hands on assistance with Resident # 27 during meals. Date Initiated: 10/04/2024 Weigh the resident weekly for at least 4 weeks or until weight has stabilized Date Initiated: 10/04/2024 Weight Watcher Program Date Initiated 10/04/2024. Focus: Resident # 27 has a diet order other than Regular and is at risk for unplanned weight loss or gain. Regular with Mechanical Ground Meat texture and intolerance to lactose. Date Initiated: 09/14/2024 Revision on: 09/17/2024. Goal: Resident # 27 will maintain ideal weight and receive proper nutrition daily x 90 days. Date Initiated: 09/14/2024 Target Date: 12/27/2024. Intervention/Task: Advise dietary of resident's intolerance to lactose. Date Initiated: 09/17/2024 Determine food preferences and provide within dietary limitations. Date Initiated: 09/14/2024 Encourage meal completion and document amount consumed. Date Initiated: 09/14/2024 Monitor weight per facility protocol Date Initiated: 09/14/2024 offer sub, if resident eats less than 50% or dislikes meal and offer supplement if Resident continues to eat less than 50%. Date Initiated: 09/14/2024 Praise resident for eating well. Date Initiated: 09/14/2024 RD assess per facility protocol Date Initiated: 09/14/2024 Serve diet and snacks as ordered Date Initiated: 09/14/2024 ST eval and TX per Physicians orders as condition warrants. Date Initiated: 09/14/2024 The resident has mechanically altered diet Date Initiated: 09/14/2024. Review of Resident # 27's Weight-watchers program dated 10/11/2024 reflected Nurse Practitioner was notified on about weight variance on 10/14/2024. Review of Resident # 27's weight summary reflected 9/13/2024 weight was 178.4. 10/10/2024 weight was 167.6. weight on 10/17/2024 observed by the surveyor 164.8 which is a 7.62% weight loss in less than 60 days. Review of Resident # 28's face sheet dated 10/18/2024 reflected a [AGE] year-old female originally admitted on [DATE] with a readmitted [DATE] with diagnoses that include Unspecified protein-calorie malnutrition ( an imbalances between the nutrients our body needs and the nutrients it gets) and CHF ( a chronic condition in which the heart does not pump blood as well as it should). Review of Resident # 28's Quarterly MDS July 23,2024 reflected a BIMS score of 2 (Severe cognitive impairment). Section K revealed Swallowing disorder coded as loss of liquids/solids from mouth when eating or drinking. Weight loss coded are yes, not on a physician-prescribed weight-loss regimen. No Nutritional approaches coded. Review of Resident # 28's Physician orders printed 10/18/2024 reflected: Regular diet Regular texture, Regular consistency, RED GLASS. Super Cereal w/Breakfast, shake on lunch and dinner trays Written 9/11/2024. Readycare 2.0 three times a day for weight maintenance for 60 Days Ready Care 2.0 -90 mls PO TID x 60 days written 9/9/2024. Super Cereal one time a day for weight maintenance written 9/9/2024. Admit to [name of hospice] Hospice for comfort measures Hospice Dx: GI Bleed Hospice Medical Physician: [name of physician] every shift. Written 6/22/2024. No orders for weights noted. Review of Resident # 28' care plan reflected: Focus: Potential risk for Malnutrition Date initiated 7/11/2024 Goal: Maintain stable weight and nutritional parameters Date Initiated: 07/11/2024 Target Date: 12/29/2024 Interventions/Task: Monitor and document meal intake Date Initiated: 07/11/2024 Monitor resident weights Date Initiated: 07/11/2024 Monitor resident's labs Date Initiated: 07/11/2024 Notify the physician for any negative findings, abnormal labs, or resident noncompliance Date Initiated: 07/11/2024 Offer diet as ordered by the physician Date Initiated: 07/11/2024 Update food preferences as needed Date Initiated: 07/11/2024 Focus: Resident # 28 has a significant unplanned/unexpected weight loss. Date Initiated: 07/11/2024 Revision on: 07/11/2024 Goal: The resident's weight will stabilize within 4 weeks Date Initiated: 07/11/2024 Target Date: 12/29/2024 Resident # 28 will consume ___50% ___ two of three meals/day through the review date Initiated: 09/20/2024 Revision on: 09/20/2024 Target Date: 12/29/2024 Intervention/task: 2 cal/cc supplement with med pass Date Initiated: 09/09/2024 Administer dietary stimulant as ordered.(Mirtazapine 7.5 at HS) Date Initiated: 09/12/2024 Revision on: 09/20/2024 Alert DON if consumption is poor for more than 48 hours. Date Initiated: 07/11/2024 Dental Consult as needed Date Initiated: 07/11/2024 Encourage food related activities Date Initiated: 07/11/2024 Give the resident supplements as ordered. Alert nurse if not consuming on a routine basis. Readycare 2.0 Date Initiated: 07/11/2024 Revision on: 09/09/2024 Labs as ordered. Report results to physician and ensure dietician is aware. Date Initiated: 07/11/2024 Monitor and record food intake at each meal. Date Initiated: 07/11/2024 Monitor and report any changes in the residents eating habits to the DON Date Initiated: 07/11/2024 Notify the dietician of the weight loss upon their next visit Date Initiated: 07/11/2024 Notify the physician, resident and family of the weight loss Date Initiated: 07/11/2024 Offer substitutes as requested or indicated. Date Initiated: 07/11/2024 Place a Red Glass on the resident # 28 's meal tray to identify the resident to staff as possibly needing assistance, encouragement, and substitutes. Date Initiated: 09/09/2024 Revision on: 09/20/2024 Provide hands on assistance with resident during meals. Date Initiated: 07/11/2024 Provide resident the diet as ordered by the physician. Regular, super cereal, shake with lunch/dinner Date Initiated: 09/12/2024 Revision on: 09/12/2024 Provide verbal assistance and cues during meals Date Initiated: 07/11/2024 Refer the resident to therapy for screen Date Initiated: 07/11/2024 Social Service Consult as needed Date Initiated: 07/11/2024 Super cereal at breakfast. Date Initiated: 09/09/2024 Revision on: 09/09/2024. Weigh the resident weekly for at least 4 weeks or until weight has stabilized Date Initiated: 09/09/2024 Weight watchers assessment Date Initiated: 09/20/2024 Review of Resident # 28's weight watchers program in the medical record dated 10/14/2024 revealed notification of weight variance to Nurse practitioner . No new orders received due to decline in condition. Review of Resident # 28's weight summary report reflected weight on 6/7/2024 197, 10/4/2024 weighted 161.2 10/17/2024 with surveyor observing weight was 155.4. Which represented a weight loss of 21.32% in 3 months. Review of Resident # 30's face sheet dated 10/18/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Type 2 diabetes Mellitus with unspecified complications (a chronic condition that happens when you have a persistently high blood sugars effecting your body use of insulin) and Chronic Obstructive Pulmonary disease (COPD)( a group of lung diseases that block airflow to the lungs and make it difficult to breath). Review of Resident # 30's Quarterly MDS dated [DATE], reflected a BIMS score of 13 (cognitively intact). Review of Resident # 30's Physician Orders printed 10/18/2024 revealed Regular diet Regular texture, Regular consistency written 3/6/2024, Weekly weights x 4 one time a day every Thru for weight maintenance until 10/31/2024 written 10/9/2024. Review of Resident # 30's Care Plan dated 7/23/2024 reflected: Focus: Resident# 30 has a significant unplanned/unexpected weight gain r/t Overeating Date Initiated: 10/09/2024. Goal : Resident will not develop complications from weight gain such as skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date Date Initiated: 10/09/2024 Revision on: 10/09/2024 Target Date: 10/21/2024 Interventions/ Task: Monitor/record the resident's eating habits, and patterns to assist in determining cause of overeating Date Initiated: 10/09/2024 Revision on: 10/09/2024 Notify MD if: Increasing shortness of breath; escalating edema; increased anxiety; inability to lie flat; change in baseline level of orientation/alertness. Date Initiated: 10/09/2024 Notify nurse if: Increasing shortness of breath; escalating edema; increased anxiety; inability to lie flat; change in baseline level of orientation/alertness. Date Initiated: 10/09/2024 Weigh the resident weekly for at least 4 weeks or until weight has stabilized. Date Initiated: 10/09/2024 Revision on: 10/09/2024 Review of Resident #30's Weight Summary printed 10/18/2024 reflected 4/01/2024 weight was 133.8 10/10/2024 weight was 150. Weight on 10/18/2024 observed by surveyor resident weight was 150.4 which reflected a weight gain of 12.11 in 6 months. Review of Resident# 30's medical record from 10/10/2024 to present revealed no progress note or weight watchers indicating MD was notified of weight variance. Observation on 10/17/2024 Observation of weights by surveyor on 6 ( 2,4,6,8,25 and 26) Residents revealed , the facility final weights and the surveyors did not match on 3 ( 2,6, and 6) of the residents weighted. 10/18/2024 surveyor observation of weights on all 31 residents at the facility. Observation on 10/15/2024 in the dining room of Resident # 8 being assisted to eat her meal. Observation on 10/16/2024 of breakfast meal in the dining room Resident # 8 is being assisted to eat. Interview on 10/17/2024 at 1 PM with Resident # 4 he stated that he is okay living here, he states they take good care of him and he feels safe. He stated they weight him once a month, he was no aware of weight gain and says he does not pay attention to his weight. Interview on 10/16/2024 with Resident # 8 she stat

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 4 of 4 resident (Residents# 8, 14, 26, and 186) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene and sanitized equipment properly during medication pass on 4 residents (Residents# 8, 14, 26, and 186). This failure could place residents at risk for development of communicable diseases and infections. Findings include: Record review of Resident 8's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Epilepsy (seizures), Depression, Heart Failure, and Hypertension (high blood pressure). Record review of Resident 8's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident 8's Care Plan, reflected a Focus area was initiated for hypertension on 1/28/2015 with a goal to remain symptom free of high blood pressure. Resident 08's interventions included to take residents. Record review of Resident 14's undated face sheet, revealed he was an [AGE] year-old male admitted [DATE] with diagnoses of Malnutrition, Hypertension (high blood pressure) and Atrial Fibrillation (abnormal heart rhythm). Record review of Resident 14's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated the resident's cognitive ability was not impaired. Record review of Resident 14's Care Plan, reflected a Focus area was initiated for hypertension on 8/8/24 with a goal for resident to remain free of complications related to hypertension. Resident 14's interventions included giving the resident hypertensive medications. Record review of Resident 26's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Right-side paralysis, Depression, and stroke. Record review of Resident 26's Quarterly MDS assessment dated [DATE] revealed a BIMS score could not be determined on this resident. Record review of Resident 26's Care Plan, reflected a Focus area was initiated for depression on 9/20/23 with a goal to show decreased episodes of depression. Resident 26's interventions included to take anti-depressant medications. Record review of Resident 186's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Heart Disease, Anemia, Depression, and Hypertension. Record review of Resident 186's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident 186's Care Plan, reflected a Focus area was initiated for hypertension on 1/3/24 with a goal to remain free of complications related to hypertension. Resident 186's interventions included to take anti-hypertensive medications. Observation on 10/16/24 at 8:49 a.m. revealed MA at her medication cart with a blood pressure (BP) cuff laying on the top of the cart. She took the BP cuff into room and took Resident #26's blood pressure. Afterwards, she returned the blood pressure cuff to the top of the medication cart without cleaning the equipment. She then prepared the medications on the cart. No hand hygiene was performed between getting the residents BP and preparing medications at the cart. Many areas of the cart were touched while preparing medications. She returned inside the room and administered the medications to Resident #26. MA washed her hands after all medications were given to him. Observation on 10/16/24 at 9:06 a.m. revealed MA left Resident #26's room and moved to Resident #14's room. The blood pressure (BP) cuff was still laying on the top of the cart un-sanitized. She took the BP cuff into room and took Resident #14's blood pressure. Afterwards, she returned the blood pressure cuff to the top of the medication cart without cleaning the equipment. She then prepared the medications on the cart. No hand hygiene was performed between getting the residents BP and preparing medications at the cart. Many areas of the cart were touched while preparing medications. She returned inside the room and administered the medications to Resident #14. Afterwards she returned to the medication cart without performing any hand hygiene. MA proceeded to touch multiple areas of the medication cart and the computer on the cart. She then moved the medication cart to the next room. Observation on 10/16/24 at 9:14 am revealed MA left Resident #14's room and moved to Resident #186's room. The blood pressure (BP) cuff was still laying on the top of the cart un-sanitized as she worked on the top of the cart and on the computer. MA performed hand hygiene but did not sanitize the BP before she took the BP cuff into the room and took Resident #186's blood pressure. Direct contact with the resident's bare skin was observed while the MA was taking the blood pressure. Afterwards, she returned the blood pressure cuff to the top of the medication cart without cleaning the equipment. She then prepared the medications on the cart. No hand hygiene was performed between getting the residents BP and preparing medications at the cart. Many areas of the cart were touched while preparing medications. She returned inside the room and administered the medications to Resident #186. No hand hygiene performed after leaving the room. MA then moved the medication cart to Resident #08's room. Observation on 10/16/24 at 9:40 am. revealed MA left Resident #186's room and moved to Resident #08's room. The blood pressure (BP) cuff was still laying on the top of the cart un-sanitized. She took the BP cuff into room and took Resident #0'8's blood pressure. No hand hygiene was done before entering the room. Afterwards, she returned the blood pressure cuff to the top of the medication cart without cleaning the equipment. She then prepared the medications on the cart. No hand hygiene was performed between getting the residents BP and preparing medications at the cart. Many areas of the cart were touched while preparing medications. She returned inside the room and administered the medications to Resident #08. Afterwards, she returned to work at the medication cart without performing hand hygiene. In an interview on 10/18/24 at 1:50 PM CNA-E stated, the policy was to wash hands or sanitize hands between residents. She stated the policy on cleaning equipment between residents was to use sanitizer wipes to clean BP cuffs. CNA-E stated it was important to clean hands and equipment between residents to keep down infections. She stated the negative outcome to residents if this was not done would be residents getting sick. In an interview on 10/18/24 at 2:04 PM the ADM stated, the policy was to remove gloves and wash hands thoroughly or use hand sanitizer if appropriate between residents. She stated the policy on cleaning equipment between residents was to use proper cleaning material between resident's blood pressures. The ADM stated it was important to clean hands and equipment between residents to prevent infectious bacteria transferring from one resident to another. She stated the negative outcome to residents if this was not done would be residents would get an infection. In an interview on 10/18/24 at 2:10 PM the DON stated, the policy was to clean hands with alcohol base gel, wash hands with soap and water if resident was on isolation and use gel when gloves were removed. She stated the policy on cleaning equipment between residents was to wipe with wipes and let it dry between each resident use. The DON stated it was important to clean hands and equipment between residents for infection control and to not pass anything between residents. She stated the negative outcome to residents if this was not done would be to spread germs or infectious diseases to residents. In an interview on 10/18/24 at 2:13 PM CRN stated, the policy was to complete hand hygiene between residents, usually with alcohol-based-hand gel. She stated the policy on cleaning equipment between residents was to wipe with purple wipes between each resident use. RN-E stated it was important to clean hands and equipment between residents to cut down on the spread of infections. She stated the negative outcome to residents if this is not done, would be to spread infections. A record review of the facility policy titled, Fundamentals of Infection Control Precautions dated 2019 and with a last revision date of 3/2023 reflected the following: Hand hygiene continues to be the primary means of preventing the transmission of infection. Situations listed that require hand hygiene include: Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure ). Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant.

Based on interview, observation and record review the facility failed to ensure that the resident environment was as free of accident hazards as possible for one resident (Resident #3) out of five residents. The facility failed to ensure that the temperature of the coffee was safe for consumption and handling by Resident #3, resulting in a coffee burn. The failure could result in residents being burned due to the temperature of the coffee being too hot. Findings include: Record review of resident charts revealed that Resident #3 was admitted on [DATE] with a primary diagnosis of cerebral infarction (a diagnosis where blood flow was blocked to the brain). Resident #3's care plan dated 04/25/2024 revealed that the resident had a coffee spill event. Record review of nursing note dated 03/10/2024 revealed that Resident #3 had a coffee spill in the dining room. Resident #3 had sustained a large area of redness to upper right inner thigh. No blisters were noted in the nursing note. Cold compress was applied to both left and right thighs. Record review of nursing progress note dated 03/20/2024 revealed that Resident #3 had been seen by the wound care physician. It was noted that Resident #3 had a burn wound on her right thigh. Observation on 07/02/2024 at 10:30 AM revealed that a coffee machine was in the dining room on a table against the wall, the coffee dispenser was on, accessible to all residents. Activities staff member was sitting alone waiting to assist residents with coffee. Record review of coffee temperatures from dates July 1, 2024 and July 2, 2024 in the kitchen revealed that the coffee temperatures have consistently been 140 degrees. Interview conducted on 07/02/2024 at 2:20 PM with Resident #3 revealed that the coffee has been too hot to consume. She stated that she had gotten coffee for another resident, then it spilled on her lap. She stated that the staff had helped clean her off after and it did not hurt after that. She stated that coffee had only spilled on her one time a while ago, she could not remember the timeframe. She stated she had only gotten coffee for other residents this one time and was trying to be helpful. Interview conducted on 07/03/2024 at 10:32 AM with DM revealed that the temperature of the coffee should be 140 degrees. She stated that a thermometer has been used to check the temperatures of the coffee. The temperature of the coffee is checked before leaving the kitchen. She stated a potential negative outcome of providing coffee too hot, above 140 degrees to the residents is the residents could get severe burns. Interview conducted on 07/03/2024 at 10:40 AM with DON revealed that the expectation for the coffee was to be measured before being served. She stated that it should be 140 degrees. If the coffee is hotter than 140 degrees, it is not allowed out of the kitchen until the temperature is down. DON stated a potential negative outcome of serving coffee that is too hot for residents, is that the residents could burn themselves. Interview conducted on 07/03/2024 at 11:04 AM with LVN A revealed that Resident #3 had spilled coffee on herself in the past. She stated that she had went and tried to get the by coffee herself and ended up spilling it on her legs. She had redness burns that were treated by staff with cold compress and scheduled pain medication. She stated that a potential negative outcome of coffee being too hot for residents is getting burned. Interview conducted on 07/03/2024 at 11:23 AM with LVN B revealed that Resident #3 had spilled coffee on herself one time. She stated that because of this, the facility checks the coffee temperature to ensure that it is under 140 degrees. She stated that the residents are upset because the coffee is not hot like they like it. She stated a potential negative outcome of coffee being too hot for residents is that they can get burned really bad and have to perform treatments on them. Interview conducted on 07/03/2024 at 11:47 AM with LVN C revealed that Resident #3 is only able to use one arm, had gotten her own coffee and was wheeling out of the dining room when it spilled on herself. She stated that Resident #3 had burns on her legs. She stated a potential negative outcome of coffee being too hot for residents is burns are a possibility. Observation on 07/03/2024 at 12:30 PM revealed that the coffee was at a temperature able to consume without pain or caution of burning when a food tray was sampled with a cup of coffee and tasted. Interview conducted on 07/03/2024 at 02:14 PM with ADM revealed that the expectation for temperatures of coffee is to be 140 degrees when it leaves the kitchen. He stated that Resident #3 had gotten a cup of coffee and it had spilled on her. The accident was observed by staff members. He stated that resident is often persistent on being independent and refuses help, which is what happened at that time. He stated that the resident had no complaints of pain, no burns at the time and was provided treatment and care immediately afterward. He stated that the facility had provided the resident with an ice pack in which they monitored the redness closely. He stated that the resident was getting coffee for someone else and spilled the coffee on her lap when she was wheeling away in her wheelchair. He stated that in-services were provided immediately after the incident and all staff were aware of the coffee needing to be maintained at 140 degrees before being served. He stated if the coffee was above 140 degrees the staff will cool it down and take it out of the lobby, so it is not served to the residents. He stated that the facility has staff in the dining room watching the coffee area when residents are and are not present to provide support as necessary. They also heavily encourage the residents to ask staff for the coffee or the staff try to be proactive in providing the coffee to the residents before any accidents could occur. ADM stated that a negative outcome of providing coffee that is too hot to residents is a burn could happen, depending on where it lands and how long it sits on the skin. Record review of in-services revealed that in-services were completed for Hot liquid/Food Spills liquids must be at 140 degrees or below if served to a resident. This document was dated 03/10/2024 and was signed by staff. Record review of undated document provided by the facility called Guidelines to Serving Coffee in the nursing home on 07/03/2024 at 1:00 PM revealed the following. -As there is no published federal or state regulation for minimum or maximum coffee temperature, the decision as to the temperature at which to serve the coffee rests with the administration of each facility, based on their resident's stated preferences, and the physical layout of their building, but balanced against the safety of their individual residents and their physical and mental limitations. - The standard for coffee service will be 140 degrees unless the facility's residents have stated an overwhelming preference for coffee to be served at a higher temperature and additional safety measures have been implemented. Record review of Hot Liquid/Food Spills document dated 2003 revealed that if residents are at risk of having any hot liquid food/spilled on their person causing burns the following actions should occur. Examples of hot liquids/foods are coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance. It stated if any staff member observed a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with a liquid that is at room temperature or below, by pouring the liquid directly on the area affected.

Based on record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and a received adequate supervision and assistance devices to prevent accidents for (Resident #1) one resident reviewed for transfers. The facility failed to ensure Resident #1 was transferred properly as stated in the resident's care plan and MDS. An IJ was identified on 01/30/2024. The IJ Template was provided to the facility on [DATE] at 06:16 p.m. While the facility was removed on 01/31/2024, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure may put resident at risk for falls and injuries. Findings included: Review of Resident #1's face sheet, dated 01/30/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of osteoarthritis (inflammation of one or more joints) diabetes, morbid obesity, and dementia (group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident #1's quarterly MDS assessment, dated 11/07/2023, revealed a BIMS of 05 indicating a severe cognitive impairment. Further review of Resident #1's MDS revealed functional status for transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) self-performance as total dependence (full staff performance every time during entire 7-day period) with supports of two plus person physical assist. Review of Resident #1's care plan, undated, revealed a focus of the resident (Resident#1) had an ADL self-care performance deficit, with a goal that the resident (Resident #1) will maintain or improve current level of functions in all ADLs, and with interventions/tasks that the resident (Resident #1) requires a, Mechanical lift and staff x 2 for all transfers and resident (Resident #1) uses a wheelchair. Further review of Resident #1's care plan revealed that the resident (Resident #1) has limited physical mobility with a goal that the resident (Resident #1) will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury, and with interventions/tasks to provide supportive care, assistance with mobility as needed. Review of Resident #1's progress notes, dated 01/30/2024, revealed: -nursing progress note text on 01/15/2024 at 11:45 (11:45 a.m.), CNA (CNA A) attempted to transfer by sba (stand by assist). Resident unable to moved left leg due to increase weakness, to complete transfer. CNA (CNA A) lower resident to floor to prevent resident from falling. -nursing progress note text on 01/15/2024 at 11:52 (11:52 a.m.), notify NP of incident, gave orders to continue monitoring and for pain medication. -nursing progress note text on 01/15/2024 at 12:00 (12:00 p.m.), Resident (Resident #1) given Tramadol 50mg (milligram) tab po (by mouth) for pain to left knee. Review of Resident #1's Event Nurses' Note-Fall, dated 01/15/2024 at 11:38 (11:38 a.m.), revealed LVN A's documentation: Location occurred: Resident room. Unwitnessed or hit head? none of the above Fall: legs gave out Injury -nursing progress note text on 01/16/2024 at 09:30 (09:30 a.m.), notify NP of changes of left ankle and receive order for Xray. Review of Resident #1's x-ray results, date of service 01/16/2024, revealed an impression: 1.Mildly displaced fracture of distal shaft of the left tibula bone. Review of Resident #1's progress notes, dated 01/30/2024, revealed: -Transfer notification on 01/16/2024 at 22:09 (10:09 p.m.) Resident #1 transferred to hospital on 01/16/2024 10:00 PM related to Fx (fracture) of L (left) Leg. Review of the facility's reported incident investigation's interviews, dated 01/17/2024, revealed CNA A statement, I went into resident (Resident #1) room to ask and check on her to see if she was going to get up and she told me yes cause she had to do therapy. CNA A added, I sit her on side of the bed put her chair next to the bed put her walker in front of her gave her a few minutes to rest on the side of the bed so then she say she was ready so she stood up with her walker the (then) she stated to pivot around to get in the chair she said let her sit back down on the bed so she got up off the bed again and started to pivot toward the chair and then (then) she said she couldn't so I told her to sit back down on the bed and she said lets gone and get in the chair so she started pivoting back so that's when her left knee started buckling and she started going down so I told her I'm going to lower her to the floor. CNA added, I saw PT (PT A) told her I needing her in (Resident #1's) room went and got the Mechanical lift from CNA B told LVN B I need her in resident #1's room so we put her back in the chair with the Mechanical lift. Review of the facility's reported incident investigation's interviews, no date, revealed PT A statement, I (PT A) did not personally see the fall; however I was walking down the hall when CNA (CNA A) asked me to help her get resident (Resident #1) off the floor. While CNA A went to get the Mechanical and tell the nurse, I saw with Resident #1. I put a pillow under her head and she began to cry and tell me her L (left) leg hurt, I asked her to move both LE (lower extremities) and was able to move her LE within patient functional limitations. CNA A and CNA B returned with the Mechanical lift and all 3 of use assisted Resident #1 back into her wheelchair with the Mechanical lift. CNA A told me the nurse was on the way and I left the room with Resident #1 calmed down, laughing, and safely in her chair. Interview on 01/30/2024 at 11:52 a.m., CNA B stated she was called for help by CNA A, and we (CNA A, PT A) helped her get up off the floor with the Mechanical lift on to her wheelchair. CNA B stated she was not sure that Resident #1 was assessed by a nurse before transferring Resident #1. CNA B assumed Resident #1 was because CNA A informed her a nurse was called. CNA B stated staff were not supposed to move a resident before a nurse assessment. CNA B stated it is important to review a resident's Kardex to ensure the proper way and the needs to transfer all residents, and that there are always two or more staff assisting in a Mechanical lift transfer for a safe transfer. Interview on 01/30/2024 at 12:48 p.m., LVN A stated she remembers performing an assessment on Resident #1; pain was found in Resident #1's left knee. During the assessment, there was no swelling, redness, discoloration to her left lower extremity. LVN A stated Resident #1 was not on the floor during the assessment and confirmed Resident #1 was on her wheelchair. LVN A stated she did not see the fall. LVN A stated that it was listed as an assisted and witnessed fall. she is assuming why staff moved Resident #1. LVN A stated staff should wait for a nurse assessment before moving any residents after falls. LVN A stated staff follow the information listed in the resident's Kardex, and staff should review the Kardex before care and transfers, to ensure safety. LVN A stated the resident's conditions change, and we update the Kardex and care plan to reflect up to date care for residents. Interview on 01/30/2024 at 01:07 p.m., PT A stated she is the director of Physical Therapy. PT A stated that Resident #1 is a two-person transfer using a Mechanical lift. PT A stated on 01/15/2024, she was on the hall, then CNA A walked out of Resident #1's room and asked for assistance because Resident #1 was on the floor. PT A stated she walked in the room and saw Resident #1 on the floor and got down to her level and asked questions about range of motion and pain, CNA A and CNA B walked in the room with the Mechanical lift, and all three staff assisted Resident #1 from the floor to her wheelchair. PT A stated she does not do pain assessments; she does therapy assessments. During a phone Interview on 01/30/2024 at 01:14 p.m., CNA A confirmed Resident #1's assisted fall on 01/15/2024. CNA A stated she checked Resident #1 that day, and the resident asked to transfer to her wheelchair. During the transfer Resident #1's knee gave out. CNA A was behind Resident #1, supported her back, assisted Resident #1 to the floor, and laid Resident #1 on her back. CNA A stated Resident #1 is a two person transfer with a Mechanical lift. CNA A stated she was, just trying to help her (Resident #1). CNA A stated that staff must check all residents' Kardex to confirm proper care. CNA A stated that staff are not supposed to move residents after falls, and that a nurse must assess the residents first after falls. Phone Interview on 01/30/2024 at 01:54 p.m., the MD recalls receiving information of the incident on Resident #1 on 01/15/2024.MD stated that this is an acute fracture to Resident #1's left tibia. MD stated that if he had to assume when the fracture occurred it more than likely occurred during the time when Resident #1 was assisted to the floor or prior to Resident #1 being assisted. MD explained that Resident #1's diagnoses with a combination of morbid obesity and osteoporosis could have been contributing factors. Interview on 01/30/2024 at 01:47 p.m., the ADON stated that the Kardex must be followed from all staff to ensure proper care for residents. If not, they can drop the resident, or an accident can occur. ADON confirmed that there must be two people for all Mechanical lift transfers. ADON stated assessments are followed after all falls, and that assisted falls have the same procedure as witnessed falls and unwitnessed falls. ADON added there is no difference between a fall and an assisted fall. Interview on 01/30/2024 at 02:34 p.m., DON stated that staff have been in-serviced to always check residents' Kardex, how to use the Kardex and find information on transfers and safety, follow residents' orders, abuse and neglect, safe transfers and mechanical lift use. DON stated that CNA A has been in-serviced one on one and had to demonstrate how to use the Resident Kardex, how to find information, safe transfers, and had to demonstrate a Mechanical lift transfer safely with another staff. DON stated there is a difference between an assisted fall and unwitnessed or witnessed fall. DON stated a fall is a resident losing balance, while an assisted fall is staff guiding a resident to the floor. DON stated nursing assessments are important to gather medical details on the resident and how the fall occurred so there can be a plan of treatment and so interventions can be created. DON stated that an assessment before moving a resident is important because if staff move a resident after a fall, and before being assessed, we do not know what kind of injury occurred. and the DON said that moving a resident can cause bigger issues, because we don't know what kind of injury we are dealing with. Interview on 01/30/2024 at 02:36 p.m., LVN B stated she was not there to witness the fall, she had just started her shift, and she did not do the fall assessment after the incident. LVN B stated she performed the follow up fall assessments for Resident #1. LVN B stated staff must follow the proper way to transfer. She stated that information is listed in a resident's Kardex. LVN B stated that when a resident falls, nursing performs assessments, check for injuries, pain, swelling, bleeding, or apparent injuries, check the surroundings, and detail information on the fall. LVN B stated the risk of moving residents before a nursing assessment are bad. She stated they (residents) should not be moved until they are assessed because moving a resident might cause more harm. Review of the facility's Hydraulic Lift policy, no date, reflected the hydraulic list is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by the manufacturer recommendations. Review of the facility's Employee Disciplinary Report Action Request, dated 01/18/2024, reflected Specific Reason for requesting Disciplinary Action for CNA A-improper transfer of a resident. Request for the facility' policies for care plans and nursing assessments were not given before exit. The ADM was notified on 01/30/2024 on 01/30/2024 at 06:16 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 01/31/2024 at 12:35 p.m., and included: Plan of Removal Problem: F689 Free from Accidents/Hazards Interventions: On 1/30/24, CNA was in-serviced 1:1 by the DON on the following: o Following the Kardex for all transfers with return demonstration. o [mechanical lift] transfers with return demonstration. o Abuse and Neglect. o Fall Prevention On 1/30/24 CNA and Director of Rehab were in-serviced 1:1 by the DON on not to move or transfer a resident after a fall until a nurse performs an assessment. On 1/30/24, all residents in the facility were assessed and evaluated for transfer assistance by the DON and Director of Rehab. On 1/30/24, all resident care plans reviewed for accuracy of transfer assistance by DON and MDS Coordinator. No issues were identified. On 1/30/24 the Facility initiated our second round of mechanical lift training and check offs. All nursing staff will be checked off again prior to the start of their next shift. Training and checks will be completed by DON/ADON/and Director of Rehab. The medical director was notified by the administrator on 1/30/24 at 7:00pm. Ad hoc QAPI was held with the Medical Director and facility interdisciplinary team on 1/30/24. In-services: The Administrator, DON, and ADON were in-serviced 1:1 on the following topics below on 1/30/24 by the Regional Compliance Nurse. The DON and ADON then in-serviced all nursing staff present on the follow topics below as of 1/30/24. All staff not present will not be allowed to assume their duties until in-serviced. All new hires will be in-service on their date of hire, during facility orientation. Admin and DON will complete the in-services and monitor. Abuse and neglect policy. Hydraulic lift policy with return demonstration. How to use the Kardex in PCC to determine the transfer status of a resident with return demonstration. Fall Prevention Policy. Do not move or transfer a resident after a fall until assessed by nurse for injury. The Survey Team monitored the Plan of Removal on 01/31/2024: Observation on 01/31/2024 at 12:53 p.m., revealed signage at the clock in station stating, All Staff, clock in and go directly to DON office. Observation on 01/31/2024 from 12:57 p.m. to 02:15 p.m., revealed CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F demonstrated Kardex use, and how to find information for a proper and safe transfer. Observation on 01/31/2024, revealed CNA B and CNA C demonstrated a Mechanical lift transfer with two persons assist. Interviews on 01/31/2024 from 12:57 p.m. to 02:15 p.m., revealed CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F confirmed and stated in-services were completed from 01/30/2024 to 01/31/2024 on topics of Kardex Use, Mechanical lift, Abuse and Neglect, Fall Prevention, and Nursing assessment before moving residents. Interviews and record reviews on 01/31/2024 from 01:28 p.m. to 02:48 p.m. ADM, DON, ADON, LVN A, and LVN B confirmed and stated in-services were completed from 01/30/2024 to 01/31/2024 on topics of Kardex Use, Mechanical lift, Abuse and Neglect, Fall Prevention, and Nursing assessment before moving residents. Interview on 01/31/2024 on 01:51 p.m., Corporate Registered Nurse and DON stated staff not present, such as PRN or staff on leave, will not be allowed to assume their duties until in-serviced. All new hires will be in-service on their date of hire, during facility orientation. Admin and DON will complete the in-services and monitor. Interview on 01/31/2024 on 03:34 p.m., DON stated CNA a was in-serviced one-on-one on topics of Following the Kardex for all transfers with return demonstration, Mechanical lift transfers with return demonstration, Abuse and Neglect and fall prevention. DON stated that CNA A and PT A were in-serviced one-on-one on the topic of not to move or transfer a resident after a fall until a nurse performs an assessment. Record review on 01/31/2024, reflected Ad hoc QAPI meeting occurred, no date, on 01/30/2024 with ADM, MD (by phone), DON, Assistant Director of Operations, and Corporate Registered Nurse. Record review on 01/31/2024, reflected one on one in-services completed on CNA A on the topics of Kardex Use, Mechanical lift Lift, Abuse and Neglect, Fall Prevention, and Nursing assessment before moving residents. Record review on 01/31/2024, reflected one on one in-services completed on PT A on the topic of not to move or transfer a resident after a fall until a nurse performs an assessment. The ADM was notified on 01/31/2024 at 04:17 p.m. that the Immediate Jeopardy was lowered. While the IJ was removed on 01/31/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 of three (3) medication/treatment carts reviewed for medication storage. The facility failed to prevent the treatment cart at the nurse's station from being unattended and unlocked. This failure could place residents, unauthorized staff and visitors access to medications that could cause physical harm and decreased quality of life. Findings included: Observation on 8/28/23 at 10:16 am revealed treatment cart was unattended and unlocked. All drawers could be opened, wound supplies, wound cleaning solution, ointments and several containers of liquids could be easily accessed. In an interview on 08/28/23 AT 10:21AM, LVN A stated that the treatment cart belongs to both nurses, and each has a key. She was unaware the cart was unlocked and was unable to tell me how long it had been that way. When asked if any harm could come to a resident or visitor that might open the drawers, she stated she did not think an alert person would come from any harm but did not see why they would be looking in the cart anyway. Interview on 8/30/23 10:45 am DON stated that her expections were that the treatment cart should be considered a medication care. Medication carts should be locked when unattended and nothing on top. She continued, its important for it to be locked so unlicensed people do not get into the cart that has medications and liquids that can cause potental harm. It was the charge nurses responsibility to ensure the carts are locked and nursing managements responsibility to ensure its locked as well. Interview on 8/30/23 10:51 pm ADM stated that his expectation for the medication and treatment carts remained locked when not in use. He stated that a resident or visitor were to have access to the medications and liquids on the treatement cart, there could be potential harm. Review of the facility policy Medication Carts , not dated reads: The carts are to locked when not in use or under the direct supervision of the designated nurse .

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 (Residents #15, #25, and #35) residents reviewed for safe administration of medications . 1. Resident # 15 was administered Midodrine, a medication affecting blood pressure, outside of parameters established by the Primary Care Provider (PCP) to hold if greater than 120 systolic or greater than 90 diastolic. 2. Resident # 25 was administered Propranolol, a medication affecting blood pressure, outside of parameters established by the PCP to hold if blood pressure less than 100/60 or heart rate less than 90. 3. Resident #35 was administered Hydrochlorothiazide, a medication affecting blood pressure, without blood pressure readings documented with parameters established by the PCP to hold if blood pressure less than 100/60 These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, hospitalization , and/or death. The Findings were: 1. Record review of Admission Record revealed Resident # 15 was a [AGE] year-old man with an original admitted [DATE]. His diagnoses included: disorder of the autonomic nervous system [part of the nervous system responsible for control of the bodily functions not consciously directed such as breathing, heartbeat, digestive processes, and blood pressure]. Record review of the quarterly MDS dated [DATE] revealed Resident # 15 had a summary BIMS score of 11 indicative of intact cognition. Record review of Resident # 15's Care Plan dated 4/25/2022 revealed the resident had hypotension with the following associated Interventions/Tasks: Give medications as ordered; scheduled Midodrine HCL [hydrochloric acid] 2.5 milligrams at 0900, 1500, 2100 [9:00 AM, 3:00 PM, and 9:00 PM]. Record review of the MRR dated 04/15/2022 for Resident # 15 revealed pharmacist recommendations to add hold parameters on midodrine. Ex. Hold if blood pressure is >120/90. Record review of electronic order revealed Resident # 15 had orders dated 06/07/2022 at 1552 [ 3:52 PM] by PCP A for Midodrine HCL tablet 2.5 milligrams by mouth three times a day for hypotension hold if systolic > 120 or diastolic > 90. Record review of the MAR for June 2022 revealed Resident # 15 received midodrine HCL 2.5 milligrams by mouth three times a day for hypotension with administration instructions hold if systolic > [greater than] 120 or diastolic > 90. The Blood pressure reading for the 9:00 PM dose on 06/07/2022 was documented as 142/83 [systolic /diastolic]. Record review of Resident #15's Blood Pressure Summary tab of the electronic health record revealed on the following blood pressures: -06/07/2022 at 9:53 AM readings of 137/91 and -06/07/2022 at 9:50 PM readings of 142/83. 2. Record review of the Admission Record revealed Resident # 25 was a [AGE] year-old man with an initial admitted [DATE]. His diagnoses included: essential (primary) hypertension [type of high blood pressure that doesn't have a known cause]; repeated falls; syncope [fainting, usually caused by sudden drop in blood pressure] and collapse. Record review of the quarterly MDS dated [DATE] revealed Resident # 25 had a BIMS score of 8 indicative of moderately impaired cognition]. Record review of a Care Plan dated 05/24/2022 revealed Resident # 25 had a focus area of hypertension with the following associated Interventions/Tasks: Give antihypertensive medications as ordered. Record review of the MRR dated 04/15/2022 for Resident # 25 revealed pharmacist recommendations to add blood pressure parameters on propranolol. Ex. Hold if blood pressure is <100/60 and HR <60. Record review Resident # 25's of electronic order entry screen revealed orders dated 05/28/2022 at 0630 [6:30 AM] for Propranolol HCL tablet 10 milligrams by mouth one time a day for hypertension hold if BP [blood pressure] is < [less than] 100/60 and HR [heart rate] is <60. Record review of the MAR for May 2022 revealed Resident # 25 received Propranolol HCL 10 milligrams by mouth one time a day for hypertension with administration instructions hold if BP is <100/60 and HR [heart rate] is <60. The Blood pressure reading was 84/51 and the pulse [heart rate] was 96 for the dose administered on 05/30/2022. 3. Record review of the Admission Record revealed Resident # 35 was a [AGE] year-old female with an initial admitted [DATE]. Her diagnoses included: secondary hypertension [high blood pressure difficult to control with a one or two medications]. Record review of the MDS dated [DATE] revealed Resident # 35 had a BIMS score of 7 indicative of severely impaired cognition]. Record review of the Care Plan dated 05/24/2022 revealed Resident # 35 had a focus area of hypertension with the following associated Interventions/Tasks: weigh per facility policy. Additional focus areas included: diuretic therapy related to hypertension with associated interventions that include monitor vital signs, postural hypotension [type of low blood pressure that occurs when standing from seated or supine position]. Record review of the MRR dated 04/15/2022 for Resident # 35 revealed pharmacist recommendations to add blood pressure parameters on hydrochlorothiazide [a medication affecting blood pressure]. Ex. Hold if blood pressure is <100/60. Record review of Resident #35's electronic order entry screen revealed orders dated 05/01/2022 at 0630 [6:30 AM] for Hydrochlorothiazide tablet 12.5 milligrams by mouth one time a day, hold if BP <100/60. Record review of the MAR for May 2022 and June 2022 revealed Resident # 35 received Hydrochlorothiazide tablet 12.5 milligrams by mouth one time a day, with administration instructions to hold if BP <100/60 without documentation of blood pressure on the MAR. Record review of the Blood Pressure Summary tab of the electronic health record revealed documentation for Resident # 35 were on the following dates: 04/01/2022, 04/04/2022, 04/05/2022, 04/07/2022, 04/08/2022, 04/09/2022, 04/12/2022, 04/15/2022, 04/22/2022, 04/29/2022, 05/09/2022, 05/20/2022, and 06/03/2022. In an interview on 06/09/2022 at 11:30 AM with the DON, she stated she had a message back from prescribing physician who recommend Midodrine for Resident # 15 indicating blood pressure monitoring not necessary at the 2.5 milligram dosing. The DON stated that medications that require blood pressure or heart rate monitoring prior to administration require the blood pressure or heart rate be entered into the electronic MAR prior to administering the medication. The DON stated the MAR will reflect the blood pressure or heart rate measurements when printed. The DON stated the training and expectation is for blood pressure or heart rate measurements to be obtained prior to administering such medications for patient safety.

Based on observation, interview and record the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 17 rooms (#105) observed, in that: The wood windowsill in room [ROOM NUMBER] was cracked and the wood was splintered with 4 nails sticking out under the sill. This deficiency could affect residents by causing splinters and skin tears by the wood or the nails. The findings were: Observation on 6/7/2022 at 2:43 p.m. of room [ROOM NUMBER] revealed the wood windowsill was cracked and splintered. Further observation below the windowsill revealed there were 4 nails sticking out along the length of the windowsill. Interview on 6/8/2022 at 2:23 p.m., the Maintenance Supervisor, after he observed the windowsill revealed he was not aware the sill was cracked. He stated it most likely occurred when staff raised bed B's electric bed and it was too close to the window, causing it to crack. The Maintenance Supervisor also found a board that had come off from the bottom of the windowsill. Interview on 6/8/2022 at 2:34 p.m. with the Maintenance Supervisor reported staff notified him of any repairs that need to be done either by just telling him in person or by placing a maintenance request in the Kios communication system. The Maintenance Supervisor reported anything could happen in reference to how the cracked windowsill could affect the residents but he did not elaborate. The facility did not have a policy related to damage in resident rooms.

Based on observation, interview and records the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for x of x staff reviewed for infection control. This failure could result in the spread of communicable diseases and lead to a decreased quality of life, sickness, hospitalization and death. Findings Included: Review of Resident #1's MDS dated [DATE] reflected he had a BIMS score of 15 indicating no cognitive impairment. Review of Resident #2's MDS dated [DATE] reflected she had a BIMS score of 15 indicating no cognitive impairment. An observation on 12/23/20 at 9:45 AM revealed LVN A enter Resident #1's room and check his vital signs. Resident #1's room had signage on the door indicating he was on isolation precautions. LVN A wasn't wearing any PPE other than an N95 mask. She didn't wash or sanitize her hands prior to entering Resident #1's room nor did she wash or sanitize her hands prior to exiting the room. In an interview on 12/23/20 at 9:57 AM LVN A stated PPE is to be worn before entering any residents room on isolation and doff PPE before exiting the resident's room. She acknowledged she was not wearing a gown or gloves prior to entering Resident #1's room. She stated she thought she sanitized her hands but wasn't 100% sure. She agreed Resident #1 was on isolation and isolation precaution signage was on his door. She stated she had received training on PPE and what to wear in an isolation room. An observation on 12/23/20 at 12:10 PM revealed RN B delivered a meal tray to Resident #2. Resident #2's room had signage on the door indicating she was on isolation precautions. RN B did not have her gown completely on and was not wearing gloves. Her clothing was exposed on both sides as well as part of her back. She did not sanitize her hands prior to entering the room or before exiting after the tray was delivered. She entered Resident #1's room without doffing her gown, which was not tied and hanging open in the back. In an interview on 12/23/20 at 12:21 RN B stated she didn't know about PPE at this facility. She acknowledged she saw sign on the door about donning and doffing. She acknowledge she received training on infection control and PPE. She could not recall if donning and doffing was explained during the training. In an interview on 12/23/20 at 1:10 PM Resident #1 stated the staff wear mask and sometimes gloves. They don't always wear the blue things (gowns) over their cloths. I heard they are supposed to wear those when they come into my room. In an interview on 12/23/20 at 1:25 PM Resident #2 stated she wished they would wash their hands or use some of that sanitizer in a bottle when they are in my room. She also stated they didn't always wash their hands prior to leaving her room. She acknowledged there were a few staff who work the gowns into her room. She stated the nurse who brought her lunch in had a gown on that wasn't tied and was falling off. In an interview on 12/23/20 at 2:05 PM the ADM stated her expectation was for all staff to wash their hands then donn gown, gloves and N95 mask before entering a resident's room. She stated staff were expected to doff gown and gloves in the resident's room and wash hands and sanitize prior to exiting the room. In an interview on 12/23/20 at 3:02 PM the NC stated, all staff follow CDC guidelines with donning and doffing PPE. There is a sign on each resident's door explaining what PPE to use prior to entering resident room.

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for one of four residents (Resident #1) reviewed for infection control and wound care. LVN A failed to perform hand hygiene while performing wound care on Resident #1. This failure could failure could place residents at risk for cross-contamination and the spread of infection. Findings include: 1. Review of Resident #1 face sheet reflected a [AGE] year-old male DOB 10/13/97 who was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident # 1's (MDS) assessment dated [DATE] reflected a BIMS score of 15, indicating no impairment. Review of Resident # 1's Care Plan dated 1/24/20 reflected that the resident requires 1-persons physical assist with ADLs and a 2 person assist with transfers. The resident also has 3 pressure ulcers located on the buttock, sacral area, and left medial foot. Observation on 04/01/20 at 9:30 am revealed while LVN A was performing wound care on Resident #1. LVN entered room washed her hands and applied gloves. Resident did not have a dressing present to left medial wound. LVN then cleaned wound with normal saline soaked gauze, she pressed against wound bed then she discarded soiled gauze in a plastic bag. LVN then applied wound gel with a Q tip and cover wound with a dry dressing. LVN then assisted resident to a comfortable position, removed her gloves, washed her hands, and then took trash bag out of room. In an interview on 04/01/20 at 1:08 pm, LVN A stated hand hygiene is performed before, after, and during resident's care and between gloves changes. She also stated hand hygiene is performed when moving from dirty to the clean area to prevent cross-contamination. LVN A stated she knew that she should have washed her hands after cleaning resident # 1's wound. She also said she should not touch bedlinens with dirty gloves. In an interview on 04/01/20 at 1 pm, DON stated nurses should perform hand hygiene after cleaning a resident wound, after applying a clean dressing, and before touching items in residents' rooms. Review of Facility's Infection Control Policy revised 2018 reflected: The purpose is to provide guidelines for general infection control while caring for residents. --states that staff should implement handwashing practices consistent with accepted standards of practice. According to Potter & Perry Fundamentals of Nursing (2013), pg. 1217. When performing wound care nurses should 1. Perform hand hygiene and don clean gloves 2. Remove bed linens and patient gown if necessary to expose the wound 3. Clean wound with a cleaning agent 4. Remove gloves, perform hygiene, apply clean gloves 5. Apply topical agents and a clean dressing 6. Remove gloves, dispose of soiled supplies, and perform hand hygiene. Griffin, A., Hall, M. H., Stockert, A. P., Potter, A. P. (2013). Fundamentals of Nursing (8 ed.). St. Louis, MO: Elsevier

Based on observations, interviews, and record reviews, the facility failed to serve food in accordance with professional standards for food service safety from the facility for 1 of 1 dining room: Multiple staff members were observed touching with food items, dinnerware, and utensils with their bare hands without performing hand hygiene. These deficient practices could place residents that receive meals at risk for food borne illnesses. The findings include: Dining Observation on 03/09/2020 at 11:53 AM to 03/09/2020 at 12:43 PM CNA A touched resident's fried pie with bare hands and did not perform hand hygiene. CNA B touched the rim of cup the residents cup and touched her pants and started feeding resident without performing hand hygiene. CNA A touched the rim of resident's cup to give resident a drink without performing hand hygiene. CNA A Alternating between residents feeding them without washing or sanitizing. COTA helped another resident with feeding and did not sanitize between residents and arm touched residents roll. CNA B -touched the rim of resident's cup with finger while serving to resident performing hand hygiene. Dining Observation on 03/11/2020 at 12:23PM to 03/11/2020 at 12:27PM CNA B Scratched side of her face and did not perform hand hygiene. CNA B touched top of resident's cup with her finger. CNA A touched the inside of resident's plate when moving plate closer to the resident. In an interview on 03/11/2020 at 11:06 AM CNA A stated she was aware that she touched the rim of the cup with her fingers on Monday 03/09/2020. She also stated is aware she touched the inside of the plate with her finger touching the greens when she moved the plate. She stated that this process is not the correct process for serving food and hand hygiene and that she was aware of the correct process for serving food and hand hygiene. In an interview on 03/11/20 03:16, the DON stated staff are supposed utilize the hand sanitizer on the walls and or have it available with them. She also stated, when feeding residents staff should feed one resident with left hand and other resident with right hand. She later stated the reason for hand hygiene is for infection control. Review of the facility policy on Dietary Services Policy & Procedures Manual 2012 HR00-2.0 Section Sanitation and Food Handling reflected: --Washing your hands (with soap and hot water) before starting work, --after coughing or sneezing, --handling garbage, -- picking up an article from the floor, --after handling soaps or detergents, -- after using the toilet, --after smoking, and after all breaks. Touching something that is not clean and them handling food can cause food poisoning

Based on interview and record review, the facility failed to notify the resident and the resident's representative of a transfer/discharge and the reason for the transfer, in writing, for two of two residents (Resident #44 and Resident #46) reviewed for discharge. 1. Resident #44 and their responsible party were not provided a transfer notice when there was a facility-initiated transfer to the hospital. 2. Resident #46 and their responsible party were not provided a discharge notice. This failure could place residents at risk of not having access to available advocacy services, discharge/transfer options, and the appeal process. Findings include: 1. Review of Resident #44's face sheet reflected a [AGE] year old male resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #44's care plan, dated 12/15/2019, reflected Resident #44 was at risk for falls, potential fluid deficit, and uncontrollable pain. Review of Resident #44's nursing progress notes did not reflect an order was received to send Resident #44 to the hospital. Review of Resident #44's medical record did not reflect the resident, or the family member were notified in writing of the transfer to the hospital. Review of Resident #44's discharge summary reflected he was discharged on [DATE] to the emergency room related to unrelieved chest pain. 2. Review of Resident #46's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #46's MDS, dated [DATE] reflected resident received a 15 on the BIMS assessment. A score of 15 reflects resident was cognitively intact. Review of Resident #46's care plan, revision date of 09/06/2019 reflected, Resident #46 has impaired thought processes due to long history of [MEDICAL CONDITION] disorder, OCD, impaired decision-making [MEDICAL CONDITION] drug use. Discharge from the facility is not feasible as evidenced by her inability to manage her health and mental condition. Resident will be provided an opportunity to receive information on returning to community unless the resident has chosen not to be asked this. Review of Resident #46's progress notes from 08/29/2019 through 12/18/2019 did not reflect any documentation of discharge goals or plans. Review of Resident #46's medical record did not reflect the resident, or the family member were notified in writing of the resident-initiated discharge. Review of Resident #46's discharge summary dated 12/20/2019 reflected Resident #46 had history of delusional behavior related to dx of [MEDICAL CONDITION] and obsessive-compulsive disorder; ambulatory w ith no aide of walker or wheelchair; continent of bladder and bowel and to continue medications and treatments as ordered. The discharge summary did not reflect where the resident was discharged to. In an interview on 03/11/2020 at 12:20 P.M. SW stated nursing contacts family when a resident is transferred to the hospital. She stated when a resident is discharged home she thinks nursing contacts the family and she has never sent out anything in writing. In an interview on 03/11/2020 at 1:17 P.M. LVN E stated during a facility emergency transfer, EMS is called along with the physician and the family and we provide them with information of where they are being sent. She stated they do not notify in writing, this is something she never has done. In an interview on 03/11/2020 at 3:32 P.M. DON stated family is notified of a hospital discharge and I did not realize discharge letters needed to be sent out for a transfer and a discharge to residents, responsible party, and the ombudsman. Record Review of facility undated Admission Packet Statement of Resident Rights on page 5 reflected the following: --Receive a thirty-day written notice sent to you, your legally authorized representative, or a family member. --Appeal the discharge within 10 days of receiving notice in a Medicaid facility. Record Review of undated facility policy titled Discharge or Transfer to another facility reflected the following information: --When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer will be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers will also still be sent to the ombudsman, but they may be sent went practicable, such as a list on a monthly basis. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send out a notice of discharge to the resident and resident representative, and will also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. Notification of Discharges: For a facility-initiated transfer or discharge of a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term (LTC) Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 35 opportunities which resulted in a 5.71 percent error rate involving Resident # 43. CMA D did not administer Resident #43's [MEDICATION NAME] and [MEDICATION NAME] per physician orders. This deficient practice could place Residents receiving medication at risk of not receiving the desire therapeutic effect. Findings include Review of Resident #43's face sheet revealed a [AGE] year-old female DOB 5/19/1969 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #43's minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 8 indicating moderate cognitive impairment. Review of Resident #43's Care Plan dated 2/15/2019 revealed Resident #43 receives antipsychotic medication due to [DIAGNOSES REDACTED]. During medication administration observation on 03/10/20 09:08 am, the following was observed: CMA D administered the following medications to Resident #43 with a total of 11 pills and an eye drop. - [MEDICATION NAME] 125 cap 1 - [MEDICATION NAME] ([MEDICATION NAME]) 2mg 1 PO BID - Duloxetine 60mg 1 PO - [MEDICATION NAME] 5mg 1 PO - [MEDICATION NAME] 0.5mg 1 PO BID - Aspirin 81mg 1 PO - Fish oil 1000 mg 1 PO - Calcium + D3 600mg 10mcg (400 iu) - Multivitamin daily 1 - Vitamin D3 400 iu - Sodium [MEDICATION NAME] 10 gr (650mg) ½ tab - Artificial Tears Review of Resident #43's consolidated physician order [REDACTED]. - [MEDICATION NAME] 125mg, give 250mg by mouth two times a day related to [MEDICAL CONDITION], and anxiety disorder. (may give two 125mg capsules to equal 250mg) order dated 02/20/2020 - [MEDICATION NAME] 1mg by mouth one time a day related to [MEDICAL CONDITION], order dated 02/24/2020 In an interview on 03/10/20 at 01:04 pm, CMA D stated she has always given Resident #43 [MEDICATION NAME] 2mg in the mornings and [MEDICATION NAME] 125mg. She later stated both orders don't match the medications that are available. She also stated it is a medication error. In an interview on 03/10/20 at 03:14pm the DON stated Resident # 43, there is a cart of 1 mg and it ran out. She also stated it is considered a medication error if the wrong dosage was given. She then stated she notified the medical doctor of the medication along with Resident #43's daughter. She later stated CMA D was supposed to read the orders and compare it with the medications available. She ended by saying she was not told about the [MEDICATION NAME], she was only told about the [MEDICATION NAME]. Review of the facility's policy titled Medication Administration Procedures revised 10/25/2017 reflected: All current medications and dosage schedules are to be listed on the resident's current medication administration records. The five rights of medication should always be adhered to - Right drug - Right dose - Right resident - Right time - Right route

Based on observation, interview, and record review the facility failed to develop and implement an effective discharge care plan for 1 of 2 (Resident #46) of 1 resident reviewed for discharge. Resident #46 was discharged homme without an effective discharge care plan. This failure could place residents at risk of not having their discharge goals and needs identified, planned for, and met. Findings included: Review of Resident #46's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #46's MDS, dated [DATE] reflected resident received a 15 on the BIMS assessment. A score of 15 reflects resident was cognitively intact. Review of Resident #46's care plan, revision date of 09/06/2019 reflected, Resident #46 has impaired thought processes due to long history of [MEDICAL CONDITION] disorder, OCD, impaired decision-making [MEDICAL CONDITION] drug use. Discharge from the facility is not feasible as evidenced by her inability to manage her health and mental condition. Resident will be provided an opportunity to receive information on returning to community unless the resident has chosen not to be asked this. Review of Resident #46's nursing progress notes from 08/29/2019 through 12/18/2019 did not reflect any documentation of discharge goals or plans. Review of Resident #46's discharge summary dated 12/20/2019 reflected Resident #46 had history of delusional behavior related to dx of [MEDICAL CONDITION] and obsessive-compulsive disorder; ambulatory with no aide of walker or wheelchair; continent of bladder and bowel and to continue medications and treatments as ordered. The discharge summary did not reflect where the resident was discharged to. In an interview on 03/11/2020 at 12:20 P.M. SW stated when a resident is discharged home she thinks nursing contacts the family and she has never sent out anything in writing for an IDT discharge care planning meeting. She stated nursing handles the discharge planning meetings and she sets up Home Health Services. In an interview on 03/11/2020 at 1:30 P.M. ADON stated she may do a discharge but it depends where she is at that point. She stated sometimes she will do a discharge summary & discuss the list with them. She stated they do not hold IDT planning meetings that she is aware of and that the nurse should teach them. She stated she has no records of discharge IDT meetings and the SW sets up Home Health care. In an interview on 03/11/2020 at 3:27 P.M. DON stated they talk about discharges in morning meetings. She stated she doesn't know who holds the IDT discharge meetings. Record review of undated Comprehensive Care Plan reflects the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. The comprehensive assessment care plan will describe the following- -The resident's preference and potential for future discharge. The facility document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or appropriate entities, for that purpose. -Discharge plans in the comprehensive care plan, as appropriate. Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident.

Based on observation, interview, and record review, the facility failed to ensure each resident received food that accommodates residentnand preferences for one of five residents (Resident # 31) reviewed for food and preferences, in that; The facility failed to honor Resident #31's with food preferences. This failure could place residents who receive meals at risk of frustration, not enjoying meals, weight loss, and diminished quality of life. Findings include: Review of the Face Sheet for Resident # 31 reflected a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the initial care plan for Resident #31 dated 08/26/19 reflected Resident has a diet order other than Regular and is at risk for unplanned weight loss or gain. Mostly vegetarian but will eat certain types of meat. No Pork. Review of the MDS for Resident #31 dated on 02/05/2020, reflected a BIMS 08 indicating moderate impairment. Review of Resident #31 physician diet orders dated 08/12/19 reflected no pork products. Observation on 03/09/20 at 12:03 PM revealed meals served to Resident #31 contained fried pork chops. Observation on 03/09/2020 at 12:10 P.M. revealed Resident #31 waving at staff to come look at his tray. ADON observed Resident's meal ticket with his lunch meal and removed the meal. The ADON provided an alternative meal of chicken for Resident #31. Observation on 03/09/2020 at 12:45 P.M. revealed Resident #31 approached State surveyor and provided his meal ticket which read substitution needed for the entrée. Resident #31 dislikes read: pork and pork products. In an interview on 03/09/2020 at 2:02 P.M. Resident #31 stated he doesn't know why he is being served pork all the time because his culture eats different. He stated they know he does not eat pork and yet he is still being served pork and he sends it back. He stated it does not make him feel good because he has been here for six months and he has to look at his food to see if he can eat it. In an interview on 03/11/2020 at 1:57 PM the Dietary Cook stated meal tickets are printed by the Dietary Manager with Resident's meal preferences, allergies [REDACTED]. She stated she does not put any dislikes or allergies [REDACTED]. She also stated, the reason she does not put it on the tray is because they may just not prefer it, or they could have an allergic reaction which could be serious. She stated she compares the meal tickets and trays as she prepares the plates of food. In an interview on 03/11/20 2:05 PM the Dietary Manager stated he gets food preferences, allergies [REDACTED]. He stated he always puts the dietary meal ticket on the tray cart because it helps the dietary cooks prepare the residents meals according to their preferences. He stated if a resident does not like something it is enough reason not to put it on the plate. He stated his expectations are to have the cooks read the ticket and if changes need to be made he will make those changes. He stated the dietary cook did not read Resident #31's meal ticket and he was given pork, he was served chicken immediately. In an interview on 03/11/2020 at 2:23 P.M. LVN E stated when she helps with dining she tries to look at the ticket to make sure it matches the food on the tray. She stated when residents get admitted they fill out the dietary slip and give it to the kitchen. She stated Resident #31 was not supposed to get pork on his tray, there was no excuse for it. She ended by saying, if he would have eaten it, there would have been a problem. In an interview on 03/11/2020 at 02:29 P.M. the ADON stated she was helping pass trays out during lunch on Monday and checking the trays. She stated, she checks the trays and looks for their likes and dislikes. She stated she looked at Resident #31's tray and there was a pork chop that he should not have been served because it reads on his dietary meal ticket he does not like pork. Review of the facility Admission Packet, Page 24, under Food and Nutrition Services reflect the dietary manger will visit within your first 1-2 days in the facility to obtain food preferences, breakfast selections, and discuss other aspects of our meal service program. Policy Review of Nursing Responsibilities at Meal Service dated 2012 reflected Nursing Services will cooperate with the Dietary Department to ensure that each resident is served according to regulations.

Based on observation, interview and record review the facility failed to ensure a resident who entered the facility without limited range of motion did not experience reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable; and a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (1) of twelve (12) residents reviewed for range of motion (Resident #36). The facility failed to provide services to prevent contractures for Resident #36 when she was admitted on [DATE] thus allowing the resident to develop a contracture in her left knee. This failure led to a decreased ability to transfer and could lead to an inability to sit in a chair comfortably, skin breakdown and pain. Findings Included: Review of Resident #36's Face Sheet reflected she was an [AGE] year old female originally admitted on [DATE] and discharged . Resident #36 was admitted again on 11/19/2017 and had a readmission on 11/02/2018. [DIAGNOSES REDACTED]. Review of Resident #36's Admission MDS assessment dated [DATE] reflected in section G0400 Functional Limitation in Range of Motion: B. Lower extremity (hip, knee, ankle, foot). 1 = Impairment on one side. Each subsequent assessment reflected there was no change to the answer for section G0400 (11/09/2018, 11/16/2018, 11/30/2018, 12/24/2018). Review of Resident #36's most recent Quarterly MDS dated [DATE] reflected section G0400 Functional Limitation in Range of Motion: B. Lower extremity (hip, knee, ankle, foot). 1 = Impairment on one side. Resident #36 had a BIMS score of zero which indicated she did not answer one question correctly. She was coded as having inattention and disorganized thinking with no behaviors. Resident #36 required extensive assistance of two people for bed mobility and transferring. She last received physical therapy on 12/21/2018 and had not received any restorative therapy. Review of Resident #36's Order Summary Report dated 04/24/2019 reflected there was no order for range of motion exercises or restorative care. Review of Resident #36's Care Plan initiated on 12/20/2016 reflected a plan for Arthritis and she was to remain free of complications and was to receive daily range of motion exercises both active and passive as tolerated. There were no revisions on the care plan, but it was updated with a goal date of 07/08/2019. A care plan dated 12/20/2016 revised on 01/02/2018 with a goal date of 07/08/2019 reflected she was incontinent of bladder and the facility was to provide her an unobstructed path to the bathroom. A care plan initiated on 12/20/2016 revised on 10/12/2018 with a goal of 07/08/2019 reflected staff were to monitor her pain, and report decreased range of motion. Her pressure ulcer prevention care plan reflected it was revised on 04/12/2019 and staff were to ensure heels were floated with pillows and have frequent repositioning. A care plan dated 10/12/2018 with a goal date of 07/08/2019 reflected she had several fractures from a fall and the goal was for her to remain free of contractures with intervention of PT and OT evaluate and treat. Monitor for contracture formation. Reposition as necessary to prevent skin breakdown. Review of the ADL care plan dated 12/20/2016 and updated most recently on 01/23/2019 reflected; Resident #36 requires a Hoyer for transfers due to unable to bear weight and contractures to bilateral extremities. Walking: Resident doesn't walk nor bear weight to lower extremities. The resident requires extensive assist x 2 staff to reposition and turn in bed. Resident has limited physical mobility related to multiple fractures and contractures. Review of the Admission Nurse Note Dated 10/04/2018 reflected section I. 4. Any contractures or limited range of motion noted? 2. Yes 4 b. Lower extremity (hip, knee, ankle, foot) 1. Impairment on one side. What is the resident's weight bearing status? 2. Partial weight bearing. Signed 10/05/2018 by the DON. Observation on 04/23/19 at 01:01 PM revealed Resident #36 was transferred from her wheelchair to her bed by CNA G and RN B. CNA G and RN B lifted Resident #36 from her wheelchair by the gait belt and put her on the bed. Resident #36 had both legs bent at the hips and knees. She did not touch the floor or bear any weight. After care was given, RN B placed a pillow between Resident #36's knees to prevent skin to skin contact. Resident #36's knees were both in a bent position with a rotation to the left at the hips. While Resident #36 was laying on her back, her legs were both laying to the left. The right hip was fixed in the inward rotation, the left leg had more movement than the right. In an interview on 04/24/19 at 10:48 AM Resident #36 was lying in bed and stated she often had pain due to a failed right hip replacement. She stated that no one has tried to do stretching exercises with her left leg. She stated her right leg has intense pain and she would not want to try exercises with the right leg. She further stated if it turned out that she could not tolerate the exercises she would just tell the staff to stop. Resident #36 stated she was wanting to ask the MD about taking a muscle relaxer due to her muscle spasms. In an interview on 04/24/19 at 02:17 PM the DON stated she did not know if Resident #36 was on a restorative program (to prevent contractures) or not but the MDS nurse would know. In an observation on 04/24/2019 at 3:00 PM the MDS nurse went to the bedside and assessed Resident #36 for range of motion in her lower extremities. There were no positioning devices in place to prevent contractures (such as a pillow to keep the right leg off the left leg or between the thigh and calf). Resident #36 had her legs fully flexed at the knees (not extended). Her hips were significantly flexed. Resident #36 could not tolerate much movement of her right leg with the failed hip repair. Resident #36 stretched her left leg out as far as she could at the hip and knee. Resident #36 could not stretch her leg out to 180 degrees (straight) but could go about 100 to 110 degrees (more than half straight) with the gentle assistance of the MDS nurse. Resident #36's knee had a full rounded knee cap that had the appearance of an arthritic joint. Resident #36 did not indicate there was any significant pain in her left leg while the MDS nurse manipulated it gently. In an interview on 04/24/19 at 02:58 PM the MDS Nurse stated she did not know Resident #36's left leg had loss of range of motion. We do not have her on restorative, but we can get therapy to look at her for a plan. When asked how residents were assessed for range of motion the MDS nurse stated she observed transfers and care and she knew Resident #36 was not bearing any weight. She stated she did not get quarterly screens from therapy, but she knew they were looking at the residents at some point. The MDS Nurse stated the therapy team was out of the building for training. In an interview on 04/24/19 at 03:54 PM the Regional Nurse Consultant stated she could not find evidence in the health record that Resident #36 already had a contracture in her left leg when she was admitted . In an interview on 04/24/19 at 04:01 PM the Administrator stated she expected loss of range to be on MDS. We should usually have them on a restorative plan if they can tolerate it. We can get therapy to assess the residents and we expect them to assess them at intervals. I will ask the therapy director of rehab to assess the resident. In an interview on 04/24/19 at 04:24 PM the DON stated, When Resident #36 first had the broken hip she would sit with her legs crossed with her knees fully flexed and her feet near her buttocks and that contributed to her hip repair failure. I don't know if she had a contracture at that time. I cannot say for sure but her left leg used to be straighter. The facility did not provide a range of motion or restorative care policy. Review of the RAI Manual dated (MONTH) (YEAR) reflected: Range of Motion: Planning for Care · Individualized care plans should address possible reversible causes such as de-conditioning and adverse side effects of medications or other treatments. Definition Functional Limitation in Range of Motion Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that ensure residents were free from neglect for two (2) of 10 residents (Resident #18 and Resident #10) reviewed for neglect. A) The facility failed to ensure Resident #18 received his routine dose of [MEDICATION NAME] 34 units every morning from of 04/03/2017 to 04/17/2017 when the facility did not have a record of administration. The facility created a record of administration on 04/18/2017 and back signed it 11 times. The facility administered sliding scale insulin nine (9) times from 03/01/2017 to 03/04/2017 after it was ordered to be stopped on 02/02/2017. This deficient practice could place 12 residents who were on insulin at risk for uncontrolled high or low blood sugar which could lead to death. B. The facility failed to provide Resident #10 her prescribed, scheduled pain medication, [MEDICATION NAME]es, as ordered in April 2017 for three (3) of six (6) doses. An IJ was identified on 04/19/17. While the IJ was removed on 04/21/17 the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. This deficient practice could place 24 residents who were on a pain management program at risk for inadequate pain control and a diminished quality of life. Findings include: Review of the facility's policy entitled Abuse/Neglect revised 01/08/2003 reflected the residents had the right to be free from abuse and neglect. The policy reflected the definition of neglect Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. The policy reflected the facility must identify the neglect and investigate the incident. A) Review of Resident #18's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. He was assessed as understanding with clear comprehension and being understood. Resident #18 was assessed as needing limited assistance of one person in a wheelchair. Review of Resident #18's undated Care Plan reflected he was care planned for Diabetes Mellitus and finger stick blood sugar checks and diabetes medication as ordered by doctor as an intervention. Review of Resident #18's Physician Telephone order dated 02/02/2017 and noted by LVN F reflected an order to: a.) stop the sliding scale insulin, (still on the orders and the TAR/MARs through April 2017). b.) decrease the [MEDICATION NAME] from 40 units to 34 units, (still on the orders and the MARs through April 2017 at 40 units). In an observation on 04/18/2017 at 4:42 PM LVN I performed a finger stick blood sugar check on Resident #18 and the result was 418 milligrams per deciliter. (A normal blood sugar range for a non-diabetic is 80-110 mg/dl). LVN I stated two times, Resident #18 will get insulin according to his scale for a blood sugar of 418 as she looked at her Treatment Administration Record (TAR). LVN I administered Humalog 10 units. Review of Resident #18's Hemoglobin A1C lab results dated 03/15/2017 reflected a result of 8.0 with favorable range being 4.0 - 5.6%. Handwritten on the lab; Has order: [MEDICATION NAME] 40 units once a day and [MEDICATION NAME] 500 mg one tablet twice a day and Humalog 15 units once a day and Humalog 10 units twice a day. No new orders was written and signed by the DON. Review of Resident #18's Practitioner's note dated 03/16/2017 reflected she recorded: Now on [MEDICATION NAME] 34 units daily and Humalog 10 units before breakfast and supper and 15 units before lunch, [MEDICATION NAME] 500 mg twice a day. Lab results of Hemoglobin A1C is 8.0, accu checks (blood sugar check) up and down so will not make any changes at this time. In an interview on 04/19/2017 at 5:30 PM the DON stated she had called Resident #18's doctor regarding the lab results of 03/15/2017 with the wrong dose of insulin hand written on it. The DON stated she did not know who wrote on the lab. Review of Resident #18's March 2017 TAR reflected: a.) The sliding scale insulin that had been discontinued on 02/02/2017 had printed on the TAR and the staff had performed blood sugar checks and administered sliding scale insulin nine (9) times from 03/01/2017 - 03/04/2017. It was blocked off on March 5, and noted Discontinue 02/02/2017. b.) Handwritten; [MEDICATION NAME] 34 units every am. It was signed daily from March 5 through the end of the month. There was no record of [MEDICATION NAME] 34 or 40 units being administered from 03/02/2017 - 03/04/201. Review of Resident #18's April 2017 TAR reflected: The MAR (document utilized by medication aides) reflected LVN J had signed having given the [MEDICATION NAME] 40 units on 4/1/2017 and 4/2/2017. A new page one of the April TAR reflected it was printed on 04/18/2017 at 11:26 AM and had been back signed 11 times reflecting Resident #18 received [MEDICATION NAME] 40 units at 7:30 AM. Review of Resident #18's Order Summary Report for active orders as of 04/01/2017 printed on 04/11/2017 reflected: [MEDICATION NAME] 40 units once daily. (This Summary Report did not reflect the physician's orders written on 02/02/2017 for [MEDICATION NAME] to be decreased to 34 units daily.) In an interview on 04/19/2017 at 5:00 PM Resident #18 stated he only received two insulin injections in the mornings if his scale indicated he need a second injection. (Resident #18's orders indicated he should have routinely received two injections of insulin every morning and he did not have an active order for sliding scale insulin as of 02/02/2017). In an interview on 04/19/2017 at 5:30 PM the DON stated LVN J worked on the medication cart on 04/01/2017 - 04/02/2017 and she signed the MAR indicated [REDACTED]. The DON stated the ADON had looked everywhere for the [MEDICATION NAME] TAR for the nurses to have signed from 04/03/2017 to 04/17/2017 and she could not find one. When asked if the nurses gave the [MEDICATION NAME], the DON stated she would have to do a medication error form. In an interview on 04/19/2017 at 6:56 PM the Administrator stated LVN G had said yesterday (04/17/17) LVN F went to LVN G and told her, I've been giving the insulin and I have not been signing the TAR. We do not have an original record. LVN G printed a TAR for Resident #18's [MEDICATION NAME] yesterday that is why the date 04/18/2017 is on the bottom of the TAR. In an interview on 04/19/2017 at 6:50 PM LVN F stated I don't recall telling anyone there was not a TAR available before 4/18/2017. I usually document it when I give insulin but maybe not every time. I gave Resident #18 [MEDICATION NAME] 34 units every morning I worked. LVN F stated when LVN G printed the TAR on 04/18/2017 she back signed 11 times that she gave [MEDICATION NAME] 40 units daily for the month of April. LVN F stated I'm not able to talk about that. In an interview on 04/19/2017 at 7:45 PM LVN G stated, I cannot prove I gave Resident #18 his [MEDICATION NAME] 40 units on those days. In the back of my mind, I know he gets 40 units but I cannot actually recall giving the insulin to him. It was wrong for me to give the insulin and not have the documentation. In an interview on 04/19/2017 at 9:00 AM the Nurse Practitioner for the facility stated she would have expected the facility staff to administer insulin as ordered and document the medications when it was given. She stated she could certainly see it was dangerous to not have printed orders (a TAR) to follow while administering insulin and that not having a TAR could lead to the wrong dose being administered or none being administered. She further stated she did not understand how the medication errors could have happened and she would need to re-evaluate her patients. In an interview on 04/19/2017 at 8:57 PM the Medical Director who was also Resident #18's doctor stated it was potentially dangerous to give insulin by memory and not document what medications are being administered. The Medical Director stated he expected the facility to follow the orders as written for insulin administration and oral medications until he or his Practitioner changed the order. The Medical Director stated all orders should be written on TARs/MARs and the staff should not only follow the order but also document the medication and the amount of the medication administered. He stated what the Practitioner believes the Resident is receiving as far as medications and the resulting blood sugar readings could affect the next order. In an interview on 04/20/2017 at 2:15 PM the Regional Administrator stated the staff should not have regenerated the record for Resident #18 and back-signed it for the insulin administration. The Regional Administrator stated he expected the staff to document in a timely manner and he would make sure it never happened again. In an interview on 04/20/2017 at 3:21 PM the ADON stated she was responsible for putting new orders in the computer and she had not received the order for Resident #18's medication changes. She stated the nurses did not tell her the MAR/TARs were not correct or missing. In an interview on 04/21/2017 at 11:12 AM the Regional Nurse Consultants A and B stated they expected the Registered Pharmacist that came to the facility on a monthly basis to find discrepancies and potential medication errors and alert the staff/facility. In an interview on 04/21/2017 at 11:15 AM the Registered Pharmacist stated he looked at the orders in the charts every visit but reviewed the whole chart on a quarterly basis and he had done that in his early February visit. He further stated the staff was supposed to carry over the current orders from month to month. He stated he had worked at the facility five years. Review of the Pharmacy Services Agreement dated 07/21/2010 reflected the Consultant Pharmacist will: Perform monthly drug regimen review and prepare reports of any noted irregularities. Monitor the drug pass procedures of at least two nurses during each visit. Conduct in-service educational programs as necessary. Review of the facility Policy Medication Administration Procedures PA 03-4.02 reflected; After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. All nurses administering medication must sign and initial the designated area of each resident's MAR/TAR or resident specific master signature log. All current medications and dosage schedules are to be listed on the resident's current medication administration record. Any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval by the Quality Assurance Committee and shall be in concurrence with current statutes and regulations. B. Review of the Face Sheet for Resident #10 dated 04/21/2017 reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Admission MDS Assessment for Resident #10 dated 03/30/2017 reflected a BIMS score of 14 which indicated she was cognitively intact. Resident #10 received scheduled and as needed pain medication during the assessment period. Resident #10 had pain frequently and the pain made it hard to sleep at night and limited her daily activities. The Assessment reflected she rated her pain a 5/10. Review of the Care Plan for Resident #10 last reviewed on 03/31/2017 reflected she needed pain management for [DIAGNOSES REDACTED]. The staff was also to monitor and document for side effects of the pain medications. Review of the admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED].Apply new patch to skin every third day and remove per schedule. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Also the MAR indicated [REDACTED]. Therefore Resident #10 only received the patch on 3 days instead of the 6 days she should have received the patch. Review of the Narcotic Count Sheet for Resident #10's [MEDICATION NAME] Patches reflected on 03/23/2017 the facility received 10 patches from the pharmacy. The Sheet reflected Resident #10 was administered patches on 03/24/2017, 03/27/2017, 03/31/2017, 04/04/2017, 04/12/2017, and 04/20/2017 for a total of six (6) patches. In an interview on 04/20/2017 at 2:40 PM MA M stated she worked on the weekends of 04/08/2017 and 04/16/2017. She stated she did not apply the patches on the 8th or 16th because she did not see it and forgot. She also stated she did not know why the patches were scheduled every 4th day instead of every 3rd day per the orders. In an interview on 04/20/2017 at 2:52 PM Charge Nurse LVN G stated she expected the MA to give the medications as ordered by the physician. She stated she was not sure why the patch was scheduled for every 4th day instead of every 3rd day as ordered. She stated the ADON enters the orders in the computer. In an interview on 04/20/2017 at 3:15 PM ADON stated she entered the orders for the patches for Resident #10. She stated she inaccurately entered the patch for every 96 hours instead of every 72 hours. In an interview on 04/20/2017 at 4:15 PM Resident #10 stated she did believe the staff missed administering some pain patches this month. She stated she also believed the time in between the patches was too long. Resident #10 stated she only asked for pain medication when she really needed it. She stated she had back and right shoulder pain. She stated the pain in her right shoulder at this time was a 6-7 of 10, but she currently did not want any pain medication. She stated as long as she kept her right shoulder very still it would not bother her. Resident #10 also stated the pain would be under more control if she received the patches as ordered. Surveyor attempted to call Resident #10's physician on 04/20/2017 at 4:26 PM. He did not return the call. Review of the facility's policy entitled Pain Management; Assessment Scale revised 02/13/2007 reflected the definition of pain. The policy reflected the nursing staff would assess any complaints of pain and effectively manage the pain by administering the prescribed medications. The policy also reflected the staff was to discuss with the resident goals and a plan for pain management. The care plan team was also to assess the effectiveness of the pain management interventions and update care plans accordingly. The facility Administrator was notified on 04/19/2017 at 8:21 PM that an Immediate Jeopardy situation had been identified due to above failures. The final Plan of Removal was accepted by the survey team on 04/20/2017 at 3:58 PM. The plan reflected the following: Plan of Removal 4-20-2017 Reason - Transcription of orders for medication administration on one Resident #18 were not transcribed to the Medication Administration Record/Treatment Administration Record (MAR/TAR). Discontinued Medications were not removed from the Medication Administration Record/Treatment Administration Record and the new orders were not transcribed onto the Medication Administration Record/Treatment Administration Record. The end of month comparison was not completed at the end of March and beginning of April. Interventions: Clarify the orders for Resident #18 for insulin administration. Order clarified with Resident #18's MD on 4-19-17 by the D.O.N. and the clarified order was reported to the Administrator at 7:26 pm. Clarified order was transcribed to the Nurse TAR. No new lab orders per the physician. Resident #18 was assessed by nursing personnel on 4-19-17. At 9:05 pm Blood sugar was at 364 all vital signs were within normal limits, resident presented as his normal baseline. Resident was active in his room. MD was notified of the assessment 4-19-17 at 10:30 pm. In-service will be conducted with licensed nurses to instruct them that when they write a new order, the new order will be placed in the order bin at the nurse's station. The DON or designee will pick up all new orders each morning, 7 days per week for review and follow up. Regional Compliance Nurse will instruct the DON and Designee on this process by 4-20-17. DON or designee will enter new orders into the Clinical Software system in a timely manner after pulling them each day Monday through Friday and note on each order when it is entered. DON or designee will compare newly printed Medication Administration Record/Treatment Administration Records with the previous months Medication Administration Record/Treatment Administration Record to ensure all orders were transcribed; verify any inconsistencies by checking the physician orders and take corrective action as necessary. This will be done monthly in the last week. Identification of Other Residents: Check all resident's medication orders against the Medication Administration Record/Treatment Administration Record and the medication immediately, notify physician of any discrepancy. All orders found to have discrepancies will be verified with the physician and corrections will be made. To be completed 4-21-17. The MD was notified on 4-19-17 at 11:00 pm of any discrepancies found on the Medication Administration Record/Treatment Administration Record and the physician will be notified of any residents exhibiting Hypo or Hyper glycemia on 4-19-17. MD's Nurse Practitioner was notified on 4-20-17 at 1:30 pm of the Hypo/Hyper glycemia abnormalities and a follow up discussion will be had with the physician and the facility faxed Blood Glucose reports. Training All licensed nursing staff will be in-serviced starting 4-19-17. Staff will be in-serviced prior to their next shift. 75% of licensed staff will be in-serviced by 4-20-17 and 100% by 4-24-17. Medication Aides will be in-serviced on Medication Administration and Documentation beginning 4-20-17. Staff will be in-serviced prior to their next shift. 50% will be completed 4-20-17 and 100% will be completed by 4-24-17. The following in-services have been started: Medication administration utilizing Pharmacy Policy & Procedure Manual 2003 PA03-2.03a which includes Elements of the Medication Order, Documentation of the Medication Order, Specific Procedures for the four types of medication orders, New Verbal Orders, Written Transfer Orders, Renewed or Recapitulated (Recapped) Orders. Licensed Nurses and Medication Aides. Physician orders/transcribing utilizing written in-service dated 4-19-17 which includes instruction on not regenerating Medication Administration Record/Treatment Administration Record, Notification to DON of Missing Documentation, and Instruction on signing the Medication Administration Record/Treatment Administration Record. Licensed Nurses only. Documentation on the Medication Administration Record/Treatment Administration Record utilizing the Pharmacy Policy & Procedure Manual 2003 PA 03-4.02 Medication Administration Procedure which contains under # 5 education on documentation immediately after a medication is given. Licensed Nurses and Medication Aides. Physician Notification of Change of Condition utilizing the Change of Condition File Cards from Interact. Start on 4-20-17 and 100% complete by 4-24-17.Licensed Nurses. Monitoring: 7 days per week DON or designee will review all physician orders from previous days and verify the order was transcribed correctly. Frequency of monitoring will be at least 7 times per week for 2 weeks, then 5 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will watch a portion of 5 medication passes per week as well as 5 insulin administrations per week and take corrective action as necessary. Frequency of monitoring will be at least 7 times per week for 4 weeks, then 2 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will audit all charts daily for 2 weeks for new physician orders to ensure there are no missed orders, then after 2 weeks 10 charts will be audited daily five times per week for 4 weeks, thereafter charts will be audited randomly. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will monitor the 24 report and the Medication Administration Record/Treatment Administration Record 5 times per week to review for changes of condition. For any changes that the physician was not notified the DON/Designee will make the notification immediately. See attached document titled In-service for Medication Monitoring page 2. Monitors will be trained by Instructor: RN VP Clinical Services. Medical Director was notified of the Immediate Jeopardy on 4-19-17. Results of the Plan of Removal will be reviewed by the facility QA committee until facility is satisfied this is resolved. Monitoring for the Plan of Removal began on 04/21/2017 at 12:57 PM. The survey team monitored the current plan of removal as follows: The facility notified Resident #18's physician and obtained a clarification order for his routine and sliding scale insulin administration on 04/19/17 by the DON. The computer was updated with the current orders. The facility notified Resident #10's Physician and obtained a clarification order for the routine [MEDICATION NAME] and updated the computer with the current order. In-services were conducted beginning on 04/19/2017 with licensed nurses to instruct them on: new order processing, transcribing, administering, documenting, changes of condition and month end change-over process. The DON and ADON were in-serviced on month end processing and the monitoring process for the plan of removal. Licensed Nurses and Medication Aides were trained on Medication Administration and monitoring for changes on the MARs. Sign in sheets were reviewed with 90% of all training completed by 04/21/2017 at 7:00 PM. The DON enacted the orders/medication monitoring form for daily review on 04/21/2017 AM. The Regional Administrator stated on 04/21/2017 100% chart audit for order accuracy compared to MAR/TAR was completed and the physician had been notified of any discrepancies. Interviews conducted on 04/21/2017 reflected the DON and ADON were aware of the daily auditing process. Three charge nurses and a medication aide were interviewed for understanding of the corrective actions. On 04/21/17 at 7:30 PM the facility's Administrator was informed the IJ was removed. However, the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. The facility Form CMS-672 reflected 24 residents were on a pain management program. The facility provided a list of 12 residents who received insulin.

Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and received adequate monitoring for one (1) of ten (10) residents reviewed for medications (Resident #18). A) The facility failed to discontinue Resident #18's sliding scale insulin and he received insulin to scale nine times from 03/01/2017-03/04/2017 when the practitioner had discontinued the insulin to scale on 02/02/2017. B) The facility failed to discontinue Resident #18's [MEDICATION NAME] 10 mg one daily for blood pressure from 04/01/2017 to 04/19/2017 after it had been discontinued by the practitioner on 02/02/ 2017. An IJ was identified on 04/19/17. While the IJ was removed on 04/21/17 the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. This deficient practice could affect 12 residents with insulin orders by placing them at risk for [DIAGNOSES REDACTED], confusion and falls. This deficient practice could affect 40 residents who received medications by placing them at risk for receiving medications after the Physician had discontinued the orders which could cause low blood pressure, falls and injury. Findings Included: Review of Resident #18's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. He was assessed as understanding with clear comprehension and being understood. Resident #18 was assessed as needing limited assistance of one person in a wheelchair. Review of Resident #18's undated Care Plan reflected he was care planned for Hypertension with in intervention of give medication as ordered by doctor. Resident #18 was care planned for Diabetes Mellitus and finger stick blood sugar checks and diabetes medication as ordered by doctor as an intervention. A.Observation on 04/18/2017 at 4:42 PM revealed LVN I performed a finger stick blood sugar check on Resident #18 and the result was 418. LVN I administered Humalog 10 units. Review of Resident #18's Order Summary Report for active orders as of 04/01/2017 printed on 04/11/2017 reflected: a.) Humalog insulin per scale. b.) [MEDICATION NAME] 10 mg one time a day. c.) Humalog 10 units twice a day and 15 units once a day. Review of Resident #18's Physician Telephone order dated 02/02/2017 and noted by LVN F reflected an order to: a.) stop the sliding scale insulin, (still on the orders and the TAR/MARs through April 2017). b.) discontinue the [MEDICATION NAME]. (still on the orders and the MARs through April 2017). Record review of Resident #18's March 2017 TAR reflected: a.) The sliding scale insulin that had been discontinued on 02/02/2017 had printed on the TAR and the staff had performed blood sugar checks and administered insulin according to the results nine times from 03/01/2017 to 03/04/2017 without orders. Resident #18's blood sugar readings for 03/01/2017 to 03/04/2017 reflected a low result of 84 and a high of 291. B) Review of Resident #18's Order Summary Report for active orders as of 04/01/2017 printed on 04/11/2017 reflected: [MEDICATION NAME] 10 mg one time a day, [MEDICATION NAME] 40 mg once a day for [MEDICAL CONDITION], Losartan Potassium 100 mg once a day for Hypertension and [MEDICATION NAME] 25 mg one tablet two times a day (four medications which have actions to lower blood pressure). Review of Resident #18's Physician Telephone order dated 02/02/2017 reflected: Discontinue [MEDICATION NAME] 10 mg. Monitor blood pressures every day and as needed and notify me if consistently greater than 140/90. Review of Resident #18's April 2017 MAR indicated [REDACTED] [MEDICATION NAME] 10 mg one tablet by mouth one time a day was signed as administered from 04/01/2017 through 04/19/2017. In addition, the MAR indicated [REDACTED]. The April 2017 MAR/TAR did not reflect staff was monitoring Resident #18's blood pressure as ordered on [DATE]. In an interview on 04/19/2017 at 5:30 PM the DON stated the blood pressure pill [MEDICATION NAME] and the sliding scale insulin for Resident #18 was supposed to have been stopped on 02/02/2017 and the medications were printing on the MARs and was given after it should have been discontinued. In an interview on 04/20/2017 at 3:21 PM the ADON stated she was responsible for putting new orders in the computer and she had not received the order for Resident #18's medication changes (stop the sliding scale and [MEDICATION NAME]). The ADON further stated no one had told her there were any problems with the MAR/TARs. In an interview on 04/21/2017 the Registered Pharmacist stated he looked at the orders in the charts every visit but reviewed the whole chart on a quarterly basis and he had done that in his early February visit. He further stated the staff was supposed to carry over the current orders from month to month. Review of the Pharmacy Services Agreement dated 07/21/2010 reflected the Consultant Pharmacist will: Perform monthly drug regimen review and prepare reports of any noted irregularities. Monitor the drug pass procedures of at least two nurses during each visit. Conduct in-service educational programs as necessary. Review of the policy Medication Administration Procedures from the Pharmacy Policy and Procedure Manual 2003 reflected: All current medications and dosage schedules are to be listed on the resident's current medication administration record. Pulse and blood pressure are to be monitored and charted where applicable. The facility Administrator was notified on 04/19/2017 at 8:21 PM that an Immediate Jeopardy situation had been identified due to above failures. The final Plan of Removal was accepted by the survey team on 04/20/2017 at 3:58 PM. The plan reflected the following: Plan of Removal 4-20-2017 Reason - Transcription of orders for medication administration on one Resident #18 were not transcribed to the Medication Administration Record/Treatment Administration Record (MAR/TAR). Discontinued Medications were not removed from the Medication Administration Record/Treatment Administration Record and the new orders were not transcribed onto the Medication Administration Record/Treatment Administration Record. The end of month comparison was not completed at the end of March and beginning of April. Interventions: Clarify the orders for Resident #18 for insulin administration. Order clarified with Resident #18's MD on 4-19-17 by the D.O.N. and the clarified order was reported to the Administrator at 7:26 pm. Clarified order was transcribed to the Nurse TAR. No new lab orders per the physician. Resident #18 was assessed by nursing personnel on 4-19-17. At 9:05 pm Blood sugar was at 364 all vital signs were within normal limits, resident presented as his normal baseline. Resident was active in his room. MD was notified of the assessment 4-19-17 at 10:30 pm. In-service will be conducted with licensed nurses to instruct them that when they write a new order, the new order will be placed in the order bin at the nurse's station. The DON or designee will pick up all new orders each morning, 7 days per week for review and follow up. Regional Compliance Nurse will instruct the DON and Designee on this process by 4-20-17. DON or designee will enter new orders into the Clinical Software system in a timely manner after pulling them each day Monday through Friday and note on each order when it is entered. DON or designee will compare newly printed Medication Administration Record/Treatment Administration Records with the previous months Medication Administration Record/Treatment Administration Record to ensure all orders were transcribed; verify any inconsistencies by checking the physician orders [REDACTED]. This will be done monthly in the last week. Identification of Other Residents: Check all resident's medication orders against the Medication Administration Record/Treatment Administration Record and the medication immediately, notify physician of any discrepancy. All orders found to have discrepancies will be verified with the physician and corrections will be made. To be completed 4-21-17. The MD was notified on 4-19-17 at 11:00 pm of any discrepancies found on the Medication Administration Record/Treatment Administration Record and the physician will be notified of any residents exhibiting Hypo or Hyper glycemia on 4-19-17. MD's Nurse Practitioner was notified on 4-20-17 at 1:30 pm of the Hypo/Hyper glycemia abnormalities and a follow up discussion will be had with the physician and the facility faxed Blood Glucose reports. Training All licensed nursing staff will be in-serviced starting 4-19-17. Staff will be in-serviced prior to their next shift. 75% of licensed staff will be in-serviced by 4-20-17 and 100% by 4-24-17. Medication Aides will be in-serviced on Medication Administration and Documentation beginning 4-20-17. Staff will be in-serviced prior to their next shift. 50% will be completed 4-20-17 and 100% will be completed by 4-24-17. The following in-services have been started: Medication administration utilizing Pharmacy Policy & Procedure Manual 2003 PA03-2.03a which includes Elements of the Medication Order, Documentation of the Medication Order, Specific Procedures for the four types of medication orders, New Verbal Orders, Written Transfer Orders, Renewed or Recapitulated (Recapped) Orders. Licensed Nurses and Medication Aides. Physician orders/transcribing utilizing written in-service dated 4-19-17 which includes instruction on not regenerating Medication Administration Record/Treatment Administration Record, Notification to DON of Missing Documentation, and Instruction on signing the Medication Administration Record/Treatment Administration Record. Licensed Nurses only. Documentation on the Medication Administration Record/Treatment Administration Record utilizing the Pharmacy Policy & Procedure Manual 2003 PA 03-4.02 Medication Administration Procedure which contains under # 5 education on documentation immediately after a medication is given. Licensed Nurses and Medication Aides. Physician Notification of Change of Condition utilizing the Change of Condition File Cards from Interact. Start on 4-20-17 and 100% complete by 4-24-17.Licensed Nurses. Monitoring: 7 days per week DON or designee will review all physician orders [REDACTED]. Frequency of monitoring will be at least 7 times per week for 2 weeks, then 5 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will watch a portion of 5 medication passes per week as well as 5 insulin administrations per week and take corrective action as necessary. Frequency of monitoring will be at least 7 times per week for 4 weeks, then 2 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will audit all charts daily for 2 weeks for new physician orders [REDACTED]. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will monitor the 24 report and the Medication Administration Record/Treatment Administration Record 5 times per week to review for changes of condition. For any changes that the physician was not notified the DON/Designee will make the notification immediately. See attached document titled In-service for Medication Monitoring page 2. Monitors will be trained by Instructor: RN VP Clinical Services. Medical Director was notified of the Immediate Jeopardy on 4-19-17. Results of the Plan of Removal will be reviewed by the facility QA committee until facility is satisfied this is resolved. Monitoring for the Plan of Removal began on 04/21/2017 at 12:57 PM. The survey team monitored the current plan of removal as follows: The facility notified Resident #18's physician and obtained a clarification order for his routine and sliding scale insulin administration on 04/19/17 by the DON. The computer was updated with the current orders. The facility notified Resident #10's Physician and obtained a clarification order for the routine [MEDICATION NAME] and updated the computer with the current order. In-services were conducted beginning on 04/19/2017 with licensed nurses to instruct them on: new order processing, transcribing, administering, documenting, changes of condition and month end change-over process. The DON and ADON were in-serviced on month end processing and the monitoring process for the plan of removal. Licensed Nurses and Medication Aides were trained on Medication Administration and monitoring for changes on the MARs. Sign in sheets were reviewed with 90% of all training completed by 04/21/2017 at 7:00 PM. The DON enacted the orders/medication monitoring form for daily review on 04/21/2017 AM. The Regional Administrator stated on 04/21/2017 100% chart audit for order accuracy compared to MAR/TAR was completed and the physician had been notified of any discrepancies. Interviews conducted on 04/21/2017 reflected the DON and ADON were aware of the daily auditing process. Three charge nurses and a medication aide were interviewed for understanding of the corrective actions. On 04/21/17 at 7:30 PM the facility's Administrator was informed the IJ was removed. However, the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. The facility provided a list of 12 residents who had orders for insulin. The facility there were 40 residents at risk for receiving medications that had been discontinued.

Based on observation, interview and record review, the facility failed to ensure the resident has the right to be free from neglect for two (2) of 10 residents (Resident #18 and Resident #10) reviewed for neglect. A) The facility failed to ensure Resident #18 received his routine dose of [MEDICATION NAME] 34 units every morning from of 04/03/2017 to 04/17/2017 when the facility did not have a record of administration. The facility created a record of administration on 04/18/2017 and back signed it 11 times. The facility administered sliding scale insulin nine (9) times from 03/01/2017 to 03/04/2017 after it was ordered to be stopped on 02/02/2017. This deficient practice could place 12 residents who were on insulin at risk for uncontrolled high or low blood sugar which could lead to death. B. The facility failed to provide Resident #10 her prescribed, scheduled pain medication, [MEDICATION NAME]es, as ordered in April 2017 for three (3) of six (6) doses. An IJ was identified on 04/19/17. While the IJ was removed on 04/21/17 the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. This deficient practice could place 24 residents who were on a pain management program at risk for inadequate pain control and a diminished quality of life. Findings include: A) Review of Resident #18's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. He was assessed as understanding with clear comprehension and being understood. Resident #18 was assessed as needing limited assistance of one person in a wheelchair. Review of Resident #18's undated Care Plan reflected he was care planned for Diabetes Mellitus and finger stick blood sugar checks and diabetes medication as ordered by doctor as an intervention. Review of Resident #18's Physician Telephone order dated 02/02/2017 and noted by LVN F reflected an order to: a.) stop the sliding scale insulin, (still on the orders and the TAR/MARs through April 2017). b.) decrease the [MEDICATION NAME] from 40 units to 34 units, (still on the orders and the MARs through April 2017 at 40 units). In an observation on 04/18/2017 at 4:42 PM LVN I performed a finger stick blood sugar check on Resident #18 and the result was 418 milligrams per deciliter. (A normal blood sugar range for a non-diabetic is 80-110 mg/dl). LVN I stated two times, Resident #18 will get insulin according to his scale for a blood sugar of 418 as she looked at her Treatment Administration Record (TAR). LVN I administered Humalog 10 units. Review of Resident #18's Hemoglobin A1C lab results dated 03/15/2017 reflected a result of 8.0 with favorable range being 4.0 - 5.6%. Handwritten on the lab; Has order: [MEDICATION NAME] 40 units once a day and [MEDICATION NAME] 500 mg one tablet twice a day and Humalog 15 units once a day and Humalog 10 units twice a day. No new orders was written and signed by the DON. Review of Resident #18's Practitioner's note dated 03/16/2017 reflected she recorded: Now on [MEDICATION NAME] 34 units daily and Humalog 10 units before breakfast and supper and 15 units before lunch, [MEDICATION NAME] 500 mg twice a day. Lab results of Hemoglobin A1C is 8.0, accu checks (blood sugar check) up and down so will not make any changes at this time. In an interview on 04/19/2017 at 5:30 PM the DON stated she had called Resident #18's doctor regarding the lab results of 03/15/2017 with the wrong dose of insulin hand written on it. The DON stated she did not know who wrote on the lab. Review of Resident #18's March 2017 TAR reflected: a.) The sliding scale insulin that had been discontinued on 02/02/2017 had printed on the TAR and the staff had performed blood sugar checks and administered sliding scale insulin nine (9) times from 03/01/2017 - 03/04/2017. It was blocked off on March 5, and noted Discontinue 02/02/2017. b.) Handwritten; [MEDICATION NAME] 34 units every am. It was signed daily from March 5 through the end of the month. There was no record of [MEDICATION NAME] 34 or 40 units being administered from 03/02/2017 - 03/04/201. Review of Resident #18's April 2017 TAR reflected: The MAR (document utilized by medication aides) reflected LVN J had signed having given the [MEDICATION NAME] 40 units on 4/1/2017 and 4/2/2017. A new page one of the April TAR reflected it was printed on 04/18/2017 at 11:26 AM and had been back signed 11 times reflecting Resident #18 received [MEDICATION NAME] 40 units at 7:30 AM. Review of Resident #18's Order Summary Report for active orders as of 04/01/2017 printed on 04/11/2017 reflected: [MEDICATION NAME] 40 units once daily. (This Summary Report did not reflect the physician's orders written on 02/02/2017 for [MEDICATION NAME] to be decreased to 34 units daily.) In an interview on 04/19/2017 at 5:00 PM Resident #18 stated he only received two insulin injections in the mornings if his scale indicated he need a second injection. (Resident #18's orders indicated he should have routinely received two injections of insulin every morning and he did not have an active order for sliding scale insulin as of 02/02/2017). In an interview on 04/19/2017 at 5:30 PM the DON stated LVN J worked on the medication cart on 04/01/2017 - 04/02/2017 and she signed the MAR indicated [REDACTED]. The DON stated the ADON had looked everywhere for the [MEDICATION NAME] TAR for the nurses to have signed from 04/03/2017 to 04/17/2017 and she could not find one. When asked if the nurses gave the [MEDICATION NAME], the DON stated she would have to do a medication error form. In an interview on 04/19/2017 at 6:56 PM the Administrator stated LVN G had said yesterday (04/17/17) LVN F went to LVN G and told her, I've been giving the insulin and I have not been signing the TAR. We do not have an original record. LVN G printed a TAR for Resident #18's [MEDICATION NAME] yesterday that is why the date 04/18/2017 is on the bottom of the TAR. In an interview on 04/19/2017 at 6:50 PM LVN F stated I don't recall telling anyone there was not a TAR available before 4/18/2017. I usually document it when I give insulin but maybe not every time. I gave Resident #18 [MEDICATION NAME] 34 units every morning I worked. LVN F stated when LVN G printed the TAR on 04/18/2017 she back signed 11 times that she gave [MEDICATION NAME] 40 units daily for the month of April. LVN F stated I'm not able to talk about that. In an interview on 04/19/2017 at 7:45 PM LVN G stated, I cannot prove I gave Resident #18 his [MEDICATION NAME] 40 units on those days. In the back of my mind, I know he gets 40 units but I cannot actually recall giving the insulin to him. It was wrong for me to give the insulin and not have the documentation. In an interview on 04/19/2017 at 9:00 AM the Nurse Practitioner for the facility stated she would have expected the facility staff to administer insulin as ordered and document the medications when it was given. She stated she could certainly see it was dangerous to not have printed orders (a TAR) to follow while administering insulin and that not having a TAR could lead to the wrong dose being administered or none being administered. She further stated she did not understand how the medication errors could have happened and she would need to re-evaluate her patients. In an interview on 04/19/2017 at 8:57 PM the Medical Director who was also Resident #18's doctor stated it was potentially dangerous to give insulin by memory and not document what medications are being administered. The Medical Director stated he expected the facility to follow the orders as written for insulin administration and oral medications until he or his Practitioner changed the order. The Medical Director stated all orders should be written on TARs/MARs and the staff should not only follow the order but also document the medication and the amount of the medication administered. He stated what the Practitioner believes the Resident is receiving as far as medications and the resulting blood sugar readings could affect the next order. In an interview on 04/20/2017 at 2:15 PM the Regional Administrator stated the staff should not have regenerated the record for Resident #18 and back-signed it for the insulin administration. The Regional Administrator stated he expected the staff to document in a timely manner and he would make sure it never happened again. In an interview on 04/20/2017 at 3:21 PM the ADON stated she was responsible for putting new orders in the computer and she had not received the order for Resident #18's medication changes. She stated the nurses did not tell her the MAR/TARs were not correct or missing. In an interview on 04/21/2017 at 11:12 AM the Regional Nurse Consultants A and B stated they expected the Registered Pharmacist that came to the facility on a monthly basis to find discrepancies and potential medication errors and alert the staff/facility. In an interview on 04/21/2017 at 11:15 AM the Registered Pharmacist stated he looked at the orders in the charts every visit but reviewed the whole chart on a quarterly basis and he had done that in his early February visit. He further stated the staff was supposed to carry over the current orders from month to month. He stated he had worked at the facility five years. Review of the Pharmacy Services Agreement dated 07/21/2010 reflected the Consultant Pharmacist will: Perform monthly drug regimen review and prepare reports of any noted irregularities. Monitor the drug pass procedures of at least two nurses during each visit. Conduct in-service educational programs as necessary. Review of the facility Policy Medication Administration Procedures PA 03-4.02 reflected; After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. All nurses administering medication must sign and initial the designated area of each resident's MAR/TAR or resident specific master signature log. All current medications and dosage schedules are to be listed on the resident's current medication administration record. Any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval by the Quality Assurance Committee and shall be in concurrence with current statutes and regulations. B. Review of the Face Sheet for Resident #10 dated 04/21/2017 reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Admission MDS Assessment for Resident #10 dated 03/30/2017 reflected a BIMS score of 14 which indicated she was cognitively intact. Resident #10 received scheduled and as needed pain medication during the assessment period. Resident #10 had pain frequently and the pain made it hard to sleep at night and limited her daily activities. The Assessment reflected she rated her pain a 5/10. Review of the Care Plan for Resident #10 last reviewed on 03/31/2017 reflected she needed pain management for [DIAGNOSES REDACTED]. The staff was also to monitor and document for side effects of the pain medications. Review of the admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED].Apply new patch to skin every third day and remove per schedule. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Also the MAR indicated [REDACTED]. Therefore Resident #10 only received the patch on 3 days instead of the 6 days she should have received the patch. Review of the Narcotic Count Sheet for Resident #10's [MEDICATION NAME] Patches reflected on 03/23/2017 the facility received 10 patches from the pharmacy. The Sheet reflected Resident #10 was administered patches on 03/24/2017, 03/27/2017, 03/31/2017, 04/04/2017, 04/12/2017, and 04/20/2017 for a total of six (6) patches. In an interview on 04/20/2017 at 2:40 PM MA M stated she worked on the weekends of 04/08/2017 and 04/16/2017. She stated she did not apply the patches on the 8th or 16th because she did not see it and forgot. She also stated she did not know why the patches were scheduled every 4th day instead of every 3rd day per the orders. In an interview on 04/20/2017 at 2:52 PM Charge Nurse LVN G stated she expected the MA to give the medications as ordered by the physician. She stated she was not sure why the patch was scheduled for every 4th day instead of every 3rd day as ordered. She stated the ADON enters the orders in the computer. In an interview on 04/20/2017 at 3:15 PM ADON stated she entered the orders for the patches for Resident #10. She stated she inaccurately entered the patch for every 96 hours instead of every 72 hours. In an interview on 04/20/2017 at 4:15 PM Resident #10 stated she did believe the staff missed administering some pain patches this month. She stated she also believed the time in between the patches was too long. Resident #10 stated she only asked for pain medication when she really needed it. She stated she had back and right shoulder pain. She stated the pain in her right shoulder at this time was a 6-7 of 10, but she currently did not want any pain medication. She stated as long as she kept her right shoulder very still it would not bother her. Resident #10 also stated the pain would be under more control if she received the patches as ordered. Surveyor attempted to call Resident #10's physician on 04/20/2017 at 4:26 PM. He did not return the call. Review of the facility's policy entitled Pain Management; Assessment Scale revised 02/13/2007 reflected the definition of pain. The policy reflected the nursing staff would assess any complaints of pain and effectively manage the pain by administering the prescribed medications. The policy also reflected the staff was to discuss with the resident goals and a plan for pain management. The care plan team was also to assess the effectiveness of the pain management interventions and update care plans accordingly. Review of the facility's policy entitled Abuse/Neglect revised 01/08/2003 reflected the residents had the right to be free from abuse and neglect. The policy reflected the definition of neglect Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. The policy reflected the facility must identify the neglect and investigate the incident. The facility Administrator was notified on 04/19/2017 at 8:21 PM that an Immediate Jeopardy situation had been identified due to above failures. The final Plan of Removal was accepted by the survey team on 04/20/2017 at 3:58 PM. The plan reflected the following: Plan of Removal 4-20-2017 Reason - Transcription of orders for medication administration on one Resident #18 were not transcribed to the Medication Administration Record/Treatment Administration Record (MAR/TAR). Discontinued Medications were not removed from the Medication Administration Record/Treatment Administration Record and the new orders were not transcribed onto the Medication Administration Record/Treatment Administration Record. The end of month comparison was not completed at the end of March and beginning of April. Interventions: Clarify the orders for Resident #18 for insulin administration. Order clarified with Resident #18's MD on 4-19-17 by the D.O.N. and the clarified order was reported to the Administrator at 7:26 pm. Clarified order was transcribed to the Nurse TAR. No new lab orders per the physician. Resident #18 was assessed by nursing personnel on 4-19-17. At 9:05 pm Blood sugar was at 364 all vital signs were within normal limits, resident presented as his normal baseline. Resident was active in his room. MD was notified of the assessment 4-19-17 at 10:30 pm. In-service will be conducted with licensed nurses to instruct them that when they write a new order, the new order will be placed in the order bin at the nurse's station. The DON or designee will pick up all new orders each morning, 7 days per week for review and follow up. Regional Compliance Nurse will instruct the DON and Designee on this process by 4-20-17. DON or designee will enter new orders into the Clinical Software system in a timely manner after pulling them each day Monday through Friday and note on each order when it is entered. DON or designee will compare newly printed Medication Administration Record/Treatment Administration Records with the previous months Medication Administration Record/Treatment Administration Record to ensure all orders were transcribed; verify any inconsistencies by checking the physician orders and take corrective action as necessary. This will be done monthly in the last week. Identification of Other Residents: Check all resident's medication orders against the Medication Administration Record/Treatment Administration Record and the medication immediately, notify physician of any discrepancy. All orders found to have discrepancies will be verified with the physician and corrections will be made. To be completed 4-21-17. The MD was notified on 4-19-17 at 11:00 pm of any discrepancies found on the Medication Administration Record/Treatment Administration Record and the physician will be notified of any residents exhibiting Hypo or Hyper glycemia on 4-19-17. MD's Nurse Practitioner was notified on 4-20-17 at 1:30 pm of the Hypo/Hyper glycemia abnormalities and a follow up discussion will be had with the physician and the facility faxed Blood Glucose reports. Training All licensed nursing staff will be in-serviced starting 4-19-17. Staff will be in-serviced prior to their next shift. 75% of licensed staff will be in-serviced by 4-20-17 and 100% by 4-24-17. Medication Aides will be in-serviced on Medication Administration and Documentation beginning 4-20-17. Staff will be in-serviced prior to their next shift. 50% will be completed 4-20-17 and 100% will be completed by 4-24-17. The following in-services have been started: Medication administration utilizing Pharmacy Policy & Procedure Manual 2003 PA03-2.03a which includes Elements of the Medication Order, Documentation of the Medication Order, Specific Procedures for the four types of medication orders, New Verbal Orders, Written Transfer Orders, Renewed or Recapitulated (Recapped) Orders. Licensed Nurses and Medication Aides. Physician orders/transcribing utilizing written in-service dated 4-19-17 which includes instruction on not regenerating Medication Administration Record/Treatment Administration Record, Notification to DON of Missing Documentation, and Instruction on signing the Medication Administration Record/Treatment Administration Record. Licensed Nurses only. Documentation on the Medication Administration Record/Treatment Administration Record utilizing the Pharmacy Policy & Procedure Manual 2003 PA 03-4.02 Medication Administration Procedure which contains under # 5 education on documentation immediately after a medication is given. Licensed Nurses and Medication Aides. Physician Notification of Change of Condition utilizing the Change of Condition File Cards from Interact. Start on 4-20-17 and 100% complete by 4-24-17.Licensed Nurses. Monitoring: 7 days per week DON or designee will review all physician orders from previous days and verify the order was transcribed correctly. Frequency of monitoring will be at least 7 times per week for 2 weeks, then 5 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will watch a portion of 5 medication passes per week as well as 5 insulin administrations per week and take corrective action as necessary. Frequency of monitoring will be at least 7 times per week for 4 weeks, then 2 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will audit all charts daily for 2 weeks for new physician orders to ensure there are no missed orders, then after 2 weeks 10 charts will be audited daily five times per week for 4 weeks, thereafter charts will be audited randomly. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will monitor the 24 report and the Medication Administration Record/Treatment Administration Record 5 times per week to review for changes of condition. For any changes that the physician was not notified the DON/Designee will make the notification immediately. See attached document titled In-service for Medication Monitoring page 2. Monitors will be trained by Instructor: RN VP Clinical Services. Medical Director was notified of the Immediate Jeopardy on 4-19-17. Results of the Plan of Removal will be reviewed by the facility QA committee until facility is satisfied this is resolved. Monitoring for the Plan of Removal began on 04/21/2017 at 12:57 PM. The survey team monitored the current plan of removal as follows: The facility notified Resident #18's physician and obtained a clarification order for his routine and sliding scale insulin administration on 04/19/17 by the DON. The computer was updated with the current orders. The facility notified Resident #10's Physician and obtained a clarification order for the routine [MEDICATION NAME] and updated the computer with the current order. In-services were conducted beginning on 04/19/2017 with licensed nurses to instruct them on: new order processing, transcribing, administering, documenting, changes of condition and month end change-over process. The DON and ADON were in-serviced on month end processing and the monitoring process for the plan of removal. Licensed Nurses and Medication Aides were trained on Medication Administration and monitoring for changes on the MARs. Sign in sheets were reviewed with 90% of all training completed by 04/21/2017 at 7:00 PM. The DON enacted the orders/medication monitoring form for daily review on 04/21/2017 AM. The Regional Administrator stated on 04/21/2017 100% chart audit for order accuracy compared to MAR/TAR was completed and the physician had been notified of any discrepancies. Interviews conducted on 04/21/2017 reflected the DON and ADON were aware of the daily auditing process. Three charge nurses and a medication aide were interviewed for understanding of the corrective actions. On 04/21/17 at 7:30 PM the facility's Administrator was informed the IJ was removed. However, the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. The facility Form CMS-672 reflected 24 residents were on a pain management program. The facility provided a list of 12 residents who received insulin.

Based on observation, interview and record review the facility failed to ensure the Residents were free of any significant medication errors for two (2) of 10 residents (Resident #18 and Resident #10) reviewed for significant medications. A) The facility failed to ensure Resident #18 received his routine dose of [MEDICATION NAME] 34 units every morning from of 04/03/2017 to 04/17/2017 when the facility did not have a record of administration. The facility created a record of administration on 04/18/2017 and back signed it 11 times. The facility administered sliding scale insulin nine (9) times from 03/01/2017 to 03/04/2017 after it was ordered to be stopped on 02/02/2017. This deficient practice could place 12 residents who were on insulin at risk for uncontrolled high or low blood sugar which could lead to death. B. The facility failed to provide Resident #10 her prescribed, scheduled pain medication, [MEDICATION NAME]es, as ordered in April 2017 for three (3) of six (6) doses. An IJ was identified on 04/19/17. While the IJ was removed on 04/21/17 the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. This deficient practice could place 24 residents who were on a pain management program at risk for inadequate pain control and a diminished quality of life. Finding include: A) Review of Resident #18's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. He was assessed as understanding with clear comprehension and being understood. Resident #18 was assessed as needing limited assistance of one person in a wheelchair. Review of Resident #18's undated Care Plan reflected he was care planned for Diabetes Mellitus and finger stick blood sugar checks and diabetes medication as ordered by doctor as an intervention. Review of Resident #18's Physician Telephone order dated 02/02/2017 and noted by LVN F reflected an order to: a.) stop the sliding scale insulin, (still on the orders and the TAR/MARs through April 2017). b.) decrease the [MEDICATION NAME] from 40 units to 34 units, (still on the orders and the MARs through April 2017 at 40 units). In an observation on 04/18/2017 at 4:42 PM LVN I performed a finger stick blood sugar check on Resident #18 and the result was 418 milligrams per deciliter. (A normal blood sugar range for a non-diabetic is 80-110 mg/dl). LVN I stated two times, Resident #18 will get insulin according to his scale for a blood sugar of 418 as she looked at her Treatment Administration Record (TAR). LVN I administered Humalog 10 units. Review of Resident #18's Hemoglobin A1C lab results dated 03/15/2017 reflected a result of 8.0 with favorable range being 4.0 - 5.6%. Handwritten on the lab; Has order: [MEDICATION NAME] 40 units once a day and [MEDICATION NAME] 500 mg one tablet twice a day and Humalog 15 units once a day and Humalog 10 units twice a day. No new orders was written and signed by the DON. Review of Resident #18's Practitioner's note dated 03/16/2017 reflected she recorded: Now on [MEDICATION NAME] 34 units daily and Humalog 10 units before breakfast and supper and 15 units before lunch, [MEDICATION NAME] 500 mg twice a day. Lab results of Hemoglobin A1C is 8.0, accu checks (blood sugar check) up and down so will not make any changes at this time. In an interview on 04/19/2017 at 5:30 PM the DON stated she had called Resident #18's doctor regarding the lab results of 03/15/2017 with the wrong dose of insulin hand written on it. The DON stated she did not know who wrote on the lab. Review of Resident #18's March 2017 TAR reflected: a.) The sliding scale insulin that had been discontinued on 02/02/2017 had printed on the TAR and the staff had performed blood sugar checks and administered sliding scale insulin nine (9) times from 03/01/2017 - 03/04/2017. It was blocked off on March 5, and noted Discontinue 02/02/2017. b.) Handwritten; [MEDICATION NAME] 34 units every am. It was signed daily from March 5 through the end of the month. There was no record of [MEDICATION NAME] 34 or 40 units being administered from 03/02/2017 - 03/04/201. Review of Resident #18's April 2017 TAR reflected: The MAR (document utilized by medication aides) reflected LVN J had signed having given the [MEDICATION NAME] 40 units on 4/1/2017 and 4/2/2017. A new page one of the April TAR reflected it was printed on 04/18/2017 at 11:26 AM and had been back signed 11 times reflecting Resident #18 received [MEDICATION NAME] 40 units at 7:30 AM. Review of Resident #18's Order Summary Report for active orders as of 04/01/2017 printed on 04/11/2017 reflected: [MEDICATION NAME] 40 units once daily. (This Summary Report did not reflect the physician's orders written on 02/02/2017 for [MEDICATION NAME] to be decreased to 34 units daily.) In an interview on 04/19/2017 at 5:00 PM Resident #18 stated he only received two insulin injections in the mornings if his scale indicated he need a second injection. (Resident #18's orders indicated he should have routinely received two injections of insulin every morning and he did not have an active order for sliding scale insulin as of 02/02/2017). In an interview on 04/19/2017 at 5:30 PM the DON stated LVN J worked on the medication cart on 04/01/2017 - 04/02/2017 and she signed the MAR indicated [REDACTED]. The DON stated the ADON had looked everywhere for the [MEDICATION NAME] TAR for the nurses to have signed from 04/03/2017 to 04/17/2017 and she could not find one. When asked if the nurses gave the [MEDICATION NAME], the DON stated she would have to do a medication error form. In an interview on 04/19/2017 at 6:56 PM the Administrator stated LVN G had said yesterday (04/17/17) LVN F went to LVN G and told her, I've been giving the insulin and I have not been signing the TAR. We do not have an original record. LVN G printed a TAR for Resident #18's [MEDICATION NAME] yesterday that is why the date 04/18/2017 is on the bottom of the TAR. In an interview on 04/19/2017 at 6:50 PM LVN F stated I don't recall telling anyone there was not a TAR available before 4/18/2017. I usually document it when I give insulin but maybe not every time. I gave Resident #18 [MEDICATION NAME] 34 units every morning I worked. LVN F stated when LVN G printed the TAR on 04/18/2017 she back signed 11 times that she gave [MEDICATION NAME] 40 units daily for the month of April. LVN F stated I'm not able to talk about that. In an interview on 04/19/2017 at 7:45 PM LVN G stated, I cannot prove I gave Resident #18 his [MEDICATION NAME] 40 units on those days. In the back of my mind, I know he gets 40 units but I cannot actually recall giving the insulin to him. It was wrong for me to give the insulin and not have the documentation. In an interview on 04/19/2017 at 9:00 AM the Nurse Practitioner for the facility stated she would have expected the facility staff to administer insulin as ordered and document the medications when it was given. She stated she could certainly see it was dangerous to not have printed orders (a TAR) to follow while administering insulin and that not having a TAR could lead to the wrong dose being administered or none being administered. She further stated she did not understand how the medication errors could have happened and she would need to re-evaluate her patients. In an interview on 04/19/2017 at 8:57 PM the Medical Director who was also Resident #18's doctor stated it was potentially dangerous to give insulin by memory and not document what medications are being administered. The Medical Director stated he expected the facility to follow the orders as written for insulin administration and oral medications until he or his Practitioner changed the order. The Medical Director stated all orders should be written on TARs/MARs and the staff should not only follow the order but also document the medication and the amount of the medication administered. He stated what the Practitioner believes the Resident is receiving as far as medications and the resulting blood sugar readings could affect the next order. In an interview on 04/20/2017 at 2:15 PM the Regional Administrator stated the staff should not have regenerated the record for Resident #18 and back-signed it for the insulin administration. The Regional Administrator stated he expected the staff to document in a timely manner and he would make sure it never happened again. In an interview on 04/20/2017 at 3:21 PM the ADON stated she was responsible for putting new orders in the computer and she had not received the order for Resident #18's medication changes. She stated the nurses did not tell her the MAR/TARs were not correct or missing. In an interview on 04/21/2017 at 11:12 AM the Regional Nurse Consultants A and B stated they expected the Registered Pharmacist that came to the facility on a monthly basis to find discrepancies and potential medication errors and alert the staff/facility. In an interview on 04/21/2017 at 11:15 AM the Registered Pharmacist stated he looked at the orders in the charts every visit but reviewed the whole chart on a quarterly basis and he had done that in his early February visit. He further stated the staff was supposed to carry over the current orders from month to month. He stated he had worked at the facility five years. Review of the Pharmacy Services Agreement dated 07/21/2010 reflected the Consultant Pharmacist will: Perform monthly drug regimen review and prepare reports of any noted irregularities. Monitor the drug pass procedures of at least two nurses during each visit. Conduct in-service educational programs as necessary. Review of the facility Policy Medication Administration Procedures PA 03-4.02 reflected; After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. All nurses administering medication must sign and initial the designated area of each resident's MAR/TAR or resident specific master signature log. All current medications and dosage schedules are to be listed on the resident's current medication administration record. Any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval by the Quality Assurance Committee and shall be in concurrence with current statutes and regulations. B. Review of the Face Sheet for Resident #10 dated 04/21/2017 reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Admission MDS Assessment for Resident #10 dated 03/30/2017 reflected a BIMS score of 14 which indicated she was cognitively intact. Resident #10 received scheduled and as needed pain medication during the assessment period. Resident #10 had pain frequently and the pain made it hard to sleep at night and limited her daily activities. The Assessment reflected she rated her pain a 5/10. Review of the Care Plan for Resident #10 last reviewed on 03/31/2017 reflected she needed pain management for [DIAGNOSES REDACTED]. The staff was also to monitor and document for side effects of the pain medications. Review of the admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED].Apply new patch to skin every third day and remove per schedule. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Also the MAR indicated [REDACTED]. Therefore Resident #10 only received the patch on 3 days instead of the 6 days she should have received the patch. Review of the Narcotic Count Sheet for Resident #10's [MEDICATION NAME] Patches reflected on 03/23/2017 the facility received 10 patches from the pharmacy. The Sheet reflected Resident #10 was administered patches on 03/24/2017, 03/27/2017, 03/31/2017, 04/04/2017, 04/12/2017, and 04/20/2017 for a total of six (6) patches. In an interview on 04/20/2017 at 2:40 PM MA M stated she worked on the weekends of 04/08/2017 and 04/16/2017. She stated she did not apply the patches on the 8th or 16th because she did not see it and forgot. She also stated she did not know why the patches were scheduled every 4th day instead of every 3rd day per the orders. In an interview on 04/20/2017 at 2:52 PM Charge Nurse LVN G stated she expected the MA to give the medications as ordered by the physician. She stated she was not sure why the patch was scheduled for every 4th day instead of every 3rd day as ordered. She stated the ADON enters the orders in the computer. In an interview on 04/20/2017 at 3:15 PM ADON stated she entered the orders for the patches for Resident #10. She stated she inaccurately entered the patch for every 96 hours instead of every 72 hours. In an interview on 04/20/2017 at 4:15 PM Resident #10 stated she did believe the staff missed administering some pain patches this month. She stated she also believed the time in between the patches was too long. Resident #10 stated she only asked for pain medication when she really needed it. She stated she had back and right shoulder pain. She stated the pain in her right shoulder at this time was a 6-7 of 10, but she currently did not want any pain medication. She stated as long as she kept her right shoulder very still it would not bother her. Resident #10 also stated the pain would be under more control if she received the patches as ordered. Surveyor attempted to call Resident #10's physician on 04/20/2017 at 4:26 PM. He did not return the call. Review of the facility's policy entitled Pain Management; Assessment Scale revised 02/13/2007 reflected the definition of pain. The policy reflected the nursing staff would assess any complaints of pain and effectively manage the pain by administering the prescribed medications. The policy also reflected the staff was to discuss with the resident goals and a plan for pain management. The care plan team was also to assess the effectiveness of the pain management interventions and update care plans accordingly. The facility Administrator was notified on 04/19/2017 at 8:21 PM that an Immediate Jeopardy situation had been identified due to above failures. The final Plan of Removal was accepted by the survey team on 04/20/2017 at 3:58 PM. The plan reflected the following: Plan of Removal 4-20-2017 Reason - Transcription of orders for medication administration on one Resident #18 were not transcribed to the Medication Administration Record/Treatment Administration Record (MAR/TAR). Discontinued Medications were not removed from the Medication Administration Record/Treatment Administration Record and the new orders were not transcribed onto the Medication Administration Record/Treatment Administration Record. The end of month comparison was not completed at the end of March and beginning of April. Interventions: Clarify the orders for Resident #18 for insulin administration. Order clarified with Resident #18's MD on 4-19-17 by the D.O.N. and the clarified order was reported to the Administrator at 7:26 pm. Clarified order was transcribed to the Nurse TAR. No new lab orders per the physician. Resident #18 was assessed by nursing personnel on 4-19-17. At 9:05 pm Blood sugar was at 364 all vital signs were within normal limits, resident presented as his normal baseline. Resident was active in his room. MD was notified of the assessment 4-19-17 at 10:30 pm. In-service will be conducted with licensed nurses to instruct them that when they write a new order, the new order will be placed in the order bin at the nurse's station. The DON or designee will pick up all new orders each morning, 7 days per week for review and follow up. Regional Compliance Nurse will instruct the DON and Designee on this process by 4-20-17. DON or designee will enter new orders into the Clinical Software system in a timely manner after pulling them each day Monday through Friday and note on each order when it is entered. DON or designee will compare newly printed Medication Administration Record/Treatment Administration Records with the previous months Medication Administration Record/Treatment Administration Record to ensure all orders were transcribed; verify any inconsistencies by checking the physician orders and take corrective action as necessary. This will be done monthly in the last week. Identification of Other Residents: Check all resident's medication orders against the Medication Administration Record/Treatment Administration Record and the medication immediately, notify physician of any discrepancy. All orders found to have discrepancies will be verified with the physician and corrections will be made. To be completed 4-21-17. The MD was notified on 4-19-17 at 11:00 pm of any discrepancies found on the Medication Administration Record/Treatment Administration Record and the physician will be notified of any residents exhibiting Hypo or Hyper glycemia on 4-19-17. MD's Nurse Practitioner was notified on 4-20-17 at 1:30 pm of the Hypo/Hyper glycemia abnormalities and a follow up discussion will be had with the physician and the facility faxed Blood Glucose reports. Training All licensed nursing staff will be in-serviced starting 4-19-17. Staff will be in-serviced prior to their next shift. 75% of licensed staff will be in-serviced by 4-20-17 and 100% by 4-24-17. Medication Aides will be in-serviced on Medication Administration and Documentation beginning 4-20-17. Staff will be in-serviced prior to their next shift. 50% will be completed 4-20-17 and 100% will be completed by 4-24-17. The following in-services have been started: Medication administration utilizing Pharmacy Policy & Procedure Manual 2003 PA03-2.03a which includes Elements of the Medication Order, Documentation of the Medication Order, Specific Procedures for the four types of medication orders, New Verbal Orders, Written Transfer Orders, Renewed or Recapitulated (Recapped) Orders. Licensed Nurses and Medication Aides. Physician orders/transcribing utilizing written in-service dated 4-19-17 which includes instruction on not regenerating Medication Administration Record/Treatment Administration Record, Notification to DON of Missing Documentation, and Instruction on signing the Medication Administration Record/Treatment Administration Record. Licensed Nurses only. Documentation on the Medication Administration Record/Treatment Administration Record utilizing the Pharmacy Policy & Procedure Manual 2003 PA 03-4.02 Medication Administration Procedure which contains under # 5 education on documentation immediately after a medication is given. Licensed Nurses and Medication Aides. Physician Notification of Change of Condition utilizing the Change of Condition File Cards from Interact. Start on 4-20-17 and 100% complete by 4-24-17.Licensed Nurses. Monitoring: 7 days per week DON or designee will review all physician orders from previous days and verify the order was transcribed correctly. Frequency of monitoring will be at least 7 times per week for 2 weeks, then 5 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will watch a portion of 5 medication passes per week as well as 5 insulin administrations per week and take corrective action as necessary. Frequency of monitoring will be at least 7 times per week for 4 weeks, then 2 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will audit all charts daily for 2 weeks for new physician orders to ensure there are no missed orders, then after 2 weeks 10 charts will be audited daily five times per week for 4 weeks, thereafter charts will be audited randomly. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will monitor the 24 report and the Medication Administration Record/Treatment Administration Record 5 times per week to review for changes of condition. For any changes that the physician was not notified the DON/Designee will make the notification immediately. See attached document titled In-service for Medication Monitoring page 2. Monitors will be trained by Instructor: RN VP Clinical Services. Medical Director was notified of the Immediate Jeopardy on 4-19-17. Results of the Plan of Removal will be reviewed by the facility QA committee until facility is satisfied this is resolved. Monitoring for the Plan of Removal began on 04/21/2017 at 12:57 PM. The survey team monitored the current plan of removal as follows: The facility notified Resident #18's physician and obtained a clarification order for his routine and sliding scale insulin administration on 04/19/17 by the DON. The computer was updated with the current orders. The facility notified Resident #10's Physician and obtained a clarification order for the routine [MEDICATION NAME] and updated the computer with the current order. In-services were conducted beginning on 04/19/2017 with licensed nurses to instruct them on: new order processing, transcribing, administering, documenting, changes of condition and month end change-over process. The DON and ADON were in-serviced on month end processing and the monitoring process for the plan of removal. Licensed Nurses and Medication Aides were trained on Medication Administration and monitoring for changes on the MARs. Sign in sheets were reviewed with 90% of all training completed by 04/21/2017 at 7:00 PM. The DON enacted the orders/medication monitoring form for daily review on 04/21/2017 AM. The Regional Administrator stated on 04/21/2017 100% chart audit for order accuracy compared to MAR/TAR was completed and the physician had been notified of any discrepancies. Interviews conducted on 04/21/2017 reflected the DON and ADON were aware of the daily auditing process. Three charge nurses and a medication aide were interviewed for understanding of the corrective actions. On 04/21/17 at 7:30 PM the facility's Administrator was informed the IJ was removed. However, the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. The facility Form CMS-672 reflected 24 residents were on a pain management program. The facility provided a list of 12 residents who received insulin. Surveyor: Houston,(NAME)D.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to include the accurate dispensing and administering of all drug to meet the needs of each resident and provide consultation on all aspects of the provision of pharmacy services in the facility for one (1) of eight (8) residents observed for insulin administration by three (3) LVNs and one (1) of ten residents reviewed for medications administered by two (2) medication aides. A) The facility failed to ensure Resident #18 received his routine dose of Lantus insulin 34 units every morning from of 04/03/2017 to 04/17/2017 when the facility did not have a record of administration. The facility created a record of administration on 04/18/2017 and back signed it 11 times. The facility administered sliding scale insulin nine (9) times from 03/01/2017 to 03/04/2017 after it was ordered to be stopped on 02/02/2017. This deficient practice could place 12 residents who were on insulin at risk for uncontrolled high or low blood sugar which could lead to death. B. The facility failed to provide Resident #10 her prescribed, scheduled pain medication, Fentanyl patches, as ordered in April 2017 for three (3) of six (6) doses. An IJ was identified on 04/19/17. While the IJ was removed on 04/21/17 the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. This deficient practice could place 24 residents who were on a pain management program at risk for inadequate pain control and a diminished quality of life. Findings include: A) Review of Resident #18's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact. He was assessed as understanding with clear comprehension and being understood. Resident #18 was assessed as needing limited assistance of one person in a wheelchair. Review of Resident #18's undated Care Plan reflected he was care planned for Diabetes Mellitus and finger stick blood sugar checks and diabetes medication as ordered by doctor as an intervention. Review of Resident #18's Physician Telephone order dated 02/02/2017 and noted by LVN F reflected an order to: a.) stop the sliding scale insulin, (still on the orders and the TAR/MARs through April 2017). b.) decrease the Lantus Insulin from 40 units to 34 units, (still on the orders and the MARs through April 2017 at 40 units). In an observation on 04/18/2017 at 4:42 PM LVN I performed a finger stick blood sugar check on Resident #18 and the result was 418 milligrams per deciliter. (A normal blood sugar range for a non-diabetic is 80-110 mg/dl). LVN I stated two times, Resident #18 will get insulin according to his scale for a blood sugar of 418 as she looked at her Treatment Administration Record (TAR). LVN I administered Humalog 10 units. Review of Resident #18's Hemoglobin A1C lab results dated 03/15/2017 reflected a result of 8.0 with favorable range being 4.0 - 5.6%. Handwritten on the lab; Has order: Lantus 40 units once a day and Metformin 500 mg one tablet twice a day and Humalog 15 units once a day and Humalog 10 units twice a day. No new orders was written and signed by the DON. Review of Resident #18's Practitioner's note dated 03/16/2017 reflected she recorded: Now on Lantus 34 units daily and Humalog 10 units before breakfast and supper and 15 units before lunch, Metformin 500 mg twice a day. Lab results of Hemoglobin A1C is 8.0, accu checks (blood sugar check) up and down so will not make any changes at this time. In an interview on 04/19/2017 at 5:30 PM the DON stated she had called Resident #18's doctor regarding the lab results of 03/15/2017 with the wrong dose of insulin hand written on it. The DON stated she did not know who wrote on the lab. Review of Resident #18's March 2017 TAR reflected: a.) The sliding scale insulin that had been discontinued on 02/02/2017 had printed on the TAR and the staff had performed blood sugar checks and administered sliding scale insulin nine (9) times from 03/01/2017 - 03/04/2017. It was blocked off on March 5, and noted Discontinue 02/02/2017. b.) Handwritten; Lantus 34 units every am. It was signed daily from March 5 through the end of the month. There was no record of Lantus insulin 34 or 40 units being administered from 03/02/2017 - 03/04/201. Review of Resident #18's April 2017 TAR reflected: The MAR (document utilized by medication aides) reflected LVN J had signed having given the Lantus insulin 40 units on 4/1/2017 and 4/2/2017. A new page one of the April TAR reflected it was printed on 04/18/2017 at 11:26 AM and had been back signed 11 times reflecting Resident #18 received Lantus Insulin 40 units at 7:30 AM. Review of Resident #18's Order Summary Report for active orders as of 04/01/2017 printed on 04/11/2017 reflected: Lantus Insulin 40 units once daily. (This Summary Report did not reflect the physician's orders written on 02/02/2017 for Lantus to be decreased to 34 units daily.) In an interview on 04/19/2017 at 5:00 PM Resident #18 stated he only received two insulin injections in the mornings if his scale indicated he need a second injection. (Resident #18's orders indicated he should have routinely received two injections of insulin every morning and he did not have an active order for sliding scale insulin as of 02/02/2017). In an interview on 04/19/2017 at 5:30 PM the DON stated LVN J worked on the medication cart on 04/01/2017 - 04/02/2017 and she signed the MAR indicated [REDACTED]. The DON stated the ADON had looked everywhere for the Lantus Insulin TAR for the nurses to have signed from 04/03/2017 to 04/17/2017 and she could not find one. When asked if the nurses gave the Lantus insulin, the DON stated she would have to do a medication error form. In an interview on 04/19/2017 at 6:56 PM the Administrator stated LVN G had said yesterday (04/17/17) LVN F went to LVN G and told her, I've been giving the insulin and I have not been signing the TAR. We do not have an original record. LVN G printed a TAR for Resident #18's Lantus insulin yesterday that is why the date 04/18/2017 is on the bottom of the TAR. In an interview on 04/19/2017 at 6:50 PM LVN F stated I don't recall telling anyone there was not a TAR available before 4/18/2017. I usually document it when I give insulin but maybe not every time. I gave Resident #18 Lantus 34 units every morning I worked. LVN F stated when LVN G printed the TAR on 04/18/2017 she back signed 11 times that she gave Lantus 40 units daily for the month of April. LVN F stated I'm not able to talk about that. In an interview on 04/19/2017 at 7:45 PM LVN G stated, I cannot prove I gave Resident #18 his Lantus 40 units on those days. In the back of my mind, I know he gets 40 units but I cannot actually recall giving the insulin to him. It was wrong for me to give the insulin and not have the documentation. In an interview on 04/19/2017 at 9:00 AM the Nurse Practitioner for the facility stated she would have expected the facility staff to administer insulin as ordered and document the medications when it was given. She stated she could certainly see it was dangerous to not have printed orders (a TAR) to follow while administering insulin and that not having a TAR could lead to the wrong dose being administered or none being administered. She further stated she did not understand how the medication errors could have happened and she would need to re-evaluate her patients. In an interview on 04/19/2017 at 8:57 PM the Medical Director who was also Resident #18's doctor stated it was potentially dangerous to give insulin by memory and not document what medications are being administered. The Medical Director stated he expected the facility to follow the orders as written for insulin administration and oral medications until he or his Practitioner changed the order. The Medical Director stated all orders should be written on TARs/MARs and the staff should not only follow the order but also document the medication and the amount of the medication administered. He stated what the Practitioner believes the Resident is receiving as far as medications and the resulting blood sugar readings could affect the next order. In an interview on 04/20/2017 at 2:15 PM the Regional Administrator stated the staff should not have regenerated the record for Resident #18 and back-signed it for the insulin administration. The Regional Administrator stated he expected the staff to document in a timely manner and he would make sure it never happened again. In an interview on 04/20/2017 at 3:21 PM the ADON stated she was responsible for putting new orders in the computer and she had not received the order for Resident #18's medication changes. She stated the nurses did not tell her the MAR/TARs were not correct or missing. In an interview on 04/21/2017 at 11:12 AM the Regional Nurse Consultants A and B stated they expected the Registered Pharmacist that came to the facility on a monthly basis to find discrepancies and potential medication errors and alert the staff/facility. In an interview on 04/21/2017 at 11:15 AM the Registered Pharmacist stated he looked at the orders in the charts every visit but reviewed the whole chart on a quarterly basis and he had done that in his early February visit. He further stated the staff was supposed to carry over the current orders from month to month. He stated he had worked at the facility five years. Review of the Pharmacy Services Agreement dated 07/21/2010 reflected the Consultant Pharmacist will: Perform monthly drug regimen review and prepare reports of any noted irregularities. Monitor the drug pass procedures of at least two nurses during each visit. Conduct in-service educational programs as necessary. Review of the facility Policy Medication Administration Procedures PA 03-4.02 reflected; After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. All nurses administering medication must sign and initial the designated area of each resident's MAR/TAR or resident specific master signature log. All current medications and dosage schedules are to be listed on the resident's current medication administration record. Any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval by the Quality Assurance Committee and shall be in concurrence with current statutes and regulations. B. Review of the Face Sheet for Resident #10 dated 04/21/2017 reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Admission MDS Assessment for Resident #10 dated 03/30/2017 reflected a BIMS score of 14 which indicated she was cognitively intact. Resident #10 received scheduled and as needed pain medication during the assessment period. Resident #10 had pain frequently and the pain made it hard to sleep at night and limited her daily activities. The Assessment reflected she rated her pain a 5/10. Review of the Care Plan for Resident #10 last reviewed on 03/31/2017 reflected she needed pain management for [DIAGNOSES REDACTED]. The staff was also to monitor and document for side effects of the pain medications. Review of the admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED].Apply new patch to skin every third day and remove per schedule. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Also the MAR indicated [REDACTED]. Therefore Resident #10 only received the patch on 3 days instead of the 6 days she should have received the patch. Review of the Narcotic Count Sheet for Resident #10's Fentanyl Patches reflected on 03/23/2017 the facility received 10 patches from the pharmacy. The Sheet reflected Resident #10 was administered patches on 03/24/2017, 03/27/2017, 03/31/2017, 04/04/2017, 04/12/2017, and 04/20/2017 for a total of six (6) patches. In an interview on 04/20/2017 at 2:40 PM MA M stated she worked on the weekends of 04/08/2017 and 04/16/2017. She stated she did not apply the patches on the 8th or 16th because she did not see it and forgot. She also stated she did not know why the patches were scheduled every 4th day instead of every 3rd day per the orders. In an interview on 04/20/2017 at 2:52 PM Charge Nurse LVN G stated she expected the MA to give the medications as ordered by the physician. She stated she was not sure why the patch was scheduled for every 4th day instead of every 3rd day as ordered. She stated the ADON enters the orders in the computer. In an interview on 04/20/2017 at 3:15 PM ADON stated she entered the orders for the patches for Resident #10. She stated she inaccurately entered the patch for every 96 hours instead of every 72 hours. In an interview on 04/20/2017 at 4:15 PM Resident #10 stated she did believe the staff missed administering some pain patches this month. She stated she also believed the time in between the patches was too long. Resident #10 stated she only asked for pain medication when she really needed it. She stated she had back and right shoulder pain. She stated the pain in her right shoulder at this time was a 6-7 of 10, but she currently did not want any pain medication. She stated as long as she kept her right shoulder very still it would not bother her. Resident #10 also stated the pain would be under more control if she received the patches as ordered. Surveyor attempted to call Resident #10's physician on 04/20/2017 at 4:26 PM. He did not return the call. Review of the facility's policy entitled Pain Management; Assessment Scale revised 02/13/2007 reflected the definition of pain. The policy reflected the nursing staff would assess any complaints of pain and effectively manage the pain by administering the prescribed medications. The policy also reflected the staff was to discuss with the resident goals and a plan for pain management. The care plan team was also to assess the effectiveness of the pain management interventions and update care plans accordingly. The facility Administrator was notified on 04/19/2017 at 8:21 PM that an Immediate Jeopardy situation had been identified due to above failures. The final Plan of Removal was accepted by the survey team on 04/20/2017 at 3:58 PM. The plan reflected the following: Plan of Removal 4-20-2017 Reason - Transcription of orders for medication administration on one Resident #18 were not transcribed to the Medication Administration Record/Treatment Administration Record (MAR/TAR). Discontinued Medications were not removed from the Medication Administration Record/Treatment Administration Record and the new orders were not transcribed onto the Medication Administration Record/Treatment Administration Record. The end of month comparison was not completed at the end of March and beginning of April. Interventions: Clarify the orders for Resident #18 for insulin administration. Order clarified with Resident #18's MD on 4-19-17 by the DON and the clarified order was reported to the Administrator at 7:26 PM. Clarified order was transcribed to the Nurse TAR. No new lab orders per the physician. Resident #18 was assessed by nursing personnel on 4-19-17. At 9:05 PM Blood sugar was at 364 all vital signs were within normal limits, resident presented as his normal baseline. Resident was active in his room. MD was notified of the assessment 4-19-17 at 10:30 pm. In-service will be conducted with licensed nurses to instruct them that when they write a new order, the new order will be placed in the order bin at the nurse's station. The DON or designee will pick up all new orders each morning, 7 days per week for review and follow up. Regional Compliance Nurse will instruct the DON and Designee on this process by 4-20-17. DON or designee will enter new orders into the Clinical Software system in a timely manner after pulling them each day Monday through Friday and note on each order when it is entered. DON or designee will compare newly printed Medication Administration Record/Treatment Administration Records with the previous months Medication Administration Record/Treatment Administration Record to ensure all orders were transcribed; verify any inconsistencies by checking the physician orders and take corrective action as necessary. This will be done monthly in the last week. Identification of Other Residents: Check all resident's medication orders against the Medication Administration Record/Treatment Administration Record and the medication immediately, notify physician of any discrepancy. All orders found to have discrepancies will be verified with the physician and corrections will be made. To be completed 4-21-17. The MD was notified on 4-19-17 at 11:00 pm of any discrepancies found on the Medication Administration Record/Treatment Administration Record and the physician will be notified of any residents exhibiting Hypo or Hyper glycemia on 4-19-17. MD's Nurse Practitioner was notified on 4-20-17 at 1:30 pm of the Hypo/Hyper glycemia abnormalities and a follow up discussion will be had with the physician and the facility faxed Blood Glucose reports. Training All licensed nursing staff will be in-serviced starting 4-19-17. Staff will be in-serviced prior to their next shift. 75% of licensed staff will be in-serviced by 4-20-17 and 100% by 4-24-17. Medication Aides will be in-serviced on Medication Administration and Documentation beginning 4-20-17. Staff will be in-serviced prior to their next shift. 50% will be completed 4-20-17 and 100% will be completed by 4-24-17. The following in-services have been started: Medication administration utilizing Pharmacy Policy & Procedure Manual 2003 PA03-2.03a which includes Elements of the Medication Order, Documentation of the Medication Order, Specific Procedures for the four types of medication orders, New Verbal Orders, Written Transfer Orders, Renewed or Recapitulated (Recapped) Orders. Licensed Nurses and Medication Aides. Physician orders/transcribing utilizing written in-service dated 4-19-17 which includes instruction on not regenerating Medication Administration Record/Treatment Administration Record, Notification to DON of Missing Documentation, and Instruction on signing the Medication Administration Record/Treatment Administration Record. Licensed Nurses only. Documentation on the Medication Administration Record/Treatment Administration Record utilizing the Pharmacy Policy & Procedure Manual 2003 PA 03-4.02 Medication Administration Procedure which contains under # 5 education on documentation immediately after a medication is given. Licensed Nurses and Medication Aides. Physician Notification of Change of Condition utilizing the Change of Condition File Cards from Interact. Start on 4-20-17 and 100% complete by 4-24-17. Licensed Nurses. Monitoring: 7 days per week DON or designee will review all physician orders from previous days and verify the order was transcribed correctly. Frequency of monitoring will be at least 7 times per week for 2 weeks, then 5 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will watch a portion of 5 medication passes per week as well as 5 insulin administrations per week and take corrective action as necessary. Frequency of monitoring will be at least 7 times per week for 4 weeks, then 2 times per week for 4 weeks, then 2 times per week for 2 weeks then randomly thereafter. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will audit all charts daily for 2 weeks for new physician orders to ensure there are no missed orders, then after 2 weeks 10 charts will be audited daily five times per week for 4 weeks, thereafter charts will be audited randomly. These reviews will be documented. See attached document titled In-service for Medication Monitoring page 2. DON or designee will monitor the 24 report and the Medication Administration Record/Treatment Administration Record 5 times per week to review for changes of condition. For any changes that the physician was not notified the DON/Designee will make the notification immediately. See attached document titled In-service for Medication Monitoring page 2. Monitors will be trained by Instructor: RN VP Clinical Services. Medical Director was notified of the Immediate Jeopardy on 4-19-17. Results of the Plan of Removal will be reviewed by the facility QA committee until facility is satisfied this is resolved. Monitoring for the Plan of Removal began on 04/21/2017 at 12:57 PM. The survey team monitored the current plan of removal as follows: The facility notified Resident #18's physician and obtained a clarification order for his routine and sliding scale insulin administration on 04/19/17 by the DON. The computer was updated with the current orders. The facility notified Resident #10's Physician and obtained a clarification order for the routine Fentanyl patch and updated the computer with the current order. In-services were conducted beginning on 04/19/2017 with licensed nurses to instruct them on: new order processing, transcribing, administering, documenting, changes of condition and month end change-over process. The DON and ADON were in-serviced on month end processing and the monitoring process for the plan of removal. Licensed Nurses and Medication Aides were trained on Medication Administration and monitoring for changes on the MARs. Sign in sheets were reviewed with 90% of all training completed by 04/21/2017 at 7:00 PM. The DON enacted the orders/medication monitoring form for daily review on 04/21/2017 AM. The Regional Administrator stated on 04/21/2017 100% chart audit for order accuracy compared to MAR/TAR was completed and the physician had been notified of any discrepancies. Interviews conducted on 04/21/2017 reflected the DON and ADON were aware of the daily auditing process. Three charge nurses and a medication aide were interviewed for understanding of the corrective actions. On 04/21/17 at 7:30 PM the facility's Administrator was informed the IJ was removed. However, the facility remained out of compliance at a scope of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a severity level of pattern due to the facility's need to continue to train and monitor staff. The facility Form CMS-672 reflected 24 residents were on a pain management program. The facility provided a list of 12 residents who received insulin.

Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of one residents reviewed with pressure ulcers (Resident #6). Resident #6 had a history of [REDACTED]. This deficient practice caused Resident # 6 to develope a Stage III pressure ulcer and placed 1 additional resident who frequently use oxygen at risk for pressure ulcers. Findings Include: Review of Resident #6s Face Sheet reflected he was a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS dated [DATE] reflected he was assessed as having a BIMS score of zero which indicated he had severe cognitive impairment. He was assessed as requiring extensive assistance of one to two people for all his activities of daily living. Resident #6 was assessed as having an un-stageable pressure sore that was eschar and 4.0 x 4.5 cm and an infection of the foot. He was assessed as receiving pressure ulcer care and oxygen therapy. Review of Resident #6's undated Care Plan reflected he had a pressure ulcer to his left heel and it was un-stageable. A care plan for oxygen administration reflected he wore his oxygen continuously at 2 liters per nasal cannula and did not reflect any pressure ulcer prevention interventions for his ears such as ointment or padded tubing. Review of Resident #6's Wound Administration Record dated 04/01/2017 - 04/20/2017 reflected interventions of Barrier ointment (an extremely thick ointment) to bilateral ears every shift and Ear padding to oxygen tubing every shift The document was signed every shift every day including the days surveyor observed there was no ointment on Resident #6's ears and no padding to his cannula; 04/18- 04/19/2017. An order to cleanse the left ear with normal saline, pat dry and apply antibiotic ointment and leave open to air was documented and signed 04/18/2017 and 04/19/2017. Observation on 04/18/2017 at 10:40 AM revealed Resident #6 was in a geri-chair with oxygen in use at 2 liters per nasal cannula. His cannula was in place by being looped over both his ears. There was no padding to prevent pressure to his ears. There was no ointment on his ears. In an interview on 04/18/2017 at 10:40 AM the ADON stated Resident #6 had an un-stageable necrotic left heel pressure ulcer, and he wore oxygen every night. The ADON did not report to surveyor Resident #6 had ulceration on his left ear. Observation on 04/18/2017 at 2:35 PM revealed Resident #6 an approximately 1.5 cm long x 3 mm wide and 3 mm deep Stage III opening to the top of the left ear pinnae between his head and top ear tip in a place where his oxygen tubing would lay but he did not have oxygen on at that time. Resident #6 had his glasses on and they were tight to his head and not resting on his ears. There was no ointment on his ears. In an interview on 04/18/2017 at 2:35 PM Resident #6 stated his ear was a little sore and he had a sore on his other ear for a time but it had healed. In an interview on 04/18/2017 at 2:40 PM CNA N stated she had noticed the wound on Resident #6's ear after breakfast (on 04/18/2017) and told the nurse. Observation on 04/19/2017 at 9:15 AM revealed Resident #6 was in an activity with his heel on a pillow, there was no ointment on his ear and he was not wearing oxygen. Observation on 04/19/2017 at 11:18 AM revealed Resident #6 was in bed with his oxygen on and no ointment or oxygen tubing padding to prevent pressure to his ears. LVN G set up for wound care for his heel and applied the ointment and redressed the foot. LVN G did not perform wound care on his ear; there was no dressing or ointment on his ear. Observation on 04/19/2017 at 12:38 PM revealed Resident #6 was in his room, the Hospice staff had bathed him and his lunch was in front of him. He had his oxygen on and there were no ear pads, ointment or dressing on his ears. In an interview on 04/20/2017 at 2:49 PM the DON stated Resident #6's pressure ulcer wound assessments for the week were not in the computer yet because the hospice nurse had measured the wounds and the LVN G was clarifying the information before putting it in the computer. Review of Resident #6's computerized Wound assessment dated [DATE] reflected he had previously had ulceration to his right ear which had healed. Observation on 04/20/2017 at 6:00 PM revealed Resident #6 was in the lobby with oxygen per nasal cannula and his large, white ear padding was in place and easily visible. In an interview on 05/03/2017 at 1:51 PM the Hospice Nurse stated the hospice had been providing gray foam ear protectors but had been forgetting to bring them. In an interview on 04/19/2017 at 8:35 AM the DON stated she expected the staff to place the pads onto the nasal cannula to prevent pressure sores and Resident #6 had a pressure sore to his right ear in the past and that was why he had orders to have his cannula padded. The DON stated she could see the problem with him not having his padding to his cannula and stated we have been working on that. She stated she would expect if the nurses were putting the barrier ointment on Resident #6's ear routinely he would have the ointment or residue of the ointment on his ears. Review of the policy Oxygen Administration revised February 13, 2007 reflected: Adjust cannula (over the ears) to a snug fit and pad nares on the face and ears with gauze to protect from pressure of the tubing. The DON stated there were two (2) residents that use oxygen routinely.

Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three (3) of nine (9) residents (Residents #10, #3, and #2) reviewed for medications. A) a) The facility failed to remove from the medication cart and periodically administered Resident # 3's medication of [MEDICATION NAME] 75 mg after the medication was discontinued on 11/13/2014 and replaced with Xarelto. Both [MEDICATION NAME] and Xarelto are used to prevent blood clotting and have a blood thinning effect and could produce excessive bleeding. b) The facility obtained and administered two (2) doses [MEDICATION NAME] one (1) gram doses without a physician's orders [REDACTED]. B) The facility re-ordered and administered ten (10) doses of [MEDICATION NAME] 25 mg to Resident #10 after the medication had been discontinued on 03/14/2015. C) The facility continued to administer [MEDICATION NAME] 50 mg tablets to Resident #2 when the physician ordered a dose reduction to [MEDICATION NAME] 25 mg on 12/11/14. This resulted in an Immediate Jeopardy (IJ) on 05/24/2015 at 10:44 PM. While the IJ was removed on 05/26/2015 at 6:50 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. The deficient practice affected three (3) residents and placed an additional 46 who receive prescribed medication at risk for receiving unnecessary medications which could lead to unidentified drug reactions, changes in health status and death. Findings Include: A) a) Review of Resident #3's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the Diagnoses: [REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] reflected a BIMS score of three (3) indicating he was severely cognitively impaired. He was assessed as totally dependent on one or two staff for all activities of daily living including eating and could not walk and did not leave his room. He was assessed as having contractures of his upper and lower extremities. Resident #3's main source of nutrition/hydration was a PEG tube. Review of Resident #3's Care Plan dated 07/07/2014 and revised on 02/22/2015 reflected a Care Plan for the Diagnoses: [REDACTED]. Interventions included: Give all cardiac medications as ordered by the physician. The care plan also included Resident #3's risk for adverse reaction related to Polypharmacy with the intervention of Review medications with MD/Consulting pharmacist for: duplicate medications or prescriptions, proper dosing, timing and frequency of administration. Review as needed medications in the process. If Resident has more than one prescribing MD, ensure that each physician has the full list of meds available, including over the counter and as needed medications while ordering. In an interview on 05/24/2015 at 2:30 PM Resident #3's wife stated Resident #3 had received doses of [MEDICATION NAME] (used to treat infections caused by [MEDICAL CONDITION] viruses) one (1) gram for which he did not have an order or a [DIAGNOSES REDACTED]. In an interview on 05/24/2015 at 6:30 PM LVN G stated she made a mistake when she received the [MEDICATION NAME] from the pharmacy she wrote it on the TAR and administered one dose last night and one dose this morning without a Physician order. Review of Resident #3's May 2015 TAR reflected: [MEDICATION NAME] one (1) gram tablet three times a day X seven (7) days started on 05/23/2015 at 8:00 PM by LVN G and was given again on 05/24/2015 at 8:00 AM by LVN G. Review of Resident #3's chart reflected there was no order for [MEDICATION NAME] and no Nurse Notes reflected an order had been received for [MEDICATION NAME] and the Resident did not have any documented symptoms requiring [MEDICATION NAME] treatment. In an interview on 05/24/2015 at 5:10 PM RPh B stated he did not know why the [MEDICATION NAME] had been sent from his pharmacy to Resident #3 but an error had been made. In an interview on 05/24/ at 5:16 PM the DON stated the pharmacy had sent Resident #3 a card of [MEDICATION NAME] one (1) gram by error on 05/23/2015 and LVN G had received the medication from the pharmacy delivery person. The DON stated LVN G wrote the medication instructions from the card of [MEDICATION NAME] on the TAR and administered the medication without a physician's orders [REDACTED]. b) Review on 05/24/2015 at 2:30 PM of Resident #3's medications on the LVN/RN treatment cart (which were administered via PEG tube) compared to the May 2015 TAR revealed two (2) cards of [MEDICATION NAME] 75 mg tablets (is used to prevent blood clots after a recent [MEDICAL CONDITION] or stroke) one card sent on 10/05/2014 with three (3) tablets remaining and one card sent on 04/23/2015 with five (5) tablets missing, both cards had the instructions to give one tablet daily. The TAR reflected there was no order for [MEDICATION NAME] to be administered. [MEDICATION NAME] inhibits blood clotting and clotting won't return to normal for at least five (5) days after the drug has been stopped. Lippincott Nursing Drug Handbook '06 Review of Resident #3's hospital discharge orders dated 04/29/2015 reflected: there was no order for [MEDICATION NAME] 75 mg (inhibits blood clotting) and Resident #3 was to take Xarelto 20 mg (used to prevent blood clots) daily and Aspirin 81 mg daily (used to prevent blood clots). Xarelto - (anti-coagulant) that reduces blood clotting and can cause bleeding which rarely may lead to death www.xarelto-us.com. Review of Resident #3's handwritten admission orders [REDACTED]. The orders were transcribed and signed by the ADON. In an interview on 05/24/2015 at 6:30 PM LVN G stated she had given Resident #3 a [MEDICATION NAME] 75 mg that morning. After observing there was no place to sign the TAR for the [MEDICATION NAME], she retracted her statement and said she had not given the [MEDICATION NAME]. In an interview on 05/24/2015 at 7:00 PM with the DON and ADON the ADON stated Resident #3's [MEDICATION NAME] was stopped on 11/13/2014 and he was started on Xarelto. The DON stated Resident #3's [MEDICATION NAME] should have been pulled off the cart at that time and he should not have received the five (5) missing doses. In an interview on 05/26/2015 at 2:30 PM LVN I stated she did not administer the [MEDICATION NAME] because it is scheduled for the morning round and day shift gives it. In an interview on 05/26/2015 at 6:00PM the DON stated Resident #3 should not have been getting [MEDICATION NAME] and Xarelto at the same time and it could increased his risk for hematomas (bleeding under the skin). 05/26/2015 at 5:15 PM the facility Pharmacy Consultant stated the [MEDICATION NAME] should not have been administered without a doctors' order and bleeding can occur with either one of those medications alone so taking them together increased the risk for bleeding. In an interview on 07/24/2015 at 7:35 PM Resident #3's Primary MD stated it was absolutely a concern that Resident #3 was receiving [MEDICATION NAME] and Xarelto and he could not think of a [DIAGNOSES REDACTED].#3 to be on both medications. The Primary MD further stated he had not yet been made aware that Resident #3 had received [MEDICATION NAME] two doses which had not been ordered. The Primary MD stated he absolutely has a concern regarding Resident #3 having multiple issues with his medications not being administered according to the orders. B) Review of Resident #10's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Coli Unspecified, Hyposmolality, [MEDICAL CONDITIONS], Acute [MEDICAL CONDITION], Urinary Tract Infection, Diarrhea, Difficulty Walking and Unspecified Vitamin Deficiency. Review of Resident #10's Annual MDS assessment dated [DATE] reflected a readmission on 03/13/2015 from an acute care hospital. Resident #10 was assessed as having no difficulty hearing, seeing or communicating and his BIMS score was 15 indicating he was cognitively intact. He was assessed as having no mood or behavior problems and it was very important for him to express his daily preferences as an individual. Resident #10 was assessed as requiring extensive assistance of one to two people for his activities of daily living. Review of Resident #10's Care Plan dated 10/17/2013 and updated on 12/05/2014 reflected there was no Care Plan that included Nausea and Vomiting or [MEDICATION NAME] (a medication to treat nausea or vomiting that has a sedating effect). Resident #10 had a Care Plan for Depression with an intervention of administer medications as ordered. In an observation on 05/25/2015 at 12:00 PM during a MAR to cart medication comparison, it was noted Resident #10 had a card of 30 [MEDICATION NAME] 25 mg tablets refilled on 03/24/2015. Ten (10) tablets were missing from the card. Review of Resident #10's May 2015 MAR reflected [MEDICATION NAME] 25 mg was not listed as a medication to be given. Review of Resident #10's Discharge Orders from the hospital dated 03/13/2015 reflected there was not an order for [REDACTED]. Review of Resident # 10's Physician order [REDACTED]. Review of Resident #10's hand written readmission orders [REDACTED]. Review of Resident #10's Hospital Encounter form dated 05/20/2015 reflected a current medications list that did not include [MEDICATION NAME]. Review of Resident #10's Nurse Notes dated 04/15/2015 thru 05/23/2015 reflected no complaints of nausea or vomiting and no documentation of [MEDICATION NAME] being given. Review of Resident #10's daily Documentation dated 03/22/2015 thru 03/30/2015 for an infection and subsequent IV antibiotics reflected no complaints of nausea or vomiting. Review of the facility Pharmacy Reorder fax dated 03/24/2015 reflected the [MEDICATION NAME] 25 mg tablets with Resident #10's name on them were reordered by MA M. In an interview on 05/26/2015 at 1:35 PM MA M stated Resident #10's [MEDICATION NAME] tablets on her cart were as needed only and she had never given any. MA M stated she did not know who administered the 10 doses of [MEDICATION NAME] that were gone from Resident # 10's card. Review of Resident #10's May 2015 Nursing TAR reflected an entry: [MEDICATION NAME] ([MEDICATION NAME]) by mouth Dose: 25 mg per milliliter (liquid for injection) give 25 mg Intramuscularly (a shot) every eight (8) hours as needed for nausea and vomiting. There were no signatures on the TAR reflecting any type of [MEDICATION NAME] by mouth or by injection had been administered. Review of Resident #10's Consolidated Physician order [REDACTED]. In an interview on 05/26/2015 at 1:15 PM LVN F, Charge Nurse stated Resident #10 returned from the hospital on [DATE] and again on 05/20/2015 without an order for [REDACTED]. LVN F stated she had not given Resident #10 [MEDICATION NAME], didn't know who gave them to him because there was no documentation and Resident #10 should not have been given [MEDICATION NAME]. She stated when the nurse wrote the admission orders [REDACTED]. In an interview on 05/26/2015 at 2:20 PM LVN F stated when a resident returned from the hospital the nurses removed only medications that specifically had a discontinuation order, medications no longer listed on the orders were not removed from the cart. LVN F stated they should have been removed and that is how the staff has been instructed to do it in the future. In an interview on 05/26/2015 at 2:30 PM LVN I stated she had seen Resident #10's [MEDICATION NAME] on the cart but she had never given him any. In an interview on 05/26/2015 at 4:09 PM the ADON agreed the [MEDICATION NAME] should have been taken out of the computer and off the cart when Resident #10 readmitted on [DATE] and the medication should not have been reordered. In an interview on 05/26/2015 at 6:00 PM the DON stated she couldn't know for sure who gave the [MEDICATION NAME] to Resident #10 and that he shouldn't have received it. The DON stated she would be more observant of the MARS and carts and the errors were putting residents at risk for having adverse reactions. In an interview on 05/27/2015 at 1:30 PM Resident #10's Primary MD stated there had been recent studies regarding [MEDICATION NAME] and administering the medication to elderly. The Primary MD stated the [MEDICATION NAME] medication error for Resident #10 had the most potential risk for causing him harm. The Primary MD stated if somebody needed ten (10) nausea pills he needed to know about it because there could have been something else going on. C) Review of Resident #2's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the Diagnoses: [REDACTED]. Review of Resident #2s' Annual MDS assessment dated [DATE] reflected a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed as having no mood or behavior indicators and the Interview for Daily Preferences reflected every choice was very important to her. Resident #2 was assessed as requiring extensive to total assistance of staff in every ADL except eating. Review of Resident #2's Care Plan dated 09/12/2013 with updates reflected a Care Plan for [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], and Depression. The Depression Care Plan reflected an intervention of Medications per physician orders. Resident #2's Care Plan listed 12 medications she was allergic to. She had a Care Plan for [MEDICAL CONDITION] medications and was at risk for complications Interventions included Administer medications as ordered and consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Review of Resident #2's Consolidated Physician order [REDACTED]. Review of Resident #2's handwritten orders dated 02/23/2015 reflected, [MEDICATION NAME] ([MEDICATION NAME]) 50 mg tablet 25 mg one by mouth every day. Review of Resident #2's facility Pharmacy Consultant Recommendation reflected a recommendation dated 12/03/2014 asking the MD to consider a trial dosage reduction of [MEDICATION NAME] to 25 mg per day. The Primary MD agreed and singed the form on 12/09/2014. The order was noted on 12/11/2014. Review of Resident #2's MAR reflected an order [MEDICATION NAME] 25 mg give one tablet of 25 mg by mouth daily. MA M administered Resident #2's [MEDICATION NAME] routinely on the day shift and signed the MAR. Review of Resident #2's [MEDICATION NAME] on the medication cart reflected a card of whole [MEDICATION NAME] 50 mg tablets. There was no card of [MEDICATION NAME] 25 mg for Resident # 2 on the medication cart. In an interview on 05/26/2015 at 10:41 AM MA M stated she had never broken Resident #2's [MEDICATION NAME] 50 mg tablets in half when she administered them. MA M stated she had always administered the whole tablet to Resident # 2. In an interview on 05/26/2015 at 11:19 AM RPh C stated each time he filled Resident #2's [MEDICATION NAME] prescription he had sent whole [MEDICATION NAME] 50 mg tablets and had not been made aware there was a dosage reduction to 25 mg. He stated he had sent 30 day supply refills of the [MEDICATION NAME] 50 MG tablets on 01/26/2015, 02/23/2015, 04/14/2015 and 05/11/2015. Review of the facility provided Medication Error Form dated 05/25/2015 at 5:00 PM reflected Resident #2 had been receiving [MEDICATION NAME] 50 mg tablets instead of the [MEDICATION NAME] 25 mg tablets ordered. The form did not specify Resident #2 had received [MEDICATION NAME] 50 Mg from 12/10/2014 until surveyor intervention on 05/25/2015. The form was signed by the DON. In an interview on 05/26/2015 at 6:00 PM the DON stated she would expect the MAR to match the cards and would have expected the nurses and the facility contracted RPh to question why they did not match. In an interview on 05/26/2015 at 5:15 PM the facility Pharmacy Consultant stated he would have expected Resident #2's [MEDICATION NAME] dose to have been lowered in December 2014 when the Physician signed the Recommendation Form to lower the dose. In an interview on 05/26/2015 at 2:20 PM LVN F stated when a resident returned from the hospital the nurses removed only medications that specifically had a discontinuation order, medications no longer listed on the orders were not removed from the cart. LVN F stated they should have been removed and that is how the staff has been instructed to do it in the future. In an interview on 05/24/2015 at 7:00 PM the ADON stated the facility Pharmacy Consultant visited on 05/11/2015, and his routine was to come early in the morning and be gone by the time she got to work. The ADON stated the facility Pharmacy Consultant did not do a MAR to cart comparison. In an interview on 05/24/2015 at 7:00 PM the DON stated she expected the LVNs to remove discontinued drugs off the carts and place them in the discontinued drugs cabinet. In an interview on 05/26/2015 at 5:15 PM the facility Pharmacy Consultant stated he did a MAR to cart comparison quarterly and he typically hasn't found any errors to question the nurses about and that it was unusual for that to happen. In an interview on 05/24/2015 at 9:30 PM the DON and ADON stated when a Resident discharged to a hospital all the medications remained on the carts in anticipation of the Resident's return. When Residents returned with new orders, the Charge Nurse or the ADON should write the new hand written order sheet according to the new orders. The ADON put the order changes in the computer and printed out new MARS and TARS. No one was responsible to review the ADON entries to determine the orders were correctly put in the computer upon reentry. The DON and ADON both stated the charge nurses were responsible for making sure any medications no longer on the orders were removed from both carts and placed in the discontinued drug cabinet. The DON and ADON stated no one was assigned to see if the Charge Nurse correctly removed all discontinued medications from the carts. The ADON reviewed what she had in the computer according to the chart at the end of every month, no other person was assigned to review the entries. The DON stated auditing the carts for discontinued medications and comparing the MAR/TAR to the orders was not part of the monthly review performed by the facility's contracted RPh. The DON stated the Charge Nurse didn't have a system in place to make sure the cart was clear of discontinued drugs and added the DON/ADON did not check behind the nurses and it was ultimately the responsibility of the DON to make sure the Residents received medications as ordered by the physician. In an interview on 05/26/2015 at 6:00 PM the DON stated she could not figure out why the staff were administering medications without orders. She stated it was a systems failure in the facility when medications errors were not being caught and the Pharmacist should have been calling to question medication order changes. The DON stated Resident #10's [MEDICATION NAME] should not have been on the cart or given. The DON stated she expected the medication cards to match the MAR and the staff to give the correct dosages. The DON stated she could not remember ever talking to the facility Consultant Pharmacist about a medication error he had caught. In an interview on 05/27/2015 at 1:30 PM the Medical Director stated administering [MEDICATION NAME] to the elderly had a potential for harm and that if his patient needed ten (10) [MEDICATION NAME] he would definitely want to know about it. The Medical Director stated administering Resident #3's [MEDICATION NAME] along with Xarelto could have a potential for harm. As far as his expectations for the facility systems the Medical Director stated he expected more people to get involved in reconciling orders and checking the carts. The Medical Director stated perhaps there needed to be a different facility Pharmacy Consultant. The Medical Director stated he was concerned about the medication errors that occurred and no one had identified and further stated there was a system failure somewhere. The facility did not provide a policy regarding Unnecessary Medications but did provide the following policies: Review of the facility provided Order Changes policy dated 2003 reflected; Following the receipt and documentation of a change in a medication order, the nurse it to immediately enter the information on the resident's medication administration record. The Pharmacy must then be notified. Medication orders for which changes have been made are to be completely re-written in the medication administration record as a new order. The previous order is to be discontinued. The nurse may apply a Label Change, Check med-Sheet or a similar accessory label to the medication package for continued use of the medication. This will alert subsequent staff that the directions have been changed. The policy did not specify what to do with medications once they were discontinued by a physician. Review of the facility provided Medication Administration Procedures Policy dated 2003 reflected 4. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. The policy did not identify the staff needed to ensure the correct medication dose, route and time. Review of the facility provided policy Resident Admissions dated 2003 reflected; Upon re-admission from the hospital, all orders must be renewed by the prescriber or the attending Physician. 1. Post hospitalization orders 2.cancel all previous orders. (sic) 3. The pharmacy must be notified that the resident is a re-admission so that the previous orders can be discontinued and not appear on the physicians order sheet. On 05/24/2015 at 10:44 PM, the Administrative Director of Operations, the Regional Compliance Nurse, DON and ADON were informed that an Immediate Jeopardy existed due to systems failures to ensure: 1. Each resident received only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition. 2. The medication regimen helps promote or maintain the resident's highest practicable mental physical and psychosocial well- being, as identified by the resident and or representatives in collaboration with the attending physician and facility staff. 3. Residents who use antipsychotic drugs receive gradual dose reductions in an effort to discontinue these drugs. 4. Provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 5. The facility was managed in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 05/25/2015 at 3:54 PM the Administrative Director of Operations provided the survey team with an acceptable written plan of removal, which reflected the following: · Resident #1: A. [MEDICATION NAME] was removed from the cart. Medication error report was completed. The Physician was notified; labs were obtained and were unremarkable. B. [MEDICATION NAME] was removed from the cart. Medication error report was completed. The Physician was notified. · In-servicing of all licensed nurses and medication aides regarding the five (5) rights of medication administration began on 05/25/2015 and will continue until all licensed nurses and medication aides employed are in-serviced. Any employee not in-serviced will not be allowed to assume duty until they have been in-serviced by the DON/ADON. · In-servicing of licensed nurses regarding not writing a medication on the MAR or TAR unless a physician order [REDACTED]. Any licensed employee not in-serviced will not be allowed to assume duty until they have been in-serviced by the DON/ADON. · In-servicing all licensed nurses regarding reconciling medications upon a residents' return from the hospital ensuring that only those medications ordered are to be administered and are the only ones available on the cart. In-servicing began on 05/25/2015 and will continue until all licensed nurses employed are in-serviced. Any licensed employee not in-serviced will not be allowed to assume duty until they have been in-serviced by the DON/ADON. · A complete audit for all residents to verify correct physician orders, MARs and medications available was completed by the DON, ADON, and Regional Nurse Consultants. The audit was completed on 05/25/2015. · The DON and /or ADON will observe a portion of a medication pass at least five (5) times per week to ensure compliance. The DON/ADON will ensure that all medications ordered were given correctly and that non-ordered medications are not administered to the residents. · The DON and /or ADON will monitor at least five (5) resident records per week after the initial 100% audit to ensure the MARs and medication instructions match the physician orders. · The DON and /or ADON will monitor for readmissions daily and verify that medications have been reconciled and only those medications ordered after the hospitalization are being administered. · The Regional Nurse Consultant will review the monitoring documentation to ensure compliance with this plan. · The medical Director was notified of the Immediate Jeopardy on 05/24/2015. Findings will be reviewed in the facility QA committee and changes to the plan will be made as required. The survey team confirmed the facility had started to implement the plan of removal; observed the unnecessary medications had been removed from the cart. The medication carts were audited by the Regional Nurse Consultants. The in-services were approximately 75% complete and confirmed by staff interviews and review of the facility in-service sign in sheets. While the IJ was removed on 05/26/2015 at 6:50 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of widespread due to staff needing more time to monitor the plan or removal for effectiveness. Facility staff present at the notification of the removal of the IJ were the Regional Nurse Consultant and the Administrative Director of Operations. The facility provided a census list of 49 residents and verified all residents required prescription medication.

Based on observation, interview and record review the facility Administrator, DON and the ADON failed to administer in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to implement the facility policy, supervise, monitor and consult with the DON to ensure residents received the care and services to meet their pharmaceutical services needs to attain and maintain their highest practicable physical, mental, and psychosocial well-being. The DON failed to implement the facility policy, train, supervise and monitor the pharmaceutical services to ensure the facility nursing staff was providing the care and services required to attain or maintain their highest practicable physical, mental and psychosocial well being. A) a) Until surveyor intervention, the facility continued to periodically administer [MEDICATION NAME] 75 mg five (5) times to Resident #3 after the medication was discontinued on 11/13/2014 in addition to the physician ordered Xarelto. Both [MEDICATION NAME] and Xarelto have a blood thinning effect and could cause excessive bleeding. b) The facility obtained and administered two (2) [MEDICATION NAME] one (1) gram doses without a physician's order. Resident #3 received [MEDICATION NAME] 0.5 mg once and [MEDICATION NAME] 0.25 mg twice while an order for [REDACTED].>c) Resident # 3 received [MEDICATION NAME] 12.5 mg twice a day from 05/01/2015 while an order for [REDACTED]. B) The facility re-ordered and administered ten (10) doses of [MEDICATION NAME] 25 mg to Resident #10 after the medication had been discontinued on 03/14/2015. C) The facility continued to administer [MEDICATION NAME] 50 mg tablets to Resident #2 after the physician ordered a dose reduction to [MEDICATION NAME] 25 mg on 12/11/14. Surveyor intervened and facility began the [MEDICATION NAME] 25 mg daily. D) Resident #5 received an order on admission on 11/03/2013 for Vitamin D 4,000 IU daily and he received Vitamin D 2,000 IU daily until surveyor intervened and the order was changed on 05/24/2015 to Vitamin D 2,000 IU daily. This resulted in an Immediate Jeopardy (IJ) on 05/24/2015 at 10:44 PM. While the IJ was removed on 05/26/2015 at 6:50 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. The deficient practice affected four (4) residents and placed an additional 45 who receive medications at risk for receiving unnecessary medications which could lead to unidentified drug reactions, changes in health status and death. Findings Include: In an interview on 05/25/2015 at 11:00 AM the Corporate VP stated the Administrator had been separated from the facility on Wednesday, 05/20/2015. The former Administrator was not reached for comment regarding the following: A) Review of Resident #3's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of three (3) indicating he was severely cognitively impaired. He was assessed as totally dependent on one or two staff for all activities of daily living including eating and could not walk and did not leave his room. He was assessed as having contractures of his upper and lower extremities. Resident #3's main source of nutrition/hydration was a PEG tube. Review of Resident #3's Care Plan dated 07/07/2014 and revised on 02/22/2015 reflected a Care Plan for the Diagnoses: [REDACTED]. Interventions included: Give all cardiac medications as ordered by the physician. The care plan also included Resident #3's risk for adverse reaction related to Polypharmacy with the intervention of Review medications with MD/Consulting pharmacist for: duplicate medications or prescriptions, proper dosing, timing and frequency of administration. Review as needed medications in the process. If Resident had more than one prescribing MD, ensure that each physician had the full list of meds available, including over the counter and as needed medications while ordering. a) In an interview on 05/24/2015 at 2:30 PM Resident #3's wife told the surveyor Resident #3 had received doses of [MEDICATION NAME] one (1) gram (used to treat infections caused by [MEDICAL CONDITION] viruses) for which he did not have an order or a [DIAGNOSES REDACTED]. In an interview on 05/24/2015 at 6:30 PM LVN G stated she made a mistake when she received the [MEDICATION NAME] from the pharmacy. LVN G stated she wrote it on the TAR and administered one dose last night and one dose this morning without looking to see if there was a Physician order. Review of Resident #3's May 2015 TAR reflected: [MEDICATION NAME] one (1) gram tablet three times a day X seven (7) days started on 05/23/2015 at 8:00PM by LVN G and was given again on 05/24/2015 at 8:00 AM by LVN G. Review of Resident #3's chart reflected there was no order for [MEDICATION NAME] and no Nurse Notes reflected an order had been requested or received for [MEDICATION NAME] and the Resident did not have any documented symptoms requiring [MEDICATION NAME] treatment. In an interview on 05/24/2015 at 5:10 PM RPh B stated he did not know why the [MEDICATION NAME] had been sent from his pharmacy to Resident #3 but an error had been made. In an interview on 05/24/ at 5:16 PM the DON stated the pharmacy had sent Resident #3 a card of [MEDICATION NAME] one (1) gram by error on 05/23/2015 and LVN G had received the medication from the pharmacy delivery person. The DON stated LVN G wrote the medication instructions from the card of [MEDICATION NAME] on the TAR and administered the medication without a Physician's order and had been counseled regarding the error. (after surveyor intervention) b) Review on 05/24/2015 at 2:30 PM of Resident #3's medications on the LVN/RN treatment cart (which were administered via PEG tube) compared to the May 2015 TAR revealed two (2) cards of [MEDICATION NAME] 75 mg tablets (is used to prevent blood clots after a recent [MEDICAL CONDITION] or stroke) one card sent on 10/05/2014 with three (3) tablets remaining and one card sent on 04/23/2015 with five (5) tablets missing, both cards had the instructions to give one tablet daily. The TAR reflected there was no physician order for [REDACTED].>[MEDICATION NAME] inhibits blood clotting and clotting won't return to normal for at least five (5) days after the drug has been stopped. Lippincott Nursing Drug Handbook '06 Review of Resident #3's hospital discharge orders dated 04/29/2015 reflected: there was no order for [MEDICATION NAME] 75 mg and Resident #3 was to take Xarelto 20 mg daily (used to prevent blood clots) and Aspirin 81 mg daily (used to prevent blood clots) Xarelto - (anti-coagulant) that reduces blood clotting and can cause bleeding which rarely may lead to death www.xarelto-us.com. Review of Resident #3's handwritten admission orders [REDACTED]. The orders were transcribed and signed by the ADON. In an interview on 05/24/2015 at 6:30 PM LVN G stated she had given Resident #3 a [MEDICATION NAME] 75 mg that morning. After observing there was no place to sign the TAR for the [MEDICATION NAME], she retracted her statement and said she had not given the [MEDICATION NAME]. In an interview on 05/24/2015 at 7:00 PM with the DON and ADON the ADON stated Resident #3's [MEDICATION NAME] was stopped on 11/13/2014 and he was started on Xarelto. The DON stated Resident #3's [MEDICATION NAME] should have been pulled off the cart at that time and he should not have received the five (5) missing doses. In an interview on 05/26/2015 at 2:30 PM LVN I stated she did not administer the [MEDICATION NAME] because it is scheduled for the morning round and day shift gives it. In an interview on 05/26/2015 at 6:00PM the DON stated Resident #3 should not have been getting [MEDICATION NAME] and Xarelto at the same time and it could increased his risk for hematomas (bleeding under the skin). 05/26/2015 at 5:15 PM the facility Consultant Pharmacist stated the [MEDICATION NAME] should not have been administered without a doctors' order and bleeding can occur with either one of those medications alone so taking them together increased the risk for bleeding. In an interview on 05/24/2015 at 7:35 PM Resident #3's Primary MD stated it was absolutely a concern that Resident #3 was receiving [MEDICATION NAME] and Xarelto and he could not think of a [DIAGNOSES REDACTED].#3 to be on both medications. The Primary MD further stated he had not yet been made aware that Resident #3 had received [MEDICATION NAME] two doses which had not been ordered. The Primary MD stated he absolutely has a concern regarding Resident #3 having multiple issues with his medications not being administered according to the orders. c) In an observation on 05/24/2015 at 2:30PM of Resident #3's medications on the LVN/RN treatment cart (which were administered via PEG tube) compared to review of the May 2015 TAR revealed: · [MEDICATION NAME] 25 mg tablets (used to treat high blood pressure) broken in half and packaged as 12.5 mg halves in each bubble with the instructions to give one (1) half tablet two times a day with no directions change sticker attached. Thirty four [MEDICATION NAME] 12.5 mg half tablets had been administered since it was filled on 05/01/2015. The TAR reflected to give one and a half tablets to equal 37.5 mg twice a day.; and · One (1) card of [MEDICATION NAME] 0.5 mg (used to treat anxiety) tablets filled on 04/24/2015 with the instructions to give one tablet by mouth three times a day routinely with no directions change sticker attached and one (1) card of [MEDICATION NAME] 0.5 mg tablets cut in half with the directions of give a half tablet to equal 0.25 mg by mouth every eight (8) hours as needed filled on 11/22/2014 with no directions change sticker. The TAR reflected to give one (1)-one (1) mg tablet three times a day as needed. Review of Resident #3's hospital discharge orders dated 04/29/2015 reflected an order for [REDACTED]. Review of Resident #3's handwritten admission orders [REDACTED]½ tabs of 25 mg twice a day (which equals 37.5 mg) and [MEDICATION NAME] 1.0 mg three times a day as needed. The orders were transcribed and signed by the ADON. Review of Resident #3's handwritten admission orders [REDACTED]give ½ tab of 25 mg twice a day which equals 12.5 mg at each dose. There was not a one (1) in front of the ½ symbol. There was a discrepancy in the handwritten admission orders [REDACTED]. The orders provided by the facility had a 1 in front of the 1/2 (handwritten) and the orders provided by the pharmacy (faxed to them by the facility) only had the 1/2 handwritten. Review of Resident #3's May 2015 TAR reflected the LVN staff was signing for administering one (1) and a half tabs of 25 mg [MEDICATION NAME] to equal 37.5 mg twice a day. In an interview on 05/26/2015 at 2:30 PM LVN D stated Resident #3 used to get one (1)and a half tablets of 25 mg [MEDICATION NAME] but now LVN D only gives half a tablet of [MEDICATION NAME] 25 mg (12.5 mg) at a time. In an interview on 05/26/2015 at 3:25 PM RPh C stated when Resident #3 returned to the facility on [DATE] the admission orders [REDACTED]. On 04/09/2015 the pharmacy sent [MEDICATION NAME] 25 mg packaged as one (1) and a half tablets in each blister (37.5 mg). On 04/29/2015 we sent one (1) half tablet in each blister (12.5 mg). RPh C stated the pharmacy did not clarify with the facility and the facility did not clarify with the pharmacy regarding the proper dosage. In an interview on 05/26/2015 at 4:20 PM the ADON stated she had clearly made an error when transcribing Resident #3's [MEDICATION NAME] order to the handwritten order sheet when she left the one (1) off of the one (1) and a half tablet segment of the order. The ADON stated the pharmacy and none of the nurses had told her of the confusion and she would have expected the nurses or the pharmacy to question the change. At a later interview the ADON stated she did not write the 1 in front of the 1/2 on the order when the surveyor showed her the difference between what the facility had provided to the survey team and what the pharmacy had provided to the survey team. The ADON stated she did not know who wrote the 1 but would like to know because somebody wrote it on her orders. Review of Resident #3's count sheet for [MEDICATION NAME] 0.5 mg tablets reflected one tablet was administered on 05/01/2015 at 7:00 AM by an LVN that no longer worked at the facility during the survey. Review of Resident #3's count sheet for [MEDICATION NAME] 0.5 mg tablets which were broken in half to equal 0.25 mg reflected one 0.25 mg tablet was administered on 05/03/2014 at 8:30 PM by LVN B and one 0.25 mg tablet was administered on 05/24/2015 at 3:20 AM by LVN C. Review of Resident #3's May 2015 TAR reflected: The ex-employee that administered the 0.5 mg tablet did not document on the TAR that she had administered any [MEDICATION NAME] and LVN B and LVN C whom each had administered the 0.25 mg doses did not document on the TAR that any [MEDICATION NAME] had been administered. Review of Resident #3's Nurse Notes did not reveal [MEDICATION NAME] had been administered or why a lower than prescribed dose of [MEDICATION NAME] had been given. In an interview on 05/26/2015 at 6:00PM the DON stated there was no system for catching the [MEDICATION NAME] error and she would have expected the pharmacist to call and clarify the change. The DON stated she expected the staff to give one (1) mg of [MEDICATION NAME] even if they had to give two (2) half- tablets to equal one (1) mg of [MEDICATION NAME]. She stated she expected the nursing staff to have removed the [MEDICATION NAME] 0.25 mg tablets off the cart and for them to question the changes and variations in what the MAR indicated [REDACTED]. After having been shown the discrepancy between the orders the facility provided to the surveyor and the orders the pharmacy provided to the surveyor, the DON stated she did not know who wrote the 1 in front of the 1/2 on the physician order. In an interview on 05/24/2015 at 7:35 PM Resident #3's Primary MD stated he expected the staff to administer [MEDICATION NAME] one (1) mg as ordered. The Primary MD stated he was not as concerned about Resident #3 receiving [MEDICATION NAME] 12.5 mg twice a day instead of 37.5 mg twice a day since it was used to control blood pressure only and not used as a cardiac medication in this case. He further stated he had not yet been made aware that Resident #3 had received [MEDICATION NAME] two doses which had not been ordered and stated he was aware the wife had some concerns several weeks ago about whether Resident #3 was actually receiving the [MEDICAL CONDITION] medication as prescribed since the medication level was so low (Resident #3 returned from the hospital on [DATE] with the Diagnosis: [REDACTED].#3 having multiple issues with his medications not being administered according to the orders and he expected changes to be made. In a later interview on 05/27/2015 at 1:30 PM Resident # 3's Primary MD stated he did not realize the facility was only monitoring the Resident's blood pressure periodically. Review of Resident #3's telephone order dated 05/24/2015 (after surveyor intervention) reflected an order to discontinue [MEDICATION NAME] 1.0 mg three times a day as needed, start [MEDICATION NAME] 0.5 mg three times a day as needed and discontinue [MEDICATION NAME] 37.5 mg twice a day and start [MEDICATION NAME] 25 mg twice a day, and CBC and CMP on next available lab draw date. A telephone order dated 05/25/2015 reflected an order to routinely check Resident #3's blood pressure and pulse daily at 8:00 AM and 8:00 PM. B) Review of Resident #10's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Coli Unspecified, Hyposmolality, [MEDICAL CONDITIONS], Acute [MEDICAL CONDITION], Urinary Tract Infection, Diarrhea, Difficulty Walking and Unspecified Vitamin Deficiency. Review of Resident #10's Annual MDS assessment dated [DATE] reflected a readmission on 03/13/2015 from an acute care hospital. Resident #10 was assessed as having no difficulty hearing, seeing or communicating and his BIMS score was 15 indicating he was cognitively intact. He was assessed as having no mood or behavior problems and it was very important for him to express his daily preferences as an individual. Resident #10 was assessed as requiring extensive assistance of one to two people for his activities of daily living. Review of Resident #10's Care Plan dated 10/17/2013 and updated on 12/05/2014 reflected there was no Care Plan that included Nausea and Vomiting or [MEDICATION NAME] (a medication to treat nausea or vomiting that has a sedating effect). Resident #10 had a Care Plan for Depression with an intervention of administer medications as ordered. In an observation on 05/25/2015 at 12:00 PM during a MAR indicated [REDACTED]. Ten (10) tablets were missing from the card. Review of Resident #10's May 2015 MAR indicated [REDACTED]. Review of Resident #10's Discharge Orders from the hospital dated 03/13/2015 reflected there was not an order for [REDACTED].>Review of Resident # 10's Physician Orders reflected no order had been written for [MEDICATION NAME] since the Resident's return from the hospital on [DATE]. Review of Resident #10's hand written readmission orders [REDACTED]. Review of Resident #10's Hospital Encounter form dated 05/20/2015 reflected a current medications list that did not include [MEDICATION NAME]. Review of Resident #10's Nurse Notes dated 04/15/2015 thru 05/23/2015 reflected no complaints of nausea or vomiting and no documentation of [MEDICATION NAME] being given. Review of Resident #10's daily Documentation dated 03/22/2015 thru 03/30/2015 for an infection and subsequent IV antibiotics reflected no complaints of nausea or vomiting. Review of the facility Pharmacy Reorder fax dated 03/24/2015 reflected the [MEDICATION NAME] 25 mg tablets with Resident #10's name on them were reordered by MA M. In an interview on 05/26/2015 at 1:35 PM MA M stated Resident #10's [MEDICATION NAME] tablets on her cart were as needed only and she had never given any. MA M stated she did not know who administered Resident # 10 [MEDICATION NAME]. Review of Resident #10's May 2015 Nursing TAR reflected an entry: [MEDICATION NAME] ([MEDICATION NAME]) by mouth Dose: 25 mg per milliliter (liquid for injection) give 25 mg Intramuscularly (a shot) every eight (8) hours as needed for nausea and vomiting. There were no signatures on the TAR reflecting any type of [MEDICATION NAME] by mouth or by injection had been administered. Review of Resident #10's Consolidated Physician Orders printed on 05/05/2015 reflected an order: [MEDICATION NAME] ([MEDICATION NAME]) by mouth Dose: 25 mg per milliliter Solution PO (By mouth) - as needed: Give 25 mg intramuscularly (a shot) every eight (8) hours as needed for nausea and vomiting. In an interview on 05/26/2015 at 1:15 PM LVN F, Charge Nurse stated Resident #10 returned from the hospital on [DATE] and again on 05/20/2015 without an order for [REDACTED].#10 [MEDICATION NAME], didn't know who gave them to him because there was no documentation and Resident #10 should not have been given [MEDICATION NAME]. She stated when the nurse wrote the admission orders [REDACTED]. In an interview on 05/26/2015 at 2:20 PM LVN F stated when a resident returned from the hospital the nurses removed only medications that specifically had a discontinuation order, medications no longer listed on the orders were not removed from the cart. LVN F stated they should have been removed and that is how the staff has been instructed to do it in the future. (after surveyor intervention) In an interview on 05/26/2015 at 2:30 PM LVN I stated she had seen Resident #10's [MEDICATION NAME] on the cart but she had never given him any. In an interview on 05/26/2015 at 4:09 PM the ADON agreed the [MEDICATION NAME] should have been taken out of the computer and off the cart when Resident #10 readmitted on [DATE] and the medication should not have been reordered. The ADON stated she is responsible for checking the physician orders against the MAR indicated [REDACTED]. In an interview on 05/26/2015 at 6:00 PM the DON stated she couldn't know for sure who gave the [MEDICATION NAME] to Resident #10 and that he shouldn't have received it. The DON stated she would be more observant of the MARS and carts and the errors were putting residents at risk for having adverse reactions. In an interview on 05/27/2015 at 1:30 PM Resident #10's Primary MD stated he was extremely concerned about Resident # 10 having received 10 doses of [MEDICATION NAME] without a physician order because recent studies proved giving [MEDICATION NAME] to elderly could be harmful. The Primary MD stated if somebody needed ten (10) nausea pills he needed to know about it because there could have been something else going on besides nausea. C) Review of Resident #2's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #2s' Annual MDS assessment dated [DATE] reflected a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed as having no mood or behavior indicators and the Interview for Daily Preferences reflected every choice was very important to her. Resident #2 was assessed as requiring extensive to total assistance of staff in every ADL except eating. Review of Resident #2's Care Plan dated 09/12/2013 with updates reflected a Care Plan for [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], and Depression. The Depression Care Plan reflected an intervention of Medications per physician orders. Resident #2's Care Plan listed 12 medications she was allergic to. She had a Care Plan for [MEDICAL CONDITION] medications and was at risk for complications Interventions included Administer medications as ordered and consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Review of Resident #2's Consolidated Physician Orders printed on 05/05/2015 reflected an order for [REDACTED]. Review of Resident #2's handwritten orders dated 02/23/2015 reflected, [MEDICATION NAME] ([MEDICATION NAME]) 50 mg tablet 25 mg one by mouth every day. Review of Resident #2's Pharmacy Consultant Recommendation reflected a recommendation dated 12/03/2014 asking the MD to consider a trial dosage reduction of [MEDICATION NAME] to 25 mg per day. The Primary MD agreed and singed the form on 12/09/2014. The order was noted on 12/11/2014. Review of Resident #2's MAR indicated [REDACTED]. MA M administered Resident #2's [MEDICATION NAME] routinely on the day shift and signed the MAR. Review of Resident #2's [MEDICATION NAME] on the medication cart reflected a card of whole [MEDICATION NAME] 50 mg tablets. In an interview on 05/26/2015 at 10:41 AM MA M stated she had never broken Resident #2's [MEDICATION NAME] 50 mg tablets in half when she administered them. MA M stated she had always administered the whole tablet. In an interview on 05/26/2015 at 11:19 AM RPh C stated each time he filled Resident #2's [MEDICATION NAME] prescription he had sent whole [MEDICATION NAME] 50 mg tablets and had not been made aware there was a dosage reduction to 25 mg in December 2014. He stated he had sent 30 day supply refills of the [MEDICATION NAME] 50 MG tablets on 01/26/2015, 02/23/2015, 04/14/2015 and 05/11/2015. Review of the facility provided Medication Error Form dated 05/25/2015 at 5:00 PM reflected Resident #2 had been receiving [MEDICATION NAME] 50 mg tablets instead of the [MEDICATION NAME] 25 mg tablets ordered. The form did not specify Resident #2 had received [MEDICATION NAME] 50 Mg from 12/10/2014 until surveyor intervention on 05/25/2015. The form was signed by the DON. In an interview on 05/26/2015 at 6:00 PM the DON stated she would expect the MAR indicated [REDACTED]. In an interview on 05/26/2015 at 5:15 PM the facility Consultant Pharmacist stated he would have expected Resident #2's [MEDICATION NAME] dose to have been lowered in December 2014 when the Physician signed the Recommendation Form to lower the dose. The Consultant Pharmacist stated he does check the carts quarterly but had not seen that Resident # 2's [MEDICATION NAME] was being administered at the wrong dosage. The Consultant Pharmacist stated he felt there needed to be additional training to facility staff and could not say where the system failed. In an interview on 05/26/2015 at 2:20 PM LVN F stated when a resident returned from the hospital the nurses removed only medications that specifically had a discontinuation order, medications no longer listed on the orders were not removed from the cart. LVN F stated they should have been removed and that is how the staff has been instructed to do it in the future. (after surveyor intervention) D) Review of Resident #5's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected he could not speak, could not be understood and usually understood others. He could not be interviewed and had short and long term memory problems. Resident # 5 was totally dependent on staff for all ADLs and had a PEG tube to maintain nutrition and hydration. Review of Resident #5's Care Plan reflected he was totally dependent on staff for every ADL and his needs were anticipated. Review of Resident #5's Consolidated Physician orders dated 05/05/2015 reflected: Vitamin D 2,000 unit tablet (vitamin D is essential for healthy bones and a lack of Vitamin D can lead to health problems, including cardiovascular disease) everyday give two (2) tablets once daily. Review of Resident #5's May 2015 MAR indicated [REDACTED]of 1,000. Observation and Interview on 05/25/2015 at 1:43 PM reflected Resident #5 's Charge Nurse RN E stated he gave Resident #5 two (2) capsules of Vitamin D 1,000 IU daily. The medication cart only had Vitamin D 1,000 unit capsules on it. In an interview on 05/25/2015 at 2:00PM RN E stated he had pulled the original order from the files at surveyors request and Resident #5 should have been getting Vitamin D 4,000 IU since 11/03/2013. He stated low Vitamin D levels can affect bone health. Review of Resident #5's original admission Telephone Orders dated 11/03/2013 reflected an order for [REDACTED].>Review of Resident #5's hand written admission orders [REDACTED]. In an interview on 05/26/2015 at 4:09 PM the ADON stated she did not put the orders in the computer when Resident #5 was admitted but would have expected the total dose of 4,000 IU to have been entered so that Resident #5 would have received 4,000 IU of Vitamin D daily. Review of Resident #5's telephone orders reflected a new order dated 05/24/2015 at 10:10 PM for Vitamin D 2,000 IU give two (2) tablets of 1,000 IU daily. (after surveyor intervention) In an interview on 05/24/2015 at 7:00 PM the ADON stated the facility Consultant Pharmacist visited on 05/11/2015, and his routine was to come early in the morning and be gone by the time she got to work. The ADON stated the facility Consultant Pharmacist did not do a MAR indicated [REDACTED] In an interview on 05/24/2015 at 7:00 PM the DON stated she expected the LVNs to remove discontinued drugs off the carts and place them in the discontinued drugs cabinet. In an interview on 05/26/2015 at 5:15 PM the facility Pharmacy Consultant stated he did a MAR indicated [REDACTED]. The Consultant Pharmacist stated he was not sure where the facility pharmacy system had broken down but felt the staff required additional training. In an interview on 05/24/2015 at 9:30 PM the DON and ADON stated when a Resident discharged to a hospital all the medications remained on the carts in anticipation of the Resident's return. When Residents returned with new orders, the Charge Nurse or the ADON should write the new hand written order sheet according to the new orders. The ADON put the order changes in the computer and printed out new MARS and TARS. No one was responsible to review the ADON entries to determine the orders were correctly put in the computer upon reentry. The DON and ADON both stated the charge nurses were responsible for making sure any medications no longer on the orders were removed from both carts and placed in the discontinued drug cabinet. The DON and ADON stated no one was assigned to see if the Charge Nurse correctly removed all discontinued medications from the carts. The ADON reviewed what she had in the computer according to the chart at the end of every month, no other person was assigned to review the entries. The DON stated auditing the carts for discontinued medications and comparing the MAR/TAR to the orders was not part of the monthly review performed by the facility's contracted RPh. The DON stated the Charge Nurse didn't have a system in place to make sure the cart was clear of discontinued drugs and added the DON/ADON did not check behind the nurses and it was ultimately the responsibility of the DON to make sure the Residents received medications as ordered by the physician. In an interview on 05/26/2015 at 6:00 PM the DON stated she could not figure out why the staff were administering medications without orders. She stated it was a systems failure in the facility when medications errors were not being caught and the Pharmacist should have been calling to question medication order changes. The DON stated Resident

Based on observation, interview and record review the facility failed to ensure four (4) (Residents #10, #3, #2 and #5) of nine (9) residents reviewed for medications received pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. A) a) Until surveyor intervention, the facility continued to periodically administer Plavix 75 mg five (5) times to Resident #3 after the medication was discontinued on 11/13/2014 in addition to the physician ordered Xarelto. Both Plavix and Xarelto have a blood thinning effect and could cause excessive bleeding. b) The facility obtained and administered two (2) Valtrex one (1) gram doses without a physician's order. Resident #3 received Lorazepam 0.5 mg once and Lorazepam 0.25 mg twice while an order for [REDACTED]. c) Resident # 3 received Coreg 12.5 mg twice a day from 05/01/2015 while an order for [REDACTED]. B) The facility re-ordered and administered ten (10) doses of Promethazine 25 mg to Resident #10 after the medication had been discontinued on 03/14/2015. C) The facility continued to administer Zoloft 50 mg tablets to Resident #2 after the physician ordered a dose reduction to Zoloft 25 mg on 12/11/14. Surveyor intervened and facility began the Zoloft 25 mg daily. D) Resident #5 received an order on admission on 11/03/2013 for Vitamin D 4,000 IU daily and he received Vitamin D 2,000 IU daily until surveyor intervened and the order was changed on 05/24/2015 to Vitamin D 2,000 IU daily. This resulted in an Immediate Jeopardy (IJ) on 05/24/2015 at 10:44 PM. While the IJ was removed on 05/26/2015 at 6:50 PM, the facility remained out of compliance at a severity of potential for more than minimal harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. The deficient practice affected four (4) residents and placed an additional 45 who receive medications at risk for receiving unnecessary medications which could lead to unidentified drug reactions, changes in health status and death. Findings Include: A) Review of Resident #3's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of three (3) indicating he was severely cognitively impaired. He was assessed as totally dependent on one or two staff for all activities of daily living including eating and could not walk and did not leave his room. He was assessed as having contractures of his upper and lower extremities. Resident #3's main source of nutrition/hydration was a PEG tube. Review of Resident #3's Care Plan dated 07/07/2014 and revised on 02/22/2015 reflected a Care Plan for the Diagnoses: [REDACTED]. Interventions included: Give all cardiac medications as ordered by the physician. The care plan also included Resident #3's risk for adverse reaction related to Polypharmacy with the intervention of Review medications with MD/Consulting pharmacist for: duplicate medications or prescriptions, proper dosing, timing and frequency of administration. Review as needed medications in the process. If Resident had more than one prescribing MD, ensure that each physician had the full list of meds available, including over the counter and as needed medications while ordering. a) In an interview on 05/24/2015 at 2:30 PM Resident #3's wife told the surveyor Resident #3 had received doses of Valtrex one (1) gram (used to treat infections caused by herpes viruses) for which he did not have an order or a [DIAGNOSES REDACTED]. In an interview on 05/24/2015 at 6:30 PM LVN G stated she made a mistake when she received the Valtrex from the pharmacy. LVN G stated she wrote it on the TAR and administered one dose last night and one dose this morning without looking to see if there was a Physician order. Review of Resident #3's May 2015 TAR reflected: Valtrex one (1) gram tablet three times a day X seven (7) days started on 05/23/2015 at 8:00PM by LVN G and was given again on 05/24/2015 at 8:00 AM by LVN G. Review of Resident #3's chart reflected there was no order for Valtrex and no Nurse Notes reflected an order had been requested or received for Valtrex and the Resident did not have any documented symptoms requiring Valtrex treatment. In an interview on 05/24/2015 at 5:10 PM RPh B stated he did not know why the Valtrex had been sent from his pharmacy to Resident #3 but an error had been made. In an interview on 05/24/ at 5:16 PM the DON stated the pharmacy had sent Resident #3 a card of Valtrex one (1) gram by error on 05/23/2015 and LVN G had received the medication from the pharmacy delivery person. The DON stated LVN G wrote the medication instructions from the card of Valtrex on the TAR and administered the medication without a Physician's order and had been counseled regarding the error. (after surveyor intervention) b) Review on 05/24/2015 at 2:30 PM of Resident #3's medications on the LVN/RN treatment cart (which were administered via PEG tube) compared to the May 2015 TAR revealed two (2) cards of Plavix 75 mg tablets (is used to prevent blood clots after a recent heart attack or stroke) one card sent on 10/05/2014 with three (3) tablets remaining and one card sent on 04/23/2015 with five (5) tablets missing, both cards had the instructions to give one tablet daily. The TAR reflected there was no physician order for [REDACTED]. Plavix inhibits blood clotting and clotting won't return to normal for at least five (5) days after the drug has been stopped. Lippincott Nursing Drug Handbook '06 Review of Resident #3's hospital discharge orders dated 04/29/2015 reflected: there was no order for Plavix 75 mg and Resident #3 was to take Xarelto 20 mg daily (used to prevent blood clots) and Aspirin 81 mg daily (used to prevent blood clots) Xarelto - (anti-coagulant) that reduces blood clotting and can cause bleeding which rarely may lead to death www.xarelto-us.com. Review of Resident #3's handwritten admission orders [REDACTED]. The orders were transcribed and signed by the ADON. In an interview on 05/24/2015 at 6:30 PM LVN G stated she had given Resident #3 a Plavix 75 mg that morning. After observing there was no place to sign the TAR for the Plavix, she retracted her statement and said she had not given the Plavix. In an interview on 05/24/2015 at 7:00 PM with the DON and ADON the ADON stated Resident #3's Plavix was stopped on 11/13/2014 and he was started on Xarelto. The DON stated Resident #3's Plavix should have been pulled off the cart at that time and he should not have received the five (5) missing doses. In an interview on 05/26/2015 at 2:30 PM LVN I stated she did not administer the Plavix because it is scheduled for the morning round and day shift gives it. In an interview on 05/26/2015 at 6:00PM the DON stated Resident #3 should not have been getting Plavix and Xarelto at the same time and it could increased his risk for hematomas (bleeding under the skin). 05/26/2015 at 5:15 PM the facility Consultant Pharmacist stated the Plavix should not have been administered without a doctors' order and bleeding can occur with either one of those medications alone so taking them together increased the risk for bleeding. In an interview on 05/24/2015 at 7:35 PM Resident #3's Primary MD stated it was absolutely a concern that Resident #3 was receiving Plavix and Xarelto and he could not think of a [DIAGNOSES REDACTED].#3 to be on both medications. The Primary MD further stated he had not yet been made aware that Resident #3 had received Valtrex two doses which had not been ordered. The Primary MD stated he absolutely has a concern regarding Resident #3 having multiple issues with his medications not being administered according to the orders. c) In an observation on 05/24/2015 at 2:30PM of Resident #3's medications on the LVN/RN treatment cart (which were administered via PEG tube) compared to review of the May 2015 TAR revealed: · Coreg 25 mg tablets (used to treat high blood pressure) broken in half and packaged as 12.5 mg halves in each bubble with the instructions to give one (1) half tablet two times a day with no directions change sticker attached. Thirty four Coreg 12.5 mg half tablets had been administered since it was filled on 05/01/2015. The TAR reflected to give one and a half tablets to equal 37.5 mg twice a day.; and · One (1) card of Lorazepam 0.5 mg (used to treat anxiety) tablets filled on 04/24/2015 with the instructions to give one tablet by mouth three times a day routinely with no directions change sticker attached and one (1) card of Lorazepam 0.5 mg tablets cut in half with the directions of give a half tablet to equal 0.25 mg by mouth every eight (8) hours as needed filled on 11/22/2014 with no directions change sticker. The TAR reflected to give one (1)-one (1) mg tablet three times a day as needed. Review of Resident #3's hospital discharge orders dated 04/29/2015 reflected an order for [REDACTED]. Review of Resident #3's handwritten admission orders [REDACTED]½ tabs of 25 mg twice a day (which equals 37.5 mg) and Ativan 1.0 mg three times a day as needed. The orders were transcribed and signed by the ADON. Review of Resident #3's handwritten admission orders [REDACTED]give ½ tab of 25 mg twice a day which equals 12.5 mg at each dose. There was not a one (1) in front of the ½ symbol. There was a discrepancy in the handwritten admission orders [REDACTED]. The orders provided by the facility had a 1 in front of the 1/2 (handwritten) and the orders provided by the pharmacy (faxed to them by the facility) only had the 1/2 handwritten. Review of Resident #3's May 2015 TAR reflected the LVN staff was signing for administering one (1) and a half tabs of 25 mg Coreg to equal 37.5 mg twice a day. In an interview on 05/26/2015 at 2:30 PM LVN D stated Resident #3 used to get one (1)and a half tablets of 25 mg Coreg but now LVN D only gives half a tablet of Coreg 25 mg (12.5 mg) at a time. In an interview on 05/26/2015 at 3:25 PM RPh C stated when Resident #3 returned to the facility on [DATE] the admission orders [REDACTED]. On 04/09/2015 the pharmacy sent Coreg 25 mg packaged as one (1) and a half tablets in each blister (37.5 mg). On 04/29/2015 we sent one (1) half tablet in each blister (12.5 mg). RPh C stated the pharmacy did not clarify with the facility and the facility did not clarify with the pharmacy regarding the proper dosage. In an interview on 05/26/2015 at 4:20 PM the ADON stated she had clearly made an error when transcribing Resident #3's Coreg order to the handwritten order sheet when she left the one (1) off of the one (1) and a half tablet segment of the order. The ADON stated the pharmacy and none of the nurses had told her of the confusion and she would have expected the nurses or the pharmacy to question the change. At a later interview the ADON stated she did not write the 1 in front of the 1/2 on the order when the surveyor showed her the difference between what the facility had provided to the survey team and what the pharmacy had provided to the survey team. The ADON stated she did not know who wrote the 1 but would like to know because somebody wrote it on her orders. Review of Resident #3's count sheet for Lorazepam 0.5 mg tablets reflected one tablet was administered on 05/01/2015 at 7:00 AM by an LVN that no longer worked at the facility during the survey. Review of Resident #3's count sheet for Lorazepam 0.5 mg tablets which were broken in half to equal 0.25 mg reflected one 0.25 mg tablet was administered on 05/03/2014 at 8:30 PM by LVN B and one 0.25 mg tablet was administered on 05/24/2015 at 3:20 AM by LVN C. Review of Resident #3's May 2015 TAR reflected: The ex-employee that administered the 0.5 mg tablet did not document on the TAR that she had administered any Lorazepam and LVN B and LVN C whom each had administered the 0.25 mg doses did not document on the TAR that any Lorazepam had been administered. Review of Resident #3's Nurse Notes did not reveal Lorazepam had been administered or why a lower than prescribed dose of Lorazepam had been given. In an interview on 05/26/2015 at 6:00PM the DON stated there was no system for catching the Coreg error and she would have expected the pharmacist to call and clarify the change. The DON stated she expected the staff to give one (1) mg of Lorazepam even if they had to give two (2) half- tablets to equal one (1) mg of Lorazepam. She stated she expected the nursing staff to have removed the Lorazepam 0.25 mg tablets off the cart and for them to question the changes and variations in what the MAR said and what was on the cart. After having been shown the discrepancy between the orders the facility provided to the surveyor and the orders the pharmacy provided to the surveyor, the DON stated she did not know who wrote the 1 in front of the 1/2 on the physician order. In an interview on 05/24/2015 at 7:35 PM Resident #3's Primary MD stated he expected the staff to administer Lorazepam one (1) mg as ordered. The Primary MD stated he was not as concerned about Resident #3 receiving Coreg 12.5 mg twice a day instead of 37.5 mg twice a day since it was used to control blood pressure only and not used as a cardiac medication in this case. He further stated he had not yet been made aware that Resident #3 had received Valtrex two doses which had not been ordered and stated he was aware the wife had some concerns several weeks ago about whether Resident #3 was actually receiving the seizure medication as prescribed since the medication level was so low (Resident #3 returned from the hospital on [DATE] with the Diagnosis: [REDACTED].#3 having multiple issues with his medications not being administered according to the orders and he expected changes to be made. In a later interview on 05/27/2015 at 1:30 PM Resident # 3's Primary MD stated he did not realize the facility was only monitoring the Resident's blood pressure periodically. Review of Resident #3's telephone order dated 05/24/2015 (after surveyor intervention) reflected an order to discontinue Ativan 1.0 mg three times a day as needed, start Ativan 0.5 mg three times a day as needed and discontinue Coreg 37.5 mg twice a day and start Coreg 25 mg twice a day, and CBC and CMP on next available lab draw date. A telephone order dated 05/25/2015 reflected an order to routinely check Resident #3's blood pressure and pulse daily at 8:00 AM and 8:00 PM. B) Review of Resident #10's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Coli Unspecified, Hyposmolality, Morbid Obesity, Congestive Heart Failure, Acute Respiratory Failure, Urinary Tract Infection, Diarrhea, Difficulty Walking and Unspecified Vitamin Deficiency. Review of Resident #10's Annual MDS assessment dated [DATE] reflected a readmission on 03/13/2015 from an acute care hospital. Resident #10 was assessed as having no difficulty hearing, seeing or communicating and his BIMS score was 15 indicating he was cognitively intact. He was assessed as having no mood or behavior problems and it was very important for him to express his daily preferences as an individual. Resident #10 was assessed as requiring extensive assistance of one to two people for his activities of daily living. Review of Resident #10's Care Plan dated 10/17/2013 and updated on 12/05/2014 reflected there was no Care Plan that included Nausea and Vomiting or Promethazine (a medication to treat nausea or vomiting that has a sedating effect). Resident #10 had a Care Plan for Depression with an intervention of administer medications as ordered. In an observation on 05/25/2015 at 12:00 PM during a MAR to cart medication comparison, it was noted Resident #10 had a card of 30 Promethazine 25 mg tablets refilled on 03/24/2015. Ten (10) tablets were missing from the card. Review of Resident #10's May 2015 MAR reflected Promethazine 25 mg was not listed as a medication to be given. Review of Resident #10's Discharge Orders from the hospital dated 03/13/2015 reflected there was not an order for [REDACTED]. Review of Resident # 10's Physician Orders reflected no order had been written for Promethazine since the Resident's return from the hospital on [DATE]. Review of Resident #10's hand written readmission orders [REDACTED]. Review of Resident #10's Hospital Encounter form dated 05/20/2015 reflected a current medications list that did not include Promethazine. Review of Resident #10's Nurse Notes dated 04/15/2015 thru 05/23/2015 reflected no complaints of nausea or vomiting and no documentation of Promethazine being given. Review of Resident #10's daily Documentation dated 03/22/2015 thru 03/30/2015 for an infection and subsequent IV antibiotics reflected no complaints of nausea or vomiting. Review of the facility Pharmacy Reorder fax dated 03/24/2015 reflected the Promethazine 25 mg tablets with Resident #10's name on them were reordered by MA M. In an interview on 05/26/2015 at 1:35 PM MA M stated Resident #10's Promethazine tablets on her cart were as needed only and she had never given any. MA M stated she did not know who administered Resident # 10 Promethazine. Review of Resident #10's May 2015 Nursing TAR reflected an entry: Phenergan (Promethazine) by mouth Dose: 25 mg per milliliter (liquid for injection) give 25 mg Intramuscularly (a shot) every eight (8) hours as needed for nausea and vomiting. There were no signatures on the TAR reflecting any type of Phenergan by mouth or by injection had been administered. Review of Resident #10's Consolidated Physician Orders printed on 05/05/2015 reflected an order: Phenergan (Promethazine) by mouth Dose: 25 mg per milliliter Solution PO (By mouth) - as needed: Give 25 mg intramuscularly (a shot) every eight (8) hours as needed for nausea and vomiting. In an interview on 05/26/2015 at 1:15 PM LVN F, Charge Nurse stated Resident #10 returned from the hospital on [DATE] and again on 05/20/2015 without an order for [REDACTED]. LVN F stated she had not given Resident #10 Promethazine, didn't know who gave them to him because there was no documentation and Resident #10 should not have been given Promethazine. She stated when the nurse wrote the admission orders [REDACTED]. In an interview on 05/26/2015 at 2:20 PM LVN F stated when a resident returned from the hospital the nurses removed only medications that specifically had a discontinuation order, medications no longer listed on the orders were not removed from the cart. LVN F stated they should have been removed and that is how the staff has been instructed to do it in the future. (after surveyor intervention) In an interview on 05/26/2015 at 2:30 PM LVN I stated she had seen Resident #10's Promethazine on the cart but she had never given him any. In an interview on 05/26/2015 at 4:09 PM the ADON agreed the Promethazine should have been taken out of the computer and off the cart when Resident #10 readmitted on [DATE] and the medication should not have been reordered. The ADON stated she is responsible for checking the physician orders against the MAR at the end of each month but she did not catch this error because she does not physically look at medications on the cart. In an interview on 05/26/2015 at 6:00 PM the DON stated she couldn't know for sure who gave the Promethazine to Resident #10 and that he shouldn't have received it. The DON stated she would be more observant of the MARS and carts and the errors were putting residents at risk for having adverse reactions. In an interview on 05/27/2015 at 1:30 PM Resident #10's Primary MD stated he was extremely concerned about Resident # 10 having received 10 doses of Promethazine without a physician order because recent studies proved giving Promethazine to elderly could be harmful. The Primary MD stated if somebody needed ten (10) nausea pills he needed to know about it because there could have been something else going on besides nausea. C) Review of Resident #2's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #2s' Annual MDS assessment dated [DATE] reflected a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed as having no mood or behavior indicators and the Interview for Daily Preferences reflected every choice was very important to her. Resident #2 was assessed as requiring extensive to total assistance of staff in every ADL except eating. Review of Resident #2's Care Plan dated 09/12/2013 with updates reflected a Care Plan for Seizure Disorder, [DIAGNOSES REDACTED], and Depression. The Depression Care Plan reflected an intervention of Medications per physician orders. Resident #2's Care Plan listed 12 medications she was allergic to. She had a Care Plan for Psychotropic medications and was at risk for complications Interventions included Administer medications as ordered and consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Review of Resident #2's Consolidated Physician Orders printed on 05/05/2015 reflected an order for [REDACTED]. Review of Resident #2's handwritten orders dated 02/23/2015 reflected, Sertraline (Zoloft) 50 mg tablet 25 mg one by mouth every day. Review of Resident #2's Pharmacy Consultant Recommendation reflected a recommendation dated 12/03/2014 asking the MD to consider a trial dosage reduction of Zoloft to 25 mg per day. The Primary MD agreed and singed the form on 12/09/2014. The order was noted on 12/11/2014. Review of Resident #2's MAR reflected an order Zoloft 25 mg give one tablet of 25 mg by mouth daily. MA M administered Resident #2's Zoloft routinely on the day shift and signed the MAR. Review of Resident #2's Zoloft on the medication cart reflected a card of whole Zoloft 50 mg tablets. In an interview on 05/26/2015 at 10:41 AM MA M stated she had never broken Resident #2's Zoloft 50 mg tablets in half when she administered them. MA M stated she had always administered the whole tablet. In an interview on 05/26/2015 at 11:19 AM RPh C stated each time he filled Resident #2's Zoloft prescription he had sent whole Zoloft 50 mg tablets and had not been made aware there was a dosage reduction to 25 mg in December 2014. He stated he had sent 30 day supply refills of the Zoloft 50 MG tablets on 01/26/2015, 02/23/2015, 04/14/2015 and 05/11/2015. Review of the facility provided Medication Error Form dated 05/25/2015 at 5:00 PM reflected Resident #2 had been receiving Zoloft 50 mg tablets instead of the Zoloft 25 mg tablets ordered. The form did not specify Resident #2 had received Zoloft 50 Mg from 12/10/2014 until surveyor intervention on 05/25/2015. The form was signed by the DON. In an interview on 05/26/2015 at 6:00 PM the DON stated she would expect the MAR to match the cards and would have expected the nurses and the Consultant Pharmacist to question why they did not match. In an interview on 05/26/2015 at 5:15 PM the facility Consultant Pharmacist stated he would have expected Resident #2's Zoloft dose to have been lowered in December 2014 when the Physician signed the Recommendation Form to lower the dose. The Consultant Pharmacist stated he does check the carts quarterly but had not seen that Resident # 2's Zoloft was being administered at the wrong dosage. The Consultant Pharmacist stated he felt there needed to be additional training to facility staff and could not say where the system failed. In an interview on 05/26/2015 at 2:20 PM LVN F stated when a resident returned from the hospital the nurses removed only medications that specifically had a discontinuation order, medications no longer listed on the orders were not removed from the cart. LVN F stated they should have been removed and that is how the staff has been instructed to do it in the future. (after surveyor intervention) D) Review of Resident #5's Face Sheet reflected a [AGE] year old male admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected he could not speak, could not be understood and usually understood others. He could not be interviewed and had short and long term memory problems. Resident # 5 was totally dependent on staff for all ADLs and had a PEG tube to maintain nutrition and hydration. Review of Resident #5's Care Plan reflected he was totally dependent on staff for every ADL and his needs were anticipated. Review of Resident #5's Consolidated Physician orders dated 05/05/2015 reflected: Vitamin D 2,000 unit tablet (vitamin D is essential for healthy bones and a lack of Vitamin D can lead to health problems, including cardiovascular disease) everyday give two (2) tablets once daily. Review of Resident #5's May 2015 MAR reflected the entry: Vitamin D Dose: 2,000 units everyday give two (2) tablets once daily, handwritten was the entry of 1,000. Observation and Interview on 05/25/2015 at 1:43 PM reflected Resident #5 's Charge Nurse RN E stated he gave Resident #5 two (2) capsules of Vitamin D 1,000 IU daily. The medication cart only had Vitamin D 1,000 unit capsules on it. In an interview on 05/25/2015 at 2:00PM RN E stated he had pulled the original order from the files at surveyors request and Resident #5 should have been getting Vitamin D 4,000 IU since 11/03/2013. He stated low Vitamin D levels can affect bone health. Review of Resident #5's original admission Telephone Orders dated 11/03/2013 reflected an order for [REDACTED]. Review of Resident #5's hand written admission orders [REDACTED]. In an interview on 05/26/2015 at 4:09 PM the ADON stated she did not put the orders in the computer when Resident #5 was admitted but would have expected the total dose of 4,000 IU to have been entered so that Resident #5 would have received 4,000 IU of Vitamin D daily. Review of Resident #5's telephone orders reflected a new order dated 05/24/2015 at 10:10 PM for Vitamin D 2,000 IU give two (2) tablets of 1,000 IU daily. (after surveyor intervention) In an interview on 05/24/2015 at 7:00 PM the ADON stated the facility Consultant Pharmacist visited on 05/11/2015, and his routine was to come early in the morning and be gone by the time she got to work. The ADON stated the facility Consultant Pharmacist did not do a MAR to cart comparison. In an interview on 05/24/2015 at 7:00 PM the DON stated she expected the LVNs to remove discontinued drugs off the carts and place them in the discontinued drugs cabinet. In an interview on 05/26/2015 at 5:15 PM the facility Pharmacy Consultant stated he did a MAR to cart comparison quarterly and he typically hasn't found any errors to question the nurses about and that it was unusual for that to happen. The Consultant Pharmacist stated he was not sure where the facility pharmacy system had broken down but felt the staff required additional training. In an interview on 05/24/2015 at 9:30 PM the DON and ADON stated when a Resident discharged to a hospital all the medications remained on the carts in anticipation of the Resident's return. When Residents returned with new orders, the Charge Nurse or the ADON should write the new hand written order sheet according to the new orders. The ADON put the order changes in the computer and printed out new MARS and TARS. No one was responsible to review the ADON entries to determine the orders were correctly put in the computer upon reentry. The DON and ADON both stated the charge nurses were responsible for making sure any medications no longer on the orders were removed from both carts and placed in the discontinued drug cabinet. The DON and ADON stated no one was assigned to see if the Charge Nurse correctly removed all discontinued medications from the carts. The ADON reviewed what she had in the computer according to the chart at the end of every month, no other person was assigned to review the entries. The DON stated auditing the carts for discontinued medications and comparing the MAR/TAR to the orders was not part of the monthly review performed by the facility's contracted RPh. The DON stated the Charge Nurse didn't have a system in place to make sure the cart was clear of discontinued drugs and added the DON/ADON did not check behind the nurses and it was ultimately the responsibility of the DON to make sure the Residents received medications as ordered by the physician. In an interview on 05/26/2015 at 6:00 PM the DON stated she could not figure out why the staff were administering medications without orders. She stated it was a systems failure in the facility when medications errors were not being caught and the Pharmacist should have been calling to question medication order changes. The DON stated Resident #10's Promethazine should not have been on the cart or given. The DON stated she expected the medication cards to match the MAR and the staff to give the correct dosages. The DON stated she could not remember ever talking to the facility Consultant Pharmacist about a medication error he had caught. In an interview on 05/27/2015 at 1:30 PM the Medical Director stated administering Promethazine to the elderly had a potential for harm and that if his patient needed ten (10) Promethazine he would definitely want to know about it. The Medical Director stated administering Resident #3's Plavix along with Xarelto could have a potential for harm. As far as his expectations for the facility systems the Medical Director stated he expected more people to get invol

Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality for one (1) of one (1) Treatment LVN reviewed for skin assessments and wound care for one (1) of three (3) residents (Resident #2), and one (1) of one (1) DON for skin assessment monitoring when: A) The Treatment Nurse and DON failed identify or assess, and notify the physcian of Resident #2's left and right buttock wounds. Resident #2's entire left buttock to upper left thigh revealed an area of Moisture-associated skin damage (MASD) with multiple open full thickness wounds. Resident #2's right buttock and upper thigh revealed an area of MASD with multiple open full thickness wounds. B) The Treatment Nurse and DON failed to accurately identify, assess and notify the physician of an unstageable pressure ulcer to Resident #2's coccyx and Stage III pressure ulcer to Resdient # 2's sacral and right buttock area. The Treatment Nurse failed to provide infection control practices while performing wound care on Resident #2. C) The Treatment Nurse and DON failed to idenitfy or assess a pressure ulcer to Resident #1's left lower distal leg and a Stage III pressure ulcer to Resident # 1's lower distal leg. The Treatment Nurse failed to provide infection control practices while performing wound care on Resident #1. D) The Treatment Nurse failed to provide infection control practices while performing care on Resident #3's pressure ulcers. This deficient practice affected one (1) residents (Resident #2) and placed 11 residents with wounds at risk for wounds not being assessed, a decline in wounds, infection, and pain. Findings Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. A) Resident #2 Face Sheet reflected a [AGE] year old female who entered the facility on 03/26/2007 and most recently readmitted on [DATE]. Resident # 2's [DIAGNOSES REDACTED]. Review of Resident # 2's most recent Quarterly MDS assessment dated [DATE] reflected the Resident had a BIMS score of 10 and indicated moderate cognitive impairment. The assessment reflected Resident # 2 did not have pressure sores but did have Moisture Associated Skin Damage (MASD) and the only skin and ulcer treatments was a pressure reducing device for the bed. Review of Resident # 2's Comprehensive Care Plan reflected a plan of care dated 11/20/2014 for the Resident had actual impairment to skin integrity and does not let staff turn and reposition every two (2) hours. "Hospice recommends the skin issues are Kennedy Ulcers". Interventions included to avoid scratching and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [REDACTED]. to MD. Treatment as ordered. Observation on 01/21/2015 at 11:00 AM revealed Resident # 2 was in bed, awake and stated she was ok. Resident # 2 was not very talkative during this observation/interview. Review of the latest weekly skin report dated 01/13/2015 reflected Resident # 2 had the following skin issues: Deep Tissue Injury (DTI) of Left Foot Lower Back Pressure Ulcer, Stage II Left heel Pressure Ulcer, Stage II There was no record of Resident # 2's large area of MASD on her buttocks. Review of Resident # 2's Physician Orders reflected an order dated 08/04/2014 for "may apply happy hiney cream to peri/anal area every shift PRN redness - PRN PRN." Review of Resident # 2's Physician Order dated 01/12/2015 reflected an order for [REDACTED]. Review of Resident # 2's weekly skin assessments from 10/28/2014 through 11/18/2014 reflected the assessment revealed "escoriation" (a scratch or abrasion on the skin) to the entire buttocks. There was no record of MASD. Review of the weekly skin assessments from 11/25/2014 through 01/21/2015 for Resident # 2 reflected the facility was assessing the area as a Stage II pressure sore with macerated skin surrounding. The area grew from 4.7 cm x 3.8 cm x 0.2 on 11/25/2014 to 12.6 cm x 11 cm x 0.5 on 01/21/2015. The assessment dated [DATE] reflected there had been a decline to skin integrity and Resident # 2 was seen by a Hospice RN the morning of 01/21/2015. There was no notation of the severity of the MASD and no evidence of Resident # 2's physician being notified of the decline in the wound. In an interview on 01/21/2015 at 4:00 PM the Treatment Nurse would not answer the questions regarding if she reported Resident # 2's decline in the Resident's skin integrity to her physician. The Treatment Nurse could not tell the surveyor which physician to report Resident # 2's decline, the Hospice physician or the Resident's Primary Care Physician. The Treatment Nurse stated several times, Resident # 2 was on Hospice now. Review of a notification to Resident # 2's Primary Care Physician regarding a decline in skin integrity was provided to the surveyor on 01/22/2015. The note to the physician reflected "Resident skin integrity continues to decline. Remains on hospice Care. Family aware, will monitor." The note's fax was dated 01/22/2015 at 08:12. Observation on 01/22/2015 at 2:15 PM revealed the Treatment Nurse in Resident #2's room .Resident #2's entire left buttock to upper left thigh revealed an area of Moisture-associated skin damage (MASD) with multiple open full thickness wounds. Resident #2's right buttock and upper thigh revealed an area of MASD with multiple open full thickness wounds. The Treatment Nurse cleansed the Stage III and unstageable pressure with normal saline moist gauze going across the wound from the outside edges. The Treatment Nurse then applied Triad paste over the Stage III and Unstageable pressure sores and applied two (2) ABD pads and taped them to the wound over the upper right buttocks area of MASD which was actively bleeding. The Treatment Nurse did not wash her hands or change gloves between sites. Surveyor asked the Treatment Nurse if there was a treatment for [REDACTED].?" The Surveyor asked the Treatment Nurse if there was a physician order for [REDACTED]. Review of the Website: <http://www.ncbi.nlm.nih.gov/pubmed/ 547>: reflected: "Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION], periwound moisture-associated [MEDICAL CONDITION], and [MEDICATION NAME] moisture-associated [MEDICAL CONDITION] ...To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown. Review of the Website http://woundconsultant.com/sitebuilder/DOCUMENTATION.pdf reflected: Full Thickness- tissue destruction extending thru the dermis to involve subcutaneous tissue and possibly bone and muscle. In an interview on 1/22/2015 at 3:35 PM the Treatment Nurse stated she should clean one wound at a time and should not clean over three (3) wounds. The Treatment Nurse stated she had not notified the physician of Resident # 2's MASD and did not have a order to treat. In an interview on 1/22/2015 at 3:55 PM the DON stated each pressure ulcer should be cleansed separately and treated separately to prevent contamination of the wounds. The DON stated she expected the Treatment Nurse to notify the Physician of all wounds, including MASD. In an interview on 01/22/2015 at 3:45 PM the Hospice Nurse who had assessed Resident # 2 on 01/15/2015 stated he had not notified the Hospice physician at this point anything regarding Resident # 2, including the MASD to her buttocks and thigh. In an interview on 01/22/2015 at 4:00 PM Resident #2's Physician stated Resident #2 has been declining and is now on hospice. Resident #2's Physician stated he did not see Resident #2's wounds last week. Resident #2's Physician stated the nurses needed to treat the parts of the wounds and if one area has a different tissue type they need to treat it differently and if the wound changes the Physician should be notified. Resident #2's Physician stated the nurses should notify hospice of changes now that she is on hospice. Resident #2's Physician stated in regards to hospice "The left hand does not know what the right hand is doing." Resident #2's Physician, after looking at a photo provided to him that reflected Resident # 2's wounds and MASD surrounding the wounds, stated he did not know about the areas of MASD. In an interview on 01/26/2015 at 1:45 PM the DON stated there was not a policy specific to MASD. B) Review of the Weekly Skin Assessments for Resident # 2's facility acquired lower back pressure sore reflected the following: ? 10/28/2014 through 11/18/2014 - Excoriation to entire buttocks. ? 11/19/2014 - Stage II pressure sore measuring 4.2 cm x 2.8 cm x 0.3 cm with slough, facility acquired. This wound had been debrided by a physician on this date and since it had slough should have been categorized as a Stage III. Review of the <http://www.woundsource.com/article/identifying-types-tissues-found-pressure-ulcers> website reflected "Slough- Slough is indicative of full-thickness Stage 3 pressure ulcers or stage 4 pressure ulcers. In an interview on 01/22/2015 at 4:00 PM the Wound Care Physician stated the wound on Resident # 2 was not escoriation, it had slough and that is why he debrided it. Further review of the Weekly Skin Assessments for Resident # 2's facility acquired lower back pressure sore reflected the following: ? 11/25/2014 - Stage II pressure sore measuring 4.7 cm x 3.8 cm x 0.2 cm with Epitheal tissue. (This should have been categorized as a Stage III) ? 12/02/2014 - Stage II pressure sore measuring 10.0 cm x 3.4 cm x 0.2 cm with Epitheal Tissue. Physician Notified and wound care changed. (This should have been categorized as a Stage III) ? 12/08/2014 - Stage II pressure sore measuring 11.5 cm x 5.8 cm x 0.2 cm with [MEDICATION NAME] Tissue. Physician was not notified and wound care was not changed. (This should have been categorized as a Stage III) ? 12/16/2014 - Stage II pressure sore measuring 6.0 cm x 9.0 cm x 0.2 cm with [MEDICATION NAME] tissue. Appeared the wound improved. (This should have been categorized as a Stage III) ? 12/30/2014 - Stage II pressure sore measuring 7.0 cm x 9.1 cm x 0.3 cm with [MEDICATION NAME] tissue. Physician not notified and wound care was not changed. (This should have been categorized as a Stage III) ? 01/05/2015 - Stage II pressure sore measuring 10.0 cm x 11.0 cm x 0.4 cm with [MEDICATION NAME] tissue. Physician was not notified and wound care was not changed. (This should have been categorized as a Stage III) ? 01/12/2015 - Stage II pressure sore measuring 9.8 cm x 11.2 cm x 0.4 cm with [MEDICATION NAME] tissue. Treatment was changed. (This should have been categorized as a Stage III) Review of Resident # 2's Physician Order dated 01/12/2015 reflected a change in treatment to the lower back pressure ulcer of clean with Normal Saline, pat dry. Apply Triad Paste to open area. Cover with water proof dressing each day and as needed. Review of the weekly skin assessment dated [DATE] reflected Resident # 2 had a Stage IV Pressure Ulcer to her lower back. The measurements were 12.6 cm x 11.0 cm x 0.5 cm. It was documented to have slough, the execute was moderate, bloody and opaque. The wound had mild odor. The assessment reflected Resident # 2 remained non-compliant with turning and repositioning per staff and continued to request to lay on her back. There was an increased decline to skin integrity. The assessment reflected Resident # 2 was seen by the Hospice nurse this day, 01/21/2015 and the wound is now a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) Kennedy Ulcer. The assessment reflected to continue with current treatment and the Resident remained with Hospice services. In an interview on 01/22/2014 at 3:30 PM the Treatment Nurse stated the DON was in charge of staging the wounds. In an interview on 01/22/2014 at 4:05 PM the DON stated the Wound Care Physician staged Resident # 2's wound on 11/19/2014 but she had staged the wound each other time. The DON stated she had mis-staged the wound on several occasions since the wound had greater than 0.2 depth and had slough it should have been a Stage III. The DON stated the physician should have been notified on several occasions when the wound was changing to allow the physician to make a change in wound care. In an interview on 01/21/2015 at 4:00 PM the Treatment Nurse would not answer the questions regarding if she reported Resident # 2's decline in the Resident's skin integrity (documented on the 01/21/2015 assessment) to her physician. The Treatment Nurse could not tell the surveyor which physician to report Resident # 2's decline, the Hospice physician or the Resident's Primary Care Physician. The Treatment Nurse stated several times, Resident # 2 was on Hospice now. The Treatment Nurse was asked how it was determined Resident # 2's pressure sore was a Kennedy Ulcer when she replied the Hospice Nurse had told her it was, it was not diagnosed by a physician. In an interview on 01/22/2015 at 4:30 PM the Hospice RN stated he came in and staged Resident #2's pressure ulcer as a Stage IV on 01/21/2015. The Hospice RN; when asked about the slough covering Resident #2's coccyx area; stated "well we did not clean the wound I thought that was cream." The Hospice RN; when asked if you could stage a pressure ulcer when it is covered in slough; stated no. The Hospice RN stated he had not notified the Hospice physician regarding the pressure ulcer. Review of the http://www.bedsorefaq.com/what-is-a-kennedy-terminal-ulcer/ website reflected: A Kennedy Terminal Ulcer or Kennedy ulcer is a specific type of bed sore (also referred to as pressure sore, pressure ulcer or decubitus ulcer) that is characterized by rapid onset and rapid tissue breakdown. The ' Kennedy Ulcer ' was named after Karen Lou Kennedy-Evans- the nurse who discovered the medical condition. Like most bed sores, Kennedy ulcers are believed to develop due to poor blood circulation that results from unrelieved pressure. However, Kennedy ulcers, differ from other bed sores because of: ? Rapid onset, a wound may go from a blister to stage 4 within hours ? The wounds tend to grow downward, as opposed to horizontally ? The wounds are most often located on the sacrum ? Wounds are almost exclusive to the elderly population ? The wounds are usually irregularly shaped, frequently described as pear shaped ? Death occurs quickly, many patients succumb to kennedy ulcers within 24-48 hours of their onset Review of a notification to Resident # 2's Primary Care Physician dated 01/19/2015 (two days prior to the assessment) regarding a decline in skin integrity was provided to the surveyor on 01/22/2015. The note to the physician reflected "Resident skin integrity continues to decline. Remains on hospice care. Family aware, will monitor." The note's fax was dated 01/22/2015 at 08:12. Observation on 01/22/2015 at 2:15 PM revealed the Treatment Nurse in Resident #2's room to perform treatment to her pressure ulcer. LVN B turned Resident #2 on her side to reveal Resident #2 had a Stage III pressure ulcer approximately 14 cm by 9.5 cm by >0.2 depth extending across her coccyx, sacrum and bilateral upper buttock. The ulcer had irregular beveled edges the ulcer was covered in red granulation tissue which was yellowing in color in the center. Inside the Stage III pressure ulcer from 9 o'clock to 12 o'clock was a 4 cm by 4 cm area over her coccyx that was unstageable (meaning that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black.) The area was covered with yellow slough with the slough graying on the outer edges. The wound edges were actively bleeding from 3 o'clock to six o'clock. The peri-wound was pale pink and macerated extending out approximately 0.5 cm. The Treatment Nurse cleansed the Stage III and unstageable pressure with normal saline moist gauze going across the wound from the outside edges. The Treatment Nurse then applied Triad paste over the entire area. The Treatment Nurse then applied two (2) ABD pads and taped them to the wound. The Treatment Nurse did not wash her hands of change gloves between sites. Review of the <<http://www.woundsource.com/article/identifying-types-tissues-found-pressure-ulcers>> website reflected "Granulation tissue- The formation of granulation tissue is thought to be an intermediate step in the healing process of full-thickness wounds. Wound healing may stall in the granulation phase when nutrients are inadequate, infection is present or blood flow is impaired. " In an interview on 1/22/2015 at 3:35 PM the Treatment Nurse stated she should clean one wound at a time and should not clean over three (3) wounds. In an interview on 1/22/2015 at 3:55 PM the DON stated each pressure ulcer should be cleansed separately and treated separately to prevent contamination of the wounds. In an interview on 01/22/2015 at 4:00 PM Resident #2's Physician stated Resident #2 has been declining and is now on hospice. Resident #2's Physician stated he did not see Resident #2's wounds last week. Resident #2's Physician stated the nurses needed to treat the parts of the wounds and if one area has a different tissue type they need to treat it differently and if the wound changes the Physician should be notified. Resident #2's Physician stated the nurses should notify hospice of changes now that she is on hospice. Resident #2's Physician stated in regards to hospice "The left hand does not know what the right hand is doing." When Resident #2's Physician was asked if the Triad Paste was an appropriate treatment for [REDACTED]. In an interview on 01/23/2015 at 1:45 PM Resident # 2's Physician had a print out from the internet regarding Triad Paste and stated he was wrong on the day before. The Physician stated Triad Paste is an appropriate treatment for [REDACTED]. C) Review of Resident #1's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] reflected that Resident #1 was assessed to have a BIMS score of 15 indicating Resident #1 was cognitively intact. Resident #1 was assessed to require extensive to dependent assist of two staff for all ADL activities. Resident #1 was assessed to be at risk of developing pressure ulcers and was assessed to not have any pressure sores. Review of Resident #1's Comprehensive Care Plan reflected a problem dated 01/05/2014 "has actual impairment of skin integrity r/t BLE (bilateral lower extremities) and leg rest, re-current Achilles wound." The plan of care interventions included "monitor skin per MD orders, Treatment as ordered, and use of protective air boots to legs ..." Review of Resident #1's Consolidated Physician Orders dated 01/21/2015 reflected an order dated 08/25/2014 "Left lower distal leg- apply wet to dry dressing then foam padding, wrap with conform and secure with coban daily." In an interview on 01/22/2015 at 10:15 AM Resident #1 stated he had a sore on his left leg. Resident #1 stated the Treatment Nurse took good care it. Resident #1 stated he had pain in his sore at times and the Nurses gave him medication for the pain. Review of the Facility's Skin Report dated 01/13/2015 reflected Resident #1 had one (1) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough.) pressure ulcer to his left lower distal leg that was 1.3 cm by 1.3 cm by 0.1 cm. Review of Resident #1's Weekly Wound Assessment form/ Plan of Care dated 01/21/2015 reflected Resident #1 had a 1.0 cm by 1.0 cm by 0.1 cm Stage II pressure ulcer on this left lower distal leg with a macerated peri-wound and light exudate. The pressure ulcers tissue type was described as [MEDICATION NAME]. Further review of Resident #1's weekly wound assessment forms reflected no other pressure ulcers documented. Review of the website: <http://www.mcknights.com/ask-the-treatment-expert-defining-the-tissue-types-seen-in-pressure-ulcers/article/ 5/>: reflected "[MEDICATION NAME]: deep pink to pearly pink. The outermost layer of our skin is composed of [MEDICATION NAME] cells. As wounds heal, [MEDICATION NAME] cells regenerate across the wound surface from the edges to close the wound. [MEDICATION NAME] is seen in stage II or greater pressure ulcers." Observation on 01/22/2015 at 10:35 AM revealed the Treatment Nurse in Resident #1's room to perform a treatment to his left lower distal leg pressure ulcer. The Treatment Nurse removed a dressing to Resident #1's Achilles tendon area to reveal two (2) Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. There may include undermining and tunneling) pressure ulcers. The proximal Stage III pressure ulcer was approximately 0.5 cm by 0.5 cm no depth was noted related to the hyper-granulation of the ulcer. The distal Stage III pressure ulcer on Resident #1's Achilles tendon area; separated from the proximal ulcer by a 0.5 cm skin bridge; was approximately 2.0 cm by 2.0 cm no depth was noted related to the hyper-granulation of the ulcer. Both pressure ulcers contained the same amount of granulation tissue indicating both ulcers healed at the same rate. No signs of infection were present in the pressure ulcer. The Treatment Nurse, with normal saline moist gauze, cleansed over both pressure ulcers. The Treatment Nurse then placed a normal saline moist gauze over both pressure ulcers and covered the ulcers with a foam dressing and then wrapped Resident #1's lower leg with conform gauze and coban ( is a elastane bandage. The fabric is coated with a self-adherent substance that gives the bandage the ability to stick to itself but not to skin or clothing). (Approximations by Surveyor) Review of the Website: <http://www.hopkinsmedicine.org/gec/series/wound_care.html> "Hyper-granulation (proud flesh) may occur in wounds that are healing by second intention. This aberrant response represents overgrowth of fibroblasts and endothelial cells, and it is clinically recognized by its beefy, friable, red appearance. These highly vascular [MEDICAL CONDITION] resemble pyogenic [DIAGNOSES REDACTED] on histologic analysis, and they bleed easily. The presence of this tissue results in the inhibition of fibroblast proliferation and prevents wound healing. Treatment consists of destruction of the hyper-granulation tissue by cautery, shave excision, aluminum chloride, or curettage." Review of the Website: <http://www.hopkinsmedicine.org/gec/series/wound_care.html> "Granulation Tissue; Pink/red, moist tissue that contains new blood vessels, collagen, fibroblasts, and [MEDICAL CONDITION] cells, which fills an open, previously deep wound when it starts to heal." In an interview on 01/22/2015 the DON stated she should have staged Resident # 1's wound as a Stage III pressure sore. In an interview on 1/22/2015 at 3:35 PM the Treatment Nurse stated she should clean one wound at a time and should not clean over two wounds. The Treatment Nurse then stated she did not clean over both of Resident #1's pressure ulcers because Resident #1 only had one (1) pressure ulcer. The Treatment Nurse further stated she does not stage the pressure ulcers the DON does the staging. In an interview on 1/22/2015 at 3:50 PM the Treatment Nurse stated she went the DON to assess Resident #1's left lower leg. The Treatment Nurse and DON stated there were in fact two (2) Stage III pressure ulcers. When asked how she missed the pressure ulcer the Treatment Nurse stated she would've had to get on the floor to see it. In an interview on 1/22/2015 at 3:55 PM the DON stated each pressure ulcer should be cleansed separately and treated separately to prevent contamination of the wounds. D) Review of Resident #3's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #3's 14 day MDS reflected Resident #3 was assessed to have a five (5) BIMS score indicating he had severe cognitive impairment. Resident #3 was assessed to require extensive, two staff member assist with the ADLs of bed mobility, transfer, dressing, and personal hygiene. Resident #3 was assessed to be dependent on staff for bathing. Resident #3 was assessed to be frequently incontinent of bowel and bladder. Resident #3 was assessed to have two (2) Stage II pressure ulcers. The two (2) Stage II pressure ulcers were assessed to have worsened since last assessment. Review of Resident #3's Physician Orders reflected an order dated 01/22/2015 clean pressure ulcers right upper buttock, right mid buttock and right upper buttock outer aspect with normal saline pat dry apply silvamed gel and cover with [MEDICATION NAME] dressing and change every three (3) days. Review of Resident #3's Physician Orders reflected an order dated 01/22/2015 clean pressure ulcers right upper buttock, right mid buttock and right upper buttock outer aspect with normal saline pat dry apply silvamed gel and cover with [MEDICATION NAME] dressing and change every three (3) days. Observation on 01/22/2015 at 10:14 AM revealed the Treatment Nurse in Resident #3's room to preform wound care to his pressure ulcers. The Treatment Nurse using a saline moist gauze cleansed over all three (3) of Resident #3's pressure ulcers starting on the outside of the wounds and going across all the wounds. The Treatment Nurse then applied silversorb gel to all three (3) wounds using the same applicator. In an interview on 1/22/2015 at 3:35 PM the Treatment Nurse stated she should clean one wound at a time and should not clean over three (3) wounds. In an interview on 1/22/2015 at 3:55 PM the DON stated each pressure ulcer should be cleansed separately and treated separately to prevent contamination of the wounds. Review of the facility policy regarding Pressure Ulcer: Prevention, Assessment and Treatment Protocol dated 2003 and revised 01/30/09 reflected: "It is the policy of this Facility to provide a standardized treatment protocol for pressure sore identification and treatment. A standardized treatment protocol provides consistency of care, prevents tissue breakdown, stimulates circulation to areas of potential breakdown, reduces infection and promotes healing... 6. Nursing Action/Rationale: 1. (11) Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily... 2. Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure ulcer according to the following descriptions of different stages; Note: If wound involves necrotic tissue, staging cannot be confirmed until wound base is visible. Therefore these wounds would be un-stageable. Staging definitions are per the guidelines of the National Pressure Ulcer Advisory Panel February 2007 definitions. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, wit

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for one (1) of six (6) residents (Resident #2) reviewed for skin assessments and wound treatments. The Treatment Nurse failed to notify Resident #2's physician when the entire left buttock to upper left thigh revealed an area of Moisture-associated skin damage (MASD) with multiple open full thickness wounds. Resident #2's right buttock and upper thigh revealed an area of MASD with multiple open full thickness wounds. This deficient practice affected one (1) residents (Resident #2) and placed an additional 11 residents with wounds at risk for development of infection, pain and worsening of current wounds. Findings Include: Resident #2 Face Sheet reflected a [AGE] year old female who entered the facility on 03/26/2007 and most recently readmitted on [DATE]. Resident # 2's [DIAGNOSES REDACTED]. Review of Resident # 2's most recent Quarterly MDS assessment dated [DATE] reflected the Resident had a BIMS score of 10 and indicated moderate cognitive impairment. The assessment reflected Resident # 2 did have Moisture Associated Skin Damage (MASD) and the only skin and ulcer treatments was a pressure reducing device for the bed. Review of Resident # 2's Comprehensive Care Plan reflected a plan of care dated 11/20/2014 for the Resident had actual impairment to skin integrity and does not let staff turn and reposition every two (2) hours. "Hospice recommends the skin issues are Kennedy Ulcers". Interventions included to avoid scratching and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [REDACTED]. to MD. Treatment as ordered. Observation on 01/21/2015 at 11:00 AM revealed Resident # 2 was in bed, awake and stated she was ok. Resident # 2 was not very talkative during this observation/interview. Review of the latest weekly skin report dated 01/13/2015 reflected Resident # 2 had the following skin issues: Deep Tissue Injury (DTI) of Left Foot Lower Back Pressure Ulcer, Stage II Left heel Pressure Ulcer, Stage II There was no record of Resident # 2's large area of MASD on her buttocks. Review of Resident # 2's Physician order [REDACTED]." Review of Resident # 2's Physician order [REDACTED]. Review of Resident # 2's weekly skin assessments from 10/28/2014 through 11/18/2014 reflected the assessment revealed "escoriation" (a scratch or abrasion on the skin) to the entire buttocks. There was no record of MASD. Review of the weekly skin assessments from 11/25/2014 through 01/21/2015 for Resident # 2 reflected the facility was assessing the area as a Stage II pressure sore with macerated skin surrounding. The area grew from 4.7 cm x 3.8 cm x 0.2 on 11/25/2014 to 12.6 cm x 11 cm x 0.5 on 01/21/2015. The assessment dated [DATE] reflected there had been a decline to skin integrity and Resident # 2 was seen by a Hospice RN the morning of 01/21/2015. There was no notation of the severity of the MASD and no evidence of Resident # 2's physician being notified of the decline in the wound. In an interview on 01/21/2015 at 4:00 PM the Treatment Nurse would not answer the questions regarding if she reported Resident # 2's decline in the Resident's skin integrity to her physician. The Treatment Nurse could not tell the surveyor which physician to report Resident # 2's decline, the Hospice physician or the Resident's Primary Care Physician. The Treatment Nurse stated several times, Resident # 2 was on Hospice now. Review of a notification to Resident # 2's Primary Care Physician regarding a decline in skin integrity was provided to the surveyor on 01/22/2015. The note to the physician reflected "Resident skin integrity continues to decline. Remains on hospice Care. Family aware, will monitor." The note's fax was dated 01/22/2015 at 08:12. Observation on 01/22/2015 at 2:15 PM revealed the Treatment Nurse in Resident #2's room .Resident #2's entire left buttock to upper left thigh revealed an area of Moisture-associated skin damage (MASD) with multiple open full thickness wounds. Resident #2's right buttock and upper thigh revealed an area of MASD with multiple open full thickness wounds. The Treatment Nurse cleansed the Stage III and unstageable pressure with normal saline moist gauze going across the wound from the outside edges. The Treatment Nurse then applied Triad paste over the Stage III and Unstageable pressure sores and applied two (2) ABD pads and taped them to the wound over the upper right buttocks area of MASD which was actively bleeding. The Treatment Nurse did not wash her hands or change gloves between sites. Surveyor asked the Treatment Nurse if there was a treatment for [REDACTED].?" The Surveyor asked the Treatment Nurse if there was a physician order [REDACTED]. Review of the Website: <http://www.ncbi.nlm.nih.gov/pubmed/ 547>: revealed "Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION], periwound moisture-associated [MEDICAL CONDITION], and [MEDICATION NAME] moisture-associated [MEDICAL CONDITION] ...To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown. Review of the Website http://woundconsultant.com/sitebuilder/DOCUMENTATION.pdf reflected: Full Thickness- tissue destruction extending thru the dermis to involve subcutaneous tissue and possibly bone and muscle. In an interview on 1/22/2015 at 3:35 PM the Treatment Nurse stated she should clean one wound at a time and should not clean over three (3) wounds. The Treatment Nurse stated she had not notified the physician of Resident # 2's MASD and did not have a order to treat. In an interview on 1/22/2015 at 3:55 PM the DON stated each pressure ulcer should be cleansed separately and treated separately to prevent contamination of the wounds. The DON stated she expected the Treatment Nurse to notify the Physician of all wounds, including MASD. In an interview on 01/22/2015 at 3:45 PM the Hospice Nurse who had assessed Resident # 2 on 01/15/2015 stated he had not notified the Hospice physician at this point anything regarding Resident # 2, including the MASD to her buttocks and thigh. In an interview on 01/22/2015 at 4:00 PM Resident #2's Physician stated Resident #2 has been declining and is now on hospice. Resident #2's Physician stated he did not see Resident #2's wounds last week. Resident #2's Physician stated the nurses needed to treat the parts of the wounds and if one area has a different tissue type they need to treat it differently and if the wound changes the Physician should be notified. Resident #2's Physician stated the nurses should notify hospice of changes now that she is on hospice. Resident #2's Physician stated in regards to hospice "The left hand does not know what the right hand is doing." Resident #2's Physician, after looking at a photo provided to him that reflected Resident # 2's wounds and MASD surrounding the wounds, stated he did not know about the areas of MASD. In an interview on 01/26/2015 at 1:45 PM the DON stated there was not a policy specific to MASD. The facility provided a list of 12 residents who required wound care.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of six (6) residents (Resident #2) reviewed for skin assessments and wound treatments. Resident #2's entire left buttock to upper left thigh revealed an area of Moisture-associated skin damage (MASD) with multiple open full thickness wounds. Resident #2's right buttock and upper thigh revealed an area of MASD with multiple open full thickness wounds. The Treatment Nurse, failed to identify, assess, and notify the physician the wounds on Resident #2's left and right buttock wounds. This deficient practice affected one (1) residents (Resident #2) and placed an additional 11 residents with wounds at risk for development of infection, pain and worsening of current wounds. Findings Include: A) Resident #2's Face Sheet reflected a [AGE] year old female who entered the facility on 03/26/2007 and most recently readmitted on [DATE]. Resident # 2's [DIAGNOSES REDACTED]. Review of Resident # 2's most recent Quarterly MDS assessment dated [DATE] reflected the Resident had a BIMS score of 10 and indicated moderate cognitive impairment. The assessment reflected Resident # 2 did have Moisture Associated Skin Damage (MASD) and the only skin and ulcer treatments was a pressure reducing device for the bed. Review of Resident # 2's Comprehensive Care Plan reflected a plan of care dated 11/20/2014 for the Resident had actual impairment to skin integrity and does not let staff turn and reposition every two (2) hours. "Hospice recommends the skin issues are Kennedy Ulcers". Interventions included to avoid scratching and keep hands and body parts from excessive moisture. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols for treatment of [REDACTED]. to MD. Treatment as ordered. Observation on 01/21/2015 at 11:00 AM revealed Resident # 2 was in bed, awake and stated she was ok. Resident # 2 was not very talkative during this observation/interview. Review of the latest weekly skin report dated 01/13/2015 reflected Resident # 2 had the following skin issues: Deep Tissue Injury (DTI) of Left Foot Lower Back Pressure Ulcer, Stage II Left heel Pressure Ulcer, Stage II There was no record of Resident # 2's large area of MASD on her buttocks. Review of Resident # 2's Physician order [REDACTED]." Review of Resident # 2's Physician order [REDACTED]. Review of Resident # 2's weekly skin assessments from 10/28/2014 through 11/18/2014 reflected the assessment revealed "escoriation" (a scratch or abrasion on the skin) to the entire buttocks. There was no record of MASD. Review of the weekly skin assessments from 11/25/2014 through 01/21/2015 for Resident # 2 reflected the facility was assessing the area as a Stage II pressure sore with macerated skin surrounding. The area grew from 4.7 cm x 3.8 cm x 0.2 on 11/25/2014 to 12.6 cm x 11 cm x 0.5 on 01/21/2015. The assessment dated [DATE] reflected there had been a decline to skin integrity and Resident # 2 was seen by a Hospice RN the morning of 01/21/2015. There was no notation of the severity of the MASD and no evidence of Resident # 2's physician being notified of the decline in the wound. In an interview on 01/21/2015 at 4:00 PM the Treatment Nurse would not answer the questions regarding if she reported Resident # 2's decline in the Resident's skin integrity to her physician. The Treatment Nurse could not tell the surveyor which physician to report Resident # 2's decline, the Hospice physician or the Resident's Primary Care Physician. The Treatment Nurse stated several times, Resident # 2 was on Hospice now. Review of a notification to Resident # 2's Primary Care Physician regarding a decline in skin integrity was provided to the surveyor on 01/22/2015. The note to the physician reflected "Resident skin integrity continues to decline. Remains on hospice Care. Family aware, will monitor." The note's fax was dated 01/22/2015 at 08:12. Observation on 01/22/2015 at 2:15 PM revealed the Treatment Nurse in Resident #2's room .Resident #2's entire left buttock to upper left thigh revealed an area of Moisture-associated skin damage (MASD) with multiple open full thickness wounds. Resident #2's right buttock and upper thigh revealed an area of MASD with multiple open full thickness wounds. The Treatment Nurse cleansed the Stage III and unstageable pressure with normal saline moist gauze going across the wound from the outside edges. The Treatment Nurse then applied Triad paste over the Stage III and Unstageable pressure sores and applied two (2) ABD pads and taped them to the wound over the upper right buttocks area of MASD which was actively bleeding. The Treatment Nurse did not wash her hands or change gloves between sites. Surveyor asked the Treatment Nurse if there was a treatment for [REDACTED].?" The Surveyor asked the Treatment Nurse if there was a physician order [REDACTED]. Review of the Website: <http://www.ncbi.nlm.nih.gov/pubmed/ 547>: reflected: "Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection. Multiple conditions may result in MASD; 4 of the most common forms are incontinence-associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION], periwound moisture-associated [MEDICAL CONDITION], and [MEDICATION NAME] moisture-associated [MEDICAL CONDITION] ...To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown. Review of the Website http://woundconsultant.com/sitebuilder/DOCUMENTATION.pdf reflected: Full Thickness- tissue destruction extending thru the dermis to involve subcutaneous tissue and possibly bone and muscle. In an interview on 1/22/2015 at 3:35 PM the Treatment Nurse stated she should clean one wound at a time and should not clean over three (3) wounds. The Treatment Nurse stated she had not notified the physician of Resident # 2's MASD and did not have a order to treat. In an interview on 1/22/2015 at 3:55 PM the DON stated each pressure ulcer should be cleansed separately and treated separately to prevent contamination of the wounds. The DON stated she expected the Treatment Nurse to notify the Physician of all wounds, including MASD. In an interview on 01/22/2015 at 3:45 PM the Hospice Nurse who had assessed Resident # 2 on 01/15/2015 stated he had not notified the Hospice physician at this point anything regarding Resident # 2, including the MASD to her buttocks and thigh. In an interview on 01/22/2015 at 4:00 PM Resident #2's Physician stated Resident #2 has been declining and is now on hospice. Resident #2's Physician stated he did not see Resident #2's wounds last week. Resident #2's Physician stated the nurses needed to treat the parts of the wounds and if one area has a different tissue type they need to treat it differently and if the wound changes the Physician should be notified. Resident #2's Physician stated the nurses should notify hospice of changes now that she is on hospice. Resident #2's Physician stated in regards to hospice "The left hand does not know what the right hand is doing." Resident #2's Physician, after looking at a photo provided to him that reflected Resident # 2's wounds and MASD surrounding the wounds, stated he did not know about the areas of MASD. In an interview on 01/26/2015 at 1:45 PM the DON stated there was not a policy specific to MASD. The facility provided a list of 12 residents who required wound care.

Based on observation, interview and record review the facility failed to provide appropriate treatment and services to maintain or restore normal bladder function and to prevent urinary tract infections for one (1) of three (3) (Residents #4) residents who were reviewed residing in the facility with an indwelling catheter. This deficient practice affected one (1) (Resident # 4) resident and had the potential to affect seven (7) residents' abilities to maintain or regain continence and increased the risk for urinary tract infection that resulted in medical complications [REDACTED]. Findings Include: Review of Resident #4's Face Sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted from acute care hospital on [DATE]. The discharge summary from the hospital dated 11-20-2013 reflected discharge [DIAGNOSES REDACTED]. In an interview on 01/09/13 at 8:30 AM Resident #4 stated that she did not have a catheter when she came to the nursing home. Resident #4 stated she received the catheter when she developed a sore on her skin and was having to go to the bathroom eight times a night and the catheter was inserted for her sores get well. In an interview on 01/09/14 at 3:10 PM the DON stated that she did not know if the facility ever did an assessment on Resident #4's urinary incontinence because she had only worked in the facility for three months. The DON stated that she did not know what kind of condition Resident #4 may have to contribute to the incontinence that originally caused skin problems then followed by placement of the catheter. The DON stated she did not know if Resident #4 had ever been on a prompted void or scheduled toileting program. The DON stated that Resident #4 had a "Foley" when she started working at the facility. The DON stated that she was not sure why, but that some hospitals insert foley catheters and then the nursing homes will leave them in. DON said that she will find out and get back to me with the information. The DON stated she was not sure if Resident #4 had skin breakdown but would find out and report back. In an interview on 01/10/14 at 8:15 AM the DON stated that her team assessed Resident #4 and could not determine why Resident #4 had a catheter. The DON stated that Resident #4 does not have a [DIAGNOSES REDACTED].#4 does not have pressure ulcers anymore. The DON stated that they are working on getting all of the "Foleys" discontinued that are not indicated for each resident and they are working on contacting the doctors now. In an interview on 01/10/14 at 8:30 AM the MDS Coordinator stated that the facility had never done any assessments or monitoring regarding Resident #4's bladder incontinence since her admission to facility. The MDS Coordinator stated that no programs had been implemented or tried to help Resident #4 regain continence of her bladder. MDS Coordinator stated she was unable to identify for sure the reason or underlying condition that clinically warranted that Resident #4 had an indwelling catheter. The MDS Coordinator stated she thought that it may be [MEDICAL CONDITION] or a wound she had, but the wound was now resolved. The MDS Coordinator stated that when a resident has a catheter and the MDS Coordinator was unaware of what the resident has the catheter for, that she follows up with the resident's charge nurse and DON. The MDS Coordinator stated that she reported to the DON that Resident #4 did not have a [DIAGNOSES REDACTED]. The MDS Coordinator stated that the DON reported that the DON would follow-up with the charge nurse on the hall. In an interview on 01/10/14 at 8:40 AM the LVN Reimbursement Nurse from corporate office stated that aside from the RAI Manual instructions for bowel and bladder assessment, that the facility has a 3-day bowel and bladder elimination pattern assessment and that they also have a bowel and bladder retraining program that the facilities are to use. The LVN Reimbursement Nurse stated that they do not claim the programs for reimbursement purposes if a resident was on the program because they do not get paid. The LVN Reimbursement Nurse stated she would print and provide the survey team copies of both forms. Record review of the Bowel and Bladder Retraining Program reflected the following: Purpose: The purpose of the bowel and bladder retraining program is to help the incontinent resident regain his or her ability to control the bowel and bladder excretory functions. To enable the resident to control urination without catheter, if possible. To avoid the possibility of urinary tract infection. To prevent skin irritation and pressure ulcers. To improve the morale of the resident. To restore the residents dignity and respect. To restore optimum level of bladder function. In an interview on 01/10/14 at 8:45 AM the MDS Coordinator stated that she had been trained on the bowel and bladder assessment form and program, but that it was only used on a trial basis. The MDS Coordinator stated the staff were inconsistent with completing the form properly so they stopped using them. The MDS Coordinator stated this was stopped under the direction of her previous DON sometime between February 2013-or early [DATE] and just never started back up. Record review of the Care Plan for Resident #4 reflected the following pressure related ulcers: 05/20/2013-one stage 2 to the left buttocks (reviewed 05/27/13, 06/04/13, 06/10/13, 06/17/13, 06/26/13, 07/04/13, and 07/11/13. 07/18/2013-Area closed 07/22/13-Hospital admission 07/23/13-Readmit from hospital Stage 2-area to left buttocks re-opened 08/10/13-Area healed. 09/03/13-Resident has a pressure ulcer stage 2-coccyx 09/03/13-Resident has pressure ulcer stage 2-right buttocks 09/10/13-both areas on the coccyx and right buttocks are closed. Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #4 had an indwelling catheter. The MDS reflected Resident #4 was always continent of urine. The MDS reflected required extensive assistance with personal hygiene. Record review of SBAR Physician Communication and Progress Note dated on 11/12/13 at 7:00 PM reflected that Resident #4 had dark urine with pus like sediment in the tubing of catheter. The Note reflected the urine was bloody and thick. The Note reflected Resident #4 denied pain and burning. The Note reflected the nurse thought that the problem might be a urinary infection and requested a UA (urinalysis) with C&S (culture and sensitivity) lab. Record review of a Telephone Order on 11/12/13 signed by the physician's RN FNP for Resident #4 reflected that the facility "May collect UA with C&S in AM for lab". Record review of the Laboratory Result performed by Elite Lab Services reflected the following abnormalities of a Urinalysis report on 11/13/2013 for Resident #4: Urinalysis Results Appearance: cloudy Protein: 100 (Reference range is negative to trace) Blood: Large (Reference range is negative) Leukocytes- Moderate (Reference range is negative) White blood cells->50 (Reference range is 0-5) Red blood cells >50 (Reference range is 0-5) Bacteria 2 + (Negative - 1+) Record review of the Laboratory Result performed by Elite Lab Services reflected the following abnormalities of a urine culture and sensitivity final results reported on 11/15/2013 for Resident #4: Organisms growing from specimen are: 1. [MEDICAL CONDITION] >100,000 cfu/ml 2. Escherichia Coli 10,000 - 100,000 cfu/ml 3. [DIAGNOSES REDACTED] Pneumoniae - 10,000 - 100,000 cfu/ml Record review of a Physician's Telephone Order on 11/15/13 reflected that [MEDICATION NAME] (an anti-microbial) 100 mcg (micrograms) every 12 hours for 7 days and encourage fluids be done for Resident #4. Record review of the Nurse's Notes at 5:30 AM on 11/17/13 for Resident #4 reflected "resident to be lethargic, skin warm and dry, level of consciousness responsive-slow. Blood sugar 251. Oxygen saturation 90% reported to oncoming nurse." Record review of the Nurse's Notes at 6:37 AM on 11/17/13 for Resident #4 reflected "went into resident's room, charge nurse and weekend supervisor. BP 101/60 R= 16 P=92 T= 98.9 Oxygen saturation 92% on room air. Resident states she feels fine but skin is pale and she is not eating or taking in fluids adequately. Called MD faxed UA results and C&S to doctor this AM awaiting reply." Record review of the Telephone Order at 5:13 PM on 11/17/13 for Resident # 4 signed by the physician reflected "send resident to the ER to evaluate and treat for increased fever and shaking." Review of the Discharge Summary from the hospital dated 11/20/2013 reflected Resident #4's discharge [DIAGNOSES REDACTED]. The summary from the hospital reflected Resident #4 to be a 93-y/o (year old) female who was admitted to the hospital on [DATE] for urinary tract infection [MEDICAL CONDITION]. The Summary reflected Resident #4 had urine cultures performed at her nursing facility. The Summary reflected Resident #4 had been started on a [MEDICATION NAME] treatment regimen however the patient's infection unfortunately progressed [MEDICAL CONDITION] (systemic bloodstraem infection) and required admission. The Summary reflected Resident #4 was started on IV(antibiotics) [MEDICATION NAME], and Cipro. The Summary reflected Resident #4 also developed acute [MEDICAL CONDITION], which resolved quickly after administration of IV fluid. The Summary reflected that one day after admission the patient was feeling much better and able to be transitioned to oral Bactrim. The Summary reflected that Resident #4 was monitored for an additional night while on Bactrim and tolerated this medication very well. The Summary reflected Resident #4 was stable for discharge back to the facility on [DATE]. The Facility provided CMS Form 672 that listed 7 residents with indwelling catheters.