Every finding on record at Jefferson City Health and Rehab Center

Based on review of facility policies, medical record review, manufacturer recommendations for administration of morphine extended release capsules and tablets, the facility's investigation, including witness statements, emergency medical services (EMS) records, police reports, hospital records and interviews, the facility failed to prevent significant medication errors for 1 resident (Resident #6) of 13 sampled residents. The facility failure occurred on 5/2/2024 when a staff nurse, Licensed Practical Nurse (LPN B) administered the wrong medications to the wrong patient, which included long-acting Morphine Sulfate (a potent opioid narcotic) 30 milligrams (mg) dose, extended release formula, Trazadone (an antidepressant) 200 mg dose, and Ativan 1 mg dose (a benzodiazepine, anxiolytic medication) in crushed form to Resident #6, not prescribed to Resident #6 in error. The error resulted in onset of mental status changes (severe sedation), which required emergency medical services (EMS) intervention and resulted in acute hospitalization of Resident #6, for emergent treatment of narcotic overdose. The facility census at the time of the incident was 142. The facility was cited at F 760 Scope/Severity G (Harm). The facility was cited as past non-compliance. No additional corrective actions are required. The findings include: Review of the facility policy, Medication Administration. revised 1/17/2023, revealed .Identify resident by photo in the MAR (medication administration record) .Compare medication source with MAR to verify resident name, medication name, form, dose, route and time of administration .Administer medication as ordered in accordance with manufacturer specifications .Correct any discrepancies and report to nurse manager . Review of the facility policy, Medication Errors, revised 1/24/2024, revealed .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by ensuring .services .free of significant medication errors .Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescribers order .or accepted professional standards and principals which apply to professionals providing services .The facility will consider factors indicating errors including but not limited to .Incorrect dose, route of administration, dosage, form, time of administration .incorrect medication .crushing do not crush medications .Medication not administered in accordance with professional standards and principals .To prevent medication errors and ensure safe administration, nurses should verify .right resident, right medication, right dose, right route and right time of administration . Adverse drug reactions and significant errors will be reported to the prescriber, director of nursing and pharmacy .These events will be reviewed as part of the facility QAPI (Quality Assurance Performance Improvement Committee Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Atrial Fibrillation, Dysphagia, Acute Kidney Failure, Urinary Tract Infection, Sepsis, Cognitive Communication Deficits and Hypotension. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #6 scored 8 on the brief interview of mental status (BIMS) indicating severe cognitive impairment. Review revealed Resident #6 required assistance of one person for activities of daily living. Review of manufacturer's instructions for safe administration of Extended Release Morphine formulations posted online at the United States Food and Drug Administration (FDA) database, www.FDA.Gov/drugs, revealed a black box warning which read .instruct patients to swallow .whole to avoid exposure to potentially fatal dose of morphine .Instruct patients not to cut, break, chew, crush or dissolve the pellets .capsules to avoid the release and absorption of potentially fatal dose of morphine .Dosage Forms and Strengths .Extended Release Capsules .10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg, 100 mg, 200 mg .Accidental Ingestion .Accidental Ingestion of even one dose .can result in fatal overdose .instruct patients unable to swallow .capsules whole, to sprinkle the capsule contents on applesauce and swallow .crushing, chewing or dissolving the pellets .capsules will result in uncontrolled delivery of morphine and can lead to overdose . Review of the facility's investigation and witness statements dated 5/2-3/2024, revealed on the evening of 5/2/2024 during the nighttime medication pass, between 7:30 PM and 8:30 PM, LPN B pulled medications from the medication cart which were prescribed to another resident, (complaint survey identified as Resident #5, a hospice patient diagnosed with end-stage metastatic Lung Cancer who lived in the room next door to Resident #6) in preparation for administration. After preparing the drugs and placing them in an administration cup in crushed form, LPN B then responded to the call light which had been activated by Resident #6. LPN B mistakenly administered Resident #5's medication to Resident #6. LPN B returned to the medication cart to document medication administration to Resident #6, realized the error when she viewed her computer screen and recognized Resident #5's medication had been pulled from the cart, crushed and given to Resident #6 by mistake. LPN B immediately notified the nursing supervisor (Registered Nurse, RN A) of the error and drugs/dosages given in error. RN A then immediately notified the on-duty house supervisor and the Director of Nursing (DON) and the attending Nurse Practitioner (NP) of the error. The NP issued instructions/verbal orders to monitor Resident #6 every 15 minutes and if signs or symptoms of overdose were detected or any changes in status occurred for Resident #6, administer intranasal Narcan (a narcotic antagonist which reverses side effects of opioids) and transfer Resident #6 to the local hospital. Continued review of the facility's investigation and witness statements revealed around 30 minutes after the medication error occurred, Resident #6 exhibited signs of overdose, was found slumped in her wheelchair unresponsive to sternal rubs or verbal stimuli. Facility staff transferred Resident #6 to the bed, as others sought Narcan for administration. The facility attempted to access Narcan for administration, discovered no intranasal supplies were available and supplies of injectable Narcan, stored in the facility's secured automated drug storage device that dispenses medications, were inaccessible because the recently installed device failed to recognize the biometric identifier (fingerprint) of the authorized users on duty that evening to allow immediate access to the injectable drug. The facility then immediately called 911 and advised EMS of the situation and drug overdose. Review of the EMS run sheet dated 5/2/2024, showed the facility dialed 911 at 8:43 PM. An ambulance was dispatched to the facility at 8:45 PM and arrived to the facility at 8:48 PM. EMS began treating Resident #6 at 8:49 PM, began transport and arrived at the emergency department (ED) at 9:06 PM. Continued review of the EMS run sheet revealed .Dispatched to (facility) .for report of drug overdose .Arrived on scene to find 92 YO (year old) female unresponsive, laying semi-Fowler (head of bed elevated) with slow respirations and radial pulse .pinpoint pupils, staff on scene advised that female was given wrong medication .(200 mg Trazadone, 1 mg of Ativan and 30 mg of Morphine) at 2000 hours (8:00 PM) .Patient was then given 2 mg of Narcan via nasal .female was then transferred to cot .placed in .semi-Fowlers position .Oxygen was then applied at 2/lpm (2 liters per minute) by nasal cannula .4 lead (electrocardiogram) showed female to have A-Fib (atrial fibrillation) with known history .IV (intravenous line) was then established .normal saline was then started at bolus rate .female was now starting to become more alert and was able to open her eyes and trying to speak .Female was then transported non-emergent to (hospital) due to being closest facility .At destination report was given to receiving nurse . Review of the police report created 5/2/2014 at 10:21 PM revealed THE FOLLOWING IS A SUMMARY NOT VERBATIM OR AN ENTIRETY OF MY ACTIONS AND OBSERVATIONS [all caps] .On 5/2/2024 at 20:43 [8:43 PM] I .received a call at [facility] for an overdose .Jefferson County EMS and [NAME] City Fire Department responded to the scene as well .Upon arriving at scene, we were met at the door by nursing home staff who took us back to where the patient was. Nursing home staff was present in the room whenever I arrived at the room .Myself, Sgt (Sergeant) .and Ofc (officer) were all on scene . Continued review revealed .Jefferson County EMS .made contact with the patient [Resident #6] who had been administered [morphine .Lorazepam .trazadone crushed up] by mouth by LPN [LPN B] .[LPN B] was administering medications on this hall as part of her normal routine. [LPN B] was read her [NAME] Rights and was interviewed about the incident . Review of a police report dated 5/6/2024, showed detective notes revealed .Met with facility administrator and several staff members along with nurse on duty and [NP] was advised [LPN B] does not have any disciplinary actions, counseling or negative entries in her personnel file .Based on what was reported by several staff members .[LPN B] immediately notified 3 other nurses/coworkers as soon as she realized the wrong medications had been administered .Based on actions by the nursing staff, including [LPN B] it was determined no neglect or criminal intent or activity occurred This case will be closed as unfounded .I did report the incident to the (State Agency) .They were advised of the results of the investigation as well . Review of hospital records dated 5/2/2024, revealed Resident #6 was evaluated by the physician and underwent extensive workups in response to the incident. The physician documented Chief Complaint .Patient is resident at (facility) .Patient was given wrong medication by staff .received Morphine 30mg, Ativan 1mg, Trazadone 200mg at 8:00 PM .92 Y/O with past medical history of .who comes to us from .after receiving medication intended for another patient .She unfortunately became sedated and unresponsive .have been given Narcan en route with EMS .the drug screen is positive for opiates .patient was placed on Narcan drip in the emergency room .Because of these acute findings, hospital services was contacted for admission . Continued review of the physician note revealed HR 89 monitored, BP 133/78, SPO2 100% General: well appearing in no acute distress .Neurological: withdraws from stimulation, facial grimaces when attempting to check for pupillary responses .Psychiatric: sedated . Continued review of the hospital record showed Resident #6 was admitted to the intensive care unit (ICU) with admitting diagnoses including Drug Overdose, Altered Mental Status, Acute Cystitis without Hematuria, Acute Kidney Injury, Paroxysmal Atrial Fibrillation (chronic condition) Gastroesophageal Reflux Disease (chronic condition) and Hyperglycemia, for continued monitoring and was stabilized. Resident #6 was discharged back to the facility for continued care on 5/4/2024. During telephone interview on 6/5/2025 at 7:17 PM, LPN B recounted the incident in detail. LPN B reported she pulled medications for Resident #5 from the medication cart crushed them, placed them in pill container, then noticed the call light in Resident #6's room activated and heard Resident #6 and her roommate calling out loudly. LPN B reported she carried Resident #5's medications with her to the room to avoid leaving them exposed on the cart. LPN B reported on arrival to Resident #6's room she calmed both residents who were upset with a malfunctioning television remote control, reset the television for Resident #6, then due to the distractions, forgot the medications in her hand weren't those prescribed for Resident #6, and administered them in applesauce to Resident #6 and left the room to return to the medication cart. LPN B reported both Resident #5 and #6 received crushed medications per physician orders and the rooms were beside each other on the unit, and she traditionally gave both residents their medications in sequence nightly. LPN B reported when she returned to her cart to sign off on the administration she realized her error at once when she observed she had Resident #5's photograph, medication administration record and narcotic reconciliation log atop the cart and those medications had been pulled from Resident #5's stocks. LPN B reported she immediately notified her supervisor of the error and in short order notified the prescribing clinician, (NP) who advised to monitor Resident #6 every 15 minutes, administer Narcan if signs of overdose or sedation arose, and then transfer Resident #6 to hospital at once. LPN B reported by that time multiple staff nurses on duty from other wings which included 2 Registered Nurses came to the unit, and assisted the unit manager in monitoring of Resident #6, counting medications on the cart for both residents to verify the error and confirm exactly what was given by mistake. LPN B reported initial checks of Resident #6 showed her vital signs stable and she remained alert. But on the second 15-minute check Resident #6 was found slumped over in the wheelchair and unresponsive by other staff. LPN B reported though she could not recall precise vital signs readings she noted Resident #6's blood pressure had dropped from the prior assessment and stated .it really hit her fast . in reference to the onset of symptoms of overdose. LPN B reported the facility immediately attempted to give Narcan with the onset of symptoms in Resident #6. LPN B reported neither she or her colleagues could locate Narcan on the medication cart or unit crash cart (a specialty cart used for emergency responses) and another staff nurse (LPN D) rapidly searched other carts in the facility for intranasal Narcan, while others she couldn't recall, discovered the Narcan stocked in the facility's [name of secure drug system] was of an injectable formulation, and not readily accessible at which time they called 911. LPN B recounted her conversations with police at the facility. Interview revealed LPN B acknowledged she committed the medication error as documented in the facility investigation and stated the error was both accidental and unintentional. During interview on 6/5/2025 at 7:58 PM, LPN D recalled the incident. LPN D reported LPN B informed her of the medication error immediately when it was identified and asked her for help. During interview on 6/9/2025 at 1:40 PM the DON confirmed the facility identified LPN B's serious medication error during initial investigation of the incident, at the time it occurred, then immediately formulated a corrective action plan which was monitored by the facility Quality Assurance Committee (QA) to prevent recurrences, in response to the incident. During interview on 6/9/2025 at 9:25 PM RN A, (who was the unit charge nurse on the night of the incident) reported the incident occurred sometime between 8:00 and 8:30 PM on 5/2/2024. RN A reported EMS arrived at the scene in less than 5 minutes once summoned. (This was consistent with the EMS run sheet data). During interview on 6/10/2025 at 11:00 AM the NP reported on the night of the incident as she was leaving the building sometime around 8:45 PM, (didn't recall precise time) she was informed of the medication error by staff. The NP reported at the time she was notified over the overdose, she herself was leaving the facility due to a family emergency and ordered Resident #6 to be given Narcan if any signs of sedation or decline arose and to immediately transfer the resident to a hospital should changes occur. The NP reported she was summoned back to the facility by police and arrived there after Resident #6 was taken to the hospital and she was then interviewed about the situation. The NP confirmed long-acting formulations of Morphine were not intended to be crushed for administration. The NP reported she was informed of Resident #6's transfer to the hospital by telephone when it occurred. In response to the incident, the facility implemented corrective actions. The facility's corrective actions were validated onsite between 6/5/2025 and 6/10/2025 during the onsite survey. The facility's corrective actions are summarized as follows: 1. On 5/2/2024 Resident #6 was transferred to the hospital for emergent care. An onsite investigation of the incident was initiated by the house supervisor with witness statements obtained. 2. On 5/2/2024 a brief ad hoc Quality Assurance (QA) review of the incident was held with members of the facility nursing leadership and administrator as the investigation was underway after law enforcement left the facility. An analysis of the initial investigation findings of the incident was discussed between Administration and Nursing Leadership. Initial responses to the incident and plans to re-educate all licensed nursing staff on relevant policies and procedures including the medication administration policy and facility policies related to safe drug administration procedures was formulated. Staff education began on the night of 5/2/2024 with expectations no staff would be allowed to work shifts after 5/4/2024 until all required medication re-training and competency assessments were completed. The remedial training materials utilized in response to the incident and training plan/competency testing was also added to the facility new hire orientation training program to augment current materials in use. All new hires were required to complete the training plan. 3. On the morning of 5/3/2024 a second ad hoc QA meeting was held which included all department heads, members of nursing leadership, facility administration, medical staff, pharmacy and the medical director in attendance. Additional responses to the incident were planned. 4. On the morning of 5/3/2024 the facility obtained Narcan formulated for intra-nasal administration from multiple local pharmacies and added it to every medication cart and crash cart in the facility as a stock medication, with tracking to ensure supplies were maintained in accordance with acceptable standards and expiration dates. Intra nasally administered Narcan was also obtained from the contracted pharmacy service and added to the Pyxis system to augment supplies of injectable Narcan already on hand. 5. On 5/3/2024 the facility DON examined the medication administration policy and procedures with no negative findings or changes needed identified. 6. On 5/3/2024 Medication Administration Record (MAR) audits and interviews of all current residents with BIMS scores of 8 or higher for medication accuracy were initiated with no additional negative findings or other at-risk residents identified. The audits and interviews were completed by 5/5/2024. MAR audits for all residents with BIMs scores less than 7 were also performed with no negative findings also completed by 5/5/2024 by the DON and Staff Education Coordinator. 7. On 5/2/2024 Mandatory staff re-education for all licensed nurses was performed by the DON and designees which included the staff educator which included teaching on the 5 rights of medication administration as outlined in the facility policy and procedures, medication error policy, and procedures for medication administration for all medication types which included oral, nasal, topical, intravenous, parenteral, and injectable medication formulations. Re-training also included safe use of medical devices and glucometers. All staff were required to sign attestations training was completed and the facility policies acknowledged. All staff not on duty for vacations etc. were required to complete training prior to resumption of shifts. This was completed on 5/4/2024. 8. Observations of medication passes by the DON or designee to assess for competency for all on duty staff nurses began on 5/3/2024 and was completed by the last shift on 5/4/2024. 9. Individualized re-training and counseling was provided to LPN B on 5/4/2024 and observations of LPN B for medication administration competency were completed. 10. On 5/6/2024 the facility initiated follow up observations of medication administration and additional competency evaluations for 5 nurses per week for a minimum of 5 resident medication passes for 4 weeks then continued assessments of 3 nurses and 3 resident medication passes weekly for 4 weeks, then 1 nurse and 1 resident medication pass weekly for 2 weeks. Documentation of the medication competency follow up observations was maintained in facility logs which were reviewed by the surveyor onsite. Observations of the logs showed the facility monitored competencies across all shifts. These audits were completed by 7/12/2024 with no new concerns identified. 11. The facility held additional QA meetings in which all findings related to the facility interventions and monitoring regimen were reviewed by the QA committee. Additional QA of the incident and findings related to the mitigation plan put into place were reviewed on 5/21/2024, 6/18/2024, 7/30/2024, and 8/27/2024. The facility QA committee ceased active QA monitoring of the remediation plan on 8/28/2024. This was verified by review of the QA sign in sheets and interviews. Observation of medication passes on 6/5/2025 on the day shift were conducted. Medication pass observations on the evening shift was completed on 6/9/2025. No medication errors or deficient practices were observed. Brief interviews of nursing staff were conducted on all shifts throughout the investigation and included questions on the facility medication administration policy, med error reporting policy, narcotics policy and protocols for use of Narcan, use of the Pyxis system, and observations of the Pyxis system in operation. Observations of the Pyxis system showed it was operational, but occasionally users had to wipe the finger touch screen with a clean cloth to allow the system to rapidly identify fingerprints. Observations of the medication carts and crash carts showed Narcan for nasal administration was readily available on all carts observed. Review of medication administration competency logs, cross referenced against the current employee log, which revealed all employees present at the time of the incident who remained employed at the facility, had received retraining as reported and remedial training LPN B reported she received in interview had been documented as completed. Personnel files were reviewed for 3 licensed nurses which included one person hired after the incident and verified medication training as outlined in the corrective actions had been incorporated into the new hire competency check list contained in the file. LPN B's personnel file was reviewed as well as her current licensure status. LPN B's personnel file showed prior to 5/2/2024, there were no documented performance or disciplinary actions as reported to law enforcement. It was notable at the time of the incident; LPN B had been licensed as a nurse for around 6 months (license issued 10/11/2023) and had been employed at the facility since March 2024. LPN B separated employment from the facility to seek other employment around 2 months after the incident and left in good standing. An online check of the Tennessee Board of Nursing Licensure Verification Page showed LPN B remained licensed in good standing with the board, with no pending or prior administrative actions or orders. Review of the personnel file also showed LPN B had graduated from an accredited LPN education program. Review of the facility incident logs showed no recurrent serious medication errors documented. After May 2024. Review of the grievance logs showed no grievances filed related to medications or alleged medication errors.

Based on facility policy review, observations, and interview the facility failed to maintain a sanitary kitchen environment as evidenced by undated, unsealed food observed in 1 of 1 walk-in freezer and failed to ensure expired foods had been discarded in 1 of 1 dry storage areas, which had the potential to affect 142 of 142 residents. The findings include: Review of the facility's policy titled, Food Receiving and Storage, dated [DATE], showed .Foods shall be received and stored in a manner that complies with safe food handling practices .Foods stored in the refrigerator or freezer will be covered, labeled and dated . Observation of the dry storage area with the Certified Dietary Manager (CDM) on [DATE] at 9:40 AM, showed the following: - Four 1-pound bags of marshmallows with an expiration date of [DATE]. Observation of the facility's walk-in freezer with the CDM on [DATE] at 9:45 AM, showed the following: - One 5-pound bag of tater tots with ,d+[DATE] of the bag remaining, had not been sealed, labeled, or dated. During an interview on [DATE] at 9:50 AM, the CDM stated all food items were to be labeled, dated appropriately, and sealed after opened. The CDM confirmed the food items had not been stored properly in the walk-in freezer and expired food had not been discarded in the dry storage area.

Based on medical record review and interview, the facility failed to develop an accurate Minimum Data Set (MDS) assessment for 1 resident (Resident #132) related to discharge location, for communication needs related to interpreter services for 1 resident (Resident #92), and medication use for 1 resident (Resident #118) of 28 residents reviewed for MDS assessments. The findings include: Resident #132 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Diabetes, Hypertension, and Chronic Respiratory Failure. Review of a Nurse Progress Note dated 9/8/2023, showed Resident #132 .discharged instructions discussed with resident and son .Resident and son signed discharge instructions with copy given to resident son. Resident reminded of her appointment .Resident escorted to car via WC [wheelchair] per staff and assisted into son's personal vehicle by staff CNA [Certified Nursing Assistant] . Review of the Nurse Practitioner's Discharge Summary dated 9/8/2023, showed discharge home with home health. Review of the discharge MDS assessment dated [DATE], showed Resident #117 was discharged to an acute care hospital. During an interview on 11/1/2023 at 2:39 PM, MDS Coordinator #1 stated Resident #132 was discharged home and confirmed the MDS had been coded incorrectly. 48100 Resident #92 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia, Hemiparesis, and Expressive Language Disorder. Review of Resident #92's comprehensive care plan revised 7/31/2023, showed .ADL [Activities of Daily Living] self-care deficit .impaired mobility .risk for .has impaired communication .as evidenced by .speaking [NAME] [Spanish] .Resident uses translator phone .tablet device as needed to communicate with the staff . Review of an admission MDS assessment dated [DATE], showed Resident #92 did not need an interpreter to communicate, scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact, and required extensive 2-person assistance with bed mobility, transfers, dressing, and personal hygiene. During an interview on 11/1/2023 at 8:41 AM, CNA #2 stated Resident #92 speaks very little English, Spanish was the resident's primary language, and the staff used the phone translator application to communicate with the resident. During an interview on 11/1/2023 at 8:45 AM, Licensed Practical Nurse (LPN) #1 stated Resident # 92 speaks very little English, Spanish was the resident's primary language, and the resident used the phone translator application to communicate with the resident. During an interview on 11/1/2023 at 9:41 AM, Social Services Director (SSD) stated the primary means to communicate with Resident # 92 was to call the resident's daughter or use the phone translator application. The SSD stated the resident's primary language was Spanish and the resident spoke very little English. The SSD confirmed the facility staff used translator/ interpreter services to communicate with the resident. During an observation on 11/1/2023 at 10:05 AM, showed a staff member had communicated with Resident #92 using the phone translator application. During an interview on 11/1/2023 at 10:20 AM, a Language Interpreter had translated the conversation between the Surveyor and Resident #92. Resident #92 stated the facility communicated with her by calling her daughter or used the translator application on her phone. Resident #92 stated Spanish was her primary language, the resident understood some English, but could not speak English fluently to express her needs and wants. During a telephone interview on 11/2/2023 at 8:55 AM, Resident #92's daughter stated the facility communicated with the resident by calling her to translate or the staff used the phone translator application.The resident's daughter stated Resident #92's primary language was Spanish, could not speak English fluently, and needed an interpreter or translator to communicate with the resident. During an interview on 11/2/2023 at 1:40 PM, MDS Coordinator #2 confirmed Resident #92's primary language was Spanish and the MDS was not coded accurately to reflect the resident's communication status with the need or use of a translator or an interpreter. 38810 Resident #118 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Depression, and Post Traumatic Stress Disorder (PTSD). Review of Resident #118's Physician Orders with an order date range from 5/10/2023-9/30/2023, showed the resident did not have an order for an antipsychotic medication. Review of a quarterly MDS assessment dated [DATE], showed Resident #118 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact, and had diagnoses of Depression and PTSD. Further review showed the resident received an antipsychotic medication. Review of Resident #118's Medication Administration Record dated 9/1/2023-9/30/2023, showed the resident had not received an antipsychotic medication. During an interview on 11/1/2023 at 1:40 PM, MDS Coordinator #2 and MDS Coordinator #3 confirmed Resident #118 was not on an antipsychotic medication at the time the assessment was completed.

Based on facility policy review, medical record review, and interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) screen was accurate after mental health diagnoses was identified for 1 resident (Resident #110) of 11 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, PASARR- Pre-Admission Screen and Resident Review, dated 10/30/2023, showed, .facility must coordinate with pre-admission screening and resident review program .All residents are required to have a level I PASRR [PASSAR]screen prior to or upon admission . Resident #110 was admitted to the facility on [DATE] with diagnoses including Depression and Psychosis. Review of the PASSAR dated 1/24/2023, showed Resident #110 had no mental health diagnosis, no psychotropic medication used, and no level II condition-level I negative outcome. Review of the Hospital Discharge Summary Report dated 3/17/2023, showed Resident #110 had orders for Alprazolam (anti-anxiety medication) 0.5 milligrams (mg) three times daily for anxiety, Quetiapine Fumarate (anti-psychotic medication) 50 mg twice daily with an additional100 mg at bedtime, Vilazodone (anti-depressant medication) 20 mg daily, and Haloperidol (anti-psychotic medication) 2 mg every one hour as needed. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #110 had an active diagnosis of .Depression .Psychotic Disorder . and received anti-psychotic, anti-anxiety, and anti-depressant medications. During an interview on 11/2/2023 at 2:05 PM, the Director of Nursing (DON) confirmed Resident #110's PASARR was not accurate upon admission, did not reflect the mental health conditions and had not been re-submitted to include mental health diagnoses.

Based on facility policy review, medical record review, and interview the facility failed to revise the care plan related to fall interventions for 2 residents (Resident #87 and Resident #116) of 28 care plans reviewed. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 6/30/2022, showed .It is the policy of this facility to develop and implement a comprehensive .care plan for each resident .The comprehensive care plan will be .revised by the interdisciplinary team . Review of the facility policy titled, Falls-Clinical Protocol, revised 10/26/2023, showed .Interventions should be .implemented per the assessed needs .Update the plan of care with the new or revised interventions . Resident #87 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Chronic Kidney Disease, Depression, Anxiety Disorder, Bipolar Disorder, and Difficulty in walking. Review of a fall investigation dated 7/26/2023, showed .Resident was returning to room from lunch. Tried to ambulate without assistance from the end of Bed A to his [Resident #86] Bed B .[Intervention]Staff assist to bed after Lunch each day . Review of the comprehensive care plan revised 8/14/2023, showed .The resident is at risk for falls/injury related to history of falls, difficulty walking .Reduce the risk of injury . Further review showed the care plan had not been revised to include a new fall intervention for staff to assist Resident #87 to bed after lunch when the resident fell on [DATE]. During an interview on 11/2/2023 at 10:05 AM, the Director of Nursing (DON) confirmed Resident #87's care plan was not revised after the fall on 7/26/2023 to include the new fall intervention. 40640 Resident #116 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Dementia, Hypertension, and Repeated Falls. Review of a fall investigation dated 10/21/2023, showed .Observed on bottom .leaning back aligned with side of bed facing the doorway .clutter of over bed tables in front of resident bed .Resident [#116] had moved multiple bedside tables together .[Intervention] Room and bedside table decluttered with clear pathway . Review of the comprehensive care plan revised 10/24/2023, showed Resident #116 .is at risk for falls/injury related to Impaired mobility .history of falls . Further review showed the care plan had not been revised to include a new fall intervention for room and bedside table decluttered with clear pathway after the resident fell on [DATE]. During an interview on 11/2/2023 at 7:22 AM, the DON confirmed Resident #116's care plan was not revised after the fall on 10/21/2023 to include the new fall intervention.

Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 2 of 4 dumpsters (dumpster #2 and #4). The findings include: Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 1/1/2022, showed .Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks .Surrounding area shall be kept clean so that accumulation of debris and insect/ rodent attractions are minimized .receptacles for refuse shall be maintained in good repair . During an observation with the Certified Dietary Manager (CDM) on 10/30/2023 at 9:52 AM, the outside dumpster area had 4 dumpsters for waste disposal. The area around dumpster #4 had a plastic lid, 4 used disposable gloves, and a milk carton on the ground directly behind the dumpster. Dumpster #2 had a 2-foot gash with multiple small rust-corroded openings, of various sizes, to the bottom right panel of the dumpster. Dumpster #4 had a missing drain plug leaving a quarter sized opening to the back, bottom panel, which allowed the dumpster's liquid, organic waste to leak out of the dumpster onto the ground. During an interview on 10/30/2023 at 9:55 AM, the CDM stated the trash debris, which included used disposable gloves, milk carton, plastic lid, and liquid organic waste material, should not be present on the ground around the dumpster area. The CDM stated dumpsters #2 and #4 were old and rusted and needed to be replaced. The CDM confirmed Dumpster #4 had a drain plus missing and the area around the dumpsters had not been maintained in a good working or sanitary order.

Based on facility policy review, observation, and interview the facility failed to maintain infection control practices while delivering meal trays to residents on 1 hallway of 6 hallways observed. The findings include: Review of the facility policy titled, Hand Hygiene, revised 1/1/2022, showed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents . During an observation of meal delivery on 10/30/2023 at 12:06 PM, on the 600 hallway revealed the following: Certified Nursing Assistant (CNA) #1 retrieved a lunch tray from the meal cart, entered Resident #58's room, placed the tray on the overbed table, repositioned the resident, touched the bed control and raised the head of bed, positioned the overbed table, opened the food containers, and exited the room without washing or sanitizing the hands. CNA #1 retrieved a towel from the clean linen cart, re-entered Resident #58's room, placed the towel over the resident's shirt, opened and touched the straw with bare hands. Further observation showed CNA #1 retrieved another tray from the food cart, entered Resident #16's room, placed the tray on the overbed table, positioned the resident, opened the silverware touching the end of the fork and spoon, opened and touched the straw, placed butter on the roll with bare hands, and exited the room without washing or sanitizing the hands. Continued observation showed CNA #1 retrieved another tray from the food cart, entered Resident #11's room, placed the tray on the overbed table, touched the bed control to raise the head of bed, positioned the overbed table, opened and touched the straw, and assisted the resident with the meal. After approximately 3 minutes CNA #1 exited the room without washing or sanitizing the hands, re-entered Resident #58's room, picked up and gave the resident the spoon, encouraged the resident to eat, and exited the room without washing or sanitizing the hands. Continued observation showed CNA #1 re-entered Resident #111's room and continued to assist the resident with the meal. During an interview on 10/30/2023 at 12:27 PM, CNA #1 confirmed she failed to wash or sanitize the hands after resident contact during meal delivery and did not follow the facility's infection control policy. During an interview on 10/30/2023 at 3:46 PM, the Director of Nursing (DON) stated it was her expectation for staff to wash or sanitize the hands after resident contact during meal delivery. The DON confirmed CNA #1 failed to follow the facility's infection control policy.

Based on medical record review, review of a facility investigation and interview the facility failed to ensure 1 resident (#2) of 3 sampled residents was free from abuse. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis affecting right dominate side, Dysphagia, Diabetes Mellitus Type 2 with Neuropathy, Morbid Obesity, Heart Failure, and Anxiety. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating the resient was severely cognitively impaired. The resident required extensive assist for bed mobility, transfers, and activities of daily living (ADLs) with 2-person assist. The resident used a wheelchair for mobility. Medical record review of Resident #1's care plan showed the facility identified on 8/8/2022 the resident exhibited the behavior of screaming/verbal noises related to stroke and frustration with aphasia (impairment of ability to communicate) with monitoring and interventions implemented. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Restlessness, Agitation, and Chronic Kidney Disease. Medical record review of the admission MDS dated [DATE] revealed a BIMS score of 1 indicating the resident was severely cognitively impaired. The resident required extensive assist with bed mobility, transfers with 1-2 person assist. The resident was able to ambulate in room and corridor with 1-person assist. Medical record review of Resident #2's admission care plan revealed the facility identified she was at risk for falls and had implemented interventions and monitoring. Review of a facility investigation dated 8/25/2022 showed Resident #1 was ambulating from the dining room down the hallway in his wheelchair toward his room after lunch. Resident #1 stopped at a tray cart with dirty trays located in the hallway and began picking uneaten food off of the trays. Another resident saw Resident #1 and told him not to do that. Resident #1 began yelling. Two Certified Nurse Assistants (CNAs) were walking down the hallway with Resident #2. The CNAs approached Resident #1 and attempted to deescalate the situation. Resident #1 then focused his attention on the CNAs. Resident #2 was standing near the CNAs and Resident #1 pushed Resident #2 in attempt to get to the CNAs causing Resident #2 to lose her balance and sat down on the floor. Resident #1 was returned to his room where he received 1:1 supervision until he was transferred to the hospital for evaluation. Review of hospital documentation showed Resident #1 was admitted to the hospital for suspected urinary tract infection (UTI) and medication review. The resident received IV antibiotics for a UTI and had medications adjusted. Resident #1 returned to the facility on [DATE] with medication changes. Interview on 11/30/2022 at 11:45 AM with CNA #3 revealed Resident #1 had a history of verbal aggression towards others but had not hit anyone. During an interview on 11/30/2022 at 12:00 PM with CNA #4 she stated she was working on 8/25/2022 when the altercation occurred between Resident #1 and Resident #2. The CNA confirmed she had assisted the resident back to his room and she and the Assistant Director of Nursing (ADON) stayed with Resident #1 until he was transferred to the hospital.

Based on facility policy review, observation, and interview, the facility failed to maintain sanitary infection control practices while delivering meal trays to residents on 1 of 5 hallways, of 5 total hallways observed. The findings include: Review of the facility policy Handwashing/Hand Hygiene reviewed/revised 2/2018, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to .residents .Employees must wash their hands .under the following conditions .after direct contact with residents .After contact with objects .in the immediate vicinity of the resident . Observation of meal tray delivery on 2/19/19 at 12:43 PM, on the 500 hallway, revealed the following: Certified Nursing Assistant (CNA) #1 retrieved a meal tray from the meal cart and entered room [ROOM NUMBER] A, the meal tray was served/set up and CNA #1 exited the room without sanitizing the hands. Further observation revealed CNA #1 retrieved a second meal tray from the meal cart and entered room [ROOM NUMBER] A, touched the bedside table and placed it within the residents reach, served/set up the tray and exited the room without sanitizing the hands. Continued observation revealed CNA #1 retrieved a third meal tray from the meal cart and entered room [ROOM NUMBER] A, touched the resident's clothing, served/set up the meal tray and exited the room without sanitizing the hands. Further observation revealed CNA #1 retrieved a fourth meal tray from the meal cart, entered room [ROOM NUMBER] A and requested CNA #2's assistance to reposition Resident #58 in the bed. Continued observation revealed the two CNA's repositioned the resident in the bed, CNA #1 served/set the meal tray up, CNA #1 and CNA #2 exited the room without sanitizing the hands. Interview with CNA #1 on 2/19/19 at 12:53 PM, in the 500 hallway, confirmed she failed to sanitize the hands while delivering meal trays to residents. Further interview confirmed she and CNA #2 repositioned Resident #58 in the bed and failed to sanitize the hands after exiting the room. Interview with CNA #2 on 2/19/19 at 12:54 PM, in the 500 hallway, confirmed she assisted CNA #1 reposition Resident #58 in the bed and failed to sanitize the hands after exiting the room. Interview with the Director of Nursing (DON) on 2/19/19 at 3:22 PM, in the DON's office, confirmed the facility failed to follow the handwashing/hand hygiene policy during meal tray delivery to residents.

Based on observation and interviews, the facility failed to ensure over the bed tables were clean in 3 resident rooms (#109, #402, and #519) and failed to ensure bathroom nightlight covers were clean in 7 resident rooms (#109, #113, #207, #209, #210, #402, and #409) of 20 resident rooms observed for cleanliness. The findings included: Observation and interview with the Director of Nursing (DON) on 4/4/18 from 7:00 AM to 8:30 AM, during tour of resident's rooms, revealed the over the bed tables in rooms #109, #402, and #519 were sticky to the touch and had a buildup of dust and grime. Continued observation revealed the bathroom nightlight covers in rooms #109, #113, #207, #209, #210, #402, and #409 had a buildup of dust and brown colored grime. Interview with the DON confirmed the facility failed to thoroughly clean the over the bed tables and the bathroom nightlight covers in the residents' rooms. Further interview confirmed .(rooms) .need to be cleaned .

Based on facility policy review, medical record review, review of employee files, review of facility investigation, and interview, the facility failed to prevent abuse of 1 resident (#139) of 32 residents reviewed. Resident #139 felt humiliated and suffered psychological harm. The findings included: Review of the facility policies, Preventing Resident Abuse and Reporting Abuse to Facility Management, revised on 11/28/16, revealed .Our facility will not condone any form of resident abuse .verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse is defined as, but is not limited to, humiliation, harassment . Medical record review revealed Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the employee file for the Central Supply Clerk (CSC) revealed the employee was also a Certified Nursing Assistant (CNA). Review revealed on 11/2/16, .Employee was angry while in the dining room serving residents lunch and was heard using inappropriate language and cussing in front of residents .behavior was very disruptive and distracting in the dining room while residents were eating . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact with the highest possible score of 15 on the Brief Interview for Mental Status (BIMS). Review of a statement dated 1/29/17, obtained by the Director of Nursing (DON) from Resident #139, pertaining to an allegation of abuse on 1/27/17, revealed .(CSC) jumped on her .was loud and rude .'made me feel humiliated' . Interview with Licensed Practical Nurse (LPN) #1 on 1/30/17 at 3:45 PM, on the 600 hall, revealed on 1/27/17 Resident #139 .came around the corner in her wheelchair crying. Continued interview revealed the CSC had yelled at her in the dining room related to the resident's oxygen, .why do you need two (tanks of) oxygen . Interview with LPN #1 on 1/30/17 at 5:10 PM, in the conference room, revealed I spoke with (DON) before leaving my shift, about 2:15 PM, on Friday (1/27/17) to see what was being done about the incident in the dining room .talked over with (DON) that (Resident #139) was yelled at .(DON) said .she had started an investigation. Interview with Resident #139 on 1/30/17 at 6:00 PM, in her room, revealed the resident had been in the main dining room for lunch on Friday, 1/27/17, when she .ran out of oxygen .have to have my oxygen .asked for my oxygen tank to be replaced, but (CSC) said she couldn't get it right away .3 times I asked her to get me a tank and she wouldn't, then (CNA #4) went out the door to get me a tank . Interview continued as the resident began to cry. Further interview revealed .she (CSC) yelled at me and told me I wasn't supposed to have 2 oxygen tanks .I was so upset .I couldn't sleep all night . Interview with the Activities Assistant (AA) on 1/31/17 at 12:25 PM, in the conference room, revealed the AA was working on bulletin boards and observed Resident #139 .as she came around the corner to the 600 Hall. Interview continued, (Resident #139) came up to me crying on Friday (1/27/17) and explained to me what happened. I told her to report it immediately to (Staff Development Coordinator (RN #3)) and (Assistant Director of Nurses). (Resident #139) said she ran out of oxygen and (CNA #4) went out the dining room door to go get her some .(CSC) asked 'Why do you need 2 oxygen (tanks)?' (Resident #139) comes to a lot of activities and she normally is not upset and I knew she was really upset that day (1/27/17). Interview with CNA #4 on 1/31/17 at 12:35 PM, in the conference room, confirmed Resident #139 was in the dining room before lunch service on 1/27/17, and reported her oxygen tanks were empty. Continued interview confirmed the CSC was yelling at Resident #139, .was very loud .sounded like a pissed off mother scolding her child .the lady (Resident #139) was crying and was tore up .everybody in there heard it .the lady (Resident #139) kept telling her she couldn't breathe .(CSC) yelled what are you doing with 8 liters of oxygen . Interview with the Assistant Director of Nurses (ADON) on 1/31/17 at 2:17 PM, in the conference room, revealed the ADON asked the Staff Development Coordinator (RN #3) what was going on after RN #3 had spoke to (CSC). Continued interview revealed the ADON, .overheard (Resident #139) reporting to (the DON) and (RN #3) about being talked to in the manner (CSC) did .aware several disciplinary actions against (CSC). Interview continued and the ADON confirmed she was aware the resident was upset and did not check on her. Interview with RN #3 on 1/31/17 at 2:28 PM, in the conference room, revealed RN #3 had been summoned by the AA to talk with Resident #139 and CNA #4 about the incident in the dining room on 1/27/17. Interview with RN #3 confirmed Resident #139 was visibly upset during the interview. Further interview revealed, (CNA #4) said (CSC) has no right to talk to (Resident #139) like that. Further interview revealed RN #3 then told the DON, (CSC) had mouthed somebody. Interview with the DON on 1/31/17 at 4:23 PM, in the conference room, revealed facility employees had witnessed the verbal abuse on 1/27/17 during lunchtime.

Based on facility policy review, review of employee education materials, medical record review, review of a facility investigation, and interview, the facility failed to follow policy for investigating and reporting an allegation of abuse timely for 1 resident (#139) of 4 residents reviewed for abuse of 32 residents reviewed. The findings included: Review of the facility policy Reporting Abuse to Facility Management revised 11/28/16, revealed .When an alleged or suspected case of .abuse is reported, the facility Administrator, DON (Director of Nursing), or individuals designated will immediately (not to exceed 24 hours .) notify the following persons or agencies of such incident as indicated by State or Federal Licensure Policy .the State licensing/certification agency responsible for surveying/licensing the facility .Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse is defined as, but is not limited to, humiliation, harassment .Any individual observing an incident of resident abuse .must immediately report such incident to the Administrator or Director of Nursing .An immediate investigation will be made . Review of an employee education document, Reporting Abuse, undated, revealed, .Provide for the Protection of the Resident .Suspend involved staff member pending investigation . Medical record review revealed Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 1/29/17, documented by the Director of Nursing (DON), related to an allegation of abuse on 1/27/17 revealed .(Resident #139) said (Central Supply Clerk (CSC)) .got upset with me & (and) questioned why I need 2 tanks (of oxygen) on my chair & I told her I can't breathe without it & it made me feel bad that she thought I didn't need 2 tanks & I was just wanting them. She also stated that (CSC) jumped on her & CNA (Certified Nursing Assistant #4) both & was loud & rude to them . Interview with Licensed Practical Nurse (LPN) #1 on 1/30/17 at 3:45 PM, on the 600 hall, revealed on 1/27/17 Resident #139 came around the corner in her wheelchair crying. Interview continued and revealed LPN #1 was told the CSC had yelled at Resident #139 in the dining room related to her oxygen, .why do you need two (tanks) of oxygen . Interview continued, I talked with (the Director of Nursing (DON)) by the end of my shift, probably by 2:15 PM. Interview with Resident #139 on 1/30/17 at 6:00 PM, in her room, revealed the resident was in the main dining room for lunch on Friday, 1/27/17, when she, .ran out of oxygen .have to have my oxygen .asked for my oxygen tank to be replaced, but (CSC) said she couldn't get it right away .3 times I asked her to get me a tank and she wouldn't, then (CNA #4) went out the door to get me a tank . Interview continued as the resident began to cry. Continued interview revealed .she (CSC) yelled at me and told me I wasn't supposed to have 2 oxygen tanks .I was so upset .I couldn't sleep all night . Further interview revealed the resident had reported the incident to the DON on 1/27/17. Interview with CNA #4 on 1/31/17 at 12:35 PM, in the conference room, confirmed Resident #139 was in the dining room before lunch service on 1/27/17 and reported her oxygen tanks were empty. Continued interview confirmed CNA #4 went through the dining room exterior door to retrieve full oxygen tanks. Continued interview confirmed the CSC was yelling at Resident #139 and .was very loud .sounded like a pissed off mother scolding her child .the lady (Resident #139) was crying and was tore up .everybody in there heard it .the lady (Resident #139) kept telling her she couldn't breathe .(CSC) yelled what are you doing with 8 liters of oxygen . Interview with the DON on 1/31/17 at 4:23 PM, in the conference room, revealed facility employees had witnessed the verbal abuse on 1/27/17 during lunchtime, the investigation of the verbal abuse was not initiated until 1/29/17, and the accused employee was allowed to finish working on 1/27/17 until 4:22 PM. Continued interview confirmed the CSC was suspended on her next scheduled workday (1/30/17 at 7:30 AM). Continued interview revealed the facility failed to follow their policy and the verbal abuse was not reported to the State agency until 1/30/17.

Based on review of the facility's Admission Packet, medical record review, and interview, the facility failed to issue a written bed-hold policy to the resident and responsible party for 2 (#86 and #103) of 3 residents reviewed for admission, transfer, and discharge rights of 32 residents reviewed. The findings included: Review of the facility's admission packet revealed .Notice of Bed-Hold Policy-If you are transferred out of the center to the hospital or choose an overnight therapeutic leave, we will provide written information about our 'bed hold' policy to you. What this means is that under certain circumstances, including receipt of written or verbal request for a bed hold, the center will 'hold' a bed for the resident to be readmitted . Medical record review revealed Resident #86 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #86 was transferred to the hospital on [DATE] due to nausea, vomiting, and difficulty breathing. Medical record review revealed no documentation a written bed-hold policy was provided to the resident or responsible party at the time of transfer to the hospital. Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #103 was transferred to the hospital on [DATE] for evaluation. Medical record review revealed no documentation a written bed-hold policy was provided to the resident or responsible party at the time of transfer to the hospital. Interview with the Assistant Director of Nursing on 1/31/17 at 9:02 AM, in the lobby, confirmed the residents were not provided a copy of the facility's bed-hold policy when the residents were transferred to the hospital. Interview with the Business Office Manager (BOM) on 1/31/17 at 9:40 AM, in the lobby, revealed the BOM was responsible to notify family members/responsible parties of the facility's bed-hold policy when residents were transferred to the hospital. Continued interview confirmed a written bed-hold notice was not provided to the family members or the resident's responsible party at the time the residents were discharged to the hospital.

Based on facility policy review, medical record review, interview, and observation, the facility failed to prevent development of a stage 2 pressure ulcer for 1 resident (#40), of 3 residents reviewed with medical devices, of 32 residents reviewed. The findings included: Review of the facility policy Prevention of Pressure Ulcers, revealed, .The most common site of a pressure ulcer is where the bone is near the surface of the body .Pressure can also come from splints, cast . Review of the facility's Clinical Practice Guideline .International NPUAP/EPUAP Pressure Ulcer Classification System revealed, .Stage II: Partial Thickness Skin Loss .Partial thickness loss of dermis presenting as a shallow open ulcer . Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the nursing assessment dated [DATE] revealed the resident did not have a pressure ulcer on admission. Further review revealed a Norton Plus Pressure Ulcer Scale used for predicting pressure ulcer risk was scored at a 9, with the instruction score 10 or less = high risk. Medical record review of the care plan dated 12/23/16 revealed the Focus problem, Risk for alteration in skin integrity. Medical record review of a Continuity of Care record dated 12/30/16, revealed the Medical Director wrote .Back brace when ambulating .Needs to get up to go to the bathroom, wear Back brace when ambulating. Medical record review of a physician's telephone order dated 12/30/16 revealed, Back brace when up in w/c (wheelchair) as tolerated . Medical record review of the December 2016 Treatment Record revealed, Back brace when up in the w/c (wheelchair) as tol (tolerated.) Medical record review of the physician's telephone orders dated 1/2/17 revealed, Order Clarification: Back brace on when ambulating. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident had scored a 12 on the Brief Interview for Mental Status (BIMS) indicating mild cognitive impairment, and the resident required assist of 1 person for transfers and ambulation. Medical record review of the resident's weekly skin check dated 1/27/17 revealed no open areas were identified. Medical record review of an Immediate Plan of Care dated 1/27/17 revealed, Problem .abrasion . Interview with Registered Nurse (RN) #1 on 1/30/17 at 9:40 AM, at the nursing station, revealed, .(Resident #40) has an open area on her back from rubbing against a brace. Interview revealed RN #1 thought the wound care nurse classified it as an abrasion . Interview with the Wound Care Nurse, RN #2, on 1/30/17 at 2:00 PM, revealed RN #2 had not observed the resident's abrasion since first observed on the previous Friday, 1/27/17. Observation of Resident #40 on 1/30/17 at 2:30 PM, with RN #2, revealed the resident was able to turn off of her back to the right side of the bed, and there was a prominent curve of the resident's spinal column. There was an open area that was not covered with a dressing and was located on the most protruding bony prominence of the curvature of the spine. The open area was circular and measured 1.5 cm (centimeters) by 1.5 cm, with a red rim visualized at the bottom portion of the open area. There was a periwound, red in color, and measuring 4 cm by 4 cm. Interview with RN #2 on 1/30/17, at 2:30 PM, during the observation in the resident's room, confirmed the size of the open area and the periwound area. Further interview revealed the RN continued to state the open area was an abrasion. Interview with the Assistant Director of Nursing (ADON) on 1/30/17, at 3:30 PM, in the conference room, confirmed the ADON supervised the facility's wound care program, and confirmed an open area on a bony prominence was a stage II pressure ulcer. Interview with Licensed Practical Nurse (LPN) #2 on 1/31/17 at 9:50 AM, in the conference room, revealed the Certified Nursing Assistants (CNA's) bathing Resident #40 on 1/27/17 reported the open area on the resident's back. Interview confirmed the physician's order written on 12/30/16 to apply the brace when the resident was in the w/c was not the order written by the physician on the Continuity of Care instructions. Further interview revealed, I noticed when she was sitting in the w/c the top of the brace came right to the bony spot on her back . Interview with the ADON on 1/31/17 at 4:00 PM, in the 300 Hall, confirmed Resident #40 had developed a stage II pressure ulcer on the bony curvature of her spine where the back brace came into contact with the curvature of her spine, and confirmed the physician had not ordered the brace to be worn in the wheelchair.

Based on review of the facility policy, observation, and interview, the facility failed to perform hand hygiene between residents for 6 of 24 residents observed in the dining room during the lunch meal service. The findings included: Review of the facility policy, Hand Hygiene, not dated, revealed .require hand hygiene .Before and after direct resident contact .Before and after assisting a resident with meals (hand washing with soap and water) . Observation of Certified Nursing Assistant (CNA) #3 on 1/29/17 at 11:10 AM, during lunch meal service in the dining room, revealed CNA #3 delivered lunch to the 1st resident, touched the eating utensils and removed a lid from her drink, while preparing the meal for consumption. Continued observation revealed CNA #3 moved a wheelchair, using both hands, and then served the 2nd resident their lunch, without sanitizing the hands. Continued observation revealed CNA #3 unwrapped the resident's eating utensils and used the utensils to cut the resident's food, then removed the lid from the resident's cup. Continued observation revealed CNA #3 assisted the 3rd resident to cut up their food. Continued observation revealed CNA #3 sanitized her hands, touched the doorknob on the dining room door, and delivered the 4th resident their meal. Continued observation revealed CNA #3 unwrapped the utensils and poured milk into the resident's cup, without sanitizing the hands. Continued observation revealed CNA #3 served the 5th resident their lunch tray, unwrapped the utensils, and used them to cut up the resident's food, without sanitizing the hands. Further observation revealed CNA #3 assisted the 6th resident to unwrap her utensils, and poured her drink into a glass without sanitizing the hands. Interview with CNA #3 on 1/29/17 at 11:23 AM, in the dining room, confirmed CNA #3 had not sanitized her hands between touching contaminated surfaces and delivering and assisting residents with meal set-up. Interview with the Director of Nursing on 1/29/17 at 11:45 AM, in the DON office, confirmed acceptable infection control practice was not performed and the facility's Hand Hygiene Policy was not followed.

Based on observation and interview, the facility failed to maintain a clean environment on 3 of 3 nurse's stations observed. The findings included: Interview and observation with the Maintenance Director on 2/3/16 at 12:41 PM, confirmed station 1, station 2, and station 3, all had a very large accumulation of dust in the ceiling heating and air vents.

Based on policy review, observation, and interview the facility failed to dispose of garbage and refuge properly and maintain a clean environment around the dumpsters and recycled dumpster bin in 1 of 1 dumpster areas observed. The findings included: Review of facility policy, Solid Waste Disposal, undated revealed .Porter .When necessary, empty trash bin into dumpster .Monitor dumpster area for cleanliness . Observation with the Dietary Manager (DM) on 2/1/16 at 9:21 AM, of the dumpster area revealed over 100 cigarette butts, numerous paper and plastic products on the ground surrounding all 4 dumpsters and the 1 recycled dumpster bin. Interview with the DM on 2/1/16 at 9:22 AM, at the dumpster area confirmed the facility failed to dispose of the garbage and refuge properly and failed to maintain a clean environment in the area surrounding the dumpsters and the recycled dumpster bin.

Based on review of facility policy, medical record review, review of facility investigation, review of a police report, observation, and interview, the facility failed to implement the abuse policy for two residents (#46, #133) of three residents reviewed. The findings included: Review of facility policy, Abuse Prevention Program, revised October 2012 revealed, "Our residents have the right to be free of abuse, neglect, misappropriation of resident property...timely and thorough investigations of all reports and allegations of abuse...Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record...The person performing the examination must complete a Report Form and obtain a written, signed, and dated statement from the person reporting the incident...All forms of abuse...must be reported immediately to the Nursing Supervisor, the Director of Nursing Services and to the Administrator...All reports of resident abuse...shall be promptly and thoroughly investigated by facility management...Witnesses will be required to sign and date any witness report they make..." Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired, frequently incontinent of bladder and bowel, and required extensive assistance with activities of daily living. Medical record review of the care plan dated September 3, 2014, revealed, "...Altered thought process related [MEDICAL CONDITION] resistive, leave safely alone and re-approach later...Attempt to identify stressors contributing to behavior and remove them if possible...Requires assist with ADLs (Activities of Daily Living)...Allow ample time for tasks. Assume unhurried manner..." Medical record review of a nurse's note dated November 6, 2014, at 6:30 a.m., revealed, "Staff entered room to get resident for breakfast. As staff assisting resident to chair res (resident) started spitting, scratching, and hitting at staff..." Medical record review of a nurse's note dated November 6, 2014, at 6:40 a.m., revealed, "Reapproached resident et adm (and administered)[MEDICATION NAME]" Medical record review of a nurse's note dated November 6, 2014, at 8:00 a.m., revealed, "Resident in calm mood..." Review of a facility investigation dated November 12, 2014, revealed the resident was non-compliant with incontinent care and included, "Date of incident 11/06/2014 Time: 06:00 a.m...on 11/6/14 at approximately 5:00 a.m., CNA (Certified Nursing Assistant #1) called the Director of Nursing (DON) to allege possible abuse of (resident) by Licensed Practical Nurse (LPN #1)...smacked the resident twice in the face and also placed a blanket over (resident's) face during the course of providing incontinent care..." Review of the facility investigation dated November 6, 2014, and signed by CNA #1, revealed, "At 4:15 this morning I told (LPN #1) that (resident) didn't want to be changed. (LPN #1) offered to help...During pericare, resident began yelling, cursing...I heard two smacks and saw from my peripheral that (LPN #1) smacked (resident) on mouth...grabbed the red blanket and put it on (resident's) face for approx (approximately) 5 seconds...We finished with care and...left the room...I then called (DON)." Review of the facility investigation dated November 6, 2014, and signed by CNA #2, revealed, "Resident refused care...(CNA #1) told (LPN #1) and (LPN #1) offered to help...(LPN #1) held both wrists. I saw (LPN #1) smack (resident) twice on the left cheek...grabbed a red blanket and held it over (resident's) face for a few seconds..." Review of facility investigation dated November 6, 2014, and signed by the Social Service Director (SSD) revealed, "Residents interviewed on 11-6-14: None of these residents reported having been abused or witnessed abuse..." Continued review revealed no statements or signatures of the residents. Review of the facility investigation dated November 7, 2014, and signed by the SSD revealed, "Staff interviewed on 11/7/14: All of these staff members work with (LPN #1). None of them have witnessed abuse by any staff in this facility. They all say the residents are safe and well taken care of..." Continued review revealed no statements or signatures of the interviewees. Review of the facility investigation dated November 10, 2014, revealed, "...Results of investigation...CNAs recollections are inconsistent with where resident was allegedly slapped..." Observation on January 27, 2015, at 2:15 p.m., in an activity area revealed the resident was not interviewable and no physical evidence of injury. Medical record review revealed no documentation regarding the resident's resistive behavior during or assessment of the resident immediately after the provision of incontinence care on November 6, 2014, at approximately 4:15 a.m. Telephone interview with CNA #1 on January 28, 2015, at 8:05 a.m., revealed incontinence care was provided to the resident the morning of November 6, 2014, after the resident refused. CNA #1 stated, "...(Resident) said no you're not changing me...I told the nurse... Other CNA tried to block (resident) from kicking...(LPN #1) held hands down. (Resident) spit on the nurse. I saw in my peripheral the nurse smacked (resident) twice...took...blanket and put on (resident's) face to block spit. Continued interview revealed another nurse was on duty, CNA #1 reported an allegation of abuse to the DON by telephone, and CNA #1 stated, "...I didn't tell (other nurse on duty at the time of the alleged incident)...didn't want the nurses to know what was going on...Later before (the) shift ended the other CNA (#2) checked (resident) and (CNA #2) told me (resident) had finger marks on (resident's) arm. Nurse was getting report at that time." Interview with LPN #2 on January 27, 2015, at 2:10 p.m., at the 100 hall nurse's station, revealed LPN #2 became aware of an allegation the resident had been abused during report on November 6, 2014, at approximately 6:30 a.m. LPN #2 stated, "...Right after report I assessed...to look for any marks...didn't see any...The CNAs should have reported it immediately to their supervisor..." Continued interview revealed LPN #2 did not document the assessment of the resident's skin in the medical record according to facility policy. Interview with the SSD on January 26, 2015, at 3:37 p.m., in the DON's office, revealed witness statements were not documented or signed and confirmed the facility had failed to implement the abuse policy for Resident #46 on November 6, 2014. Resident #133 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility investigation dated September 17, 2014, revealed the resident reported $30.00 missing to the Social Service Assistant (SSA). Review of the facility investigation revealed no dated or signed witness statements of staff or other residents. Review of an unsigned, undated facility investigation revealed, "findings of investigation passed on...during report to the 3rd shift staff. The 3rd shift staff (CNA) was changing resident around...midnight when (CNA)...found $20.00 under (resident's) arm. (CNA) placed the 2 tens in (resident's)...makeup bag and noted another $10.00 bill making $30 total. CNA reported this to the resident who was groggy and sleepy. Then, CNA immediately reported the found money to the charge nurse. The information was passed on the the 1st shift CNA and nurse during report. CNA also told another CNA/friend from another hall during their smoke break around 4 A.M. Patient notified nurse and Social Services around 930 A (9:30 a.m.) that (resident) could not find...money again..." Continued review revealed the identity of referenced staff was not identified. Review of the facility investigation and a police report (printed September 22, 2014), revealed, "...On 9/17/2014, at (3:28 p.m.)...was dispatched to (facility) in reference to a theft...around (9:00 a.m.)...on this date, (resident) awoke and couldn't find...money and told...nurse...notified (SSA) of the incident at which time they attempted to locate the money but was unsuccessful...(SSA) stated that she called all staff that had access to (resident's) room but (CNA #3)...(CNA #3) was to work again on this evening and was going to discuss the issue then when (CNA #3) arrived for work...Reported As Theft...under $500...Suspect (CNA #3)..." Medical record review of a quarterly MDS dated [DATE], revealed the resident's Brief Interview for Mental Status score was 14 on a scale of 0-15, and a score of 13-15 reflected intact cognitive ability. Interview with the SSA on January 27, 2015, at 8:20 a.m., revealed the SSA had failed to obtain signed statements of witnsses according to facility policy. Interview with the alert, oriented resident on January 27, 2015, at 8:47 a.m., revealed the resident discovered $30.00 missing and reported the missing money to a nurse and the resident was unable to identify the nurse. Continued interview revealed the SSA interviewed the resident regarding the missing money and the money had been reimbursed to the resident. Interview with the SSA on January 28, 2015, at 8:40 a.m., in the MDS office, revealed the SSA had completed the investigation, wrote the undated, unsigned findings of investigation, and stated, "...(SSA) told policeman there wasn't something right in (CNA #3's story) and verified the suspect identified on the police report was CNA #3; CNA #3's last name was misspelled on the police report..." Interview with the DON on January 28, 2015, at 8:50 a.m., in the conference room, revealed CNAs #3 and #4 were suspects, CNA #4 was the last person to see the resident's money, and the DON stated, "...we couldn't prove (CNA #4) did it..." Interview with the DON in the Administrator's office and in the presence of the Administrator and SSD, on January 28, 2015, at 9:38 a.m., revealed the facility's investigation was completed on September 17, 2014, and stated, "...I don't know why the policeman put (CNA #3) as suspect." Continued interview revealed CNA #3's employment was terminated related to a subsequent theft of money from a resident, and confirmed the facility had failed to implement the abuse policy for Resident #133 on September 17, 2014. C/O # , #

Based on medical record review, review of facility investigation, observation, and interview, the facility failed to provide care in accordance with the care plan for one resident (#46) of thirty residents reviewed. The findings included: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident was severely cognitively impaired, frequently incontinent of bladder and bowel, and required extensive assistance with activities of daily living. Medical record review of the care plan dated September 3, 2014, revealed, "...Altered thought process related [MEDICAL CONDITION] resistive, leave safely alone and re-approach later...Attempt to identify stressors contributing to behavior and remove them if possible...Requires assist with ADLs...Allow ample time for tasks. Assume unhurried manner..." Medical record review of an interdisciplinary note dated October 16, 2014, revealed the resident continued to refuse care at times and needed encouragement. Medical record review of a nurse's note dated November 6, 2014, at 6:30 a.m., revealed, "Staff entered room to get resident for breakfast. As staff assisting resident to chair res (resident) started spitting, scratching, and hitting at staff..." Medical record review of a nurse's note dated November 6, 2014, at 6:40 a.m., revealed, "...Reapproached resident et adm (and administered)[MEDICATION NAME]" Medical record review of a nurse's note dated November 6, 2014, at 8:00 a.m., revealed, "...Resident in calm mood..." Review of a facility investigation dated November 12, 2014, revealed the resident was non-compliant with incontinent care and included, "...Date of incident 11/06/2014 Time: 06:00 a.m...on 11/6/14 at approximately 5:00 a.m., CNA (Certified Nursing Assistant #1) called the Director of Nursing (DON) to allege possible abuse of (resident) by Licensed Practical Nurse (LPN #1)...smacked the resident twice in the face and also placed a blanket over (resident's) face during the course of providing incontinent care..." Review of the facility investigation dated November 6, 2014, and signed by CNA #1, revealed, "At 4:15 this morning I told (LPN #1) that (resident) didn't want to be changed. (LPN #1) offered to help...During pericare, resident began yelling, cursing..." Telephone interview with LPN #1 on January 27, 2015, at 12:43 p.m., revealed a CNA reported the resident would not allow provision of care and LPN #1 stated, "...I said if (resident's) combative, I'll come help you. We couldn't leave that (feces) on (resident). In process of changing (resident), (resident) scratched and spit at me. I held (resident's) hand...The CNAs finished changing (resident)..." Observation on January 27, 2015, at 2:15 p.m., in an activity area, revealed the resident was not interviewable. Telephone interview with CNA #1 on January 28, 2015, at 8:05 a.m., revealed the resident had a history of [REDACTED].#1 reported the refusal to LPN #1. Continued interview revealed LPN #1 instructed the CNAs to provide incontinence care and assisted with the care after the resident refused, and CNA #1 had been taught to leave a resident with resistant behavior and re-approach at a later time. Interview with the Care Plan Coordinator on January 27, 2015, at 2:37 p.m., confirmed the facility had failed to provide care according to the care plan for Resident #46 on November 6, 2014. C/O #

Based on medical record review, review of facility investigation, review of facility policy, and interview, the facility failed to maintain a complete, accurate medical record for one resident (#46) of ten patients reviewed. The findings included: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility investigation dated November 12, 2014, revealed the resident was non-compliant with incontinent care and included, "Date of incident 11/06/2014 Time: 06:00 a.m...on 11/6/14 at approximately 5:00 a.m., CNA (Certified Nursing Assistant - #1) called the Director of Nursing to allege possible abuse of (resident) by Licensed Practical Nurse (LPN #1)...smacked the resident twice in the face and also placed a blanket over (resident's) face during the course of providing incontinent care..." Review of facility policy, Abuse Prevention Program, revised October 2012 revealed, "Our residents have the right to be free of abuse, neglect, misappropriation of resident property...Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record..." Interview with Licensed Practical Nurse (LPN #2) on January 27, 2015, at 2:10 p.m., at the 100 hall nurse's station, revealed LPN #1 reported the incident during change of shift report on November 6, 2014. LPN #2 stated, "...Right after report I assessed (resident) to look for any marks or anything and I didn't see any..." Continued review revealed LPN #2 failed to document the assessment of the resident in the medical record and confirmed the facility failed to maintain a complete, accurate medical record for Resident #46. C/O #