Every finding on record at Jnh-Jaquith Inn

Based on observation, interview and facility policy review, the facility failed to properly store controlled medications for one (1) of four (4) days of survey, which had the potential to allow unauthorized individuals access to controlled substances.Findings include:Record review of the facility policy Management of Controlled Substances/Medications with an effective date of September 2025 revealed, .C. Storage of controlled substances/medications .controlled substances/medications must be stored under two locks . On 02/04/2026 at 2:41 PM, a review of the facility's medication storage room revealed a medication refrigerator that lacked an external locking mechanism. Inside the refrigerator was an unlocked, open-top box containing seven (7) vials of Lorazepam 2 mg/1 mL (milligrams/milliliter), a Schedule IV controlled substance classified as a benzodiazepine sedative.In an interview conducted at 2:45 PM on 02/04/26, Licensed Practical Nurse (LPN) #1 confirmed that the refrigerator did not have a locking mechanism and stated that the only lock present was on the door to the medication room. LPN #1 further stated that controlled substances should be secured in a locked box in accordance with regulations to prevent unauthorized access. He stated the refrigerator had been replaced within the past six months and maintenance had not installed a lock.In an interview conducted at 2:55 PM on 02/04/26, the Director of Nursing (DON) confirmed that controlled substances are required to be secured behind two locked barriers. She stated that in this instance, the Lorazepam was only secured behind one locked door (the medication room entrance). The DON stated the purpose of this requirement is to prevent unauthorized access by staff or residents.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within required timeframes for two (2) of (2) residents reviewed for death in the facility tracking log. (Resident #10 and Resident #44). Findings include:Record review of the facility policy Minimum Data Set (MDS) Assessment Policy (JNH POL J550-43, [DATE]) revealed the following highlighted language: It is the policy of this facility to ensure that the MDS assessment is completed timely, accurately, and in accordance with all applicable Federal and State regulations The MDS Coordinator is responsible for coordinating, completing, and transmitting all MDS assessments in compliance with CMS requirements .All assessments will be submitted electronically to CMS within the required timeframes . The policy also specifies that the facility will ensure accuracy of data prior to submission and that assessments must reflect the resident's current status.Resident #10Record review of the clinical record for Resident #10 revealed the resident expired at the facility on [DATE] at 07:40 AM. Review of the Minimum Data Set tracking module showed the death in facility assessment had not been transmitted within 14 days of the resident's death, as required.Record review of Resident # 10's Patient/Physician Encounter Form revealed an admission date of [DATE] with diagnoses that included dementia without behavioral disturbance and schizophrenia.A record review of Resident #10's clinical record (JNH Resident 10.pdf) revealed documentation that the resident expired in the facility on [DATE] at 7:40 a.m. The medical record contained physician documentation of death and discharge status indicating death in the facility.Review of the Minimum Data Set (MDS) tracking/assessment history within the record revealed that a Death in Facility assessment had not been completed and transmitted within 14 days of the resident's date of death . The assessment history did not reflect a transmission date within the required timeframe.Resident #44Record review of the Nurse Notes dated [DATE] at 10:10 AM, revealed (Proper name of physician) pronounced the patient deceased . Review of the Minimum Data Set tracking module showed the Death in Facility assessment had not been transmitted within 14 days of the resident's death, as required.A record review of Resident #44's clinical record revealed documentation that the resident expired in the facility on [DATE] at 10:10 AM. The medical record included documentation of death and discharge disposition reflecting death in the facility. Review of the MDS tracking/assessment history revealed that a Death in Facility assessment had not been completed and transmitted within 14 days of the resident's date of death . There was no evidence within the assessment history of timely electronic submission within the required timeframe.Record review of the Patient/Physician Encounter Form revealed an admission date [DATE] with diagnoses that included major depressive disorder single episode unspecified and type 2 diabetes mellitus. During an interview on [DATE] at 2:40 PM, Registered Nurse (RN) # 1 revealed the death in facility assessments for Resident #10 and Resident #44 were not transmitted within the required 14 day timeframe following each resident's death but stated she had completed it, but it must have not transmitted properly. She revealed facility's failure to complete and transmit required death assessments within mandated timeframes has the potential to affect the accuracy of resident assessment data used for care planning, quality measures, and regulatory compliance. RN #1 presented the state agency with the validation report for Resident #10 dated [DATE] and an MDS for Resident #10 dated [DATE]. She presented a validation report for Resident #44 dated [DATE] and an MDS dated [DATE]. She was unable to present more up to date documentation that indicated the deaths had been submitted timely and within the required time frames.

Based on observation, interview and facility policy review, the facility failed to ensure staff followed proper hair restraint practices while working in the kitchen. This failure resulted in the Coordinator of Unit creating the potential for hair contamination of food served to residents for one (1) of three (3) survey days.Findings include: A record review of the facility policy, Food Services Personal Hygiene Habits, effective August 2025, reveals, .Purpose and Applicability, this policy provides procedures for the required personal hygiene habits of employees who handle food to assist in eliminating the most common sources of food contamination .Procedure .B. Hair restraint (nets) that cover all the hair (including beards) will always be worn while in the pantry. At 9:45 AM on 2/2/26, the State Agency (SA) observed the Coordinator of Unit (COU) working in the facility's kitchen without a hair cover or beard covering while performing his daily tasks.During an interview on 2/2/26 at 9:46 AM, the COU stated that he should wear both a hair net and a beard net because they are hygienic and help ensure he remains sanitary when handling food.On 2/3/26 at 4:07 PM during the interview with the Administrator, she explains that all kitchen staff should wear head and beard coverings when preparing food in the kitchen as this ensures cleanliness and that it is just sanitary to do. She adds not doing so could put residents at risk for food borne illness.

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices. Specifically, the facility failed to ensure proper glove use and hand hygiene during medication administration via percutaneous endoscopic gastrostomy (PEG) tube for Resident #3 and failed to ensure staff used appropriate hand hygiene and barriers when handling resident food for Resident #16 for two (2) of (13) residents reviewed. Findings Include: Record review of the facility policy Hand Hygiene with an effective date of June2025 revealed, .II. POLICY It is the policy.that all employees will use proper hand hygiene techniques to prevent the spread of infectious diseases. Resident #3 On 02/04/26 at 12:17 PM, Licensed Practical Nurse (LPN) #2 was observed administering Haloperidol 5 milligrams (mg) via PEG tube to Resident #3. LPN #2 donned gloves turned off the feeding pump and then accessed the PEG tube and administered the medication while wearing the same gloves used to touch the feeding pump. After medication administration, LPN #2 walked to the resident's sink and turned on the water while still wearing the same gloves. On 02/04/26 at 12:46 PM, during an interview, LPN #2 stated she should have changed gloves between touching the feeding pump and accessing the PEG tube. She also stated gloves should have been removed before touching the sink. She acknowledged that failure to follow proper infection control practices could increase the spread of infection. On 02/04/26 at 1:25 PM, during an interview, the Director of Nursing (DON) stated LPN #2 should have changed gloves before accessing the PEG tube and should not have touched the sink with soiled gloves due to the risk of spreading infection to surfaces and residents. Record review of the Identification and Summary Sheet revealed an admission date of 1/15/2004 with diagnoses that included schizoaffective disorder. Record review of the February 2026 Medication Administration Record (MAR) revealed Haloperidol 5 mg was initialed as given at 12 PM on 2/4/26 by LPN #2. Resident #16 On 02/02/2026 at 12:54 PM, an observation was conducted of Resident #16 seated in a geri-chair while Certified Nursing Assistant (CNA) #1 assisted with the resident's meal. CNA #1 was observed using bare hands to apply condiments to a hamburger bun, mash the hamburger together, cut the hamburger, pick up pieces of food, and hand them directly to the resident. CNA #1 was also observed passing out additional meal trays to other residents without performing hand hygiene between residents. On 02/02/26 at 1:32 PM, during an interview, CNA #1 stated she believed it was acceptable to touch food with her bare hands if she had sanitized her hands beforehand. She further stated she was told not to use gloves when touching food and acknowledged that this could be an infection control issue. On 02/03/26 at 12:01 PM, during an interview, the DON stated CNA #1 should have worn gloves or used utensils when handling resident food and should not have used bare hands. She stated this was an infection control concern and placed the resident at risk for infection. Record review of Resident #16's Identification and Summary Sheet revealed an admission date of 11/21/25. Record review of Resident #16's physician orders revealed diagnoses including neurocognitive disorder with behavioral disturbance and blindness, with diet orders for finger foods and allowance for hamburgers at lunch. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired.

Based on record review and interview the facility failed to accurately submit staffing data to the Payroll Based Journal (PBJ) system for one (1) of four (4) reporting periods reviewed in 2025 (third quarter, July-September 2025). Specifically, the facility failed to ensure that hours worked by licensed nursing staff were correctly coded and reported as direct care nursing hours, resulting in inaccurate PBJ submission data.Findings include:A record review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal report revealed that the facility triggered for insufficient 24-hour nursing coverage during the third quarter of 2025 (July through September).A record review of licensed nurse staffing schedules and staffing grids for July through September 2025 revealed no lapses in licensed nurse coverage, indicating that the PBJ report did not accurately reflect actual staffing levels.In an interview conducted at 2:30 PM on 02/03/26, the Director of Nursing (DON) stated she worked frequent overtime shifts providing direct resident care during the third quarter of 2025 due to staffing shortages and limited agency coverage. The DON stated she was unsure whether her time was accurately transferred on timecards for PBJ reporting when she worked as a staff nurse rather than in her administrative role.In an interview conducted at 3:00 PM on 02/04/26, the Human Resources Director, who is responsible for PBJ submissions, stated that the discrepancy involved the Minimum Data Set (MDS) nurse rather than the Director of Nursing (DON). She stated that after reviewing timecards, she identified that licensed nurses are typically coded as 7 for PBJ submission, while the MDS nurse was coded as 6, which reflects a non-direct care position and does not count toward licensed nursing hours. She stated this coincided with a period beginning on 08/09/25 when the MDS nurse began working additional shifts as a floor nurse to address staffing shortages.In an interview conducted at 8:48 AM on 02/05/26, the MDS nurse (RN #1) confirmed that she began working additional shifts as a floor nurse in August 2025 in addition to her administrative duties but was unsure how her time was coded in the payroll system. She confirmed she worked multiple weekend and weekday shifts during this time.In an interview conducted at 9:00 AM on 02/05/26, the Administrator confirmed that during the survey the facility identified a discrepancy in how the MDS nurse's time was transferred from the timekeeping system to the PBJ report, resulting in her direct care nursing hours not being reflected accurately. The Administrator stated inaccurate PBJ reporting could impact the facility's Five-Star rating and funding. She further stated the facility had not received notification from CMS indicating an error prior to the survey.

Based on observation, interview, and record review, the facility failed to ensure resident rights to a clean and comfortable environment for three (3) of six (6) sampled residents (Residents #1, #2, and #3).Findings included:A review of the facility's policy Cleaning of Patient/Resident Areas, dated November 2024, revealed, .Policy This policy provides procedures to clean and disinfect all patient/resident areas to prevent the spread of infection.Definition A. Cleaning - the removal of foreign material.from surfaces.Procedure.B. Steps to cleaning and disinfecting in a building.2. The following should be free of stains, visible dust, streaks, gross soil, spider webs and handprints. Clean and disinfect as needed. a. Baseboards b. walls.j. door frames.m. paper towel holder.p. furniture q. handrails.Patient/Resident general areas include the following as applicable.Patient/Resident room a. Bed rails as applicable.d. Mirror.Sweep or Dry mop floor to remove all debris or dust a. Spot clean any grossly soiled area.On 12/10/25 at 2:00 PM, during a telephone interview with the complainant, she reported visiting Resident #1 on 11/23/25 and observing spots and streaks of substances she believed appeared to be blood and saliva on the wall next to his bed. She reported the floors were dirty and the bed was broken. On 12/10/25 at 3:35 PM, during an observation with the Administrator-in-Training (AIT) and Director of Nursing (DON), upon entry into the room shared by Resident #1, Resident #2, and Resident #3, there were ten (10) brown pea-sized spots and two (2) brown streaks measuring approximately four (4) inches long by one-eighth (1/8) inch wide on the door frame. The hallway handrail outside the room to the right and left of the door was sticky to the touch and discolored. Beneath the sink, a two-foot by three-foot (2 x 3) area of flooring had visible dust, debris, and blackish discoloration. The mirror above the sink was streaked with approximately thirty (30) gray streaks measuring one-eighth (1/8) inch wide and ranging from two (2) to five (5) inches in length. The top of the wall-mounted paper towel holder was covered with dust, and the front surface had brown spots and streaks that wiped away easily with a damp paper towel. The floor behind the door and at the end of Resident #2's bed was covered with lint, dust, scraps of paper, and debris, with brown, black, and rust-colored streaks throughout. The wall adjacent to Resident #2's bed had four (4) black diagonal streaks measuring approximately one-half (1/2) inch wide by four (4) inches long and an additional tan streak above the bed. Junction boxes and wire mold encasing electrical wiring along the wall behind the beds of Resident #1 and Resident #3 were covered with approximately one-sixteenth (1/16) inch of dust and debris. Resident #1's bedframe was covered with dust that wiped away easily, and the floor beneath the bed was dusty with scattered debris. A seven-inch by seven-inch (7 x 7) structural encasement in the corner of the room had twenty-two (22) maroon-colored streaks measuring two (2) to four (4) feet in length. The baseboard behind the head of bed of Resident #3 and along the far wall was covered with a one-sixteenth (1/16) inch of dust. All three wall-mounted call light boxes were covered with visible dust. The right assist rail on Resident #2's bed had a light brown discoloration that wiped away with a damp paper towel. The room was uncluttered, free from pests and malodorous smells, and all beds were functional.On 12/10/25 at 5:00 PM, during an interview, the Administrator-in-Training reported she had been notified by the family of Resident #1 that the room was dirty during their visit on 11/23/25, specifically noting the walls and floors, and that belongings of a previous resident remained in the room. She confirmed that at the time of Resident #1's admission on [DATE], some belongings of the prior resident were still present and that thorough cleaning had not occurred prior to admission. She confirmed she instructed staff to remove the belongings but did not personally inspect the room afterward.On 12/11/25 at 12:50 PM, during an interview, the facility Administrator stated resident rooms should be deep cleaned when a resident leaves and prior to a new admission, with daily cleaning ongoing. He stated the facility used a contracted housekeeping service and that oversight responsibilities rested with administration and nursing leadership.On 12/11/25 at 1:30 PM, during an interview, the Environmental Services Department Supervisor confirmed the accumulated dust, debris, and streaking observed in the room of Resident #1, Resident #2, and Resident #3 were unacceptable and indicated the areas had not been recently cleaned.Resident #1A record review of the Identification and Summary Sheet revealed the facility admitted Resident #1 on 11/21/25.A record review of the Physician Orders for Resident #1 had diagnoses including Neurocognitive Disorder.A record review of the admission Minimum Data Set (MDS) for Resident #1, with an Assessment Reference Date (ARD) of 11/28/25, revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident's cognition was severely impaired.Resident #2A record review of the Identification and Summary Sheet for Resident #2 revealed the facility admitted the resident on 8/27/18.A record review of the Quarterly Revised Orders revealed Resident #2 had diagnoses including Anoxic Brain Injury.A record review of the Quarterly MDS for Resident #2, with an ARD of 11/6/25, revealed a BIMS score of six (6), which indicated the resident's cognition was severely impaired.Resident #3A record review of the Identification and Summary Sheet for Resident #3 revealed the facility admitted the resident on 6/1/76 and he had diagnoses including Spastic Cerebral Palsy.A record review of the Quarterly MDS for Resident #3, with an ARD of 9/25/25, revealed the resident was rarely or never understood, had a documented memory problem, and was severely impaired for daily decision making.

Based on interviews, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) reflecting anticoagulant medications for two (2) of fourteen sampled residents reviewed. (Resident # 11, Resident #23) Findings include: Review of the facility's policy, Minimum Data Set (MDS) assessment dated [DATE], revealed, 1. PURPOSE AND ACCOUNTABILITY. The facility shall conduct an interdisciplinary assessment using the MDS assessment in accordance with Federal/State regulations. This assessment provides information on the resident's condition which is used to develop an individualized plan of care and to track changes in the resident's status. This policy applies to all members of the treatment team. 2. POLICY. It is the policy of the facility to utilize information from the Resident Assessment/Instrument (RAI) and to follow the Care Planning Process in accordance to State and Federal regulation to provide quality care and services which improve residents' quality of life . 4. PROCEDURE . I. Staff members who complete portions of the assessment attest to the accuracy of their section by signature . J. The completed MDS is verified and signed by the MDS Coordinator . A record review of the 2021 [NAME] Pocket Drug Guide for Nurses, revealed the classification of Plavix is listed as an antiplatelet. Resident #11 Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/23/23, revealed Resident # 11 had a Brief Interview for Mental Status, (BIMS) score of 13, which indicated the resident was cognitively intact. Section N revealed Resident #11 received anticoagulant medication for seven (7) days out of the seven (7) days in the look back period. Record review of the Identification and Summary Sheet revealed the facility admitted Resident #11 on 6/06/2005. Review of the facility's, Physicians Orders revealed the Resident #11 had an order for Plavix 75 mg (milligrams) po (by mouth) daily, prescribed on 5/15/17, and updated and signed by the physician on 9/11/23. Record review of the August 2023, Medication Administration Record (MAR) for Resident #11, revealed Plavix 75 mg was administered seven (7) days out of the seven (7) days in the look back period and all other days during the month. There were no anticoagulant medications administered. Resident #23 Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/9/23 revealed Resident #23 had a Brief Interview for Mental Status, (BIMS) score 13, which indicated the resident was cognitively intact. Review of Section N revealed Resident #23 received anticoagulant medication for seven (7) or the seven (7) days in the look back period. Record review of the Identification and Summary Sheet revealed the facility admitted Resident #23 on 6/24/15. Review of the facility's, Physicians Orders revealed Resident #23 had an order for Plavix 75 mg (milligrams) po (by mouth) daily, prescribed on 4/5/22, and updated and signed by the physician on 9/11/23. Diagnoses and comments indicated Resident #23 had a history of CVA (Cerebrovascular Accident). Record review of the August 2023 Medication Administration Record (MAR) for Resident #23, revealed Plavix 75 mg was administered seven (7) days during the seven (7) day look back period and all other days during the month. There were no anticoagulant medications administered. During an interview on 10/11/23 at 3:52 PM, Registered Nurse (RN) #1 confirmed she failed to code the MDS correctly, as she coded Plavix as an anticoagulant in section N. The nurse revealed she has problems separating the medications because anticoagulant medications also thin the blood. During an interview on 10/12/23 at 12:42 PM, RN #1 confirmed she failed to code the MDS correctly. RN #1 said she coded the Plavix as an anticoagulant in Section N, because she has problems separating the medications because both medications thin the blood. During an interview 10/12/23 at 12:47 PM, the Director of Nurses (DON) confirmed Plavix was not coded correctly. The DON confirmed Plavix is an antiplatelet and does not thin the blood. The DON said she expects the MDS nurse to code the medication correctly. During an interview with the Administrator on 10/12/23 at 1:05 PM, he revealed he expects the nurses to code the medications correctly on the MDS.

Based on staff interviews and record reviews, the facility failed to complete the comprehensive Minimum Data Set (MDS) for two (2) of 26 residents reviewed for comprehensive assessments, with the potential to affect 39 residents. Resident #15 and Resident #37. ` Findings Include: A record review of the facility's statement dated 3/31/2022 revealed, (Proper Name of Facility) utilizes the RAI (Resident Assessment Instrument) for MDS (Minimum Data Set) guidance and submission. A record review of Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual dated October 2019 revealed, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) . Resident #15 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #15 on 2/6/2013. Record review of the last completed MDS revealed a quarterly assessment with an Assessment Reference Date (ARD) of 10/27/21. Further review of the medical record revealed Resident #15's comprehensive annual assessment had not been completed. Resident #37 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #37 on 3/9/2020. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/3/21. Further review of the medical record revealed Resident #37's comprehensive annual assessment had not been completed. On 03/29/22 at 11:04 AM, in an interview with Registered Nurse #2 (RN)/MDS Nurse, she stated that the MDS assessments are not up to date because she took the position approximately three months ago and received training for one and a half (1 ½) weeks. After training, she was working on her own and it takes her longer to complete the MDS assessments. She confirmed that she is behind on completing assessments and she knows it is important for MDS assessments to be completed in a timely manner. On 03/31/22 at 11:31 AM, in an interview with the Nursing Home Administrator (NHA)/ Nursing Home (NH) Director, he stated he was not aware the MDS assessments were not current, and he confirmed it is important for them to be up to date. The current MDS nurse took the position in October or November of 2021 and the Director of Nursing (DON) should check behind the MDS nurse. He stated the DON is also new in her position and she assumed the MDS nurse was completing assessments in a timely manner. On 03/31/22 at 10:30 AM, during an interview with the Nursing Administrator, she explained the facility does not have a MDS Policy and the facility used the RAI Manual for reference in completing MDS assessments and MDS submissions. She reported she was not aware the MDS nurse was behind on MDS assessments.

Based on staff interviews and record reviews, the facility failed to complete quarterly Minimum Data Set (MDS) Assessment for 17 of 26 residents reviewed for MDS assessments, with the potential to affect 39 residents. Resident #7, Resident #10, Resident #13, Resident #16, Resident #18, Resident #19, Resident #20, Resident #22, Resident #23, Resident #26, Resident #27, Resident #30, Resident #31, Resident #33, Resident #34, Resident #35 Resident #36 Findings Include: A record review of the facility's statement dated 3/31/2022 revealed, (Proper Name of Facility) utilizes the RAI (Resident Assessment Instrument) for MDS (Minimum Data Set) guidance and submission. A record review of Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual dated October 2019 revealed, The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non- comprehensive assessment for a resident that must be completed at least every 92 days . Resident #7 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #7 on 6/1/1976. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/20/2021, which is more than 92 days. Resident #10 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #10 on 4/2/2001. Record review of the last completed MDS revealed a significant change in status assessment with an ARD of 11/11/2021, which is more than 92 days. Resident #13 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #13 on 3/4/2011. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/13/2021, which is more than 92 days. Resident #16 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #16 on 11/5/2021. Record review of the last completed MDS revealed an admission assessment with an ARD of 11/11/21, which is more than 92 days. Resident #18 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #18 on 8/22/2018 Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/17/2021, which is more than 92 days. Resident #19 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #19 on 5/18/2015. Record review of the last completed MDS revealed an annual assessment with an ARD of 10/20/2021, which is more than 92 days. Resident #20 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #20 on 6/10/2010. A Record review of the last completed MDS revealed a comprehensive assessment with an ARD of 1/23/21, which is more than 92 days. Resident #22 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #22 on 8/15/2018. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/10/2021, which is more than 92 days. Resident #23 Record review of the identification and Summary Sheet revealed the facility admitted Resident #23 on 8/27/2018. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/17/2021, which is more than 92 days. Resident # 26 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #26 on 08/10/2018. Record review of the last completed MDS revealed an annual assessment with an ARD of 11/03/2021, which is more than 92 days. Resident #27 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #27 on 4/4/2016. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/10/2021, which is more than 92 days. Resident #30 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #30 on 10/5/2015. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/27/2021, which is more than 92 days. Resident #31 A Record review of the Identification and Summary Sheet revealed the facility admitted Resident #31 on 8/16/2018. A Record review of the last completed MDS revealed a quarterly assessment with an ARD of 11/3/2021, which is more than 92 days. Resident #33 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #33 on 10/17/2016. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 12/1/2021, which is more than 92 days. Resident #34 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #34 on 3/7/2019. Record review of the last completed MDS revealed a significant change in status assessment with an ARD of 12/12/2022, which is more than 92 days. Resident #35 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #35 on 11/14/2019. Record review of the last completed MDS revealed a quarterly assessment with an ARD of 10/6/2021, which is more than 92 days. Resident #36 Record review of the Identification and Summary Sheet revealed the facility admitted Resident #36 on 11/20/2019. Record review of the last completed MDS revealed an annual assessment with an ARD of 11/10/2021 which is more than 92 days. On 03/29/22 at 11:04 AM, in an interview with Registered Nurse #2 (RN)/MDS Nurse, she stated that the MDS assessments are not up to date because she took the position approximately three months ago and received training for one and a half (1 ½) weeks. After training, she was working on her own and it takes her longer to complete the MDS assessments. She confirmed that she is behind on completing assessments and she knows it is important for MDS assessments to be completed in a timely manner. On 03/31/22 at 11:31 AM, in an interview with the Nursing Home Administrator (NHA)/ Nursing Home (NH) Director, he stated he was not aware the MDS assessments were not current, and he confirmed it is important for them to be up to date. The current MDS nurse took the position in October or November of 2021 and the Director of Nursing (DON) should check behind the MDS nurse. He stated the DON is also new in her position and she assumed the MDS nurse was completing assessments in a timely manner. On 03/31/22 at 10:30 AM, during an interview with the Nursing Administrator, she explained the facility does not have a MDS Policy and the facility used the RAI Manual for reference in completing MDS assessments and MDS submissions. She reported she was not aware the MDS nurse was behind on MDS assessments.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) regarding a urinary and bowel toileting program for one (1) of 26 MDS assessments reviewed. Resident #18 Findings include: A record review of the facility's statement dated 3/31/2022 revealed, (Proper Name of Facility) utilizes the RAI (Resident Assessment Instrument) for MDS guidance and submission. Resident #18 A record review of the Identification and Summary Sheet revealed the facility admitted Resident #18 on 8/22/2018. A record review of Resident #18's Quarterly MDS with an Assessment Reference Date (ARD) of 11/17/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18 was independent for toilet use and the coding for Section H0200 and H0500 revealed Resident #18 was on a urinary and bowel toileting program. His Brief Interview of Mental Status (BIMS) score was 13, which indicated he is cognitively intact. On 03/29/22 at 8:05 AM, during an interview with Director of Nursing (DON), she explained Resident #18 can complete his Activities of Daily Living (ADLS) on his own time and is independent. Resident #18 will occasionally have incontinent episodes, but he will change himself and he toilets independently. On 03/29/22 at 9:50 AM, during an interview with Certified Nurse Aide (CNA) #3, she explained Resident #18 walks to the shower and bathroom independently and he is not on any special bladder or bowel training program. At 1:40 PM on 03/29/22, during an interview with Resident #18, he explained he has no problems going to the bathroom and is able to go by himself. On 03/30/22 at 10:00 AM, during an interview with CNA #2, he explained Resident #18 has had occasional incontinent episodes with urine, but not with bowel movements. He confirmed Resident #18 does not use a urinal and is able to toilet self. He also stated the resident is not on any special toileting training program. At 11:00 AM on 03/30/22, during an interview the DON, she explained the facility currently does not have a bowel and bladder training program. She reported Resident #18 can toilet without assistance. She explained she did not know that RN #2 had coded Resident #18 on the MDS as having been in a bowel and bladder training program and it is coded incorrectly, which is a MDS discrepancy. She explained she depends on the MDS nurse to code the MDS assessments accurately and to submit the MDS when assessments are due. She reported the facility currently does not check MDS assessments for accuracy prior to submitting. At 12:45 PM on 03/30/22, during an interview with RN #2, she reviewed Resident #18's recent MDS with an ARD of 11/17/21 and confirmed sections H0200 and H0500 were coded for a bowel and bladder training program. She explained Resident #18 goes to the bathroom on his own and he was not in a bowel and bladder training program during the seven day lookback period. She confirmed the MDS was coded in error, and it is a MDS discrepancy. On 03/30/22 at 12:50 PM, during an interview with RN #3, she viewed and confirmed Resident #18's Quarterly MDS with an ARD of 11/17/21 sections H0200 and H0500 were coded incorrectly due to Resident #18 had no orders for a bowel and bladder training program and those programs require an in-depth assessment. 03/31/22 at 10:30 AM, during an interview with the Nursing Administrator, she explained the facility does not have a MDS Policy, the facility used the RAI Manual for reference in completing the MDS. She confirmed the facility currently does not audit MDS assessments for accuracy prior to the MDS nurse submitting the assessments.

Based on observations and interviews, the facility failed to ensure smoking refuse was disposed of in a safe and sanitary manner for one (1) of two (2) smoking area observations. On 3/29/2022 at 4:45 PM, the SA observed Resident #17 smoking in the facility courtyard. When the resident finished smoking, he threw his cigarette onto the ground in a grassy area. Certified Nursing Assistant (CNA) #1 told Resident #17, You can't throw that on the ground. Resident #17 retrieved the cigarette butt from the ground and placed it in a Styrofoam cup that had water in it. Resident #17 stated that they had been throwing the cigarettes butts on the ground and why are we changing now. The SA observed a large amount of cigarette butts in the grass in the facility courtyard, which is the designated smoking area. On 3/29/2022 at 4:47 PM, an interview with Resident #17 revealed that he had always thrown his cigarette butts in the grass, and he had not been putting his cigarettes in a cup. On 3/29/2022 at 4:53 PM, during an interview with CNA #1, she confirmed Resident #17 threw the cigarette butt on the ground and that there was a large amount of cigarette butts in the grass in the courtyard. CNA #1 stated that when she takes the residents to smoke, she brings a Styrofoam cup with water for the residents to put the cigarettes butts in when they have finished smoking. She said she does not know what the other employees do when they are assisting residents with smoking. During an interview on 03/29/22 at 04:55 PM with the Administrator and the Administrator in Training (AIT), they observed and confirmed there was a large amount of cigarette butts in the grass in the courtyard. The Administrator said this could cause a fire by throwing lit cigarette butts in the grass. The Administrator said he did not know the residents were throwing the cigarette butts in the grass. Record review of the Identification and Summary Sheet revealed the facility admitted Resident #17 on 7/15/2005. Record review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 11/24/21 revealed Resident #17 had a Brief Interview of Mental Status (BIMS) of 03 which indicated Resident #17 is cognitively impaired.

Based on staff interview, record review, and facility policy review, the facility failed to provide documented evidence the facility's Quality Assurance and Performance Improvement (QAPI) program identified and prioritized problems and opportunities that reflected organizational process, functions, and services provided to residents based on performance indicator data, resident and staff input, and other information. The facility failed to provide documented evidence the facility 's QAPI Program reviewed and analyzed data for concerns related to pressure ulcer documentation, missed treatments, and skin assessments prior to the State Agency (SA) entering the facility on 8/26/21, for the Extended Survey. This had the potential to affect 40 of 40 residents in the facility. The failure of the facility to utilize the QAPI program to determine the root cause of failure to monitor treatments and care for Pressure Ulcers and identify deficient practices was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 9/7/21, which began on 6/16/21, when the facility's QAPI Committee failed to meet, review, and analyze data to develop corrective actions to prevent the failure to monitor treatments and care for Pressure Ulcers. The facility Administrator was notified of the IJ on 9/7/21 at 5:00 PM and was presented with the IJ template. The facility submitted a credible Removal Plan on 9/8/21, in which the facility alleged all correcctive actions were comopleted to remove the IJ on 9/7/21 and the IJ was removed on 9/8/21, prior to exit. The SA validated the facility's Removal Plan on 9/10/21 and determined that the IJ was removed on 9/8/21,therefore, the scope and severity for CFR(s) 483.75(f)(4) - Quality Assurance and Performance Improvement Program, was lowered from a L level scope and severity to a F level, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A record review of the facility ' s Quality Assurance and Performance Improvement policy, dated February 2021, revealed . B. The committee must maintain documentation and demonstrate evidence of its ongoing QAPI program containing at least the following elements: systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective action or performance improvement activities .4.PROCEDURE A. The unit ' s general QAPI program will involve assessing the unit ' s quality of care and performance data for indicators. The committee will seek to identify opportunities and need to improve quality of care and performance based on the data measures .B. The committee may implement a focused QAPI action or corrective plan to improve outcomes of one or more indicators . On 8/31/2021 at 12:20 PM, in an interview with the Nurse Administrator, she stated she is aware there is a problem with missing weekly wound assessments and measurements. She also stated that in April (2021), she had made the previous Administrator, previous Minimum Data Set (MDS) Nurse, and the current Director of Nursing (DON) aware of missed documentation of weekly wound measurements, supporting devices, changes in wound conditions, and staging as part of standards of practice as well as the regulatory requirements concerning wounds. On 9/01/21 at 3:40 PM, in an interview with the Nurse Administrator, she stated I recognized in April (2021) that the documentation wasn ' t there. I met with the DON, MDS Nurse, and the Administrator, the doctor wasn ' t there. I went over it with them and told them we were going to have to QAPI (Quality Assurance and Performance Improvement) this. A record review of the QAPI sign-in sheets and topics of discussion for QAPI meetings held on March 25, 2020; June 25, 2020; September 25, 2020; September 28, 2020; December 22, 2020; March 31, 2021; and June 16, 2021, revealed pressure ulcer documentation, missed treatments and skin assessments was not discussed during these meetings. On 9/07/21 at 1:45 PM, an interview with the Nursing Home Director revealed each nursing home building on campus had its own QAPI committee and had its own QAPI meeting every three (3) months and as needed when issues arise. He stated the building administrator was in charge of the QAPI committee and meetings. He stated all the nursing home buildings on the campus had a big QAPI meeting about two (2) years ago, and all of the QAPI committees got together for one big meeting, but normally each building has its own. He stated The Administrator in collaboration with the DON determines what is discussed in each meeting. When asked, he reported the facility had not had any as needed QAPI meetings over the last twelve (12) months. He verified no issues had warranted an as needed QAPI meeting over the last twelve (12) months. On 9/07/21 at 2:50 PM, an interview with the Administrator revealed she was the facility Interim Administrator. She stated each building has its own QAPI committee and holds its own QAPI meetings every three (3) months and as needed. She stated if an urgent problem was identified, then that would trigger an emergency QAPI meeting. She stated at each QAPI meeting, each discipline does a report for the QAPI committee and highlights any areas of concern. She stated the committee used the Certification and Survey Provider Enhanced Reports ([NAME]) report in the QAPI meetings and looked at any quality indicators that are greater than seventy-five percent (75%) of comparison to national. She stated the QAPI committee reviewed the [NAME] and brought any problem areas to that discipline and interventions were put in place. When asked how the committee determined the effectiveness of interventions in resolving problems, she stated When we come back quarterly that is when results would be discussed unless something happens that makes it more urgent. She stated specific means of measuring the effectiveness of interventions would depend on the problem. She stated any staff member can report quality concerns to the QAPI committee. She stated, We teach the CNA ' s and nurses ' see something, say something ' , and tell the administrator or they can call the switchboard operator and be connected to the Administrator on Call. When asked how the committee decided which issue to work on, she stated The top three (3) quality indicators that are in the ninety ' s (90 ' s). That ' s what we pick to focus on. When asked how the committee can be sure the corrective action has been implemented, she stated In-Services and sign in sheets and focus on outcome. When asked how the committee knows when important issues occur, she responded The quarterly meeting and when the numbers are trending down. When asked how long the committee will follow identified issues or problems, the Administrator stated Most for sixty (60) to ninety (90) days. To see if the problem is corrected, and if no improvement is seen we know that didn ' t work and we have to do something else. Plan of corrections go sixty (60) to ninety (90) days, maybe six (6) months. We try to see if we can get something corrected quickly. When asked specifically about the QAPI meeting held on 6/16/21, The Administrator stated she did not remember much about that meeting because the previous Administrator had just left and I had just started work in the building. I was trying to get use to how things were done in the building. On 9/07/21 at 3:50 PM, an interview with DON #3 revealed she remembered attending the 6/16/21 QAPI meeting. She stated the committee didn ' t discuss individual wounds but instead we discussed the prospect of starting back up the wound meetings or making them part of ' Treatment Team ' or ' Stand Up ' . She explained the facility held ' Treatment Team ' meetings every week. But then everyone started quitting. She stated the reason the QAPI committee had discussed re-instituting ' Wound Meetings ' was not due to issues identified with wounds or body audits or documentation, but in an effort to make things more uniform among the buildings, especially in light of the prevalence of the employment of agency and contract staff. When asked if the issue with lack of documentation of treatments, lack of documentation of body audits and lack of documentation of wounds and wound measurements should have been brought to the attention of the QAPI committee, she stated Yes. The facility submitted an acceptable Removal Plan on 9/8/21 for the Immediate Jeopardy (IJ) and Substandard Quality of Care. Review of the facility 's Removal Plan revealed the facility took the following corrective actions to remove the IJ: Removal Plan Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit: On September 7, 2021, at 5:15p.m. the Administrator was notified of the Immediate Jeopardy related to Pressure Wounds and Quality Assurance and Performance Improvement (QAPI). The facility failed to ensure residents who were admitted to the facility without pressure ulcers, did not acquire pressure ulcers, pressure ulcers did not worsen or pressure ulcers did not become infected. This affected Residents #1, Resident #3, and Resident #12. The facility failed to provide documented evidence that through the Quality Assurance and Performance Improvement (QAPI) Program, data had been reviewed and analyzed related to identified concerns of pressure ulcer documentation, missed treatments and skin assessments. The following corrective actions were taken to remove the immediacy of the identified concerns: 1. On September 2, 2021, at 11:00 a.m. the facility QAPI Committee met to discuss and identified the facility was not following the Wounds Policy and Procedures, Wound Documentation and using the facility Nursing Home Pressure and Nonpressure Wound Report (JNH 117). The committee discussed that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The committee discussed issues that may have led to the breakdown of missing documentation, such as a high percentage of contract/agency/pull licensed nurse staff not being fully aware of what is required of them with documentation and the expectation of nurses and the role of the QAPI Committee. The committee discussed in-servicing licensed nurse staff on Wound Policy and Procedures, documentation on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The QAPI Committee reviewed Policy JNH 117; no changes were needed. 2. On September 2, 2021, at 3:00 p.m. the facility Nurse Administrator began to in-service licensed nurses on Wound Care Policy and Procedures and using Form 117 to ensure the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments are to be provided by a licensed nurse as ordered; dressings are to be labeled with nurses ' initials and date; and treatments documented on the Treatment Chart. No staff will be allowed to work until in-serviced. 3. On September 7, 2021, at 9:00a.m. the facility Licensed Practical Nurse#3 and Licensed Practical Nurse#5 began performing body audits on all residents and documented the findings on the Treatment Chart. A review of records identified thirty-nine residents were at risk for impaired skin integrity. On September 7, 2021, the body audit revealed identification a stage II on Resident #5 that was acquired in the facility. The facility building Physician staged the wound. The Physician wrote new treatment orders for Stage II Pressure Injury on Right Buttock. Physician reviewed treatment orders for all residents with skin issues; and there were no changes needed. 4. On September 7, 2021, at 6:30p.m. the facility Nursing Home Nurse Administrator in-serviced the Director of Nursing on reviewing pressure ulcer documentation, body audit documentation, and reviewing resident ' s charts weekly. 5. On September 7, 2021, at 6:45p.m. the Nurse Administrator and Director of Nursing began in-servicing all licensed nurses and certified nurse aides on Skin, Wound Care and Reporting skin issues to ensure staff is aware to immediately report any signs of skin irritation and breakdowns. The Nurse Administrator discussed QAPI and the function of QAPI addressing any concerns that require special attention in improving the quality of care for the residents. No staff will be allowed to work until in-serviced. 6. On September 8, 2021, at 10:30 a.m., the facility Quality Assurance Performance Improvement (QAPI) committee met to discuss Wounds and Wound Documentation. The meeting was conducted with the facility Hospital Director, the facility Nursing Home Director, Chief Medical Doctor, the facility Nursing Home Administrator, the facility Hospital Nurse Executive, the facility Nurse Administrator, Director of Nursing, Minimum Data Set (MDS) Nurse, Service Outcome Director, Infection Prevention Nurse, Licensed Social Worker, Behavior Health Specialist, Certified Nurse Aid, and Recreation staff to discuss and determine corrective actions to prevent further incidents. Corrective actions discussed were to perform body audits on all residents and document findings, to use the [NAME] and Infection Prevention monthly reports to track and trend wounds. 7. Beginning September 8, 2021, at 11:30a.m. the Nurse Administrator and the Director of Nursing will monitor and review the Medication Administration Report the Treatment Charts, Body Audit Documentation, Weekly Wound Report for pressure injuries, surgical and skin tears, and ensure treatments are provided. Validation On /21, the SA validated the facilities removal plan on 9/10/21 and verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through staff interviews and record review of the QAPI sign in sheet the facility discussed the Wounds Policy and Procedures and missing documentation at a QAPI meeting on 9/2/21. 2. The SA validated through record review of sign in sheets and staff interviews the Nurse Administrator initiated an in-service beginning 9/2/21 regarding the facility ' s Wound Care Policy and Procedures and the use of Form 117 for wound assessments, measurements, and treatments. No staff was allowed to work until in-serviced. 3. The SA validated through record review of resident Treatment Charts, Nurses Notes, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The SA validated through record review of the in-service sign in sheet and staff interviews the Nurse Administrator provided an in-service to the DON regarding pressure ulcer documentation, body audit documentation, and reviewing resident ' s charts weekly. 5. The SA validated through record review of the in-service sign in sheets and staff interviews that on 9/7/21 the Nurse Administrator and the DON initiated in-servicing for licensed nurses and certified nurses aides on Skin, Wound Care, and Reporting skin issues and the function of QAPI and quality of care for residents. No staff was allowed to work until in-serviced. 6. The SA validated through staff interviews and record review of the QAPI sign in sheet the facility discussed the wound documentation, Policy and Procedures and missing documentation and use of monthly reports for tracking and trending purposes at a QAPI meeting on 9/8/21. 7. The SA verified through staff interviews the Nurse Administrator and DON are monitoring and reviewing the Medication Administration Reports, Treatment Charts, Body Audit Documentation, and Weekly Wound Reports. The SA validated that all corrective actions to remove the IJ had been completed as of 9/7/21, and the IJ was removed on 9/8/21, prior to exit.

Based on record review, facility policy review and staff and resident interviews, the facility failed to correctly document and implement residents' comprehensive person-centered Care Plans for eleven (11) out of eleven (11) residents sampled who resided on the South unit. Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11. The facility's failure to implement care plans placed residents on the South Unit at risk, and in a situation likely to cause serious injury, serious impairment, serious harm or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 7/25/21, when the facility failed to implement care plan interventions related to observations, medication administration and performance of treatments. On 8/05/21 at 5:15 PM, the SA informed the Nursing Home Administrator of the IJ and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 8/07/21 at 10:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed on 8/06/21 at 5:00 PM and the IJ was removed as of 8/07/21. The SA validated the Removal Plan on 8/09/21 and determined the IJ was removed on 8/07/21, prior to exit. Therefore, the scope and severity for CFR 483.21 (b)(1) Comprehensive Care Plans (F656) was lowered from a K to an E while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included: Record review of the facility policy Standards of Care dated May 2017 revealed .2. POLICY. The Lippincott Manual of Nursing Procedures is the designated nursing reference manual for clinical practice . Care Plan Preparation page 139, undated, revealed A Care Plan directs the patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan consists of three parts: goals or expected outcomes, which describe behaviors or results to be achieved within a specified time; appropriate nursing actions or interventions needed to achieve these goals; and evaluations of the established goals. A nursing Care Plan should be written for each patient, preferably within 24 hours of admission. It's usually started by the patient's primary nurse or the nurse who admits the patient. If the Care Plan contains more than one nursing diagnosis, assign priority to each diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Update and revise the plan throughout the patient's stay, based on the patient's response.2J3 The document becomes part of the permanent patient record. Some health care facilities use standardized Care Plans that can be modified to serve many patients. Others use computer programs to facilitate development of nursing Care Plans. A nursing Care Plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the practitioner or other members of the health care team, planning patient discharge, and documenting patient care. In addition, the Care Plan can be used as a management tool to determine staffing needs and assignments. Resident #1 Record review of the Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date of 5/5/21, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated severe cognitive deficit. Record review of Resident #1's Physician's Orders revealed an order dated 7/19/21 for [MEDICATION(S)]/APAP 5/325 MG (Milligrams) take (one) 1 tablet PO (by mouth) twice daily for 28 days. Record review of the Resident #1's Medication Chart revealed on 7/25/21, the facility failed to administer the 9:00 PM dose of [MEDICATION(S)]/Apap 5/325 MG and failed to check for pain on B shift (3:00 PM-11:00 PM). Record review of Resident #1's Care Plan revealed Resident #1 had the Problem/Need with onset date of 10/13/15, and a Goal and Target Date of 8/4/21 of High Risk for Pain related to PVD, CVD, peripheral [CONDITION(S)], and GERD with the Goal of resident will have pain relief within one (1) hour of pain interventions being given for 90 days. Approaches included administration of [MEDICATION(S)] 5 MG. Take 1 (one) tablet PO (by mouth) BID (twice daily) 30 (thirty) minutes prior to wound care X (times) 28 (twenty-eight) days. Record review of Physician's Orders revealed Resident #1 had a physician's order dated 7/2/21 for [MEDICATION(S)] one (1) packet po TID (Three times daily). Record review of the Resident #1's Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)]. Record review of Resident #1's Care Plan revealed Resident #1 had the Problem/Need with onset date of 10/13/15, and a Goal and Target Date of 8/4/21 of Nutritional Status: Resident has or is at risk for nutritional issue r/t ALZ, Dementia with disturbed behaviors d/t delusions, CVD, PVD, Peripheral [CONDITION(S)], GERD, Vit B-12 deficiency, PUD ([CONDITION(S)] Disease), [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] with the Goal of Resident #1 current diet will provide his estimated nutritional needs for kcal (kilocalorie), protein, fluid and will maintain nutritional status w/in (within) acceptable parameters x (times) 90 days. Approaches included [MEDICATION(S)] 1 packet PO BID. The care plan did not reflect the current physician's order for this medication. Record review of Resident #1's Physician's Order 6/22/21 at 11:45 AM for Santyl Topical Ointment BID (two times daily) to R Trochanteric Ulcer and L Shoulder Q 12 hours Record review of Resident #1's Treatment Chart revealed on 7/25/21, an ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan revealed Resident #1 had the Problem/Need (no onset date listed), and a Goal and Target Date of 8/4/21 of Pressure Ulcer Right Trochanter Stage II with the Goal of Resident #1 wound will show evidence of healing over the next 14 days. Approaches included Wash pat dry and apply a damp to dry normal saline cover to wound bed and cover with Alldress. The care plan did not reflect the current physician's order for this treatment. Record review of Resident #1's Care Plan revealed Resident #1 had the Problem/Need (no onset date listed), and a Goal and Target Date of 8/4/21 of Pressure Ulcer Left Shoulder Stage III with the Goal of Resident #1 wound will show evidence of healing over the next 14 days. Approaches included Wash pat dry and apply a damp to dry normal saline cover to wound bed and cover with Alldress. The care plan did not reflect the current physician's order for this treatment. Resident #2 Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/26/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) Section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit. A record review of Physician's Order with an original order date of 12/1/20 and updated on 7/21/21 revealed Resident #2 had orders in place for [MEDICATION(S)] 80 mg tablet chew one (1) tablet before meals and at bedtime. A record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 8:00 PM dose of [MEDICATION(S)] 80 mg. Record review of Resident #2's Care Plan revealed Problem/Need with onset date 5/31/17 of Nutritional Status: (Proper Name) has or is at risk for a nutrition issue/condition r/t (related to) [CONDITION(S)], neurongenic bladder, depression, [NAME]'s (decubit ulcers), [CONDITION(S)], Hep C, refuses meals and supplements frequently. Goal of Resident #2 nutritional needs will be met x 90 days 8/25/21. Interventions included [MEDICATION(S)] 80 MG tablet. Chew one (1) tablet before meals and at bedtime. Record review of Resident #2's Physician Orders dated 3/17/20 revealed orders for [MEDICATION(S)] dissolve 17 GM (Grams) in juice/liquid and give by mouth twice daily. A record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of Polyethylene [MEDICATION(S)] ([MEDICATION(S)]) powder. Record review of Resident #2's Care Plan revealed Problem/Need with onset date 4/04/16 of High Risk for Constipation related to decreased mobility, side effects of medications, refusing meds listed below frequently with Goal of Resident #2 will have a bowel movement at least every (three) 3 days for (ninety) 90 days 8/25/21. Interventions included [MEDICATION(S)] dissolve 17 GM (Grams) in juice/liquid and give by mouth twice daily. A record review of Physician's Order with an original order date of 3/17/20 and updated on 7/21/21 revealed he had orders in place for [MEDICATION(S)] 2.5 mg tablet take one (1) table po twice a day. A record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 2.5 mg. Record review of Resident #2's Care Plan revealed Problem/Need with onset date 4/04/16 of Risk for bleeding/bruising related to [MEDICATION(S)]. Interventions included [MEDICATION(S)] 2.5 MG by mouth twice daily. Record review of Resident #2's Physician Orders dated 3/17/20 revealed orders for [MEDICATION(S)] 10 MG suppository Insert (one) 1 suppository rectally on Tuesday, Thursday, Sunday and Daily as needed for constipation A record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)]. Record review of Resident #2's Care Plan revealed Problem/Need with onset date 4/04/16 of High Risk for Constipation related to decreased mobility, side effects of medications, refusing meds listed below frequently with Goal of resident will have a bowel movement at least every (three) 3 days for (ninety) 90 days 8/25/21. Interventions included [MEDICATION(S)] suppository 10 MG insert (one) 1 rectally every Tuesday, Thursday and Sunday. Record review of physician's order with an original order date of 3/17/20 and updated on 7/21/21 revealed Resident #2 he had orders in place for [MEDICATION(S)] 100 mg capsule disp as [MEDICATION(S)] sodium 100 mg cap take one (1) capsule po twice daily. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] Sodium 100 mg. Record review of Resident #2's Care Plan revealed Problem/Need with onset date 4/04/16 of High Risk for Constipation related to decreased mobility, side effects of medications, refusing meds listed below frequently with Goal of resident will have a bowel movement at least every (three) 3 days for (ninety) 90 days 8/25/21. Interventions included [MEDICATION(S)] 100 MG. Take 2 Caps PO BID. The care plan did not reflect the current physician's order for this medication. Record review of Physician's Order with an original order date of 3/17/20 and updated on 7/21/21 revealed Resident #2 he had orders in place for [MEDICATION(S)] 20 mg tablet take one (1) table po three (3) times daily. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)]. Record review of Resident #2's Care Plan revealed Problem/Need with onset date 4/04/16 of H/R (High Risk) for pain r/t [CONDITION(S)] with muscle spasms, hx of back injury r/t MVA (motor vehicle accident), verbalizations of pain almost daily, recent [NAME] surgery. With Goal of Resident #2 will voice pain relief at least 1 hr after pain interventions are given x 90 days. 8/25/21 with interventions including [MEDICATION(S)] 20 mg 1 po TID (three times daily) - 8 Record review of Physician Orders dated 3/9/21 revealed orders were in place for Resident #2 for Foley cath care q (every) shift - flush w/60 cc (cubic centimeters) sterile H2O. Record review of Resident #2's Treatment Chart on 7/25/21 revealed an ordered treatment to flush Foley catheter with 60 CC sterile water was not initialed as completed on the B shift. Record review of the Resident #2's Care Plan revealed Problem/Need listed as Indwelling FOLEY Catheter & BOWEL INCONTINENCY: High Risk for Urinary Tract Infections. With Goal of Resident #2 will not have any signs or symptoms of urinary tract infections go undetected for next 90 (ninety) days. 8/25/21 with interventions Flush Foley catheter with 60 CC sterile water every shift. Resident #3 Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/12/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) Section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit. Record review of resident #3's Physician Orders revealed orders dated 5/05/21 for Vitamin C 500 MG tablet take (one) 1 tablet by mouth twice a day. A record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of Vitamin C. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/20/21 of Pressure Injury 3 Pressure Injuries .Sacrum/Coccyx Stage IV (4) with Goal Resident #3 wounds will show evidence of healing over the next 90 days 5/12/21. Interventions included Vitamin C 500 MG PO BID. Record review of Resident #3's Physician Orders revealed orders dated 12/29/20 for [MEDICATION(S)] 15 MG Tablet take (one) 1 tablet by mouth every evening. A record review of the Medication chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose [MEDICATION(S)] 15 MG. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/07/19 of High Risk for Pain with the Goal listed Resident #3 will have pain relief at least 1 (one) hour after pain interventions are given over the next 90 days. Interventions included [MEDICATION(S)] 15 MG tablet. Take 1 tablet po daily. A record review of Physician Orders with an original date of 12/29/20 and updated on 7/21/21 revealed Resident #3 has orders in place for [MEDICATION(S)] ([MEDICATION(S)]) 5 mg tablet take one (1) tablet po at bedtime. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 5 MG. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date unlisted diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #3 will not have a hypertensive crisis by next review on 8/11/21 Interventions included [MEDICATION(S)] 5 MG tablet. Take 1 tablet at bedtime. Record review of resident #3's Physician Orders revealed orders dated 12/29/20 for [MEDICATION(S)] ([MEDICATION(S)]) 20 MG capsule take (one) 1 capsule by mouth at bedtime. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 20 MG. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/07/19 of Nutritional State Resident #3 has risk for nutritional issues related to .dyspepsia with the Goal listed Resident #3 Current diet will provide resident's estimated nutritional needs .and will maintain nutritional status within acceptable parameters X 90 days 8/11/21. Interventions included [MEDICATION(S)] 20 MG PO daily. Record review of Resident #3's Physician Orders revealed orders dated 12/29/20 for [MEDICATION(S)] 20 MG tablet take (one) 1 tablet by mouth every 2:00 PM and 6:00 PM Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 20 MG. A record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/07/19 of High Risk for Pain with the Goal listed Resident #3 will have pain relief at least 1 (one) hour after pain interventions are given over the next 90 days. Interventions included [MEDICATION(S)] 20 MG PO 2PM & 6PM. Record review of Resident #3's Physician Orders revealed orders dated 12/29/20 for [MEDICATION(S)] [MEDICATION(S)] 324 MG tablet take (one) 1 tablet by mouth every 2:00 PM and 6:00 PM. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] [MEDICATION(S)] 324 MG. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/07/19 of Nutritional State Resident #3 has risk for nutritional issues related to .dyspepsia with the Goal listed Resident #3 Current diet will provide resident's estimated nutritional needs .and will maintain nutritional status within acceptable parameters X 90 days 8/11/21. Interventions included [MEDICATION(S)] Gluc 324 MG PO (by mouth) every 2:00 PM and 6:00 PM. Record review of Resident #3's Physician Orders revealed orders dated 12/29/20 for [MEDICATION(S)] 850 MG tablet take (one) 1 tablet by mouth (thirty) 30 minutes prior to lunch and dinner. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 4:00 PM dose of [MEDICATION(S)] 850 MG. Record review of Resident #3's Care Plan revealed resident had the Problem/Need with onset date 1/07/19 of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included [MEDICATION(S)] 850 MG. Take one (1) tablet by mouth thirty (30) minutes prior to lunch and dinner. Record review of a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Medication Chart revealed on 7/25/21, the facility failed to apply the ordered [MEDICATION(S)] patches at 6:00 PM. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/07/19 of High Risk for Pain with the Goal listed Resident #3 will have pain relief at least 1 (one) hour after pain interventions are given over the next 90 days. Interventions included [MEDICATION(S)] Patch 5%. Apply 2 patches to right knee every 12 hours. Record review of a Physician Order with an original order date of 9/13/19 and updated on 7/21/21 are in place for Resident #3 for [MEDICATION(S)] 10 mg suppository dispense as [MEDICATION(S)] 10 mg suppository insert one (1) suppository rectally daily. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 10 MG. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date of 1/7/19 H/R for Constipation R/T impaired mobility, hx of constipation, refusing laxatives ordered frequently, side effects (s/e's) of meds with Goal Resident #3 will have a BM at least 3 days with adherence of ordered meds for constipation x next 90 days. 8/11/21 Interventions included [MEDICATION(S)] 10 MG Suppository, Insert 1 rectally daily. Record review of Resident #3's Physician Orders revealed orders dated 9/13/19 for [MEDICATION(S)] powder dispense as polyethylene [MEDICATION(S)] powder mix 17 grams in 6 ounces of liquid and give by mouth (two) 2 times a day. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM of [MEDICATION(S)]. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date of 1/7/19 H/R for Constipation R/T impaired mobility, hx of constipation, refusing laxatives ordered frequently, s/e's of meds with Goal Resident #3 will have a BM at least 3 days with adherence of ordered meds for constipation x next 90 days. 8/11/21 Interventions included [MEDICATION(S)] 17 gm in 6 oz fluid po BID. Record review of Resident #3's Physician Orders revealed orders dated 9/13/19 for [MEDICATION(S)] 800 MG tablet take (one) 1 tablet by mouth (three) 3 times daily. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)]. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/07/19 of High Risk for Pain with the Goal listed Resident #3 will have pain relief at least 1 (one) hour after pain interventions are given over the next 90 days. Interventions included [MEDICATION(S)] 800 MG PO TID (three times a day). Record review of Resident #3's Physician Orders revealed orders dated 9/13/19, for [MEDICATION(S)] 40 MG dispense as [MEDICATION(S)] 40 MG tablet take (one) 1 tablet by mouth at bedtime. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer [MEDICATION(S)] 40 MG. Record review of Resident #3's Care Plan revealed Problem/Need with the onset date unlisted diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #3 will not have a hypertensive crisis by next review on 8/11/21 Interventions included [MEDICATION(S)] 40 MG PO (by mouth) at HS (bedtime). Record review of a Physician's Order dated 5/7/21 was in place for left heel wound - cleanse with NS, pat dry, apply Dakin's 0.25% moistened gauze to wound bed. Cover with gauze and kerlix or conform BID. Record review of Resident #3's Treatment Chart revealed on 7/25/21, an ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover w/gauze and kerlix or Conform BID was not initialed as completed on the B shift. Record review of Resident #3's Care Plan revealed Problem/Need with the no onset date listed Pressure Injury 3 Pressure Injuries Left Heel Stage iv Right Heel Stage iv .Sacrum/Coccyx Stage IV (4) with Goal Resident #3 wounds will show evidence of healing over the next 90 days 5/12/21. Interventions included Bilateral Heel Treatment wash and dry with Normal Saline and dry. Apply Kaldostat with dressing every 12 hours. The care plan did not reflect the current physician's order for this treatment. Record review of a Physician Order dated 5/19/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Treatment Chart revealed on 7/25/21, an ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . notify MD of acute changes was not initialed as completed on the B shift. Record review of Resident #3's Care Plan revealed Problem/Need with the no onset date listed Pressure Injury 3 Pressure Injuries Left Heel Stage iv Right Heel Stage iv .Sacrum/Coccyx Stage IV (4) with Goal Resident #3 wounds will show evidence of healing over the next 90 days 5/12/21. Interventions included Bilateral Heel Treatment wash and dry with Normal Saline and dry. Apply Kaldostat with dressing every 12 hours. The care plan did not reflect the current physician's order for this treatment. Record review of a Physician Order dated 7/7/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Treatment Chart revealed on 7/25/21, an ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Care Plan revealed Problem/Need with the no onset date listed Pressure Injury 3 Pressure Injuries Left Heel Stage iv Right Heel Stage iv .Sacrum/Coccyx Stage IV (4) with Goal Resident #3 wounds will show evidence of healing over the next 90 days 5/12/21. Interventions included Sacral wound care: cleanse with normal saline and pat dry. Apply Santyl BID (two times a day). The care plan did not reflect the current physician's order for this treatment. Record review of a Physician's Order dated 6/4/21 is in place for peri-area care to cleanse with Dakin's solution, pat dry apply [MEDICATION(S)] ointment to peri-wound area daily cover w/soft gauze and paper tape. Record review of Resident #3's Treatment Chart revealed on 7/25/21, a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . (The Treatment Chart did not reflect the current physician's order for this treatment.) Record review of Resident #3's Care Plan revealed Problem/Need with the onset date 1/07/19 of Suprapubic catheter and incontinent bowels with the Goal listed Resident #3 will not have any signs/symptoms of [CONDITION(S)] (urinary tract infections) X 90 days. Interventions included Cleanse suprapubic catheter site every night .with NS (Normal Saline), apply drain sponge. The Care Plan did not reflect the current Physician's Order for this treatment. Resident #4 Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)]. Record review of 5/12/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) Section C revealed a BIMS score of 0 out of 15 which indicated no cognitive deficit. Record review of Physician's Order dated 7/23/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 750 MG. Record review of Resident #4's Care Plan revealed Problem/Need with onset date unlisted of Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions did not include [MEDICATION(S)]. The Care Plan did not reflect the current physician's order. Record review of Physician's Order dated 7/23/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 200 mg. A record review of Resident #4's Care Plan revealed Problem/Need with onset date unlisted of Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included [MEDICATION(S)]([MEDICATION(S)]) 100MG by mouth take (two) 2 capsules at bedtime A record review of Physician's Orders dated 3/12/21 and updated 7/21/21 revealed Resident #4 had an order in place for Supplement: Resource 2.0 one PO (by mouth) (four times daily) QID. A record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of Resource 2.0. A record review of Resident #4's Care Plan revealed Problem/Need with onset date unlisted of ARF Nutritional Issues RT VitaminD Deficiency, Wandering, Refuses Meals, [CONDITION(S)], and Neurocognitive DO and Goal of resident will have no major changes in weight over the next 90 days 8/11/21. Interventions included Resource 2.0 carton po QID. A record review of Physician's Orders dated 3/12/21 and updated 7/21/21 revealed Resident #4 had an order in place for Promod 30 cc po (by mouth) BID twice daily. A record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of Promod. A record review of Resident #4's Care Plan revealed Problem/Need with onset date unlisted of ARF Nutritional Issues RT VitaminD Deficiency, Wandering, Refuses Meals, [CONDITION(S)], and Neurocognitive DO and Goal of resident will have no major changes in weight over the next 90 days 8/11/21. Interventions included Promod 30 CC PO BID. Resident #5 Record review of Resident #5's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's 6/30/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 14 out of 15 which indicated no cognitive deficit. A record review of Physician's Orders dated 7/13/21 and updated 7/21/21 revealed Resident #5 had an orders in place for [MEDICATION(S)] 0.5 mg orally 2 times daily. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of Risperdone 0.5 MG. Record review of Resident #5's Care Plan revealed Problem/Need with onset date 4/2/2001 of Violence: self-directed or directed at others, risk for ARF: S/E of [CONDITION(S)] Meds with Goal of resident will have no undetected S/E R/T [CONDITION(S)] meds x 90 days 9/29/21. Interventions included [MEDICATION(S)] 0.5 mg PO BID. A record review of Physician's Orders dated 7/13/21 and updated 7/21/21 revealed Resident #5 had an order in place for [MEDICATION(S)] oral tab 500 MG oral Q evening: for Sz ([CONDITION(S)]), Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 500 MG. Record review of Resident #5's Care Plan revealed Problem/Need with onset date 11/13/13 of Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included [MEDICATION(S)] 500MG by mouth very PM. Record review of Physician's Orders dated 7/13/21 and updated 7/21/21 revealed Resident #5 had an order in place for [MEDICATION(S)] 0.4 MG capsule SA disp as Tamsulosin HCL 0.4 mg Take one (1) capsule po at bedtime. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 0.4 mg Record review of Resident #5's Care Plan revealed Problem/Need with onset date 4/8/2002 of OCC (occasional) Incontinent of Bladder and Continent of Bowel: ARF: [CONDITION(S)] R/T [CONDITION(S)], occ incontinency [CONDITION(S)] Diagnosis . with Goal of resident will not have any s/sx of a [CONDITION(S)] X (ninety) 90 days 9/29/21. Interventions included [MEDICATION(S)] 0.4 mg 1 po every 24 hours. A record review of Physician's Orders dated 7/13/21 and updated 7/21/21 revealed Resident #5 had an order in place for [MEDICATION(S)] oral sol. 40 milligram, two times daily routine for: CHF. Record review of the Medication Chart revealed on 7/25/21, the facility failed to administer the 6:00 PM dose of [MEDICATION(S)] 40 mg. Record review of Resident #5's Care Plan revealed Problem/Need with onset date 11/13/2013 of Dx. Hypertension with Goal of resident will not have a hypertensive crisis over the next (ninety) 90 days 9/29/21. Interventions included [ME

Based on staff interviews, resident interviews, facility policy review, and record review the facility failed to ensure significant medication (anti-coagulants, anti-[CONDITION(S)], and pain management medications) were administered to prevent discomfort or complications for 11 of 20 residents on the South Unit of the facility. This resulted in Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11 not receiving significant medications. The facility did not have licensed nurse coverage for twenty (20) residents on the South Unit of the facility for six (6) hours from 4:55 PM through 11:00 PM on 7/25/21. None of the medications scheduled to be administered between 5:00 PM and 11:00 PM were administered to any of the twenty (20) residents on the South Unit of the facility during those six (6) hours, including Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11who missed doses of significant medications including anti-coagulants, anti-[CONDITION(S)], and pain management medications. The facility failed to provide nursing services and administration of significant medications to eleven (11) residents on the 3-11 shift on 7/25/21. This placed the residents at risk an in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/25/21 when the facility failed to provide a licensed nurse to administer necessary medications and supervision. On 8/05/21 at 5:15 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 8/07/21 at 10:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed on 8/06/21 at 5:00 PM and the IJ was removed as of 8/07/21. The SA validated the Removal Plan on 8/09/21 and determined the IJ was removed on 8/07/21, prior to exit. Therefore, the scope and severity for CFR 483.45(f)(2) (F760)- Residents are free from any significant medication errors, was lowered from a K to an E while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy, dated October 2018, titled MEDICATIONS, ADMINISTRATION, TIMING, AND TREATMENT revealed .C. Time critical medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. These medications must be administered within thirty minutes before or after their scheduled dosing time, for a total window of 1 hour. Time critical scheduled medications include but are not limited to; (1) Antibiotics, (2) Anticoagulants, (3) Insulin, (4) Anticonvulsant, (5) Immunosuppressive agents, (6) Pain medication, (7) Medications prescribed for administration within a specified period of time of the medication order . Record review of the facility schedule for 7/25/21 revealed the facility did not have licensed nurse coverage for twenty (20) residents on the South Unit of the facility for six (6) hours from 4:55 PM through 11:00 PM on 7/25/21. Record review of the facility's INVESTIGATIVE FINDINGS dated August 3, 2021, revealed The Department of Safety and Investigative Services was notified that on Sunday, July 25, 2021, B-shift only had I nurse from 4:55 PM until 1 1 PM LPN (#1) covered the North Side Hall for B & C shift. The South Side Hall did not have coverage for B-shift. A-Shift RN (#1) worked South Side Hall from 7:00 AM until 4:55 PM but did not pass any medications while she waited for a nurse to relieve her for B-Shift 3-11. The Contract Nurse, (LPN #4) scheduled for B-Shift was a no call/no show and RN (#1) left stating that she had told the DON on call that she could not stay over that day prior to working A-shift. LPN (#3) also worked A-Shift and was asked if she could stay over for B-Shift and also stated that she could not work B-Shift and left at 4:55 p.m. FINDNGS: NEGLECT - SUBSTANTIATED AGAINST THE FACILITY. (Formal names replaced by SA with Staff Indicators.) ON 8/03/21 at 3:48 PM, an interview with LPN #1 confirmed he was the only nurse on duty from 5:00 PM until 11:00 PM in the facility on 7/25/21, and he was working on the North Unit. He stated there was no nurse working on the South Unit for twenty (20) residents. LPN #1 stated RN #1 was working 'South Side' 7:00AM-3:00PM on Sunday 7/25/21 and left at 5:00 PM. LPN #1 stated he had not been asked to count the 'South Side' narcotics which is verification of accuracy of narcotic medication count and an indication that the nurse accepting the medication cart and keys also accepts responsibility for the residents. RN #1 did not tell LPN #1 when she left, and he did not know where she left the keys to the medication cart or the narcotics lock box for the 'South Side'. LPN #1 stated he had not been asked to accept the responsibility for the 'South Side' of the facility on B shift 3:00 PM -11:00 PM. When asked if he had been aware of the care not being provided, LPN #1 stated I didn't even know she (RN #1) had left. LPN #1 stated he had not reported the situation to anyone because I knew they already knew what was going on. On 8/04/21 at 9:15 AM, an interview with Medical Director (MD) #1, revealed he had been notified about the incident after noon on 7/26/21 and was told there was no licensed nurse on South Unit of the facility from 5:00 PM until 11:00 PM. MD #1 stated he found out about the incident on the afternoon of Monday, 7/26/21. When asked what he thought about the residents being without a nurse, MD #1 stated he thought it was troubling. When asked if there were any residents he felt were vulnerable MD #1 stated in his opinion the residents who received antiseizure medications were particularly at risk for negative outcomes, especially because the residents on South Side of the facility were prone to breakthrough seizures every few weeks and of the residents diagnosed with [CONDITION(S)] disorders, those prescribed linear medications were at the highest risk of breakthrough [CONDITION(S)] activity due to having missed a dose of their antiseizure medication. MD #1 stated any resident who had had a recent psychoactive medication change or had recently been started on a new psychoactive medication were most at risk for behavioral disturbances due to having missed a dose of their psychoactive medications. MD #1 stated that although there were no diabetic residents which required routine blood glucose monitoring on B shift 3:00PM - 11:00PM it would have been important to have a licensed staff member monitoring diabetic residents for signs and symptoms of [CONDITION(S)] or [CONDITION(S)]. When asked where he thought he breakdown in providing adequate staffing occurred, MD #1 stated nursing leadership. On 8/04/21 at 10:00 AM, an interview with RN #1 revealed she had left the facility at 4:55 PM without on-site licensed nurse relief. She stated she had clocked out at 4:55PM and left the facility. She stated she did not administer any medications prior to leaving. RN #1 denied asking LPN #1 to accept responsibility for the South Side of the building and stated, that's not a thing. RN #1 stated she agreed the residents needed their medicines. When asked what she considered as neglect she responded, when staff don't take care of the residents. On 8/04/21 at 11:00 AM, an interview with Nurse Administrator confirmed there was no licensed nurse on duty for the South Unit of the facility from 5:00 PM until 11:00 PM on 7/25/21. On 8/04/21 at 1:20 PM, an interview with Resident #2 revealed he was the one who reported there was no nurse on 'South Side' hall of the facility, but he could not recall the name of the nurse he reported to or the date. Resident #2 stated he realized there was a problem on 7/25/21 around 7:30 PM and he had not received any medicine. He stated medicine was usually administered by the nurses at around 6:00 PM. Resident #2 stated This Sunday (7/25/21) nobody ever came at all. When asked if there were any medication, he was particularly concerned about having not received on 7/25/21, Resident #2 responded I was supposed to get my suppository, my bowels won't move without it and I don't get it every day, only certain days every week. I get to feeling bad if I don't get it, so it worried me. Also, I was supposed to get a dose of [MEDICATION(S)] muscle relaxer that was missed and that worried me too, but I didn't really have any problem from it. When asked how it made him feel to have not received his medications to which Resident #2 responded aggravating, frustrating, disappointing, angry. It made me feel insecure. Resident #2 stated I'm dependent on these people. They are responsible for me. It's just like they don't understand that. On 8/04/21 at 1:40 PM, an interview with Resident #3 revealed he recalled not having received his medications on 'B shift' 7/25/21. Resident #3 was alert and oriented and communicated well verbally. Resident #3 stated it bothered him to think people don't come to work when they should. He denied having any negative outcome from missing his medications on 'B shift' 7/25/21. Resident #3 stated They need to do something and provided clarification, The people that run this place need to do something to make sure there is somebody here to give us our medicines and stuff. On 8/04/21 at 3:58 PM, a telephone interview with the Staffing Director revealed LPN #1 and LPN #4 were scheduled to work 3:00PM-11:00PM (B shift) on 7/25/21. The Staffing Director stated On Thursday (7/22/21) at 1:17 PM prior to the weekend I sent a text message to (LPN #4) to confirm the scheduled shifts for the weekend to review and confirm. She texted back and asked if she could be off on Saturday, but I texted her back and told her no, that I really, really needed her and she texted back and confirmed the schedule. She stated LPN #4 did not report for work or call-in on 7/25/21. She was able to confirm but unable to explain how the South Side of the facility ended up without a nurse on 7/25/21 except to say that LPN #4 was a no-call, no-show. On 8/04/21 at 4:20 PM, a telephone interview with CNA #2, revealed she worked 3:00PM-11:00PM on 7/25/21 in the facility. CNA #2 stated she remembered working on 7/25/21 and there had not been a nurse on the 'South Side' since 5:00 (PM) and that he (LPN #1) didn't accept the assignment for the South Unit. On 8/05/21 at 9:30 AM, an interview with CNA #3 stated she worked 3:00PM-11:00PM and 11:00PM-7:00AM on 7/25/21 in the facility. CNA #3 stated on 7/25/21 One (1) nurse worked 'North Side' and no nurse on 'South Side'. CNA #3 stated the only time LPN #1 came to the 'South Side' was to find a 'North Side' resident to give them their medicine. Resident #1: Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/05/21 Annual Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 0 out of 15 which indicated severe cognitive deficit for Resident #1. Record review of Resident#1's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)]/APAP 5/325MG Take 1 (one) Tablet by mouth twice daily for 28 (twenty-eight) days starting 7/19/21. Record review of Resident #1's Medication Chart revealed on 7/25/21 [MEDICATION(S)]/APAP 5/325MG Take 1 (one) Tablet by mouth twice daily for 28 (twenty-eight) days 9:00 PM Dose was not initialed on the Medication Chart. Resident #2: Record review of Resident#2's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/26/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit for Resident #2. Record review of Resident #2's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 2.5 MG by mouth twice daily, [MEDICATION(S)] 10MG suppository Insert 1 (one) suppository rectally on Tuesday, Thursday, Sunday and Daily as needed for Constipation, and [MEDICATION(S)] 20MG Tablet Take 1 Tablet by mouth 3 (three) times daily. Record review of Resident #2's Medication Chart revealed on 7/25/21 [MEDICATION(S)] suppository 10 MG insert (one) 1 rectally every Tuesday, Thursday and Sunday, Observe for side effects of [MEDICATION(S)] .Report these to MD immediately, [MEDICATION(S)] 2.5 MG by mouth twice daily, and [MEDICATION(S)] 20MG Tablet Take 1 Tablet by mouth 3 (three) times daily, were not initialed on the Medication Chart. Resident #3: Record review of Resident #3's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/12/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit for Resident #3. Record review of Resident #3's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 15 MG Tablet take (one) 1 tablet by mouth every evening, [MEDICATION(S)] 5 MG tablet take (one) 1 tablet by mouth at bedtime, [MEDICATION(S)] 20 MG tablet take (one) 1 tablet by mouth every 2:00 PM and 6:00 PM, [MEDICATION(S)] 850 MG tablet take (one) 1 tablet by mouth (thirty) 30 minutes prior to lunch and dinner, [MEDICATION(S)] 800 MG tablet take (one) 1 tablet by mouth (three) 3 times daily, [MEDICATION(S)] 5% Patch Apply 2 (two) patches to right knee every 12 (twelve) hours, [MEDICATION(S)] 500 MG tablet take (one) 1 tablet by mouth twice a day, and Observe for signs and symptoms of [CONDITION(S)] .Obtain vital signs and accu-check & report to MD, Observe for signs and symptoms of [CONDITION(S)] .Obtain vital signs and accu-check & report to MD, and Accu-Checks as needed with regular insulin per sliding scale as needed. Record review of Resident #3's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 20MG Tablet Take 1 Tablet by mouth every 2PM and 6PM, 6:00 PM Dose, [MEDICATION(S)] 5% Patch Apply 2 (two) patches to right knee every 12 (twelve) hours, 6:00 PM Dose, [MEDICATION(S)] 15MG Tablet Take 1 (one) tablet by mouth every evening, 6:00 PM Dose (once a day dose), [MEDICATION(S)] 5MG Tablet Take 1 (one) tablet by mouth at bedtime, 6:00 PM Dose (once a day dose), and [MEDICATION(S)] 500MG Tablet Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose was not initialed on the Medication Chart. Resident #4: Record review of Resident #4's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)]. Record review of 5/12/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 0 out of 15 which indicated no cognitive deficit for Resident #4. Record review of Resident #4's Physician Orders revealed orders for [MEDICATION(S)] 100 MG dispense as [MEDICATION(S)] Sodium extended release 100 MG take (one) 1 capsule by mouth each morning and (two) 2 capsules each evening dated 7/23/21, [MEDICATION(S)] 500 MG tablet dispense as [MEDICATION(S)] 500 MG tablet take (one) 1 tablet by mouth q AM and 750mg PO q PM dated 7/23/21. Record review of Resident #4's Medication Chart revealed on 7/25/21 (Resident #4's [CONDITION(S)] medication was adjusted on 7/23/21), [MEDICATION(S)] Sodium Extended 200MG ([MEDICATION(S)] 200MG) Take 200MG by mouth each bedtime, 6:00 PM Dose and [MEDICATION(S)] 750MG ([MEDICATION(S)] 750MG) Take 750MG by mouth q PM, 6:00 PM Dose were not initialed on the Medication Chart. Resident #5: Record review of Resident #5's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 6/30/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 14 out of 15 which indicated no cognitive deficit for Resident #5. Record review of Resident #4's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 500 MG tablet dispense as [MEDICATION(S)] 500 MG tablet take ½ tablet by mouth every morning and 1 (one) tablet by mouth every evening, [MEDICATION(S)] 2MG Tablet Take 1 (one) tablet by mouth at bedtime for 28 (twenty-eight) days ordered 7/13/21, and [MEDICATION(S)]/APAP 5/325 MG take 1 (one) tablet by mouth every 6 (six) hours as needed for 28 (twenty-eight) days order date of 7/14/21. Record review of Resident #5's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 10MG/ML solution Take 40MG (4 CC) by mouth twice a day, 6:00 PM Dose, [MEDICATION(S)] 500MG Tablet ([MEDICATION(S)] 500MG Tablet) Take ½ (half) tablet by mouth morning and 1 (one) tablet by mouth every evening, 6:00 PM Dose, and [MEDICATION(S)] 2MG Tablet Take 1 (one) tablet by mouth at bedtime for 28 (twenty-eight) days, started 7/13/21, 8:00 PM Dose, was not initialed on the Medication Chart. Resident #6: Record review of Resident #6's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 7/07/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 14 out of 15 which indicated no cognitive deficit for Resident #6. Record review of Resident #6's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 200 MG tablet take (one) 1 tablet by mouth twice daily for (twenty-eight) 28 days (started 7/13/21), [MEDICATION(S)] 125 MG sprinkle capsule dispense as [MEDICATION(S)] 125 MG sprinkle take (four) 4 capsules by mouth (three) 3 times daily, [MEDICATION(S)] 300 MG tablet take (one) 1 tablet by mouth every morning and (two) 2 tablets by mouth at bedtime, and [MEDICATION(S)] Tar 25 MG tablet take (one) 1 tablet by mouth twice a day. Record review of Resident #6's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 200MG Tablet Take 1 (one) tablet by mouth twice daily for 28 (twenty-eight) days, started 7/01/21, 6:00 PM Dose, [MEDICATION(S)] 125MG Sprinkle ([MEDICATION(S)] 125MG Sprinkle) Take 4 (four) capsules by mouth 3 (three) times daily, 6:00 PM Dose, [MEDICATION(S)] 300MG Tablet Take 1 (one) tablet by mouth every morning and 2 (two) tablets by mouth at bedtime, 6:00 PM Dose, and [MEDICATION(S)] [MEDICATION(S)] 25MG Tablet Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose were not initialed on the Medication Chart. Resident #7: Record review of Resident #7's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 6/09/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 0 out of 15 which indicated severe cognitive deficit for Resident #7. Record review of Resident #7's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 30 MG tablet take (one) 1 by mouth at bedtime, and [MEDICATION(S)] 60 MG tablet take (two) 2 by mouth at bedtime, Observe for non-verbal side effects of [CONDITION(S)] medications .Notify MD of these side effects, [MEDICATION(S)] 500MG Tablet ([MEDICATION(S)] 500MG Tablet) Take 1 (one) tablet by mouth twice a day. Record review of Resident #7's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 30MG Tablet Take 1 Tablet by mouth at bedtime, 6:00 PM Dose, [MEDICATION(S)] 60MG Tablet Take 1 Tablet by mouth at bedtime, 6:00 PM Dose, and [MEDICATION(S)] 500MG Tablet ([MEDICATION(S)] 500MG Tablet) Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose were not initialed on the Medication Chart. Resident #8: Record review of Resident #8's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/05/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 0 out of 15 which indicated severe cognitive deficit for Resident #8. Record review of Resident #8's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 500 MG tablet dispense as [MEDICATION(S)] 500 MG tablet take (one) 1 tablet by mouth twice a day. Record review of Resident #8's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 500MG Tablet ([MEDICATION(S)] 500MG Tablet) Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose was not initialed on the Medication Chart. Resident #9: Record review of Resident #9's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/26/21 Annual Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit for Resident #9. Record review of Resident #9's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 500 MG tablet [MEDICATION(S)] coated (EC) dispense as [MEDICATION(S)] 500 MG tablet take 1 (one) tablet by mouth twice a day, and [MEDICATION(S)] 300MG Capsule Take 1 (one) capsule by mouth 3 (three) times daily, and [MEDICATION(S)] 200 MG tablet take 1 (one) tablet twice daily for 28 days dated 07/01/21. Record review of Resident #9's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 200MG Tablet Take 1 (one) tablet by mouth twice daily for 28 (twenty-eight) days, started 7/01/21, 6:00 PM Dose and [MEDICATION(S)] 300MG Capsule Take 1 (one) capsule by mouth 3 (three) times daily, 6:00 PM Dose were not initialed on the Medication Chart. Resident #10: Record review of Resident #10's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/12/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit for Resident #10. Record review of Resident #10's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 5 MG tablet by mouth twice a day. Record review of Resident #10's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 2.5 MG Tablet Take 1 (one) tablet by mouth twice a day was not initialed on the Medication Chart. Resident #11: Record review of Resident #11's FaceSheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/05/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 0 out of 15 which indicated severe cognitive deficit for Resident #11. Record review of Resident #11's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 50 MG infatab dispense as [MEDICATION(S)] 50 MG infatab take (two) 2 tablets by mouth twice daily. Record review of Resident #11's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 50 MG infatab dispense as [MEDICATION(S)] 50 MG infatab take (two) 2 tablets by mouth twice daily was not initialed on the Medication Chart. The facility submitted an acceptable Removal Plan for the IJ on 8/06/21 at 5:00 PM. Review of the facility's Removal revealed the facility took the following actions to remove the IJ on 8/06/21: REMOVAL PLAN In response to the Immediate Jeopardy (IJ) template provided to the Administrator cited on August 5, 2021, at 5:10 p.m., the following is a summary of the event and the actions taken by the facility to remove the Immediate Jeopardy. Brief Summary On 07/25/2021 [NAME] Inn Building 78, had insufficient licensed nursing staff from 5:00p.m. - 11:00p.m., which gives us neglect of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 on South Side unit of building 78. Medications were missed and no monitoring for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 during this time frame. The following corrective actions were taken for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 affected by the insufficient licensed nursing staff and other facility Residents who could be potentially affected by insufficient licensed nursing staff in the future. 1. On July 25, 2021, at 11:30 pm Licensed Practical Nurse#1 observed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 and no negative outcomes or harm noted. On 07/26/2021 at 9:00 a.m., the attending physician was notified that there were no adverse reactions. On 7/26/2021 at 9:00 a.m. attending physician observed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, and #20 and found no negative outcomes. The attending physician reviewed care plans and no care plans needed to be revised. On July 28, 2021, at 4:52p.m., the Mississippi State Department of Health Division of Health Facilities Licensure and Certification was notified of the incident. On August 3, 2021, at 2:45p.m. the Mississippi Attorney General's Medicaid Abuse and Fraud Division was notified of the incident. 2. On July 28, 2021, at 2:30pm until 3:00pm [NAME] Nursing Home Nurse Administrator verbally counseled the Registered Nurse #1 who did not stay to work 3-11pm shift on 7/25/21. On 08/06/2021 at 3:30 p.m., the Nurse Executive did a one on one in-service with Registered Nurse#1. Registered Nurse#1 was educated and counseled on the following policies and procedures: Medication Administration, Medication Keys, Narcotics, Mandated Overtime to ensure incident of leaving the medication cart and or building without counting off with another nurse does not reoccur nor leaving patients uncared for without relief. On 08/06/2021 at 3:30p.m., the Nurse Executive contacted the MS Board of Nurses to report the actions of Registered Nurse #1. 3. On July 29, 2021, at 02:30 p.m., a Quality Assurance meeting was conducted with [NAME] Nursing Home Director, Chief Medical Doctor, Safety Investigative Services, [NAME] Inn Nursing Home Administrator, MS State Hospital Nurse Executive, [NAME] Nursing Administrator, Director of Nursing, Administrator-in-Training to discuss and determine corrective actions for further incidents of this magnitude. Corrective actions discussed were to inform resident's representative of incident on 07/25/2021. Educate staff on notifying leadership through proper communication (campus switchboard). Inservice staff on Injuries, Abuse, Neglect, Mistreatment, Misappropriation of Resident Property or Exploitation of Resident POL J530-55, Mandatory Overtime/Required Supervision Department of Mental Health (DMH), Rights of Residents J530-65, Accountability for Nursing Personnel Assignment J550-05, Management of Controlled Substances NUR210-116 and Chain of Notification for Staffing Concerns. No changes to the discussed policies were made. On 08/06/2021 at 3:30pm licensed nursing staff was in-serviced on Care Plan Policy and Procedures. On 07/30/2021 through 08/06/2021 the above policies listed were reviewed with licensed nursing staff. 4. On July 30, 2021 and August 2, 2021, Social Worker#1 called Residents #1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 representative of the incident and documented in resident's medical chart. 5. On August 2, 2021, at 07:10pm [NAME] Nursing Home Nurse Executive revised the Chain of Notification protocol, begin in-servicing all nursing staff. No staff will be allowed to work until Inservice is completed. The Chain of Notification protocol ensures the notification of nurses for availability and accessibility of nursing staff on a continuing basis to work a medication cart for shortage of Nursing Home nurses. The Chain process is as follows: The Mississippi State Hospital operator will notify the [NAME] Nursing Home Ground Supervisor, if the Ground Supervisor is not present operator will call Director of Nursing on call. If Ground Supervisor is unable to staff the nurse needed, then he/she will notify the Director of Nursing on call. Director of Nursing on call will call the building Director of Nursing who will attempt to staff the nurses needed and if unable will notify the Nursing Staffing Director or Coordinator. Nursing Staffing Director or Coordinator will attempt to staff the nursing homes and if unable will notify the [NAME] Nursing Home Administrator. The [NAME] Nursing Home Administrator on Call will determine with the Director of Nursing on call which buildings can be operated with one nurse if additional nurse cannot be found. After this occurs the [NAME] Nursing Home Director should be notified. 6. On 08/05/2021, the attending physician began to evaluate the medication load on all shifts to efficiently maximize staffing. 7. On 08/06/2021 at 10:00 a.m. an additional executive meeting was held to discuss staffing concerns and expedite contracts. Those present were, Human Resource Director, Chief Medical Officer, Service Outcome Director, Nurse Executive, and [NAME] Nursing Home Director. On 08/06/2021, [NAME] Nursing Home Nurse Executive implemented staff changes and an on-call schedule with the Staffing Director and Staffing Coordinator to ensure adequate staffing is in place. The Staffing Director and Staffing Coordinator will text and or call all scheduled nurse staff to verify commitment to their shift. The Staffing Director or Coordinator will contact scheduled nurses the day before their scheduled shift to verify commitment. The Staffing Department has personnel twenty-four hours to receive calls from employees. An employee has to call at least two hours before their shift if they are unable to work. The Staffing Department calls each building to verify the number of employees on each shift. If a building is short, the staffing personnel may pull from another building to cover staff shortage. On 07/30/2021, 8 of 15 emergency covid nursing contracts that were executed on July 16, 2021 were extended through 09/01/2021. New contracts were advertised through 08/04/2021. On 08/02/2021 through 08/06/2021, the Nurse Executive participated in interviewing 18 contract and 8 full time licensed nurse applicants. A formal offer of employment has to go through personnel. 8. The corrected actions were implemented on 08/06/2021 at 5:00 p.m. 9. The facility alleges the Immediate Jeopardy was removed on 08/07/2021 at 10:00 a.m. Validation: On 8/09/21 the SA validated the facilities removal plan by staff interview, record reviews, review of In-Service Sign-in Sheets, review of Monitoring Forms, review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The SA implement

Based on policy review, record review, staff interviews, and resident interviews the facility failed to provide sufficient qualified nursing staff to provide nursing related services to assure resident safety for one (1) of two (2) units, as evidenced by twenty (20) residents without licensed nursing services from 4:55 PM to 11:00 PM on 7/25/21 on the South Unit of the facility. Licensed Practical Nurse (LPN) #4 was scheduled to report at 3:00 PM on 7/25/21, but LPN #4 did not call in and did not arrive for her shift at the facility. Registered Nurse (RN) #1 had been scheduled to work 7:00AM until 3:30 PM on 7/25/21 and had worked since 7:00 AM and left the facility at 4:55 PM without on-site licensed nurse relief present. LPN #1 arrived for work at 3:00 PM but did not accept responsibility for the twenty (20) residents on the South Unit of the facility. The Nurse Administrator and the Registered Nurse (RN) Nurse Manager were aware RN #1 refused to stay. Contract and agency nurses did not respond to the call for replacement. No licensed nurse reported to duty on the South Unit of the facility between 4:55 PM and 11:00 PM. The facility failed to follow it's stated procedure for replacing staff in case of call-ins or no call, no shows. The Nurse Administrator and the RN Manager were aware of the staffing problem and the On-Call Administrator was not notified. The On-Call Director of Nurses failed to assure a minimum of one licensed nurse per floor, per building as needed according to the facility's policy. The facility failed to provide a licensed nurse from 4:55 PM until 11:00 PM on 7/25/21 to administer medications, treatments, and nursing services which placed the twenty (20) residents residing on the South unit of the facility in a situation which was likely to cause serious injury, harm, impairment, or possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 7/25/21, when the facility failed to provide a licensed nurse to provide necessary supervision, medications, treatments, or monitoring. On 8/05/21 at 5:15 PM, the SA informed the Nursing Home Administrator of the IJ and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 8/07/21 at 10:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed on 8/06/21 at 5:00 PM and the IJ was removed as of 8/07/21. The SA validated the Removal Plan on 8/09/21 and determined the IJ was removed on 8/07/21, prior to exit. Therefore, the scope and severity for CFR 483.35 (a)(1)(2)-F725 (Sufficient Staffing) was lowered from a K to an E while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled ACCOUNTABILITY FOR NURSING PERSONNEL ASSIGNMENT dated August 2020, SUPERSEDES February 2017 revealed 1. PURPOSE AND APPLICABILITY. This policy defines the steps to be followed in accounting for nursing personnel reporting to (Proper name of the facility) on each shift. This policy applies to all (facility) nursing personnel .3. PROCEDURE. The Director of Nursing (DON) will be responsible for preparing the (facility) nurse schedule and unit assignment for each 24-hour period. The schedule and assignment will be forwarded to the Nurse Staffing Coordinator (NSC) and placed on a master staffing schedule. B. The NSC or DON on call will verify by telephone that scheduled nurses are present in the assigned buildings/units at 7:00 a.m., Monday through Friday. The NSC or DON on call will reassign nurses as necessary to assure a minimum of one licensed nurse per floor, per building in the unit. C. The staffing personnel .will take call-ins from nursing staff every shift. The staffing personnel will notify the DON on call who will attempt to cover the shift or shifts with a nurse from their building/unit. The NSC will make changes on the Master Schedule and contact the authorized agencies for contract nurses as needed. D. The RN (Grounds) Supervisor or DON on call will take call-ins after 3:30 p.m., Monday through Friday and all shifts on weekends and Holidays .E. On weekends and holidays .The A-Shift RN supervisor . will verify that A-Shift scheduled nurses are present in their assigned building. The A-Shift RN Supervisor . will verify that B-Shift scheduled nurses are present in their assigned buildings. The B-Shift RN Supervisor or DON on call will verify that C-Shift scheduled nurses are present in their assigned building. (l) If the Nursing Services Coordinator(NSC) receives a call in from a (Proper Name of facility) nurse, a cancellation that the agency was not able to replace, or nurses shown on the written schedule cannot be accounted for, the nurse designated for staffing will call all buildings to ask (Proper Name of facility) nursing staff if they would work overtime, then call the authorized nursing agencies in an attempt to acquire the required minimum nursing staff, if staffing nurse is unable to acquire the minimum nursing staff he/she will notify the DON on call. (2) No licensed nurse will leave the assigned unit until there is relief by another licensed nurse at shift change. (3) When necessary, nurses will be pulled to buildings that has only one (l ) nurse. If a building has three (3) or more nurses, excluding the DON, a nurse will be pulled to the buildings of need to maintain a minimum of two (2) nurses on all shifts. (4) At no time will a licensed nurse leave a building without on-site licensed nurse relief. Should a nurse have to leave the building for a meal break or for an emergency, the nurse will notify the on-site RN Supervisor and/or designated staffing person for relief arrangements. F. Shift leaders will notify the shift RN Supervisor and/or DON on call immediately should a licensed nurse leave without relief and there is no other licensed nurse on the unit. The RN supervisor and/or designated staffing nurse will notify the DON on call. Record review of facility Nurse Staffing Schedule revealed no licensed staff was on duty for the South unit of the facility from 4:55 PM through 11:00 PM on 7/25/21. Record review revealed the facility completed an investigation related to insufficient staffing on 7/25/21. Record review of the facility Investigative Findings dated 8/03/21 revealed: INVESTIGATIVE FINDINGS-August 3, 2021-NEGLECT: MULTIPLE RESIDENTS-AIT-The Department of Safety and Investigative Services was notified that on Sunday, July 25, 2021, B-shift only had I nurse from 4:55 p.m. until 1 1 p.m. (LPN #1) covered the North Side Hall for B & C shift. The South Side Hall did not have coverage for B-shift. LPN (#2) worked the South Side Hall for C-Shift 11:00 p.m. until 7:00 a.m. A-Shift (RN #1) worked South Side Hall from 7:00 a.m. until 4:55 p.m. but did not pass any medications while she waited for a nurse to relieve her for B-Shift 3-11. The Contract Nurse, (LPN #4), scheduled for B-Shift was a no call/no show and (RN #1) left stating that she had told the DON on call that she could not stay over that day prior to working A-shift. (LPN #4) also worked A-Shift and was asked if she could stay over for B-Shift and also stated that she could not work B-Shift and left at 4:55 p.m. FINDNGS: NEGLECT - SUBSTANTIATED AGAINST THE FACILITY FAILURE To FOLLOW POLICY JNH POL J550-05 ACCOUNTABILITY FOR NURSNG PERSONNEL ASSIGNMENT - IS SUBSTANTIATED AGANST (Nurse Administrator) and (RN #1) . Therefore, Neglect is substantiated against the facility . Failure to follow policy JNH POL J550-05 ACCOUNTABILITY FOR NURSING PERSONNEL ASSIGNMENT is substantiated against Nurse Administrator, DON- on call and RN (#1). Nurse, LPN (#4) was a no call/ no show for B-shift on B78. Nurse Administrator, DON on call did not provide coverage for B78 B-shift. E. (2) No licensed nurse will leave the assigned unit until there is relief by another licensed nurse at shift change. (4) At no time will a licensed nurse leave a building without on-site licensed nurse relief. Should a nurse have to leave the building for a meal break or for an emergency, the nurse will notify the on-site RN Supervisor and/or designated staffing person for relief arrangements. RN (#1) notified the RN Supervisor that she was leaving but no relief was sent, and she left the South Side Unit without a licensed nurse. On 8/03/21 at 10:20 AM, in an interview with the Nursing Home Director, Administrator-in-Training (AIT), and Minimum Data Set (MDS) Nurse revealed Nursing Home Director stated the Nurse Administrator was taking DON on call over that weekend. ON 8/03/21 at 3:48 PM, an interview with LPN #1, revealed RN #1 left the faciity on [DATE] without on-site relief present, he reported that he was not sure of the time. She (RN #1) told them she couldn't stay and left at 4:55 PM and the RN Supervisor called between 6:00 PM and 6:30 PM and asked if (RN #1) was still here. LPN #1 stated he told the RN Supervisor no. When asked how he knew RN#1 had left the facility LPN #1 stated she said she couldn't stay and after I didn't see her in the building for about an hour, I knew she had left. LPN #1 stated he had not been asked to count the 'South Side' narcotics (indicated verification of accuracy of narcotic medication count), RN #1 did not tell him when she left, and he did not know where she left the keys to the medication cart or the narcotics lock box for the South Unit. LPN #1 stated he had not reported the situation to anyone because I knew they already knew what was going on. He confirmed he had not administered any medications or treatments to residents on the South Unit on 7/25/21. On 8/04/21 at 9:15 AM, an interview with the Medical Director (MD #1), revealed he found out on the afternoon of Monday, 7/26/21 that RN #1 had left the facility at 4:55 PM on 7/25/21 without on-site relief present. MD #1 stated he assessed all wounds of the residents on the South Side of building 78 on Wednesday 7/28/21 and stated, they all appeared stable. When asked what he thought about the residents being without a nurse, MD #1 stated he thought it was troubling. When asked if there were any residents he felt were vulnerable MD #1 stated in his opinion the residents who received antiseizure medications were particularly at risk for negative outcomes, especially because the residents on South Side of building 78 were prone to breakthrough seizures every few weeks and of the residents diagnosed with [CONDITION(S)] disorders, those prescribed linear medications were at the highest risk of breakthrough [CONDITION(S)] activity due to having missed a dose of their antiseizure medication. MD #1 stated any resident who had had a recent psychoactive medication change or had recently been started on a new psychoactive medication were most at risk for behavioral disturbances due to having missed a dose of their psychoactive medications. MD #1 stated that although there were no diabetic residents which required routine blood glucose monitoring on B shift 3:00PM - 11:00PM it would have been important to have a licensed staff member monitoring diabetic residents for signs and symptoms of [CONDITION(S)] or [CONDITION(S)]. When asked where he thought the breakdown in providing adequate staffing occurred, MD #1 stated Nursing leadership. On 8/04/21 at 10:00 AM, an interview with RN #1 revealed she stated she left the facility at 4:55 PM on 7/25/21 without on-site relief present. RN #1 stated she did not administer any medications or treatments to any residents on the South Unit after 4:55 PM on 7/25/21 and did not administer any medications or treatments scheduled for 6:00 PM on 7/25/21. She stated she was scheduled and worked South Side of the facility A shift 7:00 AM - 3:00 PM on 7/25/21. RN#1 stated at approximately 2:45 PM JNH Nurse Administrator phoned and asked her if she or LPN #3 (who had worked North Unit since 7:00 AM the morning of 7/25/21) could work the 3:00PM-11:00PM shift. RN #1 stated she told the Nurse Administrator she could not stay over to work B shift from 3:00 PM until 11:00 PM on the evening of 7/25/21. RN #1 stated she went down the hall and asked LPN #3, and LPN #3 also stated she could not stay over and work. RN #1 stated the Nurse Administrator, who was on-call, stated she was too tired to come in and take the keys (work). RN #1 stated at approximately 3:00 PM the Nurse Administrator texted and stated the shift had been covered. RN #1 stated at around 3:45 (PM) I called Nursing Staffing and they gave me the run around and said whoever would call me. Around 4:20 PM the Nurse Administrator texted and said LPN #4 was not coming in, and asked could I please stay, but I told her I had a family commitment, and I couldn't. RN #1 stated she gave shift report to the CNA's when they arrived for work at 3:00 PM; RN#1 stated, the residents were fine. RN #1 denied asking LPN #1 to accept responsibility for the South Side of the building and stated, that's not a thing. RN #1 stated the RN Nurse Supervisor called after 4:00 PM and asked me to stay and I told him no. The RN Supervisor said he was working the cart in another building and couldn't come work. He told me to call the operator, then the operator connected me to DON #1, and I informed her I couldn't stay, and she told me to call the Nurse Administrator back and let her know. I called her extension and didn't get an answer. RN #1 stated she was tired from working short with no housekeepers and only one (1) CNA on each side and doing three (3) people's jobs on the weekends. RN #1 stated she left the facility without an on-site relief present. When asked why she thought the alleged neglect occurred stated again that she was tired from working short with no housekeepers and only one (1) CNA on each side and doing three (3) people's jobs on the weekends she stated she told nursing administration over and over she could not stay over on 7/25/21. She stated she thought staffing and the facility being short on staff caused the problem. When asked how staff responded when the residents requested assistance, she stated I stayed until almost 5:00 (PM) and I got the residents what they wanted while I was here. When asked what she considered as neglect she responded, when staff don't take care of the residents. When asked what she would do if she suspected that a resident is not receiving necessary care and services she stated, report it. When asked what actions were taken by the nursing home, RN #1 stated she thought the facility had tried to find someone to come in to work. When asked what training had been received from the facility on neglect identification, prevention, and reporting requirements she responded In-services. On 8/04/21 at 11:00 AM, an interview with the Nurse Administrator revealed her job duties included monitoring nursing services. She stated, due to lack of staff and nurses she offered to work the cart and take call. She also stated she was the interim Director of Nurses (DON) for two (2) months at another building during June and July of 2021. The Nurse Administrator stated, I was on call the week before and that weekend DON #1, was on call that weekend and on Thursday or Friday she called me and asked me to take call and I told her I would, but I could not work due to plans for the weekend. Nurse Administrator stated on 7/23/21 she came in to work 11:00AM-7:00AM and came back and worked 11:00PM-7:00AM on 7/24/21. She stated she texted the Staffing Director at 1:02 AM she would not be able to work anymore on 7/24/21. She had not slept for twenty-four (24) hours and was sick with a virus. She stated she notified the RN nurse supervisor on 7/24/21 and let him know that I was sick and would be unable to work anymore the weekend. She stated on 7/25/21 the Nursing Home Director called her and asked her to go to the campus to check on another matter in another building. She stated while she was there, she went to her office and checked the J-Drive and saw a nurse on another building had called in for the 3:00PM-11:00PM shift. Nurse Administrator stated it was common practice to move nurses around to fill positions as needed due to call-ins. Nurse Administrator stated at 2:45 PM she phoned the facility and asked RN #1 and LPN #3 if one of them could stay and work the 3:00PM-11:00PM shift due to a call-in at a different building, but both declined. She stated that at 3:00 PM she thought she had the staffing covered, but then LPN # 4 did not show up for work for 3:00PM-11:00PM shift. She stated there was some back and forth between herself and RN #1 during which she reminded her of the MSH policy and procedure mandatory overtime and RN #1 reiterated that she could not stay over. SA asked Nurse Administrator to explain the procedure in place on 7/25/21, for notification nurses were to make on weekends or after business hours if their relief did not arrive. The Nurse Administrator explained the following: if on-site relief did not arrive the nurse on duty would call the switchboard operator, the operator would call the RN supervisor, if the RN supervisor was unable to relieve the nurse themselves, they would notify the DON on call and the Staffing Director, if the DON on call was unable to relieve the nurse the Staffing Director would call the Nurse Administrator, the Nurse Administrator would notify the administrator on call. Nurse Administrator stated she had notified the Staffing Director and the Administrator on call. She stated the staffing agency the facility had a contract with was called and texted, but no nurses responded. When asked how she monitored for the deployment of sufficient numbers of qualified and competent staff across all shifts to meet resident needs Nurse Administrator stated the facility nursing supervision and staffing department used the J Drive which she reported they all had access to. When asked how the facility determined staffing assignments based on the levels and types of care needed for the resident(s) she said they referred to the facility assessment. When asked how staff communicated across shifts, she listed the morning meeting, e-mail, text messaging, telephone calls and printed notifications posted at the timeclocks in the buildings the staffing department is located where the agency and contract staff clocked in. When asked why she thought the alleged neglect occurred, she stated it was because RN #1 left without relief. When asked how nursing supervision/administration monitored for staff burnout, which could contribute to neglect, the Nurse Administrator stated the facility tried to adhere to scheduling practices such as limiting nurses to forty (40) hours per week and using agency and contract nurses to fill in the blanks. The Nurse Administrator stated if there are concerns, such as insufficient staffing, she would report this to administration. When asked what the response of the administration, the Nurse Administrator stated the administration had developed a written Chain of notification and posted it prominently. The Nurse Administrator stated burnout is a real concern and the nursing supervision and administration try to monitor for it. She added that COVID-19 had caused additional strain on facility staffing. The Nurse Administrator confirmed that when she spoke with her, RN #1 told her she could not stay; the Nurse Administrator left the facility without ensuring sufficient staffing was in place for the South Unit of the facility. On 8/04/21 at 1:20 PM, an interview with Resident #2 revealed he was the one who reported there was no nurse on 'South Side' hall of the facility, but he could not recall the name of the nurse he reported to or the date. Resident #2 stated, The problem with the staffing of the CNAs, and the nurses and the shower help has been going on for a while. Then they make the A shift feel obligated and feel guilty to stay. He also stated his opinion was poor coordination is what I think the problem is. Resident #2 stated he realized there was a problem on 7/25/21 between 7:00 PM and 7:30 PM when he had not received any medicine. He stated medicine was usually administered by the nurses at around 6:00 PM. Resident #2 stated there were other days before 7/25/21 when medicines had been delivered late and he had been told it was because of staffing. Resident #2 stated This Sunday (7/25/21) nobody ever came at all. When asked if there were any medication, he was particularly concerned about having not received on 7/25/21, Resident #2 responded I was supposed to get my suppository, my bowels won't move without it and I don't get it every day, only certain days every week. I get to feeling bad if I don't get it, so it worried me. Also, I was supposed to get a dose of [MEDICATION(S)] muscle relaxer that was missed and that worried me too, but I didn't really have any problem from it. When asked how it made him feel to have not received his medications to which Resident #2 responded aggravating, frustrating, disappointing, angry. It made me feel insecure. Resident #2 stated, I'm dependent on these people. They are responsible for me. It's just like they don't understand that. On 8/04/21 at 1:40 PM, an interview with Resident #3 revealed he recalled not having received his medications on 'B shift' 7/25/21. Resident #3 was alert and oriented and communicated well verbally. Resident #3 stated it bothered me to think people don't come to work when they should. He denied having any negative outcome from missing his medications on 'B shift' 7/25/21. Resident #3 stated They need to do something and provided clarification, The people that run this place need to do something to make sure there is somebody here to give us our medicines and stuff. On 8/04/21 at 2:39 PM, an interview with LPN # 3 revealed on July 25, 2021, she was working 7:00AM-3:00PM shift (B shift) on the North Unit. She stated that on 7/25/21 at approximately 2:45 PM, RN #1 came down the hall and said the Nurse Administrator wanted to know if either of us would work over. LPN #3 stated she said no. She stated she finished her treatments and went back to the nurses station around 3:00 (PM) and RN #1 said the Nurse Administrator had called, and someone was coming to relieve us, but the only one who showed up was LPN #1 She stated she counted the North side narcotics with LPN #1 and left between 4:00 (PM) and 5:00 (PM). She stated RN #1 told her she was going to stay and see if anybody was going to come and RN #1 called 'staffing' and talked to the RN Nurse Supervisor, DON #2, and the Nurse Administrator. On 8/04/21 at 3:58 PM, a telephone interview with the Staffing Director revealed LPN #1 and LPN #4 were scheduled to work 3:00PM-11:00PM (B shift) on 7/25/21. The Staffing Director stated On Thursday (7/22/21) at 1:17 PM prior to the weekend I sent a text message to (LPN #4) to confirm the scheduled shifts for the weekend to review and confirm. She texted back and asked if she could be off on Saturday, but I texted her back and told her no, that I really, really needed her and she texted back and confirmed the schedule. She stated LPN #4 did not report for work or call-in on 7/25/21. She was unable to explain beyond that how the South Unit was without a nurse on 7/25/21 from 4:55 PM to 11:00 PM. When asked how residents' acuity, needs, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked how the facility's census impacts staffing levels, the Staffing Director stated that the census had held steady at forty (40) for quite a while had a maximum of forty-five (45). When asked how call-ins are handled, the Staffing Director stated they pull staff from other buildings if available, the DONs could work the cart, the RN Supervisor on the 3:00PM-11:00PM shift works the cart if needed and if none of those staff were available, they relied on Mandated Overtime. When asked if staff, residents, or families bring up workload concerns and if so, how the concerns are handled, the Staffing Director stated the facility tried to make sure there was enough staff to take care of the residents. When asked if there was a system in place to address these concerns the Staffing Director stated that even prior to the COVID-19 pandemic staffing had been a concern and it had been exacerbated by the pandemic, but staff were encouraged to report concerns to their supervisor and the concern would move up the chain of command until resolution had been accomplished if possible. She stated staffing was a difficult issue because it takes everyone working together, coming in when they are supposed to and doing what they are supposed to do while they are here in order to have an equitable workload. When asked about the turnover rate the Staffing Director reported it was high. On 8/05/21 at 12:54 PM, an interview with the Nurse Administrator revealed the Nurse Administrator stated, I had told the Staffing Director and RN Supervisor on Saturday (7/24/21) per text message I was on call the weekend before as the interim DON at another building and worked the weekend before (7/17/21 and 7/18/21) before I agreed to take call for DON #1. The Nurse Administrator stated I texted the Staffing Director and told her if she would take call until Sunday morning, I would appreciate it; the Staffing Director said she had called in sick until Thursday and another LPN could cover call-ins for day shift and the RN supervisor would be in at 3:00 PM. The Nurse Administrator stated, Nurse Executive asked Staffing Director if agency needed to be contacted and the Staffing Director responded she had and would continue to reach out to agency without success; no one returned her calls or messages. The Nurse Administrator stated I checked the J Drive and saw two (2) nurses had called in. The Nurse Administrator stated she initially intended to move LPN #4 to another building and that is why she called RN #1 at 2:45 PM before it was realized that LPN #4 was not coming in to work at 3:00 PM. Nurse Administrator stated at 4:19 PM, the RN Supervisor texted to say RN #1 had left. The Nurse Administrator also stated LPN #1 had approached her weeks before and voiced concerns that he was having to stay over frequently due to mandated overtime and on-site relief not arriving to relieve him. She stated LPN #1 inquired about compensation for working the entire building by himself and working sixteen (16) hour shifts. The Nurse Administrator stated she had reported LPN #1's concerns/request to the Nursing Home Director and was told there were no funds available for such compensation. She stated she had reported this to LPN #1. On 8/05/21 at 1:37 PM, interview with DON #1 revealed she was the full time DON of another building. She stated when she started taking call on weekends twelve years ago there was five (5) DONs taking call on weekends, around 2017 the call rotation dropped to four (4) DONs and in 2021 it dropped to three (3) DONs on the weekend call rotation. She stated prior to 2020 there was not enough staff. She stated the On-Call DON's did not have to come in to work to cover call-ins very often until 2019. She stated over the past two (2) years we've really had to fill in a good bit. In 2021 DONs are having to come in and work the cart every time, every weekend we are on call. She stated the DON on call is on call from Wednesday at 5:00 PM until the following Wednesday at 5:00 PM. She stated the DONs are also having to come in on the 3:00PM-11:00PM and the 11:00PM-7:00AM quite frequently. DON #1 stated she worked Monday, 7/19/21 through Friday 7/23/21 and worked 11:00 PM 7/23/21 until 8:00 AM 7/24/21. She stated she worked Sunday 7/25/21 7:00 PM and stayed and worked all of 11:00PM-7:00AM at another building, left at approximately 7:00 AM Monday 7/26/21 and returned and worked the cart 3:00PM-7:00PM on 7/26/21 due to call-ins. DON #1 stated If we are on call, we make every effort to find somebody to replace that person, especially if the nurse has already worked sixteen (16) hours. She stated on 7/25/21, we had no way to contact the contract nurse that was supposed to have come in. She stated the RN Supervisor was assigned to a cart. She also stated two (2) buildings were short staffed. DON #1 stated if the DON on call exhausted all resources and the nurse won't stay it's my responsibility to come in. When asked about outcomes for a resident who missed medications, DON #1 stated there could be negative outcomes such as blood sugar with hypoglycemic or hyperglycemic events, behaviors could be affected negatively. The DON #1 stated usually there is a housekeeper in the building for eight (8) hours a day. She reported the CNAs sweep after super and take out the trash and do housekeeping like cleaning up spills to provide a safe environment for the residents. She stated the nurses must help the CNAs every day because of the CNA shortage. She stated she thought Mandated Overtime was intended for emergency purposes and as a last resort. DON #1 stated Nurses are exhausted at the end of their shifts because at the end of the day the nurses can do the housekeeping and CNA work but who can do our work. On 8/05/21 at 3:00 PM, an interview with the Nursing Home Director (NHD) revealed he was aware staffing was a problem for the facility. He stated the staff were all tired and that fatigue affects performance. He stated he had been working there for fifteen (15) years and staffing had always been a problem. He stated COVID-19 escalated the challenges. He stated the facility had contracts with three staffing agencies, used contract staff and emergency COVID Contracts to try to get staffing. He stated, when everyone shows up for work, we have enough staff, other days you have call-ins because they are tired from working so much. He stated the staffing problems are a combination of call-ins and not enough staff. He stated there are disciplinary steps for excessive call-ins which could result in attendance counseling, written reprimands, and termination. When asked what effect inadequate staffing could have on residents the Nursing Home Director responded, Inconsistent staff could result in residents not getting the best care we can give them. He stated adequate staffing was important for residents to be more comfortable, happier and for their safety. When asked his opinion what effects on the residents he might expect if residents did not get medications as prescribed, he expressed concern for residents that were diabetic or had been prescribed medications that were time sensitive and stated, the medications are a concern, a legitimate issue, not having a nurse on that wing. The Nursing Home Director stated he was not aware until Wednesday 7/28/21 that the facility had been without a nurse for six (6) hours on 7/25/21. The Nursing Home Director stated the Nurse Administrator had accepted the responsibility of being on-call for the weekend. On 8/05/21 at 3:30 PM, in an interview with the facility's Interim Administrator revealed when asked how nursing supervision monitored and provided oversight to assure care and services are implemented based upon the care plan and the resident's identified needs, and if there is an acute change of condition, she responded the shift report and physician orders are reviewed in the morning meeting. When asked how the facility monitored staff/resident interactions the Interim Administrator responded direct observation was employed. When asked how the facility monitored for the deployment of sufficient numbers of qualified and competent staff across all shifts to meet resident needs, the Interim Administrator responded the J Drive was used to check for sufficient staffing, and staff competencies and in-services were used to ensure competent staff. When asked how the facility determined staffing assignments based on the levels and types of care needed for the residents, the Interim Administrator referred to the census of forty (40) residents with two nurses and the facility's policy for staf[TRUNCATED]

Based on staff interviews, resident interviews, facility policy review, and record review the facility failed to prevent the neglect of twenty (20) residents on the South Unit of the facility for six (6) hours on 7/25/21 from 4:55 PM through 11:00 PM, which resulted in Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11 not receiving medications, supervision, treatments and monitoring. The facility did not have licensed nurse coverage for twenty (20) residents on the South Unit of the facility for six (6) hours from 4:55 PM through 11:00 PM on 7/25/21. Licensed Practical Nurse (LPN) #4 was scheduled to report at 3:00 PM on 7/25/21 after having sent confirmation to the staffing director which indicated acceptance of the assignment. LPN #4 did not call in and did not arrive for her shift at the facility. Registered Nurse (RN) #1 had worked 7:00 AM and left the facility at 4:55 PM without on-site licensed nurse relief present. LPN #1 arrived for work at 3:00 PM but did not accept responsibility for the twenty (20) residents on the South Unit of the facility. The Nurse Administrator and the Registered Nurse (RN) Nurse Manager were aware RN #1 refused to stay. Contract and agency nurses did not respond to the call for replacement. No licensed nurse reported to duty on the South Unit of the facility between 4:55 PM and 11:00 PM. The facility's failure to ensure sufficient licensed staff on 7/25/21 from 4:55 PM through 11:00 PM to administer medications and treatments, and provide monitoring and supervision resulted in the deprivation of goods and services by staff of services necessary to attain or maintain physical, mental, and psychosocial well-being, and had the likelihood to cause residents residing on the South unit of the facility serious injury, harm, impairment, or possible death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 8/5/21, which began on 7/25/21, when the facility's failure to ensure sufficient licensed nurse was present to provide necessary services. On 8/05/21 at 5:15 PM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 8/07/21 at 10:00 AM, in which the facility alleged all corrective actions to remove the IJ and SQC were completed on 8/06/21 at 5:00 PM and the IJ was removed as of 8/07/21. The SA validated the Removal Plan on 8/09/21 and determined the IJ and SQC was removed on 8/07/21, prior to exit. Therefore, the scope and severity for CFR 483.12(a)(1) Abuse and Neglect (F600), was lowered from a K to an E while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled INJURIES, ABUSE, NEGLECT, MISTREATMENT, MISSAPPROPIATION OF RESIDENT, EXPLOITATION OF RESIDENTS dated July 2021, SUPERSEDES: September 2019, revealed . 2. POLICY.A. (Proper Name of Facility) residents have a right to be free from abuse, neglect, exploitation, mistreatment, sexual battery, and misappropriation of property . C. JNH will screen potential employees, train (Proper Name of Facility) staff, and put measures in place to prevent abuse, neglect, injuries, and exploitation of (Proper Name of Facility) residents .3. DEFINITION. B. Neglect: The failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility policy titled ACCOUNTABILITY FOR NURSING PERSONNEL ASSIGNMENT dated August 2020, SUPERSEDES February 2017 revealed 1. PURPOSE AND APPLICABILITY. This policy defines the steps to be followed in accounting for nursing personnel reporting to (Proper Name of Facility) on each shift. This policy applies to all (Proper Name of Facility) nursing personnel. 3. PROCEDURE. E. (2). No licensed nurse will leave the assigned unit until there is relief by another licensed nurse at shift change. (4) At no time will a licensed nurse leave a building without on-site licensed nurse relief . Record review of the facility policy, dated October 2018, titled MEDICATIONS, ADMINISTRATION, TIMING, AND TREATMENT revealed .C. Time critical medications are those for which an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. These medications must be administered within thirty minutes before or after their scheduled dosing time, for a total window of 1 hour. Time critical scheduled medications include but are not limited to; (1) Antibiotics, (2) Anticoagulants, (3) Insulin, (4) Anticonvulsant, (5) Immunosuppressive agents, (6) Pain medication, (7) Medications prescribed for administration within a specified period of time of the medication order . Record review of the facility schedule for 7/25/21 revealed the facility did not have licensed nurse coverage for twenty (20) residents on the South Unit of the facility for six (6) hours from 4:55 PM through 11:00 PM on 7/25/21. Record review of the facility's INVESTIGATIVE FINDINGS dated August 3, 2021, revealed The Department of Safety and Investigative Services was notified that on Sunday, July 25, 2021, B-shift only had I nurse from 4:55 PM until 1 1 PM LPN (#1) covered the North Side Hall for B & C shift. The South Side Hall did not have coverage for B-shift. A-Shift RN (#1) worked South Side Hall from 7:00 AM until 4:55 PM but did not pass any medications while she waited for a nurse to relieve her for B-Shift 3-11. The Contract Nurse, (LPN #4) scheduled for B-Shift was a no call/no show and RN (#1) left stating that she had told the DON on call that she could not stay over that day prior to working A-shift. LPN (#3) also worked A-Shift and was asked if she could stay over for B-Shift and also stated that she could not work B-Shift and left at 4:55 p.m. FINDNGS: NEGLECT - SUBSTANTIATED AGAINST THE FACILITY and also, Based on the information obtained, on July 25, 2021, there was only one B-shift nurse for (the facility). When A shift RN (#1) notified the DON on call, RN (Nurse Administrator) she was told that contract nurse, LPN (#4) was coming. LPN (#4) was a no call/no show. RN (#1) notified RN (Nurse Administrator) and RN Supervisor that she could not stay and was leaving. They asked LPN (#3) if she could stay, and she said that she could not stay. At 4:55 PM RN (#1) clocked out after counting the narcotics alone and left her keys in the med room. There was no licensed nurse working the South Side Hall on (the facility) until C-shift LPN (#2) arrived at I I PM Therefore, Neglect is substantiated against the facility. The Care Records for all 20 residents on (facility) South Side Hall were reviewed. (Formal names replaced by SA with Staff Indicators.) On 8/03/21 at 3:48 PM, an interview with LPN #1 confirmed he was the only nurse on duty from 5:00 PM until 11:00 PM in the facility on 7/25/21, and he was working on the North Unit. He stated there was no nurse working on the South Unit for twenty (20) residents. LPN #1 stated RN #1 was working 'South Side' 7:00AM-3:00PM on Sunday 7/25/21 and left at 5:00 PM. He stated, After I didn't see her in the building for about an hour, I knew she had left. LPN #1 stated he had not been asked to count the 'South Side' narcotics (verification of accuracy of narcotic medication count), RN #1 did not tell LPN #1 when she left, and he did not know where she left the keys to the medication cart or the narcotics lock box for the 'South Side'. LPN #1 stated he had not been asked to accept the responsibility for the 'South Side' of the facility on B shift 3:00 PM -11:00 PM. When asked why he thought the alleged neglect occurred LPN #1 stated it was because the nurse scheduled to report to work had not. When asked how staff responded when the resident requested assistance, LPN #1 stated the CNAs took care of them. When asked what he considered as neglect he stated it was when residents were not taken care of the way they were supposed to be. When asked what he would do if he suspected that a resident is not receiving necessary care and services, LPN #1 stated he would do his part to get the resident what they needed and beyond that he would report it to the DON. When asked if he had been aware of the care not being provided, LPN #1 stated I didn't even know she (South side nurse) had left. LPN #1 stated he had not reported the situation to anyone because I knew they already knew what was going on. On 8/04/21 at 9:15 AM an interview with Medical Director (MD) #1, revealed he had been notified about the incident after noon on 7/26/21 and was told there was no licensed nurse on South Unit of the facility from 5:00 PM until 11:00 PM. MD #1 stated he found out about the incident on the afternoon of Monday, July 26, 2021. When asked what he thought about the residents being without a nurse, MD #1 stated he thought it was troubling. When asked if there were any residents he felt were vulnerable MD #1 stated in his opinion the residents who received antiseizure medications were particularly at risk for negative outcomes, especially because the residents on South Side of the facility were prone to breakthrough seizures every few weeks and of the residents diagnosed with [CONDITION(S)] disorders, those prescribed linear medications were at the highest risk of breakthrough [CONDITION(S)] activity due to having missed a dose of their antiseizure medication. MD #1 stated any resident who had had a recent psychoactive medication change or had recently been started on a new psychoactive medication were most at risk for behavioral disturbances due to having missed a dose of their psychoactive medications. MD #1 stated that although there were no diabetic residents which required routine blood glucose monitoring on B shift 3:00PM - 11:00PM it would have been important to have a licensed staff member monitoring diabetic residents for signs and symptoms of [CONDITION(S)] or [CONDITION(S)]. When asked where he thought he breakdown in providing adequate staffing occurred, MD #1 stated nursing leadership. On 8/04/21 at 10:00 AM, an interview with RN #1 revealed she had left the facility at 4:55 PM without on-site licensed nurse relief. She stated she had clocked out at 4:55PM and left the facility. She stated she did not administer any medications prior to leaving. RN #1 denied asking LPN #1 to accept responsibility for the South Side of the building and stated, that's not a thing. RN #1 stated the RN Nurse Supervisor called after 4:00 PM and asked me to stay and I told him no. The RN Supervisor said he was working the cart in another building and wasn't able to come work. He told me to call the operator, then the operator connected me to DON #1 and I informed her I couldn't stay and she told me to call the Nurse Administrator back and let her know. I called her extension and didn't get an answer. RN #1 stated she agreed the residents needed their medicines. When asked what she considered as neglect she responded, when staff don't take care of the residents. When asked what training had been received from the facility on neglect identification, prevention, and reporting requirements she responded In-services. On 8/04/21 at 11:00 AM an interview with the Nurse Administrator confirmed there was no licensed nurse on duty for the South Unit of the facility from 5:00 PM until 11:00 PM on 7/25/21. The Nurse Administrator stated LPN # 4 did not show up for work at the facility for the 3:00PM-11:00PM shift. She stated the staffing agency the facility had a contract with was called and texted, but no nurses responded. When asked why she thought the alleged neglect occurred she stated it was because RN #1 left without relief. The Nurse Administrator stated LPN #1 had come to her weeks before 7/25/21 and shared with her concerns about staffing and about how he had to work the entire building alone and work mandated overtime which meant working sixteen (16) hour shifts without compensation. The Nurse Administrator stated she took the concerns of LPN #1 to the Nursing Home Director who told her there were no funds to compensate nurses for working extra units or extra shifts. The Nurse Administrator confirmed these concerns were not taken to the Quality Assurance and Performance Improvement (QAPI) committee. She stated she shared with LPN #1 the response of Administration. On 8/04/21 at 1:20 PM, an interview with Resident #2 revealed he was the one who reported there was no nurse on 'South Side' hall of the facility, but he could not recall the name of the nurse he reported to or the date. Resident #2 stated The problem with the staffing of the Certified Nurses Assistants (CNA)s, and the nurses and the shower help has been going on for a while. Then they make the A shift feel obligated and feel guilty to stay. He also stated his opinion was poor coordination is what I think the problem is. Resident #2 stated he realized there was a problem on 7/25/21 between 7:30 PM and he had not received any medicine. He stated medicine was usually administered by the nurses at around 6:00 PM. Resident #2 stated there were other days before 7/25/21 when medicines had been delivered late and he had been told it was because of staffing. Resident #2 stated This Sunday (7/25/21) nobody ever came at all. When asked if there were any medication he was particularly concerned about having not received on 7/25/21, Resident #2 responded I was supposed to get my suppository, my bowels won't move without it and I don't get it every day, only certain days every week. I get to feeling bad if I don't get it, so it worried me. Also, I was supposed to get a dose of [MEDICATION(S)] muscle relaxer that was missed and that worried me too, but I didn't really have any problem from it. When asked how it made him feel to have not received his medications to which Resident #2 responded aggravating, frustrating, disappointing, angry. It made me feel insecure. Resident #2 stated I'm dependent on these people. They are responsible for me. It's just like they don't understand that. On 8/04/21 at 1:40 PM, an interview with Resident #3 revealed he recalled not having received his medications on 'B shift' 7/25/21. Resident #3 was alert and oriented and communicated well verbally. Resident #3 stated it bothered him to think people don't come to work when they should. He denied having any negative outcome from missing his medications on 'B shift' 7/25/21. Resident #3 stated They need to do something and provided clarification, The people that run this place need to do something to make sure there is somebody here to give us our medicines and stuff. On 8/04/21 at 2:39 PM, with LPN # 3 revealed she had been aware upon her departure from the facility on 7/25/21 no one had arrived to relieve the South Unit nurse. She stated on 7/25/21 she was working the 7:00AM-3:00PM shift on the 'North Side' of the facility and the only nurse who showed up at 3:30 PM for shift change was LPN #1. When asked what could happen if a resident doesn't get their medications LPN #3 responded the resident could have increased behaviors, could get sick, could have problems with their blood pressure, among other things. When asked she stated she was not sure what could happen if a resident diagnosed with [CONDITION(S)] did not their antiseizure medication. LPN #3 stated if a topical medication was missed a wound could get worse or get infected. LPN #3 stated if nurses were not present to monitor residents according to their care plans and physician orders lots of things could happen but did not elaborate. When asked what she considered neglect, LPN #3 stated When the residents aren't getting taken care of, not getting what they need. On 8/04/21 at 3:58 PM, a telephone interview with Staffing Director revealed LPN #1 and LPN #4 were scheduled to work 3:00PM-11:00PM (B shift) on 7/25/21. The Staffing Director stated On Thursday (7/22/21) at 1:17 PM prior to the weekend I sent a text message to (LPN #4) to confirm the scheduled shifts for the weekend to review and confirm. She texted back and asked if she could be off on Saturday, but I texted her back and told her no, that I really, really needed her and she texted back and confirmed the schedule. She stated LPN #4 did not report for work or call-in on 7/25/21. She was able to confirm but unable to explain how the South Side of the facility ended up without a nurse on 7/25/21 except to say that LPN #4 was a no-call, no-show. On 8/04/21 at 4:20 PM, a telephone interview with CNA #2, revealed she worked 3:00PM-11:00PM on 7/25/21 in the facility. CNA #2 stated she remembered working on 7/25/21 and there had not been a nurse on the 'South Side' since 5:00 (PM). On 8/05/21 at 9:30 AM, an interview with CNA #3 stated she worked 3:00PM-11:00PM and 11:00PM-7:00AM on 7/25/21 in the facility. CNA #3 stated on 7/25/21 One (1) nurse worked 'North Side' and no nurse on 'South Side'. CNA #3 stated the only time LPN #1 came to the 'South Side' was to find a 'North Side' resident to give them their medicine. Resident #1: Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/05/21 Annual Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) Section C revealed a BIMS score of 0 out of 15 which indicated severe cognitive deficit for Resident #1. Record review of Resident #1's Physician Orders dated 7/21/21 revealed orders for Santyl Ointment 30 grams (GM) apply topically every 12 hours and as needed when soiled until healed, [MEDICATION(S)] capsule take (two) 2 capsules by mouth twice daily, Acidophilus Capsule Take 2 (two) Capsules by mouth twice daily, [MEDICATION(S)]/APAP 5/325MG Take 1 (one) Tablet by mouth twice daily for 28 (twenty-eight) days starting 7/19/21, Arginaide 1 (one ) pack by mouth three (3) times a day, and for [MEDICATION(S)] Sulfate 220 milligrams (MG) per milliliter (ML) [MEDICATION(S)] Give 220 MG (5ML) by mouth 3 (three) times a day. Record review of Resident #1's Medication Chart revealed on 7/25/21 [MEDICATION(S)] Sulfate 220MG/ML [MEDICATION(S)] Give 220MG (5ML) by mouth 3 (three) times a day, 6:00 PM Dose, Acidophilus Capsule Take 2 (two) Capsules by mouth twice daily, 6:00 PM Dose, [MEDICATION(S)]/APAP 5/325MG Take 1 (one) Tablet by mouth twice daily for 28 (twenty-eight) days. 9:00 PM Dose, Arginaide 1 (one) pack by mouth three (3) times a day, 6:00 PM Dose, was not initialed on the Medication Chart. Record review of Resident #1 Treatment Chart revealed on 7/25/21 on B shift (3 to 11) Wound Care: Right Back scapula area Wash wound, and pat dry Apply scant amount of Santyl to wound bed and cover with gauze and Aldress every (twelve) 12 hours and as needed when soiled until healed. Notify MD of acute changes. On 7/25/21 on B shift (3-11). This was not initialed on the Treatment Chart. Resident #2: Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/26/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit for Resident #2. Record review of Resident #'s2 Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] suppository 10 MG insert (one) 1 rectally every Tuesday, Thursday and Sunday, [MEDICATION(S)] 100 MG. Take (two) 2 capsules by mouth twice daily, Observe for side effects of [MEDICATION(S)] .Report these to MD immediately, [MEDICATION(S)] 2.5 MG by mouth twice daily, Polyethylene [MEDICATION(S)] Powder ([MEDICATION(S)] Power) Dissolve 17 Grams in 6 (six) ounces of juice/water and give by mouth 2 (two) times a day, [MEDICATION(S)] 10MG suppository Insert 1 (one) suppository rectally on Tuesday, Thursday, Sunday and Daily as needed for Constipation, and [MEDICATION(S)] 20MG Tablet Take 1 Tablet by mouth 3 (three) times daily. Record review of Resident #2's Medication Chart revealed on 7/25/21 [MEDICATION(S)] suppository 10 MG insert (one) 1 rectally every Tuesday, Thursday and Sunday, [MEDICATION(S)] 100 MG. Take (two) 2 capsules by mouth twice daily, observe for side effects of [MEDICATION(S)] .Report these to MD immediately, [MEDICATION(S)] 2/5 MG by mouth twice daily, Polyethylene [MEDICATION(S)] Powder ([MEDICATION(S)] Power) Dissolve 17 Grams in 6 (six) ounces of juice/water and give by mouth 2 (two) times a day, [MEDICATION(S)] 10MG suppository Insert 1 (one) suppository rectally on Tuesday, Thursday, Sunday and Daily as needed for constipation, [MEDICATION(S)] 20MG Tablet Take 1 Tablet by mouth 3 (three) times daily, was not initialed on the Medication Chart. Record review of Resident #2 Treatment Chart revealed on 7/25/21 on B shift (3 to 11) Flush foley catheter with 60 (sixty) cc sterile water every shift. This was not initialed on the Treatment Chart. Resident #3: Record review of resident #3's Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 5/12/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) Section C revealed a BIMS score of 15 out of 15 which indicated no cognitive deficit for Resident #3. Record review of Resident #3's Physician Orders dated 7/21/21 revealed orders for Vitamin C 500 MG tablet take (one) 1 tablet by mouth twice a day, [MEDICATION(S)] 15 MG Tablet take (one) 1 tablet by mouth every evening, [MEDICATION(S)] 5 MG tablet take (one) 1 tablet by mouth at bedtime, [MEDICATION(S)] 20 MG capsule take (one) 1 capsule by mouth at bedtime, [MEDICATION(S)] 20 MG tablet take (one) 1 tablet by mouth every 2:00 PM and 6:00 PM, [MEDICATION(S)] [MEDICATION(S)] 324 MG tablet take (one) 1 tablet by mouth every 2:00 PM and 6:00 PM, [MEDICATION(S)] 850 MG tablet take (one) 1 tablet by mouth (thirty) 30 minutes prior to lunch and dinner, [MEDICATION(S)] powder dispense as Polyethylene [MEDICATION(S)] powder mix 17 grams in 6 ounces of liquid and give by mouth (two) 2 times a day, [MEDICATION(S)] 800 MG tablet take (one) 1 tablet by mouth (three) 3 times daily, [MEDICATION(S)] 40 MG dispense as [MEDICATION(S)] 40 MG tablet take (one) 1 tablet by mouth at bedtime, [MEDICATION(S)] 500 MG tablet take (one) 1 tablet by mouth twice a day, and Santyl Ointment 300 Grams apply topically every (twelve) 12 hours to wounds, and Observe for signs and symptoms of [CONDITION(S)] .Obtain vital signs and accu-check & report to MD, Observe for signs and symptoms of [CONDITION(S)] .Obtain vital signs and accu-check & report to MD, and Accu-Checks as needed with regular insulin per sliding scale as needed. Record review of Resident #3's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 20MG Tablet Take 1 Tablet by mouth every 2PM and 6PM, 6:00 PM Dose, [MEDICATION(S)] [MEDICATION(S)] 324MG Tablet Take 1 (one) tablet by mouth every 2PM and 6PM, 6:00 PM Dose; [MEDICATION(S)] 5% Patch Apply 2 (two) patches to right knee every 12 (twelve) hours, 6:00 PM Dose; [MEDICATION(S)] 10MG suppository Insert 1 (one) suppository rectally Daily, 6:00 PM Dose; Polyethylene [MEDICATION(S)] Powder ([MEDICATION(S)] Power) Dissolve 17 Grams in 6 (six) ounces of juice/water and give by mouth 2 (two) times a day, 6:00 PM Dose; Vitamin C 500MG Tablet Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose; [MEDICATION(S)] 15MG Tablet Take 1 (one) tablet by mouth every evening, 6:00 PM Dose (once a day dose); [MEDICATION(S)] 5MG Tablet Take 1 (one) tablet by mouth at bedtime, 6:00 PM Dose (once a day dose); [MEDICATION(S)] 20MG Tablet Take 1 (one) tablet by mouth at bedtime, 6:00 PM Dose (once a day dose); [MEDICATION(S)] 40MG Tablet Take 1 (one) tablet by mouth at bedtime, 6:00 PM Dose (once a day dose); [MEDICATION(S)] 500MG Tablet Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose was not initialed on the Medication Chart. Record review of Resident #3's Treatment Chart revealed on 7/25/21 on B shift (3 to 11) Suprapubic catheter/Perineal area: cleanse with Dakin's solution, pat dry, apply [MEDICATION(S)] ointment to peri-wound area twice daily cover with soft gauze and paper tape, Wound Care: Left Heel wound: Cleanse with Normal Saline, pat dry, apply Dakin's solution to gauze and apply to wound bed. Cover with [MEDICATION(S)] or Conform twice daily, Right Heel: Apply damp to dry Normal Saline dressing. Every twelve (12) hours. Notify MD of acute changes, Treatment to coccyx: Irrigate with 0.25% Dakin's Solution then rinse with Normal Saline, pat dry, pack with Calcium Alginate with Silver, cover with gauze and abdominal dressing, secure with Medi pore tape twice daily and as needed due to soilage. These were not initialed on the Treatment Chart. Resident #4: Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)]. Record review of 5/12/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 0 out of 15 which indicated no cognitive deficit for Resident #4. Record review of Resident #4's Physician Orders revealed orders for [MEDICATION(S)] 100 MG dispense as [MEDICATION(S)] Sodium extended release 100 MG take (one) 1 capsule by mouth each morning and (two) 2 capsules each evening dated 7/23/21, [MEDICATION(S)] 500 MG tablet dispense as [MEDICATION(S)] 500 MG tablet take (one) 1 tablet by mouth twice a day dated 7/23/21, Promod 30CC (ML) by mouth twice a day dated 7/21/21, and Resource 2.0 by mouth four (4) times a day (with documentation of percent consumed) dated 7/21/21. Record review of Resident #4's Medication Chart revealed on 7/25/21 (Resident #4's [CONDITION(S)] medication was adjusted on 7/23/21), [MEDICATION(S)] Sodium Extended 200MG ([MEDICATION(S)] 200MG) Take 200MG by mouth each bedtime, 6:00 PM Dose; [MEDICATION(S)] 750MG ([MEDICATION(S)] 750MG) Take 750MG by mouth twice a day, 6:00 PM Dose; Promod 30CC (ML) by mouth twice a day, 6:00 PM Dose; Resource 2.0 by mouth four (4) times a day (with documentation of percent consumed), 6:00 PM Dose was not initialed on the Medication Chart. Resident #5: Record review of resident Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 6/30/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 14 out of 15 which indicated no cognitive deficit for Resident #5. Record review of resident's Physician Orders dated 7/21/21 revealed orders for [MEDICATION(S)] 500 MG tablet dispense as [MEDICATION(S)] 500 MG tablet take ½ tablet by mouth every morning and 1 (one) tablet by mouth every evening, Check for pain every shift using pain rate scale # 0-10; record, [MEDICATION(S)] 40MG Take 40MG by mouth at bedtime, [MEDICATION(S)] ([MEDICATION(S)]) 0.4MG Capsule Take 1 (one) capsule by mouth every 24 (twenty-four) hours, [MEDICATION(S)] 10MG/ML solution Take 40MG (4 CC) by mouth twice a day, Polyethylene [MEDICATION(S)] Powder ([MEDICATION(S)] Power) Dissolve 17 Grams in 6 (six) ounces of juice/water and give by mouth 2 (two) times a day, Lortisone 0.5% cream to bilateral inguinal rash twice daily (7:00AM-3:00PM shift and 3:00PM-11:00PM shift), [MEDICATION(S)] 2MG Tablet Take 1 (one) tablet by mouth at bedtime for 28 (twenty-eight) days ordered 7/13/21, [MEDICATION(S)]/APAP 5/325 MG take 1 (one) tablet by mouth every 6 (six) hours as needed for 28 (twenty-eight) days order date of 7/14/21, and [MEDICATION(S)] 0.5MG Tablet ([MEDICATION(S)] 0.5MG) Take 1 tablet by mouth twice a day order date 7/30/21. Record review of Resident #5's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 40MG Take 40MG by mouth at bedtime, 6:00 PM Dose; [MEDICATION(S)] 0.5MG Tablet ([MEDICATION(S)] 0.5MG) Take 1 tablet by mouth twice a day, 6:00 PM Dose; [MEDICATION(S)] ([MEDICATION(S)]) 0.4MG Capsule Take 1 (one) capsule by mouth every 24 (twenty-four) hours, 6:00 PM Dose; [MEDICATION(S)] 10MG/ML solution Take 40MG (4 CC) by mouth twice a day, 6:00 PM Dose; [MEDICATION(S)] 500MG Tablet ([MEDICATION(S)] 500MG Tablet) Take ½ (half) tablet by mouth morning and 1 (one) tablet by mouth every evening, 6:00 PM Dose; Polyethylene [MEDICATION(S)] Powder ([MEDICATION(S)] Power) Dissolve 17 Grams in 6 (six) ounces of juice/water and give by mouth 2 (two) times a day, 6:00 PM Dose; [MEDICATION(S)] 2MG Tablet Take 1 (one) tablet by mouth at bedtime for 28 (twenty-eight) days, started 7/13/21, 8:00 PM Dose, was not initialed on the Medication Chart. Record review of Resident #5's Treatment Chart revealed on 7/25/21 on B shift (3 to 11) Lortisone 0.5% cream to bilateral inguinal rash Twice Daily. This was not initialed on the Treatment Chart. Resident #6: Record review of the Face Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 7/07/21 Quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) section C revealed a BIMS score of 14 out of 15 which indicated no cognitive deficit for Resident #6. Record review of resident #6's physician orders dated 7/21/21 and MDS section N revealed orders for [MEDICATION(S)] 200 MG tablet take (one) 1 tablet by mouth twice daily for (twenty-eight) 28 days (started 7/13/21), [MEDICATION(S)] 20 milliequivalents tablet take (one) 1 tablet by mouth twice a day, [MEDICATION(S)] 125 MG sprinkle capsule dispense as [MEDICATION(S)] 125 MG sprinkle take (four) 4 capsules by mouth (three) 3 times daily, [MEDICATION(S)] 15 MG tablet take (one) 1 tablet by mouth at bedtime, [MEDICATION(S)] ([MEDICATION(S)]) 0.4MG Capsule Take 2 (two) capsules by mouth every 24 (twenty-four) hours , [MEDICATION(S)] 300 MG tablet take (one) 1 tablet by mouth every morning and (two) 2 tablets by mouth at bedtime, [MEDICATION(S)] powder dispense as Polyethylene [MEDICATION(S)] Powder dissolve 17 Grams and give by mouth twice a day, and [MEDICATION(S)] Tar 25 MG tablet take (one) 1 tablet by mouth twice a day. Record review of Resident #6's Medication Chart revealed on 7/25/21 [MEDICATION(S)] 200MG Tablet Take 1 (one) tablet by mouth twice daily for 28 (twenty-eight) days, started 7/01/21, 6:00 PM Dose; [MEDICATION(S)] 20MEQ (milliequivalents) Tablet Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose; [MEDICATION(S)] 125MG Sprinkle ([MEDICATION(S)] 125MG Sprinkle) Take 4 (four) capsules by mouth 3 (three) times daily, 6:00 PM Dose; [MEDICATION(S)] 15MG Tablet Take 1 (one) tablet by mouth at bedtime, 6:00 PM Dose; [MEDICATION(S)] ([MEDICATION(S)]) 0.4MG Capsule Take 2 (two) capsules by mouth every 24 (twenty-four) hours, 6:00 PM Dose; [MEDICATION(S)] 300MG Tablet Take 1 (one) tablet by mouth every morning and 2 (two) tablets by mouth at bedtime, 6:00 PM Dose; Polyethylene [MEDICATION(S)] Powder ([MEDICATION(S)] Power) Dissolve 17 Grams in 6 (six) ounces of juice/water and give by mouth 2 (two) times a day, 6:00 PM Dose; [MEDICATION(S)] [MEDICATION(S)] 25MG Tablet Take 1 (one) tablet by mouth twice a day, 6:00 PM Dose were not initialed on the Medication Chart. Resident #7: Record review of resident Identification and Summary Sheet with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on policy review, record review, staff interviews, and resident interviews the facility administration failed to use its resources effectively and efficiently to ensure licensed staff was available to provide care for twenty (20) of (20) residents on the South Unit with a sample of eleven (11) residents for six (6) hours on 7/25/21 from 4:55 PM through 11:00 PM. Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11. Licensed Practical Nurse (LPN) #4 was scheduled to report at 3:00 PM on 7/25/21 after having sent confirmation to the staffing director which indicated acceptance of the assignment. LPN #4 did not call in and did not arrive for her shift at the facility. Registered Nurse (RN) #1 had worked since 7:00 AM and left the facility at 4:55 PM without on-site licensed nurse relief present. LPN #1 arrived for work at 3:00 PM but did not accept responsibility for the twenty (20) residents on the South Unit of the facility. The Nurse Administrator and the Registered Nurse (RN) Nurse Manager were aware RN #1 refused to stay. Contract and agency nurses did not respond to the call for replacement. No licensed nurse reported to duty on the South Unit of the facility between 4:55 PM and 11:00 PM. The facility failed to follow it's stated procedure for replacing staff in case of call-ins or no call, no shows. The Nurse Administrator and the RN Manager were aware of the staffing problem and the On-Call Administrator was not notified. The On-Call Director of Nurses failed to report to duty as needed. The Nurse Administrator, Director of Nurses and the Nursing Home Director stated they were aware of on-going staffing issues and shortages prior to this incident and that their strategies to remedy the situation were not effective. The facility' s failure to provide administrative oversight and supervision to ensure sufficient nursing staff to provide supervision, care and services placed residents on the South Unit at risk, and in a situation likely to cause serious injury, serious impairment, serious harm or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 7/25/21, when the facility failed to provide administrative oversight to ensure sufficient licensed nurses were available to provide necessary supervision, medications, treatments or monitoring. On 8/05/21 at 5:15 PM the SA informed the Nursing Home Administrator of the IJ and provided the facility with the IJ Template. The facility submitted an acceptable Removal Plan on 8/07/21 at 10:00 AM, in which the facility alleged all corrective actions to remove the IJ were completed on 8/06/21 at 5:00 PM and the IJ was removed as of 8/07/21. The SA validated the Removal Plan on 8/09/21 and determined the IJ was removed on 8/07/21, prior to exit. Therefore, the scope and severity for CFR 483.70 - Administration (F835), was lowered from a K to an E while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy, dated August 2020, SUPERSEDES: February 2017 titled ACCOUNTABILITY FOR NURSING PERSONNEL ASSIGNMENT revealed PURPOSE AND APPLICABILITY. This policy defines the steps to be followed in accounting for nursing personnel reporting to (Proper Name of Facility) on each shift. This policy applies to all (Proper Name of Facility) nursing personnel .3. PROCEDURE. A. The Director of Nursing (DON) will be responsible for preparing the (Proper Name of Facility) nurse schedule and unit assignment for each 24-hour period. The schedule and assignment will be forwarded to the Nurse Staffing Coordinator (NSC) and placed on a master staffing schedule. B. The NSC or DON on call will verify by telephone that scheduled nurses are present in the assigned JNH buildings/units at 7:00 a.m., Monday through Friday. The NSC or DON on call will reassign nurses as necessary to assure a minimum of one licensed nurse per floor, per building in the unit. C. The staffing personnel .will take call-ins from nursing staff every shift. The staffing personnel will notify the DON on call who will attempt to cover the shift or shifts with a nurse from their building/unit. The NSC will make changes on the Master Schedule and contact the authorized agencies for contract nurses as needed. D. The RN (Grounds) Supervisor or DON on call will take call-ins after 3:30 p.m., Monday through Friday and all shifts on weekends and Holidays. E. On weekends and holidays, the A-Shift RN supervisor .will verify that A-Shift scheduled nurses are present in their assigned building. The A-Shift RN Supervisor .will verify that B-Shift scheduled nurses are present in their assigned buildings. The B-Shift RN Supervisor or DON on call will verify that C-Shift scheduled nurses are present in their assigned building. (l) If the NSC receives a call in from a (Proper Name of Facility) nurse, a cancellation that the agency was not able to replace, or nurses shown on the written schedule cannot be accounted for, the nurse designated for staffing will call all buildings to ask (Proper Name of Facility) nursing staff if they would work overtime, then call the authorized nursing agencies in an attempt to acquire the required minimum nursing staff, if staffing nurse is unable to acquire the minimum nursing staff he/she will notify the DON on call.(2) No licensed nurse will leave the assigned unit until there is relief by another licensed nurse at shift change.(3) When necessary, nurses will be pulled to buildings that has only one (l ) nurse. If a building has three (3) or more nurses, excluding the DON, a nurse will be pulled to the buildings of need to maintain a minimum of two (2) nurses on all shifts. (4) At no time will a licensed nurse leave a building without on-site licensed nurse relief. Should a nurse have to leave the building for a meal break or for an emergency, the nurse will notify the on-site RN Supervisor and/or designated staffing person for relief arrangements. F. Shift leaders will notify the shift RN Supervisor and/or DON on call immediately should a licensed nurse leave without relief and there is no other licensed nurse on the unit. The RN supervisor and/or designated staffing nurse will notify the DON on call. Record review of facility Nurse Staffing Schedule revealed no licensed staff was on duty for the South unit of the facility from 4:55 PM through 11:00 PM on 7/25/21. Record review revealed the facility completed an investigation related to insufficient staffing on 7/25/21. Record review of the facility Investigative Findings dated 8/03/21 revealed: INVESTIGATIVE FINDINGS-August 3, 2021-NEGLECT: MULTIPLE RESIDENTS-AIT-The Department of Safety and Investigative Services was notified that on Sunday, July 25, 2021, B-shift only had I nurse from 4:55 p.m. until 1 1 p.m. (LPN #1) covered the North Side Hall for B & C shift. The South Side Hall did not have coverage for B-shift. LPN (#2) worked the South Side Hall for C-Shift 11:00 p.m. until 7:00 a.m. A-Shift (RN #1) worked South Side Hall from 7:00 a.m. until 4:55 p.m. but did not pass any medications while she waited for a nurse to relieve her for B-Shift 3-11. The Contract Nurse, (LPN #4), scheduled for B-Shift was a no call/no show and RN #1 left stating that she had told the DON on call that she could not stay over that day prior to working A-shift. (RN #1) worked A-Shift and was asked if she could stay over for B-Shift and also stated that she could not work B-Shift and left at 4:55 p.m. FINDNGS: NEGLECT - SUBSTANTIATED AGAINST THE FACILITY FAILURE To FOLLOW POLICY JNH POL J550-05 ACCOUNTABILITY FOR NURSNG PERSONNEL ASSIGNMENT - IS SUBSTANTIATED AGANST (Nurse Administrator) and (RN #1) . Therefore, Neglect is substantiated against the facility . Failure to follow policy JNH POL J550-05 ACCOUNTABILITY FOR NURSING PERSONNEL ASSIGNMENT is substantiated against Nurse Administrator, DON- on call and RN (#1). LPN (#4) was a no call/ no show for B-shift on B78. Nurse Administrator, DON on call did not provide coverage for B78 B-shift. E. (2) No licensed nurse will leave the assigned unit until there is relief by another licensed nurse at shift change. (4) At no time will a licensed nurse leave a building without on-site licensed nurse relief. Should a nurse have to leave the building for a meal break or for an emergency, the nurse will notify the on-site RN Supervisor and/or designated staffing person for relief arrangements. RN (#1) notified the RN Supervisor that she was leaving but no relief was sent, and she left the South Side Unit without a licensed nurse. On 8/03/21 at 10:20 AM, an interview with Nursing Home Director (NHD), Administrator-in-Training (AIT), and Minimum Data Set (MDS) Nurse revealed Nursing Home Director stated the Nurse Administrator was taking DON call over that weekend. The NHD stated the C shift nurse came in at 11:00 PM. The Medical Director (MD #1) rounded Monday morning (7/26/21) and had no concerns. MDS Nurse stated when the 11:00PM to 7:30AM arrived no one verified the narcotics count with her. The MDS Nurse stated there were no residents with tracheostomies, feeding tubes, or residents with orders for routine blood glucose monitoring on the 3:00 PM to 11:00 PM shift. ON 8/03/21 at 3:48 PM, an interview with LPN #1, revealed LPN #1 stated She (RN #1) told them she couldn ' t stay and left at 4:55 PM and the RN Supervisor called between 6:00 PM and 6:30 PM and asked if RN #1 was still here. LPN #1 stated he told the RN Supervisor no. When asked how he knew RN#1 had left the facility LPN #1 stated she said she couldn ' t stay and after I didn ' t see her in the building for about an hour, I knew she had left. LPN #1 stated he had not been asked to count the ' South Side' narcotics (indicated verification of accuracy of narcotic medication count), RN #1 did not tell him when she left, and he did not know where she left the keys to the medication cart or the narcotics lock box for the ' South Side ' . LPN #1 stated he had not reported the situation to anyone because I knew they already knew what was going on. LPN #1 stated he had personally gone to the Nurse Administrator with concerns related to the facility ' s staffing issues but nothing was done. On 8/04/21 at 9:15 AM, an interview with Medical Director (MD #1), revealed he found out about the incident on the afternoon of Monday, July 26, 2021. MD #1 stated he assessed all wounds of the residents on the South Side of building 78 on Wednesday 7/28/21, and stated they all appeared stable. When asked what he thought about the residents being without a nurse, MD #1 stated he thought it was troubling. When asked if there were any residents he felt were vulnerable MD #1 stated in his opinion the residents who received antiseizure medications were particularly at risk for negative outcomes, especially because the residents on South Side of building 78 were prone to breakthrough seizures every few weeks and of the residents diagnosed with [CONDITION(S)] disorders, those prescribed linear medications were at the highest risk of breakthrough [CONDITION(S)] activity due to having missed a dose of their antiseizure medication. MD #1 stated any resident who had had a recent psychoactive medication change or had recently been started on a new psychoactive medication were most at risk for behavioral disturbances due to having missed a dose of their psychoactive medications. MD #1 stated that although there were no diabetic residents which required routine blood glucose monitoring on B shift 3:00PM - 11:00PM it would have been important to have a licensed staff member monitoring diabetic residents for signs and symptoms of [CONDITION(S)] or [CONDITION(S)]. When asked where he thought he breakdown in providing adequate staffing occurred, MD #1 stated Nursing Leadership. On 8/04/21 at 10:00 AM, an interview with RN #1 revealed she confirmed she was scheduled and worked South Side of the facility A shift 7:00 AM - 3:00 PM on 7/25/21. LPN stated at approximately 2:45 PM JNH Nurse Administrator phoned and asked her if she or LPN #3 (who had worked North Unit since 7:00 AM the morning of 7/25/21) could work the 3:00PM-11:00PM shift. RN #1 stated she told the Nurse Administrator she could not stay over to work B shift from 3:00 PM until 11:00 PM on the evening of 7/25/21. RN #1 stated she went down the hall and asked LPN #3 and LPN #3 also stated she could not stay over and work. RN #1 stated the Nurse Administrator, who was on-call, stated she was too tired to come in and take the keys (work). RN #1 stated at approximately 3:00 PM the Nurse Administrator texted and stated the shift had been covered. RN #1 stated at around 3:45 (PM) I called Nursing Staffing and they gave me the run around and said whoever would call me. Around 4:20 PM the Nurse Administrator texted and said LPN #4 was not coming in, and asked could I please stay, but I told her I had a family commitment, and I couldn ' t. RN #1 stated she gave shift report to the CNA ' s when they arrived for work at 3:00 PM. RN#1 stated, the residents were fine. RN #1 denied asking LPN #1 to accept responsibility for the South Side of the building and stated, that ' s not a thing. RN #1 stated the RN Nurse Supervisor called after 4:00 PM and asked me to stay and I told him no. The RN Supervisor said he was working the cart in another building and couldn ' t come work. He told me to call the operator, then the operator connected me to DON #1, and I informed her I couldn ' t stay, and she told me to call the Nurse Administrator back and let her know. I called her extension and didn ' t get an answer. RN #1 stated she was tired from working short with no housekeepers and only one (1) CNA on each side and doing three (3) people ' s jobs on the weekends. RN #1 stated she left the facility without an on-site relief present. When asked why she thought the alleged neglect occurred stated again that she was tired from working short with no housekeepers and only one (1) CNA on each side and doing three (3) people ' s jobs on the weekends she stated she told nursing administration over and over she could not stay over on 7/25/21. She stated she thought staffing and the facility being short on staff caused the problem. When asked how staff responded when the residents requested assistance, she stated I stayed until almost 5:00 (PM) and I got the residents what they wanted while I was here. When asked what she considered as neglect she responded, when staff don ' t take care of the residents. When asked what she would do if she suspected that a resident is not receiving necessary care and services she stated, report it. When asked what actions were taken by the nursing home, RN #1 stated she thought the facility had tried to find someone to come in to work. When asked what training had been received from the facility on neglect identification, prevention, and reporting requirements she responded In-services. On 8/04/21 at 11:00 AM, an interview with Nurse Administrator revealed her job duties included monitoring nursing services. She stated, due to lack of staff and nurses she offered to work the cart and take call. She also stated she was the interim Director of Nurses (DON) for two (2) months at another building during June and July of 2021. Nurse Administrator stated, I was on call the week before and that weekend DON #1, was on call that weekend and on Thursday or Friday she called me and asked me to take call and I told her I would, but I could not work due to plans for the weekend. Nurse Administrator stated on 7/23/21 she came in to work 11:00AM-7:00AM and came back and worked 11:00PM-7:00AM on 7/24/21. She stated she texted the Staffing Director at 1:02 AM she would not be able to work anymore on 7/24/21. She had not slept for twenty-four (24) hours and was sick with a virus. She stated she notified the RN nurse supervisor on 7/24/21 and let him know that I was sick and would be unable to work anymore the weekend. She stated on 7/25/21 the Nursing Home Director called her and asked her to go to the campus to check on another matter in another building. She stated while she was there, she went to her office and checked the J-Drive and saw a nurse on another building had called in for the 3:00PM-11:00PM shift. Nurse Administrator stated it was common practice to move nurses around to fill positions as needed due to call-ins. Nurse Administrator stated at 2:45 PM she phoned the facility and asked RN #1 and LPN #3 if one of them could stay and work the 3:00PM-11:00PM shift due to a call-in at a different building, but both declined. She stated that at 3:00 PM she thought she had the staffing covered, but then LPN # 4 did not show up for work for 3:00PM-11:00PM shift. She stated there was some back and forth between herself and RN #1 during which she reminded her of the MSH policy and procedure mandatory overtime and RN #1 reiterated that she could not stay over. SA asked Nurse Administrator to explain the procedure in place on 7/25/21, for notification nurses were to make on weekends or after business hours if their relief did not arrive. The Nurse Administrator explained the following: if on-site relief did not arrive the nurse on duty would call the switchboard operator, the operator would call the RN supervisor, if the RN supervisor was unable to relieve the nurse themselves, they would notify the DON on call and the Staffing Director, if the DON on call was unable to relieve the nurse the Staffing Director would call the Nurse Administrator, the Nurse Administrator would notify the administrator on call. Nurse Administrator stated she had notified the Staffing Director or the Administrator on call. She stated the staffing agency the facility had a contract with was called and texted, but no nurses responded. When asked how she monitored for the deployment of sufficient numbers of qualified and competent staff across all shifts to meet resident needs Nurse Administrator stated the facility nursing supervision and staffing department used the J Drive which she reported they all had access to. When asked how the facility determined staffing assignments based on the levels and types of care needed for the resident(s) she said they referred to the facility assessment. When asked how staff communicated across shifts, she listed the morning meeting, e-mail, text messaging, telephone calls and printed notifications posted at the timeclocks in the buildings the staffing department is located where the agency and contract staff clocked in. When asked why she thought the alleged neglect occurred? She stated it was because RN #1 left without relief. When asked how nursing supervision/administration monitored for staff burnout, which could contribute to neglect, Nurse Administrator stated the facility tried to adhere to scheduling practices such as limiting nurses to forty (40) hours per week and using agency and contract nurses to fill in the blanks. Nurse Administrator stated if there are concerns, such as insufficient staffing she would report this to administration. When asked what the response of the administration, the Nurse Administrator stated the administration had developed a written Chain of notification and posted it prominently. The Nurse Administrator stated burnout is a real concern and the nursing supervision and administration try to monitor for it, she added that COVID-19 had caused additional strain on facility staffing. On 8/04/21 at 1:20 PM, an interview with Resident #2 revealed he was the one who reported there was no nurse on 'South Side ' hall of the facility, but he could not recall the name of the nurse he reported to or the date. Resident #2 stated The problem with the staffing of the CNAs, and the nurses and the shower help has been going on for a while. Then they make the A shift feel obligated and feel guilty to stay. He also stated his opinion was poor coordination is what I think the problem is. Resident #2 stated he realized there was a problem on 7/25/21 between 7:00 PM and 7:30 PM when he had not received any medicine. He stated medicine was usually administered by the nurses at around 6:00 PM. Resident #2 stated there were other days before 7/25/21 when medicines had been delivered late and he had been told it was because of staffing. Resident #2 stated This Sunday (7/25/21) nobody ever came at all. When asked if there were any medication, he was particularly concerned about having not received on 7/25/21, Resident #2 responded I was supposed to get my suppository, my bowels won ' t move without it and I don ' t get it every day, only certain days every week. I get to feeling bad if I don't get it, so it worried me. Also, I was supposed to get a dose of [MEDICATION(S)] muscle relaxer that was missed and that worried me too, but I didn't really have any problem from it. When asked how it made him feel to have not received his medications to which Resident #2 responded aggravating, frustrating, disappointing, angry. I made me feel insecure. Resident #2 stated I ' m dependent on these people. They are responsible for me. It ' s just like they don ' t understand that. On 8/04/21 at 1:40 PM, an interview with Resident #3 revealed he recalled not having received his medications on ' B shift ' 7/25/21. Resident #3 was alert and oriented and communicated well verbally. Resident #3 stated it bothered him to think people don ' t come to work when they should. He denied having any negative outcome from missing his medications on ' B shift ' 7/25/21. Resident #3 stated They need to do something and provided clarification The people that run this place need to do something to make sure there is somebody here to give us our medicines and stuff. On 8/04/21 at 2:39 PM, in an interview with LPN # 3 revealed on July 25, 2021, she was working 7:00AM-3:00PM shift (B shift) on the North Unit. She stated that on 7/25/21 at approximately 2:45 PM RN #1 came down the hall and said the Nurse Administrator wanted to know if either of us would work over. LPN stated she said no. She stated she finished her treatments and went back to the nurses station around 3:00 (PM) and RN #1 said the Nurse Administrator had called, and someone was coming to relieve us, but the only one who showed up was LPN #3. She stated she counted the North side narcotics with LPN #1 and left between 4:00 (PM) and 5:00 (PM). She stated RN #1 told her she was going to stay and see if anybody was going to come and RN #1 called 'staffing' and talked to the RN Nurse Supervisor, DON #2, and the Nurse Administrator. On 8/04/21 at 3:58 PM, in a telephone interview with the Staffing Director revealed LPN #1 and LPN #4 were scheduled to work 3:00PM-11:00PM (B shift) on 7/25/21. The Staffing Director stated On Thursday (7/22/21) at 1:17 PM prior to the weekend I sent a text message to (LPN #4) to confirm the scheduled shifts for the weekend to review and confirm. She texted back and asked if she could be off on Saturday, but I texted her back and told her no, that I really, really needed her and she texted back and confirmed the schedule. She stated LPN #4 did not report for work or call-in on 7/25/21. She was unable to explain beyond that how ' South Unit was without a nurse on 7/25/21 from 5:00 PM to 11:00 PM. When asked how residents ' acuity, needs, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked how the facility ' s census impacts staffing levels, Staffing Director stated that the census had held steady at forty (40) for quite a while had a maximum of forty-five (45). When asked how call-ins are handled, Staffing Director stated they pull staff from other buildings if available, the DONs could work the cart, the RN Supervisor on the 3:00PM-11:00PM shift works the cart if needed and if none of those staff were available, they relied on Mandated Overtime. When asked if staff, residents, or families bring up workload concerns and if so, how the concerns are handled, Staffing Director stated the facility tried to make sure there was enough staff to take care of the residents. When asked if there a system in place to address these concerns the Staffing Director stated that even prior to the COVID-19 pandemic staffing had been a concern and it had been exacerbated by the pandemic, but staff were encouraged to report concerns to their supervisor and the concern would move up the chain of command until resolution had been accomplished if possible. She stated staffing was a difficult issue because it takes everyone working together, coming in when they are supposed to and doing what they are supposed to do while they are here in order to have an equitable workload. When asked about the turnover rate the Staffing Director reported it was high. On 8/05/21 at 12:54 PM, an interview with Nurse Administrator revealed the Nurse Administrator stated, I had told the Staffing Director and RN Supervisor on Saturday (7/24/21) per text message I was on call the weekend before as the interim DON at another building and worked the weekend before (7/17/21 and 7/18/21) before I agreed to take call for DON #1.The Nurse Administrator stated I texted the Staffing Director and told her if she would take call until Sunday morning, I would appreciate it; the Staffing Director said she had called in sick until Thursday and another LPN could cover call-ins for day shift and the RN supervisor would be in at 3:00 PM. The Nurse Administrator stated the Nurse Executive asked Staffing Director if agency needed to be contacted and the Staffing Director responded she had and would continue to reach out to agency without success; no one returned her calls or messages. The Nurse Administrator stated I checked the J Drive and saw two (2) nurses had called in. Nurse Administrator stated she initially intended to move LPN #4 to another building and that is why she called RN #1 at 2:45 PM before it was realized that LPN #4 was not coming in to work at 3:00 PM. Nurse Administrator stated at 4:19 PM the RN Supervisor texted to say RN #1 had left. The Nurse Administrator also stated LPN #1 had approached her weeks before and voiced concerns that he was having to stay over frequently due to mandated overtime and on-site relief not arriving to relieve him. She stated LPN #1 inquired about compensation for working the entire building by himself and working sixteen (16) hour shifts. The Nurse Administrator stated she had reported LPN #1 ' s concerns/request to the Nursing Home Director and was told there were no funds available for such compensation. She stated she had reported this to LPN #1. Human Resources Record review revealed the Nurse Administrator acted as the interim DON for another building for approximately six (6) weeks until July 22, 2021. She agreed to take call for DON #1 for the weekend of 7/24/21 and 7/25/21. On 8/05/21 at 1:37 PM, an interview with DON #1 revealed she was the full time DON of another building. She stated when she started taking call on weekends twelve years ago there was five (5) DONs taking call on weekends, around 2017 the call rotation dropped to four (4) DONs and in 2021 it dropped to three (3) DONs on the weekend call rotation. She stated prior to 2020 there was not enough staff. She stated the On-Call DON ' s did not have to come in to work to cover call-ins very often until 2019. She stated over the past two (2) years we ' ve really had to fill in a good bit. In 2021 DONs are having to come in and work the cart every time, every weekend we are on call. She stated the DON on call is on call from Wednesday at 5:00 PM until the following Wednesday at 5:00 PM. She stated the DONs are also having to come in on the 3:00PM-11:00PM and the 11:00PM-7:00AM quite frequently. DON #1 stated she worked Monday, 7/19/21 through Friday 7/23/21 and worked 11:00 PM 7/23/21 until 8:00 AM 7/24/21. She stated she worked Sunday 7/25/21 7:00 PM and stayed and worked all of11:00PM-7:00AM at another building, left at approximately 7:00 AM Monday 7/26/21 and returned and worked the cart 3PM-7:00PM on 7/26/21 due to call-ins. DON #1 stated If we are on call we make every effort to find somebody to replace that person, especially if the nurse has already worked sixteen (16) hours. She stated on 7/25/21, we had no way to contact the contract nurse that was supposed to have come in. She stated the RN Supervisor was assigned to a cart. She also stated two (2) buildings were short staffed. DON #1 stated if the DON on call exhausted all resources and the nurse won ' t stay it ' s my responsibility to come in. When asked about outcomes for a resident who missed medications, DON #1 stated there could be negative outcomes such as blood sugar with hypoglycemic or hyperglycemic events, behaviors could be affected negatively. DON #1 stated usually there is a housekeeper in the building for eight (8) hours a day. She reported the CNAs sweep after supper and take out the trash and do housekeeping like cleaning up spills to provide a safe environment for the residents. She stated the nurses must help the CNAs every day because of the CNA shortage. She stated she thought Mandated Overtime was intended for emergency purposes and as a last resort. DON #1 stated Nurses are exhausted at the end of their shifts because at the end of the day the nurses can do the housekeeping and CNA work but who can do our work. On 8/05/21 at 3:00 PM, an interview with Nursing Home Director (NHD) revealed he was aware staffing was a problem for the facility. He stated the staff were all tired and that fatigue affects performance. He stated he had been working there for fifteen (15) years and staffing had always been a problem. He stated COVID-19 escalated the challenges. He stated the facility had contracts with three staffing agencies, used contract staff and emergency COVID-19 contracts to try to get staffing. He stated, when everyone shows up for work, we have enough staff, other days you have call-ins because they are tired from working so much. He stated the staffing problems are a combination of call-ins and not enough staff. He stated there are disciplinary steps for excessive call-ins which could result in attendance counseling, written reprimands, and termination. When asked what effect inadequate staffing could have on residents the Nursing Home Director responded, Inconsistent staff could result in residents not getting the best care we can give them. He stated adequate staffing was important for residents to be more comfortable, happier and for their safety. When asked his opinion (remembering he is not a nurse or a doctor) what effects on resident he might expect if residents did not get medications as prescribed, he expressed concern for residents that were diabetic or had been prescribed medications that were time sensitive and stated, the medications are a concern, a legitimate issue, not having a nurse on that wing. Nursing Home Director stated he was not aware until Wednesday 7/28/21 that the facility had been without a nurse for six (6) hours on 7/25/21. On 8/05/21 at 3:30 PM, an interview with the facility's Interim Administrator revealed when asked how nursing supervision monitored and provided oversight in order to assure care and services are implemented based upon the care plan and the resident's identified needs, and if there is an acute change of condition, she responded the shift report and physician orders are reviewed in the morning meeting. When asked how the facility monitored staff/resident interactions? The Interim Administrator responded direct observation was employed. When asked how the facility monitored for the deployment of sufficient numbers of qualified and competent staff across all shifts to meet resident needs, The Interim Administrator responded the J Drive was used to check for sufficient staffing, and staff competencies and in-services were used to ensure competent staff. When asked how t [TRUNCATED]

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the development of pressure ulcers and the worsening of pressure ulcers due to pressure ulcers becoming infected for three (3) of 12 residents reviewed for pressure ulcers, Residents #1, #3, and #12. The facility's failure to assess and provide treatment resulted in Resident #1 developing four (4) new pressure ulcers and acquiring a wound infection which required debridement procedures and hospitalization . The facility's failure to assess and provide treatment to residents who were at risk for skin breakdown and to prevent further skin breakdown also affected Residents #3 who had existing wounds in which one (1) wound became infected and required debridement procedures and antibiotic therapy and Resident #12 who developed one (1) pressure ulcer that required debridement procedures, antibiotic therapy, and hospitalization . The facility's failure to provide services necessary to treatment and prevent pressure ulcers caused significant harm to Residents #1, #3, and #12 and placed other residents at risk for skin breakdown, in a situation that was likely to cause serious injury, harm, impairment, or death. The State Survey Agency (SSA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 3/4/21, as a result of the facility's failure to prevent Resident #1's initial pressure ulcer. On 9/7/21 at 5:15 PM, the SSA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ template to the Nursing Home Administrator. The facility submitted a credible Removal Plan on 9/8/21, and determined the IJ was removed, prior to exit. Therefore, the scope and severity for CFR(s) 483.25(b)(1)(i)(ii) - Treatment/Services to Prevent/Heal Pressure Ulcers (F686) was lowered from a J level scope and severity to a D level, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility's SKIN/WOUND CARE policy, dated February 2016, revealed, PROCEDURE: A. IDENTIFICATION OF PATIENTS/RESIDENTS AT RISK FOR PRESSURE ULCERS . (2) each patient/resident will have a skin audit completed by the nurse at the following times as part of the identification process: . ( e ) Weekly by the nurse (3) The skin audit will include: (b) Nurse audit will include inspection of each pressure point for discoloration. (4) Skin audit documentation includes a. Narrative nurse's notes (monthly) C. Initial discovery of pressure ulcer. The nurse will: a. Document in nurses notes on the wound/ulcer documentation form Wound/Ulcer Nurse Note MSH-530 .D. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . f. Document the treatment on the treatment record/Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse will document on each wound weekly and document the following in the nurse's notes on Wound/Ulcer documentation form MSH-530. (1) Classification of wound .(2) Location (3) Accurate measurements in centimeters .(4) Description of the wound tissue and surrounding tissue. (5) Description of drainage, odor, eschar, undermining or tunneling if present (6) Description of pain if present and treatments . (7) Pressure or absence of palpable peripheral pulses if wound is on an extremity (8) Any lab or x-ray ordered for suspected wound infection (9) Any changes from previous week (10) Preventive and/or pressure-relieving devices in use (11) Current treatment. Resident #1 Record review of Resident #1's Face Sheet, revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Minimum Data Set (MDS) Section C dated 5/5/21, revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated severely cognitive impairement. Section M of the MDS dated [DATE] revealed Resident #1 had two (2) Stage 2 pressure ulcers and one (1) Stage 3 pressure ulcer. Record review of the MDS Assessment Notes dated 7/28/21 revealed Resident #1 was totally dependent on staff for bed mobility and transfers. Record review of Pressure and Nonpressure Wound Report (Form JNH 117) and (Physician) Progress Notes revealed from 3/4/21 through 5/7/21 revealed Resident #1 had four (4) in-house acquired pressure ulcers to develop. The pressure ulcers sites were Left Trochanter (Stage 3), Right Trochanter (Stage 3), Left Shoulder (Stage 3) and Right Posterior Scapula (Stage IV) in which the pressure ulcer to the Right Posterior Scapula became infected. The infection caused Resident #1 to have a twenty-day acute care hospital stay. Record review of Pressure and Nonpressure Wound Report (Form JNH 117) and the Treatment Records revealed a lack of weekly body audits, wound assessments, measurements, and missed treatments. On 8/26/21 at 12:20 PM, SA observation revealed Resident #1 had a clean, dry dressing on his left posterior shoulder dated 8/25/21, a dressing on the resident's left hip, dated 8/25/21 and right hip had a dressing dated 8/25/21. Resident was lying on his right side and SA was unable to observe if he had dressing to right scapula. On 9/01/21 at 2:30 PM, SA observed Resident #1 during wound care of Right posterior scapula and noted the wound to be a round area which had well approximated edges and a healthy dark pink appearance. Resident #1 Right Trochanter Record review of the Pressure and Nonpressure Wound Report (Form JNH 117) revealed the following: On 3/4/21-Resident #1 had a Stage II pressure area on his right trochanter with partial thickness skin loss and a small amount of bloody drainage. The area measured 0.3 centimeters (cm) length, 0.3 cm width, 0 cm depth. This was the first documented assessment of Resident #1's pressure wound to his Right Trochanter. 3/10/21 - Stage II with a small amount of bloody drainage and measures 1.5 cm length, 1.0 cm width 0 cm depth. 3/23/21 -(13 days from previous assessment) Stage II 5.0 cm length, 3.3 cm width, 0 cm depth. 4/12/21- (19 days from the previous assessment) pressure injury to the right trochanter Stage III (previous assessment was a Stage 2) full thickness with moderate amount of bloody serous drainage and measures 5 cm length x 3 cm width x 0 cm. 4/22/21 -(9 days from previous assessment) a full thickness skin loss injury with small amount of bloody drainage and slough present and measurement 4.5 cm length, 5.5 cm width, and 0.2 cm depth 4/28/21- noted a full thickness injury with a small amount of bloody drainage and measures 4.5 cm length, 3.4 cm width, and 0.2 cm depth. There were no Pressure and Nonpressure Wound Reports after 4/28/21 even though there continued to be treatments ordered and on the Treatment Chart through the month of July 2021. A record review of the Treatment Chart' for the month of March 2021, revealed St (Stage) II (2) Wash R (Right) Trochanter with soap and H2O (water), pat dry q (every) 12 hours, apply scant amt (amount) Santyl, cover with gauze q 12/hr (12 hours) was started on 3/4/21 and was missed 22 times. A record review of the Treatment Chart' for the month of April 2021, revealed St II Wash R Trochanter with soap and H2O, pat dry q 12 hours, apply scant amt Santyl, cover with gauze q 12/hr was missed 14 times from 4/1/21 until the order was changed on 4/12/21. Wash wounds Lt (Left) and Rt (Right) hip with NS (Normal Saline), pat dry, apply scant amount of Santyl to wound bed and cover with gauze, Alldress q (every) 12 hrs. Notify MD of any changes was missed five (5) times between 4/7/21 until it was changed on 4/12/21. Wash Stage III pressure injury to Rt trochanter (upper leg) with normal saline, pat dry and apply damp to dry dressing with NS cover with Alldress BID (two times daily) was missed seven times from 4/12/21 through 4/30/21. A record review of the Treatment Chart for the month of May 2021, revealed Rt Trochanter: wash stgIII (Stage 3) pressure injury w/NS pat dry; cover w/Alldress BID was missed 21 times. A record review of the Treatment Chart for the month of June 2021, revealed Resident #1 was transferred to the hospital on 6/2/21 and returned 6/22/21. Clean Rt Trochanter and Lt shoulder with ns (normal saline) pat dry apply Santyl 2X (two times) daily and cover with Alldress was missed five (5) times from 6/23/21 to 6/30/21. A record review of the Treatment Chart for the month of July, 2021, revealed Clean Rt Trochanter and Lt shoulder w/NS; pat dry and apply Santyl BID and cover w/Alldress was missed 17 times. Resident #1 Left Posterior Shoulder Record review of the Pressure and Nonpressure Wound Report (Form JNH 117) dated 4/12/21 revealed a Stage III (Stage 3) pressure ulcer to the left posterior shoulder with full thickness skin loss and a moderate amount of serosanguinous drainage and slough present in the wound bed. The pressure area measures 6 cm length, 5 width, 0 cm depth. This is the first assessment of the wound to the left posterior shoulder, however, a review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The area measured 5 cm length, 4.5 cm width, and 0.3 cm depth. On 4/28/21 noted a full thickness injury with a small amount of bloody drainage and measures 5 cm length, 4 cm width, and 0.2 cm depth. There were no Pressure and Nonpressure Wound Reports after 4/28/21 even though there continued to be treatments ordered and on the Treatment Chart through the month of July, 2021. Record review of the Treatment Chart' for the month of April 2021, revealed Left shoulder apply Santyl q (every) 12 hrs with dressing was missed 3 times from 4/1/21 until 4/9/21. Wash Stage III pressure injury to Left Shoulder with normal saline and apply damp to dry dressing cover with Alldress BID was missed six (6) times from 4/12/21 through 4/30/21. A record review of the Treatment Chart for the month of May 2021, revealed Lt Shoulder w/NS; apply damp to dry dsg (dressing) w/NS and cover w/Alldress (with Alldress) BID was missed 20 times. A record review of the Treatment Chart for the month of July 2021, revealed Clean Rt Trochanter and Lt shoulder w/NS; pat dry and apply Santyl BID and cover w/Alldress was missed 17 times. Resident #1 Left Trochanter A record review of the Pressure and Nonpressure Wound Report (Form JNH 117) revealed the following: 4/12/21- Stage III (Stage 3) pressure ulcer to the left trochanter with full thickness skin loss and a moderate amount of serosanguinous drainage. The pressure area measures 4 cm length, 3.8 width, 0 cm depth. This is the first assessment of the wound to the left posterior shoulder, however, a review of the Treatment Chart for April 2021 revealed 4/7/21 Wash wounds Lt (Left) and Rt (Right) hip with NS (Normal Saline) and pat dry apply scant amount of Sanytl to wound bed and cover with gauze, Alldress q (every) 12 h rs (hours. Notify MD (Medical Director) of any changes which means the wound was not assessed and recorded by the nurse until 5 days after the Treatment was started. 4/22/21- (9 days from previous assessment) revealed Stage II (Stage 2) partial thickness pressure injury with no drainage. The area measured 3.1 cm length, 1.0 cm width, and 0.1 cm depth. 4/28/21- noted a Stage II (Stage 2) partial thickness injury with no drainage and measures 2.8 cm length, 1 cm width, and 0.1 cm depth. There were no Pressure and Nonpressure Wound Reports after 4/28/21 even though there continued to be treatments ordered and on the Treatment Chart through the month of May 2021. A record review of the Treatment Chart' for the month of April 2021, revealed 4/7/21 Wash wounds Lt (Left) and Rt (Right) hip with NS (Normal Saline), pat dry, apply scant amount of Santyl to wound bed and cover with gauze, Alldress q (every) 12 hrs. Notify MD of any changes was missed five (5) times between 4/7/21 until it was changed on 4/12/21. 4/12/21 Wash left trochanter (upper leg) with NS (Normal Saline), pat dry and apply scant amount of Santyl and cover with Alldress BID q 12 hrs was missed one (1) time from 4/12/21 through 4/30/21. A record review of the Treatment Chart for the month of May 2021, revealed Lt trochanter w/NS; pat dry and apply scan amt of Santyl, Cover w/Alldress q 12 hours was missed 19 times. A record review of the Treatment Chart for the month of June 2021, revealed Resident #1 was transferred to the hospital on 6/2/21 and returned 6/22/21. There are no further treatments listed for this wound on the Treatment Chart. Resident #1 Right Posterior Scapula A record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were never any Pressure and Nonpressure Wound Report (Form JNH 117) completed for this wound which would describe the wound in detail including measurements and staging. A record review of the Treatment Chart for the month of May 2021, revealed Wound care to back Rt posterior scapula apply Santyl to wound bed and cover with Alldress Q 12 hours was started on 5/7/21 and was missed 20 times. A record review of the Treatment Chart for the month of June, 2021, revealed Resident #1 was transferred to the hospital on 6/2/21 and returned 6/22/21. Wound care to R (Right) back scapula area Clean with NS pat dry, apply Santyl to wound bed then pack wound bed with damp to dry gauze with NS then apply Alldress Q 12 hrs (hours) and PRN (As Needed) when soiled until healed. Notify MD of acute changes was missed five (5) times from 6/23/21 to 6/30/21. A record review of the Treatment Chart for the month of July 2021, revealed WOUND CARE: Rt. back scapula area; clean w/NS, pat dry, apply Santyl to wound bed then pack w/ damp to dry gauze w/ NS, Apply Alldress Q 12 hr and prn when soiled until healed. Notify MD of acute changes was missed 22 times. A record review of Progress Notes dated 5/7/21, completed by MD #1 revealed R posterior back (Scapula) indurated with 5 cm diameter ulcer with exudate debrided of exudate . A record review of Progress Notes dated 5/14/21 completed by MD #1 revealed R back (Posterior Scapula) . area debrided. A record review of Progress Notes dated 5/19/21 completed by MD #1 revealed R back ulcer (Posterior Scapula) .large exudate .debrided. A record review of Progress Notes dated 5/26/21 completed by MD #1 revealed R back (posterior) scapula area .sharp cross hatching of wound bed. A record review of Nurse Notes dated 6/1/21 at 10:45 AM revealed Resident temp 100.3 ax at 0900 . A record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) [MEDICATION(S)] 1 gm IM now and 1 gm [MEDICATION(S)] x (times) 3 days 3) [MEDICATION(S)] 500 mg po (by mouth) TID (Three times daily) x (times) 3 days after [MEDICATION(S)] IM order is finished in 5 days 4) Obtain Complete Blood Count (CBC) d/t (due to) elevated temp and wounds. A record review of Nurse Notes dated 6/1/21 at 11:35 AM revealed CBC and wound culture obtained . A record review of Nurse Notes dated 6/2/21 at 10:15 AM revealed MD assessed res (resident) wounds .crosshatched debrided back (scapula) wound r/t moderate amount of slough present in wound bed. A record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of (Name of Local Hospital) Discharge Summary dated 6/22/21 revealed the date of admission to (Name of Local Hospital) of 6/2/21 and date of discharge of 6/22/21. A record review of the Culture Wound W Gram Stain indicated the source of the culture as the Right Posterior Scapula dated 6/1/21 with heavy growth proteus mirablis, and acinetrobacter baumanni complex, and diptheroids which indicates infection. A record review of the Infection Surveillance Checklist dated 6/1/21 indicated Resident #1 had increased temperature and pus at wound, skin, or soft tissue site and heat (warmth) at affected site, redness at the affected side, and swelling at the affected site. The checklist also indicates tenderness or pain at affected site and fever. A record review of Progress Notes dated 7/9/21 completed by MD #1 revealed R posterior shoulder (Scapula) Stage IV (Stage 4) . is the first recorded staging of this wound. A record review of Building 78 Wound Report for May 2021, revealed Resident #1's name listed on the report in the left column under the heading of Resident. His four (4) wounds are listed Lt Shoulder, Lt trochanter, Rt trochanter, Rt posterior scapular in the column with the heading Decubitus Injury Site. The other information on the form which includes Stage (Staging does not change), Skin Tear, Abrasion, Lesion, Measurement (LxWxD)(Length times Width x Depth) with columns dated in handwritting 5/4/21, 5/11/21, 5/18/21, 5/25/21, and Signature column are all blank with no information indicated in those columns for Resident #1. A record review of Building 78 Wound Report for June 2021, revealed Resident #1's name, wounds, and measurements are not listed on the report. A record review of Building 78 Wound Report for July 2021, revealed Resident #1's name listed on the report in the left column under the heading of Resident. His four (4) wounds are listed L Shoulder, L trochanter, R trochanter, R pos scapular/back in the column with the heading Decubitus Injury Site. The other information on the form which includes Stage (Staging does not change), Skin Tear, Abrasion, Lesion, Measurement (LxWxD) with columns dated in handwritten form 7/6/21, 7/13/21, 7/20/21, 7/28/21, and Signature column are all blank with no information except for on 7/6/21 there are measurements listed L Shoulder 5L x 4W x 0, L Trochanter 4.5 x 6W x 0, R Trochanter 4.3 x 2.6 x 0, R Pos Scapular/Back 7L x 4.5 W x 1.5. A record review of the Treatment Chart' for the month of March 2021, revealed [MEDICATION(S)] to buttock/periarea with brief change (every shift) was missed 34 times. Notify MD of any skin changes (every shift) was missed 35 times. There were no weekly body audits noted on the Treatment Chart for March. A record review of the Treatment Chart' for the month of April 2021, revealed [MEDICATION(S)] to buttock/peri area with brief change (every shift) was missed 22 times. Notify MD of any skin changes (every shift) was missed 23 times. Gel cushion to geri-chair (every shift) was missed 19 times. Alternating air mattress to bed on and functioning (every shift) was missed 19 times. Turn from side to side w/in (while in) bed Avoid Rt Side (every shift) was missed 19 times. There was no weekly body audit information noted on the Treatment Chart for April. A record review of the Treatment Chart for the month of May 2021, revealed Wkly Body Audits check for breakdown/any new skin problems P=Present A=Absent if present notify MD (Medical Director) and document in Nurses notes was missed for the month which means there were no weekly body audits for May. Notify MD of any Skin Changes (every shift) was missed 22 times. [MEDICATION(S)] to buttocks/per-area w/brief change was missed 22 times. Gel cushion to geri-chair (every shift) was missed 24 times. Alternating air mattress to bed (every shift) was missed 23 times. Turn from side to side w/in (while in) bed Avoid Rt (Right) Side (every shift) was not documented the entire month which means this intervention was missed 93 times. A record review of the Treatment Chart for the month of June 2021, revealed Resident #1 was transferred to the hospital on 6/2/21 and returned 6/22/21. Notify MD of any skin changes was missed four (4) times from 6/23/21 to 6/30/21. [MEDICATION(S)] to buttocks/per-area w/brief change was missed for (4) times from 6/23/21 to 6/30/21. Wkly Body audits check for breakdown/any new skin problems P=Present A=Absent if present notify MD and document in Nurses notes was missed and there were no weekly body audits performed in June. Gel cushion to geri-chair (every shift) was missed 7 times. Alternating air mattress to bed (every shift) was missed 5 times. A record review of the Treatment Chart for the month of June 2021, revealed Clean Rt Trochanter and Lt shoulder w/NS; pat dry and apply Santyl BID and cover w/Alldress was missed 5 times. A record review of the Treatment Chart for the month of July 2021, revealed Notify MD of any skin changes (every shift) was missed 21 times. [MEDICATION(S)] to buttocks/per-area w brief change (every shift) was missed 20 times. Wklyl body Audits check for breakdown/any new ski problems P=Present A=Absent if present Notify MD and document in Nurses notes was missed one (1) of four (4) times. Gel cushion to geri-chair (every shift) was missed 23 times. Alternating air mattress to bed (every shift) was missed 21 times. A record review of Nurses Notes dated 4/23/21 at 3:50 PM, revealed Late entry for 4/22/21. MD debrided R Trochanter removing some slough .MD also debrided L shoulder .removing moderate slough from wound bed. On 8/27/21 at 11:30 AM, in an interview with the Director of Nursing, she confirmed Resident #1 was hospitalized in June due to a wound infection. On 9/01/21 at 10:45 AM, a telephone interview with wife and Resident Representative (RR) for Resident # 1 revealed she telephoned and kept up to date on the resident's condition. When asked how satisfied she was with the care provided for her husband, RP stated It couldn't be that good or he wouldn't have developed holes in his skin. There's just one way to say it, they neglected him. They didn't turn him or something the way he should have been. Resident #3 Record review of Resident #3's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #3's Minimum Data Set (MDS) Section C dated 5/12/21, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicates he is cognitively intact. A record review of the MDS Section M dated 5/12/21 revealed Resident #3 had one (1) Stage 2 pressure ulcer and two (2) Stage 4 pressure ulcers. A record review of Pressure and Nonpressure Wound Report (Form JNH 117) and Treatment Charts revealed Resident #3 had six (6) existing pressure ulcers Left Heel (Stage 3), Right Heel (Unstageable), and Coccyx/Sacrum (Stage 3), Left Foot Medial (Stage not documented), Left Foot Medial (Stage not documented), Left Medial Toe (Stage not documented , and Right Medial (Foot) (Stage not documented) that were receiving treatments. He developed a new facility acquired pressure injury to the Left Gluteal Crease (Stage 2) on 4/28/21. The pressure ulcer to the coccyx/sacrum became infected and required debridement and antibiotic therapy. A record review of Pressure and Nonpressure Wound Report (Form JNH 117) and the Treatment Records revealed a lack of weekly body audits, wound assessments, measurements, and missed treatments. Observation of the wound on Resident #3's coccyx,on 8/27/21 at 1:45 PM, revealed the wound an had the appearance of being a very small opening at the coccyx with a void below the skin of undeterminable depth. The skin around the opening was clear and clean and intact with normal brown color with no indication of infection at the opening or surrounding area. The left and right heels had no open areas or discoloration. In an interview with the Nurse Administrator on 8/31/2021 at 1:30 PM , she thought Resident #3 was admitted with wounds to the right heel, left heel, and coccyx/sacrum when he was admitted to the facility.However, the facility was unable to provide any supporting documentation. The facility was able to provide Treatment Charts for the months (July, August, and September of 2020) in which treatments began for the wounds to the left heel, right heel, and coccyx/sacrum. Resident #3 Left Heel A record review of the Treatment Chart for July 2020 revealed W-D(wet to dry) NS (normal saline) to L (left) Heel Q (every) 12hr (hours).Documentation began on on the Treatment Chart on 7/15/2020. A record review of the Pressure and Nonpressure Wound Report (Form JNH 117)revealed the following: 4/8/21 left heel pressure area was a Stage 3 with a small amount of bloody drainage. The pressure area measured 2.5 cm length, 3.0 cm width, and 0 cm depth. 4/22/21- (13 days from the previous assessment) indicated full thickness skin loss with a small amount of serous drainage. The wound measurements were 3.0 cm length, 2.7 cm width, and 0.2 cm depth. There were no other Pressure and Nonpressure Wound Report (Form JNH 117) completed for April, May, June, or July of 2021 for this wound even though there continued to be treatments ordered and on the Treatment Chart through the month of July, 2021. A record review of the Treatment Chart' for the month of April 2021, revealed Lt Heel: wash with NS and dry. Apply Kaldestat w/drsg. Q 12 hrs. was missed 22 times. A record review of the Treatment Chart for the month of May 2021 revealed Lt Heel-wash and dry with NS Apply Kaldestat w/drsg Q 12 hrs was missed 6 times from 5/1/21 to 5/6/21 (Order was changed 5/7/21). Wound Care: Left Heel Wound - Cleanse w/NS, pat dry, apply Dankin's 0.25% moistened Gaue to wound bed. Cover w/gauze and kerlix or Conform BID was missed 22 times from 5/7/21 through 5/31/21. A review of the Treatment Chart for the month of June 2021 revealed Wound care: Left Heel wound - Cleanse w/ NS, pat dry, apply Dankins's 0.25% moistened gauze to wound bed. Cover w/gauze and kerlix or Conform BID was missed nine (9) times. A review of the Treatment Chart for the month of July 2021 revealed Wound care: Left Heel wound - Cleanse w/ NS, pat dry, apply Dankins's 0.25% moistened gauze to wound bed. Cover w/gauze and kerlix or Conform BID was missed 24 times. A record review of the Encounter Date: 7/6/21 (Wound Clinic) revealed Wound 05/06/21 Pressure Injury Left; Plantar (Active) Wound Length (cm) 0 cm, Wound Width (cm) 0 cm, Wound Depth 0cm Wound Healing % (percent) 100. Resident #3 Right Heel A record review of the Treatment Chart for August 2020 revealed Dress R heel wet to dry NS q 12 hrs in which documentation began 8/3/20. A record review of the Pressure and Nonpressure Wound Report (Form JNH 117) dated 4/8/21 indicated the right heel pressure area was Unstageable and there was eschar present in the wound bed. The pressure area measured 1 cm length, 1.2 cm width, and 0 cm depth. There were no other Pressure and Nonpressure Wound Report (Form JNH 117) completed for April, May, June, or July of 2021 for this wound even though there continued to be treatments ordered and on the Treatment Chart through the month of July, 2021. A record review of the Treatment Chart' for the month of April 2021, revealed Rt Heel: wash and dry. Apply Kaldestat w/ drsg. Q 12 hrs was missed 34 times. A record review of the Treatment Chart for the month of May 2021 revealed Right heel ulcer apply damp to dry NS dressing Q 12 h Notify MD of acute change q12 hr was missed 12 times from 5/20/21 to 5/31/21. (The treatment did not start until 5/20/21). The previous treatment from the April Treatment Chart for the right heel was not carried over to the May Treatment Chart). A review of the Treatment Chart for the month of June 2021 revealed Rt Heel: Apply damp to dry NS dsg Q 12 hr. notify MD of acute changes was missed 14 times. A review of the Treatment Chart for the month of July 2021 revealed Rt Heel: Apply damp to dry NS dsg Q 12 hr. notify MD of acute changes was missed 24 times. Resident #3 Coccyx/Sacrum A record review of the Treatment Chart for September 2020 revealed Sacrum - cleanse with NS, pat dry with gauze apply Santyl to Wound bed and cover with bordered gauze 2 times daily. A record review of the Pressure and Nonpressure Wound Report (Form JNH 117) revealed the following: 4/8/21 indicated the coccyx pressure area was a Stage 3 with full thickness skin loss. The pressure area measured 4 cm length, 3.5 cm width, and 0.5 cm depth. 4/22/21- (13 days from the previous assessment) indicated a Stage 3 pressure area with full thickness skin loss with a moderate amount of serosanguinous drainage. The wound measurements were 2.3 cm length, 0.8 cm width, and 2.0 cm depth. There were no other Pressure and Nonpressure Wound Report (Form JNH 117) completed for April, May, June, or July of 2021 for this wound. even though there continued to be treatments ordered and on the Treatment Chart through the month of July, 2021. A record review of the Treatment Chart' for the month of April 2021, revealed Coccyx Wound Care: Clean, pack with Kaldestat cover with alldress q 12 hrs Scant amount of Santyl to Surround abrasion R buttocks q 12 hrs was missed 15 times. A record review of the Treatment Chart for the month of May 2021 revealed Coccyx wound care: Clean, pack w/kaldestate. Cover w/Alldress Q 12 hrs scant amount Santyl to surrounding abrasion L buttocks Q 12 was missed six (6) times from 5/1/21 to 5/6/21 (Order was changed on 5/7/21). Wound Care: Coccyx wound - irrigate w/[MEDICATION(S)], rinse with NS-pat dry then apply Dankins 0.25% solution moistened gauze to wound bed. Cover w/dry gauze and ABD pad. Secure w/[MEDICATION(S)] tape BID (Two times daily) and PRN (as needed), soilage was missed 22 times from 5/7/21 through 5/31/21. Stay off coccyx as much as possible (every shift) was missed 37 times. A review of the Treatment Chart for the month of June 2021 revealed Wound Care: Coccyx wound - irrigate w/[MEDICATION(S)], rinse with NS - pat dry then Apply Dankins 0.25% solution moistened gauze to wound bed. Cover w/dry gauze and ABD (Abdominal) pad. Secure w/[MEDICATION(S)] tape BID and PRN, soilage was missed 17 times. Stay off coccyx as much as possible (every shift) was missed 15 times. A review of the Treatment Chart for the month of July 2021 revealed Stay off coccyx as much as possible (every shift) was missed 27 times. Wound Care: Coccyx wound - irrigate w/[MEDICATION(S)], rinse with NS - pat dry then Apply Dankins 0.25% solution moistened gauze to wound bed. Cover w/dry gauze and ABD (Abdominal) pad. Secure w/[MEDICATION(S)] tape BID and PRN, soilage was missed 6 times from 7/1/21 to 7/6/21 (Order changed 7/7/21). Treatment to coccyx irrigate with 0.25% Dakins solution then rinse with NS pat dry pack with calcium alginate with silver, cover with gauze and ABD secure with [MEDICATION(S)] tape BID and prn soilage was missed 19 times from 7/7/21 to 7/31/21. A record review of the Progress Notes completed by MD #1 dated 4/28/21 at 11:00 AM reveal Pt's coccygeal/sacral [NAME] (Decubutis Ulcer) continues to remain clean but has been tunnelling and will require wound clinic referral A record review of Physicians Orders dated 5/5/21 at 9:35 AM

Based on staff interviews, record reviews, and facility policy review the facility failed to maintain an accurate medical record as evidenced by medications and treatments were not accurately documented on the Medication and Treatment Charts for 12 of 12 residents reviewed. Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12. Finding Include: Record review of the facility's, (Proper Name) Nursing Documentation policy, dated March 2021, revealed, 1. PURPOSE AND APPLICABILITY. The purpose of this policy is to provide nurses with guidelines for documenting in resident medical records. This policy applies to all licensed nurses at (Proper Name). 2. POLICY. It is the professional responsibility of all licensed nurses to provide an accurate, in-depth clinical record of care for assigned residents . Resident #1 Record review of the Physician's Orders with an original date of 6/22/21 and updated 7/21/21 revealed Resident #1 had orders in place for the following medications and treatments: [MEDICATION(S)] 0.125 mg (milligram)tab Take one (1) tablet PO (By Mouth) daily, [MEDICATION(S)] Sulf (Sulfate) 220mg/5ml (milliliters) Elix ([MEDICATION(S)]) Give 220 mg (5 ml) po three (3) times a day, [MEDICATION(S)] capsule Disp (Dispense) as Acidophilus capsule Take two (2) capsules po twice daily. [MEDICATION(S)]/Apap ([MEDICATION(S)]/Acetaminophen) 5/325 mg Take one (1) table po twice daily for 28 days. Resident #1 also had a Physician's Order dated 7/2/21 for [MEDICATION(S)] one (1) packet po TID (Three times daily). Resident #1 had Physician's Orders for treatments for Wound care to R back scapula area Clean with NS (Normal Saline), pat dry, apply Santyl to wound bed then pack wound bed with damp to dray gauze with NS then apply Alldress Q (every) 12 hrs (hours) and prn (as needed) when soiled, until healed. Notify MD of any acute changes dated 6/23/21 at 5:03 PM. He also has a treatment order dated 6/22/21 at 11:45 AM for Santyl Topical Ointment BID (two times daily) to R Trochanteric Ulcer and L Shoulder Q 12 h rs. Record review of the Medication Chart for the month of July 2021 revealed, [MEDICATION(S)] 0.125 mg tab (tablet) take 1 tablet po (by mouth) daily was missed one (1) time. [MEDICATION(S)] Sulf (Sulfate) 220 mg/5 ml (milliliters) [MEDICATION(S)] give 220 mg (5 ml) po 3 times a day was missed one (1) time. Acidophilus capsule comp (compare) to [MEDICATION(S)] capsule take 2 capsules po twice daily was missed (1) time. [MEDICATION(S)]/Apap 5/325 mg take 1 tablet po twice daily for 28 days was missed one (1) time. [MEDICATION(S)] 1 pack po TID (Three times daily) was missed one (1) time. Monitor for s/sx (signs and symptoms) of pain (facial signs, moaning, verbal, etc.) Q (every) Shift. Document according to the scale below. If pain is noted, document intervention and outcome in the nurse's notes was missed two (2) times. Record review of the Treatment Chart for the month of July 2021, revealed Clean Rt (Right)Trochanter and Lt (Left) shoulder w/NS; pat dry and apply Santyl BID (Two times daily) and cover w/Alldress (with Alldress) was missed 17 times. WOUND CARE: Rt. back scapula area; clean w/NS (with Normal Saline), pat dry, apply Santyl to wound bed then pack w/ damp to dry gauze w/ NS, Apply Alldress Q 12 hr (hours) and prn (as needed) when soiled until healed. Notify MD of acute changes was missed 22 times. Notify MD of any skin changes (every shift) was missed 21 times. [MEDICATION(S)] to buttocks/per-area w brief change (every shift) was missed 20 times. Wklyl (Weekly) body Audits check for breakdown/any new skin problems P=Present A=Absent if present Notify MD and document in Nurses notes was missed one (1) of four (4) times. Gel cushion to geri-chair (every shift) was missed 23 times. Alternating air mattress to bed (every shift) was missed 21 times. Lt hand splint during daytime was missed five (5) times. Sz. ([CONDITION(S)]) precaution (every shift) was missed 22 times. Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output, etc.) Y=Yes N=No If yes, notify MD and document was missed five (5) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed six (6) times. Monitor for effectiveness of meds Y=Effective N=Non-effective notify MD if non-effective was missed six (6) times. Resident #2 Record review of Physician's Orders with an original order date of 12/1/20 and updated on7/21/21 revealed Resident #2 had orders in place for [MEDICATION(S)] 80 mg tablet chew one (1) tablet before meals and at bedtime. Physician's order with an original order date of 3/17/20 and updated on 7/21/21 revealed he had orders in place for [MEDICATION(S)] Powder disp as polyethylene [MEDICATION(S)] powder dissolve 17 grams in six (6) ounces of juice/water and give po two (2) times a day and [MEDICATION(S)] 2.5 mg tablet take one (1) table po twice a day, [MEDICATION(S)] 100 mg capsule disp as [MEDICATION(S)] sodium 100 mg cap take one (1) capsule po twice daily, [MEDICATION(S)] 10 mg suppository insert one (1) suppository rectally on Tues. (Tuesday), Thurs. (Thursday), Sun. (Sunday) and daily as needed for constipation, Caclofen 20 mg tablet take one (1) table po three (3) times daily. Physician orders dated 3/9/21 were in place for to bed: alt air mattress, Foley cath care q shift - flush w/60 cc sterile H2O, Ensure leg strap is in place, Change foley bag q 15 days and prn, and Bilateral heel protectors or shoes on at all times. Record review of the Medication Chart for the month of July 2021 revealed, [MEDICATION(S)] 80 mg tablet chew 1 tablet before meals and at bedtime was missed two (2) times. Polyethylene [MEDICATION(S)] powder comp. to [MEDICATION(S)] powder dissolve 17 grams in 6 ounces of juice/water and give po 2 times a day was missed one (1) time. [MEDICATION(S)] 2.5 mg tablet take 1 tablet po twice a day was missed one (1) time. [MEDICATION(S)] sodium 100 mg cap comp to [MEDICATION(S)] 100 mg capsule take 1 capsule po twice daily was missed one (1) time. [MEDICATION(S)] 10 mg suppositor(y) insert 1 suppository rectally on Tues. (Tuesday), Thurs. (Thursday), Sun. (Sunday) and daily as needed for constipation was missed three (3) times. [MEDICATION(S)] 20 mg tablet take 1 tablet po 3 times daily was missed one (1) time. Monitor for s/sx (signs and symptoms) of pain (facial signs, moaning, verbal, etc.) Q (every) Shift. Document according to the scale below. If pain is noted, document intervention and outcome in the nurse's notes was missed one (1) time. Record review of the Treatment Chart for the month of July 2021 revealed Foley cath. (catheter) care Q AM and PRN was missed five (5) times. Flush foley cath. w/60 cc sterile H2O Q shift was missed 19 times. Weekly weights until further notice was missed four (4) times. Alt (alternating) air mattress to bed (every shift) was missed 17 times. Bilateral heel protectors or shoes at all times was missed 17 times. Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output, etc.) Y=Yes N=No If yes, notify MD and document was missed six (6) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed six (6) times. Monitor for effectiveness of meds Y=effective N=Non-effective notify MD if non-effective was missed six (6) times. Wklyl body Audits check for breakdown/any new skin problems P=Present A=Absent if present Notify MD and document in Nurses notes was missed three (3) of four (4) times. Change foley bag q 15 days and prn was missed two (2) times. Resident #3 Record review of Physician Orders with an original date of 12/29/20 and updated on 7/21/21 revealed Resident #3 has orders in place for [MEDICATION(S)] 20 mg table take one (1) table po every 2 PM and 6 PM, [MEDICATION(S)] Gluc 324 mg tab take one (1) table po every 2 PM and 6 PM, [MEDICATION(S)] 850 mg tablet take one (1) tablet po 30 minutes prior to lunch and dinner, [MEDICATION(S)] 15 mg tablet take one (1) tablet po every evening, [MEDICATION(S)] 5 mg tablet take one (1) tablet po at bedtime, and [MEDICATION(S)] 20 mg capsule take one (1) capsule po at bedtime. A physician order with an original date of 5/22/20 and updated on 7/21/21 revealed he has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders with an original order date of 9/13/19 and updated on 7/21/21 are in place for [MEDICATION(S)] 10 mg suppository disp as [MEDICATION(S)] 10 mg suppository insert one (1) suppository rectally daily, [MEDICATION(S)] 10 gm/15 ml syrup give 45 cc po every day, [MEDICATION(S)] powder disp as polyethylene [MEDICATION(S)] powder mix 17 grams in 6 ounces of liquid and give po two (2) times a day, [MEDICATION(S)] 800 mg table take one (1) table po three (3) times daily, and [MEDICATION(S)] 40 mg tablet disp as [MEDICATION(S)] 40 mg tablet take one (1) tablet po at bedtime. A Physician Order with an original order date of 4/22/21 and updated on 7/21/21 is in place for [MEDICATION(S)] sod 500 mg tab take one (1) tablet po twice a day. Physician Orders with an original order date of 5/5/21 and updated on 7/21/21 are in place for Vitamin C 500 mg tablet take one (1) tablet po twice a day and Multivitamin tablet take one (1) tablet po daily. A physician's order dated 5/7/21 was in place for left heel wound - cleanse with NS, pat dry, apply Dakin's 0.25% moistened gauze to wound bed. Cover with gauze and kerlix or conform BID. Keeps heels floating for pressure relief at all times. Coccyx wound - irrigate with [MEDICATION(S)] then rinse with NS pat dry apply Dakin's 0.25 % solution moistened gauze to wound bed. Cover with gauze and ABD and secure with [MEDICATION(S)] tape BID and prn for soilage. Stay off coccyx as much as possible (this order was changed on 7/7/21). A Physician Order dated 7/7/21 revealed an order to change wound care to coccyx to irrigate with 0.25% Dakins solution then rinse with NS pat dry pack with calcium alginate with silver, cover with gauze and ABD secure with [MEDICATION(S)] tape BID and prn soilage. A review of a physician order dated 5/19/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify MD of acute changes. Physician orders dated 3/10/21 are noted for air mattress to bed, irrigate cath w/60 cc sterile H2O Monday and Thursday night and prn and skin monitor daily. A Physician's Order dated 6/4/21 is in place for peri-area care to cleanse with Dakin's solution, pat dry apply [MEDICATION(S)] ointment to peri-wound area daily cover w/soft gauze and paper tape. Record review of the Medication Chart for the month of July 2021 revealed [MEDICATION(S)] 20 mg tablet take 1 table po every 2 PM and 6 PM was missed three (3) times, [MEDICATION(S)] gluc 324 mg tab take 1 tablet PO every 2 PM and 6 PM was missed three (3) times, [MEDICATION(S)] 850 mg tablet take 1 tablet po 30 minutes prior to lunch and dinner was missed four (4) times, [MEDICATION(S)] 5% patch apply 2 patches to right knee every 12 hours was missed three (3) times. [MEDICATION(S)] 10 mg suppository comp. to [MEDICATION(S)] 10 mg suppo insert 1 suppository rectally daily was missed one (1) time. Polyethylene [MEDICATION(S)] powder comp. to [MEDICATION(S)] powder mix 17 grams in 6 ounces of liquid and give po 2 times a day was missed three (3) times. [MEDICATION(S)] 800 mg tablet take 1 tablet po 3 times daily was missed three times. Vitamin C 500 mg tablet take 1 tablet po twice a day was missed two (2) times. Multivitamin tablet take 1 tablet po daily was missed one (1) time. [MEDICATION(S)] 15 mg tablet take 1 tablet po every evening was missed one (1) time. [MEDICATION(S)] 5 mg tablet take 1 tablet po at bedtime was missed one (1) time. [MEDICATION(S)] 20 mg capsule take 1 capsule po at bedtime was missed one (1) time. [MEDICATION(S)] 40 mg tablet comp to [MEDICATION(S)] 40 mg tablet take 1 tablet po at bedtime was missed one (1) time. [MEDICATION(S)] Sod 500 mg tab take 1 tablet po twice a day was missed two (2) times. Monitor for s/sx (signs and symptoms) of pain (facial signs, moaning, verbal, etc.) Q (every) Shift. Document according to the scale below. If pain is noted, document intervention and outcome in the nurse's notes was missed two (2) times. Record review of the Treatment Chart for the month of July 2021 revealed Wound care: Left Heel wound - Cleanse w/ NS, pat dry, apply Dankins's 0.25% moistened gauze to wound bed. Cover w/gauze and kerlix or Conform BID was missed 24 times. Rt Heel: Apply damp to dry NS dsg Q 12 hr. notify MD of acute changes was missed 24 times. Stay off coccyx as much as possible (every shift) was missed 27 times. Wound Care: Coccyx wound - irrigate w/[MEDICATION(S)], rinse with NS - pat dry then Apply Dankins 0.25% solution moistened gauze to wound bed. Cover w/dry gauze and ABD (Abdominal) pad. Secure w/[MEDICATION(S)] tape BID and PRN, soilage was missed 6 times from 7/1/21 to 7/6/21 (Order changed 7/7/21). Treatment to coccyx irrigate with 0.25% Dakins solution then rinse with NS pat dry pack with calcium alginate with silver, cover with gauze and ABD secure with [MEDICATION(S)] tape BID and prn soilage was missed 19 times from 7/7/21 to 7/31/21. Alt air mattress (every shift) was missed 25 times. Monitor skin daily was missed ten (10) times. Keep heels floating for pressure relief at all Xs (every shift) was missed 24 times. Sheepskin padding to w/c when OOB (out of bed) (every shift) was missed 26 times. Turn Q 2-4 hr Lt to Rt Side. Avoid time on back (notify MD of acute changes (every shift) was missed 27 times. Wkly (weekly) Body Audits check for breakdown/any new skin problems P=Present A=Absent if present notify MD and document in Nurses notes was missed two (2) out of four (4) times. Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output, etc.) Y=Yes N=No If yes, notify MD and document was missed eight (8) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed eight (8) times. Monitor for effectiveness of meds Y=Effective N=Non-effective notify MD if non-effective was missed eight (8) times. Diabetic foot monitor: skin tears, open areas, cracks, injuries? Y=Yes N=No If yes document in NN (Nurses Notes) and notify MD (daily) was missed 24 times. Any new callouses, corns, bunions? Y=Yes N=No (daily) was missed 24 times. Pedal Pulses: P=Present and strong bil (bilateral) D=Present, difficult to palpate U=Unable to palpate (daily) was missed 24 times. Any new nail problems? Y=Yes N=No If y es document in NN (daily) was missed 24 times. Nails clipped by nurse today? Y=Yes N=No (daily) was missed 24 times. Apply clean socks and lotion (daily) was missed 24 times. Anti dandruff shampoo w/bath Q M-W-F (Monday, Wednesday, Friday) was missed six (6) times. Irrigate cath w/ 60 ml sterile H2O q Monday and Thursday night and prn was missed three (3) times. Suprapubic Cath./Peri-area: cleanse w/Dankin's solution, pat dry apply [MEDICATION(S)] oint to peri-wound area BID cover w/soft gauze and paper tape was missed 26 times. Resident #4 Record review of Physician's Orders dated 3/12/21 and updated 7/21/21 revealed Resident #4 had an order in place for Supplement: Resource 2.0 one PO (by mouth) (four times daily) QID. Promod 30 cc po (by mouth) BID twice daily. Physician's order with an original order date of 7/23/21 for [MEDICATION(S)] 500 mg po (by mouth) every morning and [MEDICATION(S)] 750 mg po (by mouth) every evening and [MEDICATION(S)] 200 mg po q hs x 1week (by mouth every bedtime for one (1) week). Record review of the Medication Chart for July 2021 revealed the facility failed to document the ordered doses. Promod 30 cc po BID was missed one (1) time. Resource 2.0 po QID was missed two (2) times. [MEDICATION(S)] 500mg po q am (every morning) was missed one (1) time. [MEDICATION(S)] 750 mg po q pm (every evening) was missed one (1) time. [MEDICATION(S)] 200 mg po q hs (every bedtime) was missed one (1) time. Record review of the Treatment Chart for July 2021 revealed the facility failed to document the following: Wanderguard Bracelet at all times was missed 15 times. Check Wanderguard for placement q (every) shift was missed 19 times. Check Wanderguard q (every) day to ensure it alarms was missed five (5) times. Position on Left side or back w/bed w/bolsters was missed five (5) times. Turn Q 2hr. was missed 18 times. Resident #5 Record review of Physician's Orders dated 7/13/21 and updated 7/21/21 revealed Resident #5 had an order in place for [MEDICATION(S)] 0.5 mg orally 2 times daily, [MEDICATION(S)] 40 mg oral one time daily, [MEDICATION(S)] oral tab 500 MG oral Q evening: for Sz ([CONDITION(S)]), [MEDICATION(S)] oral sol. 40 milligram, two times daily routine for: CHF, Polyethylene [MEDICATION(S)] 3350 oral powder 17 gram oral two times daily for: constipation, [MEDICATION(S)] oral tab. 2 milligram oral Qhsx28 days (every bedtime for twenty-eight days), [MEDICATION(S)] oral cap., delayed release (EC) cap. 30 mg oral Q (every) evening: for Depression, [MEDICATION(S)] 1% solution apply topically twice daily. [MEDICATION(S)] 0.5% cream to bilateral inguinal rash BID. Record review of the Medication Chart for July 2021 revealed the facility failed to document the ordered doses. Riperidone 0.5MG Tablet Take 1 Tablet PO twice a day was missed two (2) times. [MEDICATION(S)] 40MG Capsule Take 1 Capsule PO daily was missed two (2) times. [MEDICATION(S)] 500MG Tablet Take ½ tablet PO every morning and 1 tablet every evening was missed one time. [MEDICATION(S)] 10MG/ML solution Take 40MG (4 CC) PO 2 Times a day was missed one (1) time. Polyethylene [MEDICATION(S)] 3350 oral powder 17 gram in liquid and give PO two times a day was missed two (2) times. [MEDICATION(S)] 2 MG Tablet Take 1 tablet PO at bedtime for 28 days was missed three (3) times. [MEDICATION(S)] 40MG PO at HS (bedtime) was missed one (1) time. Record review of the Treatment Chart for July 2021 revealed the facility failed to document the following: [CONDITION(S)] Precautions was missed 12. Trapeze bar above bed was missed 37 times. [MEDICATION(S)] lotion to upper body/arms/torso Q Day (may apply per self) was missed two (2) times. Dressing to Meatus: clean site with warm water; pat dry, apply Vaseline, gauze, & cover w/gauze dsg. Q day & prn was missed two (2) times. [MEDICATION(S)] 0.5% cream to bilateral inguinal rash BID was missed twenty (20) times. Elevate HOB (head of bed) with neck bolster was missed nineteen (19) times. Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output etc) Y=Yes N=No If yes, notify MD and document was missed five (5) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed five (5) times. Monitor for effectiveness of meds Y=effective N=Non-effective notify MD if non-effective was missed eight (8) times. Weekly (Wkly) Body Audits check for breakdown / any new skin problems P=Present a=Absent if present notify MD and document in Nurses notes was missed three (3) times. DIABTIC FOOT MONITOR: skin tears, open areas, cracks, injuries? Y=YES N=NO If yes document in NN (nurses notes) and notify MD was missed 18 times. Any new callouses, corns, bunions? Y=YES N=NO was missed 18 times. Pedal Pulses: P=Present and strong bil. D=Present, difficult to palpate, U=Unable to palpate was missed 18 times. Any new nail problems? Y=YES N=NO. If yes document in NN missed 18 times. Nails clipped by nurse today? Y=YES N=NO was missed 18 times. Apply clean socks and lotion was missed 18 times. Resident #6 Record review of Physician's Orders dated 5/17/21 and updated 7/21/21 revealed Resident #6 had orders in place for Potassium CL 20MEQ (milliequivalents) Tablet Take 1 tablet PO Twice a Day, [MEDICATION(S)] 50MG Tablet Disp as [MEDICATION(S)] HCL 50 MG Tablet Take 1 Tablet PO Daily, [MEDICATION(S)] 125 MG Sprinkle Cap Disp as [MEDICATION(S)] 125MG Sprinkle Take 4 Capsules PO 3 Times Daily, [MEDICATION(S)] 15 MG Tablet Take 1 Tablet PO at Bedtime, [MEDICATION(S)] 0.4MG Capsule SA Disp as Tamsulosin HCL 0.4 MG Capsule Take 2 capsules PO Daily, [MEDICATION(S)] Carb 300MG Tablet Take 1 Tablet PO Every Morning and 2 Tablets PO at Bedtime, Polyethylene [MEDICATION(S)] 3350 oral powder 17 gram in liquid and give PO Twice a day, [MEDICATION(S)] Tar 25MG Tablet Take 1 Tablet PO Twice a Day. Physician's order dated 7/13/21 and updated 7/21/21 for [MEDICATION(S)] 200 MG Tablet Take 1 Tablet PO Twice Daily for 28 Days. Record review of the Medication Chart for July 2021 revealed the facility failed to document the ordered doses. [MEDICATION(S)] 200 MG Tablet Take 1 Tablet PO Twice Daily for 28 Days was missed one (1) time. Potassium CL 20MEQ Tablet Take 1 Tablet PO Twice a Day missed one (1) time. [MEDICATION(S)] HCL 50 MG Tablet Comp to [MEDICATION(S)] 50 MG Tablet Take 1 Tablet PO Daily missed one (1) time. [MEDICATION(S)] 125MG Sprinkle Compl to [MEDICATION(S)] 125 MG Sprinkle Take 4 Capsules PO 3 times Daily missed two (2) times. [MEDICATION(S)] 15 MG Tablet Take 1 Tablet PO at Bedtime missed one (1) time. Tamsulosin HCL 0.4 MG Capsule Comp. to [MEDICATION(S)] 0.4MG Capsule Take 2 Capsules PO Daily missed one (1) time. [MEDICATION(S)] Carb([MEDICATION(S)]) 300MG Tablet Take 1 Tablet PO every Morning and 2 Tablets PO at Bedtime missed one (1) time. Polyethylene [MEDICATION(S)] 3350 oral powder 17 gram in liquid and give PO Twice a day missed one (1) time. [MEDICATION(S)] TAR(tartarate) 25MG Tablet Take 1 Tablet PO Twice A Day missed one (1) time. Record review of the Treatment Chart for July 2021 revealed the facility failed to document the following: Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output, etc.) Y=YES N=NO If yes, notify MD and document was missed nine (9) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed nine (9) times. Monitor for effectiveness of meds Y=effective N=non-effective notify MD if non-effective was missed nine (9) times. Weekly (Wkly) Body Audits check for breakdown / any new skin problems P=Present a=Absent if present notify MD and document in Nurses notes was missed two (2) times. [CONDITION(S)] Precautions was missed 23 times., OOB (Out of Bed) to chair w/cushion missed twenty-three (23) times. Pt confined to w/c w/stand by assistance w/transfer pending PT missed five (5) times. [MEDICATION(S)] to buttock Q shift & PRN missed twenty-five (25) times. DIABTIC FOOT MONITOR: skin tears, open areas, cracks, injuries? Y=YES N=NO If yes document in NN (nurses notes) and notify MD was missed 25 times. Any new callouses, corns, bunions? Y=YES N=NO was 25 times. Pedal Pulses: P=Present and strong bil. D=Present, difficult to palpate, U=Unable to palpate was missed 25 times. Any new nail problems? Y=YES N=NO. If yes document in NN 25 times. Nails clipped by nurse today? Y=YES N=NO was missed twenty-five (25) times. Apply clean socks and lotion was missed 25 times. HOB (Head of Bed) elevated at all Xs (times) was missed 28 times. Resident #7 Record review of Physician's Orders dated and updated revealed Resident #7 had orders in place for [MEDICATION(S)] Powder Disp as Polyethylene [MEDICATION(S)] Powder Mix 17 gram in 6 oz of Juice and give PO Twice a day. Cos opt Eye drops disp as Dorzol-[MEDICATION(S)] Ophthalmic S Instill 1 Drop into Each Eye At Bedtime. [MEDICATION(S)] 10 mg suppository disp as [MEDICATION(S)] 10 mg suppository insert 1 suppository rectally ab bedtime. [MEDICATION(S)] 30 MG Tablet Take 1 Tablet at Bedtime. [MEDICATION(S)] 60 MG Tablet Take 1 Tablet at Bedtime. Record review of the Medication Chart for July 2021 revealed the facility failed to document the ordered doses. Polyethylene [MEDICATION(S)] 3350 oral powder 17 gram in liquid and give PO Twice a day missed one dose. Dorzol-[MEDICATION(S)] Ophthalmic S Comp. to Cos opt Eye Drops Instill 1 Drop into Each Eye At Bedtime missed one dose. [MEDICATION(S)] 10 MG Suppository Insert 1 Suppository Rectally at Bedtime missed one time. [MEDICATION(S)] 30 MG Tablet Take 1 Tablet PO at Bedtime missed one time. [MEDICATION(S)] 60 MG Tablet Take 1 Tablet PO at Bedtime missed one time. Record review of resident #7's Treatment Chart for July 2021 revealed the facility failed to document the following: Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output, etc.) Y=YES N=NO If yes, notify MD and document was missed five (5) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed five (5) times. Monitor for effectiveness of meds Y=effective N=non-effective notify MD if non-effective was missed five (5) times. Weekly (Wkly) Body Audits check for breakdown / any new skin problems P=Present a=Absent if present notify MD and document in Nurses notes was missed two (2) times. [MEDICATION(S)] Blue shampoo Q bath day M-W-F (Monday-Wednesday-Friday) was missed seven (7) times. Heel pillows at all Xs (times) was missed 19 times. TWE (Tap Water Enema) Q M-W-F (Monday, Wednesday, Friday) document result in NN (Nurses Notes) was missed eight (8) times. Velcro safety strap w/in chair was missed 20 times. Resident #8 Record review of Physician's Orders dated 7/01/21 and updated 7/28/21revealed Resident #8 had orders in place for [MEDICATION(S)] 12 mcg/hr (micrograms per hour) Patch. Apply one (1) Patch Topically Q 48 hrs X 28 days. Physician's order dated 3/06/21 and updated 7/21/21 for Vitamin C 500MG Tablet Take 1 Tablet PO Twice A Day. Physician's orders dated 3/3/25/21 and updated 7/21/21 for [MEDICATION(S)] Gluc 324MG Tablet Take 1 Tablet PO Twice A Day and [MEDICATION(S)] 7.5 MG Tablet Take 1 Tablet PO Daily. Physician's order dated 4/16/19 and updated 7/21/21 for Polyethylene [MEDICATION(S)] 3350 oral powder 17 gram in liquid and give PO Twice a day. Record review of the Medication Chart for July 2021 revealed the facility failed to document the ordered doses. Polyethylene [MEDICATION(S)] 3350 oral powder 17 gram in liquid and give PO Twice a day missed two doses. Vitamin C 500MG Tablet Take 1 Tablet PO Twice A Day was missed two (2) times. [MEDICATION(S)] Gluc 324MG Tablet Take 1 Tablet PO Twice A Day was missed two (2) times. [MEDICATION(S)] 7.5 MG Tablet Take 1 Tablet PO Daily was missed one (1) time. [MEDICATION(S)] 12 mcg/hr (micrograms per hour) Patch. Apply one (1) Patch Topically Q 48 hrs X 28 days was missed one (1) time. Record review of Resident #8's Treatment Chart for July 2021 revealed the facility failed to document the following: Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output, etc.) Y=YES N=NO If yes, notify MD and document was missed five (5) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed five (5) times. Monitor for effectiveness of meds Y=effective N=non-effective notify MD if non-effective was missed five (5) times. Weekly (Wkly) Body Audits check for breakdown / any new skin problems P=Present a=Absent if present notify MD and document in Nurses notes was missed two (2) times. Apply Aquaphonr Oint To dry skin daily was missed nine (9) times. Heel Protectors to Bilateral heels at all Xs (times) was missed 18 times. Position resident Rt (right) to Lt (left) side. Avoid placing resident on back. Was missed 19 times. LacHydrin Lotion to [NAME] Lower Ext. BID was missed 15 times. DIABETIC FOOT MONITOR: skin tears, open areas, cracks, injuries? Y=YES N=NO If yes document in NN (nurses notes) and notify MD was missed 20 times. Any new callouses, corns, bunions? Y=YES N=NO was missed 23 times. Pedal Pulses: P=Present and strong bil. D=Present, difficult to palpate, U=Unable to palpate was missed 25 times. Any new nail problems? Y=YES N=NO. If yes document in NN 25 times. Nails clipped by nurse today? Y=YES N=NO was missed 25 times. Apply clean socks and lotion was missed 25 times. HOB (Head of Bed) elevated at all Xs (times) was missed 25 times. Clean neb mask after each use: to clean: wash all pieces (except tubing) wigh soap & H2O (water), rinse for 30 sec. allow to air dry/or dry with paper towel. Place mask & tubing in clean Ziplock bag was missed six (6) times. Disinfect once daily. Clean neb mask with cavi-wipes, allow to sit for 2 (two) minutes Rinse with warm H2O. [NAME] with paper towel & store in Ziplock bag was missed eight (8) times. Change Neb mask/tubing Q 72 hrs. was missed two (2) times. Resident #9 Record review of Physician's Orders dated 7/1/21 revealed Resident #9 had an order in place for [MEDICATION(S)] 200 mg tablet take 1 tablet po twice daily for 28 days. Physician's orders with an original order date of 7/29/13 and updated 7/21/21 are in place for [MEDICATION(S)] 10 mg suppository disp as [MEDICATION(S)] 10 mg suppository insert 1 suppository rectally ab bedtime and Milk of Magnesia [MEDICATION(S)] Give 45 cc po twice daily. A physician's order with an original date of 7/9/18 and updated 7/21/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders with a original order date of 4/1/19 and updated on 7/21/21 are in place for [MEDICATION(S)] 0.5 mg disp as [MEDICATION(S)] 0.5 mg tablet take 1 tablet po twice daily and [MEDICATION(S)] 2 mg tablet disp as [MEDICATION(S)] 2 mg tablet take 1 tablet po twice a day. A physician's order with an original date of 3/12/20 and updated on 7/21/21 is in place for [MEDICATION(S)] 300 mg capsule take 1 capsule po 3 times daily. No physician order available for Prune/fiber juice with AM meds and Boost TID and prn if res consumes less than 50% of meals. Record review of the Medication Chart for July 2021 revealed the facility failed to document the ordered doses. [MEDICATION(S)] 200 mg tablet take 1 tablet po twice daily for 28 days as missed one (1) time. [MEDICATION(S)] 10 mg suppository Insert 1 suppository rectally at bedtime was missed one (1) time. Milk of Magnesia suspension give 45 cc po twice daily was missed one (1) time. [MEDICATION(S)] Sod 500 MG tablet comp to [MEDICATION(S)] 500 mg tab take 1 tablet po twice a day was missed one (1) time. [MEDICATION(S)] 0.5 mg tablet comp to [MEDICATION(S)] 0.5 mg tab take 1 tablet po twice a day was missed two (2) times. [MEDICATION(S)] 2 mg tablet comp. to [MEDICATION(S)] 2 mg tablet take 1 tablet po twice a day was missed two (2) times. [MEDICATION(S)] 300 mg capsule Take 1 capsule po 3 times daily was missed five (5) times. Prune/fiber juice with AM meds was missed one (1) time. Boost TID & PRN if res consumes less than 50% of meals was missed six (6) times. Monitor for s/sx of pain (facial signs, moaning, verbal, etc.) Q Shift. Document according to the scale below. If pain is noted, document intervention and outcome in the nurse's notes was missed nine (9) times. Record review of the Treatment Chart for July 2021 revealed the facility failed to document the following: TWE (Tap Water Enema) Q M-W-F (Monday, Wednesday, Friday) document result in NN (Nurses Notes) was missed eight (8) times. Monitor for dehydration QD (dry [MEDICATION(S)] membranes, tenting, fever, decreased Output, etc.) Y=Yes N=No If yes, notify MD and document was missed five (5) times. Monitor for side effects of [CONDITION(S)] meds QD P=Present N=Noneffective notify MD if non-effective was missed five (5) times. Monitor for effectiveness of meds Y=effective N=Non-effective notify MD if non-effective was missed five (5) times. Weekly (Wkly) Body Audits check for breakdown / any new skin problems P=Present a=Absent if present notify MD and document in Nurses notes was missed two (2) times. Resident #10 Record review of Physician's Orders with an original date of 9/30/20 and updated 7/21/21 revealed Resident #10 had orders in place for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDI

Based on observation, staff interview, and facility policy review, the facility failed to prevent the likelihood of the spread of COVID-19 virus as evidenced by lack of proper hand hygiene, lack of wearing a mask, and contamination of meal trays and pantry items for three (3) of three (3) tours of the facility. Findings include: Review of the facility's, Pandemic Coronavirus Disease (COVID-19) Infection Prevention Practices policy, dated May 2020, revealed its purpose provides infection prevention guidelines to control/prevent pandemic Coronavirus disease (COVID-19) in patients, residents, employees, and visitors. The policy/plan revealed A. Basic infection prevention principles for preventing the spread of pandemic COVID-19 at (Name of )State Hospital (Initials of state hospital): (1) Minimize chance for exposure, e. All employees entering the (Initials for state hospital) campus are required to wear appropriate face masks at all times. Review of the facility's Hand Hygiene policy, dated April 2019, revealed it is the policy of (Initials for name of state hospital) that all employees will use proper hand hygiene techniques to prevent the spread of infectious diseases to include: H. After touching objects that may be contaminated with disease causing microorganisms and O. After contact with inanimate objects in the vicinity of the patient/resident. Review of the facility's Personal Items policy, not dated, revealed personal items should be stored outside the food service area of the pantry. An observation, on 8/17/20 at 11:28 AM, revealed a single glove hanging on the handrail on the south side hallway near the exit door. Direct Care Trainee (DCT) #1 picked the glove up with her bare hand and put the glove in the garbage can in room [ROOM NUMBER]. She did not wash her hands or use hand sanitizer. She then stood in the hallway touching her clothes and putting her hands inside her pockets and then entered rooms [ROOM NUMBERS] touching the doorknob and door facing. An interview, on 8/17/20 at 11:35 AM, with DCT #1, revealed she should have disposed of the glove in the red garbage can and she should have put on a glove to pick it up. She confirmed she did not wash her hands or use hand sanitizer after she threw the glove away. She stated that she just wasn't thinking. She stated that what she did spreads germs. The DCT #1 stated she has hand sanitizer in her pocket and always uses it, but confirmed she did not use it after she disposed of the glove. An interview, on 8/17/20 at 12:15 PM, with the Director of Nursing (DON), revealed DCT #1 should have put a glove on to get the glove off the hand rail because it could have been dirty, and it should have been put in a red bag container and not in a resident's trash can. An observation, on 8/17/20 at 12:37 PM, with the Director of Nursing, during the lunch meal tray delivery revealed Certified Nursing Assistant (CNA) #2 dressed in full Personal Protective Equipment (PPE) came out of a resident's room with a meal tray in her hand. She set the tray on top of metal table, opened the draw and picked up a roll of plastic trash bags and then placed them back in the drawer and then removed her PPE. She stated she was going to put the tray on the bottom of the meal cart. An interview, on 8/17/20 at 12:39 PM, with CNA #1, confirmed the meal tray was contaminated after being brought out of an isolation room. An observation, at 12:41 PM on 8/17/20, with the DON, revealed the remaining lunch trays on the cart. The food and beverages were in disposable ware and the eating utensils were disposable, but were being taken into all the resident rooms on a metal tray. An interview, on 8/17/20 at 12:42 PM, with the DON, revealed the staff pick up the metal trays at the end of the meal and put them on the cart and take them back to the pantry. She stated that when the trays come out of the rooms, they are contaminated and are going through the building back to the pantry. The DON stated that they had not thought about that. An observation, on 8/17/20 at 2:15 PM, revealed Dietary Staff #1 was sitting in the pantry in the food prep area without a mask on. When questioned, he donned a surgical grade mask. On the cabinet beside him was an open box of plastic wrap that he confirmed he would be using to wrap resident food in. Beside the box of plastic wrap was a cell phone and charger and a dirty cloth mask. An interview, on 8/17/20 at 2:17 PM, with Dietary Staff #1, revealed the cell phone, charger, and mask were his personal items. He confirmed the personal items should not be in the pantry because of contamination. He stated that they should be in his personal drawer. Dietary staff #1 confirmed that facility policy was for staff to wear masks at all times and that he should have his mask on. An interview, on 8/17/20 at 2:25 PM, with Dietary Staff #2, revealed she had not noticed that dietary Staff #1 did not have on his mask. Dietary staff #2 stated that Dietary Staff #1's personal things should not have been on the counter with kitchen supplies and he should have had his mask on. She stated that he was not being sanitary. An interview on 8/17/20, with the Administrator, at 2:30 PM, revealed Dietary Staff #1 should have known not to put his personal things on the counter and he should not have been sitting over supplies used for the residents. The Administrator stated that he had contaminated the plastic wrap. The Administrator stated that Dietary Staff #1 knew it was the facility policy for staff to wear a mask at all times and he should have had one on. Review of Staff Education/Continuing Education sign-in sheets revealed DCT #1 received training to prevent the spread of infection on 5/22/20. Review of Staff Education/Continuing Education sign-in sheets revealed CNA #2 received training on safety measures/training for COVID-19 on 3/25/20. Review of Staff Education/Continuing Education sign-in sheets revealed Dietary Staff #1 received training to educate on the requirement and importance of wearing a mask to prevent the spread of COVID-19 on 7/23/20. Review of Staff Education/Continuing Education sign-in sheets revealed Dietary Staff #1 received training to educate on the requirement and importance of wearing a mask to prevent the spread of COVID-19 on 7/23/20.

MS # Based on staff interview, record review, and policy review, the facility failed to follow the care plan to monitor/supervise a resident, with a known history of choking risk and/or aspiration, related to the resident taking food from others that are not on his current diet. This resulted in the resident choking, with asphyxiation and death. This affected one (1) of nine (9) residents, Resident #1. Resident #1 took a hotdog from another resident's tray and choked. Resident #1 had orders and a care plan for one on one (1:1) supervision during meals to prevent this behavior from occurring. The failure to implement 1:1 supervision during meals for Resident #1, as care planned, resulted in Resident #1 taking a hot dog from another resident's tray and eating it. Resident #1 choked on the hot dog and expired. This situation placed Resident #1 and other residents who had orders for supervision/monitoring, in a situation that caused or was likely to cause serious injury, harm, impairment or death. The situation was identified to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE], when Resident #1 was not supervised during meals, per care plan, and choked on a hot dog causing his death. On [DATE] at 3:25 PM, the SA notified the facility's Administrator of the IJ and SQC. An Acceptable Corrective Action Plan (CAP) was received on [DATE] at 6:25 PM, in which the facility alleged removal of the IJ on [DATE]. The SA validated the corrective action plan and determined the IJ was removed on [DATE], prior to Surveyor entrance on [DATE]. Findings Include: Review of the facility's policy, Treatment Team, dated (MONTH) (YEAR), revealed: Facility will provide treatment to each resident using an interdisciplinary team approach. Each building will maintain an interdisciplinary treatment team for the purpose of defining and coordinating treatment for [REDACTED]. 9. Certified Nursing Assistants (CNA): A CNA will attend the treatment team meeting and will be prepared to discuss the resident's activities of daily living. Other responsibilities will include mentioning problems in behavior and cognitive ability and bringing up any barriers to the resident's well-being that may be evident. Review of Resident #1's care plan, initiated [DATE], revealed Resident #1 was at risk for choking or aspiration related to the resident taking and eating food from other residents trays that was not on his current diet. Interventions included, One to One (1:1) during meals in dining room, redirect him if he starts to take food from others tray, serve ordered diet, observe for signs and symptoms of aspiration: coughing, wheezing, fever, and Shortness of Breath (SOB), obtain vital signs (V/S) and report to MD, may perform [MEDICATION NAME] maneuver prn (as needed) if resident is choking to clear the airway, and Nurse to notify MD. The documented goal included that the resident will not aspirate over the next 90 days. Review of the facility's face sheet revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, meaning Resident #1 was not able to make competent decision for himself and was cognitively impaired. Review of the Activity of Daily Living Record (ADL), dated (MONTH) (YEAR), failed to identify Resident #1 required the special observation of 1:1 during meals. Review of the facility's investigation revealed on [DATE], during dinner time in the North side dining room, Resident #1 took a hot dog from another resident's tray and choked on it. Agency CNA #1 was putting up trays and had her back turned to Resident #1 when he took the hot dog. Another resident (Resident #2) informed CNA #1 that Resident #1 had taken something off another resident's tray. CNA #1 asked Resident #1 if he had taken anything from the tray and the CNA indicated that Resident #1 just looked at her. CNA #1 asked him twice if he was alright and he did not answer. At this time Licensed Practical Nurse (LPN) #1 entered the dining room after Resident #2 informed him that Resident #1 was choking. LPN #1 asked Resident #1 if he could speak and Resident #1 shook his head, No. LPN #1 performed four (4) to five (5) back blows without success. Staff stood Resident #1 up and LPN #1 performed several abdominal thrusts that were unsuccessful in dislodging an obstruction. Staff sat him down in his wheelchair and rolled him into the hallway away from the other residents. Registered Nurse (RN) #1 was also alerted by Resident #2 of the incident and arrived to the dining room after calling 911/Code Blue (at 5:59 PM) and retrieving the crash cart. RN #1 attempted abdominal thrusts unsuccessfully. Resident #1 became unresponsive and was lowered to the floor. RN #1 started chest compressions while LPN #1 put together the ambu-bag and started ventilations. Resident #1 remained apneic and pulseless and code efforts ceased with pronouncement of death at 6:36 PM. Investigation revealed that Resident #1 was a one to one (1:1) observation, meal time only. There was no staff assigned to monitor Resident #1 during meal time by the CNA Supervisor. The Agency staff assigned to the North side unit was not given a shift report by LPN #1, when they arrived to the facility; Building 78. Interview with CNA #1 on [DATE] at 8:30 AM, revealed she arrived at the facility at approximately 4:00 PM on [DATE]. CNA #1 stated neither the LPN on duty nor the CNA Supervisor gave her report when she got to work. CNA #1 stated she was not told that Resident #1 was 1:1 during meal time. CNA #1 stated no one gave her an assignment, she just took it upon herself to do what needed to be done. CNA #1 stated she was the only staff person present in the Dining Room when Resident #1 choked. CNA #1 stated there had been another CNA in the dining room with her but she thought she had stepped out to assist with hall feeding. CNA #1 stated after feeding the last resident that required assistance she started picking up trays. CNA #1 stated she was placing trays on the cart and had her back turned to Resident #1 when Resident #2 said to her, He just put something in his mouth, indicating Resident #1. Resident #2 informed CNA #1 that Resident #1 had put a hot dog in his mouth. CNA #1 stated she asked Resident #1 if he was ok and he just looked at her with a surprised look on his face like he had been caught doing something he wasn't supposed to. CNA #1 stated she asked him again if he was ok and he didn't respond. CNA #1 stated Resident #1 had to have wheeled himself in his wheelchair to the table and came back to his table quickly. CNA #1 stated all the trays from Resident #1's table had been removed. CNA #1 stated she was not aware there was a book to document Resident #1's special monitoring during meal time, and there was no assignment sheet prepared and given to her indicating the need for 1:1 during meals for Resident #1. CNA #1 acknowledged she had been trained to review the assignment sheet and ADL/Care plan for resident's that she gave care to, however, she had not reviewed the actual care plan for Resident #1 on [DATE]. Interview with LPN #1 on [DATE] at 9:50 AM, revealed he had finished medication pass and was sitting at the Nurse's Station signing medication records when Resident #2 came to the Station and told him Resident #1 was choking. LPN #1 stated he went to the dining room and asked Resident #1 if he could talk. He stated Resident #1 shook his head, No. LPN #1 stated Resident #1 was not choking but he had a wild-eyed look. LPN #1 stated he leaned Resident #1 forward and initiated four (4) to five(5) back blows and nothing came up. LPN #1 stated he then stood Resident #1 up and administered abdominal thrust which were unsuccessful in dislodging any object. Resident #1 was moved to the hallway and his pulse checked and he was pulseless. Cardio-Pulmonary Resuscitation (CPR) was initiated and RN #1 from Southside came over and assisted in resuscitation efforts after Code Blue was called. LPN #1 stated Resident #1 was transported to the facility hospital where CPR efforts continued and Resident #1 eventually pronounced deceased . LPN #1 confirmed that he was aware of the supervision and care plan required for Resident #1, but stated the CNA told him that she was not aware of the 1:1 supervision required for Resident #1 during meals. Interview with Registered Nurse (RN) #1 on [DATE] at 11:45 AM, revealed Resident #1 was care planned to be 1:1 because he had a history of [REDACTED]. RN #1 stated he had choked once before on bread. RN #1 stated Resident #1 had an order and was care planned for 1:1 and staff failed to follow the care plan. RN #1 stated CNA's receive an assignment sheet that directs them on tasks to complete, but on this particular night no assignment sheet was given to the CNA. RN #1 stated staff assigned to that hall were agency staff and they were late and trickled in during the shift. Interview with the Director of Nursing (DON) on [DATE] at 8:45 AM, revealed the Minimum Data Set (MDS) Nurse is responsible for care plans and staff nurses update the care plan as needed. The DON stated the care plan is an important part of the medical record because it gives guidance to the staff to the care needed by the resident. The DON stated the CNA's do have access to the care plan. The DON stated that staff failed to follow the care plan for Resident #1, and did not monitor the resident 1:1 as ordered and care planned. The DON stated, Had the care plan been followed the outcome might have been different. Interview with RN #3 (MDS Coordinator) on [DATE] at 9:00 AM, revealed the care plan was developed in (MONTH) (YEAR) (for 1:1 during meals), after Resident #1 choked, to promote safety for Resident #1, and to prevent the incident from reoccurring. RN #3 stated the staff failed to follow the care plan and did not provide 1:1 monitoring and the resident expired as a result of choking. Interview with Resident #1's Physician on [DATE] at 9:30 AM, revealed Resident #1 had impulsive behavior and would grab food off other resident's trays spontaneously. The Physician stated the resident needed to be monitored closely because he couldn't comprehend that he would choke. The Physician stated that Resident #1 choked in (MONTH) and it was decided then that he needed to be placed 1:1 for monitoring, due to his behavior of taking food. On [DATE] at 3:25 PM, the Facility Administrator was notified that the situation of supervision for Resident #1 was deemed an Immediate Jeopardy (IJ). The Facility submitted the following Corrective Action Plan (CAP): 1. On (MONTH) 7, (YEAR), during dinner time at 5:30 PM, in the North side dining room, Resident #1 choked on a hot dog that he removed from another resident's tray at approximately 5:50 PM. CNA #1 was putting trays on the rack and had her back turned to Resident #1 when he removed the hot dog from another tray. Resident #1 had a physician's orders [REDACTED]. CNA #2 (Lead CNA) and LPN #1 did not complete a CNA assignment sheet at the beginning of the shift. The special observation order was not communicated to the CNA staff by either the Lead CNA (CNA #2) or LPN #1. 2. Resident #2 informed CNA #1 that Resident #1 had removed something from another resident's tray and was choking. CNA #1 asked Resident #1 if he had taken anything from another tray and Resident #1 just looked at her. CNA #1 then asked Resident #1 twice if he was alright and Resident #1 did not answer. At 5:50 PM, LPN #1 arrived in the dining room after being alerted by Resident #2 of the choking incident. 3. LPN #1 asked Resident #1 if he could speak and Resident #1 shook his head No. LPN #1 performed four (4) to five (5) back blows which was unsuccessful in dislodging the obstruction. LPN #1 also attempted the [MEDICATION NAME] maneuver without success. Resident #2 went approximately 10 feet away to the South side dining room to get RN #1. RN #1 was located just outside the South side dining room and responded at approximately 5:55 PM. RN #1 initiated a Code Blue and retrieved the crash cart. LPN #1 received training for CPR certification on (MONTH) 17, (YEAR). RN #1 received training for CPR certification on (MONTH) 11, (YEAR). MS State Hospital provides CPR training including the [MEDICATION NAME] maneuver upon hire during general orientation and every two (2) years thereafter to all staff of the facility. 4. RN #1 attempted the [MEDICATION NAME] maneuver (abdominal thrusts) without success. Resident #1 became unresponsive without pulse or respiration and was lowered to the floor. LPN #1 and RN #1 initiated Cardio-Pulmonary Resuscitation (CPR) and Code Blue. When Code Blue was initiated, Mississippi State Hospital Police Officers and the Human Resource (HR) Evening Administrator were notified. 5. The Medical Officer on Duty (MOD) arrived at 6:04 PM on [DATE], and the Automated External Defibrillator (AED) was applied with No shock advised. CPR efforts were continued as Resident #1 and LPN #1 were transported to the Hospital in Building 60. Advanced Cardiac Life Support (ACLS) care was initiated at Building 60 without success. During the resuscitative process, the hot dog was dislodged and removed. The MOD made death pronouncement of Resident # 1 at 6:36 PM ([DATE]). Listed below are the immediate actions taken to remove the immediate jeopardy. 6. The HR Evening Administrator notified the Director of Safety and Investigative Services (SAIS) at 8:32 PM on (MONTH) 7, (YEAR), of the unexpected death (of Resident #1). The HR Evening Administrator also notified Licensed Nursing Home Administrator (LNHA) #2 who was on call. The SAIS Director notified the facility's LNHA, Nurse Executive Director (NED), and Executive Director of all nursing homes on campus at 8:51 PM. LNHA #1 notified the facility's Director of Nursing (DON) at 9:00 PM. 7. LNHA #2 reported the unexpected death to MS Department of Health, Division of Licensure and Certification on (MONTH) 7, (YEAR) at 9:29 PM. 8. LNHA #1 notified the Attorney General's Office via online report on (MONTH) 11, (YEAR) at 9:08 AM. 9. LNHA #2 instructed the HR Evening Administrator to place CNA #2 (Lead CNA) and LPN #1 on administrative leave and to escort CNA #1 (agency staff) from the facility. 10. CNA#2 (Lead CNA) and LPN #1 were placed on administrative leave pending the outcome of the investigation. CNA #2 (Lead CNA) was placed on administrative leave on (MONTH) 7, (YEAR) at 10:02 PM. LPN #1 was placed on administrative leave on (MONTH) 8, (YEAR) at 12:04 A.M. 11. CNA #1 (agency staff) was instructed to clock out at 9:42 PM on [DATE], and not return to the facility pending the outcome of the investigation. CNA #1 was escorted off campus by MSH Police Officers. 12. The Nurse Executive Director notified RN #2, who was responsible for scheduling between the dates of (MONTH) 7, (YEAR) and (MONTH) 10, (YEAR), not to allow CNA #1 (agency staff) to work another shift until further notice. 13. Beginning on (MONTH) 7, (YEAR) at 11:00 PM, the following in-services were initiated and conducted by the Nurse Executive Director for the four (4) CNAs and the two (2) Licensed Nurses: Policy A: Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents-Resident has right to be free from abuse/neglect, what constitutes abuse with emphasis on the definition of neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Policy B: Resident Observation-Guidelines for monitoring residents on observation for medical and behavioral reasons. Three (3) levels of observation defined with emphasis placed on one on one. One on one is constant observation of a resident. One on one observation will require the assignment of a staff member to be in the immediate proximity such that the resident could not injure self or others. Any level of special observation will require physician order [REDACTED]. (Example: 1:1 during meals to prevent resident from taking food from other trays.) Policy C: Shift Report- purpose of shift report, start time, attendees, pertinent information, shift report document tool, example of guideline: All special observations shall be listed on the shift report each shift. Policy D: Rights of Residents-Resident right for a safe environment including but not limited to receiving treatment and supports for daily living safely. Policy E: Foreign-Body Airway Obstruction/Code Blue/CPR/AED-guidelines for initiating measures to remove foreign-body airway obstructions and code blue/CPR. All staff will respond when a resident experiences apparent choking, Cardio or [MEDICAL CONDITION] Arrest. Foreign body airway management such as [MEDICATION NAME] Maneuver using abdominal thrusts. 14. In addition to the aforementioned policies, four (4) CNAs/NAs and two (2) Licensed Nurses received the following in-service education beginning (MONTH) 7, (YEAR) at 11:00 PM, by the Nurse Executive Director. The written information provided for inservice education contained the following: -All care assignments for Certified Nursing Assistants/ Nursing Assistants on all shifts shall be made by the Shift Leader and the Licensed Nurse responsible for the care of the resident. -The Licensed Nurse shall assure all assignments are properly made and documented on the assignment sheet for each resident under his/her care and shall indicate such by signing behind the CNA Shift Leader on the bottom of the assignment sheet. -The Licensed Nurse and the Shift Leader shall both review the assignments together with focus on residents who have special observation orders such as: one to one, VC (visual contact) and time checks. -These special observations shall be documented on each assignment sheet each shift for the Nursing Assistant/CNA by the Lead CNA and approved by the Licensed Nurse. Special observation orders shall be documented on the nursing shift report sheet each shift by the Licensed Nurse. Special observation orders shall be reviewed verbally in each shift report as well by the Licensed Nurse and the Lead CNA. The Licensed Nurse responsible for the care of each resident shall speak directly to the CNA/Nursing Assistant during shift report and review the care the resident is to receive with special emphasis on special observation orders. If a CNA reports to duty after the shift report, upon arrival the CNA shall receive individual shift report from the Lead CNA. -Also, beginning [DATE] at 11:00 PM, all special observation orders shall be placed on the CNA/NA ADL documentation record. It is the responsibility of the Nurse when special observation orders are received to place this on the treatment plan and CNA/NA ADL record at the time of noting the physician order. -Beginning (MONTH) 7, (YEAR), the special observation monitoring rounds will be documented every two (2) hours by the Licensed Nurse on the same form (MSH 31A-Patient Observation) utilized by the CNAs/NAs for documenting resident observation behavior and safety. -This process will require the Licensed Nurse to go to the resident while on the unit, review the resident and observe CNA/NA staff is providing the level of observation ordered. The License Nurse shall sign off on the MSH 31A observation record indicating this. (Example: Resident safe and special observation in place by the CNA/NA as ordered.) The Licensed Nurse shall sign his/her name and credentials, date and time. Again, this shall be conducted by the Licensed Nurse every two (2) hours. -Any problems noted with the supervision of the resident will be addressed at the time of the occurrence by the Licensed Nurse and reported to the HR Grounds Administrator on duty for further follow up and review. The Nursing Home DON on call and Nursing Home Administrator on call shall be notified by the HR Grounds Administrator on duty of any problems. 15. On (MONTH) 7, (YEAR) at 10:45 PM, a written directive was posted by the Nurse Executive Director at the time clock informing all CNAs/NAs and Licensed Nurses to report directly to their Shift Leader and Nurse prior to accepting patient assignments. You must receive in-service education before taking an assignment. No facility or agency staff will be allowed to work until in-service education has been provided. 16. The Nurse Executive reviewed the resident census on (MONTH) 7, (YEAR) at 11:40 PM, to identify all residents with special observation orders. Two (2) residents were identified as having special observation orders, (Resident #3 and Resident #4). Next, the Nurse Executive Director ensured the two (2) residents, identified as having special observation orders, were noted on the twenty-four (24) hour nursing shift report. 17. Resident #1's care plan was reviewed at 10:10 PM on [DATE], by the Nurse Executive Director. The comprehensive care plan for Resident #1 contained the problem with the resident removing food from other resident's tray and included the intervention for the one to one special observation during meals. 18. The care plans were reviewed by the Nurse Executive Director and two (2) additional residents, Residents #3 and #4, were identified as having a special observation order. The comprehensive care plan for Resident #3 and #4 contained the special observation order. 19. On [DATE] at 11:50 PM, the ADL records were reviewed by the Nurse Executive Director for Resident #3 and Resident #4 to ensure special observation orders from the comprehensive care plan were noted for the CNA/NAs. 20. On (MONTH) 7, (YEAR) at 11: 45 PM, the Nurse Executive Director verbally reviewed the special observations with the four (4) 11 PM-7 AM shift CNAs and the two (2) Licensed Nurses. 21. On (MONTH) 8, (YEAR) at 2:00 AM, the Nurse Executive Director verbally requested the HR Night Administrator to participate in the monitoring of the special observations. The HR Night Administrator did conduct rounds at 3:00 AM to ensure the safety of the residents on special observation. The documentation of special observation by the CNAs and Nurse was complete. 22. On (MONTH) 8, (YEAR), at 6:54 AM, the Nurse Executive emailed all HR Evening and Night Administrators and their supervisor. The email contained actions initiated on (MONTH) 7, (YEAR), following the unexpected death of Resident #1, and communication regarding their role in assisting with the monitoring of special observations and documentation on the MSH 31 A form. 23. On Monday, (MONTH) 9, (YEAR) at 2:30 PM, a special called Quality Assurance meeting was held to review the incident on (MONTH) 7, (YEAR), which resulted in the unexpected death of Resident #1. The following members were in attendance. MS State Hospital Clinical Director, Nurse Executive Director, Director of Safety and Investigative Services, JNH Social Worker, Director of Service Outcomes, JNH DON, JNH LNHA, Executive Director for all nursing homes, RN #1, Resident #1's Attending Physician, Accreditation and Licensure Director, Accreditation & Licensure Coordinator, Acting Medical Director for JNH, Medical Officer on Duty ([DATE]), Safety and Investigative Services RN Investigator, Policy Coordinator, JNH Head Nurse, and Chief of Medical Staff. The following concerns were identified: -There was no shift report given, no assignment sheet was completed, and there was no CNA assigned to provide Resident #1's special observation as ordered. -The facility's policy for Resident Observation was not followed. LPN #1 did not assign a staff member to provide the 1:1 observation. There was no staff constantly observing resident in immediate proximity during the evening meal such that the resident could not do self-harm. -The comprehensive care plan for Resident #1 contained the special observation order for one to one during meals; however, the care plan was not followed. The ADL document for Resident #1 did not contain the special observation information; therefore, CNA #1 was not aware of the special observation order. -LPN # 1 did not ensure that an assignment sheet was completed. CNA #2 (Lead CNA) did not give a verbal report to the other CNAs after they clocked in. -All policies used for in-service education initiated on (MONTH) 7, (YEAR) at 11:00 PM, were reviewed and discussed with no changes. -Nurses will maintain visual contact of the dining room during meal times. -Previous actions beginning on (MONTH) 7, (YEAR) were reviewed, discussed, accepted and in-service education will be continued. -Between [DATE] - [DATE], the Nurse Executive Director in-serviced seven (7) Licensed Nurses and RN #1 in-serviced two (2) Licensed Nurses and 15 CNAs on the required policies. -On [DATE], DON in-serviced two (2) Licensed Nurses and three (3) CNAs on the required policies. -On [DATE], DON in-serviced two (2) Licensed Nurses on the required policies. -On [DATE], DON in-serviced one (1) Licensed Nurse, three (3) CNAs, one (1) social worker, one (1) clinical Nutrition Manager, one (1) activities staff, two (2) pantry staff, and three (3) housekeeping staff on the required policies. As of [DATE], 100% of facility Licensed Nurses (14) and (21) CNAs have been trained on the required in-services. No facility staff on medical leave, personal leave, or agency staff will be allowed to work without the in-service education initiated on [DATE]. The facility alleges all activities to remove the Immediate Jeopardy were accomplished on [DATE]. The Immediate Jeopardy was considered removed on [DATE], prior to the entrance of MS Department of Health Surveyor on [DATE]. On [DATE], the SA validated the facility had implemented the following measures prior to surveyor arrival on [DATE], to remove the IJ. 1. The SA validated the facility's investigation of Resident #1's failure to be monitored during meal time. The SA reviewed order dated [DATE] for Resident #1 to be placed one on one during meal time. Verified through interview with the DON that the assignment sheet for Resident #1 was not completed on ,[DATE] shift. Verified through interview with LPN #1 and CNA #2 that special observation order was not communicated to CNA #1 upon arrival to work. 2. The SA validated through interview with Resident #2, that he notified LPN #1 of Resident #1 choking. Validated through interview with LPN #1 the events that transpired related to Resident #1. 3. The SA validated through interview with LPN #1 the steps taken to try to dislodge the foreign object. LPN #1 verified he was CPR certified and CPR certification was reviewed for LPN #1 and RN #1. 4. The SA validated through interview with RN #1 the steps taken to provide CPR and attempt to dislodge foreign object. 5. The SA verified through interview with the MOD that she arrived at 6:04 PM on [DATE], and the efforts taken to revive Resident #1. 6. The SA validated notification of all parties of the incident by reviewing the Personnel Incident Report. Verified through interview with the Administrator that she was notified on [DATE] at 8:49 PM, and the DON was notified at 9:28 PM. Reviewed the message from Safety and Investigative Services notifying all Department Heads of the incident. 7. The SA verified documentation that noted Mississippi State Department of Health (MSDH) was notified of the incident on [DATE] at 9:29 PM. 8. The SA verified documentation that noted the Attorney General Office (AG0) was notified of the incident on [DATE]. 9. The SA verified that CNA #2 was placed on administrative leave by reviewing the Administrative Leave Report dated [DATE]. 10. The SA verified that LPN #1 was placed on administrative leave by reviewing the Administrative Leave Report dated [DATE]. 11. The SA verified through review of CNA #1's time sheet log that she clocked out at 9:42 PM on [DATE]. Verified through interview with CNA #1 that she is not allowed to work pending the outcome of the investigation. 12. The SA validated the statement by the DON on call to not allow CNA #1 to work until further notice. 13. The SA verified through record review and staff interview that in-service education began on [DATE]. This in-service education was initiated by the Nurse Executive Director and continued by the DON. Staff was in-serviced on Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents, Resident Observation, Shift Report, Rights of Residents, and Foreign Body Airway Obstruction Code Blue/CPR/AED guidelines. On [DATE], the SA verified the in-services by interviewing two (2) Registered Nurses, four (4) Licensed Practical Nurses, and four (4) Certified Nursing Assistants. 14. The SA verified through record review and staff interview that in-service education began on [DATE]. This in-service education was initiated by the Nurse Executive Director and continued by the DON. Staff was in-serviced on all care assignments to be made by the shift leader and the Licensed Nurse responsible for the care of the resident. The Licensed Nurse assuring all assignments are properly made and documented on the assignment sheet. The Licensed Nurse and the shift leader shall both review the assignments together with focus on residents who have special observation orders. All special observation orders shall be placed on ADL (Activities of Daily Living) documentation record. The Licensed Nurse is responsible for making every two (2) hour monitoring rounds and documenting on the Patient Observation form. Problems noted with the supervision of the resident will be addressed at the time of the occurrence by the Licensed Nurse and reported to the Grounds Administrator on duty. The SA verified documentation of special observation on residents that required special observation. The SA verified every two (2) hours rounds were being made by the Licensed Nurse. On [DATE], the SA verified the in-services by interviewing two (2) Registered Nurses, four (4) Licensed Practical Nurses, and four (4) Certified Nursing Assistants. 15. The SA verified the written report posted at the time clock notifying all CNA's and l Licensed Nurses to report directly to their Shift Leader and Nurse prior to accepting patient assignments. The directive informed staff they must receive in-service education before taking an assignment. 16. The SA validated through record review and interview that care plan reviews were completed on [DATE], by the Nurse Executive Director and two (2) other residents, Resident #3 and Resident #4, were identified as having special observations. 17. The SA validated through record review that Resident #1's care plan was reviewed on [DATE], and included intervention for one on one. 18. The SA validated through record review and interview that all resident care plans were reviewed and two (2) residents were identified as having special observation needs, Resident #3 and Resident #4. 19. The SA validated through record review and interview the ADL records were reviewed on [DATE], and included special observation recommendations. 20. The SA validated through record review and interview that in-service education was held on [DATE], by the Nurse Executive Director, which included all topics discussed. 21. The SA validated through interview and review of E-mail, a request by the Nurse Executive Director to have all evening and night Administrators participate in monitoring special observations and rounds to be made. 22. The SA validated through review of records that an E-mail was sent alerting all Evening and Night Administrators of actions initiated on [DATE], following the unexpected death. 23. The SA validated through record review and interview of staff in attendance that a QA meeting was held on [DATE], and included Resident #1's attending Physician, (TRUNCATED)

MS # Based on staff interview, resident interview, record review, and facility policy review, the facility failed to ensure one (1) of nine (9) residents reviewed, Resident #1, was provided the supervision during dining to ensure a safe and accident free dining process as ordered and care planned. Resident #1 had orders for one on one (1:1) monitoring/supervision during meal time, due to a history of getting food from other resident trays and choking. Certified Nursing Assistant (CNA) #1, who had not been informed of Resident #1's orders and care plan, did not monitor Resident #1 during a meal 1:1, and he took a hot dog off another resident's tray, ate it, and choked. The [MEDICATION NAME] maneuver was attempted by several staff members and was unsuccessful. Resident #1 expired on [DATE] at 6:36 PM, due to asphyxiation. The facility's failure to ensure the correct information about resident care was provided to staff prior to assignment, and to monitor Resident #1 during meal time as ordered, resulted in Resident #1 obtaining a hot dog off another resident's tray and eating it. This caused Resident #1 to choke and expire. This placed other residents who had orders for close monitoring/supervision in a situation that was likely to cause serious injury, harm, impairment or death. The situation was identified to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE]. On [DATE] at 3:25 PM, the SA notified the facility's Administrator of the IJ and SQC. Based on the facility's implementation of corrective actions as of [DATE], initiated prior to the SA facility entrance on [DATE], the SA determined the IJ to be Past Non-Compliance and removed on [DATE]. Findings include: Review of the facility's policy, Safe Environment/Supervision, dated (MONTH) (YEAR), revealed: This policy establishes guidelines to ensure that the resident environment remains as free of accident hazards as possible and to ensure each resident receives supervision and assistance devices to prevent accidents. Review of the facility's policy, Resident Observation, dated (MONTH) (YEAR), revealed: This policy establishes guidelines for monitoring residents for medical and behavioral reasons. 2A. One on one (1:1) observation is the constant observation of a resident by a staff member for the purpose of continuously monitoring the resident's behavioral and/or medical condition. One on one observation will require the assignment of a staff member to be in the immediate proximity such that the resident could not injure himself/herself or another resident or staff member. Review of the facility's policy, Shift Report, dated (MONTH) (YEAR), revealed: This policy ensures a reporting system for each oncoming shift to receive the necessary information about each patient/resident in order to provide consistent, continuous care. This policy applies to all licensed and unlicensed care staff in all programs. Review of the facility's policy, Assignment Sheets, dated (MONTH) (YEAR), revealed: 1. This policy provides guidelines for the use of the nursing assignment sheet. It applies to all staff, licensed and unlicensed, in all programs of (facility). 2. Assignment sheets will be used for each patient/ resident area in order to provide accountability of patient/resident care and to ensure all patient/resident care has been completed. Review of the facility's face sheet revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, meaning Resident #1 was not able to make competent decision for himself and was cognitively impaired. Review of Resident #1's physician order [REDACTED].#1 had an order in place to supervise the patient in the dining room one to one (1:1) during meals. Review of the Activity of Daily Living Record (ADL) dated (MONTH) (YEAR), failed to identify Resident #1 required the special observation of one on one during meal time. Review of the Time Out, One to One, Visual Contact and Time Check Observation Report, revealed documentation of Resident #1 requiring one to one. There was documented evidence of 1:1 monitoring up to [DATE] at 1:00 PM. There was no documentation of 1:1 beyond this point. Review of the facility's documented investigation revealed on [DATE], during dinner time in the North Side Dining Room, Resident #1 took a hot dog from another resident's tray and choked on it. CNA #1 was putting up trays and had her back turned to Resident #1 when he took the hot dog. Another resident, Resident #2, informed CNA #1 that Resident #1 had taken something off another resident's tray. CNA #1 asked Resident #1 if he had taken anything from the tray and Resident #1 just looked at her. CNA #1 asked him twice if he was alright and he did not answer. At this time Licensed Practical Nurse (LPN) #1 entered the dining room after Resident #2 had informed him that Resident #1 was choking. LPN #1 asked Resident #1 if he could speak and Resident #1 shook his head, No. LPN #1 performed four (4)-five (5) back blows without success. They stood Resident #1 up and LPN #1 performed several abdominal thrusts that were unsuccessful in dislodging the obstruction. They sat him down in his wheelchair and rolled him away from the other residents. Registered Nurse (RN) #1, was also alerted by Resident #2, arrived to the dining room after calling 911/Code Blue (at 5:59 PM) and retrieving the crash cart. RN #1 attempted abdominal thrusts unsuccessfully. Resident #1 became unresponsive and was lowered to the floor. RN #1 started chest compressions while LPN #1 started ventilations via the Ambu bag. The Medical Doctor on Duty (MOD), arrived and the AED (Automated External Defibrillator) was applied with, No Shock Advised. Resident #1 and LPN #1 were transferred to the campus Hospital, Building 60, with Cardio [MEDICAL CONDITION] Resuscitation (CPR) continuing in the medical transport. After arrival to Building 60, with continued CPR efforts, Resident #1 remained apneic and pulseless and code efforts ceased with pronouncement of death at 6:36 PM ([DATE]). The investigation documented that Resident #1 was a one to one (1:1) observation, meal time only, which was not provided. There was no staff assigned to monitor Resident #1 during meal time by the CNA Supervisor. The Agency staff assigned to North Side was not given a shift report by LPN #1 when they arrived at the facility. Interview with CNA #1 on [DATE] at 8:30 AM, revealed she got to work on [DATE], got her assignment, and reported to facility at approximately 4:00 PM. CNA #1 stated neither the LPN on duty nor the CNA Supervisor gave her report when she got to work. CNA #1 stated she was not told that Resident #1 was 1:1 during meal time. CNA #1 stated no one gave her an assignment, she just took it upon herself to do what needed to be done. CNA #1 stated she was the only staff person present in the Dining Room when Resident #1 choked. CNA #1 stated there had been another CNA in the dining room with her, but she thought she had stepped out to assist with hall feeding. CNA #1 stated she started picking up trays after feeding the last resident that required assistance and was placing trays on the cart. CNA #1 stated that she had her back turned to Resident #1 when Resident #2 said to her, He just put something in his mouth. Resident #2 informed CNA #1 that it was a hot dog. CNA #1 stated she asked Resident #1 if he was okay and he just looked at her with a surprised look on his face like he had been caught doing something he wasn't supposed to. CNA #1 stated she asked him again if he was okay and he didn't respond. CNA #1 stated at that time LPN #1 arrived in the dining room and asked Resident #1 if he could talk. CNA #1 stated she was not sure of the Residents response, but LPN #1 started initiating back blows and nothing came up. CNA #1 stated that Resident #1 was wheeled to the doorway and stood up and abdominal thrust performed, without success. CNA #1 stated RN #1 arrived and CPR was initiated. CNA #1 stated she didn't know which table the hot dog was removed from, but Resident #1 had to have wheeled himself in his wheelchair to that table and came back to his table quickly. CNA #1 stated all the trays from Resident #1's table had been removed when the event occurred. CNA #1 stated she had worked in the facility prior, but had never been specifically told that Resident #1 was supervised during meals. CNA #1 stated that monitoring/observational needs were supposed to be documented on the assignment sheet, but there had been no assignment sheet prepared that day/shift, so she was not aware of the 1:1 supervision required for Resident #1 during meals. Interview with LPN #1 on [DATE] at 9:50 AM, revealed he had finished medication pass and was at the Nurse's Station signing medication records when Resident #2 came to the Nurse Station and told him Resident #1 was choking. LPN #1 stated he went to the dining room and asked Resident #1 if he could talk and he shook his head No. LPN #1 stated Resident #1 was not choking but had a wild-eyed look. LPN #1 stated he leaned Resident #1 forward and initiated four (4)-five (5) back blows and nothing came up. LPN #1 stated he stood Resident #1 up and administered abdominal thrusts which were unsuccessful in dislodging anything. LPN #1 stated that Resident #1 was moved to the hallway, pulse checked, and the Resident was pulseless; CPR was initiated and RN #1 from Southside came over and assisted in resuscitation efforts after Code Blue was called. LPN #1 stated the Medical Doctor on Duty (MOD) arrived and CPR efforts continued. LPN #1 stated Resident #1 was transported to the facility hospital where CPR efforts continued and Resident #1 was eventually pronounced deceased . LPN #1 stated he worked in the dining room when they were short staffed. LPN #1 stated otherwise, he walks by the dining room periodically and makes sure everything is okay. LPN #1 stated the CNA Supervisor is responsible for notifying CNA's of their assignments and the Nurse is responsible for notifying them of any new orders. LPN #1 stated the CNA Supervisor (CNA #2) should have told CNA #1 that Resident #1 was 1:1 during meals. LPN #1 stated that CNA #1 told him she did not know that Resident #1 was supposed to be 1:1 and was not monitoring him 1:1 during the meal. Interview with Resident #2 on [DATE] at 11:10 AM, revealed he was in the North dining room when Resident #1 choked on the hot dog. Resident #2 stated there was one (1) CNA present in the dining room at the time of the incident. Resident #2 stated the other CNA had left out of the dining room. Resident #2 stated he saw Resident #1 roll his wheelchair to another table and he picked up the hot dog and take a big bite. Resident #2 stated he told Resident #1 to quit and reported to CNA #1 that the Resident had taken the hot dog. Resident #2 stated after he told CNA #1 that Resident #1 had gotten the hot dog, he also reported it to the LPN and the RN. Resident #2 stated that Resident #1 was supposed to be 1:1 during meals because he had taken food from other residents before and got choked, but staff were able to get the food up then. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #2 was cognitively intact and had no mental impairments. Interview with RN #1 on [DATE] at 11:45 AM, revealed she was working South side when Resident #2 came and told her that Resident #1 was choking. RN #1 stated she went to North side dining room and assisted with efforts to dislodge an obstruction. RN #1 stated she attempted to suction Resident #1 but was not able to remove any object. RN #1 stated MOD arrived and applied the AED with No Shock Advised. Resident #1 was transported to the facility campus hospital. Interview with the MOD on [DATE] at 1:40 PM, revealed she was notified that a Code Blue had been called for Building 78 and she reported to the building. She stated upon her arrival, LPN #1 and RN #1 was providing CPR to Resident #1. The MOD stated she hooked up the AED and it showed No Shock Advised. She stated other facility staff arrived and Resident #1 was transported to the grounds hospital where CPR efforts were continued. The MOD stated she periodically performed finger sweeps with nothing seen or felt. The MOD stated during the process of performing CPR, a five (5) centimeter Frankfurter was removed. The MOD stated that Resident #1 remained apneic and pulseless during CPR and was pronounced deceased at 6:36 PM. The MOD stated she listed the cause of death as Asphyxiation Secondary to Airway Obstruction. Interview with the Director of Nursing (DON) on [DATE] at 2:20 PM, revealed Resident #1 was 1:1 during meals due to a history of taking food off other resident trays and choking. The DON stated she was not sure what the CNA Supervisor (CNA #2) told CNA #1 to do as far as duties. The DON stated an assignment sheet was not made out for [DATE]. The DON stated staff are supposed to receive report from the Nurse as far as medical issues and the Lead CNA gives the report on the specific assignment. Interview with CNA Supervisor (CNA #2) on [DATE] at 4:06 PM, revealed when CNA #1 reported to Building 78 she was told the block of rooms she would have on the North Hall. CNA #2 stated she did not tell CNA #1 that Resident #1 was 1:1. CNA #2 stated she had worked with CNA #1 in the past and couldn't recall if she told her then whether Resident #1 was 1:1 during meals. CNA #1 stated she assumed CNA #1 knew Resident #1 was 1:1, because everyone else knew. Interview with Resident #1's Physician on [DATE] at 9:30 AM, revealed Resident #1 had impulsive behavior and would grab food off other resident's trays spontaneously. The Physician stated Resident #1 could not comprehend that he would choke and needed to be monitored closely. The Physician stated that Resident #1 choked in April, and it was decided then that he needed to be placed 1:1 for monitoring, due to his behavior of taking other resident's food. On [DATE] at 3:25 PM, the Facility Administrator was notified that the situation of supervision for Resident #1 was deemed an Immediate Jeopardy (IJ). The Facility submitted the following Corrective Action Plan (CAP): 1. On (MONTH) 7, (YEAR), during dinner time at 5:30 PM, in the North side dining room, Resident #1 choked on a hot dog that he removed from another resident's tray at approximately 5:50 PM. CNA #1 was putting trays on the rack and had her back turned to Resident #1 when he removed the hot dog from another tray. Resident #1 had a physician's orders [REDACTED]. CNA #2 (Lead CNA) and LPN #1 did not complete a CNA assignment sheet at the beginning of the shift. The special observation order was not communicated to the CNA staff by either the Lead CNA (CNA #2) or LPN #1. 2. Resident #2 informed CNA #1 that Resident #1 had removed something from another resident's tray and was choking. CNA #1 asked Resident #1 if he had taken anything from another tray and Resident #1 just looked at her. CNA #1 then asked Resident #1 twice if he was alright and Resident #1 did not answer. At 5:50 PM, LPN #1 arrived in the dining room after being alerted by Resident #2 of the choking incident. 3. LPN #1 asked Resident #1 if he could speak and Resident #1 shook his head No. LPN #1 performed four (4) to five (5) back blows which was unsuccessful in dislodging the obstruction. LPN #1 also attempted the [MEDICATION NAME] maneuver without success. Resident #2 went approximately 10 feet away to the South side dining room to get RN #1. RN #1 was located just outside the South side dining room and responded at approximately 5:55 PM. RN #1 initiated a Code Blue and retrieved the crash cart. LPN #1 received training for CPR certification on (MONTH) 17, (YEAR). RN #1 received training for CPR certification on (MONTH) 11, (YEAR). MS State Hospital provides CPR training including the [MEDICATION NAME] maneuver upon hire during general orientation and every two (2) years thereafter to all staff of the facility. 4. RN #1 attempted the [MEDICATION NAME] maneuver (abdominal thrusts) without success. Resident #1 became unresponsive without pulse or respiration and was lowered to the floor. LPN #1 and RN #1 initiated Cardio-Pulmonary Resuscitation (CPR) and Code Blue. When Code Blue was initiated, Mississippi State Hospital Police Officers and the Human Resource (HR) Evening Administrator were notified. 5. The Medical Officer on Duty (MOD) arrived at 6:04 PM on [DATE], and the Automated External Defibrillator (AED) was applied with No shock advised. CPR efforts were continued as Resident #1 and LPN #1 were transported to the Hospital in Building 60. Advanced Cardiac Life Support (ACLS) care was initiated at Building 60 without success. During the resuscitative process, the hot dog was dislodged and removed. The MOD made death pronouncement of Resident # 1 at 6:36 PM ([DATE]). Listed below are the immediate actions taken to remove the immediate jeopardy. 6. The HR Evening Administrator notified the Director of Safety and Investigative Services (SAIS) at 8:32 PM on (MONTH) 7, (YEAR), of the unexpected death (of Resident #1). The HR Evening Administrator also notified Licensed Nursing Home Administrator (LNHA) #2 who was on call. The SAIS Director notified the facility's LNHA, Nurse Executive Director (NED), and Executive Director of all nursing homes on campus at 8:51 PM. LNHA #1 notified the facility's Director of Nursing (DON) at 9:00 PM. 7. LNHA #2 reported the unexpected death to MS Department of Health, Division of Licensure and Certification on (MONTH) 7, (YEAR) at 9:29 PM. 8. LNHA #1 notified the Attorney General's Office via online report on (MONTH) 11, (YEAR) at 9:08 AM. 9. LNHA #2 instructed the HR Evening Administrator to place CNA #2 (Lead CNA) and LPN #1 on administrative leave and to escort CNA #1 (agency staff) from the facility. 10. CNA#2 (Lead CNA) and LPN #1 were placed on administrative leave pending the outcome of the investigation. CNA #2 (Lead CNA) was placed on administrative leave on (MONTH) 7, (YEAR) at 10:02 PM. LPN #1 was placed on administrative leave on (MONTH) 8, (YEAR) at 12:04 A.M. 11. CNA #1 (agency staff) was instructed to clock out at 9:42 PM on [DATE], and not return to the facility pending the outcome of the investigation. CNA #1 was escorted off campus by MSH Police Officers. 12. The Nurse Executive Director notified RN #2, who was responsible for scheduling between the dates of (MONTH) 7, (YEAR) and (MONTH) 10, (YEAR), not to allow CNA #1 (agency staff) to work another shift until further notice. 13. Beginning on (MONTH) 7, (YEAR) at 11:00 PM, the following in-services were initiated and conducted by the Nurse Executive Director for the four (4) CNAs and the two (2) Licensed Nurses: Policy A: Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents-Resident has right to be free from abuse/neglect, what constitutes abuse with emphasis on the definition of neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Policy B: Resident Observation-Guidelines for monitoring residents on observation for medical and behavioral reasons. Three (3) levels of observation defined with emphasis placed on one on one. One on one is constant observation of a resident. One on one observation will require the assignment of a staff member to be in the immediate proximity such that the resident could not injure self or others. Any level of special observation will require physician order [REDACTED]. (Example: 1:1 during meals to prevent resident from taking food from other trays.) Policy C: Shift Report- purpose of shift report, start time, attendees, pertinent information, shift report document tool, example of guideline: All special observations shall be listed on the shift report each shift. Policy D: Rights of Residents-Resident right for a safe environment including but not limited to receiving treatment and supports for daily living safely. Policy E: Foreign-Body Airway Obstruction/Code Blue/CPR/AED-guidelines for initiating measures to remove foreign-body airway obstructions and code blue/CPR. All staff will respond when a resident experiences apparent choking, Cardio or [MEDICAL CONDITION] Arrest. Foreign body airway management such as [MEDICATION NAME] Maneuver using abdominal thrusts. 14. In addition to the aforementioned policies, four (4) CNAs/NAs and two (2) Licensed Nurses received the following in-service education beginning (MONTH) 7, (YEAR) at 11:00 PM, by the Nurse Executive Director. The written information provided for inservice education contained the following: -All care assignments for Certified Nursing Assistants/ Nursing Assistants on all shifts shall be made by the Shift Leader and the Licensed Nurse responsible for the care of the resident. -The Licensed Nurse shall assure all assignments are properly made and documented on the assignment sheet for each resident under his/her care and shall indicate such by signing behind the CNA Shift Leader on the bottom of the assignment sheet. -The Licensed Nurse and the Shift Leader shall both review the assignments together with focus on residents who have special observation orders such as: one to one, VC (visual contact) and time checks. -These special observations shall be documented on each assignment sheet each shift for the Nursing Assistant/CNA by the Lead CNA and approved by the Licensed Nurse. Special observation orders shall be documented on the nursing shift report sheet each shift by the Licensed Nurse. Special observation orders shall be reviewed verbally in each shift report as well by the Licensed Nurse and the Lead CNA. The Licensed Nurse responsible for the care of each resident shall speak directly to the CNA/Nursing Assistant during shift report and review the care the resident is to receive with special emphasis on special observation orders. If a CNA reports to duty after the shift report, upon arrival the CNA shall receive individual shift report from the Lead CNA. -Also, beginning [DATE] at 11:00 PM, all special observation orders shall be placed on the CNA/NA ADL documentation record. It is the responsibility of the Nurse when special observation orders are received to place this on the treatment plan and CNA/NA ADL record at the time of noting the physician order. -Beginning (MONTH) 7, (YEAR), the special observation monitoring rounds will be documented every two (2) hours by the Licensed Nurse on the same form (MSH 31A-Patient Observation) utilized by the CNAs/NAs for documenting resident observation behavior and safety. -This process will require the Licensed Nurse to go to the resident while on the unit, review the resident and observe CNA/NA staff is providing the level of observation ordered. The License Nurse shall sign off on the MSH 31A observation record indicating this. (Example: Resident safe and special observation in place by the CNA/NA as ordered.) The Licensed Nurse shall sign his/her name and credentials, date and time. Again, this shall be conducted by the Licensed Nurse every two (2) hours. -Any problems noted with the supervision of the resident will be addressed at the time of the occurrence by the Licensed Nurse and reported to the HR Grounds Administrator on duty for further follow up and review. The Nursing Home DON on call and Nursing Home Administrator on call shall be notified by the HR Grounds Administrator on duty of any problems. 15. On (MONTH) 7, (YEAR) at 10:45 PM, a written directive was posted by the Nurse Executive Director at the time clock informing all CNAs/NAs and Licensed Nurses to report directly to their Shift Leader and Nurse prior to accepting patient assignments. You must receive in-service education before taking an assignment. No facility or agency staff will be allowed to work until in-service education has been provided. 16. The Nurse Executive reviewed the resident census on (MONTH) 7, (YEAR) at 11:40 PM, to identify all residents with special observation orders. Two (2) residents were identified as having special observation orders, (Resident #3 and Resident #4). Next, the Nurse Executive Director ensured the two (2) residents, identified as having special observation orders, were noted on the twenty-four (24) hour nursing shift report. 17. Resident #1's care plan was reviewed at 10:10 PM on [DATE], by the Nurse Executive Director. The comprehensive care plan for Resident #1 contained the problem with the resident removing food from other resident's tray and included the intervention for the one to one special observation during meals. 18. The care plans were reviewed by the Nurse Executive Director and two (2) additional residents, Residents #3 and #4, were identified as having a special observation order. The comprehensive care plan for Resident #3 and #4 contained the special observation order. 19. On [DATE] at 11:50 PM, the ADL records were reviewed by the Nurse Executive Director for Resident #3 and Resident #4 to ensure special observation orders from the comprehensive care plan were noted for the CNA/NAs. 20. On (MONTH) 7, (YEAR) at 11: 45 PM, the Nurse Executive Director verbally reviewed the special observations with the four (4) 11 PM-7 AM shift CNAs and the two (2) Licensed Nurses. 21. On (MONTH) 8, (YEAR) at 2:00 AM, the Nurse Executive Director verbally requested the HR Night Administrator to participate in the monitoring of the special observations. The HR Night Administrator did conduct rounds at 3:00 AM to ensure the safety of the residents on special observation. The documentation of special observation by the CNAs and Nurse was complete. 22. On (MONTH) 8, (YEAR), at 6:54 AM, the Nurse Executive emailed all HR Evening and Night Administrators and their supervisor. The email contained actions initiated on (MONTH) 7, (YEAR), following the unexpected death of Resident #1, and communication regarding their role in assisting with the monitoring of special observations and documentation on the MSH 31 A form. 23. On Monday, (MONTH) 9, (YEAR) at 2:30 PM, a special called Quality Assurance meeting was held to review the incident on (MONTH) 7, (YEAR), which resulted in the unexpected death of Resident #1. The following members were in attendance. MS State Hospital Clinical Director, Nurse Executive Director, Director of Safety and Investigative Services, JNH Social Worker, Director of Service Outcomes, JNH DON, JNH LNHA, Executive Director for all nursing homes, RN #1, Resident #1's Attending Physician, Accreditation and Licensure Director, Accreditation & Licensure Coordinator, Acting Medical Director for JNH, Medical Officer on Duty ([DATE]), Safety and Investigative Services RN Investigator, Policy Coordinator, JNH Head Nurse, and Chief of Medical Staff. The following concerns were identified: -There was no shift report given, no assignment sheet was completed, and there was no CNA assigned to provide Resident #1's special observation as ordered. -The facility's policy for Resident Observation was not followed. LPN #1 did not assign a staff member to provide the 1:1 observation. There was no staff constantly observing resident in immediate proximity during the evening meal such that the resident could not do self-harm. -The comprehensive care plan for Resident #1 contained the special observation order for one to one during meals; however, the care plan was not followed. The ADL document for Resident #1 did not contain the special observation information; therefore, CNA #1 was not aware of the special observation order. -LPN # 1 did not ensure that an assignment sheet was completed. CNA #2 (Lead CNA) did not give a verbal report to the other CNAs after they clocked in. -All policies used for in-service education initiated on (MONTH) 7, (YEAR) at 11:00 PM, were reviewed and discussed with no changes. -Nurses will maintain visual contact of the dining room during meal times. -Previous actions beginning on (MONTH) 7, (YEAR) were reviewed, discussed, accepted and in-service education will be continued. -Between [DATE] - [DATE], the Nurse Executive Director in-serviced seven (7) Licensed Nurses and RN #1 in-serviced two (2) Licensed Nurses and 15 CNAs on the required policies. -On [DATE], DON in-serviced two (2) Licensed Nurses and three (3) CNAs on the required policies. -On [DATE], DON in-serviced two (2) Licensed Nurses on the required policies. -On [DATE], DON in-serviced one (1) Licensed Nurse, three (3) CNAs, one (1) social worker, one (1) clinical Nutrition Manager, one (1) activities staff, two (2) pantry staff, and three (3) housekeeping staff on the required policies. As of [DATE], 100% of facility Licensed Nurses (14) and (21) CNAs have been trained on the required in-services. No facility staff on medical leave, personal leave, or agency staff will be allowed to work without the in-service education initiated on [DATE]. The facility alleges all activities to remove the Immediate Jeopardy were accomplished on [DATE]. The Immediate Jeopardy was considered removed on [DATE], prior to the entrance of MS Department of Health Surveyor on [DATE]. On [DATE], the SA validated the facility had implemented the following measures prior to surveyor arrival on [DATE], to remove the IJ. 1. The SA validated the facility's investigation of Resident #1's failure to be monitored during meal time. The SA reviewed order dated [DATE] for Resident #1 to be placed one on one during meal time. Verified through interview with the DON that the assignment sheet for Resident #1 was not completed on ,[DATE] shift. Verified through interview with LPN #1 and CNA #2 that special observation order was not communicated to CNA #1 upon arrival to work. 2. The SA validated through interview with Resident #2, that he notified LPN #1 of Resident #1 choking. Validated through interview with LPN #1 the events that transpired related to Resident #1. 3. The SA validated through interview with LPN #1 the steps taken to try to dislodge the foreign object. LPN #1 verified he was CPR certified and CPR certification was reviewed for LPN #1 and RN #1. 4. The SA validated through interview with RN #1 the steps taken to provide CPR and attempt to dislodge foreign object. 5. The SA verified through interview with the MOD that she arrived at 6:04 PM on [DATE], and the efforts taken to revive Resident #1. 6. The SA validated notification of all parties of the incident by reviewing the Personnel Incident Report. Verified through interview with the Administrator that she was notified on [DATE] at 8:49 PM, and the DON was notified at 9:28 PM. Reviewed the message from Safety and Investigative Services notifying all Department Heads of the incident. 7. The SA verified documentation that noted Mississippi State Department of Health (MSDH) was notified of the incident on [DATE] at 9:29 PM. 8. The SA verified documentation that noted the Attorney General Office (AG0) was notified of the incident on [DATE]. 9. The SA verified that CNA #2 was placed on administrative leave by reviewing the Administrative Leave Report dated [DATE]. 10. The SA verified that LPN #1 was placed on administrative leave by reviewing the Administrative Leave Report dated [DATE]. 11. The SA verified through review of CNA #1's time sheet log that she clocked out at 9:42 PM on [DATE]. Verified through interview with CNA #1 that she is not allowed to work pending the outcome of the investigation. 12. The SA validated the statement by the DON on call to not allow CNA #1 to work until further notice. 13. The SA verified through record review and staff interview that in-service education began on [DATE]. This in-service education was initiated by the Nurse Executive Director and continued by the DON. Staf (TRUNCATED)

CI MS #9543 Based on observation, interview, record review and facility policy review, the facility failed to ensure that all exit doors of the facility were locked at all times and failed to provide adequate supervision to prevent one (1) of five (5) residents, Resident #1, from exiting the building. Resident #1 exited the building (time between 1:30 a.m. and 1:43 a.m.) on 7/3/11 unsupervised and without staff knowledge. Resident #1 was seen by LPN #1 at the nursing station "no more than 15-20 minutes" before he was found. Resident #1 was seen "about 1:30 a.m." on 7/3/11 by CNA #1 who was assigned to do bed checks. CNA #1 stated that Resident #1 was seen standing in the hallway on the west side. Resident #1 was seen outside another building across two (2) streets from the building where he resided. A LPN in building 36 notified the police who picked him up and took him back to the facility. Police checked exit doors and found the doors at the end of two long hallways where residents reside unlocked. All 34 of the 34 residents residing in the facility had been assessed as at risk for wandering/elopement risk. The lack of implementation of safety measures to ensure that all doors were kept locked at all times, and lack of visual monitoring of Resident #1 who exhibited exit seeking behavior, failed to prevent Resident #1 from exiting the building without staff supervision or staff knowledge. This was deemed an Immediate Jeopardy (IJ) on 7/27/11 at 8:35 a.m. The IJ was determined to begin on 7/3/11 and was removed on 7/8/11. The DON (in the absence of the Administrator) was notified of the IJ on 7/27/11 at 8:35 a.m. The facility provided a credible Allegation of Compliance (AoC) on 7/28/11. Based on verification of the facility's implementation of corrective actions through observations, staff interviews and in-service reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered effective 7/8/11 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor and evaluate interventions for effectiveness. Findings Include: The facility submitted the following information to the state agency: Incident: Elopement: Resident Neglect. Date received 7/14/11. On 7/5/11 at approximately 1:45 a.m. resident (name of resident) was found outside Building 36. (Resident's name) was escorted back to Building 46 per campus police. (Name of LPN) was notified and examined (Name of Resident). There were no visible injuries to (Name of Resident). Further investigation revealed the incident occurred on 7/3/11 rather than on 7/5/11 as the facility had documented on the report.. Weather history for 7/3/11 during the night revealed the temperature was 68-70 degrees Fahrenheit with 50% humidity. On 7/26/11 there were 34 of 34 residents in Building 46 with wandering behaviors/elopement risk. Two additional residents were observed, interviewed and records and documents were reviewed to determine prevention plans for risk potential for elopement. There were no concerns noted for these residents (Residents #4 and #5). Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observing and pacing the suspected path the resident had ambulated from building 46 to building 36 on 7/26/11 at 2:45 p.m. revealed the following: There were 20 paces (footsteps) from the suspected exit to either a street beside the building or a grassy area between the street and the building. There were an additional 66 steps along this path to a grassy lawn in front of the building. An additional 100 steps across this lawn down a slight incline to a sidewalk with 80 additional steps across the first street to another grassy lawn with trip hazards (tree roots) protruding over approximately 15 of these 80 steps. There were 36 more steps across the street in front of building 36 and onto a sidewalk with steps leading to the building. This was a total of 302 footsteps. Walk time was approximately 5 minutes. Traffic was light at this time and RN #3 remarked that there would have been little traffic at that time of the morning. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/11 revealed a score of six (6) on a Brief Interview for Mental Status (BIMS). A score of 0-7 equals severe cognitive impairment. Care plans reflected: 1) "Resident frequently leaves programs early even during programs of assessed interest, thinking he is discharged . (Dated 4/12/11). 2) Resident is at risk for falls (10/29/10) related to psychotropic drugs (with a notation dated 1/11/11: Res. fell out of front door onto ground as staff was entering building; no injuries). 3) Resident is at risk for wandering (5/5/10) related to impaired cognition secondary to dementia and paranoid schizophrenia. Resident with a history of attempting to elope. Resident wears a wander-guard. The goal was that "Resident will have no episodes of wandering from building without staff assistance." This care plan's first update was 7/2/10 and remained in effect with the most recent update of 4/29/11. Treatment team meeting minutes dated 5/11/11 reflected "exit seeks; kicks doors". A physician's note dated 5/18/11 reflected "Consult Dr. (name withheld) Pt. continues to be agitated and exit seeking." A nurse's note (NN) for Resident #1 dated 3/22/11 at 1:00 a.m. reflected "Res.(Resident) Pounding on front door & saying the president's here to see me, let me out, I have to go!" "Res. Refused to be redirected continues pounding and pushing against front door." A 5/31/11 NN at 10:15 a.m. revealed the Resident #1's physician was notified of the resident's unsteady gait with orders to place on 1:1 (one on one) until further notice. A 6/1/11 NN for Resident #1 at 3:00 p.m. revealed that the resident remained on 1:1 observation, still with unsteady gait. A NN dated 6/11/11 at 3:15 p.m. reflected that Resident #1 had been at front door trying to exit several times during that shift. A nurse's note dated 7/3/11 at 1:55 a.m. for Resident #1 revealeal "Res. Escorted back to B46 by security staff & administrator (name withheld). Res. Alert & awake but confused. Res. Checked for skin tears. No wounds, bruises or open areas. Skin intact. Resident #1 replied "no" when asked by nurse if he fell outside. On 7/3/11 at 2:10 a.m. the nurse's notes recorded that the Nursing Home Administrator called and started per every hour door checks. At 2:45 a.m. on 7/3/11 the nurse's notes recorded that Resident #1 was wandering up and down hallway and at 2:55 a.m. on 7/3/11 another physician ordered "visual contact" and he was placed on visual contact per protocol. Review of the "Building Checks" policy dated May 2010 revealed a procedure for the employee responsible for completing the Daily Building Check Form to: (B) tour the building area a minimum of every thirty minutes on all units and document on the form and; (H) All doors, with the exception of the front door, will be locked at all times. The front door will be locked at 7:00 p.m. There was an exception for units with enclosed secure courtyards. There was an untitled "Statement to safety and investigations", dated 7/7/11, signed by the nursing home administrator that reflected: "Jaquith Inn, Building 69, is a locked building for male behavior, dementia, and wander risk residents. The exterior doors of building 69 close automatically, and lock with a magnetic lock without any key being necessary. Our temporary housing for residents in building 46 serves the same population of residents. Building 46 is to be a locked unit the same as building 69. However, the exterior door locks on building 46 do not close automatically, nor do they lock magnetically without a key. Staff must remember to physically close the doors and lock them with their ward key every time. Following the incident with (named Resident #1) we have reinstituted a thirty minute door lock check on all exterior doors. The check is monitored in a log kept at the nurses' station". CNA #6 was responsible for doing building checks which included checking the exit doors, based on interview with RN #2 on 7/26/11 at 1:40 p.m. RN #2 stated that her investigation revealed that police found two (2) doors unlocked when Resident #1 was returned to the facility. She stated that CNA #6 told her she had only checked the front, east and west entrances at the beginning of her shift (11p - 7 a). A review of RN #2's investigative report revealed that CNA's failure to follow policy was substantiated and due to the door being unlocked, Resident #1 was able to get outside of Building 46 and cross two streets at 1:43 a.m. on 7/3/11 and try to enter Building 36. RN #2 recorded that "Neglect is substantiated for CNA #6 by not checking all doors every thirty minutes to assure they were secure". Interview with the DON on 7/26/11 at 12:50 p.m. revealed that due to sprinklers being installed in Building 69, Resident #1 was moved to Building 46. She stated that all the residents in building 46 are assessed as wanderers. Documentation of building checks/door lock checks were reviewed on 7/27/11 and had been initialed per protocol. Interview with LPN #1 on 7/27/11 at 5:05 a.m. revealed that she was at the nurses' station no more than 15-20 minutes before Resident #1 was found outside. LPN #1 stated that Resident #1 had come to the nurse's station and that she told him to go back to bed. LPN #1 stated that Resident #1 wandered off and she saw him banging on the exit door on the west side and redirected him. LPN #1 stated that the two (2) doors the police found unlocked were the east end doors. Interview with CNA #1 on 7/27/11 at 5:10 a.m. revealed that Resident #1 was observed in the hallway "about 1:30 in the morning". She said she was doing bed check and he was standing in the hallway on the west side. She stated that she has had to do door checks before and stated that they must check every door to be sure they are locked and "it's done every 30 minutes". Interview with Resident #1's physician on 7/27/11 at 10 a.m. revealed that he had checked out Resident #1 the day after the holiday and that his exit seeking behavior is strong. He stated they've tried every medication, including Lithium but nothing truly elicits a good response. He stated the resident was not harmed and this was a new building for both the residents and the staff. Telephone interview with CNA #6 on 7/26/11 at 1:20 p.m. revealed the following: CNA #6 related that she had checked all the doors on 7/3/11 except those down at the end of the hallways. CNA #6 stated that she checked the front door and those down at the end at "about 11:00 p.m." on 7/3/11. CNA #6 said "yes", she was to do every 30 minute checks and that she did them but didn't record them. CNA #6 said that she did not cheek all the doors. CNA #6 stated that she had seen Resident #1 at about 1:30 a.m. on 7/3/11 in the hallway. She said "he wanders all the time". On 7/27/11 at 2:15 p.m. a tour of building 46 revealed that all exit doors were locked. The nurse at the nursing station pointed out where the door check sheets are kept. They were in place and initialed per protocol. Observation of Resident #1 on 7/26/11 at 2:55 p.m. revealed a wander-guard bracelet on his right wrist but RN #3 stated that wander-guards don't respond in this building. She explained how they worked in building 69 where doors closed and magnetically locked automatically but due to sprinklers being installed in that building, this is a temporary move for these residents. An observation and interview with Resident #1 at 2:45 p.m. on 7/27/11 reflected a medium stature individual dressed in dark pants and a bright yellow shirt with socks and white athletic shoes. When asked what door he went out he said his shoes are too small and he needs larger shoes. Again when asked about the exit door he looked at his shoes and asked if I was getting him size 13. He began to get somewhat agitated so the questioning ceased. Two (2) police officer's reports were received on the morning of 7/28/11. Review of Police Officer #1's report dated 7/27/11 reflected that they had been notified "by a LPN in building 36" at "approximately 0143 (1:43 a.m.) hours" about a patient outside the building". Police Officer #1 recorded that they (Police Officers #1, #2 and #3) went and picked up Resident #1 and took him to Building 46. Police Officer #1 recorded that the police officers checked the building to see if any doors were open. He recorded that Police Officer #3 found one (1) door open, the east exit door on the west side. Police Officer #2's written report dated 7/27/11 reflected that at 0143 "the LPN from building 36 called and reported that a patient was outside building 36". He recorded the names of the three (3) police officers who responded and wrote that all three officers checked doors in building 46 and that at 0150 Police Officer #3 found the east exit door on the west side unlocked. Police Officer #2 concluded his report with a statement that Resident #1 had stated that his mother was outside and he had to go see her, and that Resident #1 was pushing on the east side hallway exit door, trying to get out. "Credible Allegation of Compliance" Staff and Residents were relocated from Building 69 to Building 46 on June 22, 2011 due to the installation of a full sprinkler system on Building 69. Building 69 had magnetic locks on all three exit doors which lock automatically when closed. The eight exit doors on Building 46 do not have magnetic locks, therefore, must be locked manually with a key upon entering and exiting the building. In preparation for relocating residents from Building 69 to Building 46 for the sprinkler project all building staff were informed during shift change report prior to relocation that all eight exit doors on Building 46 do not automatically lock as the ones on Building 69. In addition, prior to relocating residents to Building 46, signage was placed on all eight exit doors stating "Close door and lock with key". On 7/03/11 at approximately 1:30 a.m. Resident #1 was observed in Building 46 by LPN #1. On 7/03/11 at approximately 1:43 a.m. Resident #1 was found in front of Building 36 which is located across from Building 46. Resident #1 was off Building 46 unsupervised for less than 13 minutes. At approximately 1:50 a.m. on 7/03/11, Resident #1 was returned safely to Building 46 by Mississippi State Hospital (MSH) Campus Police Officer #2. At approximately 1:55 a.m. on 7/03/11 LPN #1 examined Resident #1 and no visible injuries were found. Additionally, on 7/03/11 at 8:00 a.m. Resident #1 was assessed by RN #1 and no visible injuries were found. On 7/03/11 after Resident #1 was returned safely to Building 46, all eight exit doors on Building 46 were checked by MSH campus Police Officer #1, MSH Campus Police Officer #2 and MSH Campus Police Officer #3 and all doors were locked. On 7/03/11 at 2:55 a.m. Resident #1 was placed on visual contact by the Medical Officer of the Day#1. Medical Officer of the Day is the attending physician on campus on call after hours. Visual Contact is defined as continuous observation of residents by one staff member for the purpose of monitoring behavioral and/or medical conditions. There is no defined distance between the observer and resident, but the observer must be able to visualize the actions of the resident assigned to them. On 7/03/11, at approximately 2:00 a.m., NHA #1 was onsite and immediately began the investigation of this incident. On 07/05/11, the first working day after the holiday, the Mississippi State Hospital's Safety and Investigative Services Investigator #1 continued the investigation of this incident at approximately 8:00 a.m. Due to the fact that the investigation was ongoing it was not yet determined who was responsible for the unlocked door, CNA #1 continued to work on 07/05/11 and 07/07/11. On 07/08/11 the completed investigation revealed that CNA #1 could have been responsible for the unlocked doors. On 07/08/11 at approximately 11:00 p.m. CNA #1 was placed on administrative leave by Mississippi State Hospital Evening Administrator #1 pending the outcome of the investigation. CNA #1 has not worked at Jaquith Nursing Home since 07/07/11. On 07/15/11 CNA #1 was mailed a pre-termination notice by Personnel Officer #1. According to Mississippi State Personnel Board policy and procedures CNA #1 has a pre-termination hearing scheduled on 08/02/11 at 10:00 a.m. CNA #1 must remain on administrative leave pending the outcome of the mandatory pre-termination hearing. CNA #1 has not worked at Jaquith Nursing Home since 07/07/11. Thirty four of thirty four residents of Jaquith Inn have been identified by Building 46 physician to be at risk for wandering and have the potential to be affected by the deficient practice. Because this is a locked building, there was no need to reassess residents for risk of wandering. All resident care plans are reviewed and updated quarterly or as needed by the building nursing staff. On 07/03/11 at approximately 2:00 a.m., the night RN Supervisor #1 and the NHA #1 began in-servicing Jaquith Inn staff on the following policies: J530-36 Building Checks (Inservicing began on 07/03/11). The purpose of this policy is to establish procedures for conducting building checks during waking hours and maintaining written documentation of these checks. J500-15 Wander Elopement, (In-servicing began on 07/03/11). The purpose of this policy is to establish procedures when a resident of Jaquith Nursing Home is determined to be at risk for wandering or elopement. J500-48 Missing Resident, (in-servicing began on 07/03/11). The purpose of this policy is to establish procedures to be followed when a resident of Jaquith Nursing Home is determined to be missing from the Mississippi state Hospital (MSH) Grounds, or when a resident does not return from an approved pass. J530-55 Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents, (In-servicing began on 07/03/11). The purpose of this policy is to affirm that Jaquith Nursing Home (JNH) residents have a right to be free from abuse, neglect, sexual battery, mistreatment, exploitation, and misappropriation of property and to outline procedures for complying with Centers for Medicare, Medicaid Services (CMS) and the Mississippi Vulnerable Adult Act of 1986 as annotated. No staff was allowed to work on the unit (until) he/she was in-serviced. No changes were made to the above policies as a result of this incident. On 07/03/11 at 2:30 a.m. staff (CNA or Nurse) began hourly checks of all eight exit doors to verify that they were locked. Documentation of these checks has been recorded on the Record of Building Rounds Form. This form was utilized from 07/03/11 to 07/05/11. On 07/05/11 a revised Building Check Form was utilized, which changed the frequency of checks from hourly to every thirty minutes. See record of Building Rounds Form and Building Check Form. A staff member (CNA or Nurse) was assigned the task of checking all eight exit doors to verify they were locked each shift (7:00 am - 3:30 p.m., 3:00 p.m. - 11:30 p.m. and 11:00 p.m. - 7:30 a.m.). On 07/03/11 at 7:00 a.m., NHA #1 began communicating this incident with building staff during shift change reports (7 a.m., 3:00 p.m. and 11:00 p.m.). As a quality assurance measure on 07/04/11-07/05/11 the NHA #1 began reviewing building staff's documentation of hourly door checks on the Record of Building Rounds Form for compliance. As an ongoing quality assurance measure on 07/06/11 the NHA #1 began reviewing building staff's documentation of thirty minute door checks on the Building Check Form for compliance. The purpose of the NHA's monitoring tool is to confirm that exit door checks are being conducted and documented. Since this practice has been implemented on 07/03/11 at 2:30 a.m. all monitoring documentation has been completed and facility is 100% compliant in that no resident has left the building unsupervised and no doors have been left unlocked. This QA monitor will remain in effect until the installation of the full sprinkler system on Building 69 is complete and residents are relocated back to Building 69. As an additional quality assurance measure, any noted deficient practice will be reported by the NHA to the Jaquith Nursing Home Director. As an ongoing quality assurance measure, the JNH Director will report the findings to the JNH Executive Committee for further corrective action if necessary. Verification of AOC: Random interviews with Maintenance/Housekeeping, Activities, Nursing Staff (Licensed Practical Nurses and Registered Nurses), and Certified Nurse Assistants (CNA) were conducted from 7/26/11 at 9 a.m. to 7/28/11 at 12:10 p.m. On 7/28/11 at 12:10 p.m. there was evidence through observations, random interviews, and written staff statements that the monitoring of doors and the visual checks on Resident #1 continued to be conducted. Observation of exit doors were checked at 1:50 p.m. on 7/26/11 and at 2:15 p.m. on 7/27/11 and all were found to be locked. Also, all exit doors had signs posted warning staff to "Close door and lock with key". Visitors could not get in or out without staff unlocking the door. The "Building Check" procedure reflected that at least every shift the charge CNA reviewed documentation of the "Building Check Form" and signed the form, including the date and time of the review. Building checks were being done as evidenced by initials on logs. In-service records were reviewed with the Director of Nursing (DON) on 7/26/11 at 12:50 p.m. to ensure that all staff had been in-serviced on checking/locking doors, wandering/elopement protocols, missing residents, and Abuse/Neglect policies. Wandering/Elopement/Abduction was also reviewed with the DON on 7/26/11 at 12:50 p.m. Review of the "Abuse and Neglect" policy and procedure noted that neglect is defined as "A failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness". This neglect had now been addressed. "Resident Accountability Sheet"(s) on 7/26/11 were reviewed and were verified for documentation of tasks completed. Interview with the Human Resource staff on 7/26/11 at 1:50 p.m. and review of the personnel record for CNA #6, who had failed to check all exit doors, revealed that CNA #6 was no longer employed at the facility. Two (2) additional residents, Resident #4 and Resident #5, that had been identified as high risk for elopement were reviewed for verification of assessments and care plan implementation. Interview on 7/27/11 at 10 a.m. with Resident #1's physician verified that he had been notified and had examined Resident #1. The physician noted that Resident #1 was not harmed. Review of police reports on 7/28/11 revealed that two (2) of the three (3) police officers that had brought Resident #1 back to the facility found unlocked doors. Based on verification of the facility's corrective actions that was validated by staff interviews, observation and in-service form reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 7/8/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

CI MS #9543 Based on observation, interview, record review and facility policy review, the facility failed to implement written policies and procedures that prohibit neglect/adequate supervision of residents to prevent one (1) of five (5) sampled residents, Resident #1, from exiting the building unsupervised. Resident #1 exited the building (approximate time between 1:30 a.m. and 1:43 a.m.) on July 3, 2011 through an unlocked door, unsupervised and without staff knowledge. Resident #1 exited the building through an unlocked East exit door on the West Wing that should have been locked. According to a police investigation report, the police were notified by a Licensed Practical Nurse (LPN) that a patient was seen at 1:43 a.m. outside another building across two (2) streets from the building where the resident resided. Resident #1 was picked up and brought back to the facility and that was when the police found an unlocked door. Resident #1 was last seen by Licensed Practical Nurse (LPN) #1 near the nurse's station "no more than 15-20 minutes before he was found outside". He was seen by CNA #1 "at about 1:30 in the morning" in the hallway. CNA # 6 had been assigned to check all eight (8) exit doors every thirty (30) minutes to ensure they were all locked. CNA #6 checked some of the eight (8) doors, but failed to check at least two (2) doors that were down two (2) long hallways where residents resided. These doors could not be viewed from the nurses' station or the front of the building. The lack of implementation of the procedure to check all exit doors and neglecting to supervise residents with wandering behavior was deemed an Immediate Jeopardy (IJ) on 7/27/11 at 8:35 a.m. The IJ was determined to begin on 7/3/11 and was removed on 7/8/11. The DON (in the absence of the Administrator) was notified of the IJ on 7/27/11 at 8:35 a.m. The facility provided a credible Allegation of Compliance (AoC) on 7/28/11. Based on the facility's implementation of corrective actions the IJ was removed and the scope and severity was lowered effective 7/8/11 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. Findings Include: Cross Refer to F-323 for the facility's failure to lock doors and provide visual observation to ensure that Resident #1 did not leave the building without staff knowledge and supervision. "Credible Allegation of Compliance" Staff and Residents were relocated from Building 69 to Building 46 on June 22, 2011 due to the installation of a full sprinkler system on Building 69. Building 69 had magnetic locks on all three exit doors which lock automatically when closed. The eight exit doors on Building 46 do not have magnetic locks, therefore, must be locked manually with a key upon entering and exiting the building. In preparation for relocating residents from Building 69 to Building 46 for the sprinkler project all building staff were informed during shift change report prior to relocation that all eight exit doors on Building 46 do not automatically lock as the ones on Building 69. In addition, prior to relocating residents to Building 46, signage was placed on all eight exit doors stating "Close door and lock with key". On 7/03/11 at approximately 1:30 a.m. Resident #1 was observed in Building 46 by LPN #1. On 7/03/11 at approximately 1:43 a.m. Resident #1 was found in front of Building 36 which is located across from Building 46. Resident #1 was off Building 46 unsupervised for less than 13 minutes. At approximately 1:50 a.m. on 7/03/11, Resident #1 was returned safely to Building 46 by Mississippi State Hospital (MSH) Campus Police Officer #2. At approximately 1:55 a.m. on 7/03/11 LPN #1 examined Resident #1 and no visible injuries were found. Additionally, on 7/03/11 at 8:00 a.m. Resident #1 was assessed by RN #1 and no visible injuries were found. On 7/03/11 after Resident #1 was returned safely to Building 46, all eight exit doors on Building 46 were checked by MSH campus Police Officer #1, MSH Campus Police Officer #2 and MSH Campus Police Officer #3 and all doors were locked. On 7/03/11 at 2:55 a.m. Resident #1 was placed on visual contact by the Medical Officer of the Day#1. Medical Officer of the Day is the attending physician on campus on call after hours. Visual Contact is defined as continuous observation of residents by one staff member for the purpose of monitoring behavioral and/or medical conditions. There is no defined distance between the observer and resident, but the observer must be able to visualize the actions of the resident assigned to them. On 7/03/11, at approximately 2:00 a.m., NHA #1 was onsite and immediately began the investigation of this incident. On 07/05/11, the first working day after the holiday, the Mississippi State Hospital's Safety and Investigative Services Investigator #1 continued the investigation of this incident at approximately 8:00 a.m. Due to the fact that the investigation was ongoing it was not yet determined who was responsible for the unlocked door, CNA #1 continued to work on 07/05/11 and 07/07/11. On 07/08/11 the completed investigation revealed that CNA #1 could have been responsible for the unlocked doors. On 07/08/11 at approximately 11:00 p.m. CNA #1 was placed on administrative leave by Mississippi State Hospital Evening Administrator #1 pending the outcome of the investigation. CNA #1 has not worked at Jaquith Nursing Home since 07/07/11. On 07/15/11 CNA #1 was mailed a pre-termination notice by Personnel Officer #1. According to Mississippi State Personnel Board policy and procedures CNA #1 has a pre-termination hearing scheduled on 08/02/11 at 10:00 a.m. CNA #1 must remain on administrative leave pending the outcome of the mandatory pre-termination hearing. CNA #1 has not worked at Jaquith Nursing Home since 07/07/11. Thirty four of thirty four residents of Jaquith Inn have been identified by Building 46 physician to be at risk for wandering and have the potential to be affected by the deficient practice. Because this is a locked building, there was no need to reassess residents for risk of wandering. All resident care plans are reviewed and updated quarterly or as needed by the building nursing staff. On 07/03/11 at approximately 2:00 a.m., the night RN Supervisor #1 and the NHA #1 began in-servicing Jaquith Inn staff on the following policies: J530-36 Building Checks (Inservicing began on 07/03/11). The purpose of this policy is to establish procedures for conducting building checks during waking hours and maintaining written documentation of these checks. J500-15 Wander Elopement, (In-servicing began on 07/03/11). The purpose of this policy is to establish procedures when a resident of Jaquith Nursing Home is determined to be at risk for wandering or elopement. J500-48 Missing Resident, (in-servicing began on 07/03/11). The purpose of this policy is to establish procedures to be followed when a resident of Jaquith Nursing Home is determined to be missing from the Mississippi state Hospital (MSH) Grounds, or when a resident does not return from an approved pass. J530-55 Injury, Abuse, Neglect, Mistreatment, or Exploitation of Residents, (In-servicing began on 07/03/11). The purpose of this policy is to affirm that Jaquith Nursing Home (JNH) residents have a right to be free from abuse, neglect, sexual battery, mistreatment, exploitation, and misappropriation of property and to outline procedures for complying with Centers for Medicare, Medicaid Services (CMS) and the Mississippi Vulnerable Adult Act of 1986 as annotated. No staff was allowed to work on the unit (until) he/she was in-serviced. No changes were made to the above policies as a result of this incident. On 07/03/11 at 2:30 a.m. staff (CNA or Nurse) began hourly checks of all eight exit doors to verify that they were locked. Documentation of these checks has been recorded on the Record of Building Rounds Form. This form was utilized from 07/03/11 to 07/05/11. On 07/05/11 a revised Building Check Form was utilized, which changed the frequency of checks from hourly to every thirty minutes. See record of Building Rounds Form and Building Check Form. A staff member (CNA or Nurse) was assigned the task of checking all eight exit doors to verify they were locked each shift (7:00 am - 3:30 p.m., 3:00 p.m. - 11:30 p.m. and 11:00 p.m. - 7:30 a.m.). On 07/03/11 at 7:00 a.m., NHA #1 began communicating this incident with building staff during shift change reports (7 a.m., 3:00 p.m. and 11:00 p.m.). As a quality assurance measure on 07/04/11-07/05/11 NHA #1 began reviewing the building staff's documentation of hourly door checks on the Record of Building Rounds Form for compliance. As an ongoing quality assurance measure on 07/06/11 the NHA #1 began reviewing building staff's documentation of thirty minute door checks on the Building Check Form for compliance. The purpose of the NHA's monitoring tool is to confirm that exit door checks are being conducted and documented. Since this practice has been implemented on 07/03/11 at 2:30 a.m. all monitoring documentation has been completed and facility is 100% compliant in that no resident has left the building unsupervised and no doors have been left unlocked. This QA monitor will remain in effect until the installation of the full sprinkler system on Building 69 is complete and residents are relocated back to Building 69. As an additional quality assurance measure, any noted deficient practice will be reported by the NHA to the Jaquith Nursing Home Director. As an ongoing quality assurance measure, the JNH Director will report the findings to the JNH Executive Committee for further corrective action if necessary. Verification of the AoC: Random interviews with Maintenance/Housekeeping, Activities, Nursing Staff (Licensed Practical Nurses and Registered Nurses), and Certified Nurse Assistants (CNA) were conducted from 7/26/11 at 9 a.m. to 7/28/11 at 12:10 p.m. On 7/28/11 at 12:10 p.m. there was evidence through observations, random interviews, and written staff statements that the monitoring of doors and the visual checks on Resident #1 continued to be conducted. Observation of exit doors were checked at 1:50 p.m. on 7/26/11 and at 2:15 p.m. on 7/27/11 and all were found to be locked. Also, all exit doors had signs posted warning staff to "Close door and lock with key". Visitors could not get in or out without staff unlocking the door. The "Building Check" procedure reflected that at least every shift the charge CNA reviewed documentation of the "Building Check Form" and signed the form, including the date and time of the review. Building checks were being done as evidenced by initials on logs. In-service records were reviewed with the Director of Nursing (DON) on 7/26/11 at 12:50 p.m. to ensure that all staff had been in-serviced on checking/locking doors, wandering/elopement protocols, missing residents, and Abuse/Neglect policies. Wandering/Elopement/Abduction was also reviewed with the DON on 7/26/11 at 12:50 p.m. Review of the "Abuse and Neglect" policy and procedure noted that neglect is defined as "A failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness". This neglect had now been addressed. "Resident Accountability Sheet"(s) on 7/26/11 were reviewed and were verified for documentation of tasks completed. Interview with the Human Resource staff on 7/26/11 at 1:50 p.m. and review of the personnel record for CNA #6, who had failed to check all exit doors, revealed that CNA #6 was no longer employed at the facility. Two (2) additional residents, Resident #4 and Resident #5, that had been identified as high risk for elopement were reviewed for verification of assessments and care plan implementation. Interview on 7/27/11 at 10 a.m. with Resident #1's physician verified that he had been notified and had examined Resident #1. The physician noted that Resident #1 was not harmed. Review of police reports on 7/28/11 revealed that two (2) of the three (3) police officers that had brought Resident #1 back to the facility found unlocked doors. Based on verification of the facility's corrective actions that was validated by staff interviews, observation and in-service form reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 7/8/11 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on observation, record review, staff interview and policy review, the facility failed to assess and provide interventions to prevent constipation and/or fecal stasis for one (1) of 11 residents reviewed. Resident #1 did not receive as needed (prn) laxatives as ordered for no documented bowel movements (BM) in three (3) days. Resident #1 had 10 days documented that he did not have a BM. Resident was identified on the care plan to have a problem of constipation. Resident #1 had an x-ray on 4/3/11 with the results of "Fecal Stasis". Orders were received for to increase the Milk of Magnesia (MOM) to 45 cc (cubic centimeters) daily, [MEDICATION NAME] suppository now, and then every three (3) days, and Magnesium [MEDICATION NAME] one bottle now with a repeat KUB in three (3) days. The facility failed to follow their policy for "Constipation Prevention Measures and Management." Findings include: Record review revealed that Resident #1 moved into the home on 7/20/05 with [DIAGNOSES REDACTED]. Observation on 5/4/11 at 5:25 p.m. revealed Resident #1 was sitting in the dining room in a wheelchair eating the supper meal. Review of the 2/15/11 Care Plan for Resident #1 revealed that the problem: "Resident at risk for constipation/fecal impaction secondary to psychtrophic ([MEDICAL CONDITION]) medication usage." The problem was identified on 6/10/09. The Goal and Target Date noted: "Resident will be free from constipation/fecal impaction X (times) 90 days." Approaches planned for this problem were as follows: "Tap water enema every three (3) days as needed for absence of bowel movement (BM)." "Digital rectal exam prn (as necessary) for constipation." "Notify nurse if the resident doesn't have a BM (bowel movement) every three (3) days." "Monitor abdomen for distention as well as lack of bowel sounds." "Encourage fluids every two hours while awake and prn (as needed). " "Administer laxatives/stool softeners as ordered. Monitor effectiveness and results. Notify MD (physician) of lack of BM in 24 hours." Review of the March 2011 Medication Chart for Resident #1 revealed that [MEDICATION NAME] 5 milligrams [MEDICATION NAME] coated tablets two (2) twice a day and juice with fiber each a.m. were routinely given. There was an order for [REDACTED]. Review of the March 2011 documentation regarding the monitoring of the number of daily bowel movements; the Medication Chart; the nurse's notes and the physician's orders [REDACTED]. MOM 30 cc was documented as being given on 3/5-/1 on the Medication Chart. There were no results documented on the Medication Chart to show if the MOM was effective from the dose of MOM. There was no other MOM documented as being administered on the Medication Chart for the month of March 2011. The nurse's notes documented on 3/5/11 at 1:00 p.m. that "MOM given @ (at) this X (time) for NO BM X three (3) days. Will report to oncoming nurse to monitor for effectiveness." The next entry in the nurse's notes was dated 3/8/11 at 11:00 a.m. that noted: "CNA (Certified Nurse Aide) reported no BM X three (3) days MOM 30 cc po (by mouth) given. Results pending." The next nurse's notes entry was 3/9/11 at 3:00 p.m. and documented: "Manually checked residual. Full of soft brown stool (BM). Peri-care done. Tolerated O.K. Gave 1000 cc of TWE (tap water enema). O (no) c/o (complaints of) discomfort or pain noted. Call light in reach." On 3/9/11 there was documentation that the resident had one (1) extra large soft brown BM. From 3/10/11 through 3-14-11 (five (5) days), zero (0) was documented as the number of daily bowel movements in the past 24 hours. On 3/15/11 there was documentation that the resident had one (1) large hard brown BM. From 3/16/11 through 3/18/11 (three (3) days), zero (0) was documented as the number of daily bowel movements in the past 24 hours. On 3/19/11 there was documentation that the resident had one (1) large hard brown bowel movement. From 3/20/11 through 3/29/11 (10), zero (0) was documented as the number of daily bowel movements in the past 24 hours. The nurse's notes did not address BMs from 3/9/11 until 3/25/11 at 9:15 a.m. and documented: "CNA (Certified Nurse Aide) reported no BM X three (3) days. MOM 30 cc po given. Results pending." On 3/29/11 at 10:00 a.m. the nurse's notes documented " MOM given @ this X for NO BM x three (3) days. Will report to oncoming shift to monitor results." On 3/30/11 there was documentation that the resident had one (1) large soft brown bowel movement. The nurse's notes on 3/30/11 at 10:30 a.m. documented "CNA reported no BM x eight (8) days. MOM not effective. No N/V (Nausea/vomiting) noted @ (at) this time. 1000 cc TWE given @ this X. Large amount of brown formed stool noted. Abdomen not distended. Will cont (continue) to monitor for changes." From 3/31/11 through 4/3/11 (four (4) days), zero (0) was documented as the number of daily bowel movements in the past 24 hours. After the 3/30/11 entry the nurse's notes did not address BM's again until 4/4/11 at 11:00 a.m. The documentation noted: "New Order KUB (abdominal x-ray) today R/T (related to) MD notified of irregular bowel habits." On 4/4/11 at 3:00 p.m. the nurse's notes documented KUB complete. Results/orders pending per MD review. "On 4/4/11 at 4:45 p.m. the nurse's notes stated (Name of Physician #1) called with med (medication) changes of MOM 45 cc po daily, [MEDICATION NAME] supp (suppository) now, then every day X three (3) days, Mag [MEDICATION NAME] one (1) bottle now, KUB in three (3) days." There was no documentation in the nurse's notes regarding the effectiveness of these measures. Review of the physician's orders [REDACTED]. Review of the report of the 4/4/11 KUB revealed: "Extensive fecal stasis is present. There are no findings to suggest bowel obstruction. Fecal impaction is present in the rectum. The liver and spleen are not enlarged." The reporting physician was (Name of Physician #2). Review of the report of the 4/8/11 KUB revealed: "Since 4/4/11 the fecal stasis has significantly decreased. Mild fecal impaction persists in the rectum. The liver and spleen are not enlarged. The bowel gas pattern does not suggest obstruction." The reporting Physician was Physician #2. Interview on 5/6/11 at 10:30 a.m. with MD #1, employed by and caring for the residents in the facility revealed he believed that the policy for Constipation Prevention Measures and Management was implemented but that there was a problem with the documentation rather than a patient care problem. MD #1 stated that the resident was eating and there was no problem with nausea, vomiting, or abdominal distention. MD #1 stated that he would define constipation as a large amount of stool and would [DIAGNOSES REDACTED]. Interview per telephone on 5/6/11 at 9:40 a.m. with MD #2, the reporting MD for the 4/4/11 and 4/8/11 KUBs revealed that fecal stasis means that feces in the colon is more than normal. Extensive stasis meant severe stasis, much more than normal. MD #2 stated that he would only use the term "impaction" for situations where the distal colon contains a large amount of feces. MD #2 stated that he/she would not mention feces or fecal impaction if the x-ray was normal. Interview on 5/6/11 at 10:25 a.m. with Registered Nurse (RN) #1, Director of Nursing (DON), RN #2, and the Head Nurse for Building 78 where Resident #1 was housed, confirmed that there was no documentation of Resident #1 being assessed, monitored and receiving measures as outlined in facility policy and per the care plan other than as was found in the existing record. Review of the 5/5/11 KUB report, reported by MD #3, revealed: "History: Follow up fecal stasis. Abdomen one view: The liver and spleen are normal size. Normal gas pattern. No evidence of fecal stasis. No evidence obstruction or ileus. The impaction in the rectosigmoid area is no longer present." Review of the home's "Constipation Prevention Measures and Management" policy, dated November 2007 noted: " (1) PURPOSE AND APPLICABILITY. This policy provides guidelines to identify patient/residents that are at increased risk for experiencing constipation and to provide necessary care for patients/residents that are so identified. This policy applies to all patient/residents and staff in all facilities of Mississippi State Hospital." (2). DEFINITION. "Constipation is defined as having a bowel movement fewer that (than) three (3) times per week and is characterized by stools that are usually formed, dry, small in size, and difficult to eliminate. If left untreated constipation could lead to fecal impaction." (3). POLICY. "Staff will strive to maintain each patient/resident's normal bowel function. An interdisciplinary approach will be used in monitoring and treating patient/residents identified at increased risk for constipation. (4) E. "All patients/residents will be monitored for frequency of bowel movements; and results are documented each shift on the ADL (Activities of Daily Living) record for (name of facility), the Patient Care Flow Sheet for IPS, Crisis Centers and the Intake and Output Form. Any patient/resident with chronic constipation will also receive Intake and Output Monitoring." F. "The nurse will be responsible for monitoring above documentation and ensure bowel movements are being recorded on the form." G. "If no bowel movement has been documented for three consecutive days, the nurse will assess the patient/resident. The nurse will assess for abdominal discomfort or distention and bowel sounds in each abdominal quadrant. If constipation is suspected a gloved lubricated finger will be inserted into the rectum." (1) "If soft stool is present, consult standing orders and/or obtain an order for [REDACTED]." (2) "If no stool is present, consult standing orders and/or obtain an order for [REDACTED]." (3) "If hard stool is present, manually remove the feces if necessary and consult standing orders and/or obtain an order for [REDACTED]. "If a patient/resident receives treatment for constipation, the nurse will document results or lack of results in the nurse's notes every 24 hours until results are obtained. After initiation of treatment, if the patient/resident has not returned to normal bowel function by 24 hours, the nurse will continue to chart every shift documenting abdominal distension, nausea and vomiting and vital signs until bowel function returns to normal." I. "If no results are obtained by the end of the shift, the off going nurse will report it to the on-coming nurse. The on-coming nurse will monitor and record the results in the nurse's notes. The physician/practitioner will be notified of results and documented accordingly..."

Based on record review, observation, and interview, the facility failed to follow the care plan for one (1) of 11 residents reviewed. The facility failed to assess and provide interventions to prevent constipation and/or fecal stasis. Resident #1 did not receive as needed (prn) laxatives as ordered for no documented bowel movements (BM) in three (3) days. Resident #1 had 10 days documented that he did not have a BM. Resident #1 was identified on the care plan to have a problem of constipation. Resident #1 had an x-ray on 4/3/11 with the results of "Fecal Stasis." Orders were received to increase the Milk of Magnesia (MOM) to 45 cc (cubic centimeters) daily, [MEDICATION NAME] suppository now, and then every three (3) days, and Magnesium [MEDICATION NAME] one bottle now with a repeat KUB in three (3) days. The facility failed to follow their policy for "Constipation Prevention Measures and Management." Findings include: Cross refer to F-309 for the facility's failure to ensure that the facility policy was carried out when Resident #1 did not have bowel movements in three (3) days. This resulted in Resident #1 having a problem with fecal stasis.

CI MS #8618 Based on a partial extended survey, observation, interviews, and medical record review, the facility failed to ensure that two (2) of seven (7) residents (Residents #2 and 3) were free from verbally abusive language and a verbal threat by staff in the facility. Profane, threatening language was uttered to Resident # 2 by a pantry worker. The Resident #2 stated he/she was angry, but "got past it". Sexually demeaning statements were made to Resident #3 by a Certified Nursing Assistant (CNA) in the presence of other staff and residents. The facility also failed to ensure that one (1) of seven (7) residents in the facility (Resident #4) was free from physically abusive action. Resident #4's arm was twisted by a Nurse Aide (NA) in training in the presence of other residents and staff. The Resident #4 stated that it hurt the arm but was not broken but could have been. Facility policy addresses the fact that residents have a right to be free from abuse. The facility defines abuse as the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. The facility defines verbal abuse as the use of language that willfully includes disparaging and derogatory terms to residents. Findings Include: Resident #2 Resident #2, date of birth 6/10/72, was confined to a wheelchair, dependent on staff for most activities of daily living (ADLs). .[DIAGNOSES REDACTED]. An assessment dated [DATE] reflected no problems with memory or cognitive decision-making. A care plan approach for ADLs was to provide assistance with transfers, meals, hygiene as needed. On 9/1/10 the facility reported that at 5:30 p.m. on 8/25/10 Resident #2 was allegedly verbally abused by a pantry worker in the dining room by stating "here, get this damn ice". Interview with Resident #2 at 4:45 p.m. on 9/14/10 revealed that when fresh ice was requested, the worker starting "cursing something awful, kept using foul language, slammed doors". He/she stated that she just "went off"; that there was no need to talk to us like that. The resident stated he/she was angry, but "got past it". Interview with a Certified Nursing Assistant (CNA) on 9/14/10 revealed that she was on duty in the dining room the evening of the incident. She stated that she went to the pantry window and asked for some ice and the pantry worker told her "I just gave him some (G-D) ice and he don't need no more". The CNA stated that when she proceeded to try to get the ice the pantry worker kept cursing. She stated both doors and windows were open and lots of resident heard it, then the pantry worker started slamming doors. Interview with the Director of Nursing (DON) at 7:30 p.m. on 9/14/10 revealed that Resident #2 is "very believable", that he/she had heard this staff member using foul language before and said he/she just had to report this one. Resident #3 Resident #3, date of birth 11/4/52, was confined to a wheelchair and dependent on staff for all ADLs. [DIAGNOSES REDACTED]. An assessment dated [DATE] reflected no long or short term memory loss and a need for incontinent care. Care plan approaches for dependence on ADLs included "maintain a routine structured environment" and monitor resident frequently for needs or complaints and to provide resident with incontinent briefs to maintain dignity. The facility failed to honor this resident's dignity as evidenced by notice to the state agency on 6/13/10 in which the facility reported that a CNA had used sexually demeaning remarks to the resident. Interview with the Resident #3 on 9/14/10 at 5:20 p.m. revealed that a CNA was cursing him because he had a bowel movement and it was all over him. He stated that he told her if she didn't want to clean him up, to get someone else. He became embarrassed to continue but when encouraged, stated that the CNA then started making comments about his small (d ...) and you can't get it up, and said nasty things, pointing to another resident in the room, stated that he has a big (d ...) and doesn't know what to do with it. This resident could not be interviewed due to his mental capacity. Resident # 3 stated there was another staff member in the room who heard it and didn't say anything and another in the hallway who heard it and they all failed to report it. He stated that the Administrator fixed things when told. He said that it upset him, but you have to forget and move on. There was no opportunity to interview any of the three staff due to phones disconnected and/or no answer/no voice mail. Interview with the Administrator at 6:15 p.m. on 9/14/10 revealed that investigation found the CNA to have made those remarks and that she was terminated as well as the CNA who failed to report and the one that was in the hallway who failed to report it. Interview with the Director of Nursing (DON) at 7:30 p.m. on 9/14/10 revealed that the remarks were overheard by several other staff and investigated and appropriate action was taken. Resident #4 Resident #4, date of birth 6/26/46, has [DIAGNOSES REDACTED]. An assessment dated [DATE] reflected no problems with short or long term memory and a psychology behavioral care plan dated 5/28/10 reflected that Resident #4 is generally very friendly, enjoys interacting with others and to be vigilant of his/her non-verbal and verbal behaviors when on the unit and if he/she appears to be getting upset, allow him/her time to talk with you about his/her concerns. A care plan approach addressed "approach resident in a calm and polite manner" and "provide resident with respect and dignity at all times". Dignity and respect were not afforded Resident #4 as exhibited by facility notice to the state agency on 6/28/10 indicating that on 6/16/10 while 2 pantry workers were preparing supper they heard a resident scream. The resident told them that someone hurt his/her arm and pointed to a male Nurse Aide (NA), leaving the dining room. Interview with Resident #4 on 9/14/10 at 6:25 p.m. revealed a resident who was very talkative and explained that this man, added worker, came up to him/her and twisted his/her arm, then shoved the arm against the wall. The Resident #4 demonstrated how the arm was shoved against the wall. The Resident #4 stated that he/she screamed and the NA left the room. Attempts to reach the NA found that the phone had been disconnected. Interview with the Administrator on 9/14/10 at 6:15 p.m. confirmed the above and stated that the NA was in training and not yet certified, and that he had been terminated. The Resident #4 stated that it hurt the arm but was not broken but could have been. He/she stated that he/she was able to ambulate with the walker back to the bedroom.