Every finding on record at John Knox Manor Inc I I

Based on observations, interviews, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and the facility's policies titled Ovens/Cleaning, Mixer Cleaning, Holding Temperatures, and Dish Washing Area; the facility failed to prevent the potential for cross-contamination and foodborne illness as evidenced by: Direct connections existed between the sewage system and the drains of the dish machine, the three-compartment sink, and two preparation sinks; Two oven door handles had a greasy residue to touch; A standing mixer had batter residue on the upper interior housing; On 01/02/2024 a half-full gallon container of whole milk with an expiration date of 12/22/2023 was observed in the reach-in refrigerator; The resident nourishment refrigerators on the three units (East, West, and North) used temperature logs with a temperature range of 36 to 46 degrees Fahrenheit ( F), instead of 41 F or less; The final rinse temperature of the dish machine exceeded 194 F and reached 202 F; which resulted in the Plate Simulator Thermometer Puck only reaching 149.7 F, instead of 160 F, the minimum plate surface temperature for sanitizing. This had the potential to affect 58 of 58 residents who received meals from the facility's kitchen. Findings include: An undated facility policy titled Ovens/Cleaning revealed . Purpose To ensure that the ovens are clean and free from build-up of grease . Policy . Ovens should be cleaned . daily as spills occur. The facility's policy titled Policy for Mixer Cleaning, dated 06/17/2002 revealed . Purpose - To ensure that the mixer is maintained in a clean and sanitized condition. Procedure: . 3. Wipe machine with soapy cloth including . underside of shaft. An undated facility policy titled HOLDING TEMPERATURES revealed . Policy: The wholesomeness of food must be safeguarded through safe and sanitary practices which includes effective control of food temperatures at all times . Procedure: . 3. Proper holding temperatures for equipment include: Refrigerators 36-40 degrees Freezers 10-0 degrees Dish Machine Rinse 180 degrees . 4. Equipment temperatures will be recorded daily . An undated facility policy titled Dish Washing Area revealed . Mechanical Dish Washing: To ensure effective dish washing, all equipment must be functioning at optimum levels. Procedures: . Rinse Temperature: The rinse temperature must be maintained at a minimum of 180 degrees Fahrenheit during a minimum rinse cycle of twelve seconds. The 2022 U.S. Food and Drug Administration Food Code included the following: . 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 [degrees] C [Centigrade/Celsius] (41 F) or less. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified . shall be discarded if it: (1) Exceeds the . time . specified . or (3) Is inappropriately marked with a date or day . 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: . (2) For all other machines, 82 C (180 F). 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. [Annex 3, pages 172-173] 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature. The initial kitchen observation was conducted with the Dietary Manager (DM) on 01/02/2024. On 01/02/2024 at 3:58 PM, two oven door handles on the stove had a greasy residue upon touch. On 01/02/2024 at 4:03 PM, the meat preparation sink's drain pipe was observed to extend into a floor drain. On 01/02/2024 at 4:05 PM, the dish machine's drain pipe was observed to extend into a floor drain. Also, the drain pipe from the three-compartment sink extended into a floor drain. On 01/02/2024 at 4:13 PM, the vegetable preparation sink was observed to have a p-trap drain that was plumbed into the wall with no air gap. On 01/02/2024 at 4:16 PM the standing mixer was observed to have small remnants of pink and yellow batter on the upper, inner housing of the standing mixer. On 01/02/2024 at 4:22 PM, a half-full gallon container of whole milk, dated 12/22/2023 by the manufacturer, was observed inside the reach-in refrigerator. On 01/03/2024 at 4:46 PM, the Director of Maintenance (DOM) was interviewed in the kitchen area during drain observations with DM in attendance. The DOM said the drain under the three-compartment sink must be re-plumbed. The DOM said the vegetable preparation sink's drain did not have a back-flow device. The DOM said the dish machine's drain pipe and the meat preparation sink's drain pipe could be corrected. The DOM further said the problem with a drain extending into a floor drain was the potential for back-up and cross-contamination. On 01/03/2024 at 5:43 PM, the [NAME] Wing nourishment refrigerator was observed. The temperature record or log posted on the front of the refrigerator for January 2024 was a pharmacy refrigerator log, which included: . (Temp range = 36-46 degrees) . On 01/04/2024 at 9:25 AM, East Wing nourishment refrigerator was observed. The temperature record posted on the front of the refrigerator for January 2024 was a pharmacy refrigerator log, which included: . (Temp range = 36-46 degrees) . In addition, the January 2024 temperature record had the following temperatures recorded: 44 F for January 3 and 46 F for January 4. Inside the refrigerator were: six pre-packaged individual portions of gelatin desserts, two pre-packaged individual portions of cranberry juice, and two pre-packaged individual portions of honey-thick cranberry juice. On 01/04/2024 at 9:30 AM, the North Wing nourishment refrigerator was observed. The temperature record posted on the front of the refrigerator for January 2024 was a pharmacy refrigerator log, which included: . (Temp range = 36-46 degrees) . On 01/04/2024 at 10:00 AM a direct observation of the dishwashing process began. A plate surface temperature monitoring device (Plate Simulator Thermometer Puck) was placed in the dish machine by the Dietary Aide (DA). The DA said she used it to check and then record the plate surface temperature before beginning dishwashing each morning. She said it took a few runs of the machine for the Plate Simulator Thermometer Puck to reach temperature. The DA said she had already completed the check earlier and it had reached the minimum 160 F that was required. The recorded temperature of the Plate Simulator Thermometer Puck was 162 F. At 10:05 AM, the Plate Simulator Thermometer Puck had been run through the Dish Machine three times. The Plate Simulator Thermometer Puck's temperature had reached 149.7 F and the Dish Machine's final rinse temperature had reached 204 F. At 10:09 AM the DOM arrived and began to assess the dish machine problem with the DM in attendance. The DOM said he thought the higher the temperature, the better. At 11:00 AM, the DM provided copies of dishwashing temperature records. The Daily Kitchen Monitors had the dish machine's wash temperatures recorded, but not the final rinse temperatures. The Plate Simulator Thermometer Puck only recorded the simulated plate surface sanitizing temperatures. Per the DM, records were not kept of the dish machine's final rinses' temperatures. On 01/04/2024 at 3:20 PM, the DM was interviewed. The DM said the problem with the drain pipes from the dishwashing machine, the meat preparation sink, and the three-compartment sink extending into the floor drains was that, if there was a backflow, it could come up the drain and cause cross-contamination. The DM further said backflow could occur inside the drain of the vegetable preparation sink and then back-up into the sink, since it did not have a backflow prevention device. The DM said the oven door handles having sticky, oily residue meant they were not clean and cross-contamination could be a problem. The DM also said the standing mixer was not properly cleaned and cross-contamination could be a problem. The DM said the out of date gallon of whole milk found in the reach-in refrigerator could have been spoiled and it should have been discarded on the 22nd of December. The DM said the temperature log being used for the nourishment refrigerators was based on recommended temperatures for medicines; not recommended food refrigeration temperatures, which would have a range of 32 F to 41 F. The DM said the dish machine final rinse was too hot and reached 202 F which was too hot for dishwashing. The DM further said the final rinse should be 180 F to 194 F, because water turned to steam when hotter than 194 F. The DM additionally said if the plate simulator did not reach 160 F something was wrong with the final rinse temperature. The DM said the Plate Simulator Thermometer Puck was used to ensure the dish machine was sanitizing the dishes properly. The DM said it was important to sanitize the dishes to prevent cross-contamination and illness. On 01/04/2024 at 3:51 PM, the Registered Dietitian (RD) was interviewed via phone. The RD said food preparation sinks had to have an air gap. The RD also said there was the potential for back-up into the vegetable preparation sink since it did not have a backflow prevention device. The RD said oily residue on the oven door handles could cause one's hand to slip and potentially lead to an accident. The RD said the visible remainders of white and pink batter on the standing mixer could fall into something being mixed and then there would be something in the mixture that should not be in there. The RD said the gallon of whole milk, dated 12/22/2023, potentially could have been used and they should not use out-of-date milk. When asked the problem with a pharmacy refrigerator log being used for the nourishment refrigerator's temperature log, so that temperatures of 44 F and 46 F were recorded without concern; the RD said 44 F and 46 F were not within the acceptable temperature range.

Based on interviews, residents' medical records, and the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manuals, the facility failed to ensure Section J of RI #43's discharge MDS assessment with an ARD of 09/28/2023 was accurately coded to reflect a fall during the assessment period and Section N of Resident Identifier (RI) #19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/2023 was accurately coded to reflect the medications received during the assessment period. This had the potential to affect two of 17 sampled residents whose MDS assessments were reviewed. Findings include: 1.) The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 October 2019 Section J documented Section J1800: Any Falls Since Admission or Reentry or Prior Assessments . Coding Instructions . Code 1, yes if the resident has fallen since the last assessment . RI #43 was admitted to the facility on [DATE] and readmitted on [DATE] and a diagnosis of History of Falling with onset date of 09/06/2022. A facility Incident Report dated 08/21/2023 documented that RI #43 was found on his/her right side on the floor in front of his/her door. A review of RI #43's MDS assessment dates revealed RI #43 had an Annual MDS with an ARD date of 07/13/2023 and the next assessment was the Discharge MDS with ARD of 09/28/2023. Section J of RI #43's Discharge MDS with an ARD of 09/28/2023 indicated RI #43 had not fallen since the last assessment under section J1800. On 01/03/2024 at 4:30 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON reported that RI #43 had a fall on 08/21/2023. On 01/03/2024 at 5:38 PM an interview was conducted with the Registered Nurse (RN) #7, the acting MDS Coordinator. RN #7 said RI #43's fall was not coded accurately because it was an oversight. On 01/03/2024 at 5:50 PM an interview was conducted with the Corporate Nurse (CN), RN. The CN stated RI #43's fall should be coded in section J1800 on the MDS assessment. She said it should have been coded on the 09/28/2023 MDS assessment, but it was not. In a follow-up interview on 01/04/2023 at 9:11 AM with the CN. The CN stated the MDS Coordinator was responsible for coding falls on MDS assessments. The CN stated the negative outcome of not coding RI #43's fall on the MDS assessment could be an inaccuracy of the care plan. 2.) The Centers for Medicare &Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023 Section N documented: . N0415: High-Risk Drug Classes: Use and Indication .E. Anticoagulant ( . warfarin, heparin, or low-molecular weight heparin) . Do not code antiplatelet medications such as aspirin . or clopidogrel as N0415E, Anticoagulant. N0415I1Check if an antiplatelet medication (e.g., aspirin . clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N015I2 Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) . RI #19 was admitted to the facility on [DATE]. Section N of RI #19's quarterly MDS assessment with an ARD of 11/23/2023 documented the use of anticoagulant medication and did not document the use of antiplatelet medication. On 01/04/2024 at 4:00 PM a review of RI #19's November 2023 physician orders revealed an order for aspirin and clopidogrel but no order was found for anticoagulants that would need to be coded on the MDS assessment. A search of RI #19's orders revealed an active order for clopidogrel 75 milligram (mg) with start date of 08/01/2023 and aspirin 81 mg, also with a start date of 08/01/2023. On 01/04/2024 at 4:17 PM, an interview was conducted with the RN #7. RN #7 said RI #19's quarterly MDS, with an ARD of 11/23/2023, had been inaccurately coded for the use of anticoagulant medication. RN #7 said RI #19 had not received anticoagulant medication but was prescribed aspirin and clopidogrel which were classified as antiplatelet medication. RN #7 said that the MDS should be coded to reflect the use of antiplatelet medication to ensure the resident received appropriate care. 49218

Based on observations, interviews, residents' medical records, the facility policy titled Handwashing/Hygiene, and the Center for Disease Control (CDC) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings the facility failed to ensure Licensed Practical Nurse (LPN) #9, did not create the potential for cross-contamination when she picked up a straw from the floor, placed the straw on the medication cart, and then without performing hand hygiene administered medications to Resident Identifier (RI) #314. Further, after another staff member discarded the dirty straw and before the medication cart was cleaned or disinfected, LPN #9 dropped a tablet on the surface of the medication cart where the straw from the floor had been placed while preparing medications for RI #46 and placed the medication in medication cup along with other medications and took the medication to RI #46. This deficient practice had the potential to affect two of 58 residents residing in the facility. Findings include: The facility policy titled, Handwashing/Hygiene, with an effective date of 10/01/2022 documented: Policy Statement Handwashing is the most effective means of preventing and controlling the spread of infection . Policy Interpretation and Implementation . When to use Alcohol Based Hand Rubs (ABHR) . 6. Before handling medication . The CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings with a revised date of 11/29/2022 documented . Core Practice Category . Standard Precautions . Core Practices . Use Standard Precautions to care for all patients in all settings. Standard Precautions include: . 5c . Medication Safety . 2. Use aseptic technique when preparing and administering medications . RI #314 was admitted to the facility 12/15/2023 and had a diagnosis of Dementia. RI #46 was admitted to the facility on [DATE] and had a diagnosis of Dementia. On 01/04/2024 at 09:25 AM, LPN #9 was observed with a water cup, straw, and pill cup in her left hand. LPN #9 dropped the straw on the floor, picked up the straw with her right hand, placed the straw on the medication cart, and retrieved another straw from the cart. LPN #9 continued without washing or sanitizing her hands and took the medications, the cup of water, and the straw into RI #314's room. LPN #9 placed the medication cup, water cup, and the straw on the resident's bedside table. LPN #9 picked up the straw with her right hand and opened the straw without washing her hands and put the straw in the water cup and then administered the medications to RI #314. LPN #9 performed hand hygiene and exited the room. On 01/04/2024 at 09:27 AM LPN #9 remained in RI #314's room and LPN #8 was observed as she took the straw from the medication cart and threw the straw in the trash. LPN #8 did not clean or disinfect the medication cart after throwing away the straw. On 01/04/2024 at 09:33 LPN #9 began dispensing pills from medication cards and dropped one pill on the medication cart where the dirty straw had been placed. LPN #9 picked the pill up and put it in the medication cup. LPN #9 finished dispensing the medications and entered RI #46's room to administer the medications. On 01/04/2024 at 09:39 AM, an interview was conducted with LPN #9. LPN #9 stated after she picked up the straw off the floor she did not wash or sanitize her hands before administering medications to RI #314 because she did not think to wash her hands after picking up the straw off the floor. LPN #9 said that there was a risk of contamination when she did not wash her hands after picking up the straw off the floor and before administering medication to RI #314. LPN #9 stated that she did not wash or sanitize the medication cart before pulling the medications for RI #46. LPN #9 stated she did not think to wash or sanitize the cart after the dirty straw was on the medication cart. LPN #9 stated there was a risk of contamination when the medication cart was not sanitized after the straw had been placed on the cart. LPN #9 said that the medication cart should have been cleaned with a sanitizing wipe. On 01/04/2024 at 09:47 AM, an interview was conducted with LPN #8. LPN #8 stated she saw LPN #9 pick up the straw off the floor and put it on the medication cart and did not see LPN #9 perform hand hygiene after picking the up from the floor. LPN #8 said that she put the straw in the trash and no one cleaned the medication cart after the straw had been on the cart. LPN #8 stated there was a risk of contamination from dirty to clean. LPN #8 stated the medication cart should have been sanitized before pulling medication and before passing any more medications. On 01/04/2024 at 10:38 AM, an interview was conducted with Registered Nurse #7, the Infection Control Nurse/Infection Preventionist (IP). The IP said if a staff member picked up a straw from the floor the staff member should throw the straw in trash and wash their hands. The IP stated that a straw from the floor should never be placed on the medication cart. The IP said the nurse should have discarded the straw, washed her hands, gotten a new straw, administered the medications, and then washed her hands. The IP said there was a risk of infection when the nurse picked the straw from the floor, put it on the medication cart, then got a new straw, put the straw in the resident's water cup, and administered medication to a resident without washing her hands. The IP said once the straw from the floor had been placed on the medication cart, the straw should have been discarded and the surface of medication cart should have been sanitized. The IP stated there was a risk of infection when the nurse picked up a straw from the floor, put the straw on the medication cart, pulled medications, popped a pill out of a medication card onto the medication cart, and then placed the pill in a medication cup without sanitizing the medication cart top.

Based on observation, interview, record review and a facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, the facility failed to ensure licensed staff did not remove a nebulizer medication for Resident Identifier (RI) #48 from the medication cart and place it in her uniform pocket. This was observed on 11/7/18 and affected one of five nurses observed for medication pass. Findings Include: A review of a facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated (MONTH) (YEAR) revealed, Purpose The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway.Steps .1. Assemble equipment and supplies on the resident's overbed table. RI #48 was admitted to the facility on [DATE]. RI #48's [DIAGNOSES REDACTED]. A review of RI #48's Physician order [REDACTED]. ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] 0. 5MG (milligram)/ 3 ML (milliliter) . Solution Dose: 1 ml inhalation four times per day . On 11/07/18 at 8:30 AM Employee Identifier (EI ) #2, Licensed Practical Nurse, was observed giving RI #48 the AM medication. EI #2 prepared the medications and removed the vial of [MEDICATION NAME]-(Iprat) [MEDICATION NAME] from the box in the medication cart and placed it in her uniform pocket. EI #2 went in RI #48's room and gave the by mouth medications. EI #2 then removed the mask and container for the nebulizer medication from the plastic bag, then removed the [MEDICATION NAME] vial from her pocket and poured the medication in the nebulizer container. EI #2 administered the medication treatment to RI #48. On 11/7/18 at 9:05 AM, an interview was conducted with EI #2. EI #2 was asked what was the policy on where to place medication once it was removed from the medication cart. EI #2 replied, it should be placed on a barrier on the overbed table. EI #2 was asked where did she put the [MEDICATION NAME] vial when she removed it from the medication cart. EI #2 replied, in her pocket. EI #2 was asked if the uniform pocket was clean or dirty. EI #2 replied, dirty. EI #2 was asked what would the risk be of placing the [MEDICATION NAME] vial in her pocket before giving the medication. EI #2 replied, infection control issue, something from her pocket could get on the vial. On 11/08/18 at 8:52 AM an interview was conducted with EI #1, Registered Nurse, Infection Control. EI #1 was asked what was the policy on where the nurse should place Iprat medication when removing it from the medication cart. EI #1 replied, either place it in the nebulizer cup or place the vial on a barrier on the overbed table. EI #1 was asked when should a nurse put an Iprat vial she removed from the medication cart in her pocket. EI #1 replied, never. EI #1 was asked would the uniform pocket be clean or dirty. EI #1 replied, dirty. EI #1 was asked what would the risk be of a nurse removing an Iprat vial from the medication cart and placing it in her pocket before giving the medication to a resident. EI #1 replied, if the nurse had any germs in her pocket, which most likely would, it could be transferred to the resident.

Based on observation, record review, and interview, the facility: 1) failed to prevent potential cross-contamination by the scoop being stored on top of the thickener, sectional plates not allowed to air dry, and spoons wet nested; and 2) failed to ensure the high temperature dish machine did not exceeded the 194 degrees Fahrenheit (F), as directed in the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) . These failures had the potential to affect all 62 of 62 residents receiving meals from the dietary department. Findings include: 1) A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . On 12/05/17 at 9:35 AM a scoop was observed stored inside of a can of thickener. One of three sectional plates were observed wet with water droplets. Flat ware was observed, and three of six spoons had water in the spoon bowls and were wet nested. Employee Identifier (EI) #6, the Dietary Manager was interviewed on 12/7/17 at 3:00 PM. When asked about the scoop stored inside the can of thickener, EI #6 said the scoop was a concern for cross contamination. EI #6 agreed one of three sectional plates was observed with water droplets. She said the water droplets were a concern because the water was a conductor for infection, and per policy, the plates should be stored correctly. EI #6 said the spoons were also wet and nested together, and not allowed to air dry. EI #6 explained wet nesting created the potential for bacteria growth. 2) A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than . (194 degrees F) . On 12/05/17 at 9:35 AM the dish machine rinse temperature was observed to read 195 degrees F. A record review of the facility DISH MACHINE TEMPERATURE LOG for December 2017, revealed that for 10 of 12 opportunities, the documented rinse temperature exceeded 194 degrees F. The November 2017 log revealed dietary staff failed to monitor/document the final rinse temperature for 2 meals (Breakfast and Lunch) on 11/30/2017. For 90 opportunities, 54 exceeded 194 degrees F. The Dietary Manager, EI #6 was interviewed on 12/07/2017 at 3:00 PM. EI #6 validated the documented temperature monitoring logs for the dish machine exceeded the standard of 194 degrees F.

Based on record review, interviews with staff, and review of the facility policy titled Charting and Documentation, the facility failed to ensure Resident #41's medical record accurately reflected his/her frequency of behaviors. This affected one of 16 sampled residents for whom medical records were reviewed. Findings include: Review of the facility's undated policy titled CHARTING AND D(NAME)UMENTATION revealed the following: DEFINITION OF RECORD The patient's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the patient's condition . Resident # 41 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident # 41's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 10/19/2017, documented Resident # 41 had severely impaired cognition. Resident # 41's comprehensive care plans revealed a history of behaviors including exit seeking, easily upset and agitated, resisting care, and yelling and screaming. However, review of Resident # 41 's BEHAVIOR AND MOOD RECORD(s) from 07/01/2017-12/06/2017 revealed only one day where staff documented Resident # 41 exhibited behaviors. Employee Identifier (EI) #2, Social Worker, was interviewed on 12/06/17 at 4:55 PM regarding Resident # 41's behaviors. After running a behavior report, EI #2 stated it was showing Resident # 41 did not have any behaviors. EI #2 stated she thought the behavior report did not show any behaviors because Certified Nursing Assistants (CNAs) were not documenting them. EI #2 said the importance of CNAs documenting a resident's behaviors was if they do not document the behaviors, it makes it look as if it is not happening. EI #2 explained if the CNAs documented behaviors, she would then review and discuss the behaviors in the morning meeting to address the problem. She further stated another reason it was important for behaviors to be documented was if a resident had a medication dose reduction and started acting out again, facility staff would need the documentation to support medication changes. EI #2 said the documentation should reflect how the resident is at any given time. EI #2 said the CNAs would be able to confirm Resident # 41 exhibited behaviors on a frequent basis, but it was not documented. EI #3, a CNA who routinely cared for Resident # 41, was interviewed on 12/07/17 at 9:10 AM. EI #3 stated Resident # 41 had routine dementia type behaviors, such as getting confused and asking for help a lot, but nothing she would report. EI #4, another CNA that cared for Resident # 41, was interviewed on 12/07/17 at 9:17 AM . EI #4 stated Resident # 41 usually wandered around and asked for family or his/her car, and last month he/she thought he/she was pregnant about every other day. When asked how often Resident # 41 exhibited behaviors, EI #4 said maybe one out of four days that she worked per week. EI #4 said behaviors should be documented in the computer as they occur because staff should keep track of behaviors so they can be addressed. EI #5, Registered Nurse Supervisor, was interviewed on 12/06/17 at 5:44 PM regarding Resident # 41. When asked what types of behaviors Resident # 41 exhibited, EI #5 stated when the resident gets agitated, he/she will start hollering and want to go off the hall. EI #5 explained Resident # 41 used a lot of profanity and refused medications, threw items, etc. When asked how frequently Resident # 41's behaviors occurred, EI #5 said Resident # 41 had behaviors multiple times per day. EI #5 stated the CNAs and nurses can both document behaviors. When asked why it was important to ensure behaviors were documented, EI #5 said it was needed to make sure there was no safety concern and to ensure medication is dosed appropriately. EI #1, the Director of Nursing, was interviewed on 12/07/17 at 9:53 AM. After reviewing behavior documentation for Resident # 41, EI #1 stated the behaviors were not specified but the documentation did reflect Resident # 41 was short-tempered, irritable, restless, anxious, and tired at times. EI #1 said on 12/1/17 it was documented Resident # 41 was yelling out and wanting to put the fire out next door. EI #1 said that was the only documentation she saw that specified a behavior. When asked what the expectation was regarding documenting behaviors, EI #1 said staff should document the agitation or specific behaviors if they occur. EI #1 stated Resident # 41's documentation of behaviors was not an accurate reflection of his/her behaviors because they were not being documented. EI #1 said it was important to document behaviors in the record so anyone reviewing it would know the resident. Lillian Bowden, Registered Nurse Marie Carastro, Dietitian Melissa Eller, Laboratorian Fred Hillard, Registered Nurse Donna Milstead, Registered Nurse Angela Parker, Social Worker Jill Rush, Registered Nurse

Based on observation, interview, and review of the facility's nurse staffing information from 6/2016 through 12/2017, the facility failed to ensure the nurse staffing information included the actual number of nursing staff present each shift. This affected 18 of 18 months reviewed, was observed on three of four days of survey, and had the potential to affect all 63 residents residing in the facility. Findings include: On 12/05/17 at 2:39 PM nurse staffing information was observed posted on the wall across from the nurse work station. It did not contain the actual number of nursing staff present, only actual hours worked. On 12/06/2017 at 2:30 PM nurse staffing information was observed posted on the wall across from the work station. The posting did not contain the actual number of nursing staff present, only the actual hours worked. On 12/7/17 at 9:26 AM the nurse staffing information was observed posted on the wall across from the work station. The posting did not list the actual number of nursing staff present, only the actual hours worked. On 12/05/17 at 2:48 PM the previous 18 months (06/2016 through current) of nurse staffing information was reviewed. None of the forms included the actual number of nursing staff present for each shift. On 12/07/17 at 10:11 AM , Employee Identifier (EI) #1, the Director of Nursing (DON), was interviewed regarding the nurse staffing information posted on the hall. EI #1 explained the Registered Nurse Supervisor and Charge Nurse were responsible for filling the form out each shift. When asked what information should be included on the posting, EI #1 reviewed the form and said the form had everything she thought it was supposed to have, including the census and staff ratio per shift. After reviewing the regulation related to the required components of the nurse staffing information, EI #1 said, according to the regulation, all of the components were not included. EI #1 said they were not listing the actual number of nursing staff present, only the actual hours worked.

Based on observation, interview and review of a facility policy titled, 5.3 Storage and Expiration of Medications, the facility failed to ensure the Medication Disposition Form for Alprazolam (Xanax), 29 ,[DATE] tablets, dated [DATE], included: 1. The strength of the medication 2. The date of destruction 3. The appropriate number of signatures of witnesses. In addition, the policy titled, 5.3 Storage and Expiration of Medications .revealed the facility failed to ensure stored Schedule II (2) -V (4) controlled substance, that included Ativan 2 MG (milligrams) (two vials) were stored in a locked compartment permanently affixed inside the refrigerator. This was found in one of one refrigerator that was observed to contain controlled drugs. Finding Included: A facility policy titled 8.2 Disposal/Destruction of Expired or Discontinued Medications, with an Revision Date [DATE],documented: PROCEDURE: 1. Facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environment regulations . 6. Facility should enter the following information on the drug destruction form when medication are destroyed: . 6.2 . strength of the medication . 6.5 Date of destruction; 6.6 Signature of witnesses; . (In (name of State), discontinued medications left in a facility after discharge will be disposed by the Facility within 90 days of the date the medication was discontinued by the prescriber.) . 10. Facility should record destruction of controlled substances on: 10.1 Medication Disposition/Destruction Form; 10.2 Controlled Substance Count Form; or, 10.3 Medication Destruction Log Book. (In (name of State), Periodically, the Director of Nursing follows the procedure listed by the Bureau of Controlled Substances and inventories on the Controlled Substances Surrender Form the discontinued and outdated medications . these controlled medications may then be destroyed in a manner meeting the approval of the Bureau in the presence of a registered pharmacist or two nurses.) (In (name of State), Schedule II, III, IV and V, controlled substances that have been dispensed and not used by the patient shall not be returned to the Pharmacy and shall be securely stored by the nursing home until destroyed. A document must be completed showing the name and quantity of the drug, strength and dosage form . This documentation, at the time of destruction, shall be witnessed and signed by the Consultant Pharmacist, Director of Nursing, and the nursing home Administrator or his/her designee excluding the above.) . The second policy titled 5.3 Storage and Expiration of Medications . with a revised date of [DATE], included: . 12. Controlled Substance Storage: . 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., (that is) a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). On [DATE] at 5:45 p.m., the surveyor reviewed the facility's Controlled Destruction forms, that included a form titled Medication Disposition Form dated [DATE], for Alprazolam (Xanax), 29 ,[DATE]'s tablets. However, the facility failed to obtain three signatures on this form, which the medication method of destruction was to incinerate. The form titled RECORD OF MEDICATION DISPOSAL (no date) included controlled drugs failed to have a date of destruction for the following medications: [REDACTED] Hydrocodone-Acetaminophen ,[DATE] MG quantity of 20 Alprazolam (Xanax) 0.25 MG quantity of 30 Lorazepam 1 MG quantity of 15 Oxycodone-Acetaminophen ,[DATE] MG quantity of 13 Hydrocodone-Acetaminophen ,[DATE] MG quantity of 17 Hydrocodone-Acetaminophen ,[DATE] MG quantity of 3 On [DATE] at 10:55 a.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Director Of Nursing (DON). The surveyor asked EI #2 who was responsible to ensure the Record of Medication Disposal for controlled medications was dated for the above listed medications. EI #2 called the Pharmacist's name and the Assistant DON's name. EI #2 said she was a witness. The surveyor asked EI #2 what was the month and year the medications were destroyed by the facility's method of incineration. EI #2 stated, It would be hard to tell, because there is no date. The surveyor asked EI #2 should the form have had a date and year when the medications were destroyed. EI #2 stated Yes. On [DATE] at 10:08 a.m., the surveyor and the Director Of Nursing (DON), EI #2 observed the medication in the East Hall drug room. EI #2 opened the refrigerator, the surveyor observed Ativan 2 MG vial, (two vials) in the door/shelf of the refrigerator and not stored in a locked compartment, that was permanently affixed to the inside of the refrigerator. On [DATE] at 10:55 a.m., the surveyor conducted an interview with EI #2, the DON. The surveyor asked EI #2 how many signatures are required on the Medication Disposal form for controlled medications. EI #2 stated Three. The surveyor asked EI #2 how should medications be stored in the refrigerator. EI #2 stated, I had been informed today ([DATE]) it (the Ativan) should be in a separate lock box in the refrigerator.

Based on observation, interviews and review of a facility policy titled Administering Oral Medications, the facility failed to ensure a Licensed Nurse, Employee Identifier (EI) #8, did not touch Resident Identifier (RI) #12's medications with bare hands while administering the morning medications on 11/18/16. This affected RI #12, one of 10 residents observed during the Medication Administration Observations. The facility further failed to ensure EI #3 did not touch RI #3's food with her bare hand. The facility further failed to ensure a CNA (Certified Nursing Assistant), EI #10 removed her contaminated gloves before going from a soiled area of the resident's body to a clean area RI #10's body. This affected RI #2, one of (5) five residents sampled for incontinent care. Findings Include: The facility's policy titled Administering Oral Medications dated December 24, 2014, documented: Policy Statement The purpose of this procedure is to provide guidelines for the safe administration of oral medications . Steps in Procedure . 9 . e. Do not touch the medicine with your hands . A facility policy titled INCONTINENT CARE/PERICARE UPDATED 10/09 ., documented the following: . PROCEDURE: . 4. WASH HANDS AND DON GLOVES . 6. REMOVE SOILED BRIEF AND REMOVE ANY FECAL MATERIAL WITH TISSUE WIPING FROM FRONT TO BACK. FEMALE (VAGINAL AREA TO RECTUM) . 7. WASH HANDS BEFORE RE-GLOVING IF BM WAS REMOVED. 8. CHANGE GLOVES AND PLACE IN PLASTIC BAG WITH SOILED BRIEF . 1. On 11/18/16 at 8:35 a.m., during the morning Medication Administration Observation, the surveyor observed Employee Identifier (EI) #8, a Licensed Practical Nurse (LPN), handled RI #12's medication with her bare hands. EI #8 held the medication, Amantodine 100 milligrams (MG) with her bare hands, and used a pair of scissors to cut the tip of the capsule and squeezed the medication in a clear plastic calibrated 30 cc (cubic centimeters) medication cup and administered to RI #12 to take orally. On 11/17/16 at 3:20 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 how did she open the prescribed drug during the medication pass on 11/17/16. EI #8 said she attempted to cut the perforated lines with the scissors and that did not work. EI #8 said she cut it at an angle to open it. The surveyor asked EI #8 should she use an ink pen point to puncture he package. EI #8 said no sir, she should not have done that. The surveyor asked EI #8 why. EI #8 said because the tip of the pen is not sterile. The surveyor asked EI #8 should she touch the medication with her bare hands. EI #8 said no sir. The surveyor asked EI #8 when she opened the capsule, how did she extract the medication in it's liquid form. EI #8 said she cut the tip and squeezed it out. The surveyor asked EI #8 if she wore gloves. EI #8 said no sir and she should have. The surveyor asked EI #8 why she should not have touched the medication with her bare hands. EI #8 said it's cross contamination. On 11/18/16 at 10:55 a.m., the surveyor conducted an interview with EI #2, the Director Of Nursing (DON). The surveyor asked EI #2 when administering medications should the staff /the nurse touch the medication with their bare hands. EI #2 stated No. 2. RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) assessment dated [DATE], assessed RI #2 as Always Incontinent of Bowel and Urinary and required extensive assistance of one staff member. On 11/17/2016 at 9:15 a.m., the surveyor observed RI #2 sitting in a wheelchair in the room. RI #2 was being tracked (constantly monitored) by the surveyor during this time. At 10:52 a.m. the CNA entered the room to change RI #2. On 11/17/16 at 10:57 a.m., the surveyor observed EI #9, the assigned CNA, and another CNA transferred RI #2 from the wheelchair to the bed with a Hoyer lift. At 11:05 a.m., EI #9 provided incontinent care on RI #2. EI #9 washed her hands and applied gloves to remove an adult brief. The brief was soiled with urine, a moderate amount. EI #9 discarded this pair of gloves and washed her hands, then applied a new pair of gloves. EI #9 cleaned RI #2's perineal area and the resident's vaginal area while wearing gloves. EI #9 used those same contaminated gloves to pat dry RI #2's peri area with a large bath towel. RI #2 was repositioned on the right side and EI #9 wiped the resident front back to front (Rectum toward the vaginal) area while wearing the same contaminated gloves. Then EI #9 used a large bath towel to pat dry RI #2's buttocks while wearing the same pair of contaminated gloves during this incontinent care procedure. 2). The 2013 U.S. Public Health Service Food Code, Protection from Contamination after Receiving 3-301.11 Preventing Contamination from Hands. . (B) . Employees may not contact exposed, READY-TO-EAT FOOD with their bare hands . (C) . Employees shall minimize bare hand and arm contact with exposed food . RI #3 was admitted to the facility on [DATE] with a Fracture of unspecified part of neck of Left Femur, subsequent encounter for closed fracture, [DIAGNOSES REDACTED]and Heart Failure. A five day Admission Minimum (MDS) data set [DATE] identified RI #3 with a Cognition skills score of 12 out of 15 which means the resident was cognitively intact. The assessment documented that RI #3 could feed his/herself with only set up help. During an Resident Interview with RI #3,on 11/17/16 at 5:25 p.m., a Certified Nursing Assistant (CNA) brought in the resident's supper tray, and sat it on a table in front of her. The meal consisted of a hamburger and french fries. RI # 3 requested some ketchup on the hamburger and french fries. The CNA, Employee Identifier (EI) # 3 opened a ketchup packet, then picked up the hamburger bread top bun with the other hand, and placed the ketchup on the hamburger meat. Then RI # 3 requested that the hamburger be cut in half. EI # 3 placed one hand over the top of the hamburger and using a knife she cut the hamburger in half. In an interview with EI # 3 on 11/17/16 at 5:38 p.m., the surveyor asked what is the proper procedure for cutting resident's food. EI # 3 said, I thought it was the way I done it. Surveyor asked, is that what you were taught. EI #3 said Yes The surveyor inquired, were you taught it was ok to touch residents' food with your bare hands. EI # 3 said, Yes, never seen any different. EI # 3 was asked, if she ever wore gloves when handling food at the nursing home. EI # 3 said, no ma'am. EI # 3 was asked if she thought it was sanitary to touch resident food. EI #3 said no ma'am. EI # 3 was asked, why is it important not to touch residents food. EI # 3 said, so, not to transfer any germs. Then EI # 3 said, she had made a bad call.

Based on interview and record review the facility failed to report two allegations of abuse within 24 hours of the occurrence. This affected two of six allegations reviewed. Findings Include: The facility policy titled .Abuse Policy and Procedure, Policy for Reporting Abuse (updated 3/7/11) documented: .10. REPORTING: Any alleged violation involving . abuse . must be reported to the Supervisor, Assistant Administrator and Administrator. A. The RN/Department Head will promptly start the investigation and notify the . and Administrator. .C. The Administrator/designee will report the occurrence within 24 hours. During a review of abuse allegations of the Online Incident Reporting System Report the following was identified: 1) A resident on resident altercation that occurred on 08/20/16 was not reported to the Online Incident Reporting System Report until 08/22/16. On 11/18/16 at 9:15 a.m., Employee Identifier (EI) #5, Certified Nursing Assistant (CNA) was asked if she was a witness to the incident on 08/20/16 between two residents. EI #5 replied yes. EI #5 was asked what did she do. EI #5 replied she reported it to the Registered Nurse (RN) Supervisor. On 11/18/16 at 10:35 A.M., EI #6, RN Supervisor, was asked if he was the nurse working on the day of the incident between the two residents. EI #6 replied yes. EI #6 was asked what day was that incident and when did he report it to the Administrator. EI #6 replied Saturday and he made a missed call of the perception of the incident. EI #6 was asked if he did not report the incident within the 24 hours did he follow the policy. EI #6 replied he did not follow the policy. 2) An alleged incident of physical abuse that occurred on 10/24/16 was not reported to the Online Incident Reporting System Report until 10/26/16. On 11/18/16 at 10:25 a.m., EI #7, Speech Therapist, was asked did she recall the incident in October 2016 with Resident Identifier (RI) #10. EI #7 replied yes. EI #7 was asked who did she report it to. EI #7 replied the Rehab Director (who was no longer employed at the facility). EI #7 further explained that the Director she had prior to the one that no longer worked there, told her to report an allegation of abuse to her first. EI #7 stated she reported the incident to the Rehab Director on Monday. On 11/18/16 at 4:55 p.m. EI #1, Administrator and Abuse Coordinator, was asked when are abuse allegations to be reported. EI #1 replied within 24 hours. EI #1 was asked was she aware of the two incidents that were not reported within 24 hours. EI #1 replied she knew the therapist did not report it. EI #1 was asked about the resident on resident altercation. EI #1 commented the nurse told me he did not think it was abuse and was inserviced on what he should have done.

Based on observations, interview and record reviews the facility failed to ensure Resident Identifier (RI) #3 received a supplemental drink at the dinner meal on 11/17/16. This affected one of nine sampled residents observed for meals. Findings include: FUNDAMENTALS OF NURSING, 2013 Eighth Edition, Potter Perry, Chapter 23 documented: Health Care Providers' Orders. The health care provider physician or advanced practice nurse is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients. RI #3 was admitted to the facility on [DATE] with a Fracture of unspecified part of Neck of Left Femur, [MEDICAL CONDITION] Fibrillation and Heart Failure, and [MEDICAL CONDITION] Reflux Disease. A five day Admission Minimum (MDS) data set [DATE] identified RI #3 with A Brief Interview for Mental Status score of 12 out of 15 which indicated RI #3 was moderately impaired in cognition in daily decision making skills. The assessment also documented that RI #3 could feed his/herself with set up help only. On 8/24/2016 The Dietary Nutritional Assessment - admission note, identified RI #3 . weight (lbs) 131.6 .NUTRITION PRESCRIPTION: NAS INTAKE: 40-60% NUTRITIONAL SUPPLEMENTS: Ensure [MEDICATION NAME] with each meal SPECIFICATION OF NUTRITIONAL CONCERNS/GOAL/ ASSESSMENT: Resident is at risk for altered nutrition and hydration status evidenced by advanced age of 103, therapeutic diet with supplements and diuretic and post surgery . PLAN/RECOMMENDATIONS; Continue dietary regimen - Supplement in progress. NUTRITION PRESCRIPTION: NAS INTAKE: 40-60% NUTRITIONAL SUPPLEMENTS: Ensure [MEDICATION NAME] with each meal . RI #3's current Physician order [REDACTED]. 8/18/2016 MEAL SUPPLEMENT: (signed by MD Electronically). The surveyor observed four meals on RI # 3 on 11/16/2016 lunch and supper. RI #3 received the magic cup and Ensure [MEDICATION NAME] at both meals. On 11/17/16 at lunch, RI #3 received the Ensure [MEDICATION NAME] and drank 20%. During an interview with RI #3,on 11/17/16 at 5:35 p.m. Employee Identifier (EI) #3 brought in the RI #3's supper tray, and sat it on a table in front of her/him in front of the resident. The meal consisted of a hamburger, french fries, baked beans, lettuce and tomatoes. RI #3 also received a magic cup (ice cream) tea and juice. The surveyor observed the meal until 6:00 p.m. The resident did not receive the Ensure [MEDICATION NAME] as ordered. In an interview with EI #3 on 11/17/16 at 5:38 p.m., the surveyor asked, did you notice on RI #3's tray card that he/she was suppose to get a Ensure [MEDICATION NAME] drink. EI #3 said yes, but the CNA that usually takes care of RI #3 said the resident does not drink it and said the resident just takes milk, so I just took the milk. The surveyor asked if the tray card read Ensure [MEDICATION NAME], but another CNA stated the resident never drank it, what should you do. EI #3 replied, I guess talk to my supervisor. EI #3 was asked why is it important to follow the diet from the kitchen. EI # 3 said, maybe what the doctor says is necessary for resident. In an interview with the Certified Registered Dietitian, EI #4 on 11/18/16 at 9:50 a.m., revealed RI #3's current diet was Regular with no added salt with Ensure [MEDICATION NAME] with all three meals. When questioned about RI #3's supplements, EI #4 said, RI #3 came in on a supplement, we added Prostat and we changed the Ensure to clear Ensure [MEDICATION NAME] because she did not like the thicker Ensure.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner and in a manner to prevent foodborne illness by the following: 1.) A large mixer that was stored and not in use contained white, brown and yellow residue on the underside; 2.) The griddle grease tray contained an accumulation of dark yellow residue and black chunks of crusty particles; 3.) Cold food on the 9/30/14 lunch trayline was not maintained at 41 degrees or below; and 4.) A dietary staff member did not know how to accurately calibrate a thermometer. This had the potential to affect all 63 residents who receive meals from the kitchen. Findings Include: 1.) During the initial tour on 9/30/14 at 7:52 AM, the mixer was observed stored with white, brown and yellow residue on the underside of the mixer. A review of the 2013 Food and Drug Administration's Food Code revealed: "...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch..." During an interview on 9/30/14 at 2:28 PM, Employee Identifier (EI) #3, Dietary Manager was asked when was the large mixer cleaned. EI #3 said "After each use." EI #3 was asked if she taught staff to clean the underside where the attachments go. EI #3 said she did and they were supposed to clean all of it. The surveyor asked EI #3 what would be the potential harm if it was not cleaned. EI #3 replied, "It has the potential to grow bacteria or something undesirable." 2.) During initial tour on 09/30/14 at 7:52 AM, the griddle grease tray was observed to contain an accumulation of dark yellow residue and black chunks of crusty particles. The surveyor asked dietary staff had it been used today and they said it had not. A review of the 2013 Food and Drug Administration's Food Code revealed: "...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch (B) ...pans shall be kept free of encrusted grease deposits and other soil accumulations..." On 9/30/14 at 2:28 PM, EI #3 was asked what was the potential harm with residue and particles in the grease tray. EI #3 said it would be harder to clean and the quality of food would be affected. EI #3 was asked if she had a schedule of who cleaned what and when. EI #3 said most of the equipment was cleaned after each use. The surveyor ask if that meant staff cleaned at the end of their shift. EI #3 said they did and they deep clean once a week. EI #3 said each person had a designated area. 3) During the lunch trayline observation on 9/30/14 at 10:50 AM, the cook (EI #4) placed all the food items on the steam table, then began checking temperatures with a digital thermometer. The ham and cheese croissants were 44 degrees F (Fahrenheit) and the macaroni salad was 42 degrees F. EI #4 did not check the temperature of the deviled eggs on the trayline. EI #4 did not remove the two items when they were registering above the safe temperature of 41 degrees or below. EI #4 continued to check temperatures of the other food items then began to plate the sandwiches, macaroni salad and deviled eggs. These items were served to residents. During an interview with EI #3 at 11:50 AM, EI #3 was asked to check the temperature (temps) of the ham croissants, macaroni salad and deviled eggs. The ham croissants were 50 degrees F and the deviled eggs were 45 degrees F. EI #4 was standing near EI #3 and EI #4 (cook) was asked what the temperature of the cold food was supposed to be. EI #4 said, "No higher than Forty-two degrees." EI #4 was asked if she checked the temperature of the eggs. EI #4 said she did and they were 42 degrees, but she did not write it down on the sheet. EI #4 was asked why she did not do anything when she noticed the temps were about 41 degrees. EI #4 said it was because it went up as she brought the items from the cooler to the steamtable and the steamtable gets warm from the hot food items. A review of the Dietary In Service (dated 9-23-24, 2014) documented: ..."The SAFE Flow of Food... f. Holding... iii. Cold hold 41 degrees F or lower..." On 9/30/14 at 2:28 PM, EI #3 was asked what should the cold food (macaroni and ham croissants) be on trayline. EI #3 said "41 or colder." EI #3 was asked what should EI #4 have done when the food temps were 42 and 44 degrees. EI #3 said either calibrate the thermometer or get a different thermometer to see if it was an accurate reading. EI #3 was asked what was the potential harm if cold food was not kept at 41 degrees or below. EI #3 said it was getting in the danger zone and growing bacteria. 4) During lunch trayline observation on 9/30/14 at 10:50 AM, EI #4 was checking food temperatures with a digital thermometer. After completing the temperature checks, EI #4 was asked how she knew the thermometer was reading accurate temperatures. EI #4 said that was the thermometer they gave her to use and it should show room temperature (it registered 75 degrees). EI #4 did not know how to calibrate for accuracy. EI #4 was asked if she ever put the thermometer in ice water. EI #4 replied, "Yes." EI #4 obtained a container of ice water and placed the thermometer in it. EI #4 was asked what temperature it should read in the ice water. EI #4's first response was 23 degrees, then EI #4 said, "At least thirty-two." The thermometer registered 36 degrees. EI #4 was asked if that was ok. EI #4 replied, "Well, as long as it is at least thirty-two, it's accurate to the best of my ability." A review of the inservice documentation showed EI #4 was inserviced on 5/16/14 regarding the calibration of the thermometers. The procedure that was used for the training documented "...Ice-Point Method for Calibrating a Thermometer... 1. Fill a large container with crushed ice. Add tap water until the container is full... 2. Put the thermometer stem or probe into the ice water. Make sure the sensing area is under water. Wait 30 seconds, or until the indicator stem stops moving... 3. Adjust the thermometer so it reads 32 degrees F..." A review of the Dietary In Service (dated 9-23-24, 2014) including the facility policy revealed: "...The SAFE Flow of Food... f. Holding... iii. Cold hold 41 degrees F or lower..." A review of the facility's recipe for "Deviled Eggs" (not dated) documented "...Hold at 41 F or cooler ..." On 9/30/14 at 2:28 PM, the Dietary Manager (EI #3) was asked how she trained staff to make sure they know the digital thermometer is accurate. EI #3 said they have inservice's on calibration of thermometers.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #13, 14 and 15's discharge summary included a recapitulation (recap) of the resident's stay. This affected three of four discharged residents whose records were reviewed. Findings Include: 1.) A review of RI #14's "Record of Admission" revealed RI #14 was admitted to the facility on [DATE]. RI #14's "Discharge Summary" revealed a discharge date of [DATE]. There was a section titled "Synopsis of Resident Stay." However, the only thing typed in this section was: "Attach copy of the Resident's Plan of Care." There was nothing attached, and there was no recap of the resident's stay. 2.) A review of RI #15's "Record of Admission" revealed RI #15 was admitted on [DATE]. RI #15's "Discharge Summary" revealed a discharge date of [DATE]. There was a section titled, "Synopsis of Resident Stay." However, the only thing typed in this section was: "Attach copy of Resident's Plan of Care." There was nothing attached, and there was no recap of the resident's stay. A review of the facility policy titled, "DISCHARGE OF PATIENT" (not dated) revealed: "Objective: 1. TO PROVIDE SAFE DEPARURE FROM THE HEALTH CARE FACILITY... Procedure: ...13. COMPLETE D/C (discharge) SUMMARY LPN (Licensed Practical Nurse)/RN (Registered Nurse) ...15. WRITE DISCHARGE SUMMARY, INCLUDING ...ANY PERTINENT INFO LPN..." On 9/30/14 at 5:24 PM, Employee Identifier (EI ) #1 DON (Director of Nursing) was asked who was responsible for completing the discharge summary. EI #1 said, "The nurse that discharges the resident." EI #1 was asked if she was aware that the regulations specify that there's supposed to be a recap of the resident's stay as part of the discharge summary. EI #1 replied, "No." The surveyor asked EI #1 who would normally be responsible for the recap section. EI #1 said Social Services took care of the discharge planning and setting up home health, etc. EI #1 was asked if she knew why it was important to include the recap. EI #1 said "To give the entity picking up the resident's care the information they need to provide continuity of care." The surveyor asked EI #1 what would be the potential harm/problem with not having the recap if the resident's stay on the discharge summary. EI #1 replied, "I guess that the provider would possibly not be able to meet a need of the resident." On 10/1/14 at 10:15 AM, the surveyor talked with EI #2 (Administrator) regarding the discharge summary for the residents. EI #2 said she did not feel there was no more than minimal harm potentially to the residents because the discharge planning was very thorough and services were set up for the residents (such as home health, medications, etc). EI #2 further stated, "Yes, there was not a synopsis of a recap of their stay, but appropriate discharge planning was done." 3.) A review of RI #13's "Record of Admission" revealed the resident was admitted on [DATE]. RI #13's "Discharge Summary" revealed a discharge date of [DATE]. There was a section titled, "Synopsis of Resident Stay" on the Discharge Summary. However, there was nothing written or typed on it. This section was left blank. There was nothing attached, and there was no recap of the resident's stay. On 10/02/14 at 10:30 AM a surveyor asked the Administrator, EI #2 who was responsible for the Discharge Summaries. EI #2 said they were done by nursing, the medical director and social services. EI #2 said they just do necessary information on the discharge summary and have not been doing a recapitulation.

Based on observation, interview, and record review the facility failed to ensure a CNA (Certified Nursing Assistant) provided incontinent care to RI (Resident Identifier) #6, a resident with a history of UTI (Urinary Tract Infection), in a manner to prevent cross contamination. This affected one of three observations of incontinent care. Findings include: A review of the facility Policy and Procedure titled "INCONTINENT CARE/PERICARE" UPDATED 10/09 documented "OBJECTIVE: 1. TO PROVIDE PERSONAL HYGIENE TO INCONTINENT PATIENTS BY CLEANING THE PERINEUM (AREA BETWEEN THE THIGHS, GENITALS AND ANUS) 2. TO PROVIDE COMFORT FOR THE PATIENT BY REMOVING EXCRETIONS THAT CAN CAUSE IRRITATION, SKIN BREAK DOWN, INFECTION, AND ODOR....PROCEDURE:...6....WIPING FROM FRONT TO BACK. FEMALE (VAGINAL AREA TO RECTUM)...FEMALE...2. SEPARATE THE LABIA WITH ONE HAND AND WITH THE OTHER HAND WIPE DOWN ONE SIDE OF THE VAGINA (VAGINA TO RECTUM) 3. USING A SEPARATE SIDE OF THE CLOTH WIPE DOWN THE OTHER SIDE (VAGINA TO RECTUM) 4. USING ANOTHER CLEAN SIDE OF THE CLOTH WIPE DOWN THE CENTER OF THE VAGINA (VAGINA TO THE RECTUM)...6. RINSE AND PAT DRY VAGINAL AREA..." RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 09-02-2013 revealed RI #6 had both long and short term memory loss and was severely impaired in cognitive skills for daily decision making. The MDS further revealed RI #6 was always incontinent of Bowel and Bladder and required total assistance of one person for toilet use. On 11-06-2013 at 9:55 AM incontinent care for RI #6 was observed. EI (Employee Identifier) #1, CNA was observed to wet a washcloth at the sink and proceeded to clean bowel movement (BM) from RI #6's buttock using the same area of the washcloth for three consecutive wipes without changing the position of the washcloth. As EI #1 continued to clean RI #6's buttock with the BM soiled washcloth she went further forward into the perineal area with each wipe. RI #6's front perineal area was never cleaned during the incontinent care. On 11-06-2013 at 10:10 AM the surveyor observed EI #1 to complete the incontinent care and call for assistance to use the lift to place RI #6 into her gerichair. The surveyor asked EI #1 to open RI #6's brief to see if the perineal area was clean. EI #1 went to wet a washcloth at the sink and proceeded to clean RI #6's labia using the same area of the washcloth for three consecutive wipes without changing the position of the washcloth while wiping from back to front. EI #2, CNA stopped EI #1 during incontinent care. On 11-06-2013 at 3:45 PM an interview was conducted with EI #3, LPN (Licensed Practical Nurse)/Quality Assurance Coordinator. The surveyor asked EI #3 what could happen if CNA's provided improper incontinent care, for instance wiping back to front or using a soiled corner of a cloth. EI #3 replied "They could get a UTI". On 11-06-2013 at 3:55 PM an interview was conducted with EI #2 CNA. The surveyor asked EI #2 why she stopped EI #1 during incontinent care. EI #2 replied "Because she was doing it wrong". The surveyor asked EI #2 what could happen if RI #6 was not cleaned properly. EI #2 replied "She could get a bad UTI and could get a rash from being soiled too long". On 11-06-2013 at 4:00 PM an interview was conducted with EI #1, CNA. The surveyor asked EI #1 why she wiped RI #6's buttock three times with the same area of the cloth. EI #1 replied "I wasn't paying attention, I thought she was still having a BM". EI #1 was asked why she cleaned RI #6's labia with the same area of the cloth three times. EI #1 replied "My nerves, I don't know why I did it like that". EI #1 was asked why she cleaned RI #6's labia from back to front. EI #1 replied "I didn't catch it, I don't know why I would do that". EI #1 was asked if RI #6 was thoroughly cleaned and EI #1 stated no. EI #1 was asked what could happen if RI #6 was not cleaned thoroughly and EI #1 replied "She could get a urinary tract infection, redness, irritation to her skin".

Based on observation, record review and interviews, the facility failed to ensure a CNA (Certified Nursing Assistant) washed her hands after removing soiled gloves and before re-gloving and applying ointment to RI (Resident Identifier) #6's perineal area. This affected one out of three observations of hand washing during incontinent care. Findings include: Potter and Perry, "FUNDAMENTAL OF NURSING", Eighth Edition, copyright 2013, Chapter 28, Infection Prevention and Control, page 411, documents: "The CDC...recommends the following:...1....wash hands with water and either a nonantimicrobial or antimicobial soap...3a. Before, after, and between direct patient contact...b. After contact with body fluids or excretions,...c. When moving from a contaminated to a clean body site during patient care...g. After removing gloves...". A review of the facility policy and procedure titled "INCONTINENT CARE/PERICARE" UPDATED 10/09 revealed "PROCEDURE:...4. WASH HANDS AND DON GLOVES...". RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent Quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 09-02-2013 revealed RI #6 had both long and short term memory loss and severely impaired cognitive skills for daily decision making. The MDS further revealed RI #6 was always incontinent of bowel and bladder and required total assistance of one person for toilet use. On 11-05-2013 at 1:10 PM RI #6 was observed during incontinent care. EI (Employee Identifier) #4 cleaned BM (Bowel Movement) with toilet paper from front to back, with a clean piece of paper each time. EI #4 then discarded the gloves and soiled paper into the trash bag at the foot of the bed. EI #4 proceeded to wash RI #6 with soap and water and washcloths. Gloves were changed frequently after each wipe. Clean gloves were worn to rinse and pat dry. Clean gloves were worn to apply ointment to buttocks. EI #4 never washed her hands in between changing gloves or during any part of incontinent care. On 11-05-2013 at 2:15 PM EI #4, CNA was asked if she should have washed her hands after she cleaned the resident prior to putting on A & D Ointment. EI #4 replied "yes". On 11-06-2013 at 5:00 PM EI #3, the LPN (Licensed Practical Nurse)/QA (Quality Assurance) Coordinator was asked what she would expect a CNA to do in regard to handwashing during incontinent care. EI #3 replied "I would expect her to wash her hands after cleaning BM". EI #3 was asked what could happen if a CNA cleaned BM, removed gloves, and applied ointment without washing her hands after cleaning BM. EI #3 replied "Cross contamination, E. coli/bacteria".

Based on observation, record review and interviews, the facility failed to ensure items were dated with a use by date /opened date, or thawed date in the refrigerator, freezer and dry storage area. The facility further failed to ensure staff did not put their drinks in the walk-in cooler. These observations were made during the initial tour of the Kitchen on 10/10/12 at 8:20 AM. Findings include: The facility's policy for food storage, revised 02/28/2002, included the procedures; Staples or Canned Goods: " 4. Food must be stored ... and in a manner that prevents environmental or cross contamination. ... 7. Any staple items taken out of original package must be stored in a plastic container with a tight fitting lid and labeled with date package opened." On 10/10/12 at 8:20 AM, the following observations were made: A. Reach in refrigerator - 16 Mighty Shakes had no thaw date listed on the cartons B. Walk in refrigerator - 1. three, one gallon containers with liquids were not labled or dated: 2. one gallon container half full of buttermilk ranch dressing had no open date listed. C. Freezer - 1. A pound cake wrapped in plastic wrap had no date listed. D. Dry storage area - 1. A box of plastic spoons, forks and knives was observed with the box top opened and unsecured. On 10/10/12 at 11:30 AM, while in the dry storage area, an observation was made of two boxes of white beans opened and the beans were not sealed and did not list an open date. In the walk-in refrigerator, an observation was made of a staff member's large drinking cup with a plastic sandwich bag on top. On 10/11/12 at 9:15 AM, Employee Identifier (EI) #4, the Dietary Manager, was asked what the procedure was for dating opened and left over items. EI #4, replied when leftovers are placed in the refrigerator they can be kept up to three (3) days. EI #4, said that would be the date placed on the items. EI #4, stated for mayonnaise and salad dressing the opened date is placed on the item. EI #4, further said the person opening the item or the person placing the item in the refrigerator was responsible for dating the item. The Cook was usually responsible for the leftovers, the only leftovers is what will be the alternate the next day. The Cook was responsible for ensuring the dry storage products are labled when opened. EI #4, said, the Health Shakes are thawed out the day their needed. EI #4, said the Health Shakes can be kept for fourteen (14) days after their thawed. EI #4, said the Health Shakes did not have an expiration date on them but a code or something. On 10/11/12 at 1:55 PM, Employee Identifier (EI) #5, The Cook and Baker, was asked what was the process for placing leftovers in the refrigerator. EI #5 said the leftovers were placed in a small container and the temperature was lowered. A labled with the date was placed on the container and it was placed in the refrigerator. EI #5 said leftovers could only be kept for three (3) days. EI #5 said the person on the line usually the Cook was responsible for placing the leftovers in the refrigerator. She said after lunch the second Cook would label and date the leftovers. EI #5 said the tray servers were responsible for the Health Shakes. EI #5 further said when she opens a dry item she places it in a sealed container and affixes a label with the opened date. When asked about the container of white beans without a label and in an opened and unsealed container, she said that would have been EI #6, the second Cook.

Based on observations, interviews and record reviews, the facility failed to ensure a nurse did not handle medications without washing her hands and applying gloves prior to administering medications to Resident Identifier (RI) #9. The facilty further failed to ensure a nurse did not turn off the water faucet with bare hands prior to administering medication. The nurse failed to wear gloves while administering an injection. This affected RI #6, and RI #9, two of 13 sampled residents. Findings Included: A review of the facility's policy and procedure titled, "HANDWASHING PROCEDURE," without a date, revealed the following: "...Procedure... ...K. Wash hands (for at least 10-20 seconds) using plenty of lather and friction... ...Q. Turn off the facet with a clean paper towel... . RATIONALE E. Reaching over the sink increases the risk of touching the edge which is considered contaminated. The inside of the sink is considered a contaminated area. F. Hands are considered contaminated if they come in contact with the faucet. Microorganism spread easily from the hands to the faucet. ...." 1. On 10/10/12 at 12:25 PM, a surveyor observed a Licensed Practical Nurse, Employee Identifier (EI) #3 go to administer medications to RI #9. The medication ([MEDICATION NAME] - [MEDICATION NAME] 10-100 tablet), was in a small medication cup, and then placed in a clear plastic drinking cup, and a small bottle of eye drops. The medication had been left in the resident's room by EI #3. EI # 3 picked up the plastic cup and took the small medication cup out of the drinking cup, then filled the plastic drinking cup with water. She then asked RI # 9 to take the medication. RI # 9, opened her mouth and EI # 3 dropped the medication into her mouth from the medication cup. Then EI # 3 handed her the water, which she drank. EI # 3 then picked up the eye drops and went to the sink and washed and dried her hands and put on gloves. EI # 3 then administers the eye drops to RI # 9. RI #9 leaned her head back and EI #3, the LPN, placed one drop in the right eye, and waited a minute or two before placing the drop in the second eye. While waiting between the eye drops, the LPN, noticed the door to the room was open. EI #3 reached out with her gloved left hand to push the door closed, then immediately used the same hand to pull down RI #9's lower lid to administer the eye drop in the second eye. In an interview with EI #3 on 10/10/12 at 3:20 PM, she was asked what she did when she entered the resident's room to give the medications. EI #3 said she went over to the medications sitting on the bedside table, got some water from the sink, and dropped the pill into the resident's mouth and gave her the water. EI #3 was asked, what should she have done before giving RI #9 the pill. EI #3 answered, "Handwashing, we can't do that enough. I knew I should have." In an interview with the Director of Nursing, EI # 2 on 10/12/12 at 10:30 AM, she was asked the procedure for passing out medications. EI #2 said, prepare one medication at a time, wash your hands between residents and do not leave the cart unlocked. If the resident can pick up the cup, then sanitizer is ok. And not to leave the medication unattended. 2. On 10/10/12 at 4:00 PM, the following observation was made during medication pass. EI #1(LPN) washed her hands and turned off the faucet with her bare hands, then obtained insulin in a syringe, entered RI #6's room and administered the insulin injection without gloves. EI #1 washed her hands for 5 seconds and turned off the facet with her bare hands. EI #1 performed a finger stick blood sugar for RI #6, washed her hands and turned off the facet with her bare hands. EI #1 then administered medications by mouth with water to RI #6, washed her hands for 3 seconds and turned off the water faucet with her bare hands. On 10/10/12 at 4:10 PM, during an interview with EI #1, the surveyor asked how did she turn off the faucet while administering medications to RI #6 during the medication pass observation. EI #1 said she just turned it off with her bare hands. EI #1 said she should have turned it off with the back of her hand. When the surveyor asked was there another method that she could have used to turn off the faucet, EI #1 said with a paper towel. The surveyor asked EI #1 if she used a paper towel when she gave medications and performed a finger stick blood sugar on RI #6. EI #1 said, no she didn't think so. The surveyor asked EI #1 how long she should wash her hands during medication pass and or resident care. EI #1 said she was taught for about a minute. The surveyor asked EI #1 if she washed her hands for a minute during medication pass observation for RI #6. EI #1 responded no, she just washed them for a few seconds. When the surveyor inquired about the potential negative effect that could occur when improper hand washing was done during care, EI #1 said she could chance contamination.

Based on observation, record review and interview, the facility failed to assess, provide a medical justification/ symptom and reassess Resident Identifier (RI) #13 for the least restrictive device, use and continued use of a self releasing wheelchair belt. This resident was unable to release the belt upon request by a staff. This affected one of 4 residents sampled for restraints. Findings include: RI #13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. RI #13's recent quarterly Minimum Data Set (MDS) assessment, dated 05/02/2012, identified the resident with a score of "3" out of a possible "15 " on her Brief Interview Mental Status (BIMS), indicating the resident was severely impaired in cognition. The MDS also indicated RI #13 had no behaviors or signs or symptoms of [MEDICAL CONDITION]. RI #13 was identified with requiring extensive assistance by one person for transfers and locomotion on and off the unit. Her mobility device was a wheelchair. For balancing during transition and walking, RI #13 was reflected as not steady, only able to stabilize with staff assistance. The restraint section of the MDS did not reflect a trunk restraint. On 10/11/12 at 11:00 AM, RI #13 was observed in the hall by the nurses' station sitting in her wheelchair with a seatbelt intact. On 10/11/12 at 4:20 PM, RI #13 was in her room, sitting in her wheelchair with the seatbelt intact. Her son was also in the room. The Director of Nursing (DON) Employee Identifier (EI) #2, asked the resident if she could release the belt, pointing down to the buckle. The resident looked at EI #2, mumbling. EI #2 asked the resident several times to release the seatbelt. The resident did not follow the requests. After a review of the chart and finding no original assessment, no order, no medical symptom or justification, or reassessments for the use of the seatbelt, EI #2 was asked to provide the documentation. These documents were not provided. On 10/12/12 at 10:15 AM, EI #2 was interviewed. She said she could not find a care plan, original assessment or reassessment for the seatbelt. When asked if the physician wrote an order or provided a justification for the belt, EI #2 replied not normally for a seatbelt. She said nursing could apply a seatbelt in an emergency situation, such as on weekends. EI #2 said when the facility had their own therapy staff, physical therapy provided the assessments. There were no evaluations done now. EI #2 said RI #13 just fell through. The facility provided a policy and procedure for Restraints, Safety belts and Devices, (no date). Procedures documented included: "... A. Devices that staff can initiate without care team approval includes Bed/Chair alarms string or tenders, bean bag chair. B. After the care team has been notified of the need for positioning devices or resident has had a fall, the PT (physical therapy) department is notified and decisions of best equipment is discussed between care team and therapy... D. The least restrictive device will be used whenever possible." Another document provided was Safety Belts, (no date). Procedures included: "1) Once it is determined a safety belt is to be used the following procedure will take place. ... 2. A resident that has a safety belt will be assessed by Therapy quarterly and PRN (as needed). 3. Safety belts are only to be used after other interventions have failed and the care team along with Therapy agree this is the best method."

Based on observations, interviews and record reviews the facility failed to ensure medications were not left unsecured on the nightstand of Resident Identifier (RI) #9 for more than an hour. This affected one of 13 sampled residents. Findings included: The Policy and Procedures for "LTC (Long Term Care)Facility's Pharmacy Services and Procedures Manual 6.0 General Dose Preparation and Medication Administration dated 12/01/07 and Revised 5/01/10 documented: "... 3.9 Facility staff should not leave medications or chemicals unattended. ...." RI # 9 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. RI # 9's Minimum Data Set (MDS) assessment dated [DATE] identified RI # 9 with a 12 out of 15 on her Brief Interview Mental Status, indicating her cognition was intact. RI # 9 was continent of bowels and had a catheter for her bladder. For Activities of Daily living skills such as transferring, dressing and ambulation, RI # 9 was documented as requiring extensive assistance of one person for physical assist. On 10/10/12 at 11:05 AM, the surveyor observed a Licensed Practical Nurse, Employee Identifier (EI) #3 enter RI #9's room to administer medications. The medication was a tablet in a small medication cup, and then placed in a clear plastic drinking cup, and a small bottle of eye drops. The resident's daughter was visiting and was assisting her mother to the toilet. EI #3 placed the medications on RI #9's bed side table. EI #3 waited a minute or two, then left the resident's room, with the medication still on the bedside table. EI #3 was observed to go in and check on two other residents and then return to the medication cart and administer medications to other residents. At 11:45 AM, RI #9's medication continue to be sitting on the bed side table in the resident's room. At 12:22 PM, the surveyor interviewed EI # 3 regarding her medication pass. The surveyor went to the Medication Cart and inquired of RI #9's medications. EI #3 said she had given RI # 9 her medications and documented on the MAR (Medication Administration Record) that the medications were given. EI #3 identified to the surveyor where she had documented the medicines as given. When EI #3 was asked by the surveyor, if she could see the medication bottles or bubble pack for RI #9's medication; EI #3 showed the surveyor the bubble pack for the medication, "Carbodopa-Levodpa 10-100 Tab (Tablet) Take 1 Tablet By Mouth Twice Daily with Breakfast & at Noon (Paralysis Agitans)". The push card also documented, "May Cause Drowsiness Alcohol may intensify this effect. May cause Dizziness Medication affects Blood Pressure. May cause Discoloration of Urine or Feces" Then EI #3 showed the surveyor the "Systane Ultra Eye Drops" box; however, as EI #3 shook the box for the eye drops, she realized the box was empty. The prescription for the eye drops, documented: "Instill 1 drop in both eyes three times daily." The surveyor asked EI #3, where the medication was. EI #3 said, Oh, she knew where the medications were, they're in a room. At 12:15 PM, EI # 3 left the surveyor and went into another resident's room, then later accompanied by the surveyor she went into RI #9's room. When she entered the room, RI #9 was eating her lunch. EI #3 picked up the plastic cup and took the small medication cup out of the drinking cup, then filled the plastic drinking cup with water. She then asked RI #9 to take the medication. RI #9, opened her mouth and EI #3 dropped the medication into her mouth from the medication cup. Then EI #3 handed her the water, which she drank. EI #3 then picked up the eye drops and went to the sink and washed and dried her hands and put on gloves. EI #3 then administers the eye drops to RI #9. In an interview with EI #3 on 10/10/12 at 3:20 PM, she was asked if she left RI #9's medicine on her bedside table. EI #3 said, yes, she did. EI #3 was asked, when she acknowledged that she had not given RI #9 her medications, did she realize she had already signed off on giving these medicines in the MAR. EI #3 stated, yes, when she left (another residents room), she went back to the medication cart, and she forgot. She said in her mind, she thought she had finished up in RI # 9's room. EI #3 was asked, before she took the medications to RI #9's room, did she document them as given. EI #3 replied, no when she came back from the room she had gone to after RI #9's room, she documented the medication as given.

Based on observations, interviews and record reviews the facility failed to ensure medications were not documented as given until they were actually administered. This affected Resident Identifier (RI) # 9, a resident which had medications left on the nightstand for over an hour, before being administered. However, they were documented on the MAR (Medication Administration Record) as already given. This affected one of thirteen sampled residents. Findings Included: The LTC (Long Term Care) Facility's Pharmacy Services and Procedure Manual Policy # Title: 6.0 General Dose Preparation and Medication Administration dated 12/01/07 and Revised 05/01/10 stimulates: " 6. After Medication Administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refuse, PRN (as needed) medications, application sight) on appropriate forms. ..." On 10/10/12 at 11:05 AM, the surveyor observed a Licensed Practical Nurse, Employee Identifier (EI) #3 enter RI # 9's room to administer medications. Observed was a medication tablet in a small medication cup and a small bottle of eye drops. The resident's daughter was visiting and was assisting her mother to the toilet. EI # 3 placed the medications on RI # 9's bed side table, waited a minute or two, then left the resident's room. The medications remained on the bedside table. EI #3 was observed to go in and check on two other residents and then return to the medication cart and administer medications to other residents. At 12:15 the surveyor observed the medications still in RI #9's room. On 10/10/12 at 12:22 PM , the surveyor asked EI #3 about RI #9's medications. EI #3 showed the surveyor the two medications RI #9 received, and both medications were documented as given. The surveyor asked to see the pill bottles, or push cards. EI #3 showed the surveyor the push card for the medicine "[MEDICATION NAME]-[MEDICATION NAME] 10-100 Tab (Tablet). The other medication left in the resident's room was [MEDICATION NAME] Ultra High Performance Eye Drops. In an interview with EI #3 on 10/10/12 at 3:20 PM, she was asked, when she took the medications to RI #9's room, was that when she documented them as given. EI # 3 said, No, when she came back from another residents room, she did. She said she thought, or was thinking she was finished with RI #9. An interview with the DON, EI #2 on 10/12/12 at 10:30 AM, she was asked, when was the Licensed Practical Nurse (LPN) suppose to document on the MAR that a medication was administered. EI #2 said, after the nurse has actually given the medication to the resident.

Based on interviews, record and policy review, the facility failed to monitor and supervise Resident Identifier (RI) #1's whereabouts, a confused and ambulatory resident, to ensure that RI #1 did not exit the facility without staff knowledge. RI #1, a confused and ambulatory resident, exited the facility without staff knowledge on [DATE]. The facility had identified this resident to be at risk for falls. Per RI #1's medical record, the resident needed more supervision, and the family had been asked to consider providing sitters for the resident. On [DATE], between 8:30 and 9:00 AM, the Certified Registered Nurse Practitioner (CRNP) had identified that RI #1 was unsafe and at risk for exiting the facility due to the resident's [DIAGNOSES REDACTED]. The CRNP ordered for the facility to continue the use of the code alert bracelet (secure care monitor / ankle bracelet); however, the Licensed Practical Nurse (LPN) and the Registered Nurse (RN) failed to implement the order. Around 6:15 PM, a visitor notified staff that RI #1 had left the facility. The resident's empty wheelchair was found parked at the front door with the chair alarm sounding. Staff found that RI #1 had fallen outside face down on the pavement. RI #1 sustained a bloody nose and a knot above the left eye; the resident was transferred to a local hospital and admitted for treatment of [REDACTED]. RI #1 expired in the hospital on [DATE]. This deficient practice affected RI #1, one of five sampled residents for behaviors and falls, and posed an immediate threat to the health and safety of residents, as it was likely to cause serious injury, harm or death. On [DATE] at 1:45 PM, the Administrator, Assistant Administrator and Director of Nursing (DON) were made aware that the surveyors identified substandard quality of care at an immediate jeopardy level of "J" in F323. The Immediate Jeopardy (IJ) began on [DATE], and was relieved on [DATE] at 6:55 PM, when the facility implemented immediate corrective actions to remove the immediacy. The scope and severity level of F323 was lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance with F323. Findings include: RI #1 was admitted to the facility on [DATE] with diagnoses, to include increased cognitive difficulties/altered mental status, new TIA (Transient Ischemic Attack) vs. CVA Cerebrovascular Accident), Hypertension, A-Fib (Atrial Fibrillation), Depression, Mild Type II Diabetes, Osteoporosis, Vertigo and visual problems with retinal bleeding in left eye. An Admission MDS (Minimum Data Assessment), with an ARD (Assessment Reference Date) of [DATE] noted that RI #1 was admitted from the hospital and scored a 07 on the BIMS (Brief Interview for Mental Status), which indicated severe cognitive impairment. RI #1 required limited, one person assistance with transfer, ambulation, toilet use and hygiene. RI #1 was noted as unsteady with transitions and walking, requiring human assistance with stabilization. At the time of this assessment, RI #1 utilized a walker and wheelchair for mobility. A review of the facility document, "Informed Consent on Elopement" revealed, "It is the policy of John Knox Manor, Inc II assess each resident to admission and ongoing once they are admitted for their potential to elope and leave the premises without permission. The following control methods have been established and may be used with your loved one for their safety. 1. Secure Care Monitor- tried for 7 days upon admission; permanent if resident is considered a risk by nursing staff. 2. Bed/Chair Alarms..." According to the [DATE], "Daily Transmitter Testing Log", RI #1 received a Secure Care Monitor, or ankle alarm / bracelet, on Wednesday, [DATE]. In a progress note regarding RI #1, dated [DATE], the attending physician noted, "She has had a history of [REDACTED]. Her memory and thought process has definitely declined..." According to the "Daily Transmitter Testing Log" for [DATE], EI #11 (Central Supply Clerk / CNA) documented the removal of RI #1's ankle bracelet on [DATE], due to no elopement attempts. On [DATE] at 8:40 AM, the surveyor interviewed EI #11, the Central Supply Clerk / CNA. The surveyor asked when RI #1's ankle bracelet was removed. EI #11 responded, "[DATE]th." The surveyor asked, "Who initiated it being taken off?" The Central Supply Clerk / CNA (EI #11) answered that she used her own judgment because RI #1 had no elopement attempts, and the ankle bracelet had been on way past time. During a follow-up interview on EI #11, Central Supply Clerk/CNA, was re-interviewed on [DATE] at 9:10 AM, the surveyor asked EI #11 what assessment did she use before removing RI #1's bracelet. EI #11 (Central Supply Clerk / CNA) stated she talked with RI #1 on the hall and told the resident, "I (EI #11) think it is time to take this off. You (RI #1) promise me (EI #11) this coming off, this gonna stay off?" EI #11 (Central Supply Clerk / CNA) stated that RI #1 replied, "I promise." A "Social Service Progress Note" dated [DATE], noted that EI #6, the Social Worker, discussed RI #1's increasing cognitive decline and the possible need for sitters with the Administrator (EI #7) and the resident's Power of Attorney (POA) /Sponsor. According to this note, if RI #1's behaviors continued, the resident may need sitters from 3:00 PM until 8:00 PM, the times noted that RI #1 experienced increased confusion. EI #6 (Social Worker) documented that the POA / Sponsor, "would be willing to have sitters with her from about 3pm until about 8pm or when she went to bed." On [DATE] at 4:45 PM, the surveyor interviewed with EI #12, a facility employee who requested to remain anonymous. The surveyor asked EI #12 (anonymous) to tell what could be remembered about RI #1's overall personality. EI #12 (anonymous) responded that RI #1 had been a resident at the facility several times for rehab, but when RI #1 came for this most recent stay, the resident was "mentally different." EI #12 added that RI #1 was "Ok" in the mornings, but in the evenings, the resident behaved as though she (RI #1) had "sundown", displaying increased agitation. According to EI #12 (anonymous), RI #1 began to put the call light to her mouth and attempt to talk into it. The surveyor asked EI #12 if it had been a surprise to hear that RI #1 had gotten out of the facility. EI #12 (anonymous) answered that it was not a surprise that RI #1 had gotten out of the facility. EI #12 (anonymous) clarified that it was not a surprise that RI #1 tried because the resident would get confused and would talk about needing to go. In a "Progress Note" dated [DATE] (no time indicated), EI #5, the Certified Registered Nurse Practitioner(CRNP), documented that RI #1 was having increased paranoia and psychosis. EI #5 planned to increase RI #1's Seroquel, get a urine culture / sensitivity laboratory test and continue the use of the code alert (secure care monitor / ankle alarm bracelet). A review of RI #1's physician's orders [REDACTED].#5, ordered the following: "...Increase Seroquel to 25 mg (milligram) p o (by mouth) Bid (twice a day) Give (2) 12.5 mg tabs now... Continue Code Alert Noted (EI #1 and EI #2's signature/title) [DATE]" On [DATE] at 5:00 PM and 5:10 PM respectively, the surveyor conducted phone interviews with LPN (EI #1) and the RN (EI #2), the two nurses who signed off the [DATE] order to continue code alert ankle bracelet for RI #1. Both nurses, EI #1 (LPN) and EI #2 (RN) reported that since the order read, "Continue Code Alert", they (EI #1 and EI #2) assumed that RI #1 was still wearing a code alert ankle bracelet, and did not go look to assure that the resident was indeed wearing a code alert ankle bracelet. During a phone interview with EI #5, the Certified Registered Nurse Practitioner (CRNP), on [DATE] at 3:25 PM, the surveyor asked if the CRNP (EI #5) recalled a resident by the name of RI #1. EI #5 (CRNP) affirmed that she did. The surveyor informed EI #5 (CRNP) of an order dated [DATE], regarding continuation of a code alert (ankle bracelet), and asked the CRNP (EI #5) if she remembered signing such an order. EI #5 (CRNP) affirmed that she did. EI #5 (CRNP) said that the Seroquel was increased because of anxiety and that she wanted to make sure RI #1 continued to wear the ankle bracelet. The surveyor asked if EI #5 (CRNP) was aware that the resident's ankle bracelet was discontinued on [DATE]. EI #5 (CRNP) replied that she was not aware that the bracelet was discontinued. The surveyor asked the reason for wanting to continue the code alert bracelet. The CRNP (EI #5) explained that the ankle bracelet is written as a safety precaution for anyone that can get up and down, is paranoid to any degree and delusional. The surveyor asked EI #5 (CRNP) what time she had visited the resident on [DATE]. EI #5 (CRNP) stated it was during the morning between 8:30 AM and 9:00 AM. In a "Nurse's Note" dated [DATE] at 9:45 (AM/PM not denoted), EI #2, a Registered Nurse (RN), noted, "Resident is very confused. N.O. (New Order) increase Seroquel to 25 mg p.o. (by mouth) BID (two times per day) Give (2) 12.5 mg p.o. now. ...continue code alert...." In a "Nurse's Note" dated [DATE] at 6:26 (AM/PM not denoted), EI #10 (LPN/Charge Nurse), noted, "Resident sent to (local hospital).... Writer summoned to outside to find resident had fallen on pavement at 6:20pm Visitor notified CNA that resident was trying to get out by the time the CNA reached the resident she had already fallen. First Aid rendered, ambulance called and resident transported to hospital." On [DATE] at 7:45 AM, the surveyor interviewed EI #10, LPN/Charge Nurse who was identified as being on duty the evening of [DATE]. The surveyor requested that EI #10 (LPN Charge Nurse) report the details of the incident concerning RI #1. EI #10 (LPN Charge Nurse) stated, "I was doing my med (medication) pass. She (RI #1) was in the dining room eating her food. I (EI #10, LPN Charge Nurse) was on the hall 10 or 15 minutes after I came out of the dining room and heard somebody saying something. (EI #9, CNA) was saying, '...somebody got out!' I (EI #10, LPN Charge Nurse) went around to the front door and saw the wheelchair empty. EI #9 and EI #8 (two CNAs) found the wheelchair first. EI #9 (CNA) said she cut off the wheelchair alarm. A visitor was here to feed (another resident). She (visitor) apparently came and got EI #8 and EI #8, EI #9 and visitor went outside and EI #9 (CNA) came back in to get me (EI #10, LPN Charge Nurse). (RI #1) was face down yelling 'get me up off this ground, get me up off this ground.' One eye was swollen and her nose was bleeding." The surveyor asked if the resident was wearing an ankle alarm (secure care monitor / ankle bracelet). EI #10 (LPN Charge Nurse) responded, "No she (RI #1) wasn't." The surveyor asked EI #10 (LPN Charge Nurse) how she would describe RI #1's usual behavior. EI #10 (LPN Charge Nurse) responded, "She (RI #1) seemed very confused and non-compliant. I (EI #10, LPN Charge Nurse) told her (RI #1) to use her light so we could assist her but when you look around she was back in the bed... When I worked with her she (RI #1) would get in the bed on her own... the recliner on her own. She (RI #1) was able to do stuff but because of the fall I felt more comfortable if I helped her. She (RI #1) had a bed, chair alarm but no ankle (i.e. secure care monitor / ankle bracelet)." The surveyor asked if EI #10 (LPN Charge Nurse) saw RI #1 leave the dining room. EI #10 (LPN Charge Nurse) responded, that she saw RI #1 go into the social worker's office. EI #10 (LPN Charge Nurse) stated she saw RI #1 when she went to the nurses desk to retrieve something but went immediately back into the dining room. When the surveyor asked EI #10 (LPN Charge Nurse) what she thought went wrong that day, EI #10 (LPN Charge Nurse) responded, "I (EI #10) was in the dining room and other staff was feeding. I (EI #10) felt like more people could have been available after (RI #1) came out of the dining room. She (RI #1) was in the first group of people." On [DATE] at 4:15 PM, the surveyor interviewed the female visitor who alerted the staff that RI #1 was out of the building on [DATE]. The visitor recalled the incident and stated, "I was leaving; came to the double doors and saw a wheelchair." According to the visitor, the doors appeared to be cracked (slightly open). When the visitor saw the wheelchair near the door, the visitor recalled thinking, "That's strange." Then, the visitor saw a lady (RI #1) walking really fast, then this lady (RI #1) started running. The visitor saw a man with boxes in his hand and asked the man if he knew the lady (RI #1). The man told the visitor that he did not. By the time the man answered, the visitor saw RI #1 fall. The visitor said that she went back into the building, down the hall and got EI #8 (CNA). The visitor reported that EI #8 (CNA) and someone else went outside. The surveyor asked what EI #8 (CNA) was doing. The visitor responded, "She was coming out of a room." The surveyor asked if there were anymore staff coming towards the door. The visitor responded, "No." On [DATE] at 1:00 PM, the surveyor re-interviewed the visitor to ask what time it was when she first noticed the wheelchair at the door. The visitor responded that it was between 6:10 PM and 6:20 PM. On [DATE] at 8:55 AM, the surveyor interviewed EI #8, CNA. The surveyor asked the CNA (EI #8) to tell what happened to RI #1, on the day of the incident, [DATE]. According to EI #8 (CNA), it was around 6:00 PM or 6:30 PM. EI #8 (CNA) recalled that she was working on the North Hall; residents were just finishing supper, and she (EI #8, CNA) was taking carts off the hall. EI #8 recalled that there was a lady visitor who was visiting someone on the East Hall. EI #8 (CNA) explained that this visitor reported to her (EI #8) that a lady (identified later as RI #1) ran out of the door. EI #8 (CNA) further explained that the lady visitor was at the corner in front of the kitchen doors, and the CNA (EI #8) was the only person that the visitor saw. EI #8 (CNA) said that she and another CNA (EI #9) ran out, the wheelchair alarm was sounding. EI #8 remembered telling EI #9 (CNA) to go back inside and get the nurse; EI #9 (CNA) turned off the chair alarm. EI #8 (CNA) said that she went out of the front door of the facility, turned the corner toward the independent living facility (assisted living facility / ALF), and saw RI #1 on the ground. Also, EI #8 (CNA) said that the visitor had come outside, and that there was an assisted living facility (ALF) employee (EI #13) already with RI #1 when EI #8 arrived at the scene of the accident. The surveyor asked EI #8 if she was the only person on the hall when the visitor came around the corner. EI #8 answered, "Yes..." The surveyor asked EI #8 (CNA) if she could hear the alarm from the North Hall. EI #8 (CNA) responded, "No." The surveyor asked EI #8 (CNA) when did she begin to hear the alarm. EI #8 stated she heard the alarm by the time she reached West Hall nurse's station. The surveyor asked EI #8 (CNA) if there was anyone at the nurse's desk. EI #8 (CNA) answered, "East Hall nurse was on the floor; no one was at the West Hall nurse's desk." The surveyor asked EI #8 (CNA) where the wheelchair was located, and she answered that it was on the inside of the door. On [DATE] at 9:10 PM, the surveyor interviewed EI #9, CNA. The surveyor asked the CNA (EI #9) to tell what happened to RI #1 on [DATE]. EI #9 (CNA) reported that she was in the North Hall's TV room feeding a resident when she heard EI #8 (CNA) hollowing for help. EI #9 (CNA) said that when she got to the door, she heard the alarm (wheelchair alarm) sounding and turned it off. Per EI #9 (CNA), EI #8 (CNA) told her (EI #9) to go and get some help. EI #9 (CNA) said that she went to get the nurse and told another nurse that EI #10 (LPN/Charge Nurse) might need help. On [DATE] at 3:55 PM, the surveyor interviewed EI #13, an employee in the facility's adjoining Assisted Living Facility (ALF) who observed RI #1 outside of the facility on [DATE]. The surveyor asked EI #13 to explain the events of [DATE], the day RI #1 exited the facility. EI #13 stated, "It was a little after 6:00, I heard someone yell 'help' ... I opened the door... (RI #1) was on the sidewalk... on the ground... face down." A facility "Incident Report" completed on [DATE] at 6:30 PM, noted that RI #1 experienced a fall outside of the facility on [DATE] at 6:20 PM. This incident report documented that, "...Visitor notified staff that resident was outside running by the time staff reached resident she had fallen down on pavement faced down. Bruises noted to face and her nose was bleeding." Per this incident report, RI #1's attending physician was notified at 6:26 PM, and the resident was transferred to a local hospital for treatment at 6:30 PM. On [DATE], a hospital consultation report read, "Reason for consultation Orbital Fx (Fracture) & Eye Injury Elderly... in nursing home who apparently was trying to leave home "running" when fell and hit face.... Pt (patient) on anticoagulants.... Difficult exam due to swelling... Diagnosis 1. Severe (left) orbital blow out fx (fracture) (with) entrapment. 2. Severe Periorbital contusion...." Another hospital consultation report dated [DATE] revealed, "PHYSICAL EXAMINATION: Patient is stuporous... There was a significant periorbital hematoma and ecchymosis.... CT (Computed Tomography) of the brain shows a small subdural hematoma on the right side...." The hospital "Death Summary" form for RI #1, with a transcription date of [DATE], noted that the resident was admitted to the hospital on [DATE], and expired on [DATE], "due to complications from closed head injury and fractures and advanced dementia and advanced age." This deficiency is written as a result of the investigation of complaint #AL 972. *********************************** Allegation of Compliance (AOC) F323 On [DATE] at 6:55 PM, the Administrator, Assistant Administrator, and DON provided the surveyors with an acceptable AOC which documents: 1. Residents on behavior management will be assessed for potential elopement risk, psychosis or hallucinations. 2. Residents will be assessed for possible causes in cognitive status changes to ensure a progressive plan of care is followed prior to discharging resident, including interviewing resident and family for possible causes for behavior changes, assessing change in cognitive status through a mini mental assessment tool, assessing need and/or changes in psychoactive medications, psych consults as needed and/or ordered by MD, in servicing staff on behavior interventions and possible causes for behavioral changes, including in group activities and diversion tactics, checking for health related causes such as UTI's, psychosocial causes, environmental factors and implementing behavior plan to reinforce appropriate behaviors. 3. Residents will be observed daily for any cognitive changes, hallucinations or increased psychosis. The social worker or his/her designee will review behavior logs daily. Concerns noted in the behavior logs will be brought to the attention of key personnel in the daily care team meeting to consider the changes in any behavioral area, including but not limited to cognitive changes, hallucinations, increased psychosis, verbal and/or physical aggression, resisting care, and wandering. 4. The charge nurse will report to administration any resident with these behaviors. After hours the administrator, assistant administrator or director of nursing must be called. The resident will be placed where visual observation can be maintained until the family is notified and one on one sitter can be secured. 5. Families of identified residents with potential for elopement will be contacted and arrangements will be made to help them seek more appropriate placement elsewhere. 6. Until the resident is relocated to another facility John Knox will require that the family provide 24 hour sitters or sit with the patient themselves until other arrangements can be made. If sponsor refuses to come or provide a sitter, John Knox Manor will provide a sitter and initiate immediate discharge procedures. 7. To monitor the front entrance we have a receptionist from 8:00 a.m. to 9:30 p.m. 8. Vincent Guard monitors the building inside and out on the night shift as extra safety precaution from 10:30 p.m. until 6:30 a.m. 9. All staff will be in-serviced to report any behavioral changes, including but not limited to cognitive changes, hallucinations, increased psychosis, verbal and /or physical aggression and wandering. After receiving an acceptable Allegation of Credible Compliance on [DATE] at 6:55 PM, facility employees were interviewed on [DATE] regarding in-services received on the topic of supervising and monitoring residents to ensure they do not exit the building. Staff interviews revealed they were in-serviced by the DON on: observation of residents with a change in mental status, supervision/monitoring of these residents, contacting the sponsor, securing a sitter and reporting changes to a supervisor and/or the administrator. On [DATE], a list of residents currently being monitored on behavior management was received (21), as was a list of residents with ankle transmitters (22). The "Behavior Management Policy" was reviewed, as well as the Behavior Progress Note and behavior log. The log was already in use and included the date, time, behavior, location, interventions and resident's response. On [DATE] at 6:55 PM, the Immediate Jeopardy was relieved and the scope and severity level of F323 was lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance of F323.

Based on record review and interviews, the facility failed to implement a Certified Registered Nurse Practitioner's (Physician's) order for continuation of code alert (secure care device) on Resident Identifier (RI) #1 on the morning of [DATE]. The Licensed Practical Nurse (LPN) and the Registered Nurse (RN) who signed off the order mistakenly assumed that the code alert (ankle bracelet / Secure Care device) was already on the resident and failed to check the resident to see if the resident was wearing a Secure Care device (code alert ankle bracelet). Around 6:15 PM, a visitor notified staff that RI #1 had left the facility. Staff found that RI #1 had fallen outside face down on the pavement. RI #1 sustained a bloody nose and a knot above the left eye; the resident was transferred to a local hospital and admitted for treatment of [REDACTED]. RI #1 expired in the hospital on [DATE]. This deficient practice affected RI #1, one of five sampled residents for behaviors and falls, and posed an immediate threat to the health and safety of residents, as it was like to cause serious injury, harm or death. On [DATE] at 1:45 PM, the facility's Administrator, Assistant Administrator and the Director of Nursing were made aware that the surveyors had an immediate jeopardy at the scope / severity level of "J" in Resident Assessment, F 281. The Immediate Jeopardy began on [DATE] and was relieved on [DATE] at 6:55 PM, when the facility implemented immediate corrective actions to remove the immediacy. The scope and severity level of F 281 was lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance with F 281. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Admission Minimum Data Set ((MDS) dated [DATE], revealed that RI #1 was admitted from the hospital and scored a 07 on the BIMS (Brief Interview for Mental Status), which indicated severe cognitive impairment. RI #1 required limited, one person assistance with transfers, ambulation, toilet use and hygiene. RI #1 was assessed as being unsteady with transitions and walking, requiring human assistance with stabilization. At the time of this assessment, RI #1 utilized a walker and wheelchair for mobility. A review of the facility document, "Informed Consent on Elopement" revealed the following: "It is the policy of John Knox Manor, Inc II to assess each resident to admission and ongoing once they are admitted for their potential to elope and leave the premises without permission. The following control methods have been established and may be used with your loved one for their safety. 1. Secure Care Monitor (ankle alarm bracelet)-tried for 7 days upon admission; permanent if resident is considered a risk by nursing staff. 2. Bed/Chair Alarms..." A review of the "Daily Transmitter Testing Log" for [DATE], revealed RI #1 received a Secure Care Monitor, or ankle alarm / ankle bracelet, on Wednesday, [DATE]. A review of the "Daily Transmitter Testing Log" for [DATE], revealed that Employee Identifier (EI) #11, a Central Supply Clerk / CNA, had removed RI #1's ankle alarm bracelet on [DATE], due to no elopement attempts. On [DATE] at 8:40 AM, the surveyor interviewed EI #11, the Central Supply Clerk / CNA. The surveyor asked when RI #1's ankle bracelet was removed. The Central Supply Clerk / CNA (EI #11) responded, "[DATE]th." The surveyor asked, "Who initiated it being taken off?" The Central Supply Clerk / CNA (EI #11) answered that she used her own judgment because RI #1 had no elopement attempts, and the ankle bracelet had been on way past time. In a follow-up interview on [DATE] at 9:10 AM, EI #11 (Central Supply Clerk / CNA) was asked, what assessment she did before removing RI #1's bracelet. EI #11 (Central Supply Clerk / CNA) stated she talked with RI #1 on the hall and told the resident, "I (EI #11) think it is time to take this off. You (RI #1) promise me (EI #11) this coming off, this gonna stay off?" EI #11 (Central Supply Clerk / CNA) stated that RI #1 replied, "I promise." In a "Progress Note" dated [DATE] (no time indicated), EI #5, the Certified Registered Nurse Practitioner(CRNP), documented that RI #1 was having increased paranoia and [MEDICAL CONDITION]. EI #5 planned to increase RI #1's [MEDICATION NAME], get a urine culture / sensitivity laboratory test and continue the use of the code alert (secure care monitor / ankle alarm bracelet). A review of RI #1's physician's orders [REDACTED].#5, ordered the following: "...Increase [MEDICATION NAME] to 25 mg (milligram) p o (by mouth) Bid (twice a day) Give (2) 12.5 mg tabs now... Continue Code Alert Noted (EI #1 and EI #2's signature/title) [DATE]" On [DATE] at 3:25 PM, during a phone interview with EI #5 (Certified Registered Nurse Practitioner), the surveyor asked if the CRNP (EI #5) recalled a resident by the name of RI #1. EI #5 affirmed that she did. The surveyor informed EI #5 (CRNP) of an order dated [DATE], regarding continuation of a code alert (ankle bracelet), and asked the CRNP (EI #5) if she remembered signing such an order. EI #5 affirmed that she did. EI #5 (CRNP) said that the [MEDICATION NAME] was increased because of anxiety and that she wanted to make sure RI #1 continued to wear the ankle bracelet. The surveyor asked if EI #5 (CRNP) was aware that the resident's ankle bracelet was discontinued on [DATE]. EI #5 (CRNP) replied that she was not aware the bracelet was discontinued. The surveyor asked the reason for wanting to continue the code alert (ankle) bracelet. The CRNP (EI #5) explained that the ankle bracelet is written as a safety precaution for anyone that can get up and down, is paranoid to any degree and delusional. The surveyor asked EI #5 (CRNP) what time she had visited the resident on [DATE]. EI #5 (CRNP) stated it was during the morning between 8:30 AM and 9:00 AM. The surveyor asked the CRNP if she was aware that RI #1 was not wearing a code alert bracelet when she was found outside on [DATE]. EI #5 (CRNP) mentioned that she had heard rumors, but was not officially aware that RI #1 was not wearing an ankle bracelet when found outside on [DATE]. During a phone interview on [DATE] at 5:00 PM, the surveyor asked EI #1, a Licensed Practical Nurse (LPN), if she was familiar with RI #1. EI #1 (LPN) answered that she was. EI #1 (LPN) affirmed that she signed off a [DATE], order. The surveyor asked what the process was for noting orders. EI #1 (LPN) explained that when an order is received, the nurse writes the order on the MAR (Medication Administration Record), and makes sure that whatever is ordered gets done. The surveyor asked what happened with the order for continue code alert (ankle bracelet). EI #1 (LPN) explained that the order was to continue code alert, but she really did not check to see if RI #1 had a code alert bracelet on. The surveyor asked why not. EI #1 (LPN) responded that since the order said to continue, she mistakenly assumed the resident had a code alert bracelet on. The surveyor asked was the policy and procedure followed for the order to continue the code alert. The LPN (EI #1) answered that it wasn't because she did not check to see if the resident had the code alert bracelet on. The surveyor asked what was the policy and the procedure for carrying out physician's orders [REDACTED]. The surveyor asked what does the cosign mean. EI #1 (LPN) replied that it indicates all orders are taken off and assures that everything has been done. The surveyor asked when the second person should cosign, before or after orders are checked. EI #1(LPN) answered that the second person should cosign after checking to see that the order is done. In a phone interview on [DATE] at 5:10 PM, the surveyor asked EI #2, a Registered Nurse (RN) if she was familiar with RI #1. EI #2 (RN) said that she was familiar with the resident. The surveyor asked the RN (EI #2) if she had cosigned an order to continue a code alert (ankle bracelet) on [DATE]. EI #2 (RN) affirmed that she did cosign the order. The surveyor asked the RN what cosigning means or indicates. EI #2 (RN) answered that it means that the orders has been taken off the chart, written on the MAR and checked with the nurse to make sure the order has been done. The surveyor asked the RN (EI #2) to clarify if that's what her signature indicated. The RN (EI #2) replied, that it did. The surveyor asked if that's what was done. EI #2 (RN) answered that she made sure the order was on the MAR (Medication Administration Record), but she did not follow the second phase of the process. The surveyor asked why not. EI #2 (RN) answered that she really did not have an answer for that question, and commented that the order just slipped through the cracks. The RN (EI #2) explained that the order said continue alert, so she (EI #2, RN) just assumed the code alert was still on. The surveyor asked if the policy and procedure had been followed with the order. EI #2 replied that the policy and procedure was not followed. The undated policy / procedure entitled, "Taking MD (Medical Doctor) orders off," document the following: "Policy: The charge nurse will take MD orders off. The chart shall remain flagged until a second nurse co-signs the order. Purpose: Dual check to ensure order is carried out. Procedure: 1. Charge nurse checks flagged charts for new orders 2. Orders are transcribed on MAR (Medication Administration Record) ...4. Once the order is completely taken off the nurse leaves the chart flagged for 2nd nurse to ensure order is complete...." In an interview on [DATE] at 3:10 PM, the surveyor referenced the Certified Registered Nurse Practitioner's (CRNP's) order to continue code alert dated [DATE], and asked EI #4, the Director of Nursing (DON), what the process was when an order is written. EI #4 (DON) reviewed the order and stated the nurses should have made sure the resident had a code alert (ankle alarm bracelet). The DON (EI #4) recalled coming into the facility that night, seeing the orders and calling both nurses. According to the DON (EI #4), the RN received a verbal counseling by phone, and the LPN was written up on Monday, [DATE], when the LPN came to work. The surveyor asked where was the code alert noted. EI #4 (DON) stated on the MAR (Medication Administration Record). The surveyor asked what happened with the order to continue code alert. EI #4 (DON) answered that the nurses did not check to see if the resident had the code alert on. The surveyor asked who was supposed to make sure the code alert was on. The DON (EI #4) replied that the LPN (EI #1) should have gotten up, checked and made sure the code alert was on the resident, and the RN (EI #2) should have made sure that the order was carried out. A review of an "Employee Warning Notice" for EI #2 (RN) dated [DATE], revealed that the DON (EI #4) verbally counseled the RN (EI #2) via phone for not ensuring orders were carried out. Per this warning notice, the violation occurred on [DATE]. An "Employee Warning Notice" for EI #1(LPN) dated [DATE], documented that the DON (EI #4) issued a warning to the LPN (EI #1) for failing to carry out order and failing to ensure what the Certified Registered Nurse Practitioner (CRNP) was writing. This employee warning notice documented that the violation occurred on [DATE]. A facility "Incident Report" completed on [DATE] at 6:30 PM, noted that RI #1 experienced a fall outside of the facility on [DATE] at 6:20 PM. This incident report documented that, "...Visitor notified staff that resident was outside running by the time staff reached resident she had fallen down on pavement faced down. Bruises noted to face and her nose was bleeding." Per this incident report, RI #1's attending physician was notified at 6:26 PM, and the resident was transferred to a local hospital for treatment at 6:30 PM. The hospital "Death Summary" form for RI #1, with a transcription date of [DATE], noted that the resident was admitted to the hospital on [DATE] and expired on [DATE], "due to complications from closed head injury and fractures and advanced dementia and advanced age." This deficiency is written as a result of the investigation of complaint #AL 972. ***************************************** Allegation of Compliance (AOC) F 281 On [DATE] at 6:55 PM, The Administrator, Assistant Administrator and the DON provided the surveyors with an acceptable AOC which documented: 1. All nurses will be re-inserviced on procedures for taking off MD orders. 2. All nurses are to put copy of all orders in the DON office for review 3. DON or designee will check to ensure all orders are carried out each 24 hours and check all day shift orders prior to leaving for the day. 4. A designee will be assigned to ensure orders are carried out on ,[DATE] and ,[DATE]. 5. Nurses involved in orders not being carried through will be terminated. ********************************* After receiving an acceptable Allegation of Credible Compliance on [DATE] at 6:55 PM, various staff members , Licensed Practical Nurses and Registered Nurses were interviewed on [DATE], regarding understanding of procedures for taking off MD orders. A review of physicians' orders for RI #2 and RI #3 revealed orders were accurately taken off and carried out for ,[DATE], 29 & 30, 2011. On [DATE] at 6:55 PM, the Immediate Jeopardy was relieved, and the scope and severity level of F 281 was lowered to a "D" level to all the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance in F 281.