Every finding on record at Kensington Health and Rehabilitation

Based on record review, interviews, and review of facility policies titled, Behavioral Assessment, Intervention, and Monitoring, Mood and Behavior, and Antipsychotic Medication Use, the facility failed to ensure Resident Identifier (RI) #75 received adequate monitoring related to the use of antipsychotic and antidepressant medications. Specifically, the facility failed: 1. to ensure RI #75 was monitored for behaviors for which an antipsychotic medication ([MEDICATION(S)]) was administered. This deficient practice affected RI #75, one of three sampled residents reviewed for unnecessary medications who received an antipsychotic medication; and 2. to ensure RI #75 was monitored for side effects of an antipsychotic ([MEDICATION(S)]) and an antidepressant ([MEDICATION(S)]) medication. This deficient practice affected RI #75, one of four sampled residents reviewed for unnecessary medications who received an antipsychotic medication and antidepressant medication. Findings included: A review of the facility's BEHAVIORAL ASSESSMENT, INTERVENTION, AND MONITORING, policy, dated 11/28/2017, indicated, . The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes . The Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT [Interdisciplinary Team] will seek and document any improvements or worsening in the individual's behavior, mood, and function.The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. A review of the facility's MOOD AND BEHAVIOR POLICY, last reviewed on 11/20/2020, indicated, Mood and Behavior tracking documentation will be completed by front line staff, . A review of the facility's ANTIPSYCHOTIC MEDICATION USE POLICY, last reviewed in December of 2020, indicated, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications .Nursing staff shall monitor for and report .side effects and adverse consequences of antipsychotic medications to the Attending Physician. A review of RI #75's ADMISSION RECORD indicated the facility originally admitted the resident to the facility on [DATE] and readmitted the resident on 12/20/2021. The admission record indicated the resident had diagnoses to include Adjustment Disorder with Depressed Mood, Unspecified [CONDITION(S)] Not Due To A Substance Or Known Physiological Condition, and Unspecified Dementia With Behavioral Disturbance. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2022, revealed RI #75 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, RI #75 had no potential indicators of [CONDITION(S)] and had exhibited no behaviors during the seven-day look back period. The MDS indicated the resident received antipsychotic and antidepressant medications seven of seven days during the look back period and had received antipsychotic medication only on a routine basis. A review of RI #75's Care Plan, last reviewed on 11/18/21, indicated the resident demonstrated verbally abusive and combative behaviors related to dementia. Interventions to address the focus area included evaluating the resident for side effects of medications and documenting observed behaviors and attempting interventions in the behavior log. The care plan also indicated the resident used [CONDITION(S)] medications related to dementia and behaviors. Interventions included to monitor and document side effects and effectiveness of the medications and monitor/record/report to the physician side effects and adverse reactions of RI #75's psychoactive medications. A review of RI #75's Order Summary Report, with active orders as of 02/18/2022, indicated the resident was to receive [MEDICATION(S)] 50 milligrams (mg) one tablet by mouth in the morning related to other symptoms and signs involving cognitive functions following unspecified [CONDITION(S)] disease and [MEDICATION(S)] 10 mg one tablet by mouth at bedtime related to unspecified [CONDITION(S)] not due to a substance or known physiological condition. A review of the electronic health record (EHR), including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2022 and February 2022 (from 02/01/2022 - 02/17/2022) revealed there was no documentation to indicate the resident was monitored for target behaviors for which [MEDICATION(S)] was administered and/or side effects potentially resulting from the [MEDICATION(S)] or [MEDICATION(S)]. On 02/17/2022 at 10:51 AM, Employee Identifier (EI) #6, Licensed Practical Nurse, was interviewed. After reviewing the physician's orders for RI #75, she stated she saw neither an order to monitor behaviors for which the [MEDICATION(S)] was administered, nor an order to monitor for side effects of the [MEDICATION(S)] or [MEDICATION(S)]. EI #6 stated a resident who received antipsychotic medication(s) should be monitored for behaviors and side effects. On 02/17/2022 at 2:05 PM, EI #2, Director of Nursing, was interviewed. She stated she expected nursing staff to monitor residents who received an antipsychotic medication for target behaviors every shift. She stated she expected staff to monitor residents who received antipsychotic and/or antidepressant medications for side effects of the medication every shift. EI #2 stated the facility's policy and procedure for the administration of antipsychotic medications required monitoring of the target behaviors for which a resident was administered the antipsychotic medication and required monitoring for side effects of antipsychotic and antidepressant medication. After reviewing the resident's EHR, EI #2 stated there was no documentation which indicated the target behaviors for which RI #75 received [MEDICATION(S)] were monitored. She stated there was no documentation of side effect monitoring for [MEDICATION(S)] or [MEDICATION(S)]. She stated behavior and side effect monitoring should be documented in a resident's MAR. On 12/17/2022 at 4:00 PM, EI #1, Administrator, was interviewed. She stated, per regulations, she expected nursing staff to monitor for target behaviors for which a resident received an antipsychotic medication and to monitor for side effects of antidepressant and antipsychotic medications. On 02/18/2022 at 2:35 PM, EI #16, Psychiatric Nurse Practitioner, was interviewed. She stated she expected facility staff to monitor residents who received an antipsychotic medication for target behaviors and to monitor residents who received antidepressant and/or antipsychotic medications for side effects of the medications.

Based on record review, observations, interviews, and review of a facility policy titled, Administration of Medications, the facility failed to ensure a medication error rate less than 5%. There were 3 errors in 33 opportunities, which resulted in a 9.09% medication error rate involving Resident Identifier (RI) #62 and RI #20 during medication pass. Specifically, the facility failed to ensure: 1. RI #62 received a Senna tablet and a multivitamin with mineral tablet as ordered by the physician; and 2. RI #20 received 30 milliliters (mL) of [MEDICATION(S)] as ordered by the physician. This deficient practice affected RI #62 and RI #20; two of six residents observed during medication pass. Findings included: The facility's ADMINISTRATION OF MEDICATIONS policy and procedure, last reviewed 11/2020, revealed, . Standards: Medications shall be administered in a safe and timely manner, and as prescribed .Practice Guidelines: To ensure that all medication(s) are administered accurately and safely .F759 - Facility must ensure that is free of medication error rates of five percent or greater .Medications must be administered in accordance with the orders, .Licensed Nurse/CMT [Certified Medication Technician] giving medication must follow the six rights to ensure safe medication administration. Each time you administer a medication, you need to be sure to have the .right medication .right dose. 1. A review of the Admission Record for RI #62 revealed the facility admitted the resident on 12/31/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #62's Order Summary Report, with active orders as of 02/16/2022, indicated the resident was to be administered an oral Senna ([MEDICATION(S)]) 8.6 milligram (mg) tablet daily for constipation and an oral Thera-M (Multiple Vitamins - Minerals) tablet daily for supplementation. On 02/16/2022 at 8:08 AM, Employee Identifier (EI) #4, Licensed Practical Nurse, was observed during medication pass. EI #4 administered one oral Senna Plus [[MEDICATION(S)] (stool softener) and senna ([MEDICATION(S)])] tablet and one multivitamin (without minerals) to RI #62. On 02/16/2022 at 10:35 AM, EI #4 stated she administered a Senna Plus tablet to RI #62 instead of a Senna tablet as ordered by the physician. On 02/16/2022 at 11:37 AM, EI #4 stated she administered a multivitamin tablet to RI #62 instead of a multivitamin with minerals tablet as ordered by the physician. 2. A review of the Admission Record for RI #20 revealed the facility admitted the resident on 11/19/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #20's Order Summary Report, with active orders as of 02/16/ , indicated the resident was to be administered 30 ml of an oral [MEDICATION(S)] 10 grams/15 mL solution ([MEDICATION(S)]) daily for constipation. On 02/16/2022 at 8:20 AM, Employee Identifier (EI) #5, Licensed Practical Nurse, was observed during medication pass. EI #5 administered 15 mL of [MEDICATION(S)] 10 grams/15 mL solution to RI #20. On 02/16/2022 at 10:41 AM, EI #5 stated she administered 15 mL of [MEDICATION(S)] to RI #20 instead of 30 mL as ordered by the physician. On 02/16/2022 at 3:45 PM, during an interview with EI #1, Administrator, she was informed of the three medication errors observed during morning medication pass. She was informed the medication error rate would be greater than 5%. EI #1 had no questions regarding the medication errors. On 02/17/2022 at 2:28 PM, EI #2, Director of Nursing, was interviewed. She stated the facility attempted to ensure a medication error rate of less than 5% by in-servicing staff on the seven rights of medication pass, by providing continuing education to staff, and by the pharmacist consultant's medication pass audits. EI #2 stated the facility initiated Quality Assessment and Assurance activity regarding medication administration based on a medication error report. She stated the facility reviewed medication error reports to determine the root cause of medication errors. The surveyor informed EI #2 of the medication error rate of 9.09% resulting from three errors in 33 opportunities. The errors were explained in detail and she stated she had no questions.

Based on interviews, record reviews and review of a facility policy titled, ADMINISTRATION OF MEDICATIONS, the facility failed to ensure Resident Identifier (RI) #1's physician order [REDACTED]. RI #1's [MEDICATION NAME] was not started until 11/03/19, causing RI #1 to miss four doses of the [MEDICATION NAME]. This deficient practice affected RI #1, one of five sampled residents. Findings Include: A review of the facility's policy titled, ADMINISTRATION OF MEDICATIONS, with a revised date of 01/19, revealed: . Standards: Medications shall be administered in a safe and timely manner, and as prescribed. Step . 3 . Action . Medications must be administered in accordance with the orders, . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's Order Summary Report (physician's orders [REDACTED]. . Pregabalin Capsule 75 MG Give 1 capsule by mouth two times a day for Pain . A review of RI #1's Medication Administration Record [REDACTED]. According to the Chart codes, 13 means the medication was not administered. On 11/20/19 at 3:43 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Licensed Practical Nurse (LPN) caring for RI #1 on 11/01/19 and 11/02/19. The surveyor asked EI #3 if RI #1 was receiving any medications for pain when the resident was admitted to the facility. EI #3 said RI #1 was to be on [MEDICATION NAME] and [MEDICATION NAME] upon admission. EI #3 said according to the pharmacy requisition, the [MEDICATION NAME] was received at the facility on 11/03/19, a Saturday. The surveyor asked EI #3 what the code of 13 on the MAR meant. EI #3 said the 13 meant not administered. The surveyor asked EI #3 what date and time was the [MEDICATION NAME] not administered. EI #3 said the [MEDICATION NAME] was to be administered on 11/01/19 and 11/02/19, at 9:00 a.m. and 5:00 p.m., but was not administered on either day. On 11/21/19 at 11:50 a.m., the surveyor conducted an interviewed with EI #2, the Certified Registered Nurse Practitioner (CRNP). The surveyor asked EI #2 when was RI #1 was admitted to the facility. EI #2 responded (MONTH) 31st (2019). The surveyor asked EI #2 should RI #1 have received the [MEDICATION NAME] as ordered by the physician. EI #2 said of course, because it was routine. On 11/21/19 at 2:40 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing (DON). The surveyor asked EI #1 if RI #1 received the [MEDICATION NAME] prescription as ordered by the physician. EI #1 said per the MAR, RI #1 did not receive the [MEDICATION NAME] as ordered. The surveyor asked EI #1 how many doses did RI #1 miss according to the MAR. EI #1 said RI #1 missed five doses.

Based on interviews, record review and review of a facility policy titled, ORDERING AND RECEIVING OF MEDICATIONS, the facility failed to ensure a written prescription for Resident Identifier (RI) #1's [MEDICATION NAME] 75 mg (milligrams) was obtained in a timely manner and sent to the pharmacy to ensure the medication would be available for administration. RI #1 was admitted to the facility with the [MEDICATION NAME] order on 10/31/19 (Friday), but it was not until 11/03/19 (Sunday), three days later that the written prescription for the [MEDICATION NAME] was obtained and faxed to the pharmacy. This deficient practice affected RI #1, one of five residents sampled for medication availability. Findings Include: A facility policy titled ORDERING AND RECEIVING OF MEDICATIONS, with an issue date of 11/28/17, revealed the following: . POLICY STATEMENT It is the policy of this facility to complete the required tasks with the ordering and receiving of medications within the electronic medical record system in a timely manner to ensure the consistent availability of physician prescribed medications for the residents that we serve . PR[NAME]EDURE . 2. Prescription orders required to be held in the possession of the pharmacy will be initially faxed to the pharmacy after receiving . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's admission Order Summary Report (physician's orders [REDACTED].#1 was admitted on [MEDICATION NAME] ([MEDICATION NAME]) 10-325 mg every eight hours as needed for pain and Pregabalin ([MEDICATION NAME]) 75 mg two times a day for pain. A review of RI #1's Medication Administration Record [REDACTED]. Review of a facility Delivery Manifest Report Details form, dated 11/03/19, revealed RI #1's [MEDICATION NAME] 75 mg was not received from the pharmacy until 11/03/19, three days after RI #1 was admitted to the facility. On 11/20/19 at 3:43 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) caring for RI #1 on 11/01/19 and 11/02/19. EI #3 said when RI #1 was admitted to the facility RI #1 was to be on [MEDICATION NAME] and [MEDICATION NAME] but came from the hospital with no written prescriptions for the medications. EI #3 said the daughter came to him and asked had the [MEDICATION NAME] been provided to RI #1. EI #1 said he informed the daughter it could not be provided unless there was a prescription written for the [MEDICATION NAME]. EI #3 said according to the pharmacy requisition, the facility did not receive the [MEDICATION NAME] until 11/03/19. On 11/21/19 at 11:33 a.m., the surveyor conducted an interview with the facility's Consultant Pharmacist. The surveyor asked the Consultant what procedures should the facility have in place to ensure residents receive their narcotic medications. The Consultant said the physician orders [REDACTED]. When asked should a residents medications be available at all times, the Consultant said yes. On 11/21/19 at 11:50 a.m., the surveyor conducted an interviewed with EI #2, the Certified Registered Nurse Practitioner (CRNP). The surveyor asked EI #2 what was the facility's policy for ensuring a resident received their narcotic pain medications as ordered. EI #2 said as soon as the nurses get the written prescription for the narcotics they are faxed directly to pharmacy. EI #2 said she was made aware on Friday (11/01/19) by the nurses that RI #1 did not have a written prescription for the [MEDICATION NAME] and [MEDICATION NAME]. EI #2 said she called the Physician and he faxed over the written prescriptions for the narcotic medications. The surveyor showed EI #2 a copy of the prescription for the [MEDICATION NAME] pain medication, written on 11/01/19, and asked EI #2 where was the written prescription for the [MEDICATION NAME]. EI #2 said there must be another prescription somewhere and went to retrieve the written prescription for the [MEDICATION NAME]. On 11/21/19 at 2:33 p.m., the surveyor conducted a second interview with EI #2. EI #2 said she was unable to locate the written prescription for the [MEDICATION NAME] and pharmacy said they had not received one either. When asked who would have been responsible for ensuring the prescription for the [MEDICATION NAME] was obtained, EI #2 said it would have been multiple people responsible for ensuring the written prescription was obtained. On 11/21/19 at 2:40 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing (DON). EI #1 said RI #1 was admitted to the facility on [MEDICATION NAME] and [MEDICATION NAME]. EI #1 said the facility's procedure for ensuring a resident received their narcotic pain medication was the medications were entered into the computer system when the resident entered the facility. EI #1 said the orders were automatically transferred to pharmacy. EI #1 said RI #1's physician wrote the prescription for the [MEDICATION NAME] on 11/01/19, but she did not know why the prescription for RI #1's [MEDICATION NAME] was not written. EI #1 said on 11/03/19, a written prescription for RI #1's [MEDICATION NAME] was sent to the pharmacy. These deficiencies were cited as a result of the investigation of complaint/report #AL 991.

Based on observation, interview, medical record review, review of a facility form titled, Smoking Guidelines and review of a facility policy titled, NOTIFICATION OF RESIDENT'S CHANGE IN CONDITION, the facility failed to ensure: 1. Resident Identifier (RI) #74's guardian was notified of a hospital visit on 5/26/19, and 2. RI #105's sponsor was notified of the resident's behavior during smoking, which resulted in him/her being placed on restriction. This affected RI #74 and RI #105, two of four sampled residents who were reviewed for notification. Findings Include: 1. A review of a policy titled, NOTIFICATION OF RESIDENT'S CHANGE IN CONDITION, with a revised date of 9/2016, revealed .POLICY STATEMENT Standards: This facility will promptly notify the resident, .Responsible Party of changes in the patients medical/mental condition PR[NAME]EDURE .Notification of Changes--Required notification to .legal rep .of .transfer or discharge . RI #74 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a court order with a date of (MONTH) 6, (YEAR), revealed RI #74 had a court appointed guardian. On 7/09/2019 at 11:03 a.m., an interview was conducted with RI #74's guardian. RI #74's guardian was asked when did she become RI #74's guardian. RI #74 guardian replied, in (YEAR). RI #74's guardian was asked when did RI #74 get sent to the hospital. RI #74's guardian replied, she did not know. RI #74's guardian stated that she heard about the hospital visit from hospice staff. RI #74's guardian stated that she had a problem with the facility not calling her regarding RI #74's hospital visit. RI #74's guardian stated the facility did not call her when they sent RI #74 to the hospital. On 7/10/2019 at 4:39 p.m., an interview was conducted with Employee Identifier (EI) #7, Social Service. EI #7 was asked who was RI #74's sponsor. EI #7 replied, RI #74's guardian. EI #7 was asked what was the facility policy on contacting resident's sponsors or guardians when there was a change in the resident's condition. EI #7 replied to notify the family when there was a change. EI #7 was asked when a resident was had a court ordered guardian, should other family members be contacted. EI #7 replied, no. EI #7 was asked should a name be listed in the progress note that was contacted. EI #7 replied, yes. they should have documented who they talked to. EI #7 was asked who was listed as RI #74 guardian on the face sheet. EI #7 replied, the niece. On 7/10/2019 at 5:15 p.m., a telephone interview was conducted with EI #15, RN (Registered Nurse). EI #15 was asked who was responsible for notifying the resident's family when there was a change in condition. EI # 15 replied, the primary nurse or the supervisor. EI #15 was asked what nurse would have notified RI #74's family. EI #14 replied, the primary nurse that was on the unit. EI #15 was asked who was responsible for notifying RI #74's family on 5/26/19 hospital visit. EI #15 replied, the primary nurse, whoever was assigned to the resident. EI #15 was asked when should family members be notified. EI #15 immediately. EI #15 was asked why was it important that family members be notified when there was a change in condition. EI #15 replied, because they have decision making power involving care when there was a significant change. EI #15 was asked what family member was notified on 5/26/19. EI #15 replied, the primary nurse would have notified the family and told me the family was notified. EI #15 was asked who should be notified regarding a change with RI #74. EI #15 replied, the guardian. On 7/11/2019 at 8:33 a.m., a telephone interview was conducted with EI #16, LPN, (Licensed Practical Nurse). EI #16 was asked what was the facility policy on contacting family members regarding a change in a resident condition. EI #16 replied, to call the family member, the doctor and document. EI #16 was asked should she have documented the family member name that she talked to. EI #16 replied, yes. EI #16 was asked why was it important to contact family members regarding a change of status with the resident. EI #16 replied to let family members know what was going on with the resident. EI #16 was asked would she have been the nurse to contact the family on that day (5/26/2019). EI #16 replied, yes, ma'am. EI #16 was asked who did she tell that she called the family member. EI #16 replied, it should have been the supervisor. On 7/11/2019 at 9:17 a.m., an interview was conducted with EI #2, RN, DON (Director of Nursing). EI #2 was asked who was RI #74 sponsor on the face sheet. EI #2 replied, the niece. EI #2 was asked who was RI #74's legal guardian. EI #2 replied, the name listed in the computer today was RI #74's legal guardian. EI #2 was asked who should be notified regarding changes to RI #74's change of condition. EI #2 replied, the legal guardian. EI #2 was asked what was the name of the family member notified on 5/26/2019 in the progress note. EI #2 replied, she did not see a family member name. EI #2 was asked what was the facility policy on contacting a family member when there was a change in condition with the resident. EI #2 replied, call the family and notify them of a change of condition. EI #2 was asked should staff document the person's name they talk to. EI #2 replied, yes they should document the name. EI #2 was asked where should staff document who they contacted regarding a change in a resident's condition. EI #2 replied, they should document in the computer charting system. 2. A review of a facility form titled, Smoking Guidelines revealed: It is the protocol of this Facility to allow residents to smoke in accordance with the accepted smoking program designed to assure safety of residents, staff and visitors. The procedures involved in providing for smoking, include but are not limited to the following: .5. Any violation .is addressed immediately and intervention provided. The issue of any violation of the smoking Guideline is then reviewed by the Interdisciplinary Team in conference within 24 hours and the family notified. RI #105 was admitted to the facility on [DATE] and readmitted [DATE], with a [DIAGNOSES REDACTED]. On 7/08/2019 at 4:22 p.m., RI #105 was out in the smoking area, but not smoking. Staff was asked why RI #105 was not smoking. The staff replied RI #105 was on restriction for behavior of throwing a cigarette on another resident and had been on restriction since (MONTH) 1, 2019. On 7/9/2019 at 2:56 p.m., during a telephone interview with RI #105's daughter/sponsor, she revealed she was not aware RI #105 was on smoking restriction. The surveyor asked RI #105's sponsor if RI #105 was currently smoking she said yes as far as she knew. On 7/09/2019 at 5:27 p.m., a brief interview was conducted with EI #7, Social Service. EI #7 revealed making an entry in RI #105's record about the behavior but did not notify the resident sponsor. On 7/09/2019 at 5:54 p.m., a second interview was conducted with EI #7. EI #7 was asked when was RI #105's sponsor/ family notified of the restriction for smoking that started on 6/28/2019. EI #7 replied, today, 7/9/2019. EI #7 was asked who was responsible for notifying a sponsor/family. EI #7 replied, she was, she guessed. EI #7 was asked when did the incident happen. EI #7 replied, at the 4:00 p.m. smoke break on 6/28/2019. EI #7 was asked when was RI #105 placed on the smoking restriction. EI #7 replied, on 6/28/2019, starting after the 4:00 p.m. smoke break. EI #7 was asked if RI #105's sponsor was notified on 6/28/2019 when the incident occurred. EI #7 replied, no. EI #7 was asked why was the sponsor not notified. EI #7 replied, she failed to notify her. On 7/11/2019 at 8:16 a.m., an interview was conducted with EI #2, Director of Nursing. EI #2 was asked where was documentation of the smoking incident for RI #105 that occurred on 6/28/19. EI #2 replied, there was no documentation. EI #2 was asked when should the sponsor have been notified of the incident on 6/28/19. EI #2 replied, immediately upon the event happening. EI #2 was asked why should the sponsor have been notified. EI #2 replied, to inform of a change. EI #2 was asked what was the change. EI #2 replied, the resident was placed on smoking restriction. EI #2 was asked what was the harm in not notifying the sponsor of the resident being restricted from smoking. EI #2 replied, it was not a continuity of care. This deficiency was written as a result of the investigation of complaint/report #AL 326.

Based on observations, interviews and review of the facility Admission Agreement, the facility failed to ensure resident rooms were not observed with peeling paint, splintered doors, torn ceiling tiles, chest of drawers with a missing drawer, broken window blinds and missing or scuffed base boards. This was observed in Room Locators (RLs) 1-19, 19 of 66 RLs in the facility. Findings Include: A review of an undated facility documented titled, Resident Rights revealed: All Residents of the Healthcare Facility are granted a Federal Statutory Bill of Rights. The following outlines these Federal Resident's Rights .57. The resident has a right to a safe, clean comfortable and homelike environment . A review of a facility form titled, Environmental Rounds Check-List dated 6/24/19, revealed no identified issues with the following: Ceiling Tiles, Wall Paint in good repair (not scuffed or peeling), Electrical outlets covered (covers not broken), and no further documentation under resident rooms identified the broken blinds or missing drawer from the chest of drawers. A review of a facility form titled, Environmental Rounds Check-List dated 7/1/19, revealed in the resident rooms list no identified issues with the following: Ceiling Tiles, Wall Paint in good repair (not scuffed or peeling), Electrical outlets covered (covers not broken), and no further documentation under resident rooms identified the broken blinds or missing drawer from the chest of drawers. A review of a facility form titled, Environmental Rounds Check-List dated 7/8/19, revealed in the resident rooms list no identified issues with the following: Ceiling Tiles, Wall Paint in good repair (not scuffed or peeling), Electrical outlets covered (covers not broken), and no further documentation under resident rooms identified the broken blinds or missing drawer from the chest of drawers. An observation was made on 7/8/19 at 3:41 PM of Room Locator (RL) #17s scuffed baseboard around the room and the door frame with a large amount of missing paint. The wall around the air conditioning unit had 5 peeling paint spots. The room door was scraped with splintered edges from bottom to approximately 30-36 inches up. In-room side of bathroom door splintered at door knob to center of door. 1/2-3/4 inch wide. An observation was made on 7/8/19 at 4:11 PM of RL #18's door frame with a large amount of peeling paint. An observation was made on 7/8/19, beginning at 4:15 PM, of environmental issues as follows: RL #12-mini blinds were torn up; the room door scrubbed the floor. RL #13-the top drawer from the chest of drawer was missing. RL #14-scuffed base boards at the bathroom and sink area; wall scuffed barong the sink with peeling caulk. RL #15-scuffed walls behind beds; a hole in ceiling tile in corner of the room. RL #16-ceiling tiles causing opening in ceiling; paint peeling over room door. An observation was made on 7/9/19 at 8:20 AM of Room Locators 12-16. No changes were noted. An observation/interview was made on 7/10/19 at 8:00 AM, with Employee Identifier (EI) #12, the Maintenance Director. EI #12 and the surveyor began on the second floor making rounds to observe the environmental concerns. EI #12 was asked to describe what he observed in each room. His findings were as follows: RL #1 had paint flaking near the floor; the emergency outlet loose at the bottom-approximately 3/8 inch away from the wall at the bottom of the outlet cover; the corner wall from about hand rail height to the floor with paint missing with rough edges and room door edges-wood had been chipped away. EI #12 said, Let me make a note of that. That is a piece of flaked paint. RL #2 -The wood edges of the door werewood chipped away; Missing paint every one of them (resident room) is going to have that. EI #12 was asked if it looked like that was recently done/scraped off paint. EI #12 answered no, it had probably been like that a couple of months. RL #3 -(He touched the hinged side of the door edges before entering the room.) EI #12 was asked what happened. EI #12 answered a piece of wood fell off. EI #12 was asked how big the piece of wood was. EI #12 answered, 1/2 X 1 inch. Edges are rough on both sides of the door. While looking at the air conditioner unit, Paint is flaky, needs touch-up RL #4 -Door edges, Rough, both sides of the door; deeper spot about a foot below door handle missing wood; needs corner guard near sink for missing sheet rock with rough edges. RL #5 -Rough edges on both sides of room door. Paint flaking/splitting by air conditioner (AC). RL #6- Peeling paint by AC, room door edges rough on both sides. RL #7 -Door wood chipped and splintered away. It is the laminate surface. RL #8 -Door splintered across bottom and both edges. RL #9 -Door splintered across bottom and both edges, floor base molding missing, paint is wrinkled/bubbled over the AC unit approximately 6 inches. RL #10- Door splintered across the width of the door approximately 6 inches down and another row splintered approximately 2 feet from the floor. RL #11-Eight inches and below, splintered across the entire door and larger chunks missing on hinge side of the door. Needed caulking by AC, 6 inches on both sides. RL #12-The room door Approximately 6 inches down on door splintered/scraped all the way across. Worse chips of wood missing on the edges. The door frame had paint flaking. AC on top with peeling paint. EI #12 was asked about the mini blinds. Blind has small bent spot, straightened it. EI #12 reported there were three screw bases for hanging pictures up that had been painted over rather that removed. EI #12 was asked if that was how it should be and he answered, No. EI #12 was asked what should have been done. EI #12 answered, They should have been removed. RL #13- The door frame had missing paint in four spots. The emergency outlet cover was loose and approximately 3/8 inch away from wall. EI #12 was asked when the chest of drawers was replaced by bed A. EI #12 answered Yesterday when I got work order from (names EI #7, the Social Services Director). EI #12 was asked you said you make rounds daily, how long was that chest missing a drawer. EI #12 answered he could not say. RL #14- EI #12 was asked he noticed about the base boards. EI #12 answered, They have missing paint (around) entire room. Caulking (is) needed around the sink. Bent mini blinds. Hardware left from window covers. RL #15 -Tear in a ceiling tile in right corner by A bed side corner; scuffed/torn sheet rock; Door scratched from height of hinge, 6-8 inches across entire room door; Hinged side edges gouged both sides 7 chunks on that hinge side. RL #16 -The room door had scratched edges with missing wood 6-8 inches from floor all the way across. Door knob side was worse with deeper scratches. EI #12 was asked to please describe the paint on the door frame. EI #12 answered the hinged side has chunk of paint missing. The other side has some missing. EI #12 had not looked across the top of the door frame and was asked what about the top of the door frame. EI #12 answered 3 pieces of hanging peeling paint. (He removed the hanging pieces of paint.) RL #17 -Door frame has peeling paint. EI #12 was asked how many spots of peeling paint and he answered, Nine. EI #12 added the door edges were rough approximately 6-8 inches from floor, scratched from there down all the way across. Eight areas of wood that had been splintered off were missing. RL #18 (Pointing at door frame) large pieces of peeling paint. Room door scratched with some areas deep and wood missing. RL #19 the kick plate is peeling/rolling up on edge; door frame has missing paint. An interview was conducted on 7/10/19 at 11:48 AM with EI #12. EI #12 reported weekly rounds were made of the facility with a housekeeping staff member and a nurse staff member. EI #12 was asked when he last made rounds on the second and third floor prior to the start of the survey. EI #12 answered Monday. EI #12 was asked where those rounds were documented. He provided a copy of Environmental Rounds Check-List dated 7/8/19. EI #12 was asked on 6/24/19, what were his identified concerns on the check list. EI #1 answered paint, they need painting. EI #12 was asked on the check list, under resident rooms, what was indicated by Wall paint in good repair (not scuffed or peeling) . EI #12 answered it should have and X beside it, not a line, to indicate that it needs to be addressed. EI #12 said that would be the same thing with the ceiling tiles. EI #12 was asked when a horizontal line was drawn next to something he was assessing, what did that mean. EI #12 answered that meant it was okay. EI #12 was asked on 7/1/19, what concerns were identified. EI #1 answered the same as the previous week, he did not mark with an X as he should have. EI #12 was asked what the concerns on 7/8/19 were. EI #12 answered it was the same, no changes. EI #12 was asked what he discussed with housekeeping staff. EI #12 answered there were issues with paint and ceiling tiles and the residents having toilet paper available. EI #12 was asked where that was documented. EI #12 answered there was no documentation of that. EI #12 was asked when the blinds were changed in RL #12. EI #12 answered 7/9/19. EI #12 was asked describe the condition of the blinds he removed and replaced with new blinds. EI #12 answered damaged, bent and some slats were missing. EI #12 was asked if he made daily rounds, why the blinds were not replaced prior to 7/9/19. EI #12 answered he did not have them in stock. He had to go and buy them. EI #12 was asked why that was not done before 7/9/19. EI #12 answered he had other items to go there to pick up. EI #12 was asked how long those blinds in RL #12 had been in that condition. EI #12 answered maybe four or five days. EI #12 was asked what was the concern of blinds in that condition being in resident rooms. EI #12 answered it might make them feel bad. EI #12 was asked to please describe the chest of drawers he removed from RL #13. EI #12 answered it was a chest of drawers with a drawer missing. EI #12 was asked how long had it been missing. EI #12 answered at least a couple of days. EI #12 was asked what was the concern of a drawer missing from a chest of drawers. EI #12 answered the residents deserve better. EI #12 was asked when he identified concerns for needed repairs such as peeling paint, scuffed and splintered doors, what was done. EI #12 answered he had brought it to the Administrator's attention. Nothing else, he did not have the finances for it. EI #12 was asked when the scuffed and splintered doors were identified. EI #12 answered about a year or so. EI #12 said it was pre-existing. EI #12 was asked what the concern of scuffed and splintered doors was. EI #12 answered it could get a splinter in a resident. EI #12 was asked what the concern of peeling areas of paint was. EI #12 answered the residents could eat it. EI #12 was asked on his check-list, what the third bullet point indicated for him to do during rounds. EI #12 answered to document in detail any findings during rounds. EI #12 said he never documented it. If it was a major issue, he would take care of it immediately. EI #12 was asked if the peeling paint and splintered doors were a major issue. EI #12 answered yes. EI #12 was asked why they were not taken care of immediately. EI #12 answered he could not say. EI #12 was asked why that was not documented. EI #12 answered he did not have the time. EI #12 was asked why was the Administrator not maintaining the original forms in her office, as indicated on the check-list. EI #12 answered he did not know. EI #12 was asked how he could provide follow-up documentation, if no documentation of the concerns existed. EI #12 answered he could not do so. An interview was conducted on 7/10/19 at 12:40 PM, with EI #1, the Administrator. EI #1 was asked what completed environmental forms were maintained in her office. EI #1 answered none. EI #1 added there was an electronic record of what activities maintenance did. EI #1 was asked if she could provide documentation that indicated the wall paint was in good repair (not scuffed or peeling). EI #1 answered the Maintenance Director was telling her what he was working on. EI #1 was asked what documentation she could provide that indicated she was aware of what needed to be done. EI #1 answered the QAPI (Quality Assurance Performance Improvement) rounds that she had made with the Maintenance Director. EI #1 was asked what she had on a weekly basis of the maintenance directors observations of what needed to be done. EI #1 answered she only had what has been done or accomplished. EI #1 was asked how often were QAPI rounds made by her. EI #1 answered at least monthly. EI #1 was asked what was the concern of large pieces of peeling paint. EI #1 answered it was a safety concern. EI #1 was asked what the concern of doors with large splintered areas was. EI #1 answered safety. EI #1 was asked what the concern of broken mini blinds was. EI #1 answered safety and esthetics.

Based on observation, interview, record review and review of the facility policy titled, RESIDENT ASSESSMENT INSTRUMENT (RAI) POLICY, the facility failed to ensure Resident Identifier (RI) #111's Admission Minimum Data Set (MDS) assessment, dated 6/27/19, was coded correctly. This affected RI #111, one of 23 sampled residents whose MDS assessments were reviewed. Findings Include: A review of a facility policy titled, RESIDENT ASSESSMENT INSTRUMENT (RAI) POLICY with an issue date of (MONTH) 28, (YEAR), revealed: .STANDARD OF PRACTICE .3 .Each individual who completes a portion of the Minimum Data Set (MDS) must certify the accuracy of that portion of the assessment .7 . This information helps the interdisciplinary team to plan care that allows the resident to reach his/her highest level of practicable level of functioning . On 7/09/2019, RI #111 was observed by the surveyor sitting up the wheelchair with no lower extremities noted. A review of RI #111's Admission MDS with an Assessment Reference Date (ARD) of 6/27/2019, revealed RI #111 had impairment on one side of the lower extremity. On 07/10/2019 at 5:42 PM, an interview was conducted with Employee Identifier (EI) #9, MDS Coordinator. EI#9 was asked, was the range of motion section coded correctly. EI#9 replied no. EI #9 was asked why was the range of motion (ROM) section not coded correctly on the MDS. EI #9 replied, it was an error. EI# 9 was asked, who was responsible for coding the MDS. EI #9 replied, she was. EI #9 was asked, what was the potential harm to the resident if the ROM was not coded correctly on the MDS. EI #9 replied the CNA and staff may not know how to transfer the resident and could cause more harm to him/her. EI #9 was asked, why should the ROM be coded correctly on the MDS. EI#9 replied, because they were the eyes and ears of the building.

Based on interviews, review of the medical record, review of a facility policy titled, SMOKING POLICY FOR RESIDENTS, and review of a facility document titled, Behavior Management Team Meeting Guidelines, the facility failed to ensure the plan of care was updated with a smoking restriction for Resident Identifier (RI) #93. This affected RI #93, one of five sampled residents identified as smokers whose care plans were reviewed. Findings Include: A review of the SMOKING POLICY FOR RESIDENTS with an issue date of 8/22/17, revealed: . POLICY STATEMENT It is the policy of this facility to establish and maintain safe resident smoking policies . SAFETY RESTRICTIONS: 1. The Attending Physician, Director of Nurses, and the Care Plan Team shall have the authority to make determinations as to which residents are responsible . and to what restrictions , if any, will need to be placed on the resident's smoking privileges. 2. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert to smoking restrictions. A review of a facility document titled, Behavior Management Team Meeting Guidelines with a revision date of 10/26/17, revealed: Purpose: Assure appropriate team interaction to provide timely, resident-specific interventions .Initiate behavior analysis * Review findings and compare information .3. Outcomes of meeting: Update care plan . A review of the medical record revealed RI #93 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set assessment, dated 6/21/19, revealed the resident had a Brief Interview for Mental Status Score of 15 out of a possible 15. This score indicated the resident was cognitively intact for daily decision making skills. A review of the nurses' note dated 7/3/19, timed 16:23 revealed: . Note Text: Resident (RI #93) has been put on 30 days smoking restriction (he/she) has been noncompliant with the smoking rules and procedures at smoking breaks. A review of the nurses' noted dated 6/25/19, timed 12:56 revealed: . (RI #93) exhibited behavior of being non-compliant with smoke break and policy of smoke break. (RI #93) has been counseled about this behavior. It is on-going and (he/she) continues to have behavior. (He/She) cursed staff when (he/she) was redirected about (his/her) behavior. (He/She) is trying to persuade other residents and is threatening them if they don't give her their cigarettes. A review of the plan of care for RI #93 revealed there was no documentation or update indicating when the smoking restriction began or any other specifics of the restriction. An interview was conducted on 7/09/19 at 8:40 AM with RI #93. RI #93 reports his/her smoking privileges had been revoked for 30 days. An interview was conducted on 7/11/19 at 10:01 AM with Employee Identifier (EI) #1, the Administrator. EI #1 reviewed the smoking policy regarding restrictions and RI #93's plan of care. When asked about the event that caused RI #93 to lose smoking privileges not being included in the care plan, EI #1 responded, EI #7, the Social Services Director, should have added it to the care plan. An interview was conducted on 7/11/19 at 10:12 AM, with EI #7, the Social Services Director. EI #7 was shown a copy of the smoking policy and directed to the section regarding restrictions. EI #7 was asked, what the policy indicated regarding restrictions being added to the plan of care. EI #7 answered it should have been noted on the care plan so that all personnel would be alerted to the smoking restrictions. EI #7 was asked what should that update to the care plan have included. EI #7 answered that RI #93 was on restriction, as of what date it began, and how long the restriction would last. EI #7 was asked if that was done and she answered no. EI #7 was asked what was the concern of the update not being added to the plan of care. EI #7 answered staff would not be aware from the care plan about the specifics of the restriction. EI #7 was asked when should that update have been done. EI #7 answered the day RI #93 was placed on restriction or on the next business day, if the Social Services Director was off.

Based on observations, interview and review of a facility policy titled, OXYGEN THERAPY POLICY the facility failed to ensure O2 (Oxygen) tubing and the humidifier water bottle were dated while in use for Resident Identifier (RI) #102. The facility also failed to ensure RI #97's O2 tubing was not found on the floor and the nurse did not attempt to place [MEDICAL CONDITION] back on RI #97 without it being cleaned or changed. This affected RI #102, and RI #97, two of four sampled residents receiving oxygen therapy. Findings Include: 1. A review of a facility policy titled, OXYGEN THERAPY POLICY with an issue date of 11/28//17 revealed, . POLICY STATEMENT Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Action . 8. Change tubing weekly. 9. Date tube when changed (weekly). A review of the medical record revealed RI #102 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #102's physician's orders [REDACTED]. Oxygen via (by way of) nasal cannula PRN (as needed) @ (at) 2 L (Liters) R/T (related to) O 2 SATS (Oxygen saturation level) of < (less than) 94% . An observation was made on 7/08/19 at 4:17 PM of RI #102 receiving Oxygen therapy via nasal cannula at 2 liters per minute (LPM), with no date on the humidifier water bottle or the tubing. An observation was made on 7/09/19 at 2:34 PM of RI #102 receiving Oxygen therapy via nasal cannula at 2 LPM, with no date on the humidifier water bottle or the tubing. An interview was conducted on 7/11/19 10:28 AM with Employee Identifier (EI) #17, the Respiratory Therapist. EI #17 was asked who initiated the Oxygen therapy for RI #102. EI #17 said he put him/her on 2 LPM of oxygen via nasal cannula. EI #17 was asked what day he initiated the oxygen for RI #102. EI #17 answered, on 7/8/19. EI #17 was asked why the tubing and the humidifier bottle were not dated. EI #17 answered he guessed he forgot. EI #17 was asked why it was important to date the tubing and humidifier bottle. EI #17 answered so staff will know when it needed to be change. 2. RI #97 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 7/09/19 at 2:00 PM, the surveyor entered RI #97's room to interview the resident. The surveyor observed the oxygen tubing and [MEDICAL CONDITION] on the floor. EI #3, Registered Nurse, entered RI #97's room. The surveyor asked EI #3 what was the blue tubing. EI #3 replied oxygen. The surveyor asked if RI #97 was on continuous O2. EI #3 replied, yes. The surveyor asked where was the mask and tubing. EI #3 replied, on the floor. EI #3 picked up the mask and tubing and was attempting to place the oxygen mask back on RI #97 when RI #97 spoke up and said she could not put that back on until it was cleaned. EI #3 asked the medication nurse, EI #4, to get a [MEDICAL CONDITION]. EI #4 entered the room with a clean mask. The surveyor asked EI #4 if the blue tubing and the mask was on the floor what should be changed. EI #4 replied, all of it, the tubing and mask. EI #4 left the room to get clean tubing and returned. On 7/10/19 at 9:19 AM, an interview was conducted with EI #3. EI #3 was asked when should the oxygen tubing be on the floor. EI #3 replied, never. EI #3 was asked what should be done if the oxygen tubing and mask was found on the floor. EI #3 replied, it should all be replaced. EI #3 was asked when should staff use the same oxygen tubing and mask that was on the floor. EI #3 replied, they should not. EI #3 was asked what was the harm in using tubing that was on the floor. EI #3 replied, infection.

Based on observation, interview and review of a facility policy titled, ADMINISTRATION OF MEDICATIONS, the facility failed to ensure the medication nurse locked the cart when unattended. This was observed on 7/10/19, and affected one of five nurses observed during medication administration and had the potential to affect the resident observed in the hallway at that time. Findings Include: A review of a facility policy titled, ADMINISTRATION OF MEDICATIONS with a revised date of (MONTH) 2019 revealed: .Action . 8. During administration of medications; the medication cart is kept closed and locked when out of sight of the medication nurse On 7/10/19 at 8:13 AM the surveyor observed Employee Identifier (EI) #6, Licensed Practical Nurse (LPN) push the medication cart up the hall. EI #6 stopped it at the nurses station. EI #6 left the cart in the hall and went into the restroom to wash her hands. EI #6 left the cart unattended and unlocked while she was in the restroom washing her hands. While the cart was left in the hall unattended and unlocked, two surveyors were in the hall and two staff passed by the cart. One resident was sitting in the wheelchair in the hall. EI #6 returned to the cart after washing her hands, realized the cart was unlocked and locked the cart. EI #6 proceeded down the hall to continue medication administration. On 7/10/19 at 8:24 AM an interview was conducted with EI #6. EI #6 was asked when should the medication cart be left unlocked. EI #6 replied, never. EI #6 was asked when the medication cart was unattended, was she at the cart. EI #6 replied, no. EI #6 was asked how long was the cart unattended and unlocked. EI #6 replied, maybe a minute, but it should be locked if unattended. EI #6 was asked who was around the medication cart. EI #6 replied, the surveyors and she was not sure of others. EI #6 was asked what was the harm of leaving a medication cart unlocked and unattended. EI #6 replied, anyone could get in it.

Based on observation, interview, record review and review of facility policies LAUNDRY AND BEDDING, SOILED, BED BATH, and PERINEAL (SKIN) CARE FOR INCONTINENT RESIDENT, the facility failed ensure: 1. soiled linen was not placed in Resident Identifier (RI) #97's closet, 2. Certified Nursing Assistants (CNA)s did not use wash cloths that had been used to clean bowel movement from RI #97 to give him/her a bed bath, including the groin area, and 3. a CNA did not touch a clean pad, Oxygen tubing, clean pillows and linens with the same soiled gloves which were used to clean bowel movement from RI #97. Findings Include: 1. A review of a facility policy LAUNDRY AND BEDDING, SOILED with a revised date of (MONTH) 1, (YEAR), revealed: POLICY INTERPRETATION AND IMPLEMENTATION .2. Place contaminated laundry in a bag or container at the location where is is used . RI #97 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 7/10/19 at 9:59 AM, family visiting RI #97 called the surveyor to the room. The family member said they were placing clean clothing in RI #97's closet and found a bundle of bed linens in the closet. The surveyor observed a ball of linens; noted were two sheets, two blankets and a green pad. These linens were not in a trash bag. An interview with RI #97 at this time revealed the resident did not know exactly when the linens were placed in the closet. RI #97 said he/she thought the staff changed the linens in the night, but not sure of the time. On 7/10/19 at 10:09 AM, an interview was conducted with Employee Identifier (EI) #5, CNA, as she entered the resident's room to check on the resident and noticed the ball of linen. EI #5 was asked where was linen to be placed when removed from a resident's bed. EI #5 replied, in a bag then in a soiled barrel. EI #5 was asked when should soiled linen be placed in a resident's closet. EI #5 replied, it should not be in there; that was nasty. EI #5 was asked who put the linens in the closet. EI #5 replied, she did not know but it had to have been the evening or night shift as RI #97 received a bath on the 3 PM-11 PM shift ;or night shift if the bed required to be changed. EI #5 was asked what was harm of soiled linen being placed in the closet. EI #5 replied, it could pass germs to resident, family or other staff. On 7/11/19 at 8:16 AM, during an interview with EI #2, DON (Director of Nursing)she was asked where should staff place linens when removed from a resident's bed. EI #2 replied, if dirty place them in a soiled bag and take them to the soiled utility room. EI #2 was asked when should soiled linens be placed in a resident's closet in the room. EI #2 replied, never. EI #2 was asked what was the harm in soiled linens being placed in a resident's closet. EI #2 replied, contaminating everything in the closet. 2. A review of an undated facility policy titled BED BATH revealed: . Action .12. wash, rinse, and dry the chest and abdomen .Wash, rinse, and pat dry the leg and foot. 13. Repeat with other leg and foot. 14. Change the bath water. Apply gloves . 15. Turn the resident to the side. 16. Wash, rinse and dry from the neck to the buttocks, including anal area. 17. Change the water. Remove and discard gloves, if worn. Wash hands and obtain a new pair of gloves. Obtain a fresh wash cloth and towel. 18. Provide perineal care. On 7/10/19 at 5:00 PM, the surveyor observed CNAs give RI #97 a bed bath. The CNAs gathered supplies including three wash cloths, a green pad, a hospital gown and soap and two bath basins. EI #10, CNA filled both basins with warm water and she and EI #11, CNA, gave the bed bath. EI #10 took a wash cloth from the wash basin, placed soap on the cloth and washed RI #97's lower abdomen and groin area. Bowel movement was observed on the wash cloth. EI #10 put the cloth in the rinse basin and rinsed the soap. Using the same cloth, EI #10 rinsed the soap from RI #97's lower abdomen and groin area. Both CNAs turned RI #97 to the left side and EI #10 washed the lower back and buttock area with the same cloths use to clean bowel movement from the front side. On 7/10/19 at 5:25 PM, an interview was conducted with EI #10, CNA. EI #10 was asked how should she give a bed bath. EI #10 replied, get supplies of five wash cloths, pads, linens, gown, soap and basins. EI #10 said one was for wash and one was for rinse, but she got mixed up and put the soiled cloth in both basins. EI #10 was asked if there was bowel movement on the cloths in both basins. EI #10 replied, yes. EI #10 was asked when should the same wash cloth used to clean bowel movement from a resident be used to continue with the bath. EI #10 replied, we were not supposed to we, were supposed to have a clean cloth. 3. A review of a facility policy titled PERINEAL (SKIN) CARE FOR INCONTINENT RESIDENT with a review date of (MONTH) (YEAR), revealed: . PRACTICE GUIDELINES .Action .4. Wash the resident's entire perineal area .6. Rinse the perineal area .7. Discard soiled linen. 8. Dry the perineal area .10. Remove gloves and discard. Wash Hands. 11. Place a dry brief (Pad) on the resident. 12. Replace any other articles .that may have been removed . On 7/10/19 at 5:00 PM, the surveyor observed EI #10,CNA place a clean brief under RI #97 with the same soiled gloves she had on to clean bowel movement from the resident. EI #10 repositioned RI #97's oxygen tubing and put clean pillows for positioning for the resident and touched the top clean linen with the same soiled gloves she had on to clean the bowel movement from RI #97. On 7/10/19 at 5:25 PM an interview was conducted with EI #10, CNA. EI #10 was asked when should gloves be changed during incontinent care. EI #10 replied, any time the gloves get soiled. EI #10 was asked if her gloves were soiled. EI #10 replied, yes with bowel movement. EI #10 was asked if she changed her gloves. EI #10 replied, no. EI #10 was asked when should she touch a clean pad, resident's oxygen tubing, clean linen and pillows with soiled gloves. EI #10 replied, they were not supposed to do it that way. EI #10 was asked what would the harm be in using a wash cloth soiled with bowel movement to continue with a bath. EI #10 replied, pass germs. EI #10 was asked what would the harm be in touching a clean pad, oxygen tubing, clean linen and resident pillows with soiled gloves. EI #10 replied, passing germs. On 7/11/19 at 8:16 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked what was the policy for giving a bed bath. EI #2 replied, get a basin of clean water and rinse water, then change wash cloths and water if soiled with bowel movement. EI #2 was asked if staff cleaned bowel movement from a resident during the bed bath what should be done with the wash cloths and water. EI #2 replied, discard the water and get new cloths and water. EI #2 was asked when should staff clean bowel movement from a resident then place the soiled wash cloth in the water basin, rinse it and use it again to continue with the bath. EI #2 replied, never. EI #2 was asked what was harm in staff using a wash cloth soiled with bowel movement to give a bed bath. EI #2 replied, infection issue. EI #2 was asked what was the policy for incontinent care. EI #2 replied, wash with clean cloths change sides of the cloth, get clean water if resident had a bowel movement. EI #2 was asked when should the CNA change their gloves during incontinent care. EI #2 replied, when soiled, and when changing the water, they should change gloves. EI #2 was asked when should the CNA clean bowel movement from the resident then with the same soiled gloves touch a clean pad, linens and oxygen tubing. EI #2 replied, never. EI #2 was asked what was the harm in a CNA touching oxygen tubing, a clean pad and linens with soiled gloves. EI #2 replied, infection control issues.

Based on observation and interviews with facility staff, this facility failed to ensure three of three emergency medication kits (E-kits) were not found with expired medications. Findings Include: An observation was made on 6/21/18 at 9:34 AM, of the third floor medication room E-kit with EI #6, Licensed Practical Nurse (LPN). The E-Kit contained the following medication, along with the expiration date: [MEDICATION NAME] injectable 1:1000 1mg/ml (Quantity (qty) 2) which expired 5/18 An observation was made on 6/21/18 at 9:51 AM, of the ground floor E-Kit with EI #2, Director of Nursing (DON). This E-kit contained a bright pink sticker that indicated: the box expires 5/01/18 and listed 2 meds that have expired. [MEDICATION NAME] injectable 1:1000 1MG/ml (qty 2) which expired 05/18 and [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]) 50 mg/ml 2ml vial which expired 06/18 An observation was made on 6/21/18 10:02 AM, with EI #2, DON of the Second floor E-kit box. This box contained [MEDICATION NAME] injectable 1:1000 1mg/ml (qty 2), which expired 5/18 On 6/21/18 at 5:07 PM, an interview was conducted with the pharmacy consultant that would have been responsible for changing out the expired E-kits. The pharmacy consultant was interviewed by phone was asked what was the process for ensuring emergency medication kits were replaced prior to expiration. The pharmacy consultant responded by saying, in general the pharmacy picks up E-kits weekly and the driver changes them out. When asked why was it important to ensure expired medications were not stocked and available for use in the facility, the consultant responded by saying, to prevent giving an expired medication. An interview was conducted with EI #2, DON on 6/21/18 5:12 PM. EI #2 was asked who was responsible for ensuring the drivers for the pharmacy picked up expired emergency medication kits. EI #2 answered, the nurses. When asked what the expiration date on the E-Kits for all three floors of the facility was, EI #2 answered 5/1/18. When asked what medications were found to be expired, EI #2 responded by saying [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and [MEDICATION NAME]. When asked what the process was for ensuring emergency medication kits were replaced prior to expiration, EI #2 answered that it was checked monthly by the consultant and should be checked weekly by the nurses for expiration dates. When asked when the last date the pharmacy consultant visited, EI #2 stated, last week. When asked if there was a log for those dates, EI #2 said no. EI #2 was asked what the facility's policy was for ensuring expired medications were not stored and available for use in the facility. EI #2 said that once it is noticed the expiration date is near or has or expired, the pharmacy would be notified and the pharmacy would swap them out. When asked what was the concern of expired medications being in stock at the facility, EI #2 said that someone could give an expired med to a resident.

Based on observations, interview and record review, the facility failed to ensure: 1) food items stored in residents nourishment refrigerators were labeled properly and disposed of prior to expiration dates. This deficient practice had the potential to affect all of the residents in the facility that received nourishments from the the residents nourishment refrigerators. This was observed in two of three nourishment rooms in the facility. 2) thermometers were sanitized between food items while checking food temperatures prior to food service for lunch on [DATE] at 11:40 AM. This deficient practice had the potential to affect all the residents in the facility that receive lunch trays. Findings include: 1) The facility's policy, USE & STORAGE OF FOOD & BEVERAGE BROUGHT IN FOR RESIDENTS, FOOD PR[NAME]UREMENT date of issue [DATE], revealed Standard Of Practice (b) Educate and Inform * . This education will include at a minimum: . 4. Proper labeling and dating of each item. 5) Leftover foods will be used within 3 days or discarded. On [DATE] @ 10:40 AM, an observation was made of the third floor nourishment refrigerator observed with Employee Identifier, (EI)#6, Registered Nurse, (RN)/Unit Manager. The following observations were made: 3 bags of food, 1 half bottle of soda, 1 bottle of water in a clear baggie, 1 coffee container and 1 half bottle of coffee creamer. There was no name or date on the refrigerated opened items. Also, noted was 1 empty box in the freezer with no name or date. Dried substances were noted in bottom of freezer and refrigerator. On [DATE] @ 10:48 AM, an observation was made of the second floor nourishment refrigerator with EI #5, Certified Nursing Assistant, (CNA). The following observations were made: 1 bag of food and 1 cup with a lid in the refrigerator door with no name or date opened. Eight cartons of [MEDICATION NAME] 1.2 noted in the refrigerator door with an expiration date of [DATE]. One box of popsicles, with two remaining, in the freezer with GRANT written on box, no date opened and an expiration date of [DATE]. One half full bottle of red Powerade, 1 insulated cup with a lid and one box of pre-packaged green vegetables in the freezer with no name or date opened. On [DATE] @ 4:35 PM an interview was conducted with EI #6. EI #6 was asked what was the facility's policy and procedure pertaining to storage of food brought in for residents. EI #6 replied, to put the resident's name and date on a label. EI #6 was asked if the food in the residents nourishment refrigerator on the third floor, observed the day before, was labeled. EI #6 replied, all of it was not labled. The UM was asked if the residents nourishment refrigerator was clean when they observed it. EI #6 reported there were some things in it that needed to be thrown out that did not have names or dates on it. When asked who was responsible for cleaning the residents nourishment refrigerators, EI #6 replied the ,[DATE] shift CNAs each night and the nurses monitor the CNAs. On [DATE] at 5:15 PM, an interview was conducted with EI #5, CNA. EI #5 was asked what was the facility's policy and procedure pertaining to storage of food brought in for residents. EI #5 replied, to put the resident's name and date on a label. EI #5 was asked about cleaning the refrigerators. EI #5 reported they, the CNAs, were to keep the refrigerator cleaned out weekly and throw out items weekly that need to be discarded. The CNA admitted the [MEDICATION NAME] in the refrigerator in was expired. 2) A review of facility policy and procedure titled FOOD: PREPARATION with a revised date of ,[DATE] was conducted. The policy read, Procedures . 3. All utensils, . will be cleaned and sanitized after each use. On [DATE] @ 11:40 AM, the surveyor observed the tray line & temperature checks with the morning cook, EI #4. At this time EI #4, was observed checking the temperatures of food items and wiping the thermometers with a wet cloth between food temperature checks. EI#4 did not sanitize thermometers between each food or liquid temperature check. [DATE] at 5:30 PM, an interview was conducted with the Dietary Manager, EI# 7. She was asked what was the facility's Policy & Procedure for checking temperatures prior to food service in the facility. EI #7 replied, to check temperatures prior to placing on the tray line; they have alcohol prep pads and they wipe the thermometer prior to placing the thermometer into the food. She reported they never use the same thermometer for another food item. They try not to. EI #7 was asked how should the thermometer be sanitized between food items, (if they had to reuse a thermometer on a tray line). The DM reported they would have to use a Sanitizer wipe or alcohol prep pad. EI #7 was asked why should the thermometer be sanitized between food items. She responded, so you will not cross contaminate. EI #7 was asked what was the potential negative outcome for the residents if the thermometer was not sanitized prior to checking temperatures of a different food item. She replied, it could make them sick.

Based on observations, interviews and review of a list of resident rights, provided by the facility, the facility failed to ensure AL (Area Locators) 1-6 were not found with missing paint, exposed sheetrock, and an unpainted piece of plywood on a wall. This was observed on area locators 1-6, on one of three floors of the facility Findings Include: The facility's copy of the Resident Rights read, 57. The resident has a right to a safe, clean, comfortable and homelike environment, . 06/20/18 09:11 AM, observations were made of the following areas: 1) Peeled paint on metal trim of windows in the dining area on third floor on the hallway side, AL #1, 2) Peeled paint with rough edge at the base of a hand rail mounting bracket between windows listed above and dining room door, AL #2, 3) Doors to the dining room on 3rd floor were scuffed and splintered, AL #3, and 4) Peeling paint was observed on the base boards down the entire hall, Al #4. 06/20/18 09:19 AM , an observation was made of AL #5. The kickboard on the door was loose on the hinge side of door, curled up and sticking out about 2 inches at bottom. In the same area, on the corner wall next to the hand basin, the corner of floor molding was missing and exposed sheet rock was noted. This was approx 8 inches of the molding. At the head of B bed in this same area , and observation was made of a piece of unpainted plywood approx 2 feet high and 3 feet wide. 06/21/18 10:27 AM, an observation was made of a painted hand rail in place at nurses station, AL #6 on both walls that were approximately 8 feet long. The paint was peeling across the entire top of the rail. 06/21/18 03:41 PM, during a tour with the Administrator Employee Identifier (EI) #1 and Maintenance Director, EI #3, an interview was also conducted at that time. EI #3, was asked to describe what he saw on the painted surface outside of the dining room on the third floor. EI #3 answered, in need of repair. When EI #3 was asked if he considered this clean comfortable and homelike. EI #3 replied, no. 06/21/18 05:26 PM, in an interview with EI #1, she was asked what the facility policy on maintaining patient areas was. EI #1 reported maintenance rounds weekly. They have daily housekeeping services and the clinical leadership and the Administrator make rounds. She also reported the CNAs were also responsible for maintaining sanitary condition, as well as providing care. EI #1 reported the policy was to assess weekly and work orders were submitted to maintenance and follow up during daily morning meetings. When asked if she considered the previously viewed concerns clean, comfortable and homelike, EI #1 replied, no and they have been addressing the issues.

Based on observation, interviews and review of the facility's policy titled Medication Administration Eye Drops, the facility failed to ensure a Licensed Practical Nurse did not place a box containing eye medication and a top of an eye drop medicine bottle on an uncleaned over-the-bed table. This affected RI (Resident Identifier) #7, one of six residents observed during medication administration. Findings Include: The facility's policy titled Medication Administration Eye Drops, dated 05/16, revealed Procedures 5. place cap on a clean . surface . On 06/20/18 at 9:18 AM, Licensed Practical Nurse (LPN) EI (Employee Identifier) #9, was observed during Resident Identifier (RI) #7's medication administration. EI #9 placed a box with Olopatadine 0.2% eye drops on the uncleaned, uncovered bare surface of the resident's over bed table (obt). After washing her hands and donning gloves, EI #9 removed the cap from med bottle, laid it on the uncleaned, uncovered bare surface of the obt. EI #9 administered the drop to the resident's eye, returned the cap to med bottle, then back to the box and placed the box back on the same obt. EI #9 ungloved, washed her hands and then returned the eye drop box to the med cart. On 6/20/18 at 10:00 AM, LPN EI #9 was interviewed. She was asked if she administered eye drops to RI #7. She replied, yes. When asked where she placed the box containing the bottle of medicine, EI #9 replied on the bedside table. When asked where she placed the top of the medicine bottle while administering the eye drops. She replied, she put it on the table. When asked what she did after administering the eye drop to RI #7, EI #9 said she gave the resident a tissue and put the top back on the bottle, put it in the box on the table and washed hands. When asked was the surface of the obt free of contaminants. EI #9 replied that if it looked sticky, she would considered it contaminated and would have cleaned it or put some type of barrier there. When asked how she knew if it was sticky, EI #9 replied, she didn't. When asked what was the facility policy regarding preventing cross contamination when administering medicines, EI #9 answered, hand washing and sanitizing the surface, putting a barrier, using gloves and infection control stuff. When asked was there a concern of placing a box of medicine on an uncleaned obt and returning it to the medication cart, EI #9 answered, cross contamination. On 06/21/18 at 4:07 PM, an interview was conducted with the DON, EI #2. She was asked if she considered a surface uncontaminated if it was not visibly sticky. EI #2 replied, no unless you knew for a fact it has been disinfected. When asked what was the facility's policy regarding preventing cross contamination when administering medications, she answered, use hand washing between residents, using gloves during direct contact, and barriers for surfaces. When asked what was the concern of placing a box of medicine on an uncleaned obt and returning it to the medication cart, EI #2 replied, cross contamination. When asked what was the concern of placing an eye drop medicine bottle lid on an unclean surface and returning it to the medicine bottle, she answered, cross contamination.

Based on a review of Resident Identifier (RI) #1's medical record, the facility's policy titled CAREPLANS, an unlabeled report prepared by Employee Identifier (EI) #4, EI #3's handwritten note and Employee Corrective Action Form, RI #1's hospital record and staff interviews, the facility failed to ensure EI #3, a Certified Nursing Assistant (CNA) transferred RI #1, a resident totally dependent on staff for transfers as care planned. RI #1 was care planned to be mechanically lifted for transfers with the assistance of two people. During a transfer on 5/6/17, EI #3 utilized a Hoyer (mechanical) lift to transfer RI #1 from the wheelchair to the bed by herself. During the transfer, RI #1 fell from the Hoyer lift and sustained a fractured left elbow, a fractured left shoulder and a broken arm. This affected RI #1, one of five residents sampled for falls. Findings include: The facility's policy titled, CAREPLANS with an issue date of November 2016, revealed . POLICY STATEMENT Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . RI #1 was admitted to the facility on [DATE]. RI #1's Quarterly Minimum Data Set with an assessment reference date of 5/5/17, revealed RI #1 was totally dependent on staff for transfers and required two plus persons physical assistance. RI #1's care plan titled The resident has an ADL (activity of daily living) Self Care Performance Deficit r/t (related to) [MEDICAL CONDITION], Limited Mobility, highly impaired vision last reviewed 2/15/17 had an intervention of . MECHANICAL LIFT FOR TRANSFERS WITH 2 PERSON ASSIST . RI #1's care plan titled Risk for Falls r/t Left Side hemi ([MEDICAL CONDITION]) . last revised 2/15/17 had an intervention of . MECHANICAL LIFT WITH 2 STAFF ASSIST FOR TRANSFERS . An unlabeled report dated 5/6/17 4:40 PM, prepared by EI #4, a Charge Nurse, revealed, RI #1 was transferred from the wheelchair to the bed and fell to the floor. The CNA stated the lift pad came off the hook. RI #1 complained of extreme pain in the left arm. Orders were received to send RI #1 to the hospital for evaluation and x-rays. An interview was conducted with EI #4, the Charge Nurse at the time of the incident, on 6/1/17 at 9:57 AM. EI #4 was asked what the care plan for RI #1 indicated regarding transfers at the time of the incident. EI #4 answered, It should be two people transferring (him/her) per Hoyer lift. EI #4 was asked what was the facility's policy regarding following the plan of care. EI #4 answered, Exactly that, following the plan of care. EI #4 was asked what was the concern of a staff member transferring a resident with a Hoyer lift, without the needed second person assisting. EI #4 answered the major concern was a patient could fall. A handwritten note written by EI #3, a CNA, dated 5/8/17 documented To Whom It May Concern: I (EI #3) was tranfereing (transferring) (RI #1) with the holyer (Hoyer) without assistance which end up in (RI #1) falling out of the lifter. It was my fault that I didn't ask anyone to spot me. So its no one fault but my own. An interview was conducted with EI #3, a CNA, on 6/1/17 at 9:42 AM. EI #3 was asked what the care plan for RI #1 indicated regarding transfers at the time of the incident. EI #3 answered Hoyer lift, two person assist. EI #3 was asked what was the facility's policy regarding following the plan of care. EI #3 answered to follow the plan of care. EI #3 was asked what was the concern of not following the plan of care. EI #3 answered, They (residents) won't get the care they are supposed to get. EI #3's Employee Corrective Action Form dated 5/8/17 revealed EI #3's employment with the facility was terminated due to EI #3 using the mechanical lift without assistance during the transfer of a resident (RI #1) that resulted in a fall with injury. An interview was conducted with EI #5, the Director of Nursing Services, on 6/1/17 at 2:13 PM. EI #5 was asked to recount the fall RI #1 had sustained on 5/6/17. EI #5 reported, RI #1 was being transferred by one CNA with mechanical lift . EI #5 was asked to summarize the cause of the fall and she answered one staff member used the lift without assistance. EI #5 was asked what the care plan for RI #1 indicated regarding transfers at the time of the incident. EI #5 answered, Mechanical lift with 2 assist. EI #5 was asked what was the facility's policy regarding following the plan of care. EI #5 answered, Each staff member has access to the Kardex and they are to use it to guide care. EI #5 was asked what was the concern of not following the plan of care. EI #5 answered, The patient doesn't get the appropriate or safest care. A review of RI #1's hsopital medical record revealed on 5/6/17 RI #1 was seen in the emergency room of the local hospital. The chief complaint was listed as fall. According to the record, RI #1 fell while being transferred from a wheelchair to bed and had symptoms of upper extremity and acute left shoulder pain. RI #1 was diagnosed as having a fractured left elbow, a fractured left shoulder and a broken arm.

Based on a review of the facility's policy titled MECHANICAL LIFT, Resident Identifier (RI) #1's medical record, an unlabeled report prepared by Employee Identifier (EI) #4, RI #1's hospital record, EI #3's handwritten note and Employee Corrective Action Form and resident and staff interviews, the facility failed to ensure EI #3, a Certified Nursing Assistant (CNA) had another staff person present when she used a mechanical (Hoyer) lift to transfer RI #1 from the wheelchair to the bed on 5/6/17. During the transfer, RI #1 fell to the floor and sustained a fractured left elbow, a fractured left shoulder and a broken arm. This affected RI #1, one of five residents sampled for falls. Findings include: The facility's policy titled, SUBJECT: MECHANICAL LIFT dated 1/4/10, revealed . Standards: . For safety, two or more personnel must be in attendance when a mechanical lift is used . RI #1 was admitted to the facility on [DATE]. RI #1's Quarterly Minimum Data Set with an assessment reference date of 5/5/17 indicated RI #1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. RI #1 was assessed as being totally dependent on staff for transfers. An unlabeled report dated 5/6/17 4:40 PM, prepared by EI #4, a Charge Nurse revealed, RI #1 was transferred from the wheelchair to the bed and fell to the floor. The Certified Nursing Assistant (CNA) stated the lift pad came off the hook. RI #1 complained of extreme pain in the left arm. Orders were received to send RI #1 to the hospital for evaluation and x-rays. An interview was conducted with EI #4, the Charge Nurse at the time of the incident, on 6/1/17 at 9:57 AM. EI #4 was asked to recount the fall RI #1 sustained on 5/6/17. EI #4 stated she heard a loud noise and ran in the direction of the noise. According to EI #4, EI #3 (CNA) placed her head out of RI #1's room and stated the noise came from in there. EI #4 stated she entered RI #1's room and saw the resident on the floor with the Hoyer (mechanical) lift over the resident. EI #4 stated the CNA (EI #3) said she was in the process of transferring the resident when the strap came loose from the Hoyer lift. When asked what caused RI #1's fall, EI #4 stated the Hoyer lift pad came off the lift. EI #4 was asked what was the concern of a staff member transferring a resident with a Hoyer lift, without the needed second person assisting. EI #4 answered the major concern was a patient could fall. A handwritten note written by EI #3, a CNA, dated 5/8/17 documented To Whom It May Concern: I (EI #3) was tranfereing (transferring) (RI #1) with the holyer (Hoyer) without assistance which end up in (RI #1) falling out of the lifter. It was my fault that I didn't ask anyone to spot me. So its no one fault but my own. An interview was conducted with EI #3, a CNA, on 6/1/17 at 9:42 AM. EI #3 was asked to recount the fall RI #1 sustained on 5/6/17. EI #3 stated she was transferring RI #1 from the wheelchair to the bed with the Hoyer lift. EI #3 acknowledged she did not have another staff person assisting her; she did it alone. EI #3 stated the Hoyer lift pad might not have been hooked completely and RI #1 fell to the floor. When asked what caused the fall, EI #3 stated she was in a hurry, she failed to make sure the Hoyer lift pad was hooked and failed to have someone spot her. EI #3 was asked what was the concern of a staff member transferring a resident with a Hoyer lift, without the needed second person assisting. EI #3 answered, An injury. EI #3's Employee Corrective Action Form dated 5/8/17 revealed EI #3's employment with the facility was terminated due to EI #3 using the mechanical lift without assistance during the transfer of a resident (RI #1) that resulted in a fall with injury. In an interview on 6/1/17 at 1:08 PM, RI #1 stated he fell from the Hoyer lift while being transferred by one person from the chair to the bed. RI #1 stated he/she was two or three feet off the floor when the pad came off the Hoyer lift. RI #1 stated it was supposed to be two people. An interview was conducted with EI #5, the Director of Nursing Services, on 6/1/17 at 2:13 PM. EI #5 was asked to recount the fall RI #1 sustained on 5/6/17. EI #5 reported, RI #1 was being transferred by one CNA with mechanical lift. It was reported one of the straps of the Hoyer pad came off of the lift resulting in the patient falling. EI #5 was asked to summarize the cause of the fall and she answered one staff member used the lift without assistance. A review of RI #1's hospital medical record revealed on 5/6/17 RI #1 was seen in the emergency room of the local hospital. The chief complaint was listed as fall. According to the record, RI #1 fell while being transferred from a wheelchair to bed and had symptoms of upper extremity and acute left shoulder pain. RI #1 was diagnosed as having a fractured left elbow, a fractured left shoulder and a broken arm.

Based on an observation, an interview, and a review of the 2013 Food Code, the facility failed to ensure the grease disposal container was not found with a heavy accumulation of food particles. This had the potential to affect all 89 residents receiving meals from the kitchen. Findings include: A review of the Food Code . 2013 U.S. (United States) DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service · Food and Drug Administration revealed: .5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils. All containers must be maintained in good repair and cleaned as necessary in order to store garbage and refuse under sanitary conditions as well as to prevent the breeding of flies . An observation was made on 5/31/17 at 6:09 p.m. in the presence of EI (Employee Identifier) #2, the Dietary Manager, of the grease disposal container. The container was observed with a heavy buildup on the grates, a chicken wing, and spaghetti noodles. An interview was conducted with EI #2 on 6/1/17 at 2:52 p.m. EI #2 was asked to describe the condition of the grease trap on 5/31/17 during the observation with the surveyor. EI #2 answered, Heavy buildup of food particles. EI #2 was asked what was the concern of a heavy buildup of food crumbs/debris including spaghetti and chicken. EI#2 answered, Not to attract rodents and pests. EI #2 was asked what was the facility policy or guidelines related to upkeep of the grease trap. EI #2 answered, We have to call for it to be cleaned when it needs it.

Based on record review and interviews, the facility failed to ensure 12 hours of in-service education was provided to CNAs (Certified Nursing Assistants). This affected 10 of 10 CNA files reviewed for training hours. Findings include: On 5/26/2016 at 4:05 PM, a review of CNA training was conducted on EI (Employee Identifier) #'s 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14. EI #5's hire date was 9/26/14. EI #6's hire date was 3/11/15. EI #7's hire date was 1/02/15. EI #8's hire date was 5/08/14. EI #9's hire date was 4/15/04. EI #10's hire date was 5/22/15. EI #11's hire date was 12/19/13. EI #12's hire date was 8/25/14. EI #13's hire date was 8/25/14. EI #14's hire date was 2/15/01. A review of the CNA files did not indicate the CNAs received 12 hours of annual in-service education. The facility was asked by the surveyor to provide proof that the CNA files reviewed had the 12 hours required annually for in-service education. The facility provided sign-in sheets with no indication of the length. Computer classroom training had no hours of proof for the hours provided. The surveyor repeatedly asked the facility to provide hours of proof and the facility failed to do so. On 5/26/2016 at 4:51 PM, an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked what was the policy regarding CNA (Certified Nursing Assistant) training. EI #1 stated, We do monthly in-services, we follow guidelines for standardized guidelines for suggested trainings and any other pertinent issues, whatever is going on. EI #1 was asked how many hours of training should CNAs complete. EI #1 said, 12 hours. EI #1 was asked who was responsible for ensuring the CNAs obtain the required training and why is it important to do so. EI #1 stated, Staff Development Coordinator, me, to keep abreast of changes and population and reinforce the knowledge they already have. EI #1 was asked who was responsible for ensuring that the required training was completed. EI #1 stated, Me. EI #1 was asked what evidence could she provide that the training was completed. EI #1 said, I can only provide monthly in-services with sign in logs and now we are on (named computer program) learning. EI #1 was asked what training should include. EI #1 stated, Dementia and abuse. EI #1 was asked how CNA competencies were monitored. EI #1 said, Skills check off list, pericare, hand washing as regular skills, and if something is going on. EI #1 was asked what was done to address any lack of competencies. EI #1 stated, Educational Training In-services. EI #1 was asked what training was offered regarding dementia and abuse. EI #1 stated, We have stop, look and listen on dementia. Dementia on (named computer program), abuse quarterly, and abuse and resident rights. EI #1 was asked if proof could be provided for 12 hours training on all 10 CNA s selected for training review. EI #1 stated, Not all 12 hours. On 5/26/2016 at 5:23 PM, an interview was conducted with EI #2, the Administrator. EI #2 was asked what was the policy regarding CNA training. EI #2 stated, We had (named computer program) learning the first part of this year. We have mandatory in-services that gives us a reminder by a certain date. The system sends a notice with so many people so far. Every month on the 1st pay day a mandatory nursing meeting is held. EI #2 was asked how many hours of training should CNAs complete. EI #2 said, 12 hours. EI #2 was asked who was responsible for ensuring the CNAs obtained the required training and why was it important to do so. EI #2 responded, Through nursing, and staffing does (during) orientation. EI #2 was asked who was responsible for ensuring that required training was completed. EI #2 said, EI #1's name. EI #2 was asked what training should include. EI #2 stated, Abuse or in-service individually, Fire Safety, Infection Control, Blood Borne Pathogen, other topics and as needed.

Based on record reviews and interviews, the facility failed to ensure RI (Resident Identifier) #17 received notification of the end of Medicare benefits two days prior to the expected end of those benefits. This affected RI #17, one of three closed records reviewed. Findings include: A review of the Centers for Medicare and Medicaid (CMS) document titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- revealed, . When to Deliver the NOMNC A Medicare provider or health plan . must deliver a completed copy of the Notice of Medicare Non-Coverage . to beneficiaries/enrollees receiving covered skilled nursing, home health . The NOMNC must be delivered at least two calendar days before Medicare covered services end . A review of the medical record for RI #17 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set) assessment dated [DATE], revealed RI #17 had long and short term memory deficit. RI #17 had moderately impaired cognition. A review of the closed medical record revealed there was no notification of Medicare Non-Coverage for RI #17. An interview was conducted with EI (Employee Identifier) #4, the Business Office Manager, on 5/26/16 at 4:45 PM. EI #4 was asked how many days was RI #17's stay at the facility. She answered 21 days. EI #4 was asked how was RI #17 notified of the expected end of Medicare benefits. She answered there was no notification because it had been predetermined the resident would not stay past 21 days and incur any charges. EI #4 was asked if a resident stayed 20-21 days, should the resident receive notification of benefits end date. She answered that she was taught a change in the level of care is what warranted a notification of Medicare non-coverage. EI #4 was asked to review the CMS form and was asked when should notice be given. She answered, It says they should be given notice two days in advance. EI #4 was asked if RI #17 was given notice two days prior to the expected end of benefits and she answered no. EI #4 was asked if RI #17 should have been notified. She answered according to this yes, but there are circumstances that determine it. An interview was conducted with EI #2, the Administrator, on 5/26/16 at 5:02 PM. EI #2 was asked how long RI #17 was admitted to the facility. He answered 21 days. EI #2 was asked how RI #17 was notified of the expected end of Medicare benefits. He answered he/she wasn't because he/she discharged on the 21st day and it was a planned discharge. EI #2 was asked to review the CMS form and was asked when should notice be given. He answered two days before the Medicare Coverage ended. EI #2 was asked if RI #17 was given notice two days prior to the expected end of benefits. He answered no. EI #2 was asked if RI #17 should have been given notification and he answered yes.

Based on interviews, record reviews, review of the facility's Nursing Admission Check-Off List and review of the facility's Glucometer Manufacture's Specifications, the facility's licensed nursing staff failed to obtain and monitor blood glucose levels (blood sugars) for a newly admitted diabetic resident, Resident Identifier (RI) #1. On 02/22/12 on the 7:00 AM - 3:00 PM shift, RI #1 was admitted to the facility with [DIAGNOSES REDACTED].#1's blood glucose level with finger stick four times a day (before each meal and bedtime). Employee Identifier (EI) #1, a licensed staff member who entered RI #1's admission orders [REDACTED]. This failure resulted in the facility failing to monitor the resident's blood glucose level with the finger stick for 12 days. EI #1 admitted that she failed to check if the blood glucose order was listed on the e-MAR. This failure resulted in RI #1 missing 44 blood glucose checks over a 12 day time frame (02/22/12 - 03/04/12). On 03/04/12, EI #4, a licensed staff member, EI #4, who worked the 7:00 AM- 3:00 PM shift and was assigned to care for RI #1, stated in an interview that she became alarmed when she noticed RI #1 was lethargic (hard to arousal) and having had no urine output during her shift. She stated she checked RI #1's blood glucose level with a Glucometer. According to EI #4, the Glucometer gave a message reading of "Hi (HIGH)." EI #4 stated she notified EI #5, the Registered Nurse (RN). EI #5 obtained a different Glucometer and checked the resident's blood glucose level again, confirming the previous results of, "Hi (According the Manufacture's Specifications for the Glucometer, a message reading of "Hi" means the resident's blood glucose level was higher than "525.") EI #4 admitted to the surveyor she was unaware RI #1 was a diabetic resident and had not monitored his blood glucose level since he had been admitted to the facility. The Certified Registered Nurse Practitioner (CRNP) was notified of RI #1's high blood glucose. The CRNP directed the facility to send the resident out to the local hospital emergency room (ER) for evaluation. RI #1's blood glucose level was checked in the ER and was determined to be 1,719 (normal range is 70 -110 according to ProLab). RI#1 was intubated and admitted to the critical care unit with a [DIAGNOSES REDACTED]. RI #1 remained in the Critical Care Unit for 8 days, and was still in the hospital at the time of the survey. This deficient practice affected RI #1, one (1) of four (4) sampled resident with diabetes that required the monitoring of their blood glucose levels. This deficient practice placed the health of RI #1 in immediate jeopardy, causing serious harm to RI #1 and had the likelihood of affecting 23 diabetic resident that resided in the facility at the time of the survey. On 03/18/2012, at 12:17 PM, EI #12, the facility's Administrator, EI #10, the Director of Nursing, EI #13, the Assistant Director Of Nursing and EI #3, the third floor Unit Manager, were notified of the surveyor's finding of Immediate Jeopardy in the area of Quality of Care, F309 at level "K". The immediate jeopardy began on 03/04/12, and was abated on 03/19/12 at 3:42 AM, with the scope and severity lowered to an "E" level to allow the facility time to monitor and/or revise their corrective action as needed to achieve substantial compliance. Findings include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's "Medication Discharge Summary" form from the Nursing Home RI #1 was discharged from with a print date of 2/16/2012) , documents "... Diagnosis: [REDACTED]. The facility's undated "Nursing Admission Check-Off List", documents a hand written entry of " ... enter resident into PCC (Point Click Care)." Also on this form were the instructions to "... Transcribe transfer orders to pre-printed physician order [REDACTED]. This infor (information) is needed in order for CNAs (Certified Nursing Assistants) to take care of residents." A review of RI #1's signed printed "All Active Orders for February 2012" physician orders [REDACTED]." A review of the screen in the Point Click Care system, the facility's computerized charting system, with a create date of 2/22/2012 at 1534 (3:34 p.m.), revealed RI #1's blood sugar checks were to be checked four times a day at 0630 (6:30 AM), 1130 (11:30 AM), 1630 (4:30 PM) and 2100 (9:00 PM). A review of RI #1's Schedule for February 2012 MAR revealed there were no blood sugar orders on the MAR for RI #1, nor was there documentation of any blood sugars taken by the facility. RI #1's Admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 03/04/2012, assessed RI #1 to have moderately impaired cognitive skills for daily decision making. RI #1 was assessed as being totally dependent on staff for transfers and bathing, needing extensive assistance for bed mobility, locomotion on and off the unit, dressing and personal hygiene and was assessed to be frequently incontinent of bladder and always incontinent of bowel. Under Section I: Active Diagnoses, RI #1 was coded to have a [DIAGNOSES REDACTED]. A nurses note for RI #1 dated 3/4/2012 documents the nurse made the following entry in the electronic medical record at 15:33 (3:33 PM): "Note Text: ... 1330 (1:30 PM) resident lying (in) bed and has not voided this shift and non responsive. BG (Blood Glucose) reading HI. call (called) RN (EI #4) to assess ... 1349 (1:49 PM) (Name of RI #1's physician) called (Name of CRNP) on call status report given and new order to send out to ER for evaluation and treatment. 1355 (1:55 PM) (Name of Ambulance Service) called for transfer ... 1420 (2:20) Resident left the facility with two attending ..." A "Comprehensive Physician's Order Sheet" for RI #1, dated 03/04/12, documents: "Send out to ER for treatment." A form titled "Prehospital Care Report Summary" (name of Ambulance service transporting RI #1) dated 3/4/2012, documents: "Call information: ... Run Type: Emergency ... Call Received: 14:00: 09 (2:00 p.m., 9 seconds) ... On Scene: 14:08:51 (2:08 p.m., 51 seconds) ... Patient Information: ... PMH (Patient Medical History): Diabetes, Hypertension,[MEDICAL CONDITION](Cardiovascular Accident), Cardiac, Other ... Clinical: ... Chief Complaint: Unresponsive ... Initial Assessment: ... Breathing - Rate: Rapid ... Skin .. Temp (Temperature) Hot ...Vitals: Time: 1420 (2:20 p.m.,) B/P (Blood Pressure) 88/51, Pulse 78, Resp. (respiration's) 22 SP02 (blood oxygen saturation level) 98 ... AOSTF (Arrived On Scene To Find) 65 YOBM (Year Old Black Male) SITTING IN BED WITH PEG (Percutaneous Endoscopic Gastrostomy) FEEDING IN PLACE. PT FAMILY IN ROOM AS WELL. RN (Registered Nurse) STATES DURING HIS BATH THIS MORNING, THE PT WAS ALERT. AT THIS TIME, THE PT IS UNRESPONSIVE. PT HOT TO TOUCH, RN STATES THEY ACQUIRED A TEMP OF 98 DEGREES AXILLARY. BG (BLOOD GLUCOSE) TAKEN AT BEDSIDE READS "HI". RN STATES THEY WERE UNAWARE THE PT WAS DIABETIC. PT HAS ONLY BEEN A RESIDENT AT (name of nursing home) APPROX (APPROXIMATELY) 2 WEEKS. FURTHER ASSESSMENT SHOWS LUNG SOUNDS CLEAR BUT RAPID BREATHING NON LABORED. PT SWITCHED FROM NASAL CANNULA AT 2LPN (liters per minute) TO NON REBREATHER AT 15LPM DUE TO 89% (percent) ROOM AIR SATURATION. PUPILS WERE EQUAL AND REACTIVE . SKIN TUGOR IS POOR ... ALL VITALS ASSESSED AS ABOVE. DUE TO INITIALLY LOW BLOOD PRESSURE, PT WAS PLACED IN TRENDELENBURG. PRESSURE WAS UNCHANGED THROUGHOUT TREATMENT AND TRANSPORT. REPORT CALLED TO MIMC (Medical Intensive Medical Care) ER. UPON ARRIVAL PT PLACED IN (room number), AND CARE SIGNED FOR BY RN ..." A hospital form titled "Patient Care Timeline (3/4/2012 14:34 (2:34 p.m.) to 3/4/2012 18:19 (6:19 p.m.).) documents the following: "14:34 (2:34 p.m., Patient arrived to ED (Emergency Department) ... 14:38:07 (2:38 p.m., 7 seconds) ED Notes Patient sent from (name of nursing home) for unresponsiveness. Patient just recently arrived to (name of nursing home) on 02/25/2012. Per (by) nurse at nursing home they did not know patient was a diabetic. BG reading "HI" ... 14:40 (2:40 p.m.,) ... BP 94/58 ... Level of Sedation: Unable to arouse ... Blood Glucose Result: (HI) ... 16:56 (4:56 p.m.) Comprehensive metabolic panel Resulted ... Glucose: 1719 (PANIC VALUE -- called to and read back by (name of RN) ... Result verified by repeat testing and recollection. PANIC VALUE (Range: 70 - 99 mg/dL) ... 17:18:54 (5:18 p.m., 54 seconds) ED Notes Using BG-60 x 0.04 with a blood glucose of 1719 the insulin drip would be at a rate of 66.3. Above the hard limit on the...pump. Dr. (name of doctor) notified. Orders received to set Insulin drip at 16 units per hour (16 ml/hr) ... 17:32:31 (5:32 p.m., 31 seconds) ED Notes Recheck fingerstick blood glucose reading "HI", Dr. (name of doctor) notified ... 18:15 (6:15 p.m.) ED Notes Upon transfer of patient to room ... patient's systolic blood pressure dropped down into the 70-80's. Call placed to Dr. (name of doctor). Condition report given. Orders received to set up for central line set up and intubation and call when ready. Also spoke with (name of person) in lab regarding 1815 blood glucose check ... 18:15 Vital Signs Critical Care ... BP: 81/43 ... Level of Sedation: Asleep, difficult to arouse ... 18:18:31 (6:18, 31 seconds) Patient transferred From room MIMC ... 18:19:04 (6:19, 4 seconds) Patient admitted To department MIMC Neuro ICU (Intensive Care Unit) ..." Review of a consultation report (from name of hospital RI #1 transferred to), with an admission date of [DATE], documents: "... Reason For Consultation: [MEDICAL CONDITION] Fibrillation. HISTORY OF PRESENT ILLNESS: This patient is a [AGE] year-old male who is admitted to the hospital with [REDACTED]. He was in sinus rhythm when he initially came in, but he has converted to [MEDICAL CONDITION] here in the Intensive Care Unit. We have been consulted to assist with his management. He is currently intubated and I have no way of obtaining any history ... MEDICATIONS: Current medications in the intensive Care Unit include ... (2) [MEDICATION NAME] ... (5) Diprivan ... (8) Versed ...(10) Intravenous insulin ... Impression: (1) Diabetic Ketoacidosis (2) [MEDICAL CONDITION] on the ventilator. (3) [MEDICAL CONDITION]. (4) History of stroke. (5) History of [MEDICAL CONDITION]. Recommendations: (1) Continue to treat diabetic ketoacidosis as you are doing. (2) We will follow as assist with his management and supportive care ..." The American Diabetes Association website, (www.diabetes.org/living-with-diabetes/.../ketoacidosis-dka.html) defines Ketoacidosis as: Ketoacidosis (key-toe-ass-i-DOE-sis) is a serious condition that can lead to diabetic coma (passing out for a long time) or even death. When your cells don't get the glucose they need for energy, your body begins to burn fat for energy, which produces [MEDICATION NAME]. [MEDICATION NAME] are acids that build up in the blood and appear in the urine when your body doesn't have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of [MEDICATION NAME] can poison the body. When levels get too high, you can develop diabetic ketoacidosis, or DKA. A review of RI #1's Blood Glucose levels from 3/4/12 to 3/6/12 while in the ED and Intensive Care unit revealed the following levels: 3/4/2012 at 1550 (3:50 p.m.) - glucose 1719 3/4/2012 at 1935 (7:35 p.m.) - glucose 1366 3/4/2012 at 2151 (9:51 p.m.) - glucose 1453 3/4/2012 at 2311 (11:11 p.m.) - glucose 1388 3/5/2012 at 0105 (1:05 a.m.) - glucose 1219 3/5/2012 at 0205 (2:05 a.m.) - glucose 1111 3/5/2012 at 0310 (3:10 a.m.) - glucose 981 3/5/2012 at 0410 (4:10 a.m.) - glucose 978 3/5/2012 at 0505 (5:05 a.m.) - glucose 908 3/5/2012 at 0605 (6:05 a.m.) - glucose 888 3/5/2012 at 0723 (7:23 a.m.) - glucose 814 3/5/2012 at 0925 (9:25 a.m.) - glucose 657 3/5/2012 at 1112 (11:12 a.m.) - glucose 533 3/5/2012 at 1450 (2:50 p.m.) - glucose 384 3/5/2012 at 2035 (8:35 p.m.) - glucose 158 3/6/2012 at 0400 (4:00 p.m.) - glucose 149 3/6/2012 at 1640 (4:40 p.m.) - glucose 143 ..." On 3/16/12 at 5:56 p.m., a phone interview was conducted with EI #1, the LPN (Licensed Practical Nurse) charge nurse admitting RI #1 to the facility on [DATE]. The surveyor asked EI #1 was she familiar with RI #1. EI #1 said she was because she did the admission on him. The surveyor asked EI #1 did she look at RI #1's admission diagnoses. EI #1 said she didn't remember looking at his [DIAGNOSES REDACTED]. EI#1 stated when she asked his wife about the areas on his heels, RI #1's wife said RI #1 was Diabetic. The surveyor asked EI #1 did RI #1 have orders to check his blood sugars. EI #1 said she didn't remember RI #1's orders. EI#1 stated the facility has a system that if the resident is Diabetic you put in orders to check the resident's blood sugars. EI#1 stated the order will come out on the resident's eMAR and on the Physicians Order Form. EI #1 said you would print out the physician's orders [REDACTED]. The surveyor asked EI #1 did she take RI #1's orders off when he was admitted . EI #1 said she did, and the 3rd floor unit Manager, EI #3, helped her. The surveyor asked EI #1 did she know RI #1 had orders to check his blood sugars. EI #1 said she could not remember and she had only worked with him one time and did not have to check his blood sugar when she worked with him. The surveyor asked EI #1 if RI #1 had a [DIAGNOSES REDACTED]. EI #1 said it should have been. The surveyor asked EI #1 since she was the one to take off RI #1's orders would they have transcribed to his MAR. EI #1 said they should have been. The surveyor asked EI #1 did she check to see if RI #1 had blood sugar check orders on his eMAR. EI #1 said she did not. The surveyor asked EI #1 had anyone told her to check the eMAR to ensure all orders had been transcribed to the eMAR. EI #1 said she really couldn't say. On 03/16/12 at 1:50 p.m., the surveyor conducted an interview with the 3rd floor unit Manager, EI #3. The surveyor asked EI #3 did RI #1 have orders to check his blood sugars (when he was admitted ). EI #3 said when RI #1 came in (was admitted ) no. The surveyor asked EI #3 how did the blood sugar orders originate. EI #3 said when a new patient comes in they have to notify the doctor and inform them (the physician or the CRNP) of the orders. EI #3 said when the facility receives a Diabetic resident and they don't have a picture of how the blood sugars run (of the new resident) as a nursing judgment they call and obtain an order to see if they can do BG checks on the resident. EI #3 said the facility got an order to do QID (four times a day) blood sugar checks on RI #1. The surveyor asked EI #3 whose responsibility is it to take orders off when residents are admitted to the facility. EI #3 said the charge nurse takes the orders off and the supervisors will help. The surveyor asked EI #3 who took RI #1's orders off. EI #3 said EI #1. The surveyor asked EI #3 why didn't RI #1's blood sugar orders show up on his eMAR. EI #3 said when EI #1 put in the orders, the Order Category was checked under "Other", the Order Type was checked under "Other General" and the Order Type should have been checked under "Other MAR Order" for the blood sugar order to show up on the eMAR. The surveyor asked EI #3 if the blood sugar order had been transcribed or put under the right heading/tab, would the order have shown up to have the blood sugars checked four times a day on the eMAR. EI #3 said yes. The surveyor asked EI #3 in her professional opinion, if RI #1's blood sugars have been checked as ordered would staff have know his blood sugars were going up. EI #3 said if the blood sugars were being checked, yes. The surveyor asked EI #3 what was DKA. EI #3 said it was when the blood sugar has gotten too high, it's elevated. The surveyor asked EI #3 was that a serious condition. EI #3 said yes. On 03/16/12 at 11:50 a.m., the surveyor conducted an interview with EI #4, the nurse assigned to care for RI #1 on 03/04/12 on the 7-3 shift. EI #4 said she did not know RI #1 was diabetic and he did not have orders to check his blood sugar on the eMAR. The surveyor asked EI #4 when diabetic residents are admitted to the facility does the facility have a protocol for monitoring the residents blood sugar. EI #5 said she normally works weekends and she knew that the facility normally checks a diabetic resident's blood sugars for seven days four times a day. The surveyor asked EI #4 what happened concerning RI #1 on that day. EI #4 said RI #1 was asleep when she came on and she helped the aide to bathe RI #1 before 11:00 a.m. EI #4 said the aide told her RI #1 had not urinated and she went back in RI #1's room after lunch to check on him and he still had not voided. EI #4 said that peaked her curiosity. RI #4 said the weekend treatment nurse , EI #14, was in the room and asked her if they had checked RI #1's blood sugar and she told EI #14 RI #1 was not diabetic. EI #4 said she did check RI #1's blood sugar and it registered high on the facility's glucometer. EI #4 said at that time she called EI #5, the weekend supervisor . On 03/16/12 at 5:23 p.m., the surveyor conducted an interview with EI #14, the weekend treatment nurse. EI #14 said she was in RI #1's room doing the treatments to his feet and he was sleeping more than he was the day before. EI #14 said she told EI #4 that was the way she slept when her sugar was up because she was a Diabetic too. EI #14 said when EI #4 got an accucheck on RI #1, RI #1's blood sugar was so high it didn't read. When the surveyor asked EI #14 what was DKA, EI #14 said that is when your [MEDICATION NAME] are in your urine, your sugar is out of whack and your body is giving off [MEDICATION NAME] in your urine. The surveyor asked EI #14 was that a serious condition. EI # 14 aid it wasn't good, and it was serious because your body could shut down. On 03/16/12 at 4:42 p.m., the surveyor conducted an interview with EI #5, the supervisor working 03/04/12. When the surveyor asked EI #5 did she observe RI #1 on 03/04/12, EI #5 said when she saw him on her first rounds he was sleeping. EI #5 said EI #4 called her about three hours later to come and check RI #1 because he was not waking up and he was lethargic. EI #5 said when she got to the floor another staff nurse gave her a glucometer to take to RI #1's room. EI#5 stated when she (EI #5) got to RI #1's room she checked his blood sugar and it showed "HI." The surveyor asked EI #5 what did high mean. EI #5 said the reading was over what the machine could register. EI #5 said usually if the machine like the one's the facility uses go over 500 it will read high. The surveyor asked EI #5 when she saw RI #1, what was his condition. EI #5 said RI #1 was lying there like he was asleep. The surveyor asked EI #5 did she attempt to arouse RI #1. EI #5 said she shook RI #1 on his left shoulder and called his name but he didn't respond. EI #5 said the nurse had already gotten RI #1's vital signs and had placed oxygen on him. EI #5 said RI #1's sister came in the room after she checked RI #1's blood glucose and the sister said his sugar was obviously high. EI #5 said that's when she (EI#5) asked if RI #1 was on insulin and asked EI #4 where was his insulin. EI #5 said EI #4 said RI #1 was not on a sliding scale. EI #5 said EI #4 was on the telephone at the time talking to the CRNP and the CRNP said to call the ambulance. EI #5 said when the ambulance attendants used their machine to check RI #1's blood they got a high reading also. EI #5 said RI #1 was transported to the hospital. When the surveyor asked EI #5 what was DKA, EI #5 said it's when the blood sugar is very, very high and it's something diabetes go into when there sugar is high.. A review of the facility's glucometer (Microdot Blood Glucose Monitoring System) manufacture's recommendations reveals that a display message of "Hi" means the blood glucose level is higher than 525 mg/dl (milligrams / deciliters). On 03/16/12 at 11:10 a.m., the surveyor conducted an interview with the facility's Medical Director, EI #9, who was also RI #1's attending Physician. The surveyor asked EI #9 was he familiar with RI #1. EI #9 said he was and RI #1 was in the hospital at the time. When the surveyor asked EI #9 what were some of RI #1's admitting diagnoses, EI #9 said he knew RI #1 had a previous stroke and well as being non insulin dependent. The surveyor asked EI #9 did the facility have policy to address newly admitted Diabetic residents. EI #9 said the facility had a standing policy to check the blood sugars for two weeks for four times a day. The surveyor asked EI #9 did he give the order to send RI #1 out for treatment on 03/04/12. EI #9 said the order would have been a phone order (didn't know by who) and he signed off on the order the next day (03/05/12). The surveyor asked EI #9 was he aware RI #1 had a blood glucose level of 1719 on his admission to the hospital. EI #9 said he was. The surveyor asked EI #9 was RI #1 diagnosed with [REDACTED]. The surveyor asked EI #9 was RI #1 placed on an insulin drip and EI #9 said yes. The surveyor asked EI #9 was DKA a serious condition. EI #9 yes, and it's a manifestation of [MEDICAL CONDITION] and hyper-blood sugars. The surveyor asked EI #9 if RI #1 had an order to check his blood sugars four times a day, should that have been done. EI #9 said yes. The surveyor asked EI #9 would the facility staff checking RI #1's blood sugars four time a day have alerted then that RI #1's blood sugars were going up. EI #9 said if they were going up yes. EI #9 said checking the blood sugars would have possibly prevented the hospitalization . On 03/17/12 at 11:59 a.m., the surveyor conducted an interview with EI #2, the licensed staff member responsible for performing the chart audit checks on 02/22/12, on the 3-11 shift. The surveyor asked EI #2 who was responsible for taking the orders off when residents are admitted to the facility. EI #2 said it would be whoever the nurse is that day. EI#2 was asked who checks behind the person taking the orders off to ensure they are correct. EI #2 said there was a system in place for doing the chart checks and she thought the 3:00 PM - 11:00 PM shifts had assigned rooms and the 11:00 PM - 7:00 AM shifts had assigned rooms. The surveyor showed EI #2 a copy of the facility's Chart Audit schedule for the 3:00 PM-11:00 PM and 11:00 PM -7:00 AM shifts. EI #2 said according to the Chart Audit schedule she would have been responsible for performing the chart audit on the room RI #1 was admitted to. EI #2 said she did work on that day (02/22/12) and did do the chart check on RI #1 on that day. EI #2 said she would have used the physician's orders [REDACTED]. The surveyor asked EI #2 what was the nurse to do when an order was on the physician's orders [REDACTED]. EI #2 said the licensed staff had been told to tell EI #3. EI #2 said she did not tell EI #3 because she didn't actually see the [DIAGNOSES REDACTED]. On 03/17/12 at 4:00 p.m., the surveyor conducted an interview with EI #3, the 3rd floor Unit Manager. EI #3 said it was after RI #1 was admitted to the facility, on a Monday (03/06/12), when she found out that the blood sugar orders for RI #1 did not appear on the eMAR. EI #3 said when she went into the facility's computer system she saw that the order had been taken off under "Other" and not under "Other MAR." EI #3 said the facility's licensed nurses did audit chart checks on the 3:00-11:00 and 11:00-7:00 shifts. EI #3 said she was alarmed when she found out that RI #1's order to have his blood sugars taken before meals and at bedtime had not been carried out as ordered. EI #3 said she was never told by EI #2 that the blood sugar orders were not on the eMAR. EI #3 said she should have been told this by EI #2 and that EI #2 should have put the orders on the eMAR herself. On 03/17/12 at 5:07 p.m., the surveyor conducted an interview with EI #10, the DON . EI #10 was asked when did she became aware that the blood sugar checks for RI #1 were not done before meals and at bedtime as ordered. EI #10 stated EI #5 , the RN supervisor called and told her that RI #1's blood sugar was high and the nurses could not find where any blood sugars had been done. EI #10 said she said something to the fact that she couldn't believe that and that she was stunned at the time. EI #10 said that she could not determine if anyone had checked behind the nurse transcribing the orders. EI#10 said the facility was now going to do paper chart checks where the nurse will have to check on the paper whether they have done the 24 hour chart checks. EI#10 stated that to her knowledge there is no way to document in the new system (the electronic medical record) that 24 hour chart checks have been done. ************************************************ On 03/19/12 the facility submitted a credible allegation of compliance for F. 309, which documented: This AOC which is an acceptable (credible) allegation of compliance was done to remove immediacy of jeopardy at: F309- Quality of Care-K Level 1. RI#1 is currently not in the facility. When he returns, he will be reassessed, his physician's orders [REDACTED]. EI #1 was verbally instructed by the DON on 3-8-12 on how to put in orders and to physically see the order transcribe to the eMAR. EI #1 will be inserviced on new policies, "Care of Adult Diabetic and the Glucometer", when she returns to work. 2. All diabetic residents physician order [REDACTED]. This was completed on 03/17/2012 and no transcription discrepancies were noted. 3. The nurse responsible for chart audits for February 2012 and March 2012 was identified as EI #2. EI #2 attended in-service on 3-16-12 on the correct way to perform chart audits. On 3-5-12 to 3-17-12 in-servicing of licensed staff began and it was reinforced that 2nd shift (3-11) is responsible for auditing charts on A/B cart and 3rd shift (11-7) is responsible for auditing charts on A/C cart. 4. Administrator has ensured that in-service has begun on: 1. 3-6-12 and 3-8-12 all licensed staff was inserviced on how when diabetic residents admitted with a [DIAGNOSES REDACTED]. The only exception is if the MD writes orders not to do BG's or if the resident refuses. 2. 3-15-12 to 3-17-12 In-service were done for: 1. Blood sugars monitoring procedure for new admits with [DIAGNOSES REDACTED]. of diabetes are admitted to the facility and there are no order for BGs checks, facility licensed staff will notify MD and obtain orders for BGs. 2. Chart checks to be completed per shift, 3-11shifts to check A/B residents' charts and 11-7 shift to check A/C residents charts Q24. ************************************** On 03/19/12 the State Surveyor reviewed the facility's information that was provided in their allegation of credible compliance. A review of in-service records and staff interviews were conducted on 03/19/12, to determine if the facility had implemented their allegation of credible compliance. The immediate jeopardy was relieved on 03/19/12 at 3:42 AM, with the scope and severity being lowered to an "E" level, to allow the facility time to monitor and revise their corrective actions to achieve substantial compliance.

Based on interviews, record reviews, and review of the facility's Nursing Admission Check-Off List, the facility's licensed nursing staff failed to enter Resident Identifier (RI) #1's physician orders [REDACTED]. This failure resulted in RI #1 missing 44 blood glucose checks over a 12 day time frame (02/22/12 - 03/04/12). On 02/22/12 on the 7:00 AM - 3:00 PM shift, RI #1 was admitted to the facility with [DIAGNOSES REDACTED].#1's blood glucose level with finger stick four times a day (before each meal and at bedtime). Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) Charge Nurse, who entered RI #1's admission orders [REDACTED]. The Unit Manager (Supervisor), EI #3, admitted it was the charge nurse and supervisors responsibility to take orders off when residents are admitted to the facility. EI #3 said the charge nurse takes the orders off and the supervisors will help. EI #3 affirmed she and EI #1 took RI #1's orders off on 02/22/12. Additionally, another LPN Charge Nurse, EI #2, identified as responsible for performing the chart audit checks on 02/22/12, for the 3:00 PM - 11:00 PM shift, revealed that during the chart audit she was to ensure all RI #1's doctor orders were transcribed on the e-MAR. EI #2 admitted she was responsible for checking behind EI #1 to ensure all RI #1's orders were transcribed correctly to the eMAR. EI #2 stated she did see on RI #1's physician orders [REDACTED]. EI #2 stated when she checked RI #1's physician orders [REDACTED]. EI #2 stated she would have been responsible for informing the Unit Manager (Supervisor), EI #3, about this but failed to do so because she was unaware that RI #1 was a Diabetic resident. On 03/04/12, EI #4, a licensed staff member who worked the 7:00 AM- 3:00 PM shift and was assigned to care for RI #1, stated in an interview that she became alarmed when she noticed RI #1 was lethargic (hard to arousal) and having had no urine output during her shift. She stated she checked RI #1's blood glucose level with a Glucometer. According to EI #4, the Glucometer gave a message reading of "Hi (HIGH)." EI #4 stated she notified EI #5, the Registered Nurse (RN). EI #5 obtained a different Glucometer and checked the resident's blood glucose level again, confirming the previous results of, "Hi (According the Manufacture's Specifications for the Glucometer, a message reading of "Hi" means the resident's blood glucose level was higher than "525.") On 03/04/12, the Certified Registered Nurse Practitioner (CRNP) was notified of RI #1's high blood glucose and directed the facility to send the resident out to the local hospital emergency room (ER) for evaluation. RI #1's blood glucose level was checked in the ER and was determined to be 1,719 (normal range is 70 -110 according to ProLab). RI#1 was intubated and admitted to the critical care unit with a [DIAGNOSES REDACTED]. RI #1 remained in the Critical Care Unit for 8 days, and was still in the hospital at the time of the survey. This deficient practice affected RI #1, one of four sampled resident with diabetes that required the monitoring of their blood glucose levels. This deficient practice placed the health of RI #1 in immediate jeopardy, causing serious harm to RI #1 and had the likelihood of affecting 23 diabetic resident that resided in the facility at the time of the survey. On the instructions of the CMS Regional Office, the Statement of Deficiencies (2567) is being amended to include the addition of F 514. On 03/30/12 at 1:22 PM, the facility's Administrator was notified of the addition of F 514 (Clinical Records), immediate jeopardy level of "K." The immediate jeopardy began on 03/04/12, and was abated on 03/19/12 at 3:42 AM, with the scope and severity lowered to an "E" level to allow the facility time to monitor and/or revise their corrective action as needed to achieve substantial compliance. Findings include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's undated "Nursing Admission Check-Off List", documents a hand written entry of " ... enter resident into PCC (Point Click Care)." Also on this form were the instructions to "... Transcribe transfer orders to pre-printed physician order [REDACTED]." A review of RI #1's signed printed "All Active Orders for February 2012" physician orders [REDACTED]." A review of the screen in the Point Click Care system, the facility's computerized charting system, with a create date of 2/22/2012 at 3:34 p.m., revealed RI #1's blood sugar checks were to be checked four times a day at 6:30 AM, 11:30 AM, 4:30 PM and 9:00 PM. A review of RI #1's Schedule for February 2012 MAR revealed there were no blood sugar orders on the MAR for RI #1, nor was there documentation of any blood sugars taken by the facility. A nurses note for RI #1 dated 3/4/2012 documents the nurse made the following entry in the electronic medical record at 3:33 PM: "Note Text: ... 1330 (1:30 PM) resident lying (in) bed and has not voided this shift and non responsive. BG (Blood Glucose) reading HI. call (called) RN (EI #4) to assess ... 1349 (1:49 PM) (Name of RI #1's physician) called (Name of CRNP) on call status report given and new order to send out to ER for evaluation and treatment. 1355 (1:55 PM) (Name of Ambulance Service) called for transfer ... 1420 (2:20) Resident left the facility with two attending ..." A "Comprehensive physician's orders [REDACTED]." A form titled "Prehospital Care Report Summary" (name of Ambulance service transporting RI #1) dated 3/4/2012, documents: "Call information: ... Run Type: Emergency ... Call Received: 14:00:09 (2:00 p.m., 9 seconds) ... Patient Information: ... PMH (Patient Medical History): Diabetes, Hypertension,[MEDICAL CONDITION](Cardiovascular Accident), Cardiac, Other ... Clinical: ... Chief Complaint: Unresponsive ... Initial Assessment: ... Breathing - Rate: Rapid ... Skin .. Temp (Temperature) Hot ...Vitals: Time: 1420 (2:20 p.m.,) B/P (Blood Pressure) 88/51, ... AOSTF (Arrived On Scene To Find) 65 YOBM (Year Old Black Male) SITTING IN BED ... AT THIS TIME, THE PT IS UNRESPONSIVE. PT HOT TO TOUCH, RN STATES THEY ACQUIRED A TEMP OF 98 DEGREES AXILLARY. BG (BLOOD GLUCOSE) TAKEN AT BEDSIDE READS "HI". RN STATES THEY WERE UNAWARE THE PT WAS DIABETIC. PT HAS ONLY BEEN A RESIDENT AT (name of nursing home) APPROX (APPROXIMATELY) 2 WEEKS. FURTHER ASSESSMENT SHOWS LUNG SOUNDS CLEAR BUT RAPID BREATHING NON LABORED. PT SWITCHED FROM NASAL CANNULA AT 2LPN (liters per minute) TO NON REBREATHER AT 15LPM DUE TO 89% (percent) ROOM AIR SATURATION. PUPILS WERE EQUAL AND REACTIVE . SKIN TUGOR IS POOR ... ALL VITALS ASSESSED AS ABOVE. DUE TO INITIALLY LOW BLOOD PRESSURE, PT WAS PLACED IN TRENDELENBURG. PRESSURE WAS UNCHANGED THROUGHOUT TREATMENT AND TRANSPORT. REPORT CALLED TO MIMC (Medical Intensive Medical Care) ER ..." On 3/16/12 at 5:56 p.m., a phone interview was conducted with EI #1, the LPN (Licensed Practical Nurse) charge nurse admitting RI #1 to the facility on [DATE]. The surveyor asked EI #1 was she familiar with RI #1. EI #1 said she was because she did the admission on him. The surveyor asked EI #1 did she look at RI #1's admission diagnoses. EI #1 said she didn't remember looking at his [DIAGNOSES REDACTED]. EI#1 stated RI #1's wife said RI #1 was Diabetic. The surveyor asked EI #1 did RI #1 have orders to check his blood sugars. EI #1 said she didn't remember RI #1's orders. EI#1 stated the facility has a system that if the resident is Diabetic you put in orders to check the resident's blood sugars. EI#1 stated the order will come out on the resident's eMAR and on the Physicians Order Form. EI #1 said you would print out the physician's orders [REDACTED]. The surveyor asked EI #1 did she take RI #1's orders off when he was admitted . EI #1 said she did, and the 3rd floor unit Manager, EI #3, helped her. The surveyor asked EI #1 did she know RI #1 had orders to check his blood sugars. EI #1 said she could not remember and she had only worked with him one time and did not have to check his blood sugar when she worked with him. The surveyor asked EI #1 if RI #1 had a [DIAGNOSES REDACTED]. EI #1 said it should have been. The surveyor asked EI #1 since she was the one to take off RI #1's orders would they have transcribed to his MAR. EI #1 said they should have been. The surveyor asked EI #1 did she check to see if RI #1 had blood sugar check orders on his eMAR. EI #1 said she did not. The surveyor asked EI #1 had anyone told her to check the eMAR to ensure all orders had been transcribed to the eMAR. EI #1 said she really couldn't say. On 03/16/12 at 1:50 p.m., the surveyor conducted an interview with the 3rd floor unit Manager, EI #3. The surveyor asked EI #3 did RI #1 have orders to check his blood sugars (when he was admitted ). EI #3 said when RI #1 came in (was admitted ) no. The surveyor asked EI #3 how did the blood sugar orders originate. EI #3 said when a new patient comes in they have to notify the doctor and inform them (the physician or the CRNP) of the orders. EI #3 said when the facility receives a Diabetic resident and they don't have a picture of how the blood sugars run (of the new resident) as a nursing judgment they call and obtain an order to see if they can do BG checks on the resident. EI #3 said the facility got an order to do QID (four times a day) blood sugar checks on RI #1. The surveyor asked EI #3 whose responsibility is it to take orders off when residents are admitted to the facility. EI #3 said the charge nurse takes the orders off and the supervisors will help. The surveyor asked EI #3 who took RI #1's orders off. EI #3 said EI #1. The surveyor asked EI #3 why didn't RI #1's blood sugar orders show up on his eMAR. EI #3 said when EI #1 put in the orders, the Order Category was checked under "Other", the Order Type was checked under "Other General" and the Order Type should have been checked under "Other MAR Order" for the blood sugar order to show up on the eMAR. The surveyor asked EI #3 if the blood sugar order had been transcribed or put under the right heading/tab, would the order have shown up to have the blood sugars checked four times a day on the eMAR. EI #3 said yes. The surveyor asked EI #3 in her professional opinion, if RI #1's blood sugars have been checked as ordered would staff have know his blood sugars were going up. EI #3 said if the blood sugars were being checked, yes. The surveyor asked EI #3 what was DKA. EI #3 said it was when the blood sugar has gotten too high, it's elevated. The surveyor asked EI #3 was that a serious condition. EI #3 said yes. On 03/16/12 at 11:10 a.m., the surveyor conducted an interview with the facility's Medical Director, EI #9, who was also RI #1's attending Physician. The surveyor asked EI #9 was he familiar with RI #1. EI #9 said he was and RI #1 was in the hospital at the time. When the surveyor asked EI #9 what were some of RI #1's admitting diagnoses, EI #9 said he knew RI #1 had a previous stroke and well as being non insulin dependent. The surveyor asked EI #9 did the facility have policy to address newly admitted Diabetic residents. EI #9 said the facility had a standing policy to check the blood sugars for two weeks for four times a day. The surveyor asked EI #9 if RI #1 had an order to check his blood sugars four times a day, should that have been done. EI #9 said yes. The surveyor asked EI #9 would the facility staff checking RI #1's blood sugars four time a day have alerted then that RI #1's blood sugars were going up. EI #9 said if they were going up yes. EI #9 said checking the blood sugars would have possibly prevented the hospitalization . On 03/17/12 at 11:59 a.m., the surveyor conducted an interview with EI #2, the licensed staff member responsible for performing the chart audit checks on 02/22/12, on the 3-11 shift. The surveyor asked EI #2 who was responsible for taking the orders off when residents are admitted to the facility. EI #2 said it would be whoever the nurse is that day. EI#2 was asked who checks behind the person taking the orders off to ensure they are correct. EI #2 said there was a system in place for doing the chart checks and she thought the 3:00 PM - 11:00 PM shifts had assigned rooms and the 11:00 PM - 7:00 AM shifts had assigned rooms. The surveyor showed EI #2 a copy of the facility's Chart Audit schedule for the 3:00 PM-11:00 PM and 11:00 PM -7:00 AM shifts. EI #2 said according to the Chart Audit schedule she would have been responsible for performing the chart audit on the room RI #1 was admitted to. EI #2 said she did work on that day (02/22/12) and did do the chart check on RI #1 on that day. EI #2 said she would have used the physician's orders [REDACTED]. The surveyor asked EI #2 what was the nurse to do when an order was on the physician's orders [REDACTED]. EI #2 said the licensed staff had been told to tell EI #3. EI #2 said she did not tell EI #3 because she didn't actually see the [DIAGNOSES REDACTED]. On 03/17/12 at 4:00 p.m., the surveyor conducted an interview with EI #3, the 3rd floor Unit Manager. EI #3 said it was after RI #1 was admitted to the facility, on a Monday (03/06/12), when she found out that the blood sugar orders for RI #1 did not appear on the eMAR. EI #3 said when she went into the facility's computer system she saw that the order had been taken off under "Other" and not under "Other MAR." EI #3 said the facility's licensed nurses did audit chart checks on the 3:00-11:00 and 11:00-7:00 shifts. EI #3 said she was alarmed when she found out that RI #1's order to have his blood sugars taken before meals and at bedtime had not been carried out as ordered. EI #3 said she was never told by EI #2 that the blood sugar orders were not on the eMAR. EI #3 said she should have been told this by EI #2 and that EI #2 should have put the orders on the eMAR herself. On 03/17/12 at 5:07 p.m., the surveyor conducted an interview with EI #10, the DON . EI #10 was asked when did she became aware that the blood sugar checks for RI #1 were not done before meals and at bedtime as ordered. EI #10 stated EI #5 , the RN supervisor called and told her that RI #1's blood sugar was high and the nurses could not find where any blood sugars had been done. EI #10 said she said something to the fact that she couldn't believe that and that she was stunned at the time. EI #10 said that she could not determine if anyone had checked behind the nurse transcribing the orders. EI#10 said the facility was now going to do paper chart checks where the nurse will have to check on the paper whether they have done the 24 hour chart checks. EI#10 stated that to her knowledge there is no way to document in the new system (the electronic medical record) that 24 hour chart checks have been done. ********************************************** On 03/19/12 the facility submitted a credible allegation of compliance, which documented: 1. RI#1 is currently not in the facility ... EI #1 was verbally instructed by the DON on 3-8-12 on how to put in orders and to physically see the order transcribe to the eMAR. EI #1 will be inserviced on new policies, "Care of Adult Diabetic and the Glucometer", when she returns to work. 2. All diabetic residents physician order [REDACTED]. This was completed on 03/17/2012 and no transcription discrepancies were noted. 3. The nurse responsible for chart audits for February 2012 and March 2012 was identified as EI #2. EI #2 attended in-service on 3-16-12 on the correct way to perform chart audits. On 3-5-12 to 3-17-12 in-servicing of licensed staff began and it was reinforced that 2nd shift (3-11) is responsible for auditing charts on A/B cart and 3rd shift (11-7) is responsible for auditing charts on A/C cart. 4. Administrator has ensured that in-service has begun A. 3-6-12 and 3-8-12 all licensed staff was inserviced on how when diabetic residents admitted with a [DIAGNOSES REDACTED]. The only exception is if the MD writes orders not to do BG's or if the resident refuses. B. 3-15-12 to 3-17-12 In-service were done for: 1. Blood sugars monitoring procedure for new admits with [DIAGNOSES REDACTED]. 2. Chart checks to be completed per shift, 3-11 shifts to check A/B residents' charts and 11-7 shift to check A/C residents charts Q24. ************************************** On 03/19/12, the State Surveyor reviewed the facility's information that was provided in their allegation of credible compliance. A review of in-service records and staff interviews were conducted on 03/19/12, to determine if the facility had implemented their allegation of credible compliance. The immediate jeopardy was relieved on 03/19/12 at 3:42 AM, with the scope and severity being lowered to an "E" level, to allow the facility time to monitor and revise their corrective actions to achieve substantial compliance.