Every finding on record at Landmark South Nursing & Rehabilitation Center

Based on interviews and record review, the facility failed to accurately code PASRR Level IIs on the residents' MDS assessments for 3 of 3 (#15, #101, and #128) residents reviewed with Level II PASRRs.Resident #15 Review of Resident #15's Clinical Record revealed an admission date of 05/05/2023 and diagnoses, which included Bipolar Disorder, Current Episode, Depressed, Severe, With Psychotic Features, and Personal History of Suicidal Behavior. Review of Resident #15's Form 142s revealed Resident #15 was approved for admission by Level II authority for temporary periods effective 10/24/2024 through 10/23/2025 and 10/24/2025 through 10/23/2026. Resident #15's Annual MDS with an ARD of 03/17/2025 revealed an answer of no to the following question: A1500 – Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? An interview was conducted with S3MDS on 01/14/2026 at 10:40 a.m. She stated she was responsible for completing MDS assessments for Resident #15. She stated when a resident had a Level II PASRR, the A1500 question on the MDS should have been answered yes. She reviewed Resident #15's clinical record and confirmed Resident #15 had a Level II PASRR. She confirmed Resident #15's MDS with an ARD of 03/17/2025 was not accurately coded for the Level II PASRR and should have been. Resident #101 Review of Resident #101's Clinical Record revealed an admission date of 08/24/2024 and diagnoses, which included Schizophrenia and Major Depressive Disorder. Review of Resident #101's BHSF Form 142s revealed Resident #101 was approved for admission by Level II authority for temporary periods effective 10/12/2024 through 10/11/2025 and 10/12/2025 through 10/11/2026. Resident #101's Annual MDS with an ARD of 04/29/2025 revealed an answer of no to the following question: A1500 – Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Resident #128 Review of Resident #128's Clinical Record revealed an admission date of 06/25/2019 and diagnoses, which included Bipolar Disorder and Generalized Anxiety Disorder. Review of Resident #128's current BHSF Form 142 revealed Resident #128 was approved for admission by Level II authority for a temporary period effective 03/01/2025 through 02/28/2026. Resident #128's Annual MDS with an ARD of 12/16/2025 revealed an answer of no to the following question: A1500 – Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? An interview was conducted with S2MDS on 01/13/2026 at 12:22 p.m. She stated she was responsible for completing MDS assessments for Residents #101 and #128. She stated when a resident had a Level II PASRR, the A1500 question on the MDS should have been answered yes. She reviewed Residents #101 and #128's clinical record and confirmed both residents had a Level II PASRR. She confirmed Resident #101's MDS with an ARD of 04/29/2025 was not accurately coded for the Level II PASRR and should have been. She confirmed Resident #128's MDS with an ARD of 12/19/2025 was not accurately coded for the Level II PASRR and should have been. An interview was conducted with S1DON on 01/13/2026 at 12:32 p.m. She confirmed when the resident had a Level II PASRR, A1500 should have been coded accurately on the comprehensive MDS.

Based on record review and interviews, the facility failed to follow its policy regarding advance directives by failing to ensure all medical records consistently reflected the resident's current wishes for code status for 1 (#27) of 32 residents reviewed for advanced directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE], when Resident #27's Advance Directive consent form was signed to indicate the resident wished to have a code status of DNR and the facility inaccurately entered a status of Cardiopulmonary Resuscitation (CPR) into the resident's clinical records. On [DATE], Resident #27 verbalized she wished to have a code status of DNR. On [DATE], S3LPN stated Resident #27 was a full code and would have received CPR in the event of an emergency. S1ADM was notified of the Immediate Jeopardy situation on [DATE] at 5:06 p.m. The Immediate Jeopardy was removed on [DATE] at 7:58 p.m., as confirmed by onsite verification through interviews and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued with a potential for more than minimal harm for any resident in the facility with an advance directive. Findings: Review of the facility's Advance Directive Consent revealed the following: CPR CPR is a group of treatments used when someone's heart and/or breathing stops. CPR is used in an attempt to restart the heart and breathing. It may consist only of mouth-to-mouth breathing or it can include pressing on the chest to mimic the heart's function and cause blood to circulate. Electric shock and drugs are also used to stimulate the heart. DNR A DNR order is a physician's written order instructing healthcare providers not to attempt CPR in case of cardiac arrest. A person with a valid DNR order will not be given CPR under these circumstances. Although the DNR order is written at the request of a person or his/her family, it must be signed by a physician to be valid. Review of the facility's policy titled, Advance Directives, revised on ,d+[DATE], revealed the following: Procedure: Valid Advance Directives, such as DNR orders will be followed to the extent permitted and required by law. Procedure: An original or exact copy of an original Advance Directive, and/or DNR order shall be obtained prior to or at the time of admission when applicable. The admitting staff will document in the medical record and will notify the attending physician verbally and obtain a physician's order if the resident has executed an Advance Directive. All staff providing care for the resident will: Review the Advance Directive and clarify any discrepancies between the Directive and current treatment plan. Review of the clinical record revealed Resident #27 was admitted to the facility on [DATE]. Review of Resident #27's written Physician's Order dated [DATE] revealed a code status of Full Code. Review of Resident #27's signed Advance Directive Consent form dated [DATE] revealed Resident #27 indicated wishes to have a status of DNR. Review of Resident #27's current Care Plan revealed the following, in part: Focus: DNR Date Initiated: [DATE] Interventions: Honor resident/family's code status request, maintain appropriate code status identification. Review of Resident #27's electronic Physicians' order dated [DATE] revealed a code status of DNR. On [DATE] at 1:28 p.m. an observation of Resident #27's physical chart revealed a red plastic divider in the front of the chart with a sticker, which indicated the resident had a code status of Full Code. Review of the Minimum Data Set with an Assessment Reference Date of [DATE] revealed Resident #27 had a BIMS of 14, which indicated intact cognition. On [DATE] at 1:50 p.m., an interview was conducted with Resident #27. Resident #27 stated her choice of code status was DNR. She stated she had this directive in place with the facility. On [DATE] at 2:17 p.m., an interview was conducted with S12LPN. She stated upon admission to the facility, the resident or resident representative would sign the Advanced Directive Consent form indicating their wishes. She stated after the consent was signed, it was brought to medical records and uploaded into the electronic health record by S13LPN. On [DATE] at 2:30 p.m., an interview was conducted with S13LPN. She stated upon admission to the facility, S12LPN would provide the Advanced Directive Consent to be filled out by the resident or resident representative. She stated once the paperwork was completed, S12LPN would then bring her the hand written consents. She stated based on the consents, she would place the code status tab into the physical chart and get a signed order from the physician. She stated after she received the signed order, she would update the electronic health record to reflect the order. She reviewed Resident #27's clinical record and confirmed the resident had a written physician's order dated [DATE] which indicated a full code status and a signed advanced directive dated [DATE] indicating a DNR status. She confirmed the physicians order should have reflected the advanced directive consent form and stated the resident was a DNR. She confirmed she added the red tab indicating the resident was a full code to the physical chart based on the physicians order. She stated she was unsure who entered the electronic physicians order reflecting the resident as a DNR status. On [DATE] at 2:02 p.m., an interview was conducted with S3LPN. S3LPN stated if she needed to determine Resident #27's code status, she would refer to the code status tab in Resident #27's physical chart. She reviewed Resident #27's physical chart and verified Resident #27's code status was full code. She stated in the event of an emergency for Resident #27, she would provide CPR. On [DATE] at 2:05 p.m., an interview was conducted with S2DON. S2DON stated the procedure to determine a resident's code status during an emergency was for the nurse to review the physician's order in the physical chart and the physician's order in the electronic medical record. S2DON reviewed Resident #27's electronic and physical chart and confirmed Resident #27's written physician's order dated [DATE] indicated Resident #27 was a full code, the signed Advance Directive Consent dated [DATE] indicated Resident #27 was a DNR, the electronic physician's order dated [DATE] indicated Resident #27 was a DNR, and the red tab in the physical chart indicated the resident should receive CPR. S2DON confirmed the information was conflicting and this could cause Resident #27 to receive CPR in an emergency situation. Plan of Removal The surveyor confirmed the following had been initiated and/or implemented prior to exit: Immediate Action Taken: 1. Resident #27's physician order was updated to reflect the resident's wishes and consent for Do Not Resuscitate on [DATE] at 4:30 p.m. 2. All residents in the facility have the potential to be affected by this alleged deficient practice. 3. All resident electronic charts and hard copy charts were audited, by the Admissions Nurse, Medical records Nurse and ADONs to ensure that the electronic code status order matched the code status physician order on the hard chart as well as confirmed with the advanced directive consent on [DATE] at 5:30 p.m. 4. An immediate in-service was initiated by the Director of Nurses on [DATE] at 6:00 p.m. with staff responsible for updating code status', Admissions Nurse, Medical Records and MDS Nurses, in the electronic chart, paper chart and code status consents. The in-service was also initiated with all present nursing staff regarding advanced directives/code status orders in the electronic chart, hard chart and code consent match. The staff were in-serviced on the Cardiac Resuscitation Orders Policy. The in-servicing of the Medical Records, Admissions Nurse and Nursing staff was completed with present staff on [DATE] and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all Nurses and Medical Records staff was generated by the Human Resources Director. The DON and ADON used this list to update every nurse on the Cardiac Resuscitation Orders Policy. 5. To ensure compliance with the facility policy of Cardiac Resuscitation orders, the Medical Records Nurse, DON or designee will review all orders, including new admit orders daily. Any new code status orders or changes will be verified to ensure correlation between the electronic chart, paper chart and the resident's code status consent form. Audits are to be performed daily for four weeks and routinely thereafter. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. 6. An Emergency QA was held on [DATE] with the facility Medical Director and QA Committee regarding the Cardiac Resuscitation Orders policy. 7. Completion date - The likelihood for serious harm will no longer exist on [DATE].

Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was dated after opening; 2. Ice machine was properly cleaned and sanitized; and 3. Ice machine rolling table was properly cleaned and sanitized. This deficient practice had the potential to affect 137 out of 142 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of the facility's undated policy titled, Storage Of Refrigerated Food revealed the following, in part; Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 4. Food taken out of original containers is put in a clean sanitized container with tight fitting lid. 5. All non-hazardous, opened food are labeled with name of food, date stored. 6. All hazardous foods are labeled with name of food and date stored. During the initial tour of the facility's kitchen on 11/07/2024 at 8:40 a.m. with S4DM, the following observations were made: Walk in Refrigerator: 1-opened gallon of milk with no open date. 1-opened thickener mix with no open date. 1-opened package of turkey meat with no open date. 2-opened cheese blocks with no open date. 2-opened salad dressing bottles with no open dates. Ice Machine: A pink sticky substance was noted on the ice machine rolling table cart. The ice machine's ice dispenser tray was completely covered with round fuzzy greenish/black particles. The fuzzy greenish/black particles were also noted to be floating in standing water in the ice machine. On 11/07/2024 at 8:40 a.m., an interview was conducted with S4DM. S4DM confirmed the above aforementioned findings. S4DM confirmed all opened items should be labeled with an open date. On 11/12/2024 at 9:46 a.m., S4DM confirmed the ice machine and table should be clean and sanitary and were not. On 11/12/2024 at 11:18 a.m., an interview was conducted with S5MS who stated he was responsible for cleaning all ice machines. On 11/13/2024 at 4:45 p.m., an interview was conducted with S1ADM. He stated S5MS was responsible for scheduled cleanings of all ice machines. He confirmed the ice machine and table should be clean and sanitary and was not. S1ADM confirmed on 11/07/2024 at 4:50 p.m. all opened items should be labeled with an open date. 50093

Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan for 1 (#113) of 5 (#14, #20, #91, #113, and #119) residents reviewed for unnecessary medications by failing to ensure: 1. Resident #113 care plan addressed her use of antidepressant and psychotropic medications; and 2. Resident #113's care plan addressed her suicidal ideations. Findings: Review of Resident #113's clinical record revealed an admitted [DATE]. Further review revealed Resident #113 had diagnoses, which included Alzheimer's Disease and Anxiety Disorder. Review of Resident #113's Medication Administration Records from 10/11/2024 to 11/14/2024 revealed the following, in part: Seroquel 25 mg Give 0.5 mg by mouth at bedtime was administered from 10/11/2024 to 10/31/2024; Seroquel 25 mg Give 1 tablet by mouth at bedtime was administered from 11/01/2024 to 11/11/2024; Seroquel 50 mg Give 1 tablet by mouth at bedtime was administered from 11/12/2024 to 11/13/2024; and Lexapro 20 mg Give 1 tablet by mouth in the morning was administered from 10/12/2024 to 11/14/2024. Review of Resident #113's Progress Notes revealed the following, in part: 10/23/2024 at 4:06 p.m., .therapy came to Social Services and spoke about Resident #113 constantly saying she is going to kill herself. 11/04/2024 at 11:03 a.m., Therapy came to talk to Social Services and explained that Resident #113 stated that If I could get a gun and kill myself I would. Review of Resident #113's current Care Plan revealed it did not reflect Resident #113's use of antidepressant and psychotropic medications nor her suicidal ideations. On 11/14/2024 at 12:24 p.m., an interview was conducted with S9LPN. S9LPN reviewed Resident #113's orders and confirmed the resident received Lexapro and Seroquel. S9LPN confirmed the resident received antipsychotic and antidepressant medications. On 11/14/2024 at 12:34 p.m., an interview was conducted with S8MDS. S8MDS reviewed Resident #113's care plan and confirmed Resident #113 was not care planned for psychotropic and antidepressant medications nor suicidal ideations. S8MDS confirmed Resident #113's suicidal ideation on 10/23/2024 should have been care planned. On 11/14/2024 at 12:49 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #113's care plan and confirmed the resident was not care planned for suicidal ideations, antidepressants nor psychotropic medications. S2DON confirmed Resident #113 should have been care planned for psychotropic and antidepressant medication use. S2DON confirmed Resident #113's suicidal ideation from 10/23/2024 should have been care planned by 11/06/2024.

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#80) of 6 (#4, #24, #33, #68, #80, and #84) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing catheter care to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions, revised on 03/2024, revealed the following, in part: Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. indwelling medical devices). For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device care or use: urinary catheter Review of Resident #80's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included personal history of urinary tract infections. Review of Resident #80's current physician's orders revealed the following, in part: Start Date 08/30/2024: Enhanced Barrier Precautions - gown and gloves to be worn during high contact resident care activities (urinary catheter). Start Date: 11/09/2024: Catheter, indwelling, 16FR Foley Catheter On 11/12/2024 at 12:55 p.m., an observation was made of the Enhanced Barrier Precautions sign posted on Resident #80's door. The sign revealed the following, in part: Providers and staff must also: Wear gloves and a gown for the following high-contact activities. Device care or use: urinary catheter On 11/12/2024 at 12:45 p.m., an observation was made of S10CNA performing catheter care for Resident #80 without wearing a gown. On 11/12/2024 at 1:00 p.m., an interview was conducted with S10CNA. S10CNA confirmed Resident #80 was on EBP and she did not wear a gown while performing catheter care and should have. She stated she did not wear a gown because she was busy performing other tasks. On 11/13/2024 at 11:50 a.m., an interview was conducted with S11LPN. S11LPN confirmed Resident #80 was on EBP. S11LPN confirmed S10CNA should have worn a gown while performing catheter care for Resident #80. On 11/13/2024 at 12:16 p.m., an interview was conducted with S2DON. S2DON confirmed staff should wear a gown while performing catheter care for a resident who is on EBP.

Based on interview and record review, the facility failed to ensure adequate monitoring for effectiveness and side effects of psychotropic medication was completed for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for unnecessary medications. Findings: Review of the facility's policy titled Psychotropic Medications dated 10/2022 revealed the following: The use of PRN psychotropic medications require a screen pre and post administration. Documentation should include behavior the drug is intended to reduce, physiological, environmental and pharmacological interventions. As well as post administration behavior and side effects. A pre and post administration screen should be completed for each use of PRN Psychotropic medications. Residents that use psychotropic medications shall have side effect monitoring. Review of the facility's policy titled Drug Administration and Documentation dated 12/2023 revealed the following: PRN medications will be documented on the MAR and the reason for giving as well as the result/response for each dose given will be noted in the clinical record. Review of Resident #1 clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Other Non-traumatic Intracerebral Hemorrhage, Chronic pain syndrome, Other Specified Anxiety Disorders, Other Specified Depressive Episodes, Pulmonary Fibrosis, and Raynaud's Syndrome. Review of Resident #1's physician orders dated May 2024 revealed, in part, an ordered dated 05/27/2024 for Xanax 0.25 mg 1 tablet by mouth twice daily as needed for feeling agitated or Panic disorder for 14 days. Review of Resident #1's MAR dated May 2024 and June 2024 revealed, in part, Resident #1 received the above medication on the following dates: 05/27/2024 at 9:17 p.m.; 05/28/2024 at 8:00 p.m.; 05/30/2024 at 4:00 a.m.; 05/31/2024 at 8:00 a.m.; 05/31/2024 at 8:00 p.m.; 06/01/2024 at 5:05 p.m.; 06/02/2024 at 4:00 a.m.; 06/03/2024 at 3:45 a.m.; and 06/03/2024 at 9:20 a.m. There was no documentation of a screen performed pre administration or reason for administering the above medication on the following dates: 05/28/2024 at 8:00 p.m.; 05/30/2024 at 4:00 a.m.; 05/31/2024 at 8:00 a.m.; 05/31/2024 at 8:00 p.m.; and 06/03/2024 at 3:45 a.m. There was no documentation of a screen performed post administration or response to the above medication on the following dates: 05/28/2024 at 8:00 p.m.; 05/31/2024 at 8:00 p.m.; and 06/03/2024 at 3:45 a.m. On 07/18/2024 at 11:35 a.m., an interview was conducted with S2DON. She reviewed the policy titled Psychotropic Medications. She stated a pre and post administration screen should be completed for each use of as needed psychotropic medication. She reviewed Resident #1's MAR for administration of the above medication and reviewed Resident #1's nurse's notes for the dates and times of administration. She confirmed there was no documentation a pre-administration or post-administration screen had been performed on Resident #1 for the aforementioned dates.

Based on observation and interview the facility failed to ensure medication Carts were locked when unattended for 1 (Cart F) of 6 (Cart A, Cart B, Cart C, Cart D, Cart E, and Cart F) medication carts observed. Findings: Review of the facility's policy titled Drug Administration and Documentation dated 12/2023 revealed the following: The medication cart is not to be taken into the resident's room, and therefore, is to be locked whenever unattended. On 07/17/2024 at 8:01 a.m., an observation was made of Cart F unlocked and unattended near room [ROOM NUMBER]. On 07/17/2024 at 10:15 a.m., an interview was conducted with S4LPN. She stated the medication cart should be locked at all times and confirmed Cart F was not locked when it was left unattended near room [ROOM NUMBER]. On 07/18/2024 at 11:35 a.m., an interview was conducted with S2DON. She stated medication carts should be locked when left unattended, and confirmed the surveyor should not have observed Cart F unlocked if it was left unattended.

Based on observation and interview, the facility failed to post the required nurse staffing information on a daily basis. Findings: On 07/18/2024 at 8:15 a.m., an observation was made of posted staffing dated 07/17/2024. On 07/18/2024 at 10:00 a.m., an observation was made of posted staffing dated 07/17/2024. On 07/18/2024 at 12:30 p.m., an observation was made of posted staffing dated 07/17/2024. On 07/18/2024 at 12:55 p.m., an interview was conducted with S3WC. S3WC stated she was responsible for posting the daily staffing information. She stated she did not post the daily staffing information for the day, and should have. On 07/18/2024 at 1:03 p.m., an interview was conducted with S1ADM. He stated S3WC was responsible for posting the daily staffing information. He confirmed the daily staffing currently posted was dated 07/17/2024 and was not current.

Based on observations, interviews and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (R1 and R2) of 5 (#1, #2, #3, R1, R2) residents reviewed. Findings: Review of the facilities policy, Call Light/Bell, dated 01/2024, revealed the following, in part: Purpose: To provide the resident a means of communication with staff members Procedure 1. Ensure resident has call light in reach when in resident room 7. Place the call light within the resident's reach before leaving the room. Resident R1 A review of Resident R1's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Alzheimer's disease, Urinary Tract Infections, and Cognitive Communication Deficit. A review of Resident R1's current Care Plan revealed the following: Onset: 05/30/2019 Problem: Resident was at risk for injury from falls. Interventions: Place call light within reach. On 05/20/2024 at 9:40 a.m., an observation was conducted of Resident R1. She was observed resting in her bed with her call light noted on the floor and not in reach. Resident R2 A review of Resident R2's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Systemic Lupus, Cognitive Communication Deficit, and Dementia. A review of Resident R2's current Care Plan revealed the following: Onset 04/02/2023 Problem: Resident was at risk for falls. Interventions: Place call light within reach. 06/14/2023- Call don't fall sign placed in bathroom and room; 06/22/2023- Staff in-serviced on keeping call light within reach and clipped to bed or recliner; and 07/21/2023- Educated resident on importance of using the call light. On 05/20/2024 at 10:02 a.m., an observation was conducted of Resident R2. She was observed sitting up in her wheelchair with her call light behind her on the floor and not in reach. On 05/20/2024 at 10:02 a.m., an interview was conducted with Resident R2. She stated she was not able to transfer without assistance. She stated she would press the button for assistance, but she was not able to reach the call light. She stated would like to get in her recliner but was not able to call for assistance. On 05/20/2024 at 10:29 a.m., an observation was conducted of Resident R2. She was noted sitting in her wheelchair and her call light was not in reach of the resident. On 05/20/2024 at 10:29 a.m., an interview was conducted with S5LPN. She confirmed Resident R2 utilized her call light and it should be within reach. She further confirmed the call light was on the floor and Resident R2 was not able to reach it. On 05/21/2024 at 10:39 a.m., an interview was conducted with S3ADON. She stated she was not sure if Resident R1 would use the call light because she normally would yell out but the call light should be placed within reach. She confirmed Resident R2 was able to use her call light and it should be placed within reach when staff exited the room. On 05/21/2024 at 1:00 p.m., an interview was conducted with S4ADON. She stated she was not sure if Resident R1 would use the call light but the call light should be placed within reach. She confirmed Resident R2 was able to use her call light and it should be placed within reach when staff exited the room. On 05/21/2024 at 1:26 p.m., an interview was conducted with S2DON. She stated she expected when staff exited the residents room to leave the call light within reach.

Based on record review and interviews, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours after the incident, to the facility Administrator and to the State Survey Agency within the specified timeframe for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for accidents. Findings: Review of the facility's policy titled, Incident Investigation and Reporting, reviewed on 05/21/2024, dated 10/2022, revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or reportable incidents as required by state and federal requirements. 2. Relevant Terms: Injury of unknown origin: a. Source of injury was not observed by any person and b. The source of injury could not be explained by the resident and c. The injury is suspicious due to the extent or location of the injury or the number of injuries at one time or the incidence of injury over time. 3. The administrator shall report no later than 2 hours after forming the suspicion, if the events that cause the suspicion involve abuse or result in serious bodily injury 5. Additional incidents that must have a thorough investigation and may require reporting . D. Unwitnessed Falls-consider abuse or neglect Review of Resident #1's clinical record revealed, resident was admitted to the facility on [DATE] with diagnosis which included Parkinson's Disease, Dementia, Cognitive Communication Deficit, Hallucinations, Fracture of Upper Left Humerus and Fracture of Superior Right Rim of Left Pubis. Review of Resident #1's Quarterly MDS with an ARD of 05/14/2024 revealed the provider assessed Resident #1 as having a BIMS of 11, indicated resident exhibited moderate cognitive impairment. Further review of the facility's assessment revealed Resident #1 required total dependence for all ADLs and transfer. Review of Resident #1's nurse's note dated 02/12/2024 by S6LPN revealed, in part, S6LPN was summoned to Resident #1's room when CNA found Resident #1 on the floor. Further review revealed, upon entering Resident #1's room, Resident #1 was noted to be face down on the floor to the right side of the bed with her head next to the foot of the bed and her feet towards the head of the bed. S6LPN's assessment revealed Resident #1 had a protruding knot above the left eyebrow with bruising noted to the left side of the scalp; abrasions to the left knee, the left lateral great toe, and the smaller toes on the right foot; Resident #1 complained of pain to the left arm; the left shoulder appeared increased in size with some surrounding edema; and Resident #1 was unable to lift the left arm without crying. Further review also revealed, Resident #1 was confused and unable to answer direct, simple questions. A review of Resident #1's Incident/Accident report dated 02/12/2024 at 4:00 p.m. revealed, in part: Incident Type: found on floor Incident Level: Non-Witnessed Reported to Supervisor: Yes Resident Condition at Time of incident: Mobility-bedfast, no independent movement; Mental-disoriented-not follow commands Review of Resident #1's hospital records dated 02/15/2024 revealed the following X-Ray results: Pelvis: acute left superior and inferior pubic rami fracture. Left shoulder: acute displaced/impacted surgical neck proximal humeral fracture. On 05/21/2024 at 12:34 p.m., an interview was conducted with S6LPN. S6LPN stated she was the floor nurse for Resident #1 on 02/12/2024. S6LPN further stated she had not observed Resident #1 attempting to transfer out of the bed independently prior to the incident. S6LPN stated prior to the unwitnessed fall, Resident #1 had a temperature of 100.7F and was very confused. S6LPN stated she was called to Resident #1's room by a CNA when Resident #1 was found on the floor. S6LPN stated she reported the incident to S4ADON immediately. S6LPN stated Resident #1 had altered mental status prior to the incident. S6LPN stated Resident #1 was confused and could not verbalize how she got on the floor. On 05/21/2024 at 1:24 p.m., an interview was conducted with S2DON. S2DON confirmed she was immediately made aware Resident #1 had an unwitnessed fall, resulting in an injury with fractures on 2/12/2024. She stated S1ADM was made aware of that incident the day of the incident or within 24 hours during morning meetings. On 05/21/2024 at 1:45 p.m., an interview was conducted with S1ADM. S1ADM stated he was aware Resident #1 had an unwitnessed fall, resulting in injuries on 2/12/2024. He verified he did not report the unwitnessed incident which resulted in fractures to the state agency. He stated it was his understanding that unwitnessed falls did not need to be reported.

42681 Based on record reviews and interviews, the facility failed to protect the residents' right to be free from physical abuse by Resident #39 for 1 (#17) of 3 (#17, #41 and #137) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy titled, Incident Investigation and Reporting revealed the following, in part: Purpose: 1. Each resident residing in this facility has the right to be free from any type of abuse including: physical abuse. Physical Abuse: this includes but is not limited to hitting, slapping, pinching and kicking. Resident #39 Review of Resident # 39's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebrovascular Disease, Traumatic Hemorrhage of Cerebrum without Loss of Consciousness, Lack of Coordination, Recurrent Depressive Disorders, Delusional Disorders, Bipolar Disorder, Dementia, Alzheimer's Disease and Cognitive Communication Deficit. Review of Resident #39's Quarterly MDS with an ARD of 07/04/2023 revealed the provider assessed the resident as having a BIMS of Blank, indicating the resident was unable to be assessed. Review of Resident #39's Care Plan revealed the following, in part: Problem: Resident has physical behavioral symptoms directed towards others. Problem: Resident has verbal behaviors directed towards others including staff: Resident threatens to falsely accuse staff of physical harm to her. Review of Resident #39's Nurse's Notes dated June - July 2023 revealed the following, in part: 06/10/2023 at 1:34 a.m. At approximately 1:00 a.m. Resident #39 begin hitting at me with a closed fist. She is fidgeting and restless. Approximately 1:15 a.m. Notified on call provider. Send to Behavior Health Unit for evaluation if behaviors continue per Nurse Practitioner. Signed by S5LPN. 07/10/2023 at 2:50 p.m. Late Entry at 1:38 p.m. Notified S2DON Resident #17 reported Resident #39 struck her to her left eye. Resident #39 sitting in room, did not respond verbally when asked did she hit or touch another person this morning. She only looked at me and shook her head no, and continued to play with her doll. Signed by S6LPN. Review of the facility's Incident Investigation for Resident #39 revealed the following, in part: Incident type: Contact-Resident Date/Time: 07/10/2023 at 1:38 p.m. Type of injury: None apparent Location: Hallway on unit Incident reported by S6LPN Narrative: 1:38 p.m. Notified by S2DON that Resident #17 reported Resident #39 struck her on her left eye. Resident #39 sitting in her wheelchair at this time. She did not respond verbally when asked did she hit or touch another resident this morning. She only looked at me and shook her head no. Resident #17 Review of Resident #17's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis which included Spastic Quadriplegic Cerebral Palsy. Review of Resident #17's Quarterly MDS with an ARD of 10/25/2023 revealed, in part, a BIMS of 15, which indicated she was cognitively intact. Review of Resident #17's Medication Administration Record dated July 2023 revealed the following, in part: Monitor discoloration under left eye daily times 7 days. Report any significant changes to doctor, such as increased swelling, redness or pain. Initialed by the nurse indicating task was completed 07/11/2023 - 07/17/2023. Review of the facility's Incident Investigation for Resident #17 revealed the following, in part: Incident type: Contact-Resident Date/Time: 07/10/2023 at 1:39 p.m. Type of injury: Pain, Bruise, Localized tissue edema, Reddened . Location: Hallway Incident reported by S6LPN Narrative: 1:38 p.m. Notified by S2DON that Resident #17 reported Resident #39 struck her on her left eye. Resident #17 sitting in her wheelchair at this time. Noted redness to left corner of eye with small amount of swelling. When asked about incident, Resident #17 stated while sitting in hallway Resident #39 struck her on her left eye. The corner of Resident #17's left eye was red with bruising and below left eye had minimal swelling. Review of Resident #17's 24-hour follow up investigation documented by S3ADON revealed the following, in part: No swelling noted, small amount of redness noted under left eye. Review of the facility's Self-Reported Incident Report revealed the following, in part: Resident #17 - Victim Resident #39 - Accused Accused Allegation - Physical Abuse Allegation Findings: Substantiated Date/Time - 07/10/2023 at 7:38 a.m. Type of Injury - Redness, Swelling Incident reported by S1ADM Incident Description: Resident #17 reported to S2DON Resident #39 hit her in the eye. Camera footage reviewed, which suggested Resident #39 plucked, with her finger, Resident #17 in the head while passing in her wheelchair. An interview was conducted on 12/12/2023 at 9:30 a.m. with Resident #17. She said on 07/10/2023 at 7:30 a.m., she and Resident #39 were sitting in their wheelchairs on Hall A waiting for the CNA staff to transport them to the dining room. She said Resident #39's wheelchair was parked behind her in the hallway. She said Resident #39 reached from behind her and hit her on the left side of her head near the corner of her left eye. She said her left eye was swollen and red after the incident. She said she had a bruise under her left eye for a few days. An interview was conducted on 12/12/2023 at 12:40 p.m. with S3ADON. She said on 07/10/2023 at 1:30 p.m. she was informed by S6LPN that Resident #17 accused Resident #39 of hitting her to the left side of her face near her left eye. She said she assessed Resident #17's left eye 24-hours after the incident and observed a small amount of redness noted under her left eye. An interview was conducted on 12/12/2023 at 1:15 p.m. with S6LPN. She said on 07/10/2023 at 1:30 p.m., S2DON informed her Resident #17 accused Resident #39 of hitting her on the left side of her face. She said she assessed Resident #17 and found dark colored bruising to the corner of her left eye. She said Resident #17 told her Resident #39 rolled past her on Hall A and hit her on the left side of her head near her left eye. An interview was conducted on 12/12/2023 at 2:00 p.m. with S2DON. She said on 07/10/2023 at 1:30 p.m., Resident #17 reported that Resident #39 hit her on the left eye. She said she watched video surveillance of the incident which occurred on 07/10/2023 at 7:38 a.m. between Resident #39 and Resident #17. She said Resident #39's wheelchair was parked right behind Resident #17's wheelchair on Hall A. She said Resident #39 propelled herself forward, reached around and plucked with her finger the left side of Resident #17's face near her left eye. She said after assessing Resident #17's eye, a red mark was observed under her left eye. An interview was conducted on 12/13/2023 at 3:00 p.m. with S1ADM. He said he was made aware of the incident on 07/10/2023 at 1:38 p.m. involving Resident #17 and Resident #39. He said the facility's video surveillance revealed Resident #39 plucked Resident #17 to the left side of her head near the corner of her left eye. He said the incident was substainated as physical abuse. The facility had implemented the following actions to correct the deficient practice: 1.I mmediate actions taken are as follows: a. Administrator immediately reviewed camera footage upon notification of incident by Resident #17. b. Alleged victim was assessed by floor nurse and Director of Nursing. A small discolored area was noted to Resident #17's left eye. Cold compress was ordered to left eye as needed. c. Local authorities were notified per Elder Justice Act d. Incident reports were opened on both the alleged victim and accused: -Physician notified at 2:11 p.m. -Resident representatives notified at 2:40 p.m. e. Alleged Accused immediately placed under direct staff supervision and monitored one on one. f. Alleged Accused was sent to local hospital for evaluation and treatment and possible admit to Geri-psych at 4:30 p.m. on 07/10/2023 due to behaviors. Accused returned to the facility at 10:22 p.m. and was monitored one on one, when in public spaces, for greater than 24 hours upon return from hospital. g. In-service conducted immediately with all nurses and aides regarding being observant of residents who have behaviors and not leaving residents with physically aggressive behaviors near other residents. h. Psych NP consultation initiated for accused. i. Social Services began reaching out to nursing facilities for alternate placement for Resident #39 on 07/12/2023 in order to attain an accepting facility. j. Received order to increase dose of Seroquel from 25mg to 50mg for Resident #39 on 07/13/2023. k. Social services discussed room change with accused resident representative and resident representative was in agreeance with room change due to accused interest in alleged victim. l. Urinary Analysis collected on accused with negative results 07/14/2023. m. Relocated Resident #39 to Hall B, due to bed on another hall becoming available on 07/14/2023. n. Accused seen by Psych Nurse Practitioner on 07/20/2023. 2. Residents who have the potential to be affected by residents who make physical contact with others include all residents. 3. Measures taken to reduce the likelihood of an event such as this occurring in the future are as follows: a. In-service conducted immediately with all nurses and aides regarding being observant of residents who have behaviors and not leaving residents with physically aggressive behaviors near other residents. b. Facility initiated 30 day discharge process, hearing was scheduled and discharge to accepting facility was denied by Administrative Law judge. c. Quality Assurance plan initiated requiring S2DON/designee to monitor high traffic areas for residents exhibiting escalated behaviors and staffs' ability to respond appropriately. Audits are to be conducted 3 times per week for no less than 4 weeks. d. QA rounds conducted on residents daily for two weeks ending on 07/24/2023 and twice per week for an additional two weeks ending on 08/07/2023 to ensure there is no evidence of abuse of any type. No evidence of abuse has been observed. e. Quality Assurance plan initiated requiring S2DON/designee to monitor all resident's emotional wellbeing, including Resident #17, daily for two weeks until 07/24/2023 then twice per week for two additional weeks ending 08/07/2023 f. Abuse/neglect training conducted quarterly and as needed including providing care to difficult/combative. Resident's education is conducted as needed. 4. The following Quality Assurance measures were put in place: a. Quality Assurance Plan audits are to be captured on a special care form. Results of audits to be discussed in the daily stand-up meeting with the interdisciplinary team. Negative outcomes are to result in education/discipline. The Quality Assurance Committee to meet weekly to assure substantial compliance is maintained. 5. Substantial compliance attained 07/14/2023. Throughout the survey from 12/11/2023 to 12/13/2023, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's abuse policy and procedure. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food safety by failing to ensure: 1. Canned goods did not have a compromised seal; and 2. Food products had not exceeded their expiration date. This deficient practice had the potential to affect any of the 135 residents who consumed meals prepared in the facility's kitchen. Findings: An observation was conducted on [DATE] at 8:45 a.m. during the initial kitchen tour with S1DM revealed the following: 1 black Pepper seasoning container with an expiration date of [DATE] 3 loaves of bread with green fuzzy substance 1 can of pinto beans with dents 1 can of vanilla pudding with dents 2 cans of mandarin oranges with dents An interview was conducted on [DATE] at 9:00 a.m. with S1DM. She verified the above observation. She verified expired products as well as dented cans as being a possibility of food contamination. She confirmed these products were available for use and should not have been.

Based on observation, interviews, and record review, the facility failed to implement appropriate infection control practices during resident care as evidenced by failing to ensure staff implemented proper hand hygiene and glove usage during wound care for 1 (#60) of 3 (#13, #34, and #60) residents reviewed for wound care. Findings: Review of the facility's policy titled, Hand Hygiene revealed the following In part: Policy: To cleanse hands to prevent transmission of infection or other conditions Indications for Hand Washing: 3.) Before and after procedures 4.) Before and after applying gloves 5.) When hands are visibly soiled 9.) Wearing gloves does not replace the need to perform hand hygiene Review of the Clinical Record for Resident #60 revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Pressure Ulcer Stage 3, with an onset date of 09/13/2022. An observation was conducted on 11/17/2022 at 1:30 p.m. of S2WC providing wound care for Resident #60. S2WC cleaned an abrasion noted on Resident #60's right under arm with wound cleanser on a gauze. S2WC removed her soiled gloves and applied a pair of clean gloves without performing hand hygiene. S2WC grabbed a clean dressing and scissors, and then applied the dressing to the abrasion. She removed her soiled gloves and applied a pair of clean gloves without performing hand hygiene, S2WC applied medication to an open wound noted on resident #60's sacrum with her gloved finger. Her gloves were visibly soiled at that time. S2WC removed her soiled gloves, touched her scrubs, Resident #60's bedside table, and placed trash in the biohazard bag located in her hand. S2WC placed the biohazard bag on Resident #60's bedside table and sanitized her hands. An interview was conducted with S2WC on 11/17/2022 at 1:40 p.m. S2WC confirmed she did not perform hand hygiene after removing soiled gloves and before applying clean gloves and should have. An interview was conducted with S3ADON on 11/18/2022 at 10:40 a.m. She confirmed S2WC should have performed hand hygiene between glove changes.

Based on observation, interviews, and record review, the facility failed to protect a cognitively impaired resident from physical and verbal abuse by a staff member, for 1 (Resident #1) of 1 resident reviewed for abuse out of a total sample of 35 residents reviewed. The deficient practice resulted in an actual harm on 8/15/2021 at 9:30 a.m., when S2CNA was observed throwing cold water on Resident #1 while she was unclothed and aggressively pushing Resident #1 across her bed while attempting to clothe the resident. Resident #1 grimaced at the force and was witnessed by staff telling S2CNA to leave her alone. S2CNA continued aggressively providing care while using profane and derogatory language. Soon after, S2CNA was witnessed slapping Resident #1 three times on her mouth with her hand. Resident #1was shocked and swung her arm and fist towards S2CNA. S2CNA pushed the resident's arms down and hit Resident #1 again, twice on her arm. Findings: Review of the facility's policy titled Incident Investigation and Reporting revealed, in part: Purpose: 1.Each resident in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property. 2.Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. Review of the facility's policy titled Seven Components to Reduce, Detect, and Prevent Abuse and Neglect revealed, in part: -Prevent - The facility has policies and procedures in place in order to detect and prevent the occurrence of abuse and neglect, and reviews specific incidents or lessons learned, which form a feedback loop to affect the necessary policy changes. -Protect - The facility seeks to support and protect individuals receiving services, their families, and staff. -Respond - The facility assures that the appropriate corrective, remedial, or disciplinary action occurs in accordance with applicable local, state, or federal law, in response to findings resulting from investigations. Review of the medical record for Resident #1 revealed the resident was admitted to the facility 09/23/2020 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/28/2021 revealed the resident had a BIMS (Brief Interview of Mental Status) of 00, which indicated she was severely cognitively impaired. Resident #1 had both physical and verbal behaviors towards others. Resident #1 required extensive assistance with 2+ persons physical assist for bed mobility, transfers, and toilet use. Resident required extensive assistance with 1+ person physical assist for eating and dressing and was totally dependent for bathing. A review of an interdisciplinary progress note dated 08/16/2021 at 12:07 p.m. revealed the following: Late entry for 08/15/2021. Administrator was phoned on the morning of 08/15/2021 and notified that an aide had physically abused Resident #1 at approximately 9:30 a.m. Signed S1ADM On 10/06/2021 at 9:53 a.m., an observation was conducted of Resident #1 in her room. She was unable to answer any questions regarding the incident of abuse due to her cognitive status. On 10/06/2021 at 11:33 a.m., an interview was conducted with S3HSK. She confirmed she witnessed S2CNA hit Resident #1. She stated she went into Resident #1's room to change the trash. She stated the resident was lying in bed without clothes or a blanket covering her. She stated S2CNA was in the room with Resident #1 and was walking back and forth from the bathroom with water in her hands and throwing it on Resident #1. She stated Resident #1 said it was cold and S2CNA told the resident I want to change the piss off you. She stated S2CNA was trying to turn Resident #1, but the resident was holding on to the bedrail tightly. S2CNA hit the resident's hand to get her to release the bedrail. She stated after that happened, she took her cellphone out and recorded the rest of the interaction. She stated S2CNA told the resident to pull up her pants and Resident #1 stated, I can't do it. You do it. She stated S2CNA then hit the resident in the mouth with her hands a few times and said watch your mouth. She stated S2CNA looked up at her and saw her recording, so she walked out the room. An observation of the video footage, presented by S1ADM, was reviewed with surveyors, on 10/07/2021 at 9:35 a.m. It was noted that the video was sent to the Administrator's phone on 08/15/2021 at 9:36 a.m. The following was observed: S2CNA was standing on the side of Resident #1's bed. Resident #1 was lying in bed wearing only an adult brief with no blankets covering her. S2CNA was observed aggressively pushing the resident's body across the bed as she was trying to put her clothes on. Resident #1 grimaced at the force and was heard saying leave me alone. S2CNA stated, Trust me I wish I could. Resident #1 made a statement that was inaudible and S2CNA responded, I would never put my momma in a nursing home. This[OBSCENITY]is for the birds. Crazy and out of her mind like this. S2CNA then aggressively pushed Resident #1's legs towards the middle of the bed. Resident #1 stated, Jesus help me. S2CNA stated, Yes, help her. S2CNA then told Resident #1 to pull her pants up. Resident #1 stated, I can't do it. You do it. S2CNA then slapped Resident #1 three times on her mouth with her hand and said, watch your mouth. Resident #1 then lifted her head, looked at S2CNA with a shocked facial expression, and swung her arm and fist towards S2CNA. S2CNA caught her arm, pushed it down, and hit her arm twice. The video ended. S1ADM confirmed S2CNA hit the resident as observed in the video. On 10/07/2021 at 10:15 a.m., a telephone interview was conducted with S2CNA. She stated on the day of the incident on 08/15/2021, she was bathing the resident and the resident was fighting, punching, and kicking her. She confirmed she hit the resident but stated it was a result of her reflexes. She stated it was not her intentions to hit the resident. She stated she understood it was wrong for her to hit the resident. On 10/07/2021 at 3:20 p.m., an interview was conducted with S1ADM. He confirmed physical abuse occurred on 08/15/2021 when S2CNA was observed on video hitting Resident #1.

Based on observations, interviews, and record reviews the facility failed to provide adequate supervision to prevent accidents for 1 (#5) of 1 (#5) residents investigated [MEDICAL CONDITION] of a sample of 4 (#5, #33, #34, & #109) residents investigated for accidents. An Immediate Jeopardy situation occurred for Resident #5 on 08/18/2019 at 6:46 a.m. when the resident entered the dining room unsupervised and self-served a cup of hot coffee from a dispenser. Resident #5 spilled the hot coffee onto herself resulting in 2nd -3rd [MEDICAL CONDITION] length - 13.10 centimeters (cm), width - 6.80 cm, depth 0.20 cm to the left anterior thigh. Resident #5 was severely cognitively impaired, and required extensive assistance of one person with eating. The facility was made aware of the incident when another resident brought Resident #5 to the nurses' station. During the survey on 08/29/2019 at 9:50 a.m. two severely cognitively impaired residents (#94 and #101) were observed serving themselves coffee in the dining room, and there were no staff present. Resident #94 required supervision and setup help with eating, and she ambulated with a walker. Resident #101 required supervision and one person physical assistance with eating. The Administrator was notified of the Immediate Jeopardy situation for Resident #5 and for all cognitively impaired residents requiring assistance and supervision with eating on 08/29/2019 at 3:47 p.m. The Immediate Jeopardy was removed on 08/30/2019 at 12:15 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record reviews the surveyors confirmed the following components of the plan of removal had been initiated and implemented prior to exit. The plan of removal included: Plan of Removal 1. The resident found to have been effected by the deficient practice was immediately treated for [REDACTED]. This resident was given a specialty cup with a lid on 8/19/19 in an effort to keep beverages from spilling on the resident and prevent further injury which has proven effective. 2. The Administrator, Food Service Supervisor and designees in-serviced all staff on 8/29/19, immediately following the issuance of the immediate Jeopardy notice. In-servicing includes supervision and monitoring of residents requiring assistant with meal service. Further in-servicing on coffee administration as well as to changes in the facility policy on access to coffee are on-going until all staff are in-serviced. The immediate protocol implemented to ensure residents, staff and visitors do not have access to coffee was the removal of insulated coffee dispensers from public areas thus removing the need for supervisor outside of regular meal service. Other protocols initiated related to coffee are as follows: a. All Coffee will be served in individual cups from the dietary department only. b. Coffee will be transferred from the dispensing system into a non-insulated container. Once in the container, the coffee will then be poured into individual cups and placed on trays to be administered by the dietary department only. c. Coffee will be served on the hall carts in individual cups and no longer in bulk insulated dispensers. d. No coffee will be stored in bulk containers outside of dietary at this time. e. Coffee will be offered during breakfast, 10:00 am, 2:00 pm, and the evening meal. f. The new protocol will be reviewed with the resident council and revised according to resident preference and resident safety. 3. All facility staff were given a written copy of the aforementioned protocol and signed to acknowledge understanding. Staff failure to properly implement the aforementioned policy will receive additional training and not allowed to work until competency is verified. Staff are required to receive this protocol prior to working their assigned shifts. 4. A nurse is assigned to the dining room for all meal service to increase supervision. The nurse will remain in the dining room until the conclusion of meal service. 5. Other residents at risk to be affected by the deficient practice have been assessed and placed in a designated area of the dining room thus receiving more assistance with meal service ADL's. 6. The Administrator, Foodservice Supervisor or designee will check for compliance no less than daily for 2 weeks to include observations on evenings, nights and weekends. These observations will be made on form AD-097. Following the initial two week QA, the facility will then observe meal service no less than 4 times per week until substantial compliance is achieved and monthly thereafter. 7. The Administrator will observe the video surveillance system weekly to ensure that compliance is maintained and correct any areas of concern if noted. These observations will be made on a QA tool and maintained in the Administrative office. 8. The facility has conducted an emergency QA on 8/29/19 at 6:00 pm with the facility Medical Director and Dept. Head staff to outline the aforementioned protocol with no further recommendations. The QA will be on-going until substantial compliance is achieved. The above action has been implemented and I allege the jeopardy has been removed on this date. This deficient practice had the potential for more than minimal harm for 29 (#4, #5, #12, #15, #16, #17, #18, #22, #23, #26, #29, #33, #34, #37, #42, #43, #45, #68, #75, #77, #78, #83, #86, #94, #99, #101, #109, #116, and #117) mobile and severely cognitively impaired residents residing in the facility that required supervision and/or assistance with eating according to their MDS. Findings: An interview was conducted on 08/26/2019 at 1:30 p.m. during the Resident Council Meeting with Resident #89 and Resident #112. Resident #89 and Resident #112 stated they were concerned about supervision in the dining room. They stated Resident #5 served herself hot coffee, spilled it in her lap, and was burned. An interview was conducted on 08/26/2019 at 4:15 p.m. with Resident #5. She reported she poured coffee by herself, the cup slipped, and spilled hot coffee into her lap, and it burned her leg. Review of Resident #5's record revealed her [DIAGNOSES REDACTED]. Review of Resident #5 Quarterly Minimum Data Set with Assessment Reference Date of 06/05/2019 revealed her Brief Interview for Mental Status was a four which indicated she was severely cognitively impaired. It also revealed Resident #5 required extensive, 1-person assistance with eating, had impaired range of motion, and used a wheelchair. Review of Resident #5's Investigative Report revealed in part: 08/18/2019 6:46 a.m. Another resident approached nursing station and stated Resident #5 has spilled hot coffee in her lap. Resident noted with hot wet stain on her pants, she stated her leg hurts. When pants were removed for assessment, redden area noted to upper left thigh .pain medication administered. 24 hour Follow-up: Left upper thigh remains very reddened. Resident continues to scratch and abrade area. Review of Resident #5's Nurses Notes dated 08/18/2019 at 7:13 a.m. revealed while in dining room, resident waste hot coffee to upper left thigh. Review of Wound Assessment Report for Resident #5 for the Month of (MONTH) 2019 revealed: 08/18/2019 - Wound Type: Burn; Wound Location: Left Inner Thigh -Front; Date Identified: 08/18/2019; Cause: Accident/Other trauma; Measurements: Length - 15.20 cm, Width - 7.00 cm, Depth 0.00 cm; Burn Type: Scald; Burn Depth: [MEDICATION NAME] - No loss of epithelium, skin intact, surface is dry. Burn Description: Reddened, [MEDICAL CONDITION]; Date Electronically Signed: 08/18/2019 S2DON 08/26/2019 - Wound Type: Burn; Wound Location: Left Inner Thigh -Front; across upper thigh; Date Identified: 08/18/2019; Cause: Accident/Other trauma; Measurements: Length - 13.10 cm, Width - 6.80 cm, Depth 0.20 cm; Drainage: Serosanguineous, Small; No; Pain with wound/treatment: Yes; Pain Intensity: 6; Burn Type: Scald; Burn Depth: Deep partial thickness Burn Description: Blister(s) broken; Date Electronically Signed 08/29/2019 S4TN An interview was conducted on 08/28/2019 at 9:46 a.m. with Resident #112. Resident #112 reported she saw Resident #5 spill coffee on herself on 08/18/2019. Resident #112 stated Resident #5 spilled hot coffee on her lap as she was removing the cup from the table where the coffee sits in the dining room. She said there were no staff in the dining room, and she brought Resident #5 to the Nurses' Station and let the staff know of the accident. Review of Resident #5's Current (08/2019) Care Plan revealed: Problem/Need: (Onset 08/18/2019) Resident has a burn to left upper thigh that she keeps scratching and rubbing unable to keep dressing on site d/t resident removes potential for infection Goal: Resident burn will heal through next review. Resident's burn will be decreased in size through next review. Resident will have no complications with burn through next review. Approaches: Treatment as ordered. Observe for signs and symptoms of infection and notify Medical Doctor/Nurse Practitioner (MD/NP) if present. Notify MD of any complications or worsening in wound. Problem/Need: (Onset 05/09/2018) At risk for aspiration r/t Diagnosis: [REDACTED]. Approaches: Use a sippy cup-08/19/2019. An interview was conducted on 08/28/2019 at 12:34 p.m. with S7MDS regarding Resident #5. S7MDS reviewed Resident #5's care plan and verified it contained no interventions to prevent additional coffee burns. She stated she was unaware of any approaches/interventions implemented to protect other residents. An interview was conducted on 08/28/2019 at 02:16 PM with S9CN[NAME] She said she was assigned to care for Resident #5 today. She stated she was aware that Resident #5 burned herself with coffee. She denied having received training on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. An interview was conducted on 08/28/2019 at 2:27 p.m. with S1ADM. S1ADM stated the facility was aware of Resident #5's coffee burns. He stated in response to the coffee, Resident #5 was provided a sippy cup to prevent future hot coffee spills. S1ADM stated they were bouncing ideas around as to how the facility would prevent other severely cognitively impaired residents from sustaining coffee burns; he stated he would provide me with documentation. An observation was made on 08/28/2019 at 4:56 p.m. of a body audit performed on Resident #5 by S6LPN, S9CNA, and S4TN. A red wound with small areas of beige thickened tissue was noted to Resident #5's left upper, anterior thigh. The wound was approximately 3 - 4 inches long and ranged from 1 - 2 inches wide along the length of the burn. The wound was covered with Vaseline impregnated gauze and a clear dressing. S4TN described the wound as consisting of 2nd to 3rd Degree burns. An interview was conducted on 08/29/2019 at 8:35 a.m. with S18LPN. S18LPN stated no one is directly assigned to supervise the dining room; she stated staff go in and out of dining room throughout the day. An interview was conducted with 08/29/2019 at 8:45 a.m. with S5LPN. She reported residents can get/drink coffee in the Dining Room, in their rooms, and the sitting areas. She stated she was aware that Resident #5 had [MEDICAL CONDITION] a coffee spill. She reported residents are allowed to take coffee from the Dining Room to their rooms. She reported residents get their own coffee from the dining room. She reported other than meal times, no one is assigned to supervise the dining room. She reported she had not received training on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. An interview was conducted on 08/29/2019 at 8:55 a.m. with S8DM. She stated the temperature of the coffee will be measured and documented in a log. She stated she started checking the temperatures of the coffee on 08/28/2019. However, she verified she had not documented the temperature measurements. She stated the dispenser with the coffee for the residents was not to be set out in the dining room until the temperature has cooled to 140 degrees. S8DM measured the temperature of the coffee in the dispenser in the dining room which was available for resident consumption with a facility thermometer, and the temperature measured 145 degrees Fahrenheit. An interview was conducted on 08/29/2019 at 8:55 a.m. with S11CN[NAME] She stated she has never received training on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. An interview was conducted on 08/29/2019 at 9:01 a.m. with S13CN[NAME] She stated residents get coffee from the main dining room or from their meal tray. She stated the coffee is setup on a table for the residents in the dining room. She stated staff was not required to be in the dining room at all times even when coffee is available for the residents. She stated she had not received training on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. An interview was conducted on 08/29/2019 at 9:04 a.m. with S15CN[NAME] She stated she had not received training on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. An interview was conducted on 08/29/2019 at 9:35 a.m. with S10CN[NAME] She reported Resident #5 feeds herself, but staff monitor her. She reported coffee is out in the dining room all the time for residents to get coffee. She reported she had not received training on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. She reported in the old facility, the restorative aide served the residents coffee; when they moved here on 05/10/2019 the facility decided the coffee would be left out all day. An interview was conducted on 08/29/2019 at 9:38 a.m. with S12CN[NAME] She reported coffee is available in the dining room at all times. She reported the coffee and cups were available on the cart for resident use. She reported she had not received an in-service on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. An interview was conducted on 08/29/2019 at 9:39 a.m. with S16SUN. She stated coffee was always accessible to residents in the dining room. She stated staff were not always present in the dining room. She stated she had not received training on the need to monitor/supervise residents when they are drinking coffee in the dining room to help [MEDICAL CONDITION] the incident on 8/18/2019 with Resident #5. An observation was conducted on 08/29/2019 at 9:41 a.m. of Resident #94 and Resident #101. Both residents were observed serving themselves coffee in the dining room with no staff present. The coffee dispenser was stationed on a metal rolling cart. Resident #94 used her rolling walker for support while getting coffee and carried her coffee while ambulating with her walker to a nearby table. Review of Resident #94's Quarterly MDS with an ARD of 08/05/2019 revealed the resident had a BIMS score of 04 which indicated severe cognitive impairment. Further review revealed Resident #94 ambulated independently with a walker and required supervision and set-up help with eating. Review of Resident #94's [DIAGNOSES REDACTED]. Review of Resident #101s Quarterly MDS with an ARD of 08/08/2019 revealed she had a BIMS score of 03 indicating severe cognitive impairment. Further review revealed the resident ambulated independently and required supervision and 1-person physical assist with eating, and her active [DIAGNOSES REDACTED]. An interview and observation were conducted on 08/29/2019 between 11:00 a.m. and 11:35 a.m. with Resident #94. She was observed sitting up in the dining room at a table with Resident #101. Resident #94 had her rolling walker positioned next to her. She stated she went to get coffee with Resident #101 in the dining room earlier this morning. She stated she helped Resident #101 get her coffee. She stated she had to help Resident #101 with things all the time. She stated Resident #101 could not do a lot for herself, so she helped her. She said sometimes she got coffee for herself and Resident #101 in the dining room and staff were not there to help. An interview was conducted on 08/29/2019 at 3:01 p.m. with S4TN. She reviewed Resident #5's left thigh wound documentation and confirmed the burn wound size was 13.10 cm x 6.8 cm x 0.0 and described as a deep partial thickness burn. S4TN stated the measurements should have been recorded as 13.10 cm x 6.8 cm x 0.2 cm and stated [MEDICAL CONDITION] 3rd degree burns.

Based on observations, interviews and record review, the facility failed to ensure a sanitary environment to prevent the development and transmission of infections by staff failing to sanitize hands during incontinent care and staff failing to perform appropriate handling of linen during incontinent care for 1 (#35) of 1 (#35) resident observed for incontinent care. This deficient practice had the potential to affect all 117 residents listed on the facility's Resident Census and Conditions of Residents. Findings Review of the policy titled Soiled Linen revealed the following in part: 1. Soiled linen will be placed in a lined laundry barrel. 3. Soiled linen must be sent to the laundry in appropriate barrels. Review of the policy titled Hand Hygiene revealed the following in part: Indications for handwashing: 2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room. 3. Before and after all procedures. 4. Before and after applying gloves. 9. Wearing gloves does not replace the need to perform hand hygiene. Selecting Hand Washing Method: 1. When to use alcohol-based hand rub: b. after contact with a resident's intact skin (e.g., after taking a pulse or blood pressure). f. before exiting a resident's room 2. When to wash with soap and water h. before and after assisting a resident with toileting On 08/28/2019 at 9:18 a.m., an observation was made of S14CNA assisting Resident #35 with incontinent care. The dirty brief was taken off by S14CNA, the residents' perineal area was cleaned of urine and new brief applied without changing gloves. While still wearing the soiled gloves, S14CNA proceeded to dress the resident in clean clothes and adjusted the resident's bed using the bed remote. She walked into the resident's bathroom, opening the door and the closet door in the bathroom with the same gloves. S14CNA then removed the dirty linen from the bed and carried them down the hall to the soiled linen holding area. The linen was not contained in a bag. She removed her gloves and got a sweater to place on the back of the resident's chair without washing her hands. An interview was held with S14CNA, on 8/28/2019 at 10:01 a.m. She confirmed she walked down the hall with soiled linens. She further stated it's normal to walk down the hall with soiled lines in her hand. She confirmed she did not wash her hands after taking off a dirty brief and then applying a new one. She further confirmed she handled other things in the resident's room without removing her gloves and washing her hands. She stated she would wash her hands twice, once before resident care and then once care is complete. She further stated sometimes she double gloves, so all she has to do is remove the dirty pair of gloves and continue working. She said it was not a problem or concern to walk down the hall with dirty linens. An interview was held with S3ADON, on 08/28/2019 at 3:30 p.m.She confirmed the handwashing should have been performed during peri care from dirty to clean. She stated staff should not have walked down the hall with linen in hand and not contained in a bag or the soil linen container. An interview was held with S2DON, on 08/29/2019 at 9:00 am. She confirmed handwashing should be performed during peri care when going from dirty to clean. She stated that one pair of gloves is not adequate to wear while giving care from dirty to clean. She confirmed that soiled linen should not be carried down the hall without being in a bag or container.

Based on observations, interviews, and record review, the facility failed to provide the necessary care and services for a resident to maintain or improve the ability to carry out activities of daily living. This deficient practice was evidenced by the facility failing to ensure 1 (#20) of 4 (#10, #20, #107, #109) residents investigated for nutrition received assistance with a meal. Findings: A review of Resident #20's record revealed [DIAGNOSES REDACTED]. A review of Resident #20's Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 3, which indicated Resident #20 was severely cognitively impaired and required oversight, encouragement, and cueing while eating. A review of Resident #20's Notes revealed the following entries by the Registered Dietitian: 08/23/2019 3:14 p.m. Significant weight loss, meal intake varies greatly. Eats 25-50% of most meals. Monitor wt./intake/labs/skin and hydration. Refer to any signs changes to Registered Dietitian. 05/17/2019 12:15 p.m. Weight loss with fluctuation, weight declining. Meal intake 0-75% most meals. Monitor wt/intake/labs/skin/and hydration. Refer any changes to the Registered Dietitian. Offer an alternative if the resident refuses meals. 04/19/2019 at 3:08 p.m. Meal intake 25-50% most meals. Monitor wt/intake/labs/skin/and hydration. A review of Residents #20's care plan revealed the problem Potential for weight loss. Interventions included providing the resident with verbal encouragement and cueing. An observation was made of Resident #20's meal tray on 08/28/2019 at 8:34 a.m. The resident was in her room lying flat in bed with the breakfast tray in front of her. The top of the tray was removed, but the containers were unopened. A CNA was not present. On 08/28/2019 at 8:45 a.m., an observation was made of Resident #20. The breakfast tray remained uncovered in front of the resident and the containers were unopened. The resident was awake and watching television. On 08/28/2019 at 9:30 a.m., the breakfast tray remained uncovered in front of the resident and the containers were unopened. On 08/28/2019 at 9:48 a.m., S14CNA walked into the resident's room, placed the top on her breakfast tray, and removed the breakfast tray from the room. An interview was held with S14CNA on 08/28/2019 at 10:01 a.m. She stated she did not realize the resident had not eaten her breakfast. She said her tray had been in her room since about 7 a.m. S14CNA stated it was almost lunchtime and would feed Resident #20 her lunch since the hall trays come out between 10:45 a.m. and 11:00 a.m. S14CNA stated Resident #20 required set up assistance with meals, which includes opening all food containers and condiments as necessary. She said she did not realize the containers were not opened. S14CNA stated the food was unopened today because she was in a hurry. S14CNA stated she notifies the nurse when a resident does not eat but did not tell the nurse this morning because she went on a break. S14CNA stated she should have told the nurse Resident #20 did not eat. On 08/28/2019 at 3:30 p.m., an interview was conducted with S3ADON. She confirmed the resident should have been sitting up in bed and the meal tray should have been set up with the containers opened. S3ADON stated staff should have monitored the resident while eating and offered cueing and encouragement. An interview was held with S2DON on 08/29/2019 at 9:00 a.m. She stated residents who eat in their room should be sitting up, with all meal tray containers opened, and have staff monitoring the meals. She confirmed it is not an acceptable practice for a resident's tray to be sitting in the room for 3 hours and the resident not to be provided the required assistance with the meal.

Based on record review and interviews the facility failed to implement the resident's person-centered written plan of care. This is evidenced by staff failing to hold an ordered blood pressure medication if there was a systolic blood pressure reading of less than 110 for 1(#73) of 29 total residents reviewed for care plan implementation. Findings: Review of Resident #73's record revealed the resident had an admission date of [DATE]. She had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/6/18 revealed Resident # 73 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Review of Resident #73's record revealed a care plan, with a review date of 12/12/18, was developed which identified the following: Potential for alteration in blood pressure related to [DIAGNOSES REDACTED]. Interventions included check blood pressure as ordered, administer antihypertensive as ordered, administer antilipidemic as ordered, labs as ordered, and notify the physician as needed. Review of the (MONTH) (YEAR) Physicians Orders revealed an order with a start date of 8/11/17 for [MEDICATION NAME] 10 milligram tablet 1 tablet by mouth three times a day, hold if systolic blood pressure less than 110 or pulse less than 60. An interview was conducted on 9/24/18 at 11:51 a.m. with Resident #73. Resident #73 stated that her nurses administered blood pressure medication to her when her blood pressure was too low. Review of the record for (MONTH) and (MONTH) Medication Administration Record [REDACTED] 8/7/18 - 12:00 p.m. - 109/72 8/8/18 - 12:00 p.m. - 102/76 8/8/18 - 8:00 p.m. - 107/76 8/16/18 - 12:00 p.m. - 103/74 8/18/18 - 12:00 p.m. - 95/63 8/23/18 - 12:00 p.m. - 106/81 8/24/18 - 12:00 p.m. - 109/73 9/1/18 - 8:00 a.m. - 101/71 9/1/18 - 12:00 p.m. 104/66 9/2/18 - 8:00 a.m. - 104/64 9/8/18 - 12:00 p.m. - 104/72 9/9/18 - 8:00 p.m. - 108/67 9/14/18 - 8p.m. - 97/68 9/18/18 - 8a.m. - 105/68 An interview was conducted on 9/26/18 9:48 a.m. with S6LPN. She stated she administered medications to Resident #73. She verified Resident #73 had an order for [REDACTED]. An interview was conducted on 9/26/18 at 2:40 p.m. with S1DON. She verified the physicians order revealed that the medication, [MEDICATION NAME], should have been held for a systolic blood pressure of less than 110. She then reviewed the (MONTH) and (MONTH) Medication Administration Records and verified the medication was given outside the prescribed parameter on the above dates.

Based on observation, interviews, and record reviews, the facility failed to ensure that residents who required [MEDICAL TREATMENT] received services as scheduled when residents were not transported to their [MEDICAL TREATMENT] appointments for 2 (#5, #101) of 2 (#5, #101) residents reviewed for [MEDICAL TREATMENT]. Findings: Resident #5 Resident #5 was admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. -May attend [MEDICAL TREATMENT] every Monday, Wednesday, and Friday at the [MEDICAL TREATMENT] center for 11:15 a.m. Review of Resident #5's record revealed a care plan was developed which identified the following: Resident requires [MEDICAL TREATMENT] three times a week. Approaches: Coordinate resident's transportation to the [MEDICAL TREATMENT] center as scheduled Monday, Wednesday and Friday. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/18 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated he had severe cognitive impairment. He was coded as receiving [MEDICAL TREATMENT]. An observation was made on 09/24/18 at 1:15 p.m. of Resident #5. He was lying in his bed. When asked if he went to [MEDICAL TREATMENT] today, he turned his head side to side indicating he did not go to [MEDICAL TREATMENT] today. An interview was conducted on 09/24/18 at 1:20 p.m. with S4CNA. She reported Resident #5 did not go to [MEDICAL TREATMENT] today. She said she was unsure of the reason the resident did not go to his [MEDICAL TREATMENT] appointment. An interview was conducted on 09/24/18 at 1:30 p.m. with S3LPN. She reported Resident #5 went to [MEDICAL TREATMENT] Mondays,Wednesdays, and Fridays via the facility van. She said that Resident #5 usually left the facility at approximately 10:00 a.m. She reported Resident #5 did not go to [MEDICAL TREATMENT] today due to a misunderstanding with the transportation driver. She reported S1DON was made aware the resident did not receive [MEDICAL TREATMENT] today. An interview was conducted on 09/24/14 at 1:45 p.m. with S1DON. She reported Resident #5 and Resident #101 were scheduled to go to [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays via the facility transportation van. She added that Resident #5 and #101 usually left the facility at approximately 10:00 a.m. She said at approximately 11:30 a.m. today, she was made aware that Resident #5 and Resident #101 did not go to [MEDICAL TREATMENT]. She reported S5Driver was at a doctor's appointment with another resident and did not call the facility to inform them that she was would not be available to bring Resident #5 and Resident#101 to [MEDICAL TREATMENT]. S1DON verified Resident #5 and Resident #101 should have been transported to [MEDICAL TREATMENT] today. S1DON confirmed it is the facility's responsibility to make sure the residents get to their [MEDICAL TREATMENT] appointments. An interview was conducted on 09/24/18 at 2:30 p.m. with Resident #5's [MEDICAL TREATMENT] nurse at the local [MEDICAL TREATMENT] center. She said she called the facility around 11:30 a.m. and reported the resident did not show up for his [MEDICAL TREATMENT] appointment. She said she was told there was a miscommunication with the transportation driver from the facility. Resident #101 Resident #101 was admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. -May attend [MEDICAL TREATMENT] every Monday, Wednesday, and Friday at the [MEDICAL TREATMENT] center for 11:00 a.m. to 3:50 p.m. Review of the Care Plan for Resident #101 revealed that he was care planned as receiving [MEDICAL TREATMENT]. Review of the quarterly MDS for Resident #101 with an ARD of 09/17/18 revealed he had a Brief Interview for Mental Status score of 15 (cognitively intact) and was coded as receiving [MEDICAL TREATMENT]. An interview was held with Resident #101 on 09/24/18 at 3:17 p.m. He said that he normally went to [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays and left the facility between 9:30 a.m. and 9:45 a.m. He said that he did not go to [MEDICAL TREATMENT] on 09/24/18 because the transportation driver never showed up. He said that when the driver never came to get him that he told a nurse that the driver did not come. He said that the nurse checked on what had happened with the driver and informed him that the driver was held up at an appointment with another resident. An interview was held with S5Driver on 09/25/18 at 8:37 a.m. She said that she had been the transportation driver for [AGE] years. She reported she was normally responsible for transporting Resident #5 and Resident #101 to the [MEDICAL TREATMENT] centers on Mondays, Wednesdays, and Fridays and left the facility between 9:45 a.m. and 10:00 a.m. She reported that she had to transport another resident to an appointment on Monday, 09/24/18. She said that she knew that she would not be back to transport Resident #5 and Resident #101 to [MEDICAL TREATMENT] because of the appointment time of another resident. She reported that she told the ward clerk that she needed someone to go with her to the appointment to sit with the resident. She said that normally another CNA would have went with her to stay with the other resident at the appointment, and she would have returned to the facility to take Resident #5 and Resident #101 to [MEDICAL TREATMENT]. She said she was told by the ward clerk that the ADON told her there was no one to go with her because the two restorative aides were pulled to the floor for resident care. She added that she did not want the other resident going to the appointment to be late so she went ahead and left the facility. She reported she did not have cell service in the clinic so she was unable to call the facility to inform them that she would not be there in time to transport Resident #5 and Resident #101 to [MEDICAL TREATMENT]. She said that she finished with the other appointment at 12:10 p.m. and called the facility then to see if anyone had taken the residents to [MEDICAL TREATMENT]. She said that Resident #5 and Resident #101 had not been transported to [MEDICAL TREATMENT] on Monday, 09/24/18. An interview was held with S2ADON on 09/25/18 at 8:47 a.m. She said that she had been the ADON for 3 1/2 years. She said that she knew that the transportation driver was taking another resident to a doctor's appointment on 09/24/18. She said the driver never communicated she was staying with the resident or that she would not be back to the facility in time to bring Resident #5 and Resident #101 to [MEDICAL TREATMENT]. She said that the ward clerk told her that the transportation driver asked about someone to go with her to the doctor's appointment for another resident. S2ADON said that she told the ward clerk that she did not know who they could send because the two restorative CNAs were assisting with working on the floor. She said that when she told the ward clerk about not being sure who they could send with the driver that the transportation driver had already left for the appointment. She said that she was not aware that the transportation driver would not be back to transport Resident #5 and Resident #101 to [MEDICAL TREATMENT]. She added that she did not check the time of the other appointment after the driver had already left the facility. She said it was an issue of total lack of communication.

Based on observation, interviews, and record reviews the facility failed to provide abuse, neglect, and exploitation training to their staff that at a minimum educated the staff on activities that constitute abuse and neglect and procedures for reporting incidents of abuse and neglect for 6 (S7CT, S8CT, S9CT, S10CT, S11CT, S12CT) of 6 (S7CT, S8CT, S9CT, S10CT, S11CT, S12CT) contracted therapy staff reviewed for abuse and neglect training. Findings: An interview was conducted with Resident #90 on 9/24/18 at 11:13 a.m. in the therapy room with S7CT present. S7CT actively participated in the interview by clarifying answers for Resident #90. During the interview, Resident #90 explained when she was in the shower room two of the aides got around her, poked her here and here, and said means things to her. The resident pointed to her arms and chest when she stated poked her here and here. The resident then stated she did not want to talk about it anymore and started to cry. S7CT was observed offering Resident #90 a tissues to wipe her tears. An interview was conducted with S7CT on 9/25/18 at 11:25 a.m. She stated she had worked at the facility for three and a half years. She verified she had heard Resident #90 yesterday when she spoke of how the aides got around her, poked her here and here, and said mean things to her. An interview was conducted with S7CT on 9/26/18 at 1:55 p.m. She stated she had not reported the allegation Resident #90 had made to anyone. An interview was conducted with S1DON on 9/26/18 at 2:45 p.m. She verified that any allegations of abuse should have been reported immediately. She stated all staff should have known to follow their chain of command or directly report abuse allegations to S13ADMIN. An interview was conducted with S7CT on 9/27/18 at 8:40 a.m. She stated she had not reported exactly what Resident #90 had said to S13ADMIN because she was not sure if she was supposed to. She stated that the facility did not instruct her on what to do in situations like this. An interview was conducted with S13ADMIN on 9/27/18 at 1:00 p.m. He stated that the staff are to report immediately to S13ADMIN any alleged abuse. He stated therapy services were contracted through another company and did not have to follow the facility policies and procedures. He stated contract therapy staff did not attend nor had to attend any in services or trainings provided by the facility. He stated he would hope the contract therapy staff would have reported allegations of abuse. He clarified the contract therapist were not his staff and did not have to report to him.

Based on interviews and record reviews, the facility failed to ensure 1 (resident #2) of 4 (resident #1, resident #2, resident #3, & resident #4) sampled residents reviewed for pressure ulcers maintained acceptable weight parameters. The facility failed to: 1. Notify the physician and registered dietician of a severe weight loss; 2. Reassess the resident after the severe weight loss; 3. Ensure house supplement was administered as ordered. The deficient practice resulted in an actual harm when resident #2 was found to have a 19% weight loss when his weight went from 201 pounds on 3/10/14 to 164 pounds on 4/17/14. Resident #2 had a 12% weight loss in 7 days when he went from 188 pounds on 4/10/14 to 164 pounds on 4/17/14. The facility failed to reassess resident #2 and notify the physican of the severe weight loss. It had the potential to affect any of the 118 residents who need or may need assistance with maintaining their nutritional status as documented on the facility's Resident Census and Conditions of Residents CMS Form-672. Findings: Resident #2 Review of the clinical record revealed resident #2 was admitted to the facility on [DATE]. Review of the Diagnosis / History list revealed the following: Protein-Calorie Malnutrition onset 4/28/14, Diabetes Mellitus, Dementia with Behavior onset 10/10/12, [MEDICAL CONDITION] onset 1/31/12, [MEDICAL CONDITION] onset 6/27/11, Acute Post-operative pain onset 4/28/14, Late Effect [MEDICAL CONDITIONS] 6/28/11, benign prostate [MEDICAL CONDITIONS] with urinary obstruction onset 10/10/13, pressure ulcer stage I 4/21/14, pressure ulcer stage III 4/28/14, pressure ulcer unstageable 5/6/14, Traumatic Fracture of Hip onset 4/24/14. Review of the annual minimum data set (MDS) with an assessment reference date (ARD) of 3/18/14 revealed the following in part: cognitive skills for daily decision making - moderately impaired decisions poor, cues supervision required; bed mobility - extensive assistance of 2 + persons; eating - limited assistance of 1 person; frequently incontinent of urine; frequently incontinent of bowel; at risk for developing pressure ulcer; no pressure ulcer; and no or unknown weight loss. Review of the weight change history report revealed the following: 1/10/14 199 pounds (#) 1/17/14 199 # 1/24/14 200 # 1/31/14 200 # 2/10/14 200 # 3/10/14 201 # 3/24/14 194 # 3/31/14 188 # 4/10/14 188 # 4/17/14 164 # 4/24/14 162 # 5/1/14 161 # 5/10/14 163 # 5/17/14 163 # Review of the physician progress notes [REDACTED].#, stable since January 2014; stage I pressure ulcer; approximate 6.0 x 3.0 centimeters (cm) deep purple reddened non-blanche; use zinc oxide 4 x day and as needed (prn); up only for meals; add juven 1 packet twice a day (bid), turn every (q) 2 hours (hrs). Review of the physician orders [REDACTED]. 4/21/14 11:05 a.m. vitamin C 500 milligrams (mg) by mouth (po) bid, zinc sulfate 220 mg po q day (d), add juven 1 packet bid, patient to be up in chair only for meals, turn back to side to side q 2 hrs, change diaper q 3 hrs at least to prevent skin worsening, use zinc to sacrum four times a day (qid) and prn. 4/22/14 8:54 a.m. Sacral area - cleanse area with wound cleanser, pat dry, apply zinc oxide qid until resolved. Review of the Readmit physician orders [REDACTED]. Review of the physician orders [REDACTED]. Review of the Departmental Notes revealed the following in part: 4/21/14 at 10:50 p.m. Late entry for 6-2 shift Resident seen by L ... P ..., nurse practitioner (NP). Resident noted to have pressure area, non-blanchable, purplish in color to sacral area received new orders for zinc oxide qid to sacral area until healed, vitamin C po q d, zinc 220 mg po bid, juven one packet po bid to promote wound healing, pre-[MEDICATION NAME] and renal panel in the a.m. 4/22/14 4/22/14 at 2:40 p.m. At 1345 upon making rounds resident noted to be guarding left leg/hip area complaining of pain this nurse assessed resident further no bruising to left leg/hip area noted administered Tylenol 650 mg po for pain per prn order, call placed to L ... P ..., N.P. received order to obtain portable x-ray of left hip. At 1415 x-ray tech in facility to obtain x-ray, results faxed to facility impression show fracture through the left femoral head and neck, angular deformity is noted. The bones are osteopenic, call placed to L ...P ..., N.P., new order received to send resident to hospital 4/22/14 at 3:11 p.m. ambulance in facility to transport resident to hospital emergency room (ER) 4/24/14 at 10:01 p.m. returned to facility from hospital around 2 p.m. Review of the labs revealed the following: 4/25/14 glycated hemoglobin (HgbA1C) 8.5 (normal 4.5 -6.3), Red blood cell count (RBC) 3.53 (normal 4.5-5.6), hemoglobin (Hgb) 10.0 (normal 14-18), hematocrit (Hct) 31.2 (normal 42-52), glucose 102 (normal 70-100), blood urea nitrogen (BUN) level 19 (normal 5-25), Creatinine level .8 (normal.57 - 1.25), [MEDICATION NAME] 1.7 (normal 3.5 - 5.0). Review of the physician progress notes [REDACTED]. Review of the registered dietician (RD) notes dated 4/29/14 at 8:40 a.m. revealed the following: 4/10/14 187#; 10/3/13 208.6#; significant loss; juven 1 pack bid, 4 ounces (oz) bedtime (hs) q d; continue ordered diet/juven; increase hs to bid; weekly weights x 4. Review of the Nutrition Evaluation dated 4/30/14 revealed the following in part: no extra or fortified foods at meals; average percentage of supplement intake - none; consumption 76-100% and weight loss - no. Review of the physician orders [REDACTED]. 5/1/14 no time House supplement BID and assist with feed. Review of the May 2014 electronic Medication Administration Record [REDACTED]. Review of the May 2014 monthly physician orders [REDACTED]. Review of the quarterly MDS with ARD of 5/7/14 revealed the following in part: cognitive skills for daily decision making - moderately impaired decisions poor, cues supervision required; bed mobility - extensive assistance of 2 + persons; eating - extensive assistance of 1 person; indwelling catheter; always incontinent of bowel; at risk for developing pressure ulcer; 1 stage III pressure .8 x 3.5. 0; 1 unstageable deep tissue; and no or unknown weight loss. Review of the Nutrition Evaluation dated 5/7/14 revealed the following in part: no extra or fortified foods at meals; average percentage of supplement intake - none; consumption 76-100% and weight loss - no. Review of the physician progress notes [REDACTED]. hip fx staples and sutures are removed today incision line well approximated without redness or warmth;. Wt. blank. Review of the Care Plan revealed the following in part: Problem Onset: 1/25/12 Nutritional Status: resident has potential for weight loss and aspiration. Problem Onset: 5/12/14 Nutritional status: resident has potential for weight loss and aspiration. Approaches -speech therapy (ST) to evaluate and treat as ordered; Diet LCS / Pureed honey thick liquids; supplements as ordered; Dietician to evaluate and follow up as needed; Provide assistance as needed (cueing, feeding assist); Monitor food intake at each meal and record; Report significant decline to physician and dietician; Weigh resident as ordered; Record results and report significant loss to physician and dietician. Problem Onset: 5/12/14 Recent lost weight, wt 7.5% <91 days. Approaches - Weigh resident weekly until stable; RD consult 3/14/13; Scales recalibrated; Continue diet; Notify RD and physician (MD); Diet LCS / Pureed honey thick liquids; family refuses peg placement; and supplements as ordered. Problem Onset: 4/17/14 Resident has a stage 1 pressure ulcer to sacrum. Problem Onset: 4/24/14 Impaired skin integrity stage 3 to sacrum with slough. Problem Onset: 5/12/14 Self Care Deficit: Resident requires extensive assist with ADLs. Problem Onset: 5/12/14 Resident has impaired thought processes. [DIAGNOSES REDACTED]. Review of the Wound Healing Progress Report revealed the following: Pressure Ulcer Sacrum - 8.0 x 3.0 x 0 date identified 4/17/14; Pressure Ulcer Right Heel - 3.5 x 3.5 (unstageable due to suspected deep tissue injury date identified 5/5/14). An interview was held on 5/27/14 at 1:45 p.m. with S5CNA5. She said she had been working at the facility for 6 months. She said that she routinely took care of resident #2. She explained he fed himself and ate in the dining room. She explained since he broke his hip he stays in bed and they feed him in his room. An interview was held on 5/28/14 at 2:45 p.m. with S2DON. She verified resident #2's weights on 4/10/14 of 188 pounds and 4/17/14 of 164 pounds. She explained they were correct, and there had not been a problem with the scale. After reviewing the record, she verified there was no documentation that the physician or the RD was notified of the weight loss. She provided an RD note dated 4/29/14 which revealed a weight of 187 pounds on 4/10/14. After reviewing the note, she verified it did not reveal the resident's weight of 164 # on 4/17/14. An interview was held on 5/29/14 at 9:15 a.m. with S4CorporateNurse and S3ADON. They explained S2DON was not at work. After reviewing the physician orders [REDACTED].#2 did not receive HS bid as ordered on [DATE]. She verified it was first administered on 5/7/14. After reviewing the weight change history report, S3ADON verified resident #2 weighed 4/10/14 187.6 pounds and on 4/17/14 163.8 pounds. After reviewing the high risk minutes dated 5/7/14, S4CorporateNurse verified it revealed weekly weights and increase HS BID for resident #2. After reviewing the high risk minutes dated 5/14/14, S4CorporateNurse verified it revealed resident #2 was maintaining his weight and to continue the weekly weights. S3ADON verified that weekly weights were already in place prior to 4/17/14 and the house supplement bid order was written on 5/1/14. After reviewing the high risk minutes for April 2014, S4CorporateNurse verified resident #2 was not discussed for weight loss. An interview was held on 5/29/14 at 10:05 a.m. with S4CorporateNurse. She said staff reported resident #2 had not lost 20 pounds, but he had lost weight after he returned from the hospital. She said staff reported to her there had been no problems with the scales. She explained S2DON had reported a problem with the weights and the previous director of nurses (DON) also had a similar scenario with the weight issue. An interview was held on 5/29/14 at 10:10 a.m. with S3ADON. She explained the restorative certified nurse aides (CNAs) and nurse obtained the weights; forwarded the weights to S2DON; S2DON directed reweighs for inconsistent weights; S2DON entered weights into the computer; S2DON ran a report to flag 30 day, 60 day, 90 day, and gradual weight loss; S2DON placed weight loss residents on weekly weights; RD accessed weights in computer; S2DON placed weight loss residents on high risk minutes; and MDS nurses added interventions to care plans for weight loss. An interview was held on 5/29/14 at 10:20 a.m. with S6MDS Nurse. He said that he had been in the position since March 2014. He said that he had not been informed of resident #2 having a weight loss in April 2014. He explained he is notified of residents with weight loss during the weekly High Risk Meetings. He said resident #2 was discussed in the May 2014 High Risk Meeting due to his pressure ulcer, but he was never discussed for weight loss. An interview was held on 5/29/14 at 10:30 a.m. with S3ADON. After reviewing the record, she verified the resident #2 had not been reassessed after the weight loss on 4/171/4, and the physician and the registered dietician were not notified. She said S2DON should have notified the physician, and RD, and reassessed resident #2 after the weight loss. An interview was held on 5/29/14 at 11:45 a.m. with L ... P ..., N.P. After reviewing the record, she verified she had not been notified of resident #2's current weight of 163 #s. She said that she was not contacted when resident #2 went from 188 #s on 4/10/17 to 164 #s on 4/17/14.

Based on observation, interview and record review, the facility failed to provide services necessary to prevent physical harm as necessitated by a resident's physical condition for 1 (#42) of 3 (#42, #118, #124) residents reviewed for Range of Motion in stage 2 out of a total sample of 34, by failing to: a) Accurately and consistently assess the inside of the resident's right and left hands daily; b) Consistently clean, with wound cleanser and apply gauze rolls inside the resident's hands per the physician orders; c) Provide passive range of motion to the resident's contracted hands; and d) Attempt alternate approaches to prevent the development of stage 2 pressure ulcers to the palms of the residents right and left hands. e) Adress the resident's pain during hand movement and cleaning of hands and nails. f) Implement interventions to prevent skin breakdown or tears when unable to use gauze rolls in contracted hands. The deficient practice resulted in an actual harm when Resident #42's nailtips penetrated into the resident's palms leaving open, foul smelling wounds in each of her palms. The resident exhibited nonverbal expressions of pain when fingers of her hands were opened for hand cleaning. As Needed (PRN) pain medication that was ordered, was not given to the resident. Findings: A review of the facility's Skin Care Policy and Procedure, Latest Revision: 6/11 revealed, in part, the following: It is the policy of this facility that skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. Those are: Prevent, Evaluation and Screening Ongoing Surveillance Treatment Orders Treatment Regimen Overseeing these efforts will be the DON. Every effort will be made to prevent skin breakdown. Skin problems which develop will be followed carefully and treated according to medical direction. The nursing department's procedures will be such that the staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for the development of skin breakdown. The nursing department will maintain the capability to respond to patient needs (in the area of skin integrity) by the following means: With medically directed treatment for [REDACTED]. With an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk. With a medically directed restorative and therapeutic program for residents who develop a skin problem after admission. If the resident is at risk or prone to skin breakdown, the following measures will be considered and, if implemented, placed in the care plan and on the nursing assistant assignment sheet: a) Use of a pressure reducing device b) Special positioning with support pillows c) Exercise of the joint nearest to any problem skin area. Treatment Regimen - Screening of the need for pain medication and administration as appropriate; Special pressure relieving devices or orthotic devices A review of the clinical record for Resident #42 revealed the resident was [AGE] years of age with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set completed by the facility on 7/24/13 regarding Resident #42 revealed, in part, the following: The resident had adequate hearing, unclear speech, required extensive assistance with turning and repositioning. The resident was totally dependent on staff for washing and drying her hands. The resident had impairment to both sides of her upper and lower extremities. The resident had occasional pain and received pain medication as needed (PRN). The resident was identified by the facility as at risk for pressure ulcer development. A review of the computerized August 2013 Physician order [REDACTED]. Fibersource HN via PEG (feeding tube) continuously Multivitamin tablet every day Tylenol Extra Strength 500milligram (mg) caplet, give 2 every 8 hours as needed (PRN) for pain Daily cleanse inside of both hands with wound cleanser, pat dry, and leave gauze roll in both hands daily Nail Care Weekly. Check condition and clean as needed Hospice Diagnosis: [REDACTED]. On 8/19/13 at 3:06 p.m. an observation was made of Resident #42 lying in her bed. Her eyes were closed and her arms were bent at the elbows with her hands closed, resting on her chest. The resident was not observed to have a gauze roll in either her right or left hand. On 8/21/13 at 11:12 a.m. an observation was made of Resident #42 lying in her bed. Her eyes were closed and her arms were bent at the elbows with her hands closed, resting on her chest. The resident was not observed to have a gauze roll in either her right or left hand. On 8/21/13 at 11:12 a.m. an interview was conducted with S15LPN, the nurse for Resident #42. She stated that the hospice nurse visits Resident #42 on Wednesday and Friday. She stated that the hospice nurse and facility nurses verbally communicate to each other any changes regarding the resident. On 8/21/13 at 2:58 p.m. an observation was made of Resident #42 lying in her bed. The resident's arms were bent at the elbows with her hands closed, resting on her abdomen. The resident was not observed to have a gauze roll in either her right or left hand. A review of the Physical and Occupational Therapy Documentation for Resident #42 revealed the resident was last screened for therapy on 3/19/13. Documentation on the screening form dated 3/19/13 revealed: Patient observed and therapy is not recommended. Patient currently under hospice care and not appropriate for therapy at this time. On 8/19/13 at 3:06 p.m. an interview was conducted with S18CNA. She stated that Resident #42 was unable to talk, but could understand what was said to her. She stated that the resident was not receiving restorative care. On 8/21/13 at 11:49 a.m. an interview was conducted with S15LPN. She stated that the Resident #42's hands were contracted and that the resident had a rolled gauze in her hands daily. S15LPN further stated that resident #42 did not currently have any skin breakdown. On 8/21/13 at 3:00 p.m. an interview was conducted with S17CNA while observing Resident #42. She stated that she was one of the aides for the resident. She stated that she did not know if Resident #42 still used gauze in her palms for her contractures. She stated that the hospice aide had been at the facility today (Wednesday) and bathed the resident. The resident was lying in her bed, her hands were closed with her fingers bent into the palms of her hands. While standing directly next to the resident's bed, a strong, foul odor emanated from the resident. S17CNA stated that the resident did not have any pressure ulcers. She stated that the smell was coming from the resident's hands. Surveyor requested to see the resident's hands. S17CNA donned gloves and slowly opened the resident's hands. The resident moaned and stiffened during this time. When the resident's hands were opened, the foul odor became stronger. This observation revealed that some of the resident's fingertips had penetrated the skin of her palms, exposing open, foul smelling wounds in the right and left palms of the resident's hands. There was no gauze roll in the resident's right or left hand during this observation. On 8/21/13 at 3:10 p.m. an interview was conducted with S16RN. She stated that she was the team leader for the company that provided hospice care to Resident #42. She stated that a hospice nurse had assessed Resident #42 earlier this day. Surveyor stated to S16RN that there was a strong odor emanating from the resident's hands. Surveyor asked for the hospice nurse assessment from earlier this day. S16RN stated that she would provide surveyor with the documentation after she talked to the hospice nurse. S16RN stated that she would assess the resident at this time in the presence of the surveyor. S16RN, with 2 surveyors present, entered the resident's room. The resident was lying in her bed with her arms resting on her abdomen. S16RN donned gloves and lifted the resident's right arm which revealed dark bruising to the resident's forearms. S16RN stated that the bruising was caused by the pressure of the resident's arms resting on each other. S16RN slowly opened the resident's right hand. The resident clenched her hands tighter and tensed her chest and arms. S16RN stated that the resident needed pain medication. She stated, you can tell that she's in pain by the way she tenses up. She stated that the resident had a wound in her hand and that it smelled awful. There was no visible gauze roll in the resident's hands at this time. On 8/21/13 at 3:15 p.m. an observation was made as S17CNA and S2DON assessed Resident #42's hands. S15LPN, S4QIRN and 2 surveyors were present during this observation. S17CNA and S2DON slowly opened the resident's hands. The resident became tense and clenched her hands tighter at this time. This observation revealed that some of the resident's fingertips had penetrated the skin of her palms, exposing open, foul smelling wounds in the right and left palms of the resident's hands. S4QIRN stated that she has seen this happen in many of her nursing home residents with hand contractures. She further stated that there was nothing you can do about it. There was no gauze roll in the resident's hands during this observation. S2DON stated that she had not done wound care on the resident's hands today. At this time, S2DON was requested to provide documentation of the most recent assessment conducted to the inside of Resident #42's hands. S2DON stated that she would look to see when it had been done and would get back to surveyors with the documentation. On 8/21/13 at 4:10 p.m. surveyor requested from S2DON documentation of the last time wound care/hand cleansing had been done on Resident #42's hands along with nursing assessments and CNA documentation. S2DON stated that she was still looking for the documentation. On 8/22/13 at 11:32 a.m. an interview was conducted with S16RN. She stated that her position of Team Leader is that of ADON for the hospice nurses. She stated that she coordinates care of the clients and conducts supervisory visits. She stated that she has authority to perform assessments on residents who are receiving hospice care from her employer. She stated that the hospice nurse completed an assessment of Resident #42 on 8/21/13 and communicates her findings with the facility nurse. She stated that she was having the hospice CNA and Nursing documentation of 8/21/13 hand delivered to S1Adm this morning. On 8/22/13, surveyor requested and received from S1Adm the Hospice CNA and Nursing Documentation of 8/21/13 regarding Resident #42. A review of the documentation revealed, in part, the following: CNA Note: 8/21/13, 6:15 a.m.- CNA Care documented as completed for Resident #42 is as follows: In bed, rails up; changed bed linens, position change, peri care, bed bath and nails cleaned. Observations reported to nurse: Nothing unusual to report. RN Documentation: 8/21/13, 1:00 p.m.- Resident #42 is total care, unable to do any activity. Patient noted to have bruising to all 4 extremities. Patient has noted contractures to bilateral hands and feet. Bilateral hands noted to be reddened and irritated to palms of hands. Yeast to bilateral palms. Facility staff collaborations: Staff/floor nurse: S15LPN. On 8/22/13 at 8:21a.m. an interview was conducted with S24LPN/MDS nurse. She stated that she updates Resident #42's Care Plan. She stated that she did a quarterly update to the Care Plan on 7/24/13. She stated that she also updates the Care Plan as needed. She stated that she thought the last time she updated Resident #42's Care Plan was around 8/6/13. A review of the Care Plan for Resident #42 revealed, in part, the following: Problem Onset: 5/16/13 - Contractures to bilateral hands - Stage 2 to left index finger, resolving 7/26/13 Goal & Target Date: 10/24/13 Approaches: Monitor resident skin under the devices for irritation or breakdown such as redness, pressure sore, skin tear. Keep hands and between fingers clean and dry 7/26/13 - Daily cleanse inside of both hands with wound cleanser, pat dry and leave gauze roll in both hands daily. Problem Onset: 2/17/11 - Fragile skin, risk for pressure ulcers, skin tears, bruises, rash Goal & Target Date: 10/24/13 Approaches: Notify Hospice of change Nail care weekly, check condition and clean PRN Daily observation of skin with routine care, report concern to nurse Problem Onset: 3/31/11 - Potential for eye infection Goal & Target Date: 10/24/13 Approaches: Nail care weekly, check condition and clean PRN Frequent hand washing and keep fingernails clean and clip Problem Onset: 4/27/11 - Potential for pain and discomfort Goal & Target Date: 10/24/13 Approaches: Resident is prescribed Tylenol Extra Strength Observe for verbal and non verbal signs of discomfort and indication of pain Administer pain medication as requested Problem Onset: 8/1/11: Impaired verbal communication, resident has decreased ability to understand others and to be understood Goal & Target Date: 10/24/13 Approaches: Simplify questions that can be answered with yes/no Problem Onset: 2/17/11 - Self care deficit: Resident requires assistance with eating, dressing, grooming, toileting, personal hygiene and bath Goal & Target Date: 10/24/13 Approaches: Assist with bath as scheduled Assist with personal grooming daily and PRN Problem Onset: 2/20/13 - Resident on Hospice, Hospice services involved in care related to progression of disease process Goal & Target Date: 10/24/13 Approaches: Assess for verbal and nonverbal indicators of anxiety/pain and administer medication to promote comfort, monitor effectiveness of intervention Hospice CNA to visit resident opposite days of facility CNA for assistance with ADLs Hospice aide to observe skin during care giving and provide gentle range of motion (ROM). On 8/22/13 at 8:21 a.m. an interview was conducted with S23RN/MDS nurse while she reviewed the facility's computerized charting for Resident #42. S23RN stated that the CNAs are to check residents when they bathe them and if they see something, they are supposed to notify the nurse. Surveyor requested to review Resident #42's August Body Audits, Head to Toe Nursing Assessments and Wound Care Treatments for August 2013. She stated that nursing assessments and skin treatments are documented in the computer under the Departmental Notes. A review of the facility's Nursing Data Collection dated 7/24/13 regarding Resident #42 revealed, in part, the following assessment: Bathing: Total dependence Range of Motion limitation: Upper extremity - impairment both sides Equipment/Devices: Hand rolls Prognosis - Life expectancy of less than 6 months: No Additional Information: Daily observation for changes in skin appearance during routine care. Prevention measures effective as evident by no breakdown in skin integrity due to pressure. A review of the facility's Pain Screen for Resident #42 dated 7/24/13 revealed, in part, the following: Pain: been on scheduled pain medication regimen - No Pain: received PRN pain medications - Yes Complaints of pain or recent change in pain to include location intensity, frequency, duration - No Should pain assessment interview be conducted - Yes Description of pain - Unable to describe Non-Verbal Expression of Pain - Facial Grimacing and Moaning Location of pain - joint(s) and generalized pain observed non-verbal What improves the pain? Medications for pain and rest What makes the pain worse? Movement Is resident satisfied with pain control? Yes Should staff assessment for pain be conducted - No A review of the August 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Tylenol Extra Strength (ES) 500mg caplet, give 2 every 8 hours PRN The facility documented that the resident received Tylenol ES on August 4 at 3:51 p.m.; August 14 at 3:56 p.m., August 18 at 8:20 p.m. and August 21 at 4:01 p.m. A review of the facility's Departmental Notes (Nursing notations) for Resident #42 revealed, in part, the following: 8/18/13, S13RN, Charge Nurse - Daily cleanse inside of both hands with .. scheduled for 8/18/13, 12:00 p.m. Bilateral hands are too contracted to clean inside and rolls will not fit. Risk of injuring if pulled open. 8/18/13, S13RN, Charge Nurse - Daily cleanse inside of both hands with .. scheduled for 8/18/13, 8:00 p.m. Bilateral hands are too contracted to clean inside and rolls will not fit. Risk of injuring if pulled open. A review of the August 2013 Treatment Administration Record (E-TAR) for Resident #42 revealed, in part, the following: Daily cleanse inside of both hands with wound cleanser, pat dry and leave gauze roll in both hands daily at 12:00pm and 8:00 p.m. The record was initialed as completed by a nurse each day from 8/1/13-8/13/13 and on 8/18/13. There was no documented evidence that the inside of the resident's hands had been assessed or cleaned on 8/14/13, 8:00 p.m. through 8/17/13. A further review of the nursing documentation on the E-TAR for 8/18/13 and the nursing documentation in the Departmental Notes dated 8/18/13 revealed conflicting documentation. The nurse documented in her notes that she was unable to assess and perform the care to Resident #42's hands at 12:00 p.m. and 8:00 p.m. due to the resident's contractures. The E-TAR on 8/18/13 at 12:00 p.m. and 8:00 p.m. had been initialed by a nurse that the care had been done. A review of the facility's Weekly Body Audit Roster for Resident #42 revealed that the most current body audit of the resident was conducted on 8/19/13, with no new skin issues. On 8/21/13 at 9:04 a.m. an interview was conducted with S2DON. She stated that the facility doesn't have a wound care nurse. She stated that S13RN and S14RN perform weekend wound care and that she and S3RN perform weekday wound care. On 8/22/13 at 8:45 a.m. an interview was conducted with S19CNA. She stated that Resident #42 was moved from another room to her current room on Thursday of last week (8/15/13). She stated that the resident received a shower on Friday of last week (8/16/13). She stated that the nurse puts a gauze roll in the resident's hands. She stated that she had not seen the resident with a gauze roll in her hands since she was moved onto this hall. On 8/22/13 at 9:03 a.m. an interview was conducted with S9CNA, shower aide. She stated that the hospice aide came yesterday (8/21/13) and bathed Resident #42. She stated that for bathing, the resident is a one person assist. She stated that when she bathes the resident, she doesn't open the resident's hands. She stated that the nurse puts the gauze inside the resident's hands. She stated that she did not think that the resident has had gauze in her hands when she's bathed the resident. She stated that the resident's hands are stiff and look red by them being tight for so long. She stated that the resident's hands have smelled bad for awhile. On 8/22/13, S2DON provided surveyor with Nurses Notes regarding Resident #42 which revealed, in part, the following: 8/21/13, 5:04 p.m.- per body audit and skin assessment at left hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. No drainage present, area was cleaned with wound cleanser, pat dried, dressing applied. S20NP notified of new wound site. A therapy screen will be performed. The resident is unable to keep a splint in her hand or a rolled gauze due to her extreme contractures. Measurements: approximately 0.2 x 0.2 x 0.2. 8/21/13, 5:04 p.m.- per body audit and skin assessment at right hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. The area was cleaned with wound cleanser, pat dried, dressing applied. S20NP notified of the new wound site. The resident is extremely contracted and unable to keep a splint/gauze in her hands at all times. Approximate measurements: 0.2 x 0.2 x 0.1. On 8/22/13, S2DON provided surveyor with a copy of a Care Plan for Restorative Nursing Passive Range of Motion (PROM) for Resident #42 which revealed, in part, the following: Problem Onset: 10/16/12 - Need for PROM to lower and upper extremities to maintain current range of motion to bilateral lower and upper extremities secondary potential for contractures. Goal & Target Date: Remain with current level or better range of motion to bilateral lower and upper extremities up to 7 days a week, evaluate monthly and PRN - 11/8/13 Achieved 1/11/13. Approaches: Restorative nursing will monitor progression or regression of resident's progress at least monthly. Notify restorative nurse of any refusals and/or inability to perform program. Document tolerance and time spent in program. PROM to bilateral lower and upper extremities 20 reps each joint x 2 sets. Report any discomfort during PROM to charge nurse.

Based on observation, interview and record review, the facility failed to ensure that each resident received an accurate ongoing assessment for 2 (#4, #42) of 4 (#4, #12, #42, #44) residents reviewed for Pressure Ulcers in stage 2 out of a total sample of 34, by failing to consistently and accurately perform an assessment of the entire surface of Resident #42's contracted hands. The deficience practice resulted in an actual harm when resident #42's nail tips penetrated into the resident's palms leaving open, foul smelling wounds in each of her palms. Findings: A review of the facility's Skin Care Policy and Procedure, Latest Revision: 6/11 revealed, in part, the following: It is the policy of this facility that skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. Those are: Prevent, Evaluation and Screening Ongoing Surveillance Treatment Orders Treatment Regimen Overseeing these efforts will be the DON. Every effort will be made to prevent skin breakdown. The nursing department's procedures will be such that the staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for the development of skin breakdown. The nursing department will maintain the capability to respond to patient needs (in the area of skin integrity) by the following means: With an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk With a medically directed restorative and therapeutic program for residents who develop a skin problem after admission Review of the facility policy and procedure on wound/skin management documentation revealed that upon admision or discovery of a pressure ulcer, other ulcer, open lesion, a wound/skin management documentation record is initiated and a complete assessment by an RN is done and orders for required treatments are obtained. Resident #42: A review of the clinical record for Resident #42 revealed the resident was [AGE] years of age with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set completed by the facility on 7/24/13 regarding Resident #42 revealed, in part, the following: The resident had adequate hearing, unclear speech, required extensive assistance with turning and repositioning. The resident was totally dependent on staff for washing and drying her hands. The resident had impairment to both sides of her upper and lower extremities. The resident was identified by the facility as at risk for pressure ulcer development. On 8/19/13 at 3:06 p.m. an observation was made of Resident #42 lying in her bed. The resident's eyes were closed and her arms were bent at the elbows with her hands closed and resting on her chest. The resident was not observed to have a gauze roll in either her right or left hand. On 8/19/13 at 3:06 p.m. an interview was conducted with S18CNA. She stated that Resident #42 was unable to talk, but could understand what was said to her. On 8/21/13 at 11:12 a.m. an observation was made of Resident #42 lying in her bed. The resident's eyes were closed and her arms were bent at the elbows with her hands closed and resting on her chest. The resident was not observed to have a gauze roll in either her right or left hand. On 8/21/13 at 11:12 a.m. an interview was conducted with S15LPN, the nurse for Resident #42. She stated that the hospice nurse visits Resident #42 on Wednesday and Friday. She stated that the hospice nurse and facility nurses verbally communicate to each other any changes regarding the resident. On 8/21/13 at 2:58 p.m. an observation was made of Resident #42 lying in her bed. The resident's arms were bent at the elbows with her hands closed, resting on her abdomen. The resident was not observed to have a gauze roll in either her right or left hand. A review of the computerized August 2013 Physician Orders for Resident #42 revealed, in part, the following: Daily cleanse inside of both hands with wound cleanser, pat dry, and leave gauze roll in both hands daily Nail Care Weekly. Check condition and clean as needed On 8/21/13 at 11:49 a.m. an interview was conducted with S15LPN. She stated that the resident's hands were contracted and that the resident had a rolled gauze in her hands daily. S15LPN further stated that Resident #42 did not currently have any skin breakdown. On 8/21/13 at 3:00 p.m. an interview was conducted with S17CNA while observing Resident #42. She stated that she was one of the aides for the resident. She stated that she did not know if Resident #42 still used gauze in her palms for her contractures. She stated that the hospice aide had been at the facility today (Wednesday) and bathed the resident. The resident was lying in her bed, her hands were closed with her fingers bent into the palms of her hands. While standing directly next to the resident's bed, a strong, foul odor emanated from the resident. S17CNA stated that the resident did not have any pressure ulcers. She stated that the smell was coming from the resident's hands. Surveyor requested to see the resident's hands. S17CNA donned gloves and slowly opened the resident's hands. The resident moaned and stiffened during this time. When the resident's hands were opened, the foul odor became stronger. This observation revealed that some of the resident's fingertips had penetrated the skin of her palms, exposing open, foul smelling wounds in the right and left palms of the resident's hands. There was no gauze roll in the resident's right or left hand during this observation. On 8/21/13 at 3:10 p.m. an interview was conducted with S16RN. She stated that she was the team leader for the company that provided hospice care to resident #42. She stated that a hospice nurse had assessed Resident #42 earlier this day. Surveyor stated to S16RN that there was a strong odor emanating from the resident's hands. Surveyor asked for the hospice nurse assessment from earlier this day. S16RN stated that she would provide surveyor with the documentation after she talked to the hospice nurse. S16RN stated that she would assess the resident at this time in the presence of the surveyor. S16RN, with 2 surveyors present, entered the resident's room. The resident was lying in her bed with her arms resting on her abdomen. S16RN donned gloves and lifted the resident's right arm which revealed dark bruising to the resident's forearms. S16RN stated that the bruising was caused by the pressure of the resident's arms resting on each other. S16RN slowly opened the resident's right hand. The resident clenched her hands tighter and tensed her chest and arms. S16RN stated that the resident needed pain medication. She stated, you can tell that she's in pain by the way she tenses up. She stated that the resident had a wound in her hand and that it smelled awful. There was no visible gauze roll in the resident's hands at this time. On 8/21/13 at 3:15 p.m. an observation was made as S17CNA and S2DON assessed Resident #42's hands. S15LPN, S4QIRN and 2 surveyors were present during this observation. S17CNA and S2DON slowly opened the resident's hands. The resident became tense and clenched her hands tighter at this time. This observation revealed that the resident's fingertips had penetrated into the resident's palms leaving open foul smelling wounds in each of her palms. S4QIRN stated that she has seen this happen in many of her nursing home residents with hand contractures. She further stated that there was nothing you can do about it. There was no gauze roll in the resident's hands during this observation. S2DON stated that she had not done wound care on the resident's hands today. At this time, S2DON was requested to provide documentation of the most recent assessment conducted to the inside of Resident #42's hands. S2DON stated that she would look to see when it had been done and would get back to surveyors with the documentation. On 8/22/13 at 9:03 a.m. an interview was conducted with S9CNA, shower aide. She stated that the hospice aide came yesterday and bathed Resident #42. She stated that for bathing, the resident is a one person assist. She stated that she when she bathes the resident, she doesn't open the resident's hands. She stated that the nurse puts the gauze inside the resident's hands. She stated that she did not think that the resident has had gauze in her hands when she's bathed the resident. She stated that the resident's hands are stiff and look red by them being tight for so long. She stated that the resident's hands have smelled bad for awhile. On 8/22/13 at 11:32 a.m. an interview was conducted with S16RN. She stated that her position of Team Leader is that of ADON for the hospice nurses. She stated that she coordinates care of the clients and conducts supervisory visits. She stated that she has authority to perform assessments on residents who are receiving hospice care from her employer. She stated that the hospice nurse completed an assessment of Resident #42 on 8/21/13 and communicates her findings with the facility nurse. She stated that she was having the hospice CNA and Nursing documentation of 8/21/13 hand delivered to S1Adm this morning. On 8/22/13, surveyor requested and received from S1Adm the Hospice CNA and Nursing Documentation of 8/21/13 regarding Resident #42. A review of this documentation revealed, in part, the following: CNA Note: 8/21/13, 6:15 a.m. - CNA Care documented as completed for resident #42 is as follows: In bed, rails up; changed bed linens, position change, peri care, bed bath and nails cleaned. Observations reported to nurse: Nothing unusual to report. RN Documentation: 8/21/13, 1:00 p.m.- Resident #42 is total care, unable to do any activity. Patient noted to have bruising to all 4 extremities. Patient has noted contractures to bilateral hands and feet. Bilateral hands noted to be reddened and irritated to palms of hands. Yeast to bilateral palms. Facility staff collaborations: Staff/floor nurse: S15LPN. On 8/22/13 at 8:21 a.m. an interview was conducted with S23RN/MDS nurse while she reviewed the facility's computerized charting for Resident #42. S23RN stated that the CNAs are to check residents when they bathe them and if they see something, they are supposed to notify the nurse. Surveyor requested to review Resident #42's August Body Audits, Head to Toe Nursing Assessments and Wound Care Treatments for August 2013. S23RN stated that nursing assessments and skin treatments are documented in the computer under the Departmental Notes. A review of the facility's Nursing Data Collection, dated 7/24/13, regarding Resident #42 revealed, in part, the following assessment: Bathing: Total dependence Range of Motion limitation: Upper extremity - impairment both sides Equipment/Devices: Hand rolls Prognosis - Life expectancy of less than 6 months: No Additional Information: Daily observation for changes in skin appearance during routine care. Prevention measures effective as evident by no breakdown in skin integrity due to pressure. A review of the August 2013 Treatment Administration Record (E-TAR) for Resident #42 revealed, in part, the following: Daily cleanse inside of both hands with wound cleanser, pat dry and leave gauze roll in both hands daily at 12:00 p.m. and 8:00 p.m. The record was initialed as completed by a nurse each day from 8/1/13-8/13/13 and on 8/18/13. There was no documented evidence that the inside of the resident's hands had been assessed or cleaned on 8/14/13, 8:00 p.m. through 8/17/13. A review of the facility's Departmental Notes (Nurses Notes) for Resident #42 revealed, in part, the following: 8/18/13, S13RN, Charge Nurse - Daily cleanse inside of both hands with .. scheduled for 8/18/13, 12:00 p.m. Bilateral hands are too contracted to clean inside and rolls will not fit. Risk of injuring if pulled open. 8/18/13, S13RN, Charge Nurse - Daily cleanse inside of both hands with .. scheduled for 8/18/13, 8:00 p.m. Bilateral hands are too contracted to clean inside and rolls will not fit. Risk of injuring if pulled open. On 8/21/13 at 9:04am an interview was conducted with S2DON. She stated that the facility doesn't have a wound care nurse. She stated that S13RN and S14RN perform weekend wound care and that she and S3RN perform weekday wound care. A review of the facility's Weekly Body Audit Roster for Resident #42 revealed that the most current body audit of the resident was conducted on 8/19/13, with no new skin issues. On 8/22/13, S2DON provided surveyor with Nurses Notes regarding Resident #42 which revealed, in part, the following: 8/21/13, 5:04 p.m.- per body audit and skin assessment at left hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. No drainage present, area was cleaned with wound cleanser, pat dried, dressing applied. S20NP notified of new wound site. A therapy screen will be performed. The resident is unable to keep a splint in her hand or a rolled gauze due to her extreme contractures. Measurements: approximately 0.2 x 0.2 x 0.2. 8/21/13, 5:04 p.m.- per body audit and skin assessment at right hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. The area was cleaned with wound cleanser, pat dried, dressing applied. S20NP notified of the new wound site. The resident is extremely contracted and unable to keep a splint/gauze in her hands at all times. Approximate measurements: 0.2 x 0.2 x 0.1. Resident #4 Review of the record for Resident #4 revealed [DIAGNOSES REDACTED]. Interview with S6LPN on 08/19/2013 at 2:57p.m. revealed that she completed a weekly skin audit on Resident #4 on 08/13/2013. Further interview with S6LPN revealed that she observed two dime sized areas on left gluteal area. Further interview with S6 LPN revealed she notified the nurse practioner and obtained treatment orders. Review of the nurses notes, dated 08/13/2013 at 9:17 p.m., revealed S6LPN documented that she assessed the resident during the weekly body audit and found 2 small dime sized open areas, possible pressure areas. Further review of the nurses notes revealed S6LPN informed the nurse practioner and received new orders for [MEDICATION NAME] two times a day until healed. Further review of the record revealed no assessment had been completed by an RN or a wound care nurse. Further review of the record for Resident #4 revealed last progress note by the physician or nurse practioncer was on 05/15/2013. Interview with S2DON on 08/21/2013 at 8:40 a.m. revealed that after a wound/skin issue is identified by the LPN during the weekly body audit, the RN will review the orders the next morning and complete an assessment on the identified skin area. Further interview with S1DON revealed the RN has 24 hours to assess identified wound areas on a resident. Further interview with S2DON, at this time, confirmed that no one had assessed the wound found by S6LPN on the weekly body audit for Resident #4. Interview with S3RN on 08/21/2013 at 11:55AM confirmed that she had not assessed the gluteal area and was not aware of any broken skin issues relating to sampled resident #4's buttock area. Further interview confirmed that she assessed her foot area only.

Based on observation, interview and record review, the facility failed to implement the plan of care for 1 (#42) of 3 residents (#42, #118, #124) reviewed for range of motion in stage 2 out of a total sample of 34, by failing to daily cleanse the inside of the resident's hands with wound cleaner and apply a gauze roll inside of the resident's hands according to the physician orders. The deficient practice resulted in an actual harm when resident #42's nailtips penetrated into the resident's palms leaving open, foul smelling wounds in each of her palms. Findings: A review of the facility's Skin Care Policy and Procedure, Latest Revision: 6/11 revealed, in part, the following: It is the policy of this facility that skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. Those are: Prevent, Evaluation and Screening Ongoing Surveillance Treatment Orders Treatment Regimen Overseeing these efforts will be the DON. Every effort will be made to prevent skin breakdown. Skin problems which develop will be followed carefully and treated according to medical direction. The nursing department's procedures will be such that the staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for the development of skin breakdown. The nursing department will maintain the capability to respond to patient needs (in the area of skin integrity) by the following means: With medically directed treatment for [REDACTED]. With an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk. A review of the clinical record for Resident #42 revealed the resident was [AGE] years of age with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set completed by the facility on 7/24/13 regarding Resident #42 revealed, in part, the following: The resident had adequate hearing, unclear speech, required extensive assistance with turning and repositioning. The resident was totally dependent on staff for washing and drying her hands. The resident had impairment to both sides of her upper and lower extremities. The resident was identified by the facility as at risk for pressure ulcer development. A review of the facility's Nursing Data Collection dated 7/24/13 regarding Resident #42 revealed, in part, the following assessment: Bathing: Total dependence Range of Motion limitation: Upper extremity - impairment both sides Equipment/Devices: Hand rolls Prognosis - Life expectancy of less than 6 months: No Additional Information: Daily observation for changes in skin appearance during routine care. Prevention measures effective as evident by no breakdown in skin integrity due to pressure. A review of the computerized August 2013 Physician order [REDACTED]. Daily cleanse inside of both hands with wound cleanser, pat dry, and leave gauze roll in both hands daily On 8/19/13 at 3:06 p.m. an observation was made of Resident #42 lying in her bed. Her eyes were closed and her arms were bent at the elbows with her hands closed, resting on her chest. The resident was not observed to have a gauze roll in her right or left hand. On 8/21/13 at 11:12 a.m. an observation was made of Resident #42 lying in her bed. Her eyes were closed and her arms were bent at the elbows with her hands closed, resting on her chest. The resident was not observed to have a gauze roll in her right or left hand. On 8/21/13 at 2:58 p.m. an observation was made of Resident #42 lying in her bed. The resident's arms were bent at the elbows with her hands closed, resting on her abdomen. The resident was not observed to have a gauze roll in her right or left hand. A review of the facility's Departmental Notes for Resident #42 revealed, in part, the following: Stage 2 to left index finger resolved, High Risk Skin. This note was signed by Charge Nurse, S22,RN. On 8/19/13 at 3:06 p.m. an interview was conducted with S18CNA. She stated that Resident #42 was unable to talk, but could understand what was said to her. On 8/21/13 at 11:49 a.m. an interview was conducted with S15LPN. She stated that the Resident #42's hands were contracted and that the resident had a rolled gauze in her hands daily. S15LPN further stated that Resident #42 did not currently have any skin breakdown. On 8/21/13 at 3:00 p.m. an interview was conducted with S17CNA while observing Resident #42. She stated that she was one of the aides for the resident. She stated that she did not know if Resident #42 still used gauze in her palms for her contractures. She stated that the facility aides bathe the resident on Monday, Wednesday and Friday and that the hospice aide bathes the resident on Tuesday, Thursday and Saturday. She stated that the hospice aide had been at the facility today (Wednesday) and bathed the resident. The resident was lying in her bed, her hands were closed with her fingers bent into the palms of her hands. While standing directly next to the resident's bed, a strong, foul odor emanated from the resident. S17CNA stated that the resident did not have any pressure ulcers. She stated that the smell was coming from the resident's hands. Surveyor requested to see the resident's hands. S17CNA donned gloves and slowly opened the resident's hands. The resident moaned and stiffened during this time. When the resident's hands were opened, the foul odor became stronger. This observation revealed that some of the resident's fingertips had penetrated the skin of her palms, exposing open, foul smelling wounds in the right and left palms of the resident's hands. There was no gauze roll in the resident's right or left hand during this observation. On 8/21/13 at 3:10 p.m. an interview was conducted with S16RN. She stated that she was the team leader for the company that provided hospice care to Resident #42. She stated that a hospice nurse had assessed Resident #42 earlier this day. Surveyor stated to S16RN that there was a strong odor emanating from the resident's hands. Surveyor asked for the hospice nurse assessment from earlier this day. S16RN stated that she would provide surveyor with the documentation after she talked to the hospice nurse. S16RN stated that she would assess the resident at this time in the presence of the surveyor. S16RN, with 2 surveyors present, entered the resident's room. The resident was lying in her bed with her arms resting on her abdomen. S16RN donned gloves and lifted the resident's right arm which revealed dark bruising to the resident's forearms. S16RN stated that the bruising was caused by the pressure of the resident's arms resting on each other. S16RN slowly opened the resident's right hand. The resident clenched her hands tighter and tensed her chest and arms. S16RN stated that the resident needed pain medication. She stated, you can tell that she's in pain by the way she tenses up. She stated that the resident had a wound in her hand and that it smelled awful. There was no visible gauze roll in the resident's hands at this time. On 8/21/13 at 3:15 p.m. an observation was made as S17CNA and S2DON assessed Resident #42's hands. S15LPN, S4QIRN and 2 surveyors were present during this observation. S17CNA and S2DON slowly opened the resident's hands. The resident became tense and clenched her hands tighter at this time. This observation revealed that the resident's fingertips had penetrated into the resident's palms leaving open, foul smelling wounds in each of her palms. S4QIRN stated that she has seen this happen in many of her nursing home residents with hand contractures. She further stated that there was nothing you can do about it. There was no gauze roll in the resident's hands during this observation. S2DON stated that she had not done wound care on the resident's hands today. On 8/22/13, surveyor requested and received from S1Adm the Hospice CNA and Nursing Documentation of 8/21/13 regarding Resident #42. A review of the Hospice documentation of Resident #42 revealed, in part, the following: CNA Note: 8/21/13, 6:15 a.m.-CNA Care documented as completed for resident #42 is as follows: In bed, rails up; changed bed linens, position change, peri care, bed bath and cleaned nails. Observations reported to nurse: Nothing unusual to report. RN Documentation: 8/21/13, 1:00 p.m.-Resident #42 is total care, unable to do any activity. Patient noted to have bruising to all 4 extremities. Patient has noted contractures to bilateral hands and feet. Bilateral hands noted to be reddened and irritated to palms of hands. Yeast to bilateral palms Facility staff collaborations: Staff/floor nurse: S15LPN. A review of the Care Plan for Resident #42 revealed, in part, the following: Problem Onset: 5/16/13 - Contractures to bilateral hands Stage 2 to left index finger - resolving 7/26/13 Goal & Target Date: 10/24/13 Approaches: Monitor resident skin under the devices for irritation or breakdown such as redness, pressure sore, skin tear. Keep hands and between fingers clean and dry 7/26/13 - Daily cleanse inside of both hands with wound cleanser, pat dry and leave gauze roll in both hands daily. Problem Onset: 2/17/11 - Fragile skin, risk for pressure ulcers, skin tears, bruises, rash Goal & Target Date: 10/24/13 Approaches: Notify Hospice of change Nail care weekly, check condition and clean PRN Daily observation of skin with routine care, report concern to nurse On 8/22/13 at 8:45 a.m. an interview was conducted with S19CNA. She stated that Resident #42 was moved from another room to her current room on Thursday of last week (8/15/13). She stated that the resident received a shower on Friday of last week (8/16/13). She stated that the nurse puts a gauze roll in the resident's hands. She stated that she had not seen the resident with a gauze roll in her hands since she was moved onto this hall. On 8/22/13 at 9:03 a.m. an interview was conducted with S9CNA, shower aide. She stated that yesterday the hospice aide bathed Resident #42. She stated that for bathing, the resident is a one person assist. S9CNA stated that when she bathes the resident, she doesn't open the resident's hands. She stated that the nurse puts the gauze inside the resident's hands. She stated that she did not think that the resident has had gauze in her hands when she's bathed the resident. She stated that the resident's hands are stiff and look red by them being tight for so long. She stated that the resident's hands have smelled bad for awhile. On 8/21/13 at 9:04 a.m. an interview was conducted with S2DON. She stated that the facility doesn't have a wound care nurse. She stated that S13RN and S14RN perform weekend wound care and that she and S3RN perform weekday wound care. A review of the facility's Departmental Notes for Resident #42 revealed, in part, the following: 8/18/13, 3:05 p.m.-S13RN, Charge Nurse - Daily cleanse inside of both hands with .. scheduled for 8/18/13, 12:00 p.m. Bilateral hands are too contracted to clean inside and rolls will not fit. Risk of injuring if pulled open. 8/18/13, 3:05 p.m. - S13RN, Charge Nurse - Daily cleanse inside of both hands with .. scheduled for 8/18/13, 8:00 p.m. Bilateral hands are too contracted to clean inside and rolls will not fit. Risk of injuring if pulled open. A review of the August 2013 Treatment Administration Record (E-TAR) for Resident #42 revealed, in part, the following: Daily cleanse inside of both hands with wound cleanser, pat dry and leave gauze roll in both hands daily at 12:00 p.m. and 8:00 p.m. The record was initialed as completed by a nurse each day from 8/1/13-8/13/13 and on 8/18/13. There was no documented evidence that the inside of the resident's hands had been assessed or cleaned on 8/14/13, 8:00 p.m. through 8/17/13. On 8/22/13, S2DON provided surveyor with Nurses Notes regarding Resident #42 which revealed, in part, the following: 8/21/13, 5:04 p.m.-per body audit and skin assessment at left hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. No drainage present, area was cleaned with wound cleanser, pat dried, dressing applied. S20NP notified of new wound site. A therapy screen will be performed. The resident is unable to keep a splint in her hand or a rolled gauze due to her extreme contractures. Measurements: approximately 0.2 x 0.2 x 0.2. 8/21/13, 5:04 p.m.-per body audit and skin assessment at right hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. The area was cleaned with wound cleanser, pat dried, dressing applied. S20NP notified of the new wound site. The resident is extremely contracted and unable to keep a splint/gauze in her hands at all times. Approximate measurements: 0.2 x 0.2 x 0.1.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical and mental well-being in accordance with the comprehensive assessment and plan of care for 1 (#42) of 3 (#42, #118, #124) residents reviewed for range of motion in stage 2 out of a total sample of 34, by failing to: a) Anticipate and provide pain medication prior to assessment and cleaning of the resident's hands; and b) Assess the level and intensity of pain that the resident experienced during assessment and cleaning of her hands. The deficient practice resulted in an actual harm when resident #42 experienced pain, without receiving as needed (PRN) pain medication, during movement of her hands (nursing assessment of the resident's hands; cleaning of the inside of her hands; cleaning of her nails; and application of gauze rolls to the inside of her hands). Findings: A review of the clinical record for Resident #42 revealed the resident was [AGE] years of age with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set completed by the facility on 7/24/13 regarding Resident #42 revealed, in part, the following: The resident had adequate hearing, unclear speech, required extensive assistance with turning and repositioning. The resident was totally dependent on staff for washing and drying her hands. The resident had impairment to both sides of her upper and lower extremities. The resident had occasional pain and received pain medication as needed (PRN). The resident was identified by the facility as at risk for pressure ulcer development. A review of the computerized August 2013 Physician order [REDACTED]. Fibersource HN via PEG (feeding tube) continuously Multivitamin tablet every day Tylenol Extra Strength 500milligram (mg) caplet, give 2 every 8 hours as needed (PRN) for pain Daily cleanse inside of both hands with wound cleanser, pat dry, and leave gauze roll in both hands daily Nail Care Weekly. Check condition and clean as needed Hospice Diagnosis: [REDACTED]. On 8/21/13 at 11:49 a.m. an interview was conducted with S15LPN, nurse for Resident #42. She stated that sometimes the resident would open her eyes when you talk to her. She stated that the resident will start moaning and then you know she is in pain. She stated that Resident #42's hands were contracted and that the resident had a rolled gauze in her hands daily. S15LPN further stated that Resident #42 did not currently have any skin breakdown. A review of the Care Plan for Resident #42 revealed, in part, the following: Problem Onset: 5/16/13 - Contractures to bilateral hands - Stage 2 to left index finger, resolving 7/26/13 Goal & Target Date: 10/24/13 Approaches: Monitor resident skin under the devices for irritation or breakdown such as redness, pressure sore, skin tear. Keep hands and between fingers clean and dry 7/26/13 - Daily cleanse inside of both hands with wound cleanser, pat dry and leave gauze roll in both hands daily. Problem Onset: 2/17/11 - Fragile skin, risk for pressure ulcers, skin tears, bruises, rash Goal & Target Date: 10/24/13 Approaches: Notify Hospice of change Nail care weekly, check condition and clean PRN Daily observation of skin with routine care, report concern to nurse Problem Onset: 3/31/11 - Potential for eye infection Goal & Target Date: 10/24/13 Approaches: Nail care weekly, check condition and clean PRN Frequent hand washing and keep fingernails clean and clip Problem Onset: 4/27/11 - Potential for pain and discomfort Goal & Target Date: 10/24/13 Approaches: Resident is prescribed Tylenol Extra Strength Observe for verbal and non verbal signs of discomfort and indication of pain Administer pain medication as requested Problem Onset: 8/1/11: Impaired verbal communication, resident has decreased ability to understand others and to be understood Goal & Target Date: 10/24/13 Approaches: Simplify questions that can be answered with yes/no Problem Onset: 2/17/11 - Self care deficit: Resident requires assistance with eating, dressing, grooming, toileting, personal hygiene and bath Goal & Target Date: 10/24/13 Approaches: Assist with bath as scheduled Assist with personal grooming daily and PRN Problem Onset: 2/20/13 - Resident on Hospice, Hospice services involved in care related to progression of disease process Goal & Target Date: 10/24/13 Approaches: Assess for verbal and nonverbal indicators of anxiety/pain and administer medication to promote comfort, monitor effectiveness of intervention Hospice CNA to visit resident opposite days of facility CNA for assistance with ADLs Hospice aide to observe skin during care giving and provide gentle range of motion (ROM). On 8/21/13 at 3:00 p.m. an interview was conducted with S17CNA while observing Resident #42. She stated that she was one of the aides for the resident. She stated that she did not know if Resident #42 still used gauze in her palms for her contractures. She stated that the facility aides bathe the resident on Monday, Wednesday and Friday and that the hospice aide bathes the resident on Tuesday, Thursday and Saturday. She stated that the hospice aide had been at the facility today (Wednesday) and bathed the resident. The resident was lying in her bed, her hands were closed with her fingers bent into the palms of her hands. While standing directly next to the resident's bed, a strong, foul odor emanated from the resident. S17CNA stated that the resident did not have any pressure ulcers. She stated that the smell was coming from the resident's hands. Surveyor requested to see the resident's hands. S17CNA donned gloves and slowly opened the resident's hands. The resident moaned and stiffened during this time. When the resident's hands were opened, the foul odor became stronger. This observation revealed that some of the resident's fingertips had penetrated the skin of her palms, exposing open, foul smelling wounds in the right and left palms of the resident's hands. There was no gauze roll in the resident's right or left hand during this observation. On 8/21/13 at 3:10 p.m. an interview was conducted with S16RN. She stated that she was the team leader for the company that provided hospice care to Resident #42. She stated that a hospice nurse had assessed Resident #42 earlier this day. Surveyor stated to S16RN that there was a strong odor emanating from the resident's hands. Surveyor asked for the hospice nurse assessment from earlier this day. S16RN stated that she would provide surveyor with the documentation after she talked to the hospice nurse. S16RN stated that she would assess the resident at this time in the presence of the surveyor. S16RN, with 2 surveyors present, entered the resident's room. The resident was lying in her bed with her arms resting on her abdomen. S16RN donned gloves and lifted the resident's right arm which revealed dark bruising to the resident's forearms. S16RN stated that the bruising was caused by the pressure of the resident's arms resting on each other. S16RN slowly opened the resident's right hand. The resident clenched her hands tighter and tensed her chest and arms. S16RN stated that the resident needed pain medication. She stated, you can tell that she's in pain by the way she tenses up. She stated that the resident had a wound in her hand and that it smelled awful. There was no visible gauze roll in the resident's hands at this time. A review of the facility's Pain Screen for Resident #42 dated 7/24/13 revealed, in part, the following: Pain: been on scheduled pain medication regimen - No Pain: received PRN pain medications - Yes Complaints of pain or recent change in pain to include location intensity, frequency, duration - No Should pain assessment interview be conducted - Yes Description of pain - Unable to describe Non-Verbal Expression of Pain - Facial Grimacing and Moaning Location of pain - joint(s) and generalized pain observed non-verbal What improves the pain? Medications for pain and rest What makes the pain worse? Movement Is resident satisfied with pain control? Yes Should staff assessment for pain be conducted - No On 8/21/13 at 3:15 p.m. an observation was made as S17CNA and S2DON assessed Resident #42's hands. S15LPN, S4QIRN and 2 surveyors were present during this observation. S17CNA and S2DON slowly opened the resident's hands. The resident became tense and clenched her hands tighter at this time. This observation revealed that the resident's fingertips had penetrated into the resident's palms leaving open foul smelling wounds in each of her palms. S4QIRN stated that she has seen this happen in many of her nursing home residents with hand contractures. She further stated that there was nothing you can do about it. There was no gauze roll in the resident's hands during this observation. S2DON stated that she had not done wound care on the resident's hands today. At this time, S2DON was requested to provide documentation of the most recent assessment conducted to the inside of Resident #42's hands. S2DON stated that she would look to see when it had been done and would get back to surveyors with the documentation. At no time during this observation did S2DON, S15LPN or S4QIRN state that the resident needed or should be given pain medication prior to assessing the resident's hands. Further during this observation, at no time did S2DON, S15LPN or S4QIRN ask the resident if she was experiencing pain nor did they attempt to assess the resident's non-verbal indicators of pain. A review of the August 2013 Treatment Administration Record (E-TAR) for Resident #42 revealed, in part, the following: Daily cleanse inside of both hands with wound cleanser, pat dry and leave gauze roll in both hands daily at 12:00 p.m.and 8:00 p.m. The record was initialed as completed by a nurse each day from 8/1/13-8/13/13 and on 8/18/13. A review of the August 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Tylenol Extra Strength (ES) 500mg caplet, give 2 every 8 hours PRN The facility documented that the resident received Tylenol ES on 8/4/13 at 3:51 p.m.; 8/14/13 at 3:56 p.m., 8/18/13 at 8:20 p.m. and 8/21/13 at 4:01 p.m. A review of the Hospice company's Nursing Assessment of Resident #42 revealed that on 8/21/13 at 1:00 p.m. the nurse documented, "Bilateral hands noted to be reddened and irritated to palms of hands, Yeast to bilateral hands." Negative Vocalization: Occasional moan or groan. There was no documented evidence that the resident was provided with pain medication prior to this assessment. On 8/22/13, S2DON provided surveyor with Nurses Notes regarding Resident #42 which revealed, in part, the following: 8/21/13, 5:04 p.m.- per body audit and skin assessment at left hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. No drainage present, area was cleaned with wound cleanser, pat dried, dressing applied. Measurements: approximately 0.2 x 0.2 x 0.2. 8/21/13, 5:04 p.m.- per body audit and skin assessment at right hand - stage 2 pressure ulcer noted. The area is foul smelling with a whitish peri area. The area was cleaned with wound cleanser, pat dried, dressing applied. Approximate measurements: 0.2 x 0.2 x 0.1.

Based on record review and interview, the facility failed to ensure that a resident was not administered [MEDICATION NAME] (a blood thinner) dosages in excess of the amount prescribed by the physician to clinically treat the resident's condition for 1 (#47) of 10 (#47, #95, #27, #98, #70, #156, #89, #79, #113, #93) residents reviewed with orders for alternating [MEDICATION NAME] dosages. The facility placed 1 (#47) of 10 residents who were reviewed with orders for alternating [MEDICATION NAME] dosages in Immediate Jeopardy when the interval codes for the resident's [MEDICATION NAME] orders were incorrectly entered into the computer, and the resident was administered [MEDICATION NAME] dosages in excess of the amount prescribed by the physician to clinically treat the resident's condition. Resident #47 was transferred to the emergency room after a fall on [DATE]. The emergency room record revealed that the resident had a critical INR lab value of 6.46 and bleeding in the stomach. The Immediate Jeopardy (IJ) situation began on [DATE] when the computer code for the resident's [MEDICATION NAME] orders was not entered as alternating doses on different days resulting in the resident receiving doses of [MEDICATION NAME] on days that it was not ordered to be administered. The IJ continued through [DATE] (excluding [DATE] when the [MEDICATION NAME] was administered correctly) and was removed on [DATE] at 6:52 p.m. when the resident was transferred to the emergency room . The deficient practice continued at an "E" for 9 residents (#95, #27, #98, #70, #156, #89, #79, #113, #93) in the facility on alternating [MEDICATION NAME] dosages (as noted on a list presented by the facility). Findings: Resident # 47 Review of the face sheet for Resident #47 revealed an admitted [DATE]. Her [DIAGNOSES REDACTED].Coli Infection, Cardiac Pacemaker, Dementia w/o behav Dist, [MEDICAL CONDITION] Reflux, General [MEDICAL CONDITION], Lack of Coordination, and Late effects of Cardiovascular Disease. Review of an OTIS report with an occurrence date of [DATE] revealed that it was reported to the Administrator on [DATE] that Resident #47 had fallen on [DATE] which resulted in her being transferred to the emergency room . It was noted that the resident had an open area above the right eye with swelling and bruising. It was also noted that the nurse came to assess the resident and put a pressure dressing on her head. The report revealed that the ambulance was called, and the resident was taken to the emergency room . Review of the nurse's notes from the facility for Resident #47 revealed the following: [DATE] 6:33 p.m. Pt upright in D/R in WC, AAOX1. The nurse fed pt her supper in which consumed approx 25% of supper, CNA summoned the nurse to D/R stating pt had fallen forward from W/C while she was attempting to take her to her room and place her to bed. The nurse observed pt lying on her right side with mod amt of blood coming from an open area above her eye/eyebrow area. Was cleansed with wc and pressure dressing applied wrapped with [MEDICATION NAME] and secured with tape. Ambulance services contacted for transport of pt. Nurse Practitioner also made aware and order obtained to send pt out to ER for eval and tx. Pts DTR made aware and also of [MEDICATION NAME] 500mg po X 10 days, [MEDICATION NAME] Neb tx's qid X 3 days and F/U CXR on ,[DATE]. [DATE] 6:52 p.m. Report called to ER Nurse at hospital. Also forwarded pt's xray report. [DATE] 12:13 p.m. Received phone call at 12:00 a.m. Hospital ER Nurse calling in reference to resident. Nurse requested DNR status for Resident #47. This nurse faxed information to MD. Also stated that MD will call back on resident condition. ,[DATE] 2:07 a.m. Received phone call from hospital ER. MD informed nurses that resident had expired. Review of a written statement from S23LPN ( the statement was not signed but was verified by S2DON as being S23LPN's statement regarding the fall of Resident #47 on [DATE] as she said that it was written in front of her) revealed that a CNA yelled out to her and she went to the rehab dining room. It was noted that she observed Resident #47 on the floor lying on her right side with an open area above her right eye. The statement further revealed that the CNA had stated that she attempted to remove the resident away from the table and began to propel her in her wheelchair when the resident leaned over and fell forward to the floor before she could catch her. It was noted on the statement that the nurse immediately applied pressure to the area to stop the bleeding, applied a pressure dressing, and the ambulance service was called for transport. Review of the facility's incident report dated [DATE] at 6:27 p.m. revealed Resident #47 had a fall with head injury from her wheelchair in the dining room. It was noted that the CNA stated she was propelling the patient away from the dining room and the patient began to lean forward and fell from the chair to the floor hitting the right side of her face. An open area above the right eye was observed with swelling and bruising forming and a small amount of blood was noted coming from the patient's nose. A pressure dressing was applied to the patient's head to stop the bleeding. The patient was sent to the ER for evaluation and treatment. It was also noted on the report that the resident was on [MEDICATION NAME]. As cited in an article "[MEDICATION NAME] Therapy: Evolving Strategies in Anticoagulation", published by The American Academy of Family Physicians: [MEDICATION NAME] ([MEDICATION NAME]) is the oral anticoagulant most used to control and prevent [MEDICAL CONDITION] disorders. For most indications the dose is adjusted to maintain the patient's International Normalized Ratio (INR) at 2 to 3. Review of the Hospital ED Record for Resident #47 the revealed the following: On [DATE] at 19:08 (7:08 p.m.) the patient arrived to the ED as a result of a fall. At 19:13 (7:13 p.m.) vital signs taken revealed the following: Pulse: 84, Temperature: 98.1, Respiratory rate:18, Blood Pressure:,[DATE] and Pulse Oximeter: 96%. At 19:24 (7:24 p.m.) the resident was seen by the doctor. Initial blood work included PT (Includes INR), PTT, Troponin, CPK MB level, CPK Level, CMP, and CBC. Initial Radiology tests included a Chest xray: posterior, anterior and lateral, a right wrist xray, a right shoulder xray, a right hip unilateral, a CT of the cervical spine without contrast and a CT of the head without contrast. The lab results review section of the record dated [DATE] at 20:55 (8:55 p.m.) revealed the following results: INR- 6.46 (critical), Hgb-13.3 gm/dl (normal), Hct- 42.6% (normal), and Platelets-339,000 (normal). The ED Nurses Notes revealed that on [DATE] at 23:15 (11:15 p.m.), the nurse was assisting the MD in examining the patient to determine the source of blood draining in the mouth. It was noted that they suctioned the patient and removed the dentures and examined the mouth and nose. The ED Physician notes revealed that in a reexamination/reevaluation of the patient at 23:20 (11:20 p.m.), the patient was worsening and that her vital signs at 23:00 had been: Pulse:148, Respiratory Rate: 41, Blood Pressure: ,[DATE]. The assessment information at the time of the reexamination/reevaluation revealed the following: "upper airway sounds", the patient refuses to open her mouth. [MEDICATION NAME] was placed in her mouth, oral cavity filled with bright red blood; this was suctioned out and it filled with blood again; no blood in the nasal cavity. NG tube placed and some blood was noted in the stomach; bleeding resolved spontaneously; repeat CBC pending, Vitamin K was given and Fresh Frozen Plasma was ordered. It was noted in the ED record that on [DATE] at 23:30 (11:30 p.m.), a gastrointestinal procedure was performed that revealed GI content that was dark and bloody with clots. The ED Nurses Notes from [DATE] at 23:35 (11:35 p.m.) revealed that the nurse assisted the MD in inserting a [MEDICAL CONDITION] Tube and removing blood from the patient's stomach until the bloody drainage stopped. The nurses notes revealed that on [DATE] at 0017 (12:17 a.m.) the patient showed asystole on the monitor and the time of death was called at 0027 (12:27 a.m.). Further review of the ED record revealed that an autopsy was not performed on the patient. Review of the [DATE] Physician order [REDACTED]. [MEDICATION NAME] 5mg po Tue, Thur, Sat & Sun (Tuesday, Thursday, Saturday, and Sunday) [MEDICATION NAME] 6mg po MWF (Monday, Wednesday and Friday) Review of a physician's orders [REDACTED]. Increase [MEDICATION NAME] to 6mg all days except give 5 mg on Tuesday and Thursday only. Repeat PT/INR on [DATE] Review of the [DATE] Physician order [REDACTED]. Increase [MEDICATION NAME] 6mg tablet po on Monday, Wednesday, Friday, Saturday, and Sunday only [MEDICATION NAME] 5mg tablet po on Tuesday and Thursday only. Repeat PT/INR on [DATE] Review of a physician's orders [REDACTED]. Increase [MEDICATION NAME] to 6mg po daily Repeat PT/INR on [DATE]. Review of a physician's orders [REDACTED]. Increase [MEDICATION NAME] to 7mg on Monday, Wednesday and Friday and 6mg on Tuesday, Thursday, Saturday and Sunday. Repeat PT/INR on [DATE]. Review of the [DATE] Physician order [REDACTED]. [MEDICATION NAME] 6 mg tablet po along with 1 mg on MWF to equal 7 mg ([MEDICATION NAME] 1 mg tablet along with 6 mg tablet to equal 7 mg on MWF) [MEDICATION NAME] 6 mg tablet po on Tu, Th, Sat & Sun (Tuesday, Thursday, Saturday and Sunday) Review of a physician's orders [REDACTED]. Change [MEDICATION NAME] to 8mg po q day D/C previous [MEDICATION NAME] doses PT/INR on [DATE]. Review of a physician's orders [REDACTED]. Change [MEDICATION NAME] to 7mg on Tues and Thursdays 8mg po all the other days of the week PT/INR next on [DATE] Review of the [DATE] E-MAR revealed the following entries with start dates of [DATE]: -[MEDICATION NAME] 8mg daily on M-W-F-S-S- Give [MEDICATION NAME] 6 mg tab QD and [MEDICATION NAME] 1mg tabs X 2 tabs QD to = 8 mg daily. -[MEDICATION NAME] 7mg po QD on Tues and Thursday- Give [MEDICATION NAME] 6 mg and 1 mg QD to = 7 mg QD. Further review of the [DATE] E-MAR revealed the following: -The [MEDICATION NAME] 8 mg entry with a start date of [DATE] had a check mark and initials in the blocks for Monday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], and Sunday ,[DATE]. The date block for [DATE] had an "N" with initials in it. -The [MEDICATION NAME] 7 mg entry with a start date of [DATE] had a check mark and initials in the blocks for: Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], and Sunday ,[DATE]. After reviewing the E- MAR for [DATE], it was noted that [MEDICATION NAME] 8 mg and [MEDICATION NAME] 7mg were both documented as being administered on Monday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], and Sunday ,[DATE]. According to the physician's orders [REDACTED]. Review of the [DATE] E-MAR revealed the following entries with start dates of [DATE]: -[MEDICATION NAME] 8mg daily on M-W-F-S-S- Give [MEDICATION NAME] 6 mg tab QD and [MEDICATION NAME] 1mg tabs X 2 tabs QD to = 8 mg daily. -[MEDICATION NAME] 7mg po QD on Tues and Thursday- Give [MEDICATION NAME] 6 mg and 1 mg QD to = 7 mg QD. Further review of the [DATE] E-MAR revealed the following: -The [MEDICATION NAME] 8 mg entry with a start date of [DATE] had a check mark and initials in the blocks for Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. -The [MEDICATION NAME] 7 mg entry with a start date of [DATE] had a check mark and initials in the blocks for: Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. After reviewing the E- MAR for [DATE], it was noted that [MEDICATION NAME] 8 mg and [MEDICATION NAME] 7mg were both documented as being administered on Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. According to the physician's orders [REDACTED]. Also, [MEDICATION NAME] 7 mg should not have been administered on Monday ,[DATE], Wednesday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. Review of the nurses' notes presented by the facility for [DATE] revealed the only entry related to [MEDICATION NAME] (start date [DATE]) not being administered to the resident was on [DATE]. Review of the nurses' notes presented by the facility for [DATE] revealed no entries related to [MEDICATION NAME] (start date [DATE]) not being administered to the resident for the month. Review of the INR results for Resident #47 revealed the following: [DATE] INR- 1.69 [DATE] INR-1.65 [DATE] INR-1.37 [DATE] INR- 1.65 [DATE] INR-2.48 An interview was held with S25LPN on [DATE] at 2:00 p.m. She said that the nurses entered the physician's orders [REDACTED]. She said that asterisks would come up on the MAR for the days that the medication was not to be administered. She also said that the medications would not appear on the computer screen during medication pass on the days that the medication was not to be given if the right interval code was selected. She added that there was a choice of not administered that could be selected if a medication came up on the computer screen but was not administered. Review of the nursing assignments presented by S2DON for the week of [DATE] through [DATE] revealed the following: [DATE] 100 Hall S11LPN (,[DATE]) S23LPN (,[DATE]) [DATE] 100 Hall S24LPN (6a-6p) A telephone interview was held on [DATE] at 8:21 a.m. with S23LPN. She said she had worked at the facility about a month to a month and a half. She said that Resident #47 was normally one of her assigned residents and that she was familiar with her care. She verified that the resident had fallen on [DATE] when she was assigned to the resident. She said the resident was bleeding on the right side of the head by her eye after the fall. She also said that she was able to stop the bleeding by applying pressure. She also verified that she had administered medications to Resident #47 at times. She said she did not remember the exact dosages of the resident's [MEDICATION NAME]. She said that she knew the resident was on [MEDICATION NAME] and that it changed frequently and was offered with different dosages on different days. She said that the medication dose would pop up on the medication screen on the days it was to be given. She said that sometimes the medication may come up on the screen on Wednesday, when it was ordered to be given on Tuesday and Thursday. She said that she would initial as an "FYI" on the day the dose was not given and mark not administered. She said that the medication had to be addressed on the yellow screen to avoid being turned red. She said that the computer gave you a spot to initial even if the medication was not scheduled to be given that day. She said that if the medication was not supposed to be given on a Thursday, but appeared on the screen that she initialed even though she did not give it because it was an "FYI". She said that she would have to sign to say the medication wasn't administered. She said that she selected the code "not administered" and that was what the system should read. She said she would check "administered" so the computer would show her initials for the medications that she gave and that she selected "not administered" when she did not give the medication. She said that she would give medications according to how the order read on the screen. She said she was new to the job and trying to learn the system. She said she had problems with her log- in on the computer and was frequently locked out. She said she did not think that the resident ever received [MEDICATION NAME] 7mg and [MEDICATION NAME] 8mg the same day. She said that she could not explain why her initials were present on both entries (8 mg and 7 mg) of [MEDICATION NAME] on the same day for some dates in [DATE] and [DATE]. A telephone interview was held on [DATE] at 9:16 a.m. with S24LPN. She said that she had been employed at the facility since [DATE]. She said that she usually worked the weekends, on Saturdays and Sundays and worked 6A-6P. She also said that she worked during the week if they needed her. She said that at times she had been the assigned nurse for Resident #47 and had administered medications to the resident. She said that she recalled the resident being on [MEDICATION NAME] but did not recall the dosage. She said that if a medication came up on the computer during medication pass and was not given then she would highlight the medication and choose "not administered". She said that if she chose administered for the medication her initials showed in the blank as she had to log on to the system prior to giving medications. She said that she clicked on "Prepared and Administered" once she administered a medication to a resident. She said that if a medication was not given for some reason then she clicked on "Not Administered" in the computer. She said that she did not recall clicking "not administered" regarding Resident #47's [MEDICATION NAME]. She said that each time the resident's [MEDICATION NAME] came up in the computer she administered it. She added that only medications due to be given were to come up on the screen for the medication pass at that time. She said that if a medication was not due on a certain day, then it would not come up on the screen for that day. She said that she administered the [MEDICATION NAME] to Resident #47 when it appeared on the computer screen to be given. She verified that her initials used in the computer system were S24LPN (see staff ID list). She said that if her initials were on the MAR for a medication, then she administered the medication. When asked about her initials on the MAR as administering [MEDICATION NAME] 7 mg on Saturdays (,[DATE] and ,[DATE]) and Sundays (,[DATE] and ,[DATE]) when the order was for the [MEDICATION NAME] to be given on Tuesdays and Thursdays, she said that if her initials were there, then she gave the medication. She again said that the medication should not have come up on the MAR to be given on Saturdays and Sundays if it was only ordered to be given on Tuesdays and Thursdays. An interview was held with S11LPN on [DATE] at 10:36 a.m. She said that when she received a physician's orders [REDACTED]. She said that an entry should only appear on the screen for the days it was to be administered during the nurses' medication pass. She said that normally a star would appear on the MAR for days that the medication should not be given. She added that if an entry that was only to be given on certain days pulled up during medication pass on a day that it was not due then she would check the order before giving the medication. She said that if she did not administer a medication then she would select "not administered" and then put the reason in the nurses' notes. She said that she had never been told to initial an entry that was not administered as an FYI that she had read the entry. She added that she only chose administered on her screen for her initials to pull to the MAR if she actually gave a resident a medication. She added that there were multiple choices to choose from when a medication was not administered. She said that she could not specifically remember how she had entered the code for the [MEDICATION NAME] order dated [DATE]. She verified that the order was for [MEDICATION NAME] 7 mg to be administered on Tuesdays and Thursdays and for [MEDICATION NAME] 8 mg to be administered on Mondays, Wednesdays, Fridays, Saturdays, and Sundays. She also verified that there were no "stars" on the [DATE] and [DATE] MARs for the [MEDICATION NAME] entries with start dates of [DATE] to designate the days that the medication was not to be given. An interview was held with S22MedicalRecordsLPN on [DATE] at 10:56 a.m. She said that when a physician's orders [REDACTED]. She said they entered the information under clinical application/physician's orders [REDACTED]. She added that if the physician wrote the order and signed it, then the original order stayed on the chart, and she received a pink copy. She said that the physician's orders [REDACTED]. She said that there was no documentation that the orders were rechecked once they were entered into the computer by the floor nurses. She added that all orders might not be checked. She said that there were codes to enter for medications that were to be given only on certain days. She said that an asterisk would print on the MAR for the days that the medications were not to be given. She said that the MAR did not come up in the computer when the nurses were given medications that the physician's orders [REDACTED]. She said that during medication pass the nurses selected the resident to which medication was being administered. She said that if the interval code was entered according to the physician's orders [REDACTED]. She said that the nurses should read an order if the medication was showing up on a day that it was not to be administered and check the order. She added that the order could be corrected by the nurse at that point. She said if a medication appeared that was not to be administered that day or was not administered for some reason then the nurse was to select "not administered". She said that the nurses were told to enter "not administered" if a medication was not given and were not told to enter their initials if the medication was not administered. She said that she initially gave the nurses paperwork concerning the computer use with medications. She added that the new nurses were paired with another nurse to train on the computer use during medication pass and physician's orders [REDACTED]. She also said that if a nurse mistakenly hit "administered" when the medication was not administered then the nurse could enter a nurses' note explaining that the medication was not given. An interview was held with S2DON, S21Corporate QI, and S1Administrator present on [DATE] at 11:39 a.m. S2DON said that nurses received initial training with S22Medical Records LPN for computer training related to physician's orders [REDACTED]. She added that they were paired with another nurse for orientation that usually lasted a week but longer if the nurses weren't comfortable with the system. During the interview, S2DON was asked what the nurses were to do if a medication that was not due came up in the computer system. She said that the nurses were to tap "not administered" on the computer screen if a medication was not administered. She said that the computer would pull to the nurses' notes for an explanation to be given as to why the medication(s) were not given. She said that a check and the nurses' initials came out on the MAR for medications that were administered. She added that if a medication was not administered then an "N" and the nurses' initials came up on the MAR. She verified that the nurses had never been told to mark administered in the computer as an "FYI" that the entry was read when the medication was not actually administered. She said that the computer had "order text" so that medications to be given only on certain days would not come up as being due to be administered on the days that it was not to be administered. She added that if the "order text" was entered correctly then a medication entry should not come up for a medication to be given on a day that it was not due. She said that an asterisk would come up on the MAR for days that a medication was not to be given if the entry was entered correctly. She again verified that the facility did not use an "FYI procedure" to mark medication entries that were read but not administered. According to S2DON, the floor nurse initially entered physician's orders [REDACTED]. She stated that the Medical Records nurse did random second checks on orders for correct entry but did not check every physician's orders [REDACTED]. She said that the orders that were checked by S22Medical Records LPN were not logged. She stated that at the end of the month, one of the administrative nurses checked the monthly physician's orders [REDACTED]. She said that there was no one that ensured that all physician's orders [REDACTED]. During the interview, S2DON verified the following: -The entry on the [DATE] MAR of [MEDICATION NAME] 7 mg po qd on Tues and Thursday with a start date of [DATE] was initialed as being given on Monday ,[DATE], Wednesday ,[DATE], Friday ,[DATE], and Saturday ,[DATE] and Sunday ,[DATE]. -The entry on the [DATE] MAR of [MEDICATION NAME] 8 mg daily on M-W-F-S-S with a start date of [DATE] was initialed as being given on Thursday ,[DATE]. -The entry on the [DATE] MAR of [MEDICATION NAME] 7 mg po qd on Tues and Thursday with a start date of [DATE] was initialed as being given on Monday ,[DATE], Wednesday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. -The entry on the [DATE] MAR of [MEDICATION NAME] 8 mg daily on M-W-F-S-S with a start date of [DATE] was initialed as being given on Tuesday ,[DATE] and Thursday ,[DATE]. During the interview on [DATE] at 11:39 a.m., S2DON reviewed the [DATE] and [DATE] MARs, and immediately said that it was an "order text" problem and that the order had been entered wrong. S2DON verified that the checks and initials on the MAR revealed that the resident's [MEDICATION NAME] was administered on days that it was not ordered to be given. S2DON and S21Corporate QI both said that if the orders for [MEDICATION NAME] had been entered in the computer correctly, asterisks would have appeared on the days the medication was not to be given. They verified that a nurse's note would have followed if a medication was not administered explaining the reasoning why the medication was not given because the system automatically pulled to the nurse's notes for medications marked as "not administered." The emergency room records were reviewed with S2DON concerning the resident's elevated INR of 6.46 (critical level), the nurse assisting the MD in inserting a [MEDICAL CONDITION] Tube and removing blood from the patient's stomach, and Vitamin K being administered to the resident. She also verified that the resident had expired at the ER. S2DON, S1Administrator and S21CorporateQI agreed that this was a serious situation. During the interview, S2DON verified that the nurses did not always order new medications from the pharmacy each time the dosage changed with a resident's [MEDICATION NAME] if they had medication available to administer the correct dosage. She also said that the medication cards were not dated when the nurses started using one. Review of the pharmacy dispensing monthly audit log from [DATE]-[DATE] revealed the following: [MEDICATION NAME] Sodium ([MEDICATION NAME]) 6mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 6mg, 20 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 6mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 1mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 2mg, 30 tabs was dispensed on [DATE] Review of the "blister packs" (the medication cards) dispensed by the pharmacy revealed that a medication was to be reordered from the pharmacy when 6 days of medications were remaining in the pack. Review of the "blister packs" for Resident #47 that were still present at the facility revealed the following: [MEDICATION NAME] 5mg blister pack had 12 remaining tablets [MEDICATION NAME] 2mg blister pack had 14 remaining tablets [MEDICATION NAME] 1mg blister pack had 27 remaining tablets [MEDICATION NAME] 6mg blister pack had 6 remaining tablets An interview was held with S2DON and S1Administrator on [DATE] at 2:55 p.m. They both said that there was no system in place to ensure that the entries on the MARs were checked against the physician's orders [REDACTED]. The Administrator said that the nurses were responsible for checking the orders as they put the orders in every day.

II. Based on record review and interview, the facility failed to ensure Coumadin (a blood thinner) was accurately administered for 1 (#47) of 10 (#47,#95, #27, #98, #70, #156, #89, #79, #113, #93) residents reviewed with orders of alternating Coumadin dosages. The facility placed 1 (#47) of 10 residents who were reviewed with orders of alternating Coumadin dosages in Immediate Jeopardy when the interval codes for the resident's Coumadin orders were incorrectly entered into the computer, and the resident was administered inaccurate Coumadin dosages in excess of what the physician had prescribed. Resident #47 was transferred to the emergency room after a fall on 8/8/11. The emergency room record revealed that the resident had a critical INR lab value of 6.46 and bleeding in the stomach. The Immediate Jeopardy (IJ) situation began on 7/25/11 when the computer code for the resident's Coumadin orders was not entered as alternating doses on different days resulting in the resident receiving extra doses of Coumadin on days that it was not ordered. The IJ continued through 8/8/11 (excluding 7/26/11 when the Coumadin was administered correctly) and was removed on 8/8/11 at 6:52 p.m. when the resident was transferred to the emergency room . The deficient practice continued at an "E" for 9 residents (#95, #27, #98, #70, #156, #89, #79, #113, #93) in the facility on alternating Coumadin dosages (as noted on a list presented by the facility). Findings: Resident # 47 Review of the face sheet for Resident #47 revealed an admitted [DATE]. Her [DIAGNOSES REDACTED].Coli Infection, Cardiac Pacemaker, Dementia w/o behav Dist, Esophageal Reflux, General Osteoarthrosis, Lack of Coordination, Late effects of Cardiovascular Disease. Review of an OTIS report with an occurrence date of 8/8/11 revealed that it was reported to the Administrator on 8/9/11 that Resident #47 had fallen on 8/8/11 which resulted in her being transferred to the emergency room . It was noted that the resident had an open area above the right eye with swelling and bruising. It was also noted that the nurse came to assess the resident and put a pressure dressing on her head. The report revealed that the ambulance was called, and the resident was taken to the emergency room . Review of the facility nurse's notes for Resident #47 revealed the following: 8/8/11 6:33 p.m. Pt upright in D/R in WC, AAOX1. This nurse fed pt her supper in which consumed approx 25% of supper, CNA summoned this nurse to D/R stating pt had fallen forward from W/C while she was attempting to take her to her room and place her to bed. This nurse observed pt lying on her right side with mod amt of blood coming from an open area above her eye/eyebrow area. Was cleansed with wc and pressure dressing applied wrapped with Kerlex and secured with tape. Ambulance services contacted for transport of pt. Nurse Practitioner also made aware and order obtained to send pt out to ER for eval and tx. Pts DTR made aware and also of Levaquin 500mg po X 10 days, Albuterol Neb tx's qid X 3 days and F/U CXR on 8/19. 8/8/11 6:52 p.m. Report called to ER Nurse at hospital. Also forwarded pt's xray report. 8/9/11 12:13 p.m. Received phone call at 12:00 a.m. Hospital ER Nurse calling in reference to resident. Nurse requested DNR status for Resident #47. This nurse faxed information to MD. Also stated that MD will call back on resident condition. 8/911 2:07 a.m. Received phone call from hospital ER. MD informed nurses that resident had expired. Review of a written statement from S23LPN ( the statement was not signed but was verified by the S2DON as being S23LPN's statement regarding the fall of Resident #47 on 8/8/11 as she said that it was written in front of her) revealed that a CNA yelled out to her and she went to the rehab dining room. It was noted that she observed Resident #47 on the floor lying on her right side with an open area above her right eye. The statement further revealed that the CNA had stated that she attempted to remove the resident away from the table and began to propel her in her wheelchair when the resident leaned over and fell forward to the floor before she could catch her. It was noted on the statement that the nurse immediately applied pressure to the area to stop the bleeding, applied a pressure dressing, and the ambulance service was called for transport. Review of the facility's incident report dated 8/8/11 at 6:27 p.m. revealed Resident #47 had a fall with head injury from her wheelchair in the dining room. It was noted that the CNA stated she was propelling the patient away from the dining room and the patient began to lean forward and fell from the chair to the floor hitting the right side of her face. An open area above the right eye was observed with swelling and bruising forming and a small amount of blood was noted coming from the patient's nose. A pressure dressing was applied to the patient's head to stop the bleeding. The patient was sent to the ER for evaluation and treatment. It was also noted on the report that the resident was on Coumadin. As cited in an article "Warfarin Therapy: Evolving Strategies in Anticoagulation", published by The American Academy of Family Physicians: Warfarin (Coumadin) is the oral anticoagulant most used to control and prevent thromboembolic disorders. For most indications the dose is adjusted to maintain the patient's International Normalized Ratio (INR) at 2 to 3. Review of the Hospital ED Record for Resident #47 the revealed the following: On 8/8/11 at 19:08 (7:08 p.m.) the patient arrived to the ED as a result of a fall. At 19:13 (7:13 p.m.) vital signs taken revealed the following: Pulse: 84, Temperature: 98.1, Respiratory rate:18, Blood Pressure:123/91 and Pulse Oximeter: 96%. At 19:24 (7:24 p.m.) the resident was seen by the doctor. Initial blood work included PT (Includes INR), PTT, Troponin, CPK MB level, CPK Level, CMP, and CBC. Initial Radiology tests included a Chest xray: posterior, anterior and lateral, a right wrist xray, a right shoulder xray, a right hip unilateral, a CT of the cervical spine without contrast and a CT of the head without contrast. The lab results review section of the record dated 8/8/11 at 20:55 (8:55 p.m.) revealed the following results: INR- 6.46 (critical), Hgb-13.3 gm/dl (normal), Hct- 42.6% (normal), and Platelets-339,000 (normal). The ED Nurses Notes revealed that on 8/8/11 at 23:15 (11:15 p.m.), the nurse was assisting the MD in examining the patient to determine the source of blood draining in the mouth. It was noted that they suctioned the patient and removed the dentures and examined the mouth and nose. The ED Physician notes revealed that in a reexamination/reevaluation of the patient at 23:20 (11:20 p.m.), the patient was worsening and that her vital signs at 23:00 had been: Pulse:148, Respiratory Rate: 41, Blood Pressure: 86/54. The assessment information at the time of the reexamination/reevaluation revealed the following: "upper airway sounds", the patient refuses to open her mouth. Yankauer was placed in her mouth, oral cavity filled with bright red blood; this was suctioned out and it filled with blood again; no blood in the nasal cavity. NG tube placed and some blood was noted in the stomach; bleeding resolved spontaneously; repeat CBC pending, Vitamin K was given and Fresh Frozen Plasma was ordered. It was noted in the ED record that on 8/8/11 at 23:30 (11:30 p.m.), a gastrointestinal procedure was performed that revealed GI content that was dark and bloody with clots. The ED Nurses Notes from 8/8/11 at 23:35 (11:35 p.m.) revealed that the nurse assisted the MD in inserting a Nasogastric Tube and removing blood from the patient's stomach until the bloody drainage stopped. The nurses notes revealed that on 8/9/11 at 0017 (12:17 a.m.) the patient showed asystole on the monitor and the time of death was called at 0027 (12:27 a.m.). Further review of the ED record revealed that an autopsy was not performed on the patient. Review of the May 2011 Physician order [REDACTED]. Coumadin 5mg po Tue, Thur, Sat & Sun (Tuesday, Thursday, Saturday, and Sunday) Coumadin 6mg po MWF (Monday, Wednesday and Friday) Review of a physician's orders [REDACTED]. Increase Coumadin to 6mg all days except give 5 mg on Tuesday and Thursday only. Repeat PT/INR on 6/7/11 Review of the June 2011 Physician order [REDACTED]. Increase Coumadin 6mg tablet po on Monday, Wednesday, Friday, Saturday, and Sunday only Coumadin 5mg tablet po on Tuesday and Thursday only. Repeat PT/INR on 6/7/11 Review of a physician's orders [REDACTED]. Increase Coumadin to 6mg po daily Repeat PT/INR on 6/28/11. Review of a physician's orders [REDACTED]. Increase Coumadin to 7mg on Monday, Wednesday and Friday and 6mg on Tuesday, Thursday, Saturday and Sunday. Repeat PT/INR on 7/11/11. Review of the July 2011 Physician order [REDACTED]. Coumadin 6 mg tablet po along with 1 mg on MWF to equal 7 mg (Coumadin 1 mg tablet along with 6 mg tablet to equal 7 mg on MWF) Coumadin 6 mg tablet po on Tu, Th, Sat & Sun (Tuesday, Thursday, Saturday and Sunday) Review of a physician's orders [REDACTED]. Change Coumadin to 8mg po q day D/C previous Coumadin doses PT/INR on 7/25/11. Review of a physician's orders [REDACTED]. Change Coumadin to 7mg on Tues and Thursdays 8mg po all the other days of the week PT/INR next on 8/15/11 Review of the July 2011 E-MAR revealed the following entries with start dates of 7/25/11: -Coumadin 8mg daily on M-W-F-S-S- Give Coumadin 6 mg tab QD and Coumadin 1mg tabs X 2 tabs QD to = 8 mg daily. -Coumadin 7mg po QD on Tues and Thursday- Give Coumadin 6 mg and 1 mg QD to = 7 mg QD. Further review of the July 2011 E-MAR revealed the following: -The Coumadin 8 mg entry with a start date of 7/25/11 had a check mark and initials in the blocks for Monday 7/25, Wednesday 7/27, Thursday 7/28, Friday 7/29, Saturday 7/30, and Sunday 7/31. The date block for 7/26/11 had an "N" with initials in it. -The Coumadin 7 mg entry with a start date of 7/25/11 had a check mark and initials in the blocks for: Monday 7/25, Tuesday 7/26, Wednesday 7/27, Thursday 7/28, Friday 7/29/, Saturday 7/30, and Sunday 7/31/11. After reviewing the E- MAR for July 2011, it was noted that Coumadin 8 mg and Coumadin 7mg were both documented as being administered on Monday 7/25, Wednesday 7/27, Thursday 7/28, Friday 7/29, Saturday 7/30, and Sunday 7/31. According to the physician's orders [REDACTED]. Review of the August 2011 E-MAR revealed the following entries with start dates of 7/25/11: -Coumadin 8mg daily on M-W-F-S-S- Give Coumadin 6 mg tab QD and Coumadin 1mg tabs X 2 tabs QD to = 8 mg daily. -Coumadin 7mg po QD on Tues and Thursday- Give Coumadin 6 mg and 1 mg QD to = 7 mg QD. Further review of the August 2011 E-MAR revealed the following: -The Coumadin 8 mg entry with a start date of 7/25/11 had a check mark and initials in the blocks for Monday 8/1, Tuesday 8/2, Wednesday 8/3, Thursday 8/4, Friday 8/5, Saturday 8/6, Sunday 8/7, and Monday 8/8. -The Coumadin 7 mg entry with a start date of 7/25/11 had a check mark and initials in the blocks for: Monday 8/1, Tuesday 8/2, Wednesday 8/3, Thursday 8/4, Friday 8/5, Saturday 8/6, Sunday 8/7, and Monday 8/8. After reviewing the E- MAR for August 2011, it was noted that Coumadin 8 mg and Coumadin 7mg were both documented as being administered on Monday 8/1, Tuesday 8/2, Wednesday 8/3, Thursday 8/4, Friday 8/5, Saturday 8/6, Sunday 8/7, and Monday 8/8. According to the physician's orders [REDACTED]. Also, Coumadin 7 mg should not have been administered on Monday 8/1, Wednesday 8/3, Friday 8/5, Saturday 8/6, Sunday 8/7, and Monday 8/8. Review of the nurses' notes presented by the facility for July 2011 revealed the only entry related to Coumadin (start date 7/25/11) not being administered to the resident was on 7/26/11. Review of the nurses' notes presented by the facility for August 2011 revealed no entries related to Coumadin (start date 7/25/11) not being administered to the resident for the month. Review of the INR results for Resident #47 revealed the following: 5/17/11 INR- 1.69 6/7/11 INR-1.65 6/28/11 INR-1.37 7/11/11 INR- 1.65 7/25/11 INR-2.48 An interview was held with S25LPN on 8/24/11 at 2:00 p.m. She said that the nurses entered the physician's orders [REDACTED]. She said that asterisks would come up on the MAR for the days that the medication was not to be administered. She also said that the medications would not appear on the computer screen during medication pass on the days that the medication was not to be given if the right interval code was selected. She added that there was a choice of not administered that could be selected if a medication came up on the computer screen but was not administered. Review of the nursing assignments presented by S2DON for the week of 8/1/11 through 8/8/11 revealed the following: 8/8/11 100 Hall S11LPN (6-2) S23LPN (2-10) 8/7/11 100 Hall S24LPN (6a-6p) A telephone interview was held on 8/25/11 at 8:21 a.m. with S23LPN. She said she had worked at the facility about a month to a month and a half. She said that Resident #47 was normally one of her assigned residents and that she was familiar with her care. She verified that the resident had fallen on 8/8/11 when she was assigned to the resident. She said the resident was bleeding on the right side of the head by her eye after the fall. She also said that she was able to stop the bleeding by applying pressure. She also verified that she had administered medications to Resident #47 at times. She said she did not remember the exact dosages of the resident's Coumadin. She said that she knew the resident was on Coumadin and that it changed frequently and was offered with different dosages on different days. She said that the medication dose would pop up on the medication screen on the days it was to be given. She said that sometimes the medication may come up on the screen on Wednesday, when it was ordered to be given on Tuesday and Thursday. She said that she would initial as an "FYI" on the day the dose was not given and mark "not administered". She said that the medication had to be addressed on the yellow screen to avoid being turned red. She said that the computer gave you a spot to initial even if the medication was not scheduled to be given that day. She said that if the medication was not supposed to be given on a Thursday, but appeared on the screen that she initialed even though she did not give it because it was an "FYI". She said that she would have to sign to say it wasn't administered. She said that she selected the code "not administered" and that was what the system should read. She said she would check "administered" so the computer would show her initials for the medications that she gave and that she selected "not administered" when she did not give the medication. She said that she would give medications according to how the order read on the screen. She said she was new to the job and trying to learn the system. She said she had problems with her log- in on the computer and was frequently locked out. She said she did not think that the resident ever received Coumadin 7mg and Coumadin 8mg the same day. She said that she could not explain why her initials were present on both entries (8 mg and 7 mg) of Coumadin for the same day. A telephone interview was held on 8/25/11 at 9:16 a.m. with S24LPN. She said that she had been employed at the facility since January 2011. She said that she usually worked the weekends, on Saturdays and Sundays and worked 6A-6P. She also said that she worked during the week if they needed her. She said that at times she had been the assigned nurse for Resident #47 and had administered medications to the resident. She said that she recalled the resident being on Coumadin but did not recall the dosage. She said that if a medication came up on the computer during medication pass and was not given then she would highlight the medication and choose "not administered". She said that if she chose "administered" for the medication her initials showed in the blank as she had to log on to the system prior to giving medications. She said that she clicked on "Prepared and Administered" once she administered a medication to a resident. She said that if a medication was not given for some reason then she clicked on "Not Administered" in the computer. She said that she did not recall clicking "not administered" regarding Resident #47's Coumadin. She said that each time the resident's Coumadin came up in the computer she administered it. She added that only medications due to be given were to come up on the screen for the medication pass at that time. She said that if a medication was not due on a certain day, then it would not come up on the screen for that day. She said that she administered the Coumadin to Resident #47 when it appeared on the computer screen to be given. She verified that her initials used in the computer system were S24LPN (see staff ID list). She said that if her initials were on the MAR for a medication, then she administered the medication. When asked about her initials on the MAR as administering Coumadin 7 mg on Saturdays (7/30 and 8/6) and Sundays (7/31 and 8/7) when the order was for the Coumadin to be given on Tuesdays and Thursdays, she said that if her initials were there, then she gave the medication. She again said that it shouldn't have come up on the MAR to be given on Saturdays and Sundays if it was only ordered to be given on Tuesdays and Thursdays. An interview was held with S11LPN on 8/25/11 at 10:36 a.m. She said that when she received a physician's orders [REDACTED]. She said that an entry should only appear on the screen for the days it was to be administered during the nurses' medication pass. She said that normally a star would appear on the MAR for days that the medication should not be given. She added that if an entry that was only to be given on certain days pulled up during medication pass on a day that it was not due then she would check the order before giving the medication. She said that if she did not administer a medication then she would select "not administered" and then put the reason in the nurses' notes. She said that she had never been told to initial an entry that was not administered as an FYI that she had read the entry. She added that she only chose "administered" on the screen for her initials to pull to the MAR if she actually gave a resident a medication. She added that there were multiple choices to choose from when a medication was not administered. She said that she could not specifically remember how she had entered the code for the Coumadin order dated 7/25/11. She verified that the order was for Coumadin 7 mg to be administered on Tuesdays and Thursdays and for Coumadin 8 mg to be administered on Mondays, Wednesdays, Fridays, Saturdays, and Sundays. She also verified that there were no "stars" on the July 2011 and August 2011 MARs for the Coumadin entries with start dates of 7/25/11 to designate the days that the medication was not to be given. An interview was held with S22MedicalRecordsLPN on 8/25/11 at 10:56 a.m. She said that when a physician's orders [REDACTED]. She said they entered the information under clinical application/physician's orders [REDACTED]. She added that if the physician wrote the order and signed it, then the original order stayed on the chart, and she received a pink copy. She said that the physician's orders [REDACTED]. She said that there was no documentation that the orders were rechecked once they were entered into the computer by the floor nurses. She added that all orders might not be checked. She said that there were codes to enter for medications that were to be given only on certain days. She said that an asterisk would print on the MAR for the days that the medications were not to be given. She said that the MAR did not come up in the computer when the nurses were given medications that the physician's orders [REDACTED]. She said that during medication pass the nurses selected the resident to which medication was being administered. She said that if the interval code was entered according to the physician's orders [REDACTED]. She said that the nurses should read an order if the medication was showing up on a day that it was not to be administered and check the order. She added that the order could be corrected by the nurse at that point. She said if a medication appeared that was not to be administered that day or was not administered for some reason then the nurse was to select "not administered". She said that the nurses were told to enter "not administered" if a medication was not given and were not told to enter their initials if the medication was not administered. She said that she initially gave the nurses paperwork concerning the computer use with medications. She added that the new nurses were paired with another nurse to train on the computer use during medication pass and physician's orders [REDACTED]. She also said that if a nurse mistakenly hit "administered" when the medication was not administered then the nurse could enter a nurses' note explaining that the medication was not given. An interview was held with S2DON, S21Corporate QI, and S1Administrator present on 8/25/11 at 11:39 a.m. S2DON said that nurses received initial training with S22Medical Records LPN for computer training related to physician's orders [REDACTED]. She added that they were paired with another nurse for orientation that usually lasted a week but longer if the nurses weren't comfortable with the system. During the interview, S2DON was asked what the nurses were to do if a medication that was not due came up in the computer system. She said that the nurses were to tap "not administered" on the computer screen if a medication was not administered. She said that the computer would pull to the nurses' notes for an explanation to be given as to why the medication(s) were not given. She said that a check and the nurses' initials came out on the MAR for medications that were administered. She added that if a medication was not administered then an "N" and the nurses' initials came up on the MAR. She verified that the nurses had never been told to mark administered in the computer as an "FYI" that the entry was read when the medication was not actually administered. She said that the computer had "order text" so that medications to be given only on certain days would not come up as being due to be administered on the days that it was not to be administered. She added that if the "order text" was entered correctly then a medication entry should not come up for a medication to be given on a day that it was not due. She said that an asterisk would come up on the MAR for days that a medication was not to be given if the entry was entered correctly. She again verified that the facility did not use an "FYI procedure" to mark medication entries that were read but not administered. According to S2DON, the floor nurse initially entered physician's orders [REDACTED]. She stated that the Medical Records nurse did random second checks on orders for correct entry but did not check every physician's orders [REDACTED]. She said that the orders that were checked by S22Medical Records LPN were not logged. She stated that at the end of the month, one of the administrative nurses checked the monthly physician's orders [REDACTED]. She said that there was no one that ensured that all physician's orders [REDACTED]. During the interview, S2DON verified the following: -The entry on the July 2011 MAR of Coumadin 7 mg po qd on Tues and Thursday with a start date of 7/25/11 was initialed as being given on Monday 7/25, Wednesday 7/27, Friday 7/29, and Saturday 7/30 and Sunday 7/31. -The entry on the July 2011 MAR of Coumadin 8 mg daily on M-W-F-S-S with a start date of 7/25/11 was initialed as being given on Thursday 7/28. -The entry on the August 2011 MAR of Coumadin 7 mg po qd on Tues and Thursday with a start date of 7/25/11 was initialed as being given on Monday 8/1, Wednesday 8/3, Friday 8/5, Saturday 8/6, Sunday 8/7, and Monday 8/8. -The entry on the August 2011 MAR of Coumadin 8 mg daily on M-W-F-S-S with a start date of 7/25/11was initialed as being given on Tuesday 8/2 and Thursday 8/4. During the interview on 8/25/11 at 11:39 a.m., S2DON reviewed the July 2011 and August 2011 MARs, and immediately said that it was an "order text" problem and that the order had been entered wrong. S2DON verified that the checks and initials on the MAR revealed that the resident's Coumadin was administered on days that it was not ordered to be given. S2DON and S21Corporate QI both said that if the orders for Coumadin had been entered in the computer correctly, asterisks would have appeared on the days the medication was not to be given. They verified that a nurse's note would have followed if a medication was not administered explaining the reasoning why the medication was not given because the system automatically pulled to the nurse's notes for medications marked as "not administered." The emergency room records were reviewed with S2DON concerning the resident's elevated INR of 6.46 (critical level), the nurse assisting the MD in inserting a Nasogastric Tube and removing blood from the patient's stomach, and Vitamin K being administered to the resident. She also verified that the resident had expired at the ER. S2DON, S1Administrator and S21CorporateQI agreed that this was a serious situation. During the interview, S2DON verified that the nurses did not always order new medications from the pharmacy each time the dosage changed with a resident's Coumadin if they had medication available to administer the correct dosage. She also said that the medication cards were not dated when the nurses started using one. Review of the pharmacy dispensing monthly audit log from 3/1/11-8/25/11 revealed the following: Warfarin Sodium (Coumadin) 6mg, 30 tabs was dispensed on 3/2/11 Warfarin Sodium (Coumadin) 5mg, 30 tabs was dispensed on 3/9/11 Warfarin Sodium (Coumadin) 5mg, 30 tabs was dispensed on 4/28/11 Warfarin Sodium (Coumadin) 6mg, 20 tabs was dispensed on 5/24/11 Warfarin Sodium (Coumadin) 6mg, 30 tabs was dispensed on 7/2/11 Warfarin Sodium (Coumadin) 1mg, 30 tabs was dispensed on 7/6/11 Warfarin Sodium (Coumadin) 2mg, 30 tabs was dispensed on 7/12/11 Review of the "blister packs" (the medication cards) dispensed by the pharmacy revealed that a medication was to be reordered from the pharmacy when 6 days of medications were remaining in the pack. Review of the "blister packs" for Resident #47 that were still present at the facility revealed the following: Coumadin 5mg blister pack had 12 remaining tablets Coumadin 2mg blister pack had 14 remaining tablets Coumadin 1mg blister pack had 27 remaining tablets Coumadin 6mg blister pack had 6 remaining tablets An interview was held with S2DON and S1Administrator on 8/25/11 at 2:55 p.m. They both said that there was no system in place to ensure that the entries on the MARs were checked against the physician's orders [REDACTED]. The Administrator said that the nurses were responsible for checking the orders as they put the orders in every day. II. Based on observation, interview and clinical record review, the facility failed to ensure eye drops were administered properly for 1 (#141) of 10 (#5, #8, #18, #22, #65, #103, #120, #124, #141, #154) residents observed for Medication Administration Pass. Findings: Resident #141 was an [AGE] year old man who had Cataract surgery on his right eye on 8/3/11. He had Cataract surgery on his Left eye on 8/10/11. An observation of medication administration on 8/23/11 at 11:10 a.m. revealed 1 drop of Pred Forte 1% Eye Drops (steroid) was administered in the right eye of resident #141 per S11LPN. After the eye drop was placed in the right eye, the resident asked S11LPN if he should be getting drops in both eyes. She stated no, that was another medicine. Review of the physician's orders [REDACTED]. A new order was written on 8/11/11 for Pred Forte 1% Eye Drops 1 GTT to OU (both eyes) QID (four times daily). During an interview with S11LPN on 8/23/11 at 12:00 noon, she stated the Pred Forte 1% should have been administered to both eyes, not just the right eye. She verified she had checked the box indicating she had given the drops in both eyes on the Medication Administration Record, but had administered the drop in the right eye only.

Based on record review and interview, the facility failed to ensure their resources were used effectively to maintain the resident's highest practicable well-being for 1 (#47) of 10 (#47, #95, #27, #98, #70, #156, #89, #79, #113, #93) residents reviewed with orders of alternating [MEDICATION NAME] (a blood thinner) dosages by not having a system in place to ensure that the codes for administration of medications were rechecked for accuracy once placed into the computer in an effort to prevent incorrect administration of medications. The facility placed 1 (#47) of 10 residents who were reviewed with orders of alternating [MEDICATION NAME] dosages in Immediate Jeopardy when the interval codes for the resident's [MEDICATION NAME] orders were incorrectly entered into the computer, and the resident was administered [MEDICATION NAME] dosages in excess of what the physician had prescribed as being clinically indicated to treat the resident's condition. Resident #47 was transferred to the emergency room after a fall on [DATE]. The emergency room records revealed that the resident had a critical INR lab value of 6.46 and bleeding in the stomach. The Immediate Jeopardy (IJ) situation began on [DATE] when the computer code for the resident's [MEDICATION NAME] orders was not entered as alternating doses on different days resulting in the resident receiving an extra dose of [MEDICATION NAME] on days that it was not ordered. The IJ continued through [DATE] (excluding [DATE] when the [MEDICATION NAME] was administered correctly) and was removed on [DATE] at 6:52 p.m. when the resident was transferred to the emergency room . The deficient practice continued at an "E" for 9 residents (#95, #27, #98, #70, #156, #89, #79, #113, #93) in the facility on alternating [MEDICATION NAME] dosages (as noted on a list presented by the facility). Findings: Resident # 47 Review of the face sheet for Resident #47 revealed an admitted [DATE]. Her [DIAGNOSES REDACTED].Coli Infection, Cardiac Pacemaker, Dementia w/o behav Dist, [MEDICAL CONDITION] Reflux, General [MEDICAL CONDITION], Lack of Coordination, Late effects of Cardiovascular Disease. Review of an OTIS report with an occurrence date of [DATE] revealed that it was reported to the Administrator on [DATE] that Resident #47 had fallen on [DATE] which resulted in her being transferred to the emergency room . It was noted that the resident had an open area above the right eye with swelling and bruising. It was also noted that the nurse came to assess the resident and put a pressure dressing on her head. The report revealed that the ambulance was called, and the resident was taken to the emergency room . Review of the facility nurse's notes for Resident #47 revealed the following: [DATE] 6:33 p.m. Pt upright in D/R in WC, AAOX1. This nurse fed pt her supper in which consumed approx 25% of supper, CNA summoned this nurse to D/R stating pt had fallen forward from W/C while she was attempting to take her to her room and place her to bed. This nurse observed pt lying on her right side with mod amt of blood coming from an open area above her eye/eyebrow area. Was cleansed with wc and pressure dressing applied wrapped with [MEDICATION NAME] and secured with tape. Ambulance services contacted for transport of pt. Nurse Practitioner also made aware and order obtained to send pt out to ER for eval and tx. Pts DTR made aware and also of [MEDICATION NAME] 500mg po X 10 days, [MEDICATION NAME] Neb tx's qid X 3 days and F/U CXR on ,[DATE]. [DATE] 6:52 p.m. Report called to ER Nurse at hospital. Also forwarded pt's xray report. [DATE] 12:13 p.m. Received phone call at 12:00 a.m. Hospital ER Nurse calling in reference to resident. Nurse requested DNR status for Resident #47. This nurse faxed information to MD. Also stated that MD will call back on resident condition. ,[DATE] 2:07 a.m. Received phone call from hospital ER. MD informed nurses that resident had expired. Review of a written statement from S23LPN ( the statement was not signed but was verified by the S2DON as being S23LPN's statement regarding the fall of Resident #47 on [DATE] as she said that it was written in front of her) revealed that a CNA yelled out to her and she went to the rehab dining room. It was noted that she observed Resident #47 on the floor lying on her right side with an open area above her right eye. The statement further revealed that the CNA had stated that she attempted to remove the resident away from the table and began to propel her in her wheelchair when the resident leaned over and fell forward to the floor before she could catch her. It was noted on the statement that the nurse immediately applied pressure to the area to stop the bleeding, applied a pressure dressing, and the ambulance service was called for transport. Review of the facility's incident report dated [DATE] at 6:27 p.m. revealed Resident #47 had a fall with head injury from her wheelchair in the dining room. It was noted that the CNA stated she was propelling the patient away from the dining room and the patient began to lean forward and fell from the chair to the floor hitting the right side of her face. An open area above the right eye was observed with swelling and bruising forming and a small amount of blood was noted coming from the patient's nose. A pressure dressing was applied to the patient's head to stop the bleeding. The patient was sent to the ER for evaluation and treatment. It was also noted on the report that the resident was on [MEDICATION NAME]. As cited in an article "[MEDICATION NAME] Therapy: Evolving Strategies in Anticoagulation", published by The American Academy of Family Physicians: [MEDICATION NAME] ([MEDICATION NAME]) is the oral anticoagulant most used to control and prevent [MEDICAL CONDITION] disorders. For most indications the dose is adjusted to maintain the patient's International Normalized Ratio (INR) at 2 to 3. Review of the Hospital ED Record for Resident #47 the revealed the following: On [DATE] at 19:08 (7:08 p.m.) the patient arrived to the ED as a result of a fall. At 19:13 (7:13 p.m.) vital signs taken revealed the following: Pulse: 84, Temperature: 98.1, Respiratory rate:18, Blood Pressure:,[DATE] and Pulse Oximeter: 96%. At 19:24 (7:24 p.m.) the resident was seen by the doctor. Initial blood work included PT (Includes INR), PTT, Troponin, CPK MB level, CPK Level, CMP, and CBC. Initial Radiology tests included a Chest xray: posterior, anterior and lateral, a right wrist xray, a right shoulder xray, a right hip unilateral, a CT of the cervical spine without contrast and a CT of the head without contrast. The lab results review section of the record dated [DATE] at 20:55 (8:55 p.m.) revealed the following results: INR- 6.46 (critical), Hgb-13.3 gm/dl (normal), Hct- 42.6% (normal), and Platelets-339,000 (normal). The ED Nurses Notes revealed that on [DATE] at 23:15 (11:15 p.m.), the nurse was assisting the MD in examining the patient to determine the source of blood draining in the mouth. It was noted that they suctioned the patient and removed the dentures and examined the mouth and nose. The ED Physician notes revealed that in a reexamination/reevaluation of the patient at 23:20 (11:20 p.m.), the patient was worsening and that her vital signs at 23:00 had been: Pulse:148, Respiratory Rate: 41, Blood Pressure: ,[DATE]. The assessment information at the time of the reexamination/reevaluation revealed the following: "upper airway sounds", the patient refuses to open her mouth. [MEDICATION NAME] was placed in her mouth, oral cavity filled with bright red blood; this was suctioned out and it filled with blood again; no blood in the nasal cavity. NG tube placed and some blood was noted in the stomach; bleeding resolved spontaneously; repeat CBC pending, Vitamin K was given and Fresh Frozen Plasma was ordered. It was noted in the ED record that on [DATE] at 23:30 (11:30 p.m.), a gastrointestinal procedure was performed that revealed GI content that was dark and bloody with clots. The ED Nurses Notes from [DATE] at 23:35 (11:35 p.m.) revealed that the nurse assisted the MD in inserting a [MEDICAL CONDITION] Tube and removing blood from the patient's stomach until the bloody drainage stopped. The nurses notes revealed that on [DATE] at 0017 (12:17 a.m.) the patient showed asystole on the monitor and the time of death was called at 0027 (12:27 a.m.). Further review of the ED record revealed that an autopsy was not performed on the patient. Review of the [DATE] Physician order [REDACTED]. [MEDICATION NAME] 5mg po Tue, Thur, Sat & Sun (Tuesday, Thursday, Saturday, and Sunday) [MEDICATION NAME] 6mg po MWF (Monday, Wednesday and Friday) Review of a physician's orders [REDACTED]. Increase [MEDICATION NAME] to 6mg all days except give 5 mg on Tuesday and Thursday only. Repeat PT/INR on [DATE] Review of the [DATE] Physician order [REDACTED]. Increase [MEDICATION NAME] 6mg tablet po on Monday, Wednesday, Friday, Saturday, and Sunday only [MEDICATION NAME] 5mg tablet po on Tuesday and Thursday only. Repeat PT/INR on [DATE] Review of a physician's orders [REDACTED]. Increase [MEDICATION NAME] to 6mg po daily Repeat PT/INR on [DATE]. Review of a physician's orders [REDACTED]. Increase [MEDICATION NAME] to 7mg on Monday, Wednesday and Friday and 6mg on Tuesday, Thursday, Saturday and Sunday. Repeat PT/INR on [DATE]. Review of the [DATE] Physician order [REDACTED]. [MEDICATION NAME] 6 mg tablet po along with 1 mg on MWF to equal 7 mg ([MEDICATION NAME] 1 mg tablet along with 6 mg tablet to equal 7 mg on MWF) [MEDICATION NAME] 6 mg tablet po on Tu, Th, Sat & Sun (Tuesday, Thursday, Saturday and Sunday) Review of a physician's orders [REDACTED]. Change [MEDICATION NAME] to 8mg po q day D/C previous [MEDICATION NAME] doses PT/INR on [DATE]. Review of a physician's orders [REDACTED]. Change [MEDICATION NAME] to 7mg on Tues and Thursdays 8mg po all the other days of the week PT/INR next on [DATE] Review of the [DATE] E-MAR revealed the following entries with start dates of [DATE]: -[MEDICATION NAME] 8mg daily on M-W-F-S-S- Give [MEDICATION NAME] 6 mg tab QD and [MEDICATION NAME] 1mg tabs X 2 tabs QD to = 8 mg daily. -[MEDICATION NAME] 7mg po QD on Tues and Thursday- Give [MEDICATION NAME] 6 mg and 1 mg QD to = 7 mg QD. Further review of the [DATE] E-MAR revealed the following: -The [MEDICATION NAME] 8 mg entry with a start date of [DATE] had a check mark and initials in the blocks for Monday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], and Sunday ,[DATE]. The date block for [DATE] had an "N" with initials in it. -The [MEDICATION NAME] 7 mg entry with a start date of [DATE] had a check mark and initials in the blocks for: Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE]/, Saturday ,[DATE], and Sunday [DATE]. After reviewing the E- MAR for [DATE], it was noted that [MEDICATION NAME] 8 mg and [MEDICATION NAME] 7mg were both documented as being administered on Monday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], and Sunday ,[DATE]. According to the physician's orders [REDACTED]. Review of the [DATE] E-MAR revealed the following entries with start dates of [DATE]: -[MEDICATION NAME] 8mg daily on M-W-F-S-S- Give [MEDICATION NAME] 6 mg tab QD and [MEDICATION NAME] 1mg tabs X 2 tabs QD to = 8 mg daily. -[MEDICATION NAME] 7mg po QD on Tues and Thursday- Give [MEDICATION NAME] 6 mg and 1 mg QD to = 7 mg QD. Further review of the [DATE] E-MAR revealed the following: -The [MEDICATION NAME] 8 mg entry with a start date of [DATE] had a check mark and initials in the blocks for Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. -The [MEDICATION NAME] 7 mg entry with a start date of [DATE] had a check mark and initials in the blocks for: Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. After reviewing the E- MAR for [DATE], it was noted that [MEDICATION NAME] 8 mg and [MEDICATION NAME] 7mg were both documented as being administered on Monday ,[DATE], Tuesday ,[DATE], Wednesday ,[DATE], Thursday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. According to the physician's orders [REDACTED]. Also, [MEDICATION NAME] 7 mg should not have been administered on Monday ,[DATE], Wednesday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. Review of the nurses' notes presented by the facility for [DATE] revealed the only entry related to [MEDICATION NAME] (start date [DATE]) not being administered to the resident was on [DATE]. Review of the nurses' notes presented by the facility for [DATE] revealed no entries related to [MEDICATION NAME] (start date [DATE]) not being administered to the resident for the month. Review of the INR results for Resident #47 revealed the following: [DATE] INR- 1.69 [DATE] INR-1.65 [DATE] INR-1.37 [DATE] INR- 1.65 [DATE] INR-2.48 An interview was held with S25LPN on [DATE] at 2:00 p.m. She said that the nurses entered the physician's orders [REDACTED]. She said that asterisks would come up on the MAR for the days that the medication was not to be administered. She also said that the medications would not appear on the computer screen during medication pass on the days that the medication was not to be given if the right interval code was selected. She added that there was a choice of not administered that could be selected if a medication came up on the computer screen but was not administered. Review of the nursing assignments presented by S2DON for the week of [DATE] through [DATE] revealed the following: [DATE] 100 Hall S11LPN (,[DATE]) S23LPN (,[DATE]) [DATE] 100 Hall S24LPN (6a-6p) A telephone interview was held on [DATE] at 8:21 a.m. with S23LPN. She said she had worked at the facility about a month to a month and a half. She said that Resident #47 was normally one of her assigned residents and that she was familiar with her care. She verified that the resident had fallen on [DATE] when she was assigned to the resident. She said the resident was bleeding on the right side of the head by her eye after the fall. She also said that she was able to stop the bleeding by applying pressure. She also verified that she had administered medications to Resident #47 at times. She said she did not remember the exact dosages of the resident's [MEDICATION NAME]. She said that she knew the resident was on [MEDICATION NAME] and that it changed frequently and was offered with different dosages on different days. She said that the medication dose would pop up on the medication screen on the days it was to be given. She said that sometimes the medication may come up on the screen on Wednesday, when it was ordered to be given on Tuesday and Thursday. She said that she would initial as an "FYI" on the day the dose was not given and mark "not administered." She said that the medication had to be addressed on the yellow screen to avoid being turned red. She said that the computer gave you a spot to initial even if the medication was not scheduled to be given that day. She said that if the medication was not supposed to be given on a Thursday, but appeared on the screen that she initialed even though she did not give it because it was an "FYI". She said that she would have to sign to say it wasn't administered. She said that she selected the code "not administered" and that was what the system should read. She said she would check "administered" so the computer would show her initials for the medications that she gave and that she selected "not administered" when she did not give the medication. She said that she would give medications according to how the order read on the screen. She said she was new to the job and trying to learn the system. She said she had problems with her log- in on the computer and was frequently locked out. She said she did not think that the resident ever received [MEDICATION NAME] 7mg and [MEDICATION NAME] 8mg the same day. She said that she could not explain why her initials were present on the MAR on both entries (8 mg and 7 mg) of [MEDICATION NAME] on the same day for some dates in [DATE] and [DATE]. A telephone interview was held on [DATE] at 9:16 a.m. with S24LPN. She said that she had been employed at the facility since [DATE]. She said that she usually worked the weekends, on Saturdays and Sundays and worked 6A-6P. She also said that she worked during the week if they needed her. She said that at times she had been the assigned nurse for Resident #47 and had administered medications to the resident. She said that she recalled the resident being on [MEDICATION NAME] but did not recall the dosage. She said that if a medication came up on the computer during medication pass and was not given then she would highlight the medication and choose "not administered". She said that if she chose "administered" for the medication her initials showed in the blank as she had to log on to the system prior to giving medications. She said that she clicked on "Prepared and Administered" once she administered a medication to a resident. She said that if a medication was not given for some reason then she clicked on "Not Administered" in the computer. She said that she did not recall clicking "not administered" regarding Resident #47's [MEDICATION NAME]. She said that each time the resident's [MEDICATION NAME] came up in the computer she administered it. She added that only medications due to be given were to come up on the screen for the medication pass at that time. She said that if a medication was not due on a certain day, then it would not come up on the screen for that day. She said that she administered the [MEDICATION NAME] to Resident #47 when it appeared on the computer screen to be given. She verified that her initials used in the computer system were S24LPN (see staff ID list). She said that if her initials were on the MAR for a medication, then she administered the medication. When asked about her initials on the MAR as administering [MEDICATION NAME] 7 mg on Saturdays (,[DATE] and ,[DATE]) and Sundays (,[DATE] and ,[DATE]) when the order was for the [MEDICATION NAME] to be given on Tuesdays and Thursdays, she said that if her initials were there, then she gave the medication. She again said that the medication shouldn't have come up on the MAR to be given on Saturdays and Sundays if it was only ordered to be given on Tuesdays and Thursdays. An interview was held with S11LPN on [DATE] at 10:36 a.m. She said that when she received a physician's orders [REDACTED]. She said that an entry should only appear on the screen for the days it was to be administered during the nurses' medication pass. She said that normally a star would appear on the MAR for days that the medication should not be given. She added that if an entry that was only to be given on certain days pulled up during medication pass on a day that it was not due then she would check the order before giving the medication. She said that if she did not administer a medication then she would select "not administered" and then put the reason in the nurses' notes. She said that she had never been told to initial an entry that was not administered as an FYI that she had read the entry. She added that she only chose "administered" on the screen for her initials to pull to the MAR if she actually gave a resident a medication. She added that there were multiple choices to choose from when a medication was not administered. She said that she could not specifically remember how she had entered the code for the [MEDICATION NAME] order dated [DATE]. She verified that the order was for [MEDICATION NAME] 7 mg to be administered on Tuesdays and Thursdays and for [MEDICATION NAME] 8 mg to be administered on Mondays, Wednesdays, Fridays, Saturdays, and Sundays. She also verified that there were no "stars" on the [DATE] and [DATE] MARs for the [MEDICATION NAME] entries with start dates of [DATE] to designate the days that the medication was not to be given. An interview was held with S22MedicalRecordsLPN on [DATE] at 10:56 a.m. She said that when a physician's orders [REDACTED]. She said they entered the information under clinical application/physician's orders [REDACTED]. She added that if the physician wrote the order and signed it, then the original order stayed on the chart, and she received a pink copy. She said that the physician's orders [REDACTED]. She said that there was no documentation that the orders were rechecked once they were entered into the computer by the floor nurses. She added that all orders might not be checked. She said that there were codes to enter for medications that were to be given only on certain days. She said that an asterisk would print on the MAR for the days that the medications were not to be given. She said that the MAR did not come up in the computer when the nurses were given medications that the physician's orders [REDACTED]. She said that during medication pass the nurses selected the resident to which medication was being administered. She said that if the interval code was entered according to the physician's orders [REDACTED]. She said that the nurses should read an order if the medication was showing up on a day that it was not to be administered and check the order. She added that the order could be corrected by the nurse at that point. She said if a medication appeared that was not to be administered that day or was not administered for some reason then the nurse was to select "not administered". She said that the nurses were told to enter "not administered" if a medication was not given and were not told to enter their initials if the medication was not administered. She said that she initially gave the nurses paperwork concerning the computer use with medications. She added that the new nurses were paired with another nurse to train on the computer use during medication pass and physician's orders [REDACTED]. She also said that if a nurse mistakenly hit "administered" when the medication was not administered then the nurse could enter a nurses' note explaining that the medication was not given. An interview was held with S2DON, S21Corporate QI, and S1Administrator present on [DATE] at 11:39 a.m. S2DON said that nurses received initial training with S22Medical Records LPN for computer training related to physician's orders [REDACTED]. She added that they were paired with another nurse for orientation that usually lasted a week but longer if the nurses weren't comfortable with the system. During the interview, S2DON was asked what the nurses were to do if a medication that was not due came up in the computer system. She said that the nurses were to tap "not administered" on the computer screen if a medication was not administered. She said that the computer would pull to the nurses' notes for an explanation to be given as to why the medication(s) were not given. She said that a check and the nurses' initials came out on the MAR for medications that were administered. She added that if a medication was not administered then an "N" and the nurses' initials came up on the MAR. She verified that the nurses had never been told to mark "administered" in the computer as an "FYI" that the entry was read when the medication was not actually administered. She said that the computer had "order text" so that medications to be given only on certain days would not come up as being due to be administered on the days that it was not to be administered. She added that if the "order text" was entered correctly then a medication entry should not come up for a medication to be given on a day that it was not due. She said that an asterisk would come up on the MAR for days that a medication was not to be given if the entry was entered correctly. She again verified that the facility did not use an "FYI procedure" to mark medication entries that were read but not administered. According to S2DON, the floor nurse initially entered physician's orders [REDACTED]. She stated that the Medical Records nurse did random second checks on orders for correct entry but did not check every physician's orders [REDACTED]. She said that the orders that were checked by S22Medical Records LPN were not logged. She stated that at the end of the month, one of the administrative nurses checked the monthly physician's orders [REDACTED]. She said that there was no one that ensured that all physician's orders [REDACTED]. During the interview, S2DON verified the following: -The entry on the [DATE] MAR of [MEDICATION NAME] 7 mg po qd on Tues and Thursday with a start date of [DATE] was initialed as being given on Monday ,[DATE], Wednesday ,[DATE], Friday ,[DATE], and Saturday ,[DATE] and Sunday ,[DATE]. -The entry on the [DATE] MAR of [MEDICATION NAME] 8 mg daily on M-W-F-S-S with a start date of [DATE] was initialed as being given on Thursday ,[DATE]. -The entry on the [DATE] MAR of [MEDICATION NAME] 7 mg po qd on Tues and Thursday with a start date of [DATE] was initialed as being given on Monday ,[DATE], Wednesday ,[DATE], Friday ,[DATE], Saturday ,[DATE], Sunday ,[DATE], and Monday ,[DATE]. -The entry on the [DATE] MAR of [MEDICATION NAME] 8 mg daily on M-W-F-S-S with a start date of [DATE] was initialed as being given on Tuesday ,[DATE] and Thursday ,[DATE]. During the interview on [DATE] at 11:39 a.m., S2DON reviewed the [DATE] and [DATE] MARs, and immediately said that it was an "order text" problem and that the order had been entered wrong. S2DON verified that the checks and initials on the MAR revealed that the resident's [MEDICATION NAME] was administered on days that it was not ordered to be given. S2DON and S21Corporate QI both said that if the orders for [MEDICATION NAME] had been entered in the computer correctly, asterisks would have appeared on the days the medication was not to be given. They verified that a nurse's note would have followed if a medication was not administered explaining the reasoning why the medication was not given because the system automatically pulled to the nurse's notes for medications marked as "not administered." The emergency room records were reviewed with S2DON concerning the resident's elevated INR of 6.46 (critical level), the nurse assisting the MD in inserting a [MEDICAL CONDITION] Tube and removing blood from the patient's stomach, and Vitamin K being administered to the resident. She also verified that the resident had expired at the ER. S2DON, S1Administrator and S21CorporateQI agreed that this was a serious situation. During the interview, S2DON verified that the nurses did not always order new medications from the pharmacy each time the dosage changed with a resident's [MEDICATION NAME] if they had medication available to administer the correct dosage. She also said that the medication cards were not dated when the nurses started using one. Review of the pharmacy dispensing monthly audit log from [DATE]-[DATE] revealed the following: [MEDICATION NAME] Sodium ([MEDICATION NAME]) 6mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 5mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 6mg, 20 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 6mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 1mg, 30 tabs was dispensed on [DATE] [MEDICATION NAME] Sodium ([MEDICATION NAME]) 2mg, 30 tabs was dispensed on [DATE] Review of the "blister packs" (the medication cards) dispensed by the pharmacy revealed that a medication was to be reordered from the pharmacy when 6 days of medications were remaining in the pack. Review of the "blister packs" for Resident #47 that were still present at the facility revealed the following: [MEDICATION NAME] 5mg blister pack had 12 remaining tablets [MEDICATION NAME] 2mg blister pack had 14 remaining tablets [MEDICATION NAME] 1mg blister pack had 27 remaining tablets [MEDICATION NAME] 6mg blister pack had 6 remaining tablets An interview was held with S2DON and S1Administrator on [DATE] at 2:55 p.m. They both said that there was no system in place to ensure that the entries on the MARs were checked against the physician's orders [REDACTED]. The Administrator said that the nurses were responsible for checking the orders as they put the orders in every day.