Every finding on record at Life Care Center of Crossville

Based on review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, medical record reviews, and interviews, the facility failed to accurately assess residents on the Minimum Data Set (MDS) assessment for a Level II Pre-admission Screening and Resident Review (PASARR) with a serious mental illness for 2 residents (Residents #39 and #47) of 18 residents reviewed. The findings include:Review of the RAI 3.0 User's Manual, dated 10/2025, revealed .PASRR [PASARR] Level II screening determined that the resident has a serious mental illness .Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Psychotic Disorder with Delusions, Hallucinations, and Anxiety Disorder. Further review revealed the diagnosis of Dementia was added 11/12/2024.Review of an PASARR dated 11/10/2022, revealed Resident #39 required a Level II evaluation, which was completed on 11/16/2022, and determined the resident had a serious mental illness.Review of the comprehensive care plan for Resident #39 dated 5/9/2024, revealed .PASRR [PASARR] conditions psychiatric diagnoses . Review of a PASARR for Resident #39 dated 12/10/2024, revealed the PASARR was updated with a diagnosis of Dementia, and the prior PASARR determination for Level II services remained in effect with no status change. Review of an annual MDS assessment dated [DATE], revealed Resident #39 had a diagnosis of a serious mental illness and level II PASARR had been submitted to the state designated authority. Continued review revealed the MDS was coded inaccurately regarding a Level II PASARR. Review of a quarterly MDS assessment dated [DATE], revealed Resident #39 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Bipolar Disorder, and Depression. Further review revealed the diagnoses of Anxiety, Insomnia, and Sleep Terrors/Night Terrors were added 11/8/2023.Review of the comprehensive care plan for Resident #47 dated 5/4/2023, revealed .PASRR [PASARR] conditions: Bipolar . Review of an updated PASARR dated 11/6/2023, revealed Resident #47 required a Level II evaluation, which was completed on 11/21/2023, and determined the resident met the criteria for a serious mental illness.Review of a PASARR for Resident #47 dated 12/10/2024, revealed the PASARR was updated with a diagnoses and/or medications, and the prior PASARR determination for Level II services remained in effect with no status change. Review of an annual MDS assessment dated [DATE], revealed Resident #47 had a diagnosis of a serious mental illness and level II PASARR had been submitted to the state designated authority. Continued review revealed the MDS was coded inaccurately regarding a Level II PASARR. Review of a quarterly MDS assessment dated [DATE], revealed Resident #47 scored an 8 on the BIMS assessment which indicated the resident had severe cognitive impairment.During an interview on 3/18/2026 at 9:30 AM, the Registered Nurse (RN) MDS Coordinator confirmed Resident #39's annual MDS assessment dated [DATE], and Resident #47's annual MDS assessment dated [DATE] were not coded accurately for being considered by the state level II PASARR process to have a serious mental illness.

Based on facility policy review, medical record review, interviews, and observations, the facility failed to obtain a Physician's Order prior to implementing a continuous blood glucose monitoring device and failed to incorporate the continuous blood glucose monitoring device on the comprehensive care plan for 1 resident (Resident #17) of 3 residents reviewed for insulin use.The findings include:Review of the facility policy titled, Glucose monitoring, continuous, dated 5/19/2025, revealed .A real-time continuous glucose monitor consists of three components: a sensor, a small wire catheter or needle that's inserted in the arm .and a handheld receiver .that displays the glucose data .calibrate the transmitter or reader if specified by the device manufacturer .Implementation .Verify the practitioner's order .replace the sensor at an interval established by the device manufacturer .document the procedure .includes results of glucose monitoring, assessment of the patients ability to perform glucose monitoring, manual dexterity .Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, History of Falling, and Depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had a diagnosis of Diabetes. Review of the comprehensive care plan for Resident #17 dated 1/7/2026, revealed .Diabetes Mellitus .blood sugar checks as ordered .Medication as ordered .observe and report PRN [as needed] any s/s [signs and symptoms] of hyperglycemia [elevated blood glucose] observe and report PRN any s/s of hypoglycemia [low blood glucose] . Review of the Medication Administration Record (MAR) for Resident #17 dated 3/1/2026 - 3/31/2026, revealed .Insulin Degludec [an injectable medication used to treat high glucose levels] Inject 15 units subcutaneously at bedtime for diabetes .Dapagliflozin Propanediol [a medication used to treat high glucose levels] Give 10 mg [milligrams] by mouth one time a day related to Type 2 Diabetes .Blood sugar [level] two times a day related to .Diabetes .notify provider if less than 60 or greater than 400 .During an interview and observation on 3/16/2026 at 11:20 AM, Resident #17 stated she was diabetic and monitors her own blood glucose using a device secured to the back of her left arm and reports evening glucose levels from the handheld receiver to the nurse. Resident #17 stated she [Resident #17] orders the device and has a new one placed to the backside of her arm every 10 days by the night nurse because she [Resident #17] cannot reach the area and [Resident #17] patted her arm at the location of placement. The site was not visible to this surveyor. During an observation and interview on 3/17/2026 at 3:41 PM, in Resident #17's room with the Director of Nursing (DON), Resident #17 showed surveyor and DON the glucose monitoring device secured to the backside of her left upper arm and stated she [Resident #17] orders the device and the device is brought into the facility by family from home. Resident #17 stated the night nurse secures the device to her arm every 10 days. During an interview on 3/17/2026 at 3:47 PM, the DON stated she was unaware Resident #17 was monitoring her glucose levels herself using a continuous blood glucose monitoring device and reporting it to the [night] nurse. During an interview on 3/17/2026 at 4:35 PM, the DON confirmed Resident #17's care plan did not contain use of the continuous blood glucose monitoring device and Resident #17 did not have a Physician's Order for the continuous blood glucose monitoring device, and confirmed the facility was not aware Resident #17 was using the device until it was pointed out by the surveyor during record review.

Based on facility policy review, medical record review, meal tray ticket review, observations, and interviews, the facility failed to ensure a resident received adaptive devices while eating as ordered by the physician for 1 resident (Resident #10) of 3 residents reviewed for adaptive devices.The findings include:Review of the facility's policy titled, Assistive Devices - Special Eating Equipment, dated 12/16/2021, revealed .The facility must provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat or drink independently .when special equipment is recommended, the Interdisciplinary Care Plan, [meal] tray card and resident diet profile are updated .Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dysphagia, Osteoarthritis, and Adult Failure to Thrive.Review of an Occupational Therapist's progress note dated 10/30/2024, revealed .ordered for dycem [non-skid mat] and plate guard [device around plate that is raised and allows food to be scooped against it to decrease risk of food spillage off the plate] are in place. Nursing is aware .Review of the comprehensive care plan for Resident #10 revealed an intervention dated 12/13/2024, .adaptive equipment per order as tolerated . The specific types of adaptive devices ordered were not documented on the care plan.Review of a Physician's Order for Resident #10 dated 6/27/2025, revealed .Adaptive Device: Dycem under tray, plate guard .Review of a quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 9/26/2025, revealed the resident has short-term and long-term memory deficits, and was severely impaired in cognitive skills for daily decision making. Further review revealed Resident #10 required set-up/clean-up assistance for eating. Review of a quarterly MDS assessment for Resident #10 dated 12/23/2025, revealed the resident has short-term and long-term memory deficits, and was severely impaired in cognitive skills for daily decision making. Further review revealed Resident #10 required set-up/clean-up assistance for eating.During an observation on 3/17/2026 at 12:20 PM lunch meal and 3/18/2026 at 8:10 AM breakfast meal, revealed Resident #10 sitting at a table in the dining room being fed by a staff member, and did not have a dycem mat under the tray or a plate guard. During an observation and interview on 3/18/2026 at 12:25 PM lunch meal, the Director of Nursing (DON) confirmed Resident #10 was in the dining room with the lunch tray on the table in front of her [Resident #10] and did not have a dycem mat under the tray or a plate guard. During an interview on 3/18/2026 at 12:30 PM, the DON confirmed Resident #10 had a Physician's Order for the dining adaptive devices of a dycem mat under the tray and a plate guard, and confirmed the adaptive devices were not listed on the kitchen's meal tray card and the specific type of adaptive devices ordered were not on the comprehensive care plan.

Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 4 residents (Resident #6, #19, #21, and #44) of 4 residents reviewed for hospice services. The findings include: Review of the facility's hospice contract titled, Hospice Services Agreement, dated 7/19/2021, revealed .Hospice Plan of Care .written care plan .reviewed at intervals by the Interdisciplinary Group .Hospice shall furnish facility with copy of .Plan of Care . Review of the facility's policy titled, Hospice Coordination of Care, for Resident dated 9/6/2024, revealed .provides hospice .resident's written plan of care includes the most recent hospice plan of care .obtain the following information from .hospice .most recent plan of care to each resident . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Heart Failure. Review of a Physician's Order for Resident #6 dated 6/17/2024, revealed .Hospice Consult to evaluate and treat. Review of the comprehensive care plan dated 6/17/2024, revealed Resident #6 had a .terminal prognosis . Review of the hospice communication binder (located at the nurses' station), revealed the hospice plan of care for Resident #6 revealed .Certification date .6/19/2024 to 9/16/2024 . Continued review revealed no further documentation of a new or revised care plan after 9/16/2024 for the new certification period. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident received hospice services. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, and Depression. Review of a Physician's Order for Resident #19 dated 5/4/2023, revealed .Hospice to eval and treat . Review of the comprehensive care plan dated 5/4/2023, revealed Resident #19 had a .terminal prognosis .end stage COPD .currently receiving hospice care . Review of the hospice communication binder (located at the nurses' station), revealed the hospice plan of care for Resident #19 revealed .Certification date .10/16/2023 to 12/14/2023 . Continued review revealed no documentation of a new or revised care plan after 12/14/2023. Review of a quarterly MDS assessment dated [DATE], revealed Resident #19 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had received hospice services. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Respiratory Failure, Heart Failure, and Dementia. Review of a Physician's Order for Resident #21 dated 6/16/2023, revealed .Hospice services to eval and treat. Review of a quarterly MDS assessment dated [DATE], revealed Resident #21 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had received hospice services. Review of a comprehensive care plan dated 10/9/2024, revealed Resident #21 had a .terminal prognosis .Hospice (initiated) 6/16/2023 . Review of the hospice communication binder (located at the nurses' station), revealed the hospice plan of care for Resident #21 revealed .Certification date .6/16/2023 to 9/12/2023 . Continued review revealed no documentation of a new or revised care plan after 9/12/2023. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Depression, and Dementia. Review of a Physician's Order for Resident #44 dated 7/5/2023, revealed .Hospice to eval and treat . Review of the comprehensive care plan dated 7/5/2023, revealed Resident #44 had a .terminal prognosis . Review of the hospice communication binder (located at the nurses' station), revealed the hospice plan of care for Resident #44 revealed .Certification Date .7/5/2023 to 10/2/2023 . Continued review revealed no documentation of a new or revised care plan after 10/2/2023. Review of a quarterly MDS assessment dated [DATE], revealed Resident #44 scored a 99 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident received hospice services. During an interview on 12/4/2024 at 10:30 AM, the Social Services Director (SSD) stated she was the hospice coordinator for the facility. The SSD stated there were hospice plan of care binders located at each nurse station for each resident that received hospice services. The SSD confirmed the hospice plan of care had not been updated for Residents #6, #19, #21, and #44. During an interview on 12/4/2024 at 2:24 PM, the Administrator confirmed Resident #6, #19, #21, and #44 hospice plan of care had not been updated in the medical record or in the communication binders located at the nurses' station.

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) (PASRR) timely after a new mental health diagnosis for 1 resident (Resident #14) of 7 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR) [PASRR], revised on 10/6/2022 and reviewed on 9/26/2024, revealed .A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program .Coordination includes .Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment .A nursing facility must notify the state mental health authority or state intellectual disability authority .promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review .Referral for Level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change .Examples of such changes include, but are not limited to .A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms . Review of a maximus Notice of PASRR Level I Screen Outcome for Resident #14 dated 12/7/2018, revealed .PASRR Level II Onsite Evaluation Required .DIAGNOSIS .Anxiety Disorder .Depression - mild or situational .Does the individual have a diagnosis of dementia/neurocognitive disorder .Yes .MAXIMUS OUTCOME .Refer for Level II - Level I Positive .Based on the information received, due to a (suspected or confirmed) Level II diagnosis of serious mental illness an onsite Level II will be initiated . Review of the maximus PASRR Notice of Exclusion from PASRR - Primary Neurocognitive Disorder dated 12/20/2018, revealed Your Pre-Admission Screening Resident Review (PASRR) is complete .Your neurocognitive disorder (dementia) is thought to be the primary condition needing care at the time of this review .After you admit to the nursing facility, your PASRR Level II evaluation remains good during your stay .If you have certain kinds of changes in your physical or mental health, you may need a new Level II evaluation. The nursing facility must submit a new Level I screening to Maximus to see if a new PASRR evaluation is needed .A Resident Review (RR) is the same screening for someone in a nursing facility. The nursing facility must do a RR when .A resident's condition changes .Summary of Findings Report .You were 'Ruled out' from further assessments through the PASRR Program .Dementia will likely be the primary focus of behavioral health treatment .diagnosis of mixed Dementia of the Vascular and Alzheimer's type .additional diagnosis of Depressive Disorder .diagnoses do not qualify as PASRR defined disabilities . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Major Depressive Disorder, Primary Insomnia, Generalized Anxiety, and Dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed active diagnoses included Non-Alzheimer's Dementia, Anxiety, and Depression. Review of the medical record revealed Resident #14 received a new diagnosis of Unspecified Mood [Affective] Disorder on 7/8/2022. Review of a quarterly MDS assessment dated [DATE], revealed active diagnoses included Non-Alzheimer's Dementia, Anxiety, Depression, and Unspecified Mood [Affective] Disorder. Review of the medical record revealed Resident #14 received a new diagnosis of Unspecified Psychosis on 11/7/2022. Review of a quarterly MDS assessment dated [DATE], revealed active diagnoses included Non-Alzheimer's Dementia, Anxiety, Depression, Psychotic Disorder, and Unspecified Mood [Affective] Disorder. Review of the medical record revealed Resident #14 received a new diagnosis of Schizoaffective Disorder on 1/9/2023. Review of a MAXIMUS Notice of PASRR Level I Screen Outcome for Resident #14 dated 2/5/2023, revealed .PASRR Request Has Been Cancelled .Your Level I screen has been cancelled by Maximus. The screen was cancelled because your health care professional did not complete either the Level I screening form and/or submit requested information within the required timeframe . Review of a quarterly MDS assessment dated [DATE], revealed active diagnoses included Non-Alzheimer's Dementia, Anxiety, Depression, Psychotic Disorder, Schizophrenia (Schizoaffective and Schizophreniform), and Unspecified Mood [Affective] Disorder. Review of the comprehensive care plan dated 3/30/2023, revealed Resident #14 was care planned for Major Depressive Disorder, Generalized Anxiety Disorder, Schizoaffective Disorder, Psychosis, and Mood Disorder. During an interview on 12/3/2024 at 4:20 PM, the Admissions Director and the Social Services Director stated they were responsible for PASRRs at the facility. The Admissions Director had been responsible for PASRRs for the last [AGE] years at the facility. Resident #14's PASRR dated 12/7/2018 included the diagnoses of Anxiety, Depression, and Dementia. The Admissions Director stated he resubmitted a PASRR for Resident #14 on 1/19/2023 because the resident had .new mental health diagnoses . The Admissions Director stated he uploaded supporting documentation into the ASCEND/Maximus system on 1/20/2024 and 1/24/2024 related to the new diagnoses. The Admissions Director stated Maximus cancelled the PASRR on 2/5/2023 and a unknown representative from Maximus called him at the facility on a unknown date stating if a resident already had a Level II PASRR resubmissions were never required. This surveyor reviewed the Maximus Notice of PASRR Level I Screen Outcome dated 2/5/2023 with the Admissions Director which stated the Level I screen had been cancelled due to the health care professional not completing the Level I screening form or requested information within the required timeframe. The Admissions Director stated he was unaware why the document stated he had nt submitted the requested information. During a telephone interview on 12/3/2024 at 3:54 PM, the Maximus Help Desk Representative stated the facility submitted a Level I PASRR on 1/19/2023. On 1/20/2023, a request was made by Maximus for the facility to complete the LOC (Level of Care) documentation related to the submission. The PASRR submission was cancelled on 2/5/2023 due to the facility's noncompliance with Maximus's request to complete the LOC (Level of Care) within 10 days. The Maximus Help Desk Representative stated a new Level I PASRR should be submitted anytime there is a new psychiatric diagnosis regardless of previous PASRR exclusion related to dementia/primary neurocognitive disorder. The diagnosis of dementia/neurocognitive disorder would likely make the resident exempt but a new Level I PASARR should be submitted anytime there is a new psychiatric diagnosis added.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 2 of 3 dumpsters (dumpsters A and B). The findings include: Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 9/8/2022, revealed .all waste is properly contained in the dumpsters .and are covered appropriately .all areas where garbage/refuse is located is kept clean . During an observation of the outside dumpster area on 12/2/2024 at 10:40 AM, with the Certified Dietary Manager (CDM), revealed 3 dumpsters for waste disposal. Further observation revealed dumpsters A and B had no drain plugs intact, which left a golf-ball sized opening to the bottom corner of the dumpsters. The missing dumpster plug from dumpster A and B resulted in the dumpsters' contents being left open to the elements and the potential exposure to pests. During an interview on 12/2/2024 at 10:55 AM, the CDM confirmed the drain plugs for dumpsters A and B were not intact and the dumpsters' contents were not contained properly.

Based on facility policy review, medical record review, and interview, the facility failed to ensure an assessment for potential contraindications to influenza vaccines were documented in the medical record for 4 residents (Resident #8, #12, #16, and #28) of 5 residents reviewed for immunizations. The findings include: Review of the facility's policy titled, Influenza Vaccine Policy for Residents, dated 9/24/2024, revealed .Medical contraindication refers to a condition or risk that precludes the administration of a treatment or intervention because of the substantial probability that harm to the individual may occur .Procedure .The resident is assessed for possible contraindications .assessment findings .are documented in the resident's medical record . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Diabetes, and Dementia. Review of the medical record revealed Resident #8 consented to the administration of the Influenza vaccine on 10/8/2024 and received the vaccine on 10/18/2024. The medical record did not contain an assessment for potential contraindications. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, and Functional Quadriplegia. Review of the medical record revealed Resident #12 consented to the administration of the Influenza vaccine on 10/8/2024 and received the vaccine on 10/18/2024. The medical record did not contain an assessment for potential contraindications. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease. Review of the medical record revealed Resident #16 consented to the administration of the Influenza vaccine on 9/10/2024 and received the vaccine on 10/18/2024. The medical record did not contain an assessment for potential contraindications. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dysphagia, Diabetes, and Dementia. Review of the medical record revealed Resident #28 consented to the administration of the Influenza vaccine on 10/8/2024 and received the vaccine on 10/18/2024. The medical record did not contain an assessment for potential contraindications. During an interview on 12/4/2024 at 7:32 AM, the Director of Nursing (DON) stated residents were assessed for contraindications at the time of vaccination administration. Residents were assessed with vital signs and observed for signs and symptoms of acute illness, and the medical record was reviewed for last vaccination date and allergies. The resident was also assessed for past reaction to vaccine, immunization in past 14 days, allergy to eggs, past Guillain-Barre syndrome (a condition in which the immune system attacks the nervous system). The DON confirmed residents were screened for eligibility to receive the vaccine including possible medical contraindications but the assessment was not documented in the medical record. The DON further stated the facility's residents had not had any vaccine administration reactions. During an interview on 12/4/2024 at 10:00 AM, the Infection Preventionist (IP) stated she was responsible for obtaining consent, providing education, and administering vaccinations. The IP stated she checked the residents for eligibility and contraindications of receiving the vaccine at the time of administration. Contraindications to receiving influenza vaccine would include an allergy to anything in the vaccine, previous reaction to the vaccine, any medications that interfere with the vaccine, history of Guillain-Barre syndrome, and allergy to eggs. Residents were also assessed for acute illness including cold symptoms. The IP confirmed the assessment for eligibility and contraindications to the vaccine were not documented in the resident's medical record. The IP confirmed the assessment for possible contraindications to the influenza vaccine was to be documented in the resident's medical record according to the facility's policy. The IP stated no residents had experience any vaccine reactions.

Based on facility policy review, observation, and interview, the facility failed to offer hand hygiene assistance to residents prior to meals for 3 residents (Residents #8, #23, and #16) of 3 residents observed on 2 of 4 hallways observed for meal tray distribution. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program (IPCP) and Plan, revised on 6/13/2024, revealed .The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections .residents should be advised of the IPCP's standards, policies and procedures regarding hand hygiene before eating . Review of the facility's policy titled, Feeding a Resident, reviewed on 9/10/2024, revealed .The facility will ensure that .A resident who is unable to carry out activities of daily living receives the necessary services .Assist resident with .hand hygiene prior to meals . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Type 2 Diabetes Mellitus, Dementia, Muscle Weakness, and Arthritis. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #8 required setup or clean-up assistance for eating and was dependent on staff for personal hygiene. Review of the comprehensive care plan for Resident #8 dated 10/17/2024, revealed .ADL [activities of daily living] self-care performance deficit r/t [related to] impaired mobility and dementia .EATING: The resident requires set-up/clean-up assistance .requires substantial/max assistance with personal hygiene . During an observation on 12/2/2024 at 12:16 PM, Licensed Practical Nurse (LPN) B delivered the lunch meal tray to Resident #8. LPN B set up the meal for the resident and exited the room without offering hand hygiene assistance to the resident. During an interview on 12/2/2024 at 12:18 PM, LPN B confirmed she had not offered hand hygiene assistance to the resident. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Multiple Fractures of Left Side Ribs, Displaced Fracture of Seventh Cervical Vertebra, Fracture of Left Pubis, Muscle Weakness, Adult Failure to Thrive, and Altered Mental Status. Review of an admission MDS assessment dated [DATE], revealed Resident #23 scored a 00 on the BIMS assessment which indicated the resident was severely cognitively impaired. Resident #23 was dependent on staff for eating and personal hygiene. Review of the comprehensive care plan dated 11/5/2024 for Resident #23 revealed .ADL self-care performance deficit r/t Activity Intolerance. Numerous compression fractures .EATING .requires set-up/clean-up assistance. Feeding assistance at times .PERSONAL HYGIENE .dependent on staff for personal hygiene . During an observation on 12/2/2024 at 12:22 PM, LPN C delivered the lunch meal tray to Resident #23. LPN C pulled the resident up in bed and set up the lunch tray and exited the room without offering hand hygiene assistance to the resident. During an interview on 12/2/2024 at 12:24 PM, LPN C confirmed she had not offered hand hygiene to Resident #23. LPN C confirmed hand hygiene assistance was to be offered to residents with either hand sanitizer or a wet washcloth prior to the meal. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depression, History of Falling, Muscle Spasm, and Muscle Weakness. Review of an admission MDS assessment dated [DATE], revealed Resident #16 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Resident #16 required setup or clean-up assistance for eating and was dependent on staff for personal hygiene. Review of the comprehensive care plan for Resident #16 dated 10/8/2024, revealed .ADL self-care performance deficit r/t Activity Intolerance .PERSONAL HYGIENE .dependent on staff . During an observation on 12/2/2024 at 12:30 PM, Certified Nursing Assistant (CNA) D delivered the lunch meal to Resident #16. CNA D assisted the resident to set up the lunch tray and exited the room without offering hand hygiene assistance to the resident. During an interview on 12/2/2024 at 12:32 PM, CNA D stated .sometimes I get a rag and wash them [resident's hands] before they eat . The CNA confirmed she had not offered hand hygiene assistance to Resident #16 prior to the lunch meal. During an interview on 12/2/2024 at 12:48 PM, the Director of Nursing (DON) confirmed staff were to offer hand hygiene assistance to all residents prior to meals.

Based on facility policy review, observation, and interview, the facility failed to protect the resident's right to dignity when an indwelling catheter drainage bag was left uncovered and visible to the public for 1 resident (Resident #23) of 78 residents observed for dignity. The findings include: Review of the facility's policy titled, Dignity, dated 5/6/2019, revealed .All residents will be treated with dignity and respect. Examples of treating residents with dignity and respect include .Refraining from practices demeaning to residents, such as leaving urinary catheter bags uncovered . Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with a diagnosis including Disorder of Kidney and Ureter. Review of a comprehensive care plan for Resident #23 dated 11/5/2024, revealed .resident has an Indwelling Catheter r/t [related to] obstruction . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 scored 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had an indwelling urinary catheter. During an observation on 12/2/2024 at 4:07 PM, revealed Resident #23 had no privacy dignity cover present to the bedside urinary drainage bag and the uncovered drainage bag was visible to the outside of the resident's room, into the hallway. During an observation and interview on 12/2/2024 at 4:25 PM, Licensed Practical Nurse (LPN) E confirmed Resident #23 did not have a privacy dignity cover present to the urinary bedside drainage bag which resulted in the direct visibility of the urinary drainage bag from the hallway. During an interview on 12/2/2024 at 4:27 PM, the Director of Nursing confirmed all urinary bedside drainage bags were expected to be covered with a privacy dignity cover.

Based on facility policy review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use in 1 of 4 medication carts observed for medication storage which had the potential to affect 1 resident (Resident #48) of 19 residents reviewed for insulin use. The findings include: Review of the facility's policy titled, Delivery & Storage of Medications and Supplies, revised [DATE], revealed .to be performed by licensed nurses .expiration dates will be checked . Review of the facility's policy titled, Guidance for Using Insulin Products, dated 2023, revealed .before using, insulin should be checked .storage recommendations for injectable diabetes medications .insulin lispro [Humalog] [an injectable medication used to lower blood sugar levels] .discard after .28 days . During an observation and interview on [DATE] at 8:05 AM, with Licensed Practical Nurse (LPN) A, revealed the medication cart for [NAME] hall had one injectable medication (insulin lispro) for Resident #48 stored in the top drawer and labeled as .opened [DATE] .exp [expiration date] [DATE] . LPN A confirmed the insulin lispro for Resident #48 was stored past the expiration date ([DATE]) and was available for resident use. LPN A stated this insulin cartridge dated [DATE] was the only insulin cartridge in the medication cart for Resident #48 and confirmed the resident had received the expired insulin during medication administration. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Diabetes, Morbid Obesity, and Heart Failure. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident received insulin. Review of the comprehensive care plan for Resident #48 revised [DATE], revealed the resident had an active problem of Diabetes with interventions to check blood sugars as ordered, administer medications as ordered, and monitor for symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Review of an Order Summary Report for Resident #48 dated ,d+[DATE], revealed Humalog 5 units daily and to check blood sugars before meals and at bedtime. Review of the Medication Administration Record for Resident #48 dated ,d+[DATE], revealed Humalog insulin (5 units daily) was administered 18 of 18 days past the expiration date ([DATE]-[DATE]). Further review revealed the blood sugar checks obtained from [DATE]-[DATE] ranged from ,d+[DATE] (baseline for the resident) and did not reveal any negative outcomes. Review of the Medication Administration Record for Resident #48 dated ,d+[DATE], revealed the expired Humalog insulin (5 units daily) was administered 3 of 3 days ([DATE]-[DATE]). Further review revealed the blood sugar checks obtained from [DATE]-[DATE] ranged from ,d+[DATE] and did not reveal any negative outcomes. During an interview on [DATE] at 9:18 AM, the Director of Nursing (DON) stated licensed nurses should check insulin expiration dates prior to administering the medication and discard the medication if the medication was past the expiration date. The DON confirmed the Humalog insulin dated [DATE] for Resident #48 should have been discarded and not used for insulin administration. During an interview on [DATE] at 8:10 AM, the Pharmacist stated insulin lispro (Humalog) should be discarded 28 days after opening. The Pharmacist further stated administering the insulin past the expiration date could result in the insulin medication having less effectiveness in controlling blood sugar levels. The Pharmacist stated the duration Resident #48 had received the expired insulin, would not have resulted in any decline or harm. During an interview on [DATE] at 4:20 PM, the Medical Director (MD) stated the Humalog for Resident #48 opened on [DATE] should have been discarded 28 days after opening ([DATE]). The MD stated there would be a minimum risk .if any . to using insulin past the expiration date and Resident #48 experienced no negative outcome from the facility's deficient practice of administering expired insulin.

Based on facility policy review, observation, and interview, the facility failed to ensure the kitchen equipment was maintained in a sanitary condition and failed to ensure a dented can was discarded, which had the potential to affect 78 of 78 residents. The findings include: Review of the facility's policy titled, Sanitation and Maintenance, dated 4/26/2023, revealed .cleaning fixed equipment .cleaned with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution . During an observation of the dry storage area and interview on 12/2/2024 at 9:55 AM, with the Certified Dietary Manager (CDM), revealed one 6.88 pound can of dark red kidney beans dented on one side and was available for resident use. The CDM stated the kitchen staff checked for dented cans every week and if dented cans were observed they were to be discarded. The CDM confirmed the dented can of dark red kidney beans was missed during the weekly check and should have been discarded. During an observation of the cooking area and interview on 12/2/2024 at 10:05 AM, with the CDM, revealed the deep fryer had dried brownish-yellow food debris with a grease-like residue present to the right side (from the top perimeter to the bottom edge) of the fryer. The CDM stated the deep fryer was last used on Saturday (11/30/2024) and was cleaned after use. The CDM confirmed the deep fryer needed deep cleaned to eliminate all the grease-like, brownish-yellow food debris present to the right side of the fryer.

Based on facility policy review, medical record review, facility investigation review, hospital record review, and interview, the facility failed to prevent a fall for 1 resident (Resident #8) of 5 residents reviewed for falls. The facility's failure resulted in actual HARM to Resident #8 when the resident was receiving care by facility staff and allowed to fall to the floor from the bed, resulting in injury. The findings include: Review of the facility policy titled, Area of Focus: Fall Management, reviewed 12/4/2023, revealed .To promote patient safety and reduce patient falls .the facility must ensure that .each resident receives adequate supervision .to prevent falls . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side, Diabetes, Long Term use of Anticoagulants, and Functional Quadriplegia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review revealed the resident was dependent on staff for toileting, bathing, and upper and lower body dressing. Review of the comprehensive care plan dated 12/16/2023, revealed Resident #8 was dependent on staff for toileting and required 2 staff assistance with transfers. Review of a Nursing Progress Note for Resident #8 dated 4/3/2024 at 11:15 AM, revealed .Nursing staff called to room .for a resident fall. Resident was in bed being changed [provided incontinence care] by 2 CNA's [certified nursing assistants] and when rolled [to] her side towards one CNA, resident was not able to be supported and rolled out of bed onto the floor .resident on floor face down .EMS [emergency medical services] called .resident complaining of pain .resident is yelling and crying, wanting us to roll her over .complaints of neck and head hurting .also c/o [complaints of] Rt [right] arm/ shoulder and index finger hurting. Small bump and bruising noted to right forehead .EMS arrived Neck stabilized .transport to ER [emergency room ] . Review of ER documentation for Resident #8 dated 4/3/2024, revealed XXX[AGE] year old .here for a fall .patient rolled out of bed at nursing home and landed on the floor .patient tells me she did hit her head but did not pass out .primary complaint of right index finger .patient notes pain to the right knee as well .Physical Exam .Right forehead purple ecchymosis [discoloration of the skin resulting from bleeding underneath] .right knee pain with palpation without effusion or swelling .x ray fingers .no acute fracture .x ray knee .no acute fractures .CT [computed tomography] scan of head and neck unremarkable . Review of the facility investigation documentation dated 4/3/2024, revealed Resident #8 stated, .[CNA A] let me fall in the floor on my face . Review of a facility Corrective Action Form for CNA A dated 4/3/2024, revealed .On 4/3/2024, associate provided unsatisfactory/ careless work while completing ADL [activities of daily living] care with a resident [Resident #8] while in bed. Associate did not provide proper body mechanics to meet the needs of the resident safety . Review of a weekly skin assessment for Resident #8 dated 4/8/2024, revealed .Face .L [left] eye purple bruising, L forehead fading yellow bruising (both from recent fall) . Review of a follow up Nursing Progress Note for Resident #8 dated 4/12/2024, revealed .on day of event [4/3/2024] resident returned from the ED [emergency department] .X-ray and CT scans were negative .small bruise to forehead above her left eye and also small reddened raised area to the middle of her forehead .on day after event, 4/4/2024, resident was switched to a bariatric bed . Review of a weekly skin assessment for Resident #8 dated 4/15/2024, revealed .Face .L eye purple bruising, forehead fading yellow bruising (both from recent fall) . Review of a Nurse Practitioner visit note for Resident #8 dated 4/16/2024, revealed .patient reports falling out of bed while being repositioned by staff with residual right upper extremity soreness/ weakness. X-ray of right upper extremity negative .patient reports working with occupational therapy to build strength . During an interview on 8/27/2024 at 1:13 PM, CNA A stated during Resident #8's fall on 4/3/2024 .I couldn't hold her [Resident #8] after CNA B pushed her [Resident #8] toward me, wasn't able to catch her leg in time and she [Resident #8] went through my legs . Continued interview revealed the facility implemented a corrective action plan including an assessment CNA A completed for competency and strength after Resident #8's fall. The CNA was given the option of being a hospitality Aide due to the results of the assessment. Further interview revealed CNA was transitioned to a Hospitality Aide following Resident #8's fall from bed on 4/3/2024. During an interview on 8/27/2024 at 6:49 PM, CNA B stated during Resident #8's fall on 4/3/2024 .[name of CNA A] was closest to the window and when I rolled her [Resident #8] toward [CNA A] she couldn't hold her and the resident [Resident #8] fell .after the fall they [facility leadership] moved her [CNA A] to Hospitality Aide . During an interview on 8/28/2024 at 8:54 AM, Resident #8 stated she remembered the fall, where she had injury/ bruising across her face, .and black under my eyes .I landed on my face . Continued interview revealed the resident stated CNA A let her fall, but she does feel safe with the facility staff for her transfer and toileting needs now. During an interview and facility documentation review on 8/28/2024 at 9:32 AM, the Administrator confirmed Resident #8 received an injury during the 4/3/2024 fall and confirmed CNA A received corrective action for not meeting the needs of resident safety during ADL care.

Based on facility policy review, facility documentation review, medical record review, and interview the facility failed to ensure 1 resident (Resident #9) was free from physical abuse after Resident #2 struck Resident #9 in the face, of 11 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse Prevention, dated 10/4/2022, revealed .It is the policy of this facility to prevent and prohibit all types of abuse .Identify, correct and intervene in situations in which abuse .is more likely to occur . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Aphasia, ,Diabetes, Congestive Heart Failure, Delusional Disorder, and Major Depressive Disorder with Severe Psychotic Features. The resident was discharged from the facility on 7/31/2024. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #9 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had mild cognitive impairment, required assistance of 1-2 staff members for bed mobility, transfers, toileting, and activities of daily living (ADL). Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnosis including Rheumatoid Arthritis, Dementia, Cognitive Communication Deficit, and History of Falling. Review of a quarterly MDS assessment dated [DATE], revealed Resident #2 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment, required assistance of 1-2 staff members for bed mobility, transfers, toileting, and ADL care. Resident was frequently incontinent of bladder. Review of the facility investigation documentation of resident-to-resident contact between Resident #9 and Resident #2 dated 2/13/2024 at 4:00 PM, revealed a Certified Nursing Assistant (CNA) was notified by Resident #9 that Resident #2 had struck him in the face, Resident #2 was not present in the room at the time. Licensed Practical Nurse (LPN) C responded and assessed Resident #9 who was found to have a reddened area to his cheek which quickly faded to a normal skin tone. LPN C ensured both residents were separated and safe. LPN C conducted interviews with both residents and found during the interview with Resident #9 that both were seated in their wheelchairs beside the bed when the contact took place. Resident #9 told LPN C that he reached for the call light on the bed and was struck by Resident #2 in the face. LPN C interviewed Resident #2, where he admitted striking Resident #9. Resident #9 was moved to another hallway and Resident #2 was placed on 1:1(1 staff to 1 resident) monitoring. Review of the nurses progress note for Resident #9 dated 2/13/2024 at 4:33 PM, revealed .This nurse notified that the resident was involved in a physical altercation between himself and his roommate [Resident #2] . The progress note revealed Resident #9 reported Resident #2 had struck him in the jaw. Review of the Psychosocial Progress Note for Resident #2 dated 2/14/2024 at 2:20 PM, revealed .SSD [Social Services Director] spoke with resident in the rehab [rehabilitation] gym .Resident appeared happy .stated he was missing his wife . Nothing was voiced by the resident about the altercation. Review of the Psychiatric Progress Note for Resident #2 dated 2/21/2024 showed .I am seeing this patient today for aggressive behaviors toward other residents, Depression, Anxiety. Depakote [medication to aid with behaviors .recently increased to 250 mg [milligram] by PCP [primary care physician] due to getting into a physical altercation with resident's roommate [Resident #9] .roommate has been moved to another room .[Resident #2] is doing well . No further behaviors were reported by staff. During an observation and interview on 8/27/2024 at 10:13 AM, LPN C stated she provided care to Resident #2 routinely. LPN C stated she responded to the residents' room (Resident #2 and Resident #9) and noted Resident #2 was already out of the room. LPN C stated she interviewed each resident post incident and stated this was an isolated incident and neither resident had issues previously, neither resident experienced any residual effects as a result of the prior altercation and no injuries were noted to either resident. LPN C stated there was slight redness to Resident #9's cheek which faded within moments. During an interview on 8/28/2024 at 11:10 AM, the Director of Nursing confirmed physical contact was made when Resident #2 struck Resident #9 in the face on 2/13/2024.

Based on facility policy review, medical record review, facility investigation review, personnel file review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $119.49 was taken from 1 resident (Resident #7) of 11 sampled residents reviewed for misappropriation. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised on 7/18/2023, revealed .It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property .Misappropriation of resident property is the deliberate misplacement, exploitation .use of a resident's property or money without the resident's consent . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Morbid Obesity, Acute and Chronic Respiratory Failure, Anxiety, and Quadriplegia. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility investigation documentation dated 9/5/2023, revealed Resident #7 informed the Assistant Business Office Manager (ABOM) she would not have the funds to pay her bill because someone used her debit card to purchase food at a local restaurant without the resident's permission. The ABOM instructed Resident #7 to call her bank and dispute the charges. The ABOM received a call from the resident's bank stating a police report needed to be filed to dispute the charges. The ABOM notified the facility Administrator of the alleged misappropriation. The facility started an investigation. During the facility investigation Hospitality Aide D was suspended on 9/6/2023 pending the investigation after the Hospitality Aide was identified as a possible suspect. Continued review revealed the facility substantiated the abuse and terminated Hospitality Aide D on 9/21/2023 for violation of the code of conduct. Review of a Cardholder Statement of Disputed Items dated 9/5/2023 and signed by Resident #7 on 9/6/2023 revealed the amount of $119.49 was disputed for the following reason: My Card was stolen. Review of the personnel file for Hospitality Aide D revealed the facility terminated Hospitality Aide D on 9/21/2023 for alleged violation of code of conduct. During an interview on 8/27/2024 at 9:33 AM, Resident #7 confirmed her debit card was taken by the facility Hospitality Aide without her permission with $119.49 stolen. Continued interview revealed the resident bank did reimburse her for the $119.49 after she disputed the charges. During an interview on 8/27/2024 at 9:57 AM, the Administrator confirmed the facility substantiated the allegation of misappropriation on Resident #7. The Administrator stated the $119.49 was reimbursed to Resident #7 by the resident's bank. The Administrator further confirmed the facility employed Hospitality Aide was responsible for the misappropriation of Resident #7's property.

Based on facility policy review, facility documentation review, and interview, the facility failed to report to the state agency an allegation of a threat which had the potential for abuse and create and unsafe environement for 71 residents of hte facility. The findings include: Review of the facility policy titled, Incident and Reportable Event Management, reviewed 9/14/2023, showed .the facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents .Reporting of Alleged Violations .ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported .to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services .in accordance with State law through established procedures . Review of facility witness statements conducted on 12/18/2023 showed, on 12/18/2023 resident family member became agitated at the call light system while standing at nurse's station and stated he was going to shoot the call light system next time he comes to facility. During an interview and review of facility documentation with the Administrator on 12/21/2023 at 10:15 AM, in the Administrator office, showed the facility put measures in place after the threat of using a fire arm, including notification of the local place department and notification of the state ombudsman office. Continued interview showed the administrator denied reporting of the event to other state entities and stated, if he had threatened a person I would have reported .I didn't think it was reportable since it was not a person but a call light system.

Based on review of a facility policy, medical record review, and interview the facility failed to follow physician orders and the comprehensive care plan for medication administration for 9 (#1, #3, #4, #11, #12, #13, #14, #15, #16) of 9 residents residing on the secure unit of 76 residents in the facility. The findings included: Review of the facility policy Administration of Medications revised on 5/6/2022 showed .The facility will ensure medications are administered safely and appropriately per physician order . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's comprehensive care plan dated 11/23/2020 showed .resident has hypertension .Give anti-hypertensive medications as ordered .At risk for complications related to dx [diagnosis] of Diabetes Mellitus .Blood Sugar checks as ordered .Medication as ordered . Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's comprehensive care plan dated 8/10/2021 showed .Resident has had behavior problems r/t [related to] refusing medication, cursing, and yelling at staff, spitting, and attempting to scratch staff, refusing to participate and some days constantly yelling out loud none [non] stop even though she does not need anything .administer medications as ordered .Diabetes Mellitus .Blood sugar checks as ordered, Medications as ordered . The care plan was revised on 11/19/2021 and showed .The resident is on scheduled narcotic pain medication therapy .Administer Analgesic medications as ordered by physician . Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 3, indicating severe cognitive impairment. Review of Resident #3's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's comprehensive care plan revised 5/12/2022 showed .Inadequate intake r/t [related to] poor PO [by mouth] intake aeb [as evidenced by] meeting ½ of EEN [estimated energy needs] to avoid unintended weight loss .Regular diet, puree texture, thin consistency, Supplements 2.0 med pass at 60 ml TID [three times daily], house shakes BID [twice daily], ProSource 30 ml BID . Review of Resident #4's quarterly MDS dated [DATE] showed a BIMS score of 7, indicating severe cognitive impairment. Review of Resident #4's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's comprehensive care plan dated 3/23/2021 showed .Resident has a history of behavior problem r/t verbally making inappropriate comments to staff .Resident has had repeated episodes of sharing food with another resident .Administer medications as ordered .Resident has impaired cognitive ability .Administer medications as ordered .Resident at risk for change in mood or behavior .Medications as ordered . Review of Resident #11's annual MDS dated [DATE] showed a BIMS score of 12, indicating moderate cognitive impairment. Review of Resident 11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's comprehensive care plan dated 3/7/2021 showed .resident has impaired cognitive ability impaired thought processes r/t dementia .Administer medications as ordered . The care plan was revised on 5/3/2022 and showed .Resident has a behavior history of bringing his urinal to his mouth but was stopped by a nurse .Administer Medications as ordered . The care plan was revised on 6/23/2022 and showed .resident has a [CONDITION(S)] disorder r/t head injury .Give [CONDITION(S)] medication as ordered by doctor . Review of Resident #12's quarterly MDS dated [DATE] showed a BIMS score of 14, indicating the resident was cognitively intact. Review of Resident 12's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's comprehensive care plan dated 9/17/2020 showed .at risk for change in mood or behavior due to medical condition .Medications as ordered . The care plan was revised on 9/29/2020 and showed .has a risk for behavior problems related to dx [diagnosis] of dementia with behavioral disturbances, has behavior of wandering aimlessly and searching for husband, has increased behavior problems that includes yelling towards staff, crying and wandering .Administer medications as ordered . The care plan was revised on 10/2/2020 and showed .resident uses [CONDITION(S)] medications r/t behavior management .Administer [CONDITION(S)] medications as ordered by physician .resident has a [CONDITION(S)] disorder . Review of Resident #13's quarterly MDS dated [DATE] showed a BIMS score of 3, indicating severe cognitive impairment. Review of Resident 13's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's comprehensive care plan dated 11/14/2017 showed .resident has a behavior problem including resident is mentally challenged and has outbursts of yelling out when his routine is disrupted .obsession and fearful of weather conditions, especially cold or snow. Loud outbursts, crying, screaming, fearful of balloons .Administer medications as ordered .Resident resides in secure unit due to behaviors of yelling out and disrupting others .episodes of thinking he has cuts on his arms with active bleeding, calms down after band aid or bandage is applied .is at risk for complications associated with hyper [elevated] or [CONDITION(S)] [low blood sugar] . Dx. DM [Diabetes Mellitus] .Blood sugar checks as ordered . Review of Resident #14's annual MDS dated [DATE] showed a BIMS score of 15, indicating the resident was cognitively intact. Review of Resident 14's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's comprehensive care plan dated 9/7/2021 and revised on 9/27/2021 showed .resident is on scheduled narcotic pain medication therapy r/t [CONDITION(S)] and wound .Administer Analgesic medication as ordered by physician . The care plan was revised on 3/19/2022 and showed .resident uses antidepressant medication .Administer Antidepressant medications as ordered by physician . The care plan was revised on 5/11/2022 and showed .significant weight loss in 30/90/180 days .Fortified shake daily .2.0 Med Pass 60 ml TID [three times daily] . Review of Resident #15's quarterly MDS dated [DATE] showed a BIMS score of 13, indicating the resident was cognitively intact. Review of Resident 15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. Resident # 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's comprehensive care plan dated 4/22/2022 and revised 5/5/2022 showed .resident has hypertension r/t CHF [Congestive Heart Failure] .administer medications as ordered . Review of Resident #16's admission MDS dated [DATE] showed a BIMS score of 8, indicating moderate cognitive impairment. Review of Resident 16's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review revealed the medications were not signed as administered on 5/10/2022 at 8:00 PM. During an interview with Licensed Practical Nurse (LPN) #3 on 6/27/2022 at 8:10 AM, she stated, .I worked the night shift on the 10th, I went into to PPC [Point Click Care/EMR [electronic medical record] and all the spots on the MAR for the 8:00 PM med pass were red . Indicating the medications had not been administered. During an interview with LPN #2 on 6/27/2022 at 9:30 AM, she stated .I worked the day after the residents' 8:00 PM medication pass was missed .I was told the whole process of what had occurred when I came in at 6:00 AM, from the nurse who came in at 10:00 PM, she said everything was pink indicating it was late . During an interview with the Director of Nursing (DON) on 6/27/2022 at 2:45 PM, she stated .I was made aware of the missed medications around 10:30 PM on 5/10/2022. The oncoming nurse who worked 10:00 PM to 6:00 AM went into PCC and saw all the 8:00 PM medications were red indicating it had not been signed off as administered .I spoke with .[RN #2] and she said she had not given any medications at 8:00 PM. She said everything on her MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview the DON confirmed RN #2 failed to administer 8:00 PM medications on 5/10/2022.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement care plan interventions to prevent development of and to treat a pressure ulcer for 1 resident (#5) of 3 residents reviewed for pressure ulcers. The facility's failure resulted in the development and worsening of an unstageable pressure ulcer causing actual harm to Resident #5 The findings included: Review of a facility policy Comprehensive Care Plans and Revisions issued 3/2/2022 showed .The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care .When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery . Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's comprehensive care plan dated 2/4/2022 showed .At risk for break in skin integrity .clean and dry skin after each incontinent episode .Heel boot to be in place at all times to L [left] foot 2/22/22 .weekly skin checks . Review of Resident #5's Skin Integrity Data Collection dated 2/13/2022 showed .Skin Intact: No [indicating skin was not intact] .if skin not intact choose all that apply and select site and describe each area below .[Resident #5 had] Groin redness, right buttocks sheering, left heel redness with bruising . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Nursing Wound Observation Tool dated 2/24/2022 showed .Special Equipment/Preventative Measures: mattress, heel offloading, boot .Offloading lower extremity boot was applied and resident instructed to wear when laying [lying] in bed . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's care plan revealed no documentation the care plan was revised to reflect the presence of the pressure ulcer identified on 2/22/2022. The intervention for .heel boot to be in place at all times to L foot 2/22/22 . was added to the comprehensive care plan under an existing problem on 2/22/2022. Review of Resident #5's Nursing Wound Observation Tool dated 2/28/2022 showed .Special Equipment/Preventative Measures: mattress, heel offloading, boot .Offloading lower extremity boot was applied and resident instructed to wear when laying [lying] in bed or sitting in wheelchair . Review of Resident #5's Nursing Wound Observation Tool dated 3/7/2022 showed .Special Equipment/Preventative Measures: mattress, heel offloading, boot .Indicate whether this site was acquired during the resident's stay or whether it was present on admission: Acquired [indicating the wound was acquired in the facility] .Date: 2/22/2022 .Location: Left Heel .Type: Pressure .Overall Impression: Worsening .Describe: dark brown to black in color with mild reddened wound edges .Drainage: None .Length cm 4.7 Width cm 5.2 Depth cm 0 .Any signs or symptoms of infection: No .Pain related to wound: No .Offloading lower extremity boot was applied and resident reinstructed to wear when laying [lying] in bed . Observation of Resident #5 on 3/7/2022 at 1:55 PM, in her room, showed the resident to be seated in a wheelchair and she was awake and alert. The resident's left foot was resting on the support bar of the bedside table. Non-skid socks were being worn and no heel boot was in place to the resident's left heel. Observation showed the resident's heel boot was laying in her bedside chair. During an interview with Certified Nurse Assistant (CNA) #9 on 3/7/2022 at 2:05 PM, she stated .I did not know she was supposed to have a boot on her left heel. You can look at my Kardex and it doesn't say she is supposed to have a boot on her left heel . Observation of Resident #5's Kardex with the CNA showed no special instructions for a boot for Resident #5's left heel, or for a boot while in bed. Observation with Registered Nurse (RN) #1 Wound Care Nurse on 3/7/2022 at 3:00 PM, in Resident #5's room showed the resident did not have on a heel boot. During an interview with RN #1 Wound Care Nurse on 3/7/2022 at 3:00 PM, she stated .she has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Her wound has worsened. It is darker in color from purple to black and increased in size .An order was written on 2/25/2022 for a foam boot to left foot at all times except when showering every shift. However, the order did not get to her Care plan or the CNA [Certified Nursing Assistant] Kardex .I don't know who is responsible to put it on the care plan . During an interview with Resident #5's Primary Care Physician on 3/7/2022 at 3:20 PM, the physician confirmed .If the area was caused by pressure, it could have very easily been avoided if on admission, interventions were in place to reduce pressure on her heel . Observation of Resident #5 on 3/8/2022 at 7:30 AM, in her room, showed the resident lying in bed awake and alert. Observation of her left heel showed it was wrapped with Kerlix, but no boot was present to her left heel. The resident's heel boot was observed laying in her bedside chair. During an interview with CNA #7 on 3/8/2022 at 9:30 AM, she stated .I was not aware that Resident #5 was to have a bootie on at all times until this morning at 9:00 AM. This is the first day I have worked with her since she developed the area to her left heel . During an interview with Licensed Practical Nurse (LPN) #4 on 3/9/2022 at 7:33 AM, she stated .I was aware she was to have on heel protector when she was in the bed. We are supposed to communicate it to the CNAs .there is a way to update the CNA Kardex but I'm not sure all nurses know how to do that. When you put it on the care plan you click the intervention. It will have a K beside it. It will pull to the Kardex. If the intervention is not exactly what you want, you can edit it to say what is to be done . Observation of Resident #5 on 3/9/2022 at 12:25 PM, in her room, showed the resident seated in a wheelchair; she was awake and alert. Observation of her left heel showed she did not have on a boot to her left heel. Observation of Resident #5 on 3/10/2022 at 7:45 AM, in her room, showed the resident lying in bed awake and alert. Observation of Resident #5's left heel showed it was resting on a small pillow with no boot present. During an interview with the Director of Nursing (DON) on 3/10/2022 at 10:30 AM, she stated .first there should have been communication between the nurses and the CNAs about the new order for the resident to ensure the resident was wearing heel boot to her left foot at all times except when showering. The care plan should have been updated which would auto populate to the CNA Kardex .the intervention was placed on the care plan under an existing intervention so there is no way to determine when the intervention was added to the care plan. It does have a manual date of 2/22/2022. By it being added to an existing intervention instead of a custom intervention it did not auto populate to the CNA Kardex. The CNAs caring for her had no way of knowing the new intervention. In my professional opinion implementation of the interventions would have likely prevented the wound from worsening . During the interview the DON confirmed the facility failed to implement interventions to prevent the development of and worsening of an unstageable pressure injury and the care plan was not updated to reflect the resident had an actual wound or interventions.

Based on facility policy review, review of NPIAP (National Pressure Injury Advisory Panel) Pressure Injury Stages, medical record review, observation, and interview, the facility failed to implement interventions to prevent the development of a pressure ulcer for 1 resident (#5) of 3 residents reviewed for pressure ulcers. The facility's failure resulted in the development and worsening of an unstageable pressure ulcer causing actual harm to Resident #5. The findings included: Review of a facility policy Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised on 8/25/2021 showed .Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin .When skin breakdown occurs, it requires attention and a change in the plan of care to appropriately treat the patient . Review of the current NPIAP Pressure Injury Stages showed .Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] [does not turn white when pressed] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] [turns white when pressed] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [appears yellow, white or grey and is devitalized tissue] or eschar [dry, dead, adherent tissue]. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed . Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4) . Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Admission/Readmission Collection Tool dated 2/4/2022 showed .Skin Intact: Yes [indicating skin was intact] .Indicate site(s) below and describe: [Resident #5 had] Right antecubital bruising, left antecubital bruising, coccyx redness, left lower leg (front) scabbing . Review of Resident #5's Braden Scale (an assessment tool used to assess a resident's risk of developing a pressure ulcer) dated 2/4/2022 showed a score of 18, with a score of 15-18 placing a person at mild risk for developing pressure ulcers. The resident's risk factors included decrease or impaired Bed/chair mobility and urinary or bowel incontinence. Review of Resident #5's comprehensive care plan dated 2/4/2022 showed .At risk for break in skin integrity .clean and dry skin after each incontinent episode. Heel boot to be in place at all times to L [left] foot 2/22/22 .weekly skin checks . Review of Resident #5's admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The resident required extensive assistance of two staff with bed mobility and toilet use and extensive assistance of one staff for dressing and personal hygiene. Resident #5 was dependent on two staff members for transfers. Review of Resident #5's Skin Integrity Data Collection dated 2/13/2022 showed .Skin Intact: No [indicating skin was not intact] .if skin not intact choose all that apply and select site and describe each area below .[Resident #5 had] Groin redness, right buttocks sheering, left heel redness with bruising . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Apply duoderm [type of bandage] to left heel every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for breakdown . Review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Ensure resident's heels are floated while in bed every shift for breakdown . Treatment was documented as provided as ordered. Review of Resident #5's Braden Scale dated 2/14/2022 showed a score of 18, indicating the resident was assessed as being at mild risk for developing a pressure ulcer. Review of Resident #5's Nursing Wound Observation Tool dated 2/24/2022 showed .Special Equipment/Preventative Measures: mattress, heel offloading, boot .Indicate whether this site was acquired during the resident's stay or whether it was present on admission: Acquired [indicating the wound was acquired while in the facility] .Date: 2/22/2022 [date wound was acquired] .Location: Left Heel .Type: Pressure .Stage: 1 .Describe: dark red, wine colored deep tissue pressure injury, not open .Drainage: None .Length cm [centimeter] 5 Width cm 5 Depth cm 0 .Any signs or symptoms of infection: No .Pain related to wound: No .Treatment: Duoderm removed due to it being adhesive and not wanting to open the wound with dressing changes, applied [MEDICATION(S)] antiseptic, non-adhesive foam padding, and wrapped with Kerlix [gauze bandage]. Offloading lower extremity boot was applied and resident instructed to wear when laying [lying] in bed . Review of Resident #5's Weekly Skin Integrity Data Collection dated 2/25/2022 showed .Skin Intact: Yes, New findings: No Indicate site(s) below and describe: right antecubital bruising, left antecubital bruising, Left heel blackened area, discoloration and scabbed areas to BLE [bilateral lower extremities] and BUE [bilateral upper extremities], redness to bilateral buttocks . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review showed an additional physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed an additional wound care order .Cleanse left heel with [MEDICATION(S)] and wrap with kerlix [type of bandage] every day shift every Mon, Wed, Fri . Review of Resident #5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Ensure resident is wearing heel bootie to left foot at all times except when showering every shift .Cleanse left heel with [MEDICATION(S)] and wrap with kerlix every day shift every Monday, Wednesday, Friday . Treatment was documented as provided as ordered. Review of Resident #5's Nursing Wound Observation Tool dated 2/28/2022 showed .Special Equipment/Preventative Measures: mattress, heel offloading, boot .Indicate whether this site was acquired during the resident's stay or whether it was present on admission: Acquired .Date: 2/22/2022 .Location: Left Heel .Type: Pressure .Stage: Unstageable .Specify: DTI [deep tissue injury] Overall Impression: Unchanged .Describe: dark purple, wine colored deep tissue pressure injury, not open .Drainage: None .Length cm 4 Width cm 4.5 Depth cm 0 .Any signs or symptoms of infection: No .Pain related to wound: No .Treatment: Applied [MEDICATION(S)] antiseptic, non-adhesive foam padding, and wrapped with Kerlix. Offloading lower extremity boot was applied and resident instructed to wear when laying [lying] in bed or sitting in wheelchair . Review of Resident #5's Braden Scale dated 3/2/2022 showed a score of 18, indicating the resident was at a mild risk of developing a pressure ulcer. The resident's risk factors included decrease or impaired bed/chair mobility and urinary or bowel incontinence. Continued review showed the assessment was not updated to reflect the development of the pressure ulcer on 2/22/2022. Review of Resident #5's Weekly Skin Integrity Data Collection dated 3/4/2022 showed .Skin Intact: Yes, New findings: No Indicate site(s) below and describe: right antecubital bruising, left antecubital bruising, Left heel blackened area, discoloration and scabbed areas to BLE and BUE, redness to bilateral buttocks . Review of Resident #5's Nursing Wound Observation Tool dated 3/7/2022 showed .Special Equipment/Preventative Measures: mattress, heel offloading, boot .Indicate whether this site was acquired during the resident's stay or whether it was present on admission: Acquired .Date: 2/22/2022 .Location: Left Heel .Type: Pressure .Stage: 1 .Overall Impression: Worsening .Date notified and Name of Physician: 3/7/2022 .[Primary Care Physician] .Describe: dark brown to black in color with mild reddened wound edges .Drainage: None .Length cm 4.7 Width cm 5.2 Depth cm 0 .Any signs or symptoms of infection: No .Pain related to wound: No .Treatment: Applied [MEDICATION(S)] antiseptic, with 4 X 4 gauze, non-adhesive foam padding, and wrapped with Kerlix. Offloading lower extremity boot was applied and resident reinstructed to wear when laying [lying] in bed . Observation of Resident #5 on 3/7/2022 at 1:55 PM, in her room, showed the resident to be seated in a wheelchair and she was awake and alert. The resident's left foot was resting on the support bar of the bedside table. Non-skid socks were being worn and no heel boot was in place to the resident's left heel. Observation showed the resident's heel boot was laying in her bedside chair. During an interview with Resident #5 on 3/7/2022 at 1:55 PM, when asked about the boot for her left heel, she replied .they took it off yesterday after my shower and didn't put it back on .it is over there in that chair . During an interview with Certified Nursing Assistant (CNA) #9 on 3/7/2022 at 2:05 PM, she stated .I did not know she was supposed to have a boot on her left heel. You can look at my Kardex and it doesn't say she is supposed to have a boot on her left heel . Observation of Resident #5's Kardex with CNA #9 showed no special instructions for a boot for Resident #5's left heel, or for a boot while in bed. Observation with Registered Nurse (RN) #1 Wound Care Nurse (WCN) on 3/7/2022 at 3:00 PM, in Resident #5's room, showed the resident's left foot resting on the over-the-bed table foot bar. The resident did not have on a heel boot, the wound was covered with an island dressing, and was not wrapped with Kerlix. During an interview with RN #1 WCN on 3/7/2022 at 3:00 PM, she stated .she [Resident #5] has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When I removed the island dressing there was no evidence [MEDICATION(S)] had been applied. The kerlix would add additional padding the island dressing did not provide. The island dressing is no more than an adhesive bandage. There is no date or initials on the dressing .Her wound has worsened since 2/28/2022. It is darker in color from purple to black and increased in size from 4 cm [centimeter] X 4.5 cm to a 4.7 cm X 5.2 cm. An order was written on 2/25/2022 for a foam boot to left foot at all times except when showering every shift. However, the order did not get to her care plan or the CNA Kardex .I don't know who is responsible to put it on the care plan . During an interview with Resident #5's Primary Care Physician (PCP) on 3/7/2022 at 3:20 PM, he stated .the wound needed something to keep the pressure off of it .not being wrapped in Kerlix and not having the pressure relieving boot on would have contributed to the worsening of the wound .If the area was caused by pressure, it could have very easily been avoided if on admission, interventions were in place to reduce pressure on her heel . Observation of Resident #5 on 3/8/2022 at 7:30 AM, in her room, showed the resident lying in bed awake and alert. Observation of her left heel showed it was wrapped with Kerlix, but no boot was present to her left heel. The resident's heel boot was observed laying in her bedside chair. During an interview with RN #1 WCN on 3/8/2022 at 7:45 AM, she confirmed Resident #5 did not have a boot applied to her left heel. During an interview with CNA #7 on 3/8/2022 at 9:30 AM, she stated .I was not aware that Resident #5 was to have a bootie on at all times until this morning at 9:00 AM. This is the first day I have worked with her since she developed the area to her left heel . During an interview with Licensed Practical Nurse (LPN) #4 on 3/9/2022 at 7:33 AM, she stated .We are supposed to communicate it to the CNAs. We are to update the care plan and there is a way to update the CNA Kardex, but I'm not sure all nurses know how to do that. When you put it on the care plan you click the intervention. It will have a K beside it. It will pull to the Kardex . Observation of Resident #5 on 3/9/2022 at 12:25 PM, in her room, showed the resident seated in a wheelchair; she was awake and alert. Observation of her left heel showed she did not have on a boot to her left heel. During an interview with Resident #5 on 3/9/2022 at 12:25 PM, when asked where her boot was, she stated in the bathroom, I think. They had to take if off for me to go to the bathroom and the girl got busy and someone else got me up and just forgot to put it back on . Observation of Resident #5 on 3/10/2022 at 7:45 AM, in her room, showed the resident lying in bed awake and alert. Observation of Resident #5's left heel showed it was resting on a small pillow with no boot present. During an interview with Resident #5 on 3/10/2022 at 7:45 AM, she stated .they took it off last night when they put me to bed, and I didn't get back up . During an interview with LPN #4 on 3/10/2022 at 7:50 AM, she confirmed the resident was not wearing a boot to her left heel. During an interview with the Director of Nursing (DON) on 3/10/2022 at 10:30 AM, she stated .first there should have been communication between the nurses and the CNAs about the new order for the resident to ensure the resident was wearing heel boot to her left foot at all times except when showering. The care plan should have been updated which would auto populate to the CNA Kardex .the intervention was placed on the care plan under an existing intervention so there is no way to determine when the intervention was added to the care plan. It does have a manual date of 2/22/2022. By it being added to an existing intervention instead of a custom intervention, it did not auto populate to the CNA Kardex. The CNAs caring for her had no way of knowing the new intervention. In my professional opinion, implementation of the interventions would have likely prevented the wound from worsening . During the interview she confirmed the facility failed to implement interventions to prevent development of and worsening of an unstageable pressure injury.

Based on review of a facility policy, and interview, the facility failed to provide timely notification to family members of newly developed cases of Covid-19 on 1/19/2022 affecting 79 of 93 residents and on 1/22/2022 affecting 92 of 92 residents reviewed for notification. The findings included: Review of a facility policy Coronavirus (COVVID 19) ([CONDITION(S)]-CoV-2) revised 12/27/2022 showed .COVID-19 Reporting to Residents, their Representatives, and Families as required .The facility must .Inform residents, their representatives, and families of those residing in facilities by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . During an interview with the Administrator on 1/24/2022 at 2:30 PM, she stated .on 12/30/2021 we had 1 staff member test positive .I notified both staff and families on 12/31/2021 at 10:33 AM. [confirmed viewing COVR (facility group messaging application) message]. The 2nd staff member [Certified Nursing Assistant] [CNA] tested positive on 1/2/2022 and on 1/3/2022 at 12:20 PM I notified staff and families [confirmed viewing COVR message] .1 Staff member [CNA] tested positive on 1/11/2022 and family and staff were notified on 11/12/2022 at 4:52 PM [confirmed viewing COVR messages]. 1 staff member . tested positive on 1/14/2022 .I notified staff and family 1/15/2022 at 4:54 PM [confirmed by viewing COVR message]. We had an outbreak in the secure unit on 1/18/2022, testing occurred between 8:30 PM - 9:00 PM .we had 14 residents test positive, and no staff members. All family members of the residents testing positive were notified immediately [confirmed by documentation], but other family and staff were not notified until 7:25 PM on 1/19/2022. The morning of 1/19/2022 we had 4 associates test positive which was included in the notification on 1/19/2022 at 7:25 PM [confirmed viewing COVR message]. On 1/21/2022 we had 4 residents test positive and staff members notification was made on 1/21/2022 at 7:37 PM [confirmed by COVR message]. On 1/22/2022 1 staff member tested positive .I did not send out a message to families or staff of the new positive for 1/22/2022. On 1/23/2022 we had 1 staff member [LPN] test positive and on 1/24/2022 we had 2 staff members [CNAs] test positive and I made the notification for 1/22/2022, 1/23/2022, and 1/24/2022 today [1/24/2022] at 10:29 AM . During the interview the Administrator confirmed the facility failed to make family notifications as required on 1/19/2022 by 5:00 PM of notifying families of 14 residents testing positive on 1/18/2022. Continued interview confirmed family notifications were not made on 1/22/2022 of 1 staff member testing positive until 1/24/2022 at 10:29 AM.

Based on medical record review and interview, the facility failed to ensure the care plan was updated for 2 residents (#54 and #293) of 34 residents reviewed. The findings include: Review of the medical record showed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's weekly skin assessment dated [DATE], showed .dime sized red area on left side of left eye . Review of a physician's progress note dated 11/1/2021, showed .asked to see for lesion on L [left] side of head .PLAN .Dermatology consult . Review of Resident #54's care plan initiated on 6/25/2021, showed no update had been made to reflect the development and monitoring of the skin lesion. Review of the medical record showed Resident #293 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Change for leakage or obstruction . Review of Resident #293's care plan initiated on 10/9/2021, showed no update had been made to reflect the use of a urinary catheter. During an interview conducted on 11/17/2021 at 10:45 AM, the Clinical Reimbursement Specialist confirmed Resident #54's care plan had not been updated to reflect a skin lesion and Resident #293's care plan had not been updated to reflect the use of a urinary catheter.

Based on review of facility policy, medical record review, facility investigation review, and interview the facility failed to provide supervision and assistance based on the resident's individualized care plan for toileting and personal care needs for 1 resident (#66) of 33 residents reviewed. Failure of the facility to provide care directed by the care plan resulted in HARM for Resident #66. The findings included: Review of the facility policy, Fall Management, dated 6/2016, 11/2016, revealed .promote patient safety and reduce patient falls by proactively identifying, care planning .avoidable accident: means that an accident occurred because the facility failed to .implement interventions, including supervision, consistent with a patient's needs, goals, plan of care .in order to reduce the risk of an accident . Medical record review revealed Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record of the Care Plan dated 1/12/13 and confirmed with the Director of Nursing (DON) on 6/21/17 at 10:35 AM, in the DON office to be correct for both the MDS assessment and the care plan, revealed Activities of Daily Living (ADLs) requires extensive staff assistance with all ADLs due to impaired mobility and cognitive impairment. Further review of the Falls Care Plan revealed, assist x (times) 2 with bed mobility. Medical record review of the Care Directive Certified Nurse Aide (CNA) guide for care plans dated 1/18/17, revealed, Bed Mobility assist x 2 and Toileting total. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review revealed Bed Mobility and Toilet use had been assessed as Extensive Assistance requiring 2 plus persons for physical assistance. Medical record review of the facility's investigation dated 3/6/17 revealed .CNA was providing pericare (incontinence care) to resident in bed and had resident turned on her left side when CNA turned around to reach for a washcloth and resident slid off the edge of bed . Continued review of the Witness Statement Form revealed CNA #1 .I .was changing (Resident #66) when she had a large BM (bowel movement) .on her left side when I turned away to get another washcloth she had slide off the bed onto the floor . Medical record review of the Progress Notes dated 3/6/17 revealed .staff was providing resident with pericare .slid off the bed and into the floor .observed to be sitting on her bottom .abrasion noted to middle right finger .left leg also noted to be bent behind resident with hard protrusion noted below left knee with laceration .admitted .with [DIAGNOSES REDACTED].'' Medical record review of the Skin Integrity Data Collection dated 3/6/17 revealed .right forearm and hand .skin tear to middle finger right hand .skin tear to left knee below left knee . Medical record review of the hospital's Left Leg X-Ray Two Views findings, dated 3/6/17 revealed .comminuted impacted fractures of proximal left tibia and fibula . Review of facility's inservice training, Providing Care to a Resident While in Bed, dated 3/10/16 revealed .resident should never be rolled away .never turn from resident while providing care .turn attention away .if providing care and needs to reach for an item or look away, the resident should be returned to a safe position .ensure you have appropriate amount of assistance . Interview with Licensed Practical Nurse (LPN) #3 on 6/19/17 at 9:00 AM, at the 100 nursing station confirmed she had been assigned to the care of Resident #66 on 3/6/17 .slipped off the side of the bed . she (CNA #1) rolled her over .legs must have been too close to the edge .(CNA #1) called me into the room .one leg was behind her .(Resident #66) said she had fallen . Continued interview revealed Resident #66 was totally dependent on care. Interview with the Assistant Director of Nursing (ADON) on 6/20/17 at 10:00 AM, in the 100 nursing station confirmed she assisted with Resident #66 after the fall on 3/6/17. Continued interview confirmed .(CNA #1) was on (Resident #66) right side .there was no other staff in the room .the resident was on the floor, her left leg curled behind her, her knee was discolored, a skin tear on her hand and knee .(Resident #66) said she was hurting . Further interview confirmed they called an ambulance and the resident was transported to the hospital. Telephone interview with the Medical Director on 6/21/17 at 10:00 AM, revealed .somebody changed her by herself .she was dependent on care .not sure if she could have held onto a side rail .it sounds reasonable to have 2 persons to assist her . Interview with the Director of Nursing (DON) on 6/21/17 at 10:35 AM in the DON office confirmed Resident #66 was care planned correctly as a 2 person assist for bed mobility and toileting needs. Continued interview confirmed the facility's failure to ensure the care plan for Resident #66 was followed utilizing the amount of assistance required for safe administration of care when working with Resident #66 resulted in a fall with a fracture and HARM to the resident.

Based on review of the facility's policy, review of the medical record, review of the facility's investigation, and interview, the facility failed to ensure supervision and assistance in toileting and personal care to prevent accidents for 1 resident (#66) of 3 residents reviewed for accidents resulting in HARM to Resident #66. The findings included: Review of the facility policy, Fall Management, dated 6/2016, 11/2016, revealed .promote patient safety and reduce patient falls by proactively identifying, care planning .avoidable accident: means that an accident occurred because the facility failed to .implement interventions, including supervision, consistent with a patient's needs, goals, plan of care .in order to reduce the risk of an accident . Medical record review revealed Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record of the Care Plan dated 1/12/13 and confirmed with the Director of Nursing (DON) on 6/21/17 at 10:35 AM, in the DON office to be correct for both the MDS assessment and the care plan, revealed Activities of Daily Living (ADLs) requires extensive staff assistance with all ADLs due to impaired mobility and cognitive impairment. Further review of the Falls Care Plan revealed, assist x (times) 2 with bed mobility. Medical record review of the Care Directive Certified Nurse Aide (CNA) guide for care plans dated 1/18/17, revealed, Bed Mobility assist x 2 and Toileting total. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review revealed Bed Mobility and Toilet use had been assessed as Extensive Assistance requiring 2 plus persons for physical assistance. Medical record review of the facility's investigation dated 3/6/17 revealed .CNA was providing pericare (incontinence care) to resident in bed and had resident turned on her left side when CNA turned around to reach for a washcloth and resident slid off the edge of bed . Continued review of the Witness Statement Form revealed Certified Nursing Aide (CNA) #1 .I .was changing (Resident #66) when she had a large BM (bowel movement) .on her left side when I turned away to get another washcloth she had slide off the bed onto the floor . Medical record review of the Progress Notes dated 3/6/17 revealed .staff was providing resident with pericare .slid off the bed and into the floor .observed to be sitting on her bottom .abrasion noted to middle right finger .left leg also noted to be bent behind resident with hard protrusion noted below left knee with laceration .admitted .with [DIAGNOSES REDACTED].'' Medical record review of the Skin Integrity Data Collection dated 3/6/17 revealed .right forearm and hand .skin tear to middle finger right hand .skin tear to left knee below left knee . Medical record review of the hospital's Left Leg X-Ray Two Views findings, dated 3/6/17 revealed .comminuted impacted fractures of proximal left tibia and fibula . Review of facility's inservice training, Providing Care to a Resident While in Bed, dated 3/10/16 revealed .resident should never be rolled away .never turn from resident while providing care .turn attention away .if providing care and needs to reach for an item or look away, the resident should be returned to a safe position .ensure you have appropriate amount of assistance . Interview with Licensed Practical Nurse (LPN) #3 on 6/19/17 at 9:00 AM, at the 100 nursing station confirmed she had been assigned to the care of Resident #66 on 3/6/17 .slipped off the side of the bed . she (CNA #1) rolled her over .legs must have been too close to the edge .(CNA #1) called me into the room .one leg was behind her .(Resident #66) said she had fallen . Continued interview revealed Resident #66 was totally dependent on care. Interview with the Assistant Director of Nursing (ADON) on 6/20/17 at 10:00 AM, in the 100 nursing station confirmed she assisted with Resident #66 after the fall on 3/6/17. Continued interview confirmed .(CNA #1) was on (Resident #66) right side .there was no other staff in the room .the resident was on the floor, her left leg curled behind her, her knee was discolored, a skin tear on her hand and knee .(Resident #66) said she was hurting . Further interview confirmed they called an ambulance and the resident was transported to the hospital. Telephone interview with the Medical Director on 6/21/17 at 10:00 AM, revealed .somebody changed her by herself .she was dependent on care .not sure if she could have held onto a side rail .it sounds reasonable to have 2 persons to assist her . Interview with the Director of Nursing (DON) on 6/21/17 at 10:35 AM, in the DON office confirmed Resident #66 was correctly assessed for both the MDS assessment and the care plan. Further interview confirmed the facility failed to prevent the fall which resulted in injury and HARM to Resident #66.

Based on review of Lippincott Manual Nursing Practice, review of facility policy Physician order [REDACTED]. The failure resulted in medication errors and placed 4 residents (#182, #155, #175, and #42) of 18 residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for immediate jeopardy. The Regional Vice President, Administrator, Director of Nursing, and Regional Director of Clinical Services, were informed of the Immediate Jeopardy on 9/11/15, at 10:40 AM in the Administrator's office. The Immediate Jeopardy was effective 7/24/15 through 9/11/15. An extended survey was conducted on 9/11/15. The facility submitted an Acceptable Allegation of Compliance to the survey team on 9/11/15. The survey team verified the actions taken by the facility removed the jeopardy on 9/10/15. Noncompliance continues at the severity of E level. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, revealed, .Chapter 2 Standards of Care, Ethical and Legal Issues .Accountability .Maintaining familiarity of relevant, current facility policies, procedures, and regulations as they apply to the nurse's practice and specialty area .Examining the quality (accuracy and completeness) of documentation .Common Departures from the Standards of Nursing Care .failure to .follow physician orders, follow appropriate nursing measures .adhere to facility policy or procedure .administer medications as ordered . Review of facility policy Physician order [REDACTED].A licensed nurse reviews and updates the orders, MAR's (Medication Administration Records) and TAR's (Treatment Administration Records). This is completed no later than the last day of the month. It is important to review all three documents together to ensure accuracy. Reviewing and updating includes: Comparing the newly printed physician orders [REDACTED]. Comparing the newly printed medication and treatment records to the current records for updated orders, discontinued or new orders . Medical record review revealed Resident #182 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission physician's orders [REDACTED].Xarelto (blood thinning drug) 15 mg (milligrams) PO (by mouth) BID (twice a day) c (with) meals @ (at) 8 AM & (and) 12 PM. (Dx (Diagnosis): prevention of [MEDICAL CONDITION] ([MEDICAL CONDITION]/blood clot) d/t (due to) fx (fracture) ) Stop 7/26/15. Xarelto 20 mg PO daily @ 5pm (DX: prevention [MEDICAL CONDITION]) Start 7/27/15 . Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #182's Brief Interview Mental Status (BIMS) score was 15 out of 15 (indicating the resident was cognitively intact). Medical record review of the Medication Administration Record, [REDACTED]. Medical record review of the August 2015 Physician Recapitulation Orders dated 7/30/15 signed by Registered Nurse (RN) #1, revealed the order for Xarelto had not been transcribed to the orders or MAR. Medical record review of a Physician Telephone Order dated 8/10/15, revealed .[MEDICATION NAME] (a blood thinner) 5 mg po daily .Check PT (prothombin time)/INR (international normalized ratio) 2xs (2 times) weekly (blood test to measure amount of blood thinning) .Bed rest until PT/INR > (greater than) 2 .Indication-DX [MEDICAL CONDITION] . Medical record review of a Physician Telephone Order dated 8/10/15, revealed .[MEDICATION NAME] (a blood thinner) 30 mg SQ (sub-cutaneous) BID (twice a day) until INR > 2 then D/C (discontinue) .Indication-DX [MEDICAL CONDITION] . Medical record review of Physician Telephone Orders dated 8/11/15, revealed .D/C Xarelto .Indication-DX [MEDICATION NAME] started . Medical record review of a Nursing Note dated 8/11/15 revealed, .Resident noted to have missed several doses of scheduled Xarelto due to medication error in transcribing medication to MAR indicated [REDACTED] Review of the facility investigation Incident Follow up and Recommendation Form dated 8/11/15, revealed . Summary of Investigative Facts: Resident missed doses of Xarelto 20 mg daily from August 1-10 due to medication not being transcribed to new orders and MAR for the month of August. Resident diagnosed with [REDACTED]. Medical record review of a PT/INR/[MEDICATION NAME] Flowsheet dated 8/10/15-9/10/15, revealed .Normal [MEDICATION NAME] Time (PT) = 10-13 seconds .INR Ranges: 2.0-3.0= [MEDICAL CONDITION] . Further review revealed Resident #182's INR level was 1.2 and PT level was 14 on 8/10/15. The resident reached theraputic range (above 2) 9/4/15, 25 days after being placed on [MEDICATION NAME], and bed rest. Observation during interview with Resident #182 on 9/9/15 at 8:30 AM, in the resident's room, revealed the resident was seated in a wheelchair and the resident stated, They made a mistake and I got a blood clot. Ultrasound shows I still have blood clot. Interview with Licensed Practical Nurse (LPN) #1 on 9/9/15 at 9:25 AM, in the conference room, revealed .Medical records printed the MAR forms to send to the nurses, pharmacy see orders we fax. We fax the admission orders [REDACTED].We get their (resident's) discharge packet from hospital so we have that to compare to. I compared our admission orders [REDACTED].faxed the July Physician order [REDACTED].#1 made corrections to the admission orders [REDACTED].The Xarelto was in the drawer for August, I noticed it wasn't being given .We get the new recap orders (from medical records) maybe a week before the next month .ADON (Assistant Director of Nursing) notified me that the pharmacy had called and questioned .Incident report was done. Interview with the ADON on 9/10/2015 at 11:00 AM, in the conference room, revealed the ADON had transferred the hospital discharge orders (correctly) onto the nursing home admission orders [REDACTED]. Further interview confirmed the order for the Xarelto was incorrectly transcribed from the nursing home admission orders [REDACTED]. Interview confirmed the error had been addressed and corrected by LPN #1 on the computer-generated physician admission orders [REDACTED]. Interview with RN #1 weekend supervisor, on 9/10/15 at 11:15 AM, in the conference room, revealed I check the physician orders [REDACTED]. Then go back in chart to make sure telephone orders are transcribed .Xarelto was not put on the August physician recap orders so it was not on the MAR .I failed to transcribe Xarelto onto the August orders .So the med (medication) was not given in August. Interview with the Director of Nursing on 9/10/15 at 1:16 PM in the conference room, confirmed the nursing supervisors were responsible for recapitulating orders to ensure the correct orders were placed on the medication administration record. The charge nurse from 10:00 PM-6:00 AM would've looked over it to make sure meds (medications) are transcribed. The monthly changeover was when it was missed . Interview with the Nurse Practitioner 09/11/2015 at 9:41 AM, by phone, confirmed, I would say that not getting those doses of Xarelto would contribute to a [MEDICAL CONDITION]. It was prescribed . Any postop (postoperative) surgical procedures could contribute to that (development of [MEDICAL CONDITION]) especially if .immobile. Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] (used to decrease toxic ammonia levels in patients with liver disease)15 gm (grams) po (by mouth) QID (four times a day) . Medical record review of the August Medication Administration Record [REDACTED]Time Code the administration times were listed as 8:00 AM, 12:00 PM, 4:00 PM, 12:00 PM. Further review revealed the second (repeat)12:00 PM had a line drawn through and the documentation of the medication nurses indicated the [MEDICATION NAME] was given 3 times a day. Review of the facility investigation dated 8/13/15 revealed .On admission, resident was ordered [MEDICATION NAME] 15 gm PO QID. [MEDICATION NAME] was entered in the computer as [MEDICATION NAME] 15 gm four times daily at 8 am, 12pm, 4pm, 12pm. Medication only given once at 12pm and therefore resident only received med TID (three times a day) instead of the ordered QID. Resident is free of s/s (signs/symptoms) adverse effects at this time. No change in mental status or physical function since admit .Ammonia level obtained . [MEDICATION NAME] changed to 30 grams TID per MD 8/13/15 . Interview with the Director of Nursing (DON), on 9/11/15, at 9:50 AM, in the conference room, confirmed the 12 PM time code was entered incorrectly, it should have been entered as 8 PM, and Resident #155 only received the [MEDICATION NAME] TID. Continued interview confirmed 8 doses of [MEDICATION NAME] had not been administered as ordered by the physician. Interview with the Nurse Practitioner, on 9/11/15 at 12:50 PM, by telephone, confirmed the resident had missed 8 doses [MEDICATION NAME] in 8 days, the resident had a history of [REDACTED]. Medical record review revealed Resident #175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].Ezetimibe ([MEDICATION NAME]) 10 mg po HS (bedtime) ([MEDICAL CONDITION]) .[MEDICATION NAME] (cholesterol lowering medication) . Medical record review of the MAR indicated [REDACTED]. Review of the facility investigation dated 7/24/15, 12:00 PM, revealed .Resident admitted to the facility with orders for [MEDICATION NAME] (cholesterol lowering medication) 10 mg (milligrams) po (by mouth) at HS (bedtime). Order was transcribed and faxed to pharmacy but order was not entered into the computer for the MAR (Medication Administration Record) or medical record by HIM (Health Information Management). Medication was not administered from 7/24/15-7/30/15 as ordered. Resident free from s/s (signs/symptoms) of adverse reaction . Interview with the DON, on 9/11/15, at 9:50 AM, in the conference room, confirmed the [MEDICATION NAME] was not administered as ordered by the physician. Resident #42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Physician order [REDACTED].[MEDICATION NAME] (also known as [MEDICATION NAME], a medication to treat fluid retention) 20 mg PO BID . Medical record review of a Medication Administration Record [REDACTED].[MEDICATION NAME] 20 mg tablet PO administered daily . Medical record review of a MAR indicated [REDACTED].[MEDICATION NAME] 20 mg PO BID . Continued medical record review of the MAR indicated [REDACTED]. Interview with the DON on 9/11/15 at 1:30 PM, in the conference room, confirmed the resident was to receive the [MEDICATION NAME] twice a day on admission to the facility on [DATE], and the facility failed to ensure the medication was administered as prescribed until 8/12/15. The Immediate Jeopardy was effective from 7/24/15 through 9/10/15. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on 9/11/2015. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of a new policy and procedure mandating only licensed nurses were to enter admission/readmission orders [REDACTED]. The procedure included a second licensed nurse to review and confirm the orders as accurate and complete prior to the orders becoming part of the medical record. Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing) and the facility's plan for education for nurses who were not scheduled to work. 2. Verification of the new medication administration system by the facility, which included discontinuation of an unlicensed medical records employee completing data entry and implementing admission/readmission orders [REDACTED]. Verification included review and observation reconciling new physician's orders [REDACTED]. 3. Review of the 100% audit of all anticoagulant MEDICATION ORDERS FOR [REDACTED]. 4. Review of the 100% audit of all physician orders [REDACTED]. 5. Review of the 100% audit of all current physician orders [REDACTED]. 6. Verification through interview with the Regional Vice President, Administrator, and the Director of Nursing (DON) the decision was made 8/18/15 for admission/readmission orders [REDACTED]. 7. Interview with the DON and the Staff Development Coordinator and review of the education provided to the 34 licensed nurses (except 2 outstanding PRN/as needed nurses who could not work a shift until they receive training) related to proper verification of written and oral medication orders and the proper procedure to follow if there are medications identified in a resident's medication supply not included on the MAR. 8. Verification, through interview with the DON and review of facility's September performance improvement audit conducted each Monday-Friday during the morning Nursing Leadership meeting, the facility's process and audits were identifying and correcting errors before the errors reached the resident. 9. Verification through observation and review of 2 new admissions scheduled for 9/11/15, the new admission orders [REDACTED]. Observation confirmed the process was completed accurately. 10. Verification through interviews with 3 Registered Nurses and 8 Licensed Practical Nurses confirmed comprehension of changes and implementation of the facility's new transcription and verification procedures. 11. Verification through interview with the Administrator, Medical Director, Director of Nursing, and Regional Director of Clinical Services, their participation in the facility's performance improvement committee tasked to address the system changes with medication administration. 12. Verification by interview with the Regional Vice President and the Administrator the facility discontinued the process of entering physician orders [REDACTED]. Non-compliance continues at an E level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit a plan of correction. Refer to F282, F309, and F333

Based on facility policy review, medical record review, review of facility investigations, observation, interview, and review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, the facility failed to prevent systemic failures of inaccurate medication transcription and failed to follow physician orders [REDACTED].#182, #155, and #42) of 18 residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death). The facility's failure was likely to place any resident who received medications at risk for immediate jeopardy. The Regional Vice President, Administrator, Director of Nursing, and Regional Director of Clinical Services, were informed of the Immediate Jeopardy on 9/11/15 at 10:40 AM, in the Administrator's office. The Immediate Jeopardy was effective 8/1/15 through 9/10/15. An extended survey was conducted on 9/11/15. Substandard Quality of Care was cited at F309-K. The facility submitted an Acceptable Allegation of Compliance to the survey team on 9/11/15. The survey team verified the actions taken by the facility removed the jeopardy on 9/10/15. Noncompliance continues at the E level. The findings included: Review of facility policy Physician order [REDACTED].A licensed nurse reviews and updates the orders, MAR's (Medication Administration Records) and TAR's (Treatment Administration Records). This is completed no later than the last day of the month. It is important to review all three documents together to ensure accuracy. Reviewing and updating includes: Comparing the newly printed physician orders [REDACTED]. Comparing the newly printed medication and treatment records to the current records for updated orders, discontinued or new orders . Medical record review revealed Resident #182 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission physician's orders [REDACTED].Xarelto (blood thinning drug) 15 mg (milligrams) PO (by mouth) BID (twice a day) c (with) meals @ (at) 8 AM & (and) 12 PM. (Dx (Diagnosis): prevention of [MEDICAL CONDITION] ([MEDICAL CONDITION]/blood clot) d/t (due to) fx (fracture) ) Stop 7/26/15. Xarelto 20 mg PO daily @ 5 pm (Dx: prevention [MEDICAL CONDITION]) Start 7/27/15 . Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #182's Brief Interview Mental Status (BIMS) score was 15 out of 15 (indicating the resident was cognitively intact). Medical record review of the Medication Administration Record, [REDACTED]. Medical record review of the August 2015 Physician Recapitulation Orders, dated 7/30/15, signed by Registered Nurse (RN) #1, revealed the order for Xarelto had not been transcribed onto the August recapitulation orders or MAR. Medical record review of a Nursing Note dated 8/9/15 at 10:09 AM revealed .Resident has c/o (complaint of) of right leg pain, there is some slight swelling noted no redness or pain upon moving the leg, will continue to observe . Medical record review of a Nursing Note dated 8/9/15 at 3:50 PM, revealed .c/o of pain in RLE (Right Lower Extremity) with dorsal flexion, has increased [MEDICAL CONDITION] and heat in RLE. Contacted MD by phone obtained new order for venus doppler of RLE . Medical record review of a Physician Telephone Order dated 8/9/15, revealed .Doppler (ultrasound test using reflected sound waves to evaluate blood flow through blood vessels) of RLE (right lower extremity) .Indication-DX (increase pain/[MEDICAL CONDITION]) . Medical record review of the doppler Radiology Interpretation dated 8/10/15, revealed .Right lower extremity venous study shows no evidence of hematoma .There is deep [MEDICAL CONDITIONS] seen in the right proximal femoral vein extending to the right popliteal vein . Medical record review of a Physician Telephone Order dated 8/10/15, revealed .[MEDICATION NAME] (a blood thinner) 5 mg po (by mouth) daily .Check PT (prothombin time)/INR (international normalized ratio) 2xs (2 times) weekly (blood test to measure amount of blood thinning) .Bed rest until PT/INR > (greater than) 2 .Indication-DX [MEDICAL CONDITION] . Medical record review of a Physician Telephone Order dated 8/10/15, revealed .[MEDICATION NAME] (a blood thinner) 30 mg SQ (sub-cutaneous) BID (twice a day) until INR > 2 then D/C (discontinue) .Indication-DX [MEDICAL CONDITION] . Medical record review of a Nursing Note dated 8/10/15 at 10:20 PM revealed .Resident is currently on bed rest for [MEDICAL CONDITION] in RLE . Medical record review of a PT/INR/[MEDICATION NAME] Flowsheet dated 8/10/15-9/10/15, revealed .Normal [MEDICATION NAME] Time (PT) = 10-13 seconds .INR Ranges: 2.0-3.0= [MEDICAL CONDITION] (level of the theraputic range for treatment of [REDACTED].#182 on 8/10/15. Further review revealed a theraputic range (above 2 ) was reached on 9/4/15, 25 days after being placed on [MEDICATION NAME], and bed rest. Medical record review of the Nursing Note dated 8/11/15 revealed, .Resident noted to have missed several doses of scheduled Xarelto due to medication error in transcribing medication to MAR .(Physician) notified with new orders .written 8-10-15 of [MEDICATION NAME] 5 mg PO daily and [MEDICATION NAME] 30 mg sub-q (subcutaneous) BID until INR greater than 2 then D/C [MEDICATION NAME] .[MEDICAL CONDITION] to right lower extremity .DON made aware of med (medication) error .Resident also made aware of medication error of missing doses of medication Review of the facility investigation Incident Follow Up and Recommendation Form dated 8/11/15, revealed . Summary of Investigative Facts: Resident missed doses of Xarelto 20 mg daily from August 1-10 due to medication not being transcribed to new orders and MAR for the month of August. Resident diagnosed with [REDACTED]. Recommendations/Actions Taken: [MEDICATION NAME] 5 mg daily and [MEDICATION NAME] 30 mg BID ordered on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Nursing Note dated 8/11/15 revealed .Resident was transferred to (Hospital) via EMS (Emergency Medical Services) .eval (evaluate) per resident request . Medical record review of the Physician Telephone Orders dated 8/11/15 revealed .Transfer Resident to (hospital) for Eval &TX (treatment) . Medical record review of the Hospital Nursing Narrative Notes dated 8/11/15, .Reason: [MEDICAL CONDITION] not theraputic, fever . Medical record review of the Physician Telephone Orders dated 8/12/15, revealed .Readmit from (hospital)- less than 24 hr (hour) observation . Observation during interview with Resident #182 on 9/9/15 at 8:30 AM, revealed the resident was seated in a wheelchair and the resident stated, They made a mistake and I got a blood clot. Ultrasound (reference to the doppler study) shows I still have blood clot. Interview with Licensed Practical Nurse (LPN #1) on 9/9/15 at 9:25 AM revealed .Medical records printed the MAR forms to send to the nurses, pharmacy sees orders we fax. We fax the admission orders [REDACTED].We get (resident's) discharge packet from hospital so we have that to compare to. I compared our admission orders [REDACTED].faxed the July Physician order [REDACTED].#1 made corrections to the admission orders [REDACTED].We get the new recap orders (from medical records) maybe a week before the next month .ADON (Assistant Director of Nursing) notified me that the pharmacy had called and questioned .Incident report was done. Interview with the ADON on 9/10/2015 at 11:00 AM, in the conference room, revealed the ADON had transferred the hospital discharge orders (correctly) onto the nursing home admission orders [REDACTED]. Further interview confirmed the order for the Xarelto was incorrectly transcribed from the nursing home admission orders [REDACTED]. Interview confirmed the error had been addressed and corrected by LPN #1 on the computer-generated physician admission orders [REDACTED]. Interview continued and the ADON stated, HIM (the name facility used for the medical records department) isn't entering orders into the software now, only the licensed nursing staff . Interview with RN #1 weekend supervisor, on 9/10/15 at 11:15 AM, in the conference room revealed I check the physician orders [REDACTED]. Then go back in chart to make sure telephone orders are transcribed .Xarelto was not put on the August physician recap orders so it was not on the MAR .I failed to transcribe Xarelto onto the August orders .So the med (medication) was not given in August. Interview with the Director of Nursing on 9/10/15 at 1:16 PM, in the conference room, confirmed the nursing supervisors were responsible for recapitulating orders to ensure the correct orders were placed on the medication administration record. The charge nurse from 10:00 PM-6:00 AM would've looked over it to make sure meds are transcribed. The monthly changeover was when it was missed . Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition (pages 874-875) revealed, VENOUS DISORDERS: Venous [MEDICAL CONDITION]-[MEDICAL CONDITIONS] and [MEDICAL CONDITION] embolism (PE) collectively make up the condition known as venous [MEDICAL CONDITION] .majority of symptomatic [MEDICAL CONDITION] complications in surgical patients occur after hospital discharge .Venous thrombi (blood clots) are aggregates of platelets attached to the vein wall that have a tail-like appendage containing [MEDICATION NAME], white blood cells, and many red blood cells. The 'tail' can grow or can propagate in the direction of blood flow as successive layers of the thrombus form. A propagating venous [MEDICAL CONDITION] (enlarging blood clot) is dangerous because parts of the thrombus can break off and occlude (stop blood flow) in the [MEDICAL CONDITION] blood vessels . Interview with the Nurse Practitioner on 09/11/2015 at 9:41 AM, by phone, confirmed, I would say that not getting those doses of Xarelto would contribute to a [MEDICAL CONDITION]. It was prescribed .Any postop (postoperative) surgical procedures could contribute to that (development of [MEDICAL CONDITION]) especially if .immobile. Medical record review revealed Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] (used to decrease toxic ammonia levels in patients with liver disease)15 gm (grams) po (by mouth) QID (four times a day) . Medical record review of the August Medication Administration Record [REDACTED]Time Code the administration times were listed as 8:00 AM, 12:00 PM, 4:00 PM, 12:00 PM. Further review revealed the second (repeat)12:00 PM had a line drawn through and the documentation of the medication nurses indicated the [MEDICATION NAME] was given 3 times a day. Review of the facility investigation dated 8/13/15 revealed .On admission, resident was ordered [MEDICATION NAME] 15 gm PO QID. [MEDICATION NAME] was entered in the computer as [MEDICATION NAME] 15 gm four times daily at 8 am, 12pm, 4pm, 12pm. Medication only given once at 12pm and therefore resident only received med TID (three times a day) instead of the ordered QID. Resident is free of s/s (signs/symptoms) adverse effects at this time. No change in mental status or physical function since admit .Ammonia level obtained . [MEDICATION NAME] changed to 30 grams TID per MD 8/13/15 . Medical record review of the laboratory result dated 8/13/15 revealed, .Ammonia .183 .Reference (normal range)10-35 . Medical record review of the Progress Notes dated 8/14/15 revealed .Late entry for 8/13/15 8:15 pm Observed that admission orders [REDACTED]. Order was entered into computer with time codes of 8 am, 12pm, 4pm, 12pm. Resident had been given [MEDICATION NAME] 15 gm three times daily .MD notified with new order to obtain Ammonia level. Ammonia level obtained per charge nurse .Results called from (named) lab 8/13/15 .with ammonia level of 183. (Physician) notified of lab results and new order obtained for d/c (discontinue) previous [MEDICATION NAME] order and start [MEDICATION NAME] 30 gm TID .No change in mental status since admission and no decline in physical function . Medical record review of a physician's orders [REDACTED].D/C [MEDICATION NAME] 15 gm po QID .start [MEDICATION NAME] 30 gm PO tid . Interview with the Director of Nursing (DON), on 9/11/15, at 9:50 AM, in the conference room, confirmed the 12 PM time code was entered incorrectly, it should have been entered as 8 PM, and Resident #155 only received the [MEDICATION NAME] TID. Continued interview confirmed 8 doses of [MEDICATION NAME] had not been administered as ordered by the physician. Interview with the Nurse Practitioner, on 9/11/15 at 12:50 PM, by telephone, confirmed the resident had missed 8 doses [MEDICATION NAME] in 8 days, the resident had a history of [REDACTED]. Resident #42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Physician order [REDACTED].[MEDICATION NAME] (also known as [MEDICATION NAME], a medication to treat fluid retention) 20 mg PO BID . Medical record review of a Medication Administration Record [REDACTED].[MEDICATION NAME] 20 mg tablet PO administered daily . Medical record review of a MAR indicated [REDACTED].[MEDICATION NAME] 20 mg PO BID . Continued medical record review of the MAR indicated [REDACTED]. Medical record review of a Nurse's Note dated 8/12/15 revealed, .Notified MD of medication discrepancy r/t (related to) [MEDICATION NAME] .Resident self-responsible and was notified . Observation of the resident on 9/11/15 at 7:45 AM, revealed the resident resting in their bed with no concerns identified. Interview with the DON on 9/11/15 at 1:30 PM, in the conference room, confirmed the resident was to receive the [MEDICATION NAME] twice a day on admission to the facility on [DATE], and the facility failed to ensure the medication was administered as prescribed until 8/12/15. The Immediate Jeopardy was effective from 7/24/15 through 9/10/15. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on 9/11/2015. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of a new policy and procedure mandating only licensed nurses were to enter admission/readmission orders [REDACTED]. The procedure included a second licensed nurse to review and confirm the orders as accurate and complete prior to the orders becoming part of the medical record. Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing) and the facility's plan for education for nurses who were not scheduled to work. 2. Verification of the new medication administration system by the facility, which included discontinuation of an unlicensed medical records employee completing data entry and implementing admission/readmission orders [REDACTED]. Verification included review and observation reconciling new physician's orders [REDACTED]. 3. Review of the 100% audit of all anticoagulant MEDICATION ORDERS FOR [REDACTED]. 4. Review of the 100% audit of all physician orders [REDACTED]. 5. Review of the 100% audit of all current physician orders [REDACTED]. 6. Verification through interview with the Regional Vice President, Administrator, and the Director of Nursing (DON) the decision was made 8/18/15 for admission/readmission orders [REDACTED]. 7. Interview with the DON and the Staff Development Coordinator and review of the education provided to the 34 licensed nurses (except 2 outstanding PRN/as needed nurses who could not work a shift until they receive training) related to proper verification of written and oral medication orders and the proper procedure to follow if there are medications identified in a resident's medication supply not included on the MAR. 8. Verification, through interview with the DON and review of facility's September performance improvement audit conducted each Monday-Friday during the morning Nursing Leadership meeting, the facility's process and audits were identifying and correcting errors before the errors reached the resident. 9. Verification through observation and review of 2 new admissions scheduled for 9/11/15, the new admission orders [REDACTED]. Observation confirmed the process was completed accurately. 10. Verification through interviews with 3 Registered Nurses and 8 Licensed Practical Nurses confirmed comprehension of changes and implementation of the facility's new transcription and verification procedures. 11. Verification through interview with the Administrator, Medical Director, Director of Nursing, and Regional Director of Clinical Services, their participation in the facility's performance improvement committee tasked to address the system changes with medication administration. 12. Verification by interview with the Regional Vice President and the Administrator the facility discontinued the process of entering physician orders [REDACTED]. Non-compliance continues at an E level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit a plan of correction. Refer to F281, F282, and F333

Based on medical record review, observation, interview, review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, the facility failed to provide anticoagulant therapy in accordance with the resident's plan of care for 1 resident (#182) out of 24 residents' care plans reviewed of 40 sampled residents. The facility's failure to follow the care plan placed resident #182 in Immediate Jeopardy. The Regional Vice President, Administrator, Director of Nursing, and Regional Director of Clinical Services, were informed of the Immediate Jeopardy on 9/11/15 at 10:40 AM, in the Administrator's office. The Immediate Jeopardy for resident #182 was effective 8/1/15 through 9/10/15. An extended survey was conducted on 9/11/15. Substandard Quality of Care was cited at F282-J. The facility submitted an Acceptable Allegation of Compliance to the survey team on 9/11/15. The survey team verified the actions taken by the facility removed the jeopardy on 9/10/15. Noncompliance continues at the D level. The findings included: Medical record review revealed Resident #182 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 7/7/15, revealed .Anticoagulation .Problems (Resident #182) is on an anticoagulant therapy Xarelto for [MEDICAL CONDITIONS] prevention due to multiple fractures . Approaches .Administer medications .Report to the physician any s/s (signs and symptoms) abnormal bleeding or hemorrhage as needed . Medical record review of the Admission physician's orders [REDACTED].Xarelto (blood thinning drug) 15 mg (milligrams) PO (by mouth) BID (twice a day) c (with) meals @ (at) 8 AM & (and) 12 PM. (Dx (diagnosis): prevention of [MEDICAL CONDITION] d/t (due to) fx (fracture) ) Stop 7/26/15. Xarelto 20 mg PO daily @ PM (night) (Dx: prevention [MEDICAL CONDITION]) Start 7/27/15 . Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #182's Brief Interview Mental Status (BIMS) score was 15 out of 15 (indicating the resident was cognitively intact). Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a Physician Telephone Order dated 8/9/15, revealed .Doppler (ultrasound test using reflected sound waves to evaluate blood flow through blood vessels) of RLE (right lower extremity) .Indication-DX (increase pain/[MEDICAL CONDITION]) . Medical record review of the Doppler Radiology Interpretation dated 8/10/15, revealed .Right lower extremity venous study shows no evidence of hematoma .There is deep [MEDICAL CONDITION] (blood clot) seen in the right proximal femoral vein extending to the right popliteal vein . Observation, during interview with Resident #182, on 9/9/15 at 8:30 AM, in the resident's room revealed the resident was seated in a wheelchair and stated, They made a mistake and I got a blood clot .Ultrasound shows I still have blood clot in my right leg. Interview with Registered Nurse #1 (RN) weekend supervisor, on 9/10/15 at 11:15 AM, in the conference room, confirmed .I check physician orders [REDACTED].then go back in chart to make sure telephone orders are transcribed. The Xarelto was not put on the August physician recap (recapitulation) orders so it was not on the MAR. I failed to transcribe Xarelto onto the August orders. So the med (medication) was not given in August. Interview with the Assistant Director of Nursing, on 9/10/15 at 11:30 AM, in the conference room, confirmed the resident's plan of care included administering anticoagulation the physician ordered for prevention of a [MEDICAL CONDITION]. Interview continued and confirmed the care plan was not followed and the resident developed a [MEDICAL CONDITION]. Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition (pages 874-875) revealed, VENOUS DISORDERS: Venous [MEDICAL CONDITION]-[MEDICAL CONDITIONS] and [MEDICAL CONDITION] embolism (PE) collectively make up the condition known as venous [MEDICAL CONDITION] .majority of symptomatic [MEDICAL CONDITION] complications in surgical patients occur after hospital discharge .Venous thrombi (blood clots) are aggregates of platelets attached to the vein wall that have a tail-like appendage containing [MEDICATION NAME], white blood cells, and many red blood cells. The 'tail' can grow or can propagate in the direction of blood flow as successive layers of the thrombus form. A propagating venous [MEDICAL CONDITION] (enlarging blood clot) is dangerous because parts of the thrombus can break off and occlude (stop blood flow) in the [MEDICAL CONDITION] blood vessels . Interview with the Nurse Practitioner on 09/11/2015 at 9:41 AM, by telephone, confirmed if Resident #182's Xarelto (anticoagulant drug) was not administered as part of his plan of care, a [MEDICAL CONDITION] could develop, I would say that not getting those doses of Xarelto would contribute to a [MEDICAL CONDITION]. It was prescribed .Any postop (postoperative) surgical procedures could contribute to that (development of [MEDICAL CONDITION]) especially if .immobile. The Immediate Jeopardy was effective from 7/24/15 through 9/10/15. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on 9/11/2015. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of a new policy and procedure mandating only licensed nurses were to enter admission/readmission orders [REDACTED]. The procedure included a second licensed nurse to review and confirm the orders as accurate and complete prior to the orders becoming part of the medical record. Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing) and the facility's plan for education for nurses who were not scheduled to work. 2. Verification of the new medication administration system by the facility, which included discontinuation of an unlicensed medical records employee completing data entry and implementing admission/readmission orders [REDACTED]. Verification included review and observation reconciling new physician's orders [REDACTED]. 3. Review of the 100% audit of all anticoagulant MEDICATION ORDERS FOR [REDACTED]. 4. Review of the 100% audit of all physician orders [REDACTED]. 5. Review of the 100% audit of all current physician orders [REDACTED]. 6. Verification through interview with the Regional Vice President, Administrator, and the Director of Nursing (DON) the decision was made 8/18/15 for admission/readmission orders [REDACTED]. 7. Interview with the DON and the Staff Development Coordinator and review of the education provided to the 34 licensed nurses (except 2 outstanding PRN/as needed nurses who could not work a shift until they receive training) related to proper verification of written and oral medication orders and the proper procedure to follow if there are medications identified in a resident's medication supply not included on the MAR. 8. Verification, through interview with the DON and review of facility's September performance improvement audit conducted each Monday-Friday during the morning Nursing Leadership meeting, the facility's process and audits were identifying and correcting errors before the errors reached the resident. 9. Verification through observation and review of 2 new admissions scheduled for 9/11/15, the new admission orders [REDACTED]. Observation confirmed the process was completed accurately. 10. Verification through interviews with 3 Registered Nurses and 8 Licensed Practical Nurses confirmed comprehension of changes and implementation of the facility's new transcription and verification procedures. 11. Verification through interview with the Administrator, Medical Director, Director of Nursing, and Regional Director of Clinical Services, their participation in the facility's performance improvement committee tasked to address the system changes with medication administration. 12. Verification by interview with the Regional Vice President and the Administrator the facility discontinued the process of entering physician orders [REDACTED]. Non-compliance continues at an D level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit a plan of correction. Refer to F281, F309, and F333

Based on medical record review, review of facility investigation, observation, and interview, the facility failed to prevent a significant medication error for 1 resident (#182) of 18 residents reviewed for medication errors. The facility's failure to ensure medications were administered according to physician's orders [REDACTED].#182 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Regional Vice President, Administrator, Director of Nursing, and Regional Director of Clinical Services, were informed of the Immediate Jeopardy on 9/11/15, at 10:40 AM in the Administrator's office. The Immediate Jeopardy was effective 8/1/15 through 9/10/15. An extended survey was conducted on 9/11/15. Substandard Quality of Care was cited at F333-J. The facility submitted an Acceptable Allegation of Compliance to the survey team on 9/11/15. The survey team verified the actions taken by the facility removed the jeopardy on 9/10/15. Noncompliance continues at the severity of D level. The findings included: Medical record review revealed Resident #182 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission physician's orders [REDACTED].Xarelto (blood thinning drug) 15 mg (milligrams) PO (by mouth) BID (twice a day) c (with) meals @ (at) 8 AM & (and) 12 PM. (Dx (Diagnosis): prevention of [MEDICAL CONDITION] ([MEDICAL CONDITION]/blood clot) d/t (due to) fx (fracture) ) Stop 7/26/15. Xarelto 20 mg PO daily @ 5pm (DX: prevention [MEDICAL CONDITION]) Start 7/27/15 . Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #182's Brief Interview Mental Status (BIMS) score was 15 out of 15 (indicating the resident was cognitively intact). Medical record review of the Medication Administration Record, [REDACTED]. Medical record review of the August 2015 Physician Recapitulation Orders dated 7/30/15 signed by Registered Nurse (RN) #1, revealed the order for Xarelto had not been transcribed to the orders or MAR. Medical record review of a Nursing Note dated 8/9/15 at 10:09 AM revealed .Resident has c/o (complaint of) right leg pain, there is some slight swelling noted no redness or pain upon moving the leg, will continue to observe . Medical record review of a Nursing Note dated 8/9/15 at 3:50 PM revealed .c/o of pain in RLE (Right Lower Extremity) with dorsal flexion, has increased [MEDICAL CONDITION] and heat in RLE. Contacted MD (medical doctor) by phone obtained new order for venus doppler of RLE . Medical record review of a Physician Telephone Orders dated 8/9/15, revealed .Doppler (ultrasound test using reflected sound waves to evaluate blood flow through blood vessels) of RLE .Indication-DX (increase pain/[MEDICAL CONDITION]) . Medical record review of the Doppler Radiology Interpretation dated 8/10/15, revealed .Right lower extremity venous study shows no evidence of hematoma .There is deep [MEDICAL CONDITIONS] seen in the right proximal femoral vein extending to the right popliteal vein . Medical record review of a Nursing Note dated 8/11/15 revealed, .Resident noted to have missed several doses of scheduled Xarelto due to medication error in transcribing medication to MAR indicated [REDACTED].written 8-10-15 of [MEDICATION NAME] 5 mg PO daily and [MEDICATION NAME] 30 mg sub-q (sub-cutaneous) BID until INR (International Normalized Ratio) greater than 2 then D/C (discontinue) [MEDICATION NAME] . Review of the nursing note revealed the [MEDICATION NAME] and [MEDICATION NAME] orders were based on the results of the Doppler to the right lower extremity on 8-10-15 confirming a [MEDICAL CONDITION]. Review of the facility investigation Incident Follow up and Recommendation Form dated 8/11/15, revealed . Summary of Investigative Facts: Resident missed doses of Xarelto 20 mg daily from August 1-10 due to medication not being transcribed to new orders and MAR for the month of August. Resident diagnosed with [REDACTED]. Recommendations/Actions Taken: [MEDICATION NAME] 5 mg daily and [MEDICATION NAME] 30 mg BID ordered on [DATE] for [DIAGNOSES REDACTED]. Observation during interview with Resident #182 on 9/9/15 at 8:30 AM, in the resident's room, revealed the resident was seated in a wheelchair and the resident stated, They made a mistake and I got a blood clot. Ultrasound shows I still have blood clot. Interview with Licensed Practical Nurse (LPN #1) on 9/9/15 at 9:25 AM, in the conference room, revealed .Medical records printed the MAR forms to send to the nurses, pharmacy see orders we fax. We fax the admission orders [REDACTED].We get their (residents) discharge packet from hospital so we have that to compare to. I compared our admission orders [REDACTED].faxed the July Physician order [REDACTED].#1 made corrections to the admission orders [REDACTED].We get the new recap orders (from medical records) maybe a week before the next month .ADON (Assistant Director of Nursing) notified me that the pharmacy had called and questioned .Incident report was done. Interview with the ADON on 9/10/2015 at 11:00 AM, in the conference room, revealed the ADON had transferred the hospital discharge orders (correctly) onto the nursing home admission orders [REDACTED]. Further interview confirmed the order for the Xarelto was incorrectly transcribed from the nursing home admission orders [REDACTED]. Interview confirmed the error had been addressed and corrected by LPN #1 on the computer-generated physician admission orders [REDACTED]. Interview continued and the ADON stated, HIM (the name facility used for the medical records department) isn't entering orders into the software now, only the licensed nursing staff . Interview with RN #1 weekend supervisor, on 9/10/15 at 11:15 AM, in the conference room, revealed I check the physician orders [REDACTED]. Then go back in chart to make sure telephone orders are transcribed .Xarelto was not put on the August physician recap orders so it was not on the MAR .I failed to transcribe Xarelto onto the August orders .So the med (medication) was not given in August. Interview with the Director of Nursing on 9/10/15 at 1:16 PM in the conference room, confirmed the nursing supervisors were responsible for recapitulating orders to ensure the correct orders were placed on the medication administration record. The charge nurse from 10:00 PM-6:00 AM would've looked over it to make sure meds are transcribed. The monthly changeover was when it was missed . Interview with the Nurse Practitioner 09/11/2015 at 9:41 AM, by phone, in the conference room, confirmed, I would say that not getting those doses of Xarelto would contribute to a [MEDICAL CONDITION]. It was prescribed . Any postop (postoperative) surgical procedures could contribute to that (development of [MEDICAL CONDITION]) especially if .immobile. The Immediate Jeopardy was effective from 7/24/15 through 9/10/15. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on 9/11/2015. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of a new policy and procedure mandating only licensed nurses were to enter admission/readmission orders [REDACTED]. The procedure included a second licensed nurse to review and confirm the orders as accurate and complete prior to the orders becoming part of the medical record. Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing) and the facility's plan for education for nurses who were not scheduled to work. 2. Verification of the new medication administration system by the facility, which included discontinuation of an unlicensed medical records employee completing data entry and implementing admission/readmission orders [REDACTED]. Verification included review and observation reconciling new physician's orders [REDACTED]. 3. Review of the 100% audit of all anticoagulant MEDICATION ORDERS FOR [REDACTED]. 4. Review of the 100% audit of all physician orders [REDACTED]. 5. Review of the 100% audit of all current physician orders [REDACTED]. 6. Verification through interview with the Regional Vice President, Administrator, and the Director of Nursing (DON) the decision was made 8/18/15 for admission/readmission orders [REDACTED]. 7. Interview with the DON and the Staff Development Coordinator and review of the education provided to the 34 licensed nurses (except 2 outstanding PRN/as needed nurses who could not work a shift until they receive training) related to proper verification of written and oral medication orders and the proper procedure to follow if there are medications identified in a resident's medication supply not included on the MAR. 8. Verification, through interview with the DON and review of facility's September performance improvement audit conducted each Monday-Friday during the morning Nursing Leadership meeting, the facility's process and audits were identifying and correcting errors before the errors reached the resident. 9. Verification through observation and review of 2 new admissions scheduled for 9/11/15, the new admission orders [REDACTED]. Observation confirmed the process was completed accurately. 10. Verification through interviews with 3 Registered Nurses and 8 Licensed Practical Nurses confirmed comprehension of changes and implementation of the facility's new transcription and verification procedures. 11. Verification through interview with the Administrator, Medical Director, Director of Nursing, and Regional Director of Clinical Services, their participation in the facility's performance improvement committee tasked to address the system changes with medication administration. 12. Verification by interview with the Regional Vice President and the Administrator the facility discontinued the process of entering physician orders [REDACTED]. Non-compliance continues at an D level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit a plan of correction. Refer to F281, F282, and F309

Based on medical record review, review of hospital records, review of the facility investigation, facility policy review, review of inservice records, observation and interview, the facility failed to ensure staff did not place hot coffee within reach of one resident (#1) who required assistance with eating and supervision with hot beverages, resulting in harm from a second degree burn to resident #1 of six residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long-term memory problems; had difficulty focusing attention (easily distracted, out of touch or difficulty following what was said); had disorganized thinking; was short-tempered and easily annoyed; had Hallucinations and [MEDICAL CONDITION]; had physical and verbal behavioral symptoms directed toward others and behavioral symptoms not directed towards others (hitting, rummaging, verbal symptoms like screaming, disruptive sounds), which significantly interfered with the resident's care and significantly disrupted others' care or the environment. Continued review of the MDS revealed the resident required extensive assistance with bed mobility, transfers, dressing, eating and hygiene; was totally dependent on staff for bathing; required a wheelchair for mobility; was incontinent of bowel and bladder; had no complaints of pain; and had no ulcers, wounds or other skin problems. Medical record of nurses' notes dated February 22, 2012 revealed, "...Must be fed per staff..." and February 27, 2012, "...Has to be fed all meals..." Review of a list provided by the facility on March 27, 2012, entitled "Residents requiring special supervision with hot liquids as of March 1, 2012", revealed resident #1 was included on the list. Medical record review of a dietary print-out (no date) revealed the resident received a regular, pureed diet with nectar thick liquids. Medical record review of pain assessments dated January 19, February 5 and 21, 2012, revealed the resident had no pain reported. Continued review revealed on March 1, 2012, the resident was "currently in pain." Medical record review of a nurse's note dated March 1, 2012, at 8:00 a.m., revealed, "...resident brought down to this nurse. CNA (Certified Nursing Assistant #1) helped nurse get resident to (room). Upon lying resident down on bed this nurse noted a large red/peeling area to (right) upper thigh. Dr. (name) called. N/O (New order) for [MEDICATION NAME] cream BID (twice daily) to (right) upper thigh until healed. [MEDICATION NAME] applied. When asked CNA what happened...said 'someone put resident's tray in front of her. She grabbed...coffee cup and spilled it on...lap...Resident's family requested resident to be sent to (hospital) for eval (evaluation) et (and) TX (treatment). EMS (Emergency Medical Service) here @ (at) 8:30 a.m..." Review of the hospital ER (emergency room ) record dated March 1, 2012, revealed the resident had a second degree burn on the right lower extremity. Continued review revealed [MEDICATION NAME] (pain medication) was administered and an IV (intravenous) infusion of Normal Saline (NS) at 95 ml (milliliters) per hour was administered in the hospital emergency room . Medical record review of a nurse's note dated March 1, 2012, at 12:40 p.m., revealed the resident was returned to the facility "via EMS". Medical record review of physician's orders [REDACTED].@ (at) 75 ml/hr (hour) x 48 (hours)." Medical record review of the pain flow sheet revealed the following pain medications were administered for pain in the right thigh after the burn: March 2, at 9:00 a.m., [MEDICATION NAME] 5/325 mg for pain at "9+" intensity (zero being no pain and 10 being the worst pain on the pain scale); March 2, at 12:00 p.m., [MEDICATION NAME] 5/500 mg for "10+" intensity; March 2, at 3:00 p.m., [MEDICATION NAME] (MS) 5 mg subcutaneous for "10+" intensity; March 2, at 5:00 p.m., Tylenol 650 mg for "5+" intensity; March 2, at 6:35 p.m., MS 5 mg for "10+" intensity; March 3, at 12:55 a.m., MS 5 mg for "8-9" intensity; March 3, at 4:15 a.m., Tylenol for "6" intensity; March 3, at 8:00 a.m., MS 5 mg for "6" intensity; and March 5, (time not discernible) [MEDICATION NAME] 5/325 for "6" intensity. Medical record review of a nurse's note dated March 5, 2012, at 5:50 p.m., revealed, "...New order noted to send to (hospital) ER per MD (Medical Doctor)..." Medical record review of the facility's transfer record dated March 5, 2012, which was provided to the hospital revealed, "Reason for transfer: Pain management...Skin condition: 2nd and 3rd [MEDICAL CONDITION] right hip..." Review of a hospital history and physical dated March 5, 2012, revealed, "...apparently suffered a burn after having some hot liquids spilled on (resident) a few days ago. It had been managed at the nursing home with some [MEDICATION NAME] Cream however it was not getting any better...was sent to the emergency room for evaluation. The emergency room physician reports that it had exudates present on the wound which was cleansed while there...apparently did have a foul smell to it as well...patient has severe Dementia...has an irregular shape second degree burn and one measuring approximately 4 cm (centimeters) x (times) 8 cm in length and another approximately 2 cm x 3 cm elliptical shape burn on the right hip area. Base is clean with some surrounding [DIAGNOSES REDACTED]..." Review of a hospital wound care report dated March 6, 2012, revealed, "...Patient with non-healing burn to right hip. Per family burn was caused by hot coffee at nursing home...Entire surface of burn measures 19x12 cm. Open area measures 16x5 cm. Unable to determine depth of wound due to presence of adherent yellow slough that covers 90% (percent) of open wound bed. Wound edges red. Small amount yellow drainage noted. Patient with two satellite wounds...wound to anterior lower abdomen measures 1x3 cm. Wound bed covered with adherent yellow (slough) to 100% of wound...Second...wound to posterior right thigh measuring 1.2x3 cm. Unable to determine depth due to 100% of wound bed being covered in adherent yellow slough. No odor noted to wounds..." Medical record review of a nurse's note dated March 8, 2012, at 2:30 p.m., revealed the resident returned to the facility. Medical record review of the physician's orders [REDACTED]. Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of a signed physician's orders [REDACTED]. Effective 3-9-12." Medical record review of the pain flow sheet dated March 9, 2012, revealed [MEDICATION NAME] 5/325 was administered to the resident for pain in the right thigh, with movement, with intensity of "8". Medical record review of a nurse's note dated March 13, 2012, revealed, "...Resident lying in bed with knees bent and restless saying burning, burning-given pain medication po..." Medical record review of the pain flow sheet dated March 13, 2012, revealed the resident had pain in the right thigh with movement at intensity of "7", and Tylenol 650 mg was administered. Review of the facility investigation documented by the Administrator dated March 2, 2012, revealed the facility's investigation was "...being finalized...appeared that the tray was on the table, a tech (CNA-Certified Nursing Assistant #1) was across the table...patient was pushed up to the table and reached for coffee...there were four...people in the dining room when the event occurred..." Review of a written statement by CNA #1 dated March 1012, revealed, "While feeding (another resident) the (speech therapist (ST) told me (resident #1) grab her coffee and spelt (spilled) on...self. I got up and grabed (grabbed) some towels and put one down (resident #1's) pants to keep the hot coffee off...leg...then took...to...room and...took...pants off...put a wet towel on...leg." Review of a written statement by CNA #2 dated March 1, 2012, revealed, "I was sitting at the front (dining room) feeding (another resident)...(CNA #3) was feeding (another resident)...(CNA #1) was sitting in the middle starting to feed (another resident)...and (resident #1) was sitting across the table. The Speech Therapist was feeding (another resident) when she stated, (resident #1) spelled (spilled) coffee on (self)..." Review of a written statement by the ST dated March 2, 2012, revealed, "...was in the dining room for therapy with a patient...went to get my patient's tray when another resident's family member handed me (resident #1's) tray. I put the tray at the table where (resident #1) was to be fed. (Resident) was not pushed up to the table when I set the tray down. I then proceeded to give therapeutic feeding to my patient. During the therapy, I glanced up and noticed (resident #1) holding the coffee and it spilled in...lap. The tech who was at the table with (resident) got up and used towels to dry...then took down the hall. There was a tech present at the table when the incident occurred. Other techs were present in the dining room who were not feeding anyone and were not supervising." Review of a written statement by CNA #3 dated March 12, 2012, revealed, "...I was at the second door by the front feeding (another resident)...somebody had set (resident #1's) tray in front of (resident), and the speech lady said (resident) spilled...coffee on (self)..." Review of the facility's policy entitled, "Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages" revealed, "Training objective: Participants will identify ways to reduce the risk of residents [MEDICAL CONDITION] hot [MEDICAL CONDITION] result from hot liquids that are 120 (degrees) F (Fahrenheit) or above, supervision is required to provide a safe environment...Hot beverages should be available to residents only in areas that are supervised at all times. Supervised areas may include: Dining rooms...Evaluate each resident's ability to manage hot beverages, and provide needed assistance. Keep the list of residents who need special supervision current...Develop a process to ensure that all associates involved with dining...are aware of who needs this special supervision..." Review of the inservice record dated March 1, 6 and 9, 2012, revealed, "...The associate who is assigned to feed a patient should bring the tray with them to the patient's table or bedside and feed the patient at that time. Trays should not be present at the table until the associate is ready to sit down with the patient and help them to eat...The attached policies for Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages...should be followed." Observation on March 26, 2012, at 8:55 a.m., with Licensed Practical Nurse (LPN) #2/Treatment Nurse revealed the resident lying in bed and revealed a wound to the right thigh which the Treatment Nurse measured as 8.0 cm x 1.0 cm by unstageable depth with 5-10% granulation. Observation on March 26 2012, at 12:15 p.m., revealed the resident sitting in a wheelchair near the nurses' station with non-purposeful movements including fidgeting with the pants. The pants were above the resident's knees. Observation revealed no response to communication with the resident. Review of the weekly wound report and interview on March 26, 2012, at 8:10 a.m., in the conference room, with the LPN #2/Treatment Nurse confirmed the resident was "burned with hot coffee." Continued interview revealed the wound had been measured by LPN #2/Treatment Nurse on March 26, 2012, prior to 8:10 a.m., and the wound measured 8.0 cm x 1.0 cm x unstageable. Interview on March 26, 2012, at 2:20 p.m., in the conference room, with CNA #1 revealed on March 1, 2011, CNA #1 "had just walked into dining room-running late" for the second meal setting. Continued interview revealed the CNA sat down to feed another resident when the ST told CNA #1 that resident #1 spilled coffee on self. The CNA stated, "jumped up and got a couple of bibs-lifted pants to get coffee off...put bibs between (resident's) pants and leg...ended up burning my left hand...blisters on my fingers...When I saw leg, I knew it was second degree burns...skin coming off...steam coming off (resident's) pants." Continued interview confirmed the resident was a "grabber...likes grabbing everything. Everybody knows...grabs everything. I don't know who sat the tray down but everybody knows she's a grabber." Continued interview confirmed the second meal settings in the dining room were "mostly" for residents who required feeding. CNA #1 stated, "When it happened, (resident) was yelling. You could tell she was hurting...still yelling down the hall and after...got in bed..." Interview on March 26, 2012, at 3:10 p.m., in the conference room, with the ST confirmed on March 1, 2012, the ST was feeding a resident in the dining room and observed resident #1 spill hot coffee on (resident #1). Continued interview confirmed the ST had knowledge the resident was a "grabber, but I don't know how purposeful..." Continued interview confirmed other staff was in the dining room "who were supposed to be monitoring the situation..." Telephone interview on March 26, 2012, at 7:20 p.m., with CNA #2 confirmed CNA #2 was feeding a resident in the dining room on March 1, 2012, at the time resident #1 received the burn from hot coffee. Continued interview confirmed the facility's policy required trays not be placed in front of a resident (who required feeding) until staff was ready to feed the resident. Continued interview confirmed the resident was "all the time holding the arms out reaching...constantly reaching for things..." Review of the ST's written statement dated March 2, 2012, and interview on March 27, 2012, at 8:13 a.m., in the conference room, with the ST confirmed the ST's written statement and confirmed the ST sat the resident's breakfast tray on the table in front of the resident. The ST stated, "When I placed the tray down (resident) was not pushed up to the table for feeding." Continued interview revealed, "The techs who were not feeding were in the dining room and suppose to be supervising residents. The techs who were not feeding were not supervising otherwise they would have seen (resident) had the meal tray and would have removed the tray until someone was ready to feed (resident)..." Telephone interview on March 27, 2012, at 3:15 p.m., with CNA #3 confirmed CNA #3 was feeding another resident on March 1, 2012, at the time resident #1 received the burn from hot coffee. Continued interview confirmed, "If there's something (resident #1) can reach...will grab it...have seen...jerk flower off table many times...constantly reaching..." Continued interview confirmed, "Everyone in there (in dining room at the time of the burn) was either feeding or starting to feed. No one was standing to supervise. (Resident #1) was "total feeder." Continued interview confirmed the facility's policy required trays not be placed in front of a resident (who required feeding) until staff was ready to feed the resident. Telephone interview on March 29, 2012, at 1:05 p.m., with LPN #1, who was on duty on March 1, 2012, at the time of the burn, revealed when LPN #1 first observed the resident, the area "was already blistered." LPN #1 notified the physician and received orders to apply [MEDICATION NAME] cream. Continued interview confirmed the resident was "squirming every time air was hitting it (burn) when I was putting cream on it." Continued interview confirmed the resident was constantly reaching and grabbing since LPN #1 had been employed (2010). Continued interview confirmed the resident was "a feeder"; received nectar thick liquids; and required supervision for feeding and hot liquids. Continued interview confirmed the facility's policy required trays not be placed in front of a resident (who required feeding) until staff was ready to feed the resident. Interview on March 27, 2012, at 4:00 p.m., in the conference room, with the Director of Nursing (DON), in the presence of the Administrator and the Regional Director of Clinical Services, confirmed the resident required supervision with hot beverages on March 1, 2012, the day the resident received the burn from hot coffee and confirmed the facility's policy at the time of the burn required meal trays not be served to a resident who required feeding until staff were ready to sit down and feed the resident. Continued interview confirmed the second meal service in the dining room was for residents who required supervision and, "That's why they're in that setting." C/O #

Based on medical record review, review of hospital records, review of the facility investigation, facility policy review, review of inservice records, observation and interview, the facility failed to ensure hot coffee was not placed within reach of one resident (#1), who required supervision with hot beverages, resulting in a second degree burn of resident #1 of six residents reviewed. The facility's failure resulted in harm for resident #1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long-term memory problems; had difficulty focusing attention (easily distracted, out of touch or difficulty following what was said); had disorganized thinking; was short-tempered and easily annoyed; had Hallucinations and Delusions; had physical and verbal behavioral symptoms directed toward others and behavioral symptoms not directed towards others (hitting, rummaging, verbal symptoms like screaming, disruptive sounds), which significantly interfered with the resident's care and significantly disrupted others' care or the environment. Continued review of the MDS revealed the resident required extensive assistance with bed mobility, transfers, dressing, eating and hygiene; was totally dependent on staff for bathing; required a wheelchair for mobility; was incontinent of bowel and bladder; had no complaints of pain; and had no ulcers, wounds or other skin problems. Medical record of nurses' notes dated February 22, 2012 revealed, "...Must be fed per staff..." and February 27, 2012, revealed, "...Has to be fed all meals..." Review of a list provided by the facility on March 27, 2012, entitled "Residents requiring special supervision with hot liquids as of March 1, 2012", revealed resident #1 was included on the list. Medical record review of a dietary print-out (no date) revealed the resident received a regular, pureed diet with nectar thick liquids. Medical record review of a nurse's note dated March 1, 2012, at 8:00 a.m., revealed, "...resident brought down to this nurse. CNA (Certified Nursing Assistant #1) helped nurse get resident to (room). Upon lying resident down on bed this nurse noted a large red/peeling area to (right) upper thigh. Dr. (name) called. N/O (New order) for Silvadene cream BID (twice daily) to (right) upper thigh until healed. Silvadene applied. When asked CNA what happened...said 'someone put resident's tray in front of her. She grabbed...coffee cup and spilled it on...lap...Resident's family requested resident to be sent to (hospital) for eval (evaluation) et (and) TX (treatment). EMS (Emergency Management Service) here @ (at) 8:30 a.m..." Refer to F224 C/O #